Author: Logan Young

_{Published January 10, 2020}

The latter half of 2019 saw the identification of an entirely new respiratory illness and introduction of a new diagnosis— e-cigarette, or vaping, product use associated lung injury (EVALI)—into the medical lexicon. Based on current understanding, EVALI is an acute or subacute respiratory illness that is often severe and in some cases fatal, purported to be a chemical pneumonitis resulting from inhalation of one or more toxic substances. As of November 5, the Centers for Disease Control (CDC) reports 2,051 cases of EVALI in the United States, including every state except Alaska, plus the District of Columbia, with 39 deaths in 24 states. The reported cases have affected patients as young as 13 and as old as 75, with males about twice as common as females. Nearly all of these patients have presented with acute or subacute respiratory symptoms, and not surprisingly, thoracic imaging (chest radiograph and CT) has become central to the diagnosis of these patients. Knowledge about these diseases is changing every day, and it is imperative that diagnostic radiologists have a general understanding of what vaping is, how it looks on imaging, and what we know so far.

What Is an E-cigarette, and What Is Vaping?

An e-cigarette is an electronic device that is designed to simulate traditional smoking. Instead of the combustion of tobacco (or, more recently, marijuana), e-cigarettes heat a substance (usually liquid, oil, or wax) to create a vapor that is inhaled, hence the term “vaping.” E-cigarettes were invented in 2003 and introduced in the U.S. around 2007.

Most devices have three main components: a chamber or cartridge that contains the substance to be heated and vaporized (also referred to as the e-liquid); an atomizer or heating element that vaporizes the substance in the cartridge, so that it can be inhaled; and a battery to power the heating source.

Like any piece of technology, these devices have evolved and are becoming increasingly sophisticated. Early devices tended to mimic tobacco cigarettes in shape, but now admittedly look outdated, compared to the most recent generations of products that are smaller, sleeker, and more easily concealed. Some bear more of a resemblance to USB thumb drives than smoking devices, and a few even have Bluetooth connectivity to track how much one vapes.

What Substances Do People Vape?

The substances that patients vape are almost limitless, and this variability is one of the main reasons it has been so difficult to pinpoint the recent surge of cases on one specific cause. A majority of recent cases have been associated with vaping tetrahydrocannabinol (THC) or other marijuana derivatives, and there is mounting evidence for vitamin E acetate as one of the main culprits. While a majority of patients with EVALI report vaping both THC and nicotine, some patients report vaping exclusively nicotine, so it is possibly not just the vitamin E acetate, a thickening agent in THC-containing vaping products, that is to blame.

At this time, there is little regulation of the vaping industry, although the FDA announced in September that it plans to begin regulating some of the nicotine-based substances, particularly flavored products that are perceived to be more attractive to adolescents and young adults. Some cities, such as San Francisco, have begun instituting bans on sales of e-cigarettes.

Given the lack of regulation, there are many ways that the substances are stored, filled, and refilled, as well as many suppliers from where patients get their vaping substances. Some are refillable cartridges, whereas others are disposable pods; some people create their own “home brews” or buy products off the street that may not be sterile and may be adulterated. It is suspected that some of the aftermarket or “off-the-street” products may be more likely to cause injury, and the CDC advises against their use.

Nicotine is often mixed with flavoring agents or “vape juice,” and there are more than 15,000 different flavors. Adults may prefer more traditional flavors such as tobacco, mint, or menthol that try to mimic the taste of cigarette smoking. But other flavors more unabashedly appeal to teenagers and adolescents—many of whom were never smokers prior to vaping. A study in Pediatrics found that adolescents who vaped these nontraditional flavors (including fruit, candy, sweet or dessert, buttery, or other blends not including traditional flavors) were more likely to continue vaping at six months and take more puffs per occasion. The use of these flavors resulted in greater self-reported addiction and satisfaction in another study of young adults.

Why the Recent Rise in Vaping Cases?

Vaping is becoming more popular, particularly among adolescents and young adults; the variety of substances that can be consumed has expanded; and e-cigarette companies have increased the marketing of their products, just to name a few. But with the constant media coverage, everyone thinks about vaping as a cause of lung injury, and that has led to increased recognition by physicians, including radiologists.

The first case we suspected to be lung disease due to vaping was in 2014 in an adult male patient with ground-glass opacity (GGO) on CT, although this case could never be proven, as there wasn’t even a name for this disease then. The first confirmed case we saw was in 2017 in a female who was vaping THC to help her sleep. Case reports of EVALI date back to 2012, but our original article in AJR, “Imaging Findings of Vaping-Associated Lung Injury,” is the first to review and present all of the different imaging patterns that we have encountered so far. The varied appearances underscore the confusion and difficulty in these cases, arguing in support of a multifactorial cause.

What’s the Bare Minimum Radiologists Should Know About Vaping and EVALI?

At the time of submission of our manuscript to AJR, there was no accepted case definition for what constituted vaping-associated lung injury. However, based in part on the work since published by Leyden et al. in the New England Journal of Medicine on the cases reported to the Illinois and Wisconsin state health departments, the CDC has proposed definitions of confirmed and probable cases. It must be emphasized that EVALI is still a diagnosis of exclusion, as there is no laboratory test to confirm the diagnosis.

A confirmed case of EVALI is defined as:

• using an e-cigarette or dabbing (i.e., heating concentrated cannabis oil or wax and inhaling the vapors) in 90 days prior to symptom onset
• abnormalities on either chest radiograph or CT
• negative infectious workup
• no alternative plausible diagnosis (e.g., cardiac, rheumatalogic, or neoplastic)

A probable case of EVALI is similar—the one distinction that either an infection was detected by culture or polymerase chain reaction but not suspected of being the sole cause of lung injury, or minimum testing to exclude infection was not performed.

Imaging is part of the case definition, and as such, radiologists are critical to the diagnosis. The CDC definition verbatim is “pulmonary infiltrate, such as opacities, on plain film chest radiograph or ground-glass opacities on chest CT,” but to any radiologist, this sounds like a vague and generic explanation. One can review the many different patterns of lung injury in our AJR paper, but the one commonality from the cases we present, our review of the literature, and those cases we’ve encountered since is that these patients almost universally present with bilateral opacities that look like acute lung injury and/or organizing pneumonia. Cases may be diffuse, upper- or lower-lobe predominant.

In the appropriate clinical setting, it is arguable that chest radiograph should be sufficient for the diagnosis if bilateral opacities are present, although clinicians often order CT to evaluate for alternative causes, such as pulmonary embolism. Patients who present with acute illness may require ventilatory support. Unfortunately, some patients have died. Treatment with corticosteroids seems to be effective. While most patients completely heal, there is little data on the long-term appearance of survivors of EVALI.

Lung Pathology of EVALI

For most cases of EVALI, obtaining lung tissue is unnecessary for establishing the diagnosis, although some literature on pathology now exists. The largest series of cases where pathologic specimens were available was recently published and concluded that EVALI is “a form of airway-centered chemical pneumonitis from one or more toxic substances” in the aerosolized vapor. The presence of lipid-laden macrophages and positive oil-red-O stains has raised the possibility of exogenous lipoid pneumonia due to vitamin E acetate. Regardless of the underlying pathology, macroscopic fat has not been observed on CT imaging.

What Does the Future Hold for Vaping and EVALI?

The recent illnesses and deaths represent a grave tragedy and public health crisis with little precedent. However, it is important for physicians to not focus exclusively on the negative press. Lost in the daily media shuffle is the fact that for some patients, e-cigarettes may be an effective tool for smoking cessation. Recent data from a randomized control trial in the United Kingdom found that nicotine-containing e-cigarettes were almost twice as effective for smoking cessation at one year compared to other forms of nicotine replacement, but the abstinence rate was still only 18.0% (vs 9.9%). Patients in the e-cigarette group also experienced a greater reduction in cough and phlegm production. On the other hand, can patients stop vaping once they have started? At the one-year mark, 80% of the patients using e-cigarettes in this group were still using. Many health officials are worried that it is just replacing one habit (smoking) with a slightly less bad habit (vaping). Vaping might be safer than traditional cigarette use, but at this point, we just don’t know.

Hopefully, the agents responsible for cases of EVALI will be discovered, and cases of acute lung injury will subside, but what are the long-term effects of vaping? Vaping is a new practice that has been around for barely more than a decade, and it is certainly a worry that long-term vaping could lead to more chronic lung disease and fibrosis. We have seen some indication that vaping may progress to fibrosis, although this realm is largely unexplored and ripe for imaging research.

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The opinions expressed in InPractice magazine are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher.

_{Published March 21, 2020}

When Thomas H. Berquist logs off his iPad this summer, his 12-year tenure as the 12th editor in chief of the American Journal of Roentgenology (AJR) will capstone a period of unprecedented growth for the 113-year-old publication. Truly the end of an era, only two other men will have occupied the AJR’s chief chair longer than Berquist: Lawrence Reynolds, who picked up the mantle in 1930 and died in office 31 years later, and his immediate successor, Traian Leucutia, whose editorship (1961–75) lasted just two years longer than this lauded, yet humble Mayo Clinic radiologist.

Articulating an expansive vision for radiology’s beloved “yellow journal” from his first days at the desk in late 2008, the ARRS Publications Committee, to whom Berquist has reported for some 150 issues of AJR, agrees that he’s fostered a unique editorial climate ever since—one of both exacting rigor and earnest diversity.

“Dr. Berquist is one of the most inclusive leaders that I have ever had the pleasure to work with,” says Deborah Baumgarten, ARRS Publications Committee chair. “He solicits opinions and really listens to and considers what others have said. You feel like you matter to him.”

Acknowledging achievement only if it’s data-borne, the internationally recognized author of 38 books on medical imaging tells InPractice he remains very much “a numbers guy.”

Incidentally, despite ARRS’ announcement of Berquist’s retirement more than 15 months ago, submissions to the journal continue to pour in unabated. And although AJR’s acceptance rate “still hovers right around 20%,” Berquist does admit that the overall quality of the articles being submitted is likely as good as it has ever been.

For once, there’s a causation implied by the correlation.

Two years ago, Berquist himself took to these same pages to reassert AJR’s raison d’être in two words: “evidence-based articles”. Codifying the journal’s reporting guidelines for Original Research and Review articles “to assist authors in providing optimal consistent content,” he also detailed significant revisions to the Standards for Reporting Diagnostic Accuracy Studies (STARD) and Standards for Reporting Observation Studies in Epidemiology (STROBE) checklists, “in an effort to provide more imaging-friendly guidelines.”

With humility and precision, Berquist now notes, “to date, there have been 128 STARD submissions and 33 STROBE submissions to AJR,” casually mentioning the “significant recruitment initiative” he’s spearheading to further improve these types of content enhancement, which he’s keen to note will soldier on even without him aboard.

Circulation is up, too. With AJR enjoying record readership worldwide—especially unique views and clicks, online and mobile, at AJRonline.org—as the outgoing editor in chief wrote in his “Things We Learned Along the Way” editorial from November, “the online version is the journal of record.”

It was Berquist’s predecessor, Robert Stanley, who introduced the notion of electronic article submission. Not surprisingly, his institution of web-based submissions yielded a marked increase in international authors submitting to AJR, sending Stanley and staff scrambling to enlist foreign-language reviewers. Sixteen years post-Stanley, Berquist recalls yet another telling audit.

“Currently, there are 2,321 total AJR reviewers,” he says. “Eighty percent hail from the United States, and 20% are based internationally.”

Asked how a more international distribution due to ever-increasing scholar globalization might alter the scope of AJR content to come, thus far, Berquist says he’s seen only one year, 2014, where foreign submissions outpaced submissions from the U.S. As always, Berquist’s bias tends toward scientific scrutiny, not identity politics, “particularly where a benign cultural difference could escalate to the level of significant medicolegal dilemma.”

Ultimately, he’d much rather talk residents and reviewers than matters foreign and domestic. Regarding residents, Berquist is quick to credit Howard P. Forman for initiating the journal’s Trainee Reviewer program, pointing out the present group of “61 trainee reviewers and additional new reviewers who have mentors as they begin their reviewer role.”

Naturally, Berquist has streamlined the onboarding process; it began two years ago at the Marriott Wardman Park Hotel in Washington, D.C.

In 2018, alongside Cheryl S. Merrill, ARRS’ director of publications, Berquist debuted what would eventually become an essential component of the ARRS Annual Meeting that speaks volumes about the significance of scientific integrity—a two hour course the duo affectionately dubbed “Rock the Review: How to Get a Perfect Score.” A perfect score equals 4.0, sure, but what does said “rocking it” actually look like on the page?

For that inquiry, Berquist settles in: “The review must include sophisticated, detailed comments to authors with line and page referencing to enhance the content and relevance of the work; concise, confidential comments to the editor; and the reviews must be completed in the allotted 14 days or earlier.”

As for his active reviewers, again, Berquist knows their numbers by heart.

“Ten percent of AJR reviewers have scores less than 3.0, and 40% have scores between 3.0–3.5,” he says. “Half of the reviewers for AJR, nearly 1,200, have a perfect 4.0,” Berquist half-beams, adding that each and every reviewer is evaluated at least yearly, “more frequently should their approach warrant it.” He reveals “any reviewer may request a review of themselves at any time,” too

Resigned to the inherent difficulty of “consistent communication” with more than 2,300 reviewers across the globe, Berquist’s not bereft of procedure here either.

“There are multiple data points available each day,” he says of his quality control, “including how many invitations a reviewer has received, accepted, and declined; how many times a reviewer has been uninvited for not responding; the last review accepted and completed and the last review declined; reviews in progress; and the mean reviewer score.”

Lest you think he’s all scores and no play, there are prizes— albeit hard-won ones.

Known for penning personal letters to stellar reviewers, Berquist also established “a Distinguished Reviewers category for individuals performing 10 or more reviews in a given year with score of 3.0 or higher.” Reviewers’ names are featured on the AJR masthead for the entirety of the following year, and their departmental chairs are notified of the distinction.

For “above and beyond assistance,” states Berquist, “we initiated the Gold and Silver Distinguished Reviewer Achievement Awards in 2018 for reviewers with 100 or more reviews and 50–99 reviews, respectively.” These reviews must be scored at least 3.5, and Berquist remarks that 91 AJR reviewers have received 14 gold and 77 silver trophies during the Reviewer’s Luncheon at the ARRS Annual Meeting.

“We now have Platinum and Diamond Distinguished Reviewer Achievement Awards for scores 3.5 or higher for 150– 199 reviews and 200 or more reviews, respectively,” he says with that muted smile returning.

Acknowledging that the whole notion of peer review itself is in flux, Berquist’s not averse to the creep of new ideas. His interest in zeitgeist systems thinking, like Just Culture, has been abiding, and he confesses to “a certain anticipation” for an updated model of shared accountability.

Never not teaching, the diagnostic radiologist is wont for a metaphor.

“Peer review is a lot like the Supreme Court,” Berquist claims. “It’s by no means perfect, but it’s the best we have now.”

For all reviewers, authors, and journal staff, time is always of the essence. Recalling an AJR authors’ survey “where 85% of respondents considered speed to publication extremely important,” once more, the numbers stay on Berquist’s side.

“In 2013, the time to first decision was 37.6 days,” he says. Streamlined protocols in 2017, implemented by the journal’s inhouse staff, shrunk that time down to 25 days. For 2019, Berquist tallies “the average time to first decision is 18.8 days,” compared to 20 days at the same time the previous year.

Prior to recent concerted efforts, he laments that the elapsed time from first decision to AJR publication measured a “protracted 147 days.” Understandably, Berquist happily reports that number has been cut almost in half.

Asked who or what is most responsible for this optimized circle to publication, AJR’s chief editorial officer neither hesitates nor equivocates: “The journal staff deserve the credit—all of it.”

Berquist balks at the term officer. His self-effacing streak matched only by his work ethic, this self-described “policeman with no gun” has doggedly pursued often competing commitments at AJR—everything from article enhancements, reviewer recognition, and production improvements to that ever-important journal impact factor.

And at least until June, armed or not, the buck still stops with Berquist.

“Right now, the impact score of AJR is 3.161,” he rattles off to the third decimal. “That’s the highest the score has ever been. But it’s not yet a 4, so in that regard,” he doesn’t pause, “I’ve failed.”

Impact factor is a scientometric index, yes, but Berquist concedes there are more popular proxies, especially in pixels. It was under his administration that ARRS joined Twitter, posted a DOI on Instagram, and published an AJR video to YouTube. It was during Berquist’s watch that democratized platforms such as these breathed new, sometimes second lives to articles about magnetic eyelashes as MRI artifacts and his personal favorite, radiologic detection of inadvertently ingested wire bristles from a grill-cleaning brush.

“It’s exciting, it’s all visibility, and we’re getting much better at it,” Berquist says of social media exposure. “We’re also exploring more and more things adjacent to it,” his subtle reference to AJR Podcasts, available cross-platform via iTunes and Google Play.

At the end of the day, it’s not impact factor or Just Culture or homepage views that’s kept Berquist up at night these last 12 years.

“For me, the key thing has always been scientific integrity,” he says. “In fact, it’s really only this. But in reality, there are times when I feel alone on this white horse, swinging at windmills.”

Of course, the man of La Mancha never had to traverse this modern landscape of so many open-access journals—an “exponential proliferation” our Jacksonville, Florida physician cites as his chief concern for medical publishing moving forward.

“There were about 80 radiology journals when I began at AJR,” Berquist remembers. Today, he inventories more than 800 open-access journals publishing medical imaging content on a regular basis. How could Berquist alone possibly guard against every duplicative breach?

“I’m not sure we can anymore,” Berquist answers, invoking both pronouns.

According to the editor in chief, AJR uses a huge database, Similarity Check (CrossRef), for manuscript evaluation, as well as “a 10% or greater duplication and singles source greater than or equal to 3% to help assess duplication more thoroughly.” Given that a typical year will end in more than 1,800 submissions to the cue, the journal’s two-factor safeguard invariably yields “a staggering number” of replicate queries.

Noting that medical schools, residency programs, and fellowships lack a proper course in publishing ethics—Berquist’s biggest regret is not advocating harder for a nationwide curriculum—“only 1.8% of the submissions AJR receives contain less than 10% duplication,” he sighs. “We can’t keep kicking this can down the road.”

With nuclear medicine becoming de rigueur in the 1960s, ARRS members of a certain vintage will recall how Traian Leucutia relented to rechristening AJR the American Journal of Roentgenology, Radium Therapy, and Nuclear Medicine. The late Melvin M. Figley not only changed it back in 1976, he kept the word “Roentgenology” in the title, maintaining its myriad historical associations. As radiology enters the third decade of the new millennium, does Berquist see an emerging modality or pressing topic that could necessitate another retitling of the journal?

“Believe it or not, changing the name of AJR has come up,” he says. “Imaging, as a whole, is a lot of different things, and imaging is always evolving, so if the ABR’s requirements change accordingly, I could foresee the ARRS Executive Council maybe taking a vote.”

Berquist has but one simple request for the next editor: “Whatever happens, I just hope we’ll keep on calling AJR the yellow journal.” Having championed the leading resource for practicing physicians and allied health professionals engaged in patient-centered medical imaging, let no one dare call what he’s done “yellow journalism,” though.

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The opinions expressed in InPractice magazine are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher.

The events of the Columbine school shooting in 1999, the attacks on September 11, 2001, and the anthrax mailings the following week underscored the need for health care to be prepared to respond to acts of mass violence and bioterrorism.

Many health care systems developed disaster preparedness plans, assuming that treatment would be delivered according to established standards of care with sufficient resources and facilities to serve their communities. However, with each subsequent mass casualty event it became apparent—at least in the immediate response, referred to as the “surge”—that resources were overwhelmed and delivery of health care to established standards was compromised. Consequently, health care systems needed to review and revise their disaster management plans with newly identified issues and renewed preparations.

Mass casualty incidents (MCIs) are not defined by number of victims or severity of injuries, but rather by an imbalance of supply and demand. Therefore, the definition is fluid, dependent upon the demand for and availability of limited resources to provide optimal care for a population of casualties.

The World Health Organization defines a mass casualty incident as “an event which generates more patients at one time than locally available resources can manage using routine procedures. It requires exceptional emergency arrangements and additional or extraordinary assistance.” The key message being that there is no threshold.

Multiple Casualties vs Mass Casualties

In daily operations of normal emergency care, there is an abundance of resources in relation to patient load. In this setting, health care follows our routine standard of care operations. When the emergency department experiences an influx of multiple patients in a short period of time, without overwhelming resources, this is simply a busy shift. In this multiple casualties scenario, although extra resources may be marshaled, there is no significant deviation from normal standard of care. In contrast, a mass casualty results from a rapid patient load that quickly overwhelms available resources with necessary changes to the delivery of care.

MCIs may be natural, in the form of tornadoes, hurricanes, or floods; or they may be accidental, such as a building collapse or train crash; or they may be intentional, including mass shootings, riots, or explosive detonations. What MCIs share, however, is that these events are uncommon, unpredictable, and often occur without warning. Thus, responding to these events requires planning and practice.

The Greatest Good for the Greatest Number

The goal of health care in an MCI is optimizing outcomes for the greatest number of patients. Accordingly, changes in the usual standards of care are imperative to achieve this goal. Rather than doing everything possible to save every life, it will be necessary to allocate limited resources in a different manner, due to overwhelming demand. Those resources include operating rooms (ORs), interventional radiology (IR) suites, ventilation equipment, blood products, physical space in the emergency department, and imaging equipment—to name just a few.

To that end, several considerations need to be addressed, including:

• How should current standards of care be altered in response to an MCI to save as many lives as possible?
• What is the minimal acceptable care?
• What issues and principles should guide the planning of a medical response for an MCI?
• What information, tools, and resources are available to address the needs of planners?
• When and how are non-trauma centers integrated into the response and care for an MCI?

Many disaster management plans do not provide guidance concerning altered standards of care necessary to respond to an MCI. Allocation of limited resources should be considered and planned for to ensure that access is both clinically sound and just.

Triage: Red, Green, or Yellow?

Triage is the act of sorting patients according to severity of injury, likelihood of survival, and availability of resources. It is a dynamic process, as resource accessibility changes (e.g., running out of ORs) and as patient condition changes (e.g., patient responds to fluid resuscitation and tourniquet application; conversely, a once stable “walking wounded” patient has suddenly decompensated). Moreover, triage needs to be flexible enough to respond to changes in MCI type and magnitude.

The sorting process serves to identify those patients in need of immediate medical attention, tagged red; patients with minor injuries that can clearly wait (i.e., walking wounded), tagged green; and patients who are tagged neither red nor green. These yellow-tagged patients require urgent, though not immediate medical care, repeat physical examinations, and often benefit from imaging to improve triage accuracy.

Human resources should also be considered, along with physical resources, to ensure a prolonged supply of qualified staff. Such considerations include staff transport into and out of the facility, nourishment, protection, adequate rest, and stress management.

Avoiding the Bottleneck

Multiple studies report CT and portable x-rays have created consistent bottlenecks during MCIs. Brunner J, Rocha TC, Chudgar AA, et al. The Boston Marathon bombing: after-action review of the Brigham and Women’s Hospital emergency radiology response. Radiology 2014; 273:78–87

Campion EM, Juillard C, Knudson MM, et al. Reconsidering the resources needed for multiple casualty events: lessons learned from the crash of Asiana airlines flight 214. JAMA Surg 2016; 151:512–517

Mueck FG, Wirth K, Muggenthaler M, et al. Radiological mass casualty incident (MCI) workflow analysis: single-centre data of a mid-scale exercise. Br J Radiol 2016; 89:20150918

Dick EA, Ballard M, Walker HA, et al. Bomb blast imaging: bringing order to chaos. Clin Radiol 2018; 73:509–516 To prevent the radiology bottleneck, imaging should be integrated into the MCI protocol.

The role of imaging is to improve triage accuracy: identify life threatening injuries to determine who is most in need of critical resources, including the OR, IR suite, or other life-saving measures. Detailed diagnosis at this stage to identify each and every rib fracture is not the mission in an MCI. Keep in mind that if the purpose of casualties coming to a hospital is to access such lifesaving resources, then a process modifier, such as imaging, should not be the rate-limiting step forming a bottleneck.

Essential radiological tasks are threefold: first, identify surgical and interventional cases; second, communicate critical results; and third, reduce over-triage to the OR.

During the surge, imaging should be limited to yellow-tagged and select red-tagged patients (those awaiting OR to prioritize).

Radiography during the surge phase of an MCI should be limited to portable chest x-rays to prevent misuse of non-emergent radiographs while other patients are waiting. No other radiographs should be allowed, until clearance from the senior triage physician.

CT scanning during the surge should be limited to high-priority hemodynamically stable patients and those responding to resuscitation.

Consider limiting scan protocols to a single whole-body CT (WBCT) to eliminate variation for optimal efficiency and greatest throughput. Imaging in an MCI is a departure from daily practice. CT is a limited-resource triage modifier and should always be viewed as such to prevent a bottleneck.

Imaging strategies include: a dedicated radiologist stationed at the CT console for immediate review; use of a paper form for critical imaging results; “no frills” WBCT protocols to eliminate immediate post-processing of multiplanar reformations, in favor of volume reading on a dedicated CT workstation, where possible; and consideration of thicker image slices, if scanner processing and/or hospital network is slow. Remember that spinal precautions can be maintained until after the surge, and reconstructions can be performed later, as necessary.

It is important to recognize that although CT usage during the MCI surge will be selective and may be altogether avoided, CT volumes will predictably increase post-surge. Post-surge imaging in an MCI may take up to 72 hours to complete; ensure staff are available beyond the initial phase.

Integration Is Preparation

Mass casualty events are increasing in frequency, creating stress on the hospital system as a whole, including the radiology department. Because dealing with an MCI presents a departure from routine standard of care, radiology must be incorporated into the hospital’s overall disaster management plan. Considering and understanding the issues the radiology department faces, as well as the role radiologists play in planning for these incidents, is vital for saving lives and improving outcomes.

The question is no longer if, but rather when, your department will become involved in some capacity. The need to be prepared is self-evident, and history has shown this requirement applies to all practice types, yet the integration of imaging into the MCI response remains a relatively novel concept—and can seem like an overwhelming one.

When planning and preparing for hospital-based medical care during disasters and mass casualties, radiologists must act as subject matter experts on the crucial role imaging plays. Proper integration can help develop a ready and resilient response that optimizes efficient and effective care while conserving vital resources.

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The opinions expressed in InPractice magazine are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher.

Chronic liver disease is an increasingly common and important disorder, now afflicting more than 25% of the world’s population. Regardless of its underlying cause, chronic liver disease can progress to cirrhosis, development of liver cancer, and liver-related death. Recent advances in imaging knowledge and technology have elevated the role of radiology in the diagnosis and management of patients with or at risk for chronic liver disease across its entire spectrum and course.

Noninvasive Monitoring of Chronic Liver Disease

With a rising epidemic of obesity and metabolic syndrome in the United States, nonalcoholic fatty liver disease and its progressive form, nonalcoholic steatohepatitis, are increasingly encountered in practice. Additionally, overconsumption of alcohol and viral hepatitis remain common causes of chronic liver disease. Irrespective of etiology, chronic liver disease represents a spectrum of inflammation, injury, fibrosis, and eventually, cirrhosis. Although in the past, cirrhosis was considered an irreversible injury, recent medical advances provide opportunities to halt and even reverse fibrosis. Likewise, identification and modulation of risk factors, like fat and iron deposition in the liver, are essential to managing patients at risk for or with chronic liver disease. Pathological assessment remains a reference standard, but risks and cost associated with biopsy reduce the benefit in the setting of longitudinal monitoring. Radiologists play an essential role in providing noninvasive quantitative information to direct management.

State of the art imaging options for assessing chronic liver disease focus on three key elements: liver fat, iron, and fibrosis. Liver fat can be identified by ultrasound, CT, and MRI. The most accurate, accessible, and precise method for monitoring patients with chronic liver disease is MRI-proton density fat fraction (PDFF). MRI-PDFF takes advantage of the fact that owing to differences in molecular structures, fat and water protons experience different magnetic fields and precess at different rates. This offset in frequency (“chemical shift”) is the basis for in- and opposed-phase dual echo imaging with its familiar appearance, including “India ink” etching at fat-water interfaces on opposed-phase images, due to signal cancellation when water and fat are precessing directly opposite each other. MRI-PDFF expands on this concept and is estimated by acquiring images at multiple echo times, selected to optimize separation of fat and water signals, and by taking into account several confounders that otherwise introduce errors into fat quantification. Iron is one of the most important confounders and is also an important factor contributing to chronic liver disease. Iron is ferromagnetic and causes signal decay (T2*), due to disruption of local magnetic fields. The decay of signal over time (R2*) is directly proportional to iron content over a wide pathophysiological spectrum, allowing us to estimate R2* values and convert them to liver iron concentrations. Hence, MRI-PDFF quantifies both fat and iron.

The most validated and clinically used method for estimating liver fibrosis is elastography. Elastography can be done with ultrasound or MRI. Elastography is an imaging technique that quantifies the stiffness of tissue, or resistance to deformation following application of external pressure. Imaging methods estimate stiffness by generating shear waves in the liver and measuring their propagation. Ultrasound methods differ based on how they generate shear waves and whether they produce gray-scale images (point shear wave elastography and 2D elastography) or not (vibration controlled transient elastography). Ultrasound methods measure shear wave speed, which can be converted into tissue stiffness values. The speed measurements may differ between manufacturers and etiologies of chronic liver disease, which challenges establishment of universal thresholds for stages of fibrosis. Magnetic resonance elastography (MRE) utilizes a standard system for shear wave generation and measurement across all vendors and platforms; as a result, the tissue stiffness values obtained from MRE are thought to be more reproducible.

Standardizing Diagnosis of Liver Cancer in Patients with Chronic Liver Disease

Hepatocellular carcinoma (HCC) can be confidently diagnosed based on imaging, in contradistinction to most malignancies that require tissue examination for their diagnosis. The noninvasive diagnosis of HCC is justified by the high positive predictive value of CT and MRI for this purpose when stringent criteria are applied in high-risk patients (i.e., high pre-test probability). Filippone A, Blakeborough A, Breuer J, et al. Enhancement of liver parenchyma after injection of hepatocyte-specific MRI contrast media: a comparison of gadoxetic acid and gadobenate dimeglumine. J Magn Reson Imaging 2010; 31:356–364

Roberts LR, Sirlin CB, Zaiem F, et al. Imaging for the diagnosis of hepatocellular carcinoma: A systematic review and meta-analysis. Hepatology 2018; 67:401–21

Hanna RF, Miloushev VZ, Tang A, et al. Comparative 13-year meta-analysis of the sensitivity and positive predictive value of ultrasound, CT, and MRI for detecting hepatocellular carcinoma. Abdom Radiol (NY) 2016; 41:71–90 Additionally, cross-sectional imaging assesses local spread and distant metastases.

Current standards in the noninvasive diagnosis of HCC follow the guidelines of the American Association for the Study of Liver Disease (AASLD), Organ Procurement and Transplantation Network (OPTN), and Liver Imaging Reporting and Data System (LI-RADS). Duncan JK, Ma N, Vreugdenburg TD, Cameron AL, Maddern G. Gadoxetic acid-enhanced MRI for the characterization of hepatocellular carcinoma: a systematic review and meta-analysis. J Magn Reson Imaging 2017; 45:281–290

Guo J, Seo Y, Ren S, et al. Diagnostic performance of contrast-enhanced multidetector computed tomography and gadoxetic acid disodium-enhanced magnetic resonance imaging in detecting hepatocellular carcinoma: direct comparison and a meta-analysis. Abdom Radiol (NY) 2016; 41:1960–1972

Liu X, Jiang H, Chen J, Zhou Y, Huang Z, Song B. Gadoxetic acid disodiumenhanced magnetic resonance imaging outperformed multidetector computed tomography in diagnosing small hepatocellular carcinoma: a meta-analysis. Liver Transpl 2017; 23:1505–1518 These guidelines agree on certain imaging features that should be present in an observation to provide the required high positive predictive value for HCC, such as a maximum diameter of at least 10 mm and characteristic dynamic enhancement characteristics discussed further below. Distinct differences used to exist between the three guidelines in the categorization of hepatic lesions, until the release of the latest LI-RADS guidelines for CT and MRI in 2018. The latest release comprised minor modifications to LI-RADS version 2017 to facilitate its integration into the AASLD clinical practice guidelines in August 2018. Matsui O, Kobayashi S, Sanada J, et al. Hepatocelluar nodules in liver cirrhosis: hemodynamic evaluation (angiography-assisted CT) with special reference to multi-step hepatocarcinogenesis. Abdom Imaging 2011; 36:264–272 LI-RADS and AASLD now have identical criteria for definite HCC, and the OPTN criteria are nearly identical to LI-RADS and AASLD.

LI-RADS is a comprehensive system that provides standards for terminology, technique, interpretation, and reporting of liver imaging. It has been developed by a multi-disciplinary and increasingly international team of diagnostic and interventional radiologists, hepatobiliary surgeons, hepatologists, and hepatopatholgists, alongside support from the American College of Radiology. Choi YS, Rhee H, Choi JY, et al. Histological characteristics of small hepatocellular carcinomas showing atypical enhancement patterns on gadoxetic acid enhanced MR imaging. J Magn Reson Imaging 2013; 37:1384–1391 Since its first release in 2011, LI-RADS has been updated periodically, with the latest update in 2018. Kitao A, Matsui O, Yoneda N, et al. The uptake transporter OATP8 expression decreases during multistep hepatocarcinogenesis: correlation with gadoxetic acid enhanced MR imaging. Eur Radiol 2011; 21:2056–2066

Kim BR, Lee JM, Lee DH, et al. Diagnostic performance of gadoxetic acid-enhanced liver MR imaging versus multidetector CT in the detection of dysplastic nodules and early hepatocellular carcinoma. Radiology 2017; 285:134–146

Nakamura S, Nouso K, Kobayashi Y, et al. The diagnosis of hypovascular hepatic lesions showing hypo-intensity in the hepatobiliary phase of Gd-EOBDTPA-enhanced MR imaging in high-risk patients for hepatocellular carcinoma. Acta Med Okayama 2013; 67:239–244
LI-RADS assigns a diagnostic category code for each observation to communicate the likelihood of being benign or being HCC, ranging from LR-1 (definitely benign) to LR-5 (definitely HCC). The LR-5 category has a reported specificity of 95% for HCC. In addition to the previous five categories, LI-RADS also provides three other categories—LR-NC (not categorizable), LR-TIV (tumor in vein), and LR-M (probably or definitely malignant, not necessarily HCC)—with certain criteria for each category.

The imaging diagnosis of HCC in LI-RADS is based on the presence or absence of five major imaging features and a number of ancillary features (AFs). Major features include nonrim arterial phase hyperenhancement (APHE), nonperipheral “washout” appearance, enhancing “capsule” appearance, size, and threshold growth.

The AFs are divided into three groups: AFs that favor malignancy in general, AFs that favor HCC in particular, and AFs that favor benignity. A preliminary LI-RADS category is assigned based on the present major features, then the AFs are used at the interpreter’s discretion to adjust the preliminary category.

In summary, the latest advances in imaging of HCC allow for a confident noninvasive diagnosis of this malignancy and comprehensive assessment of other lesions and pseudolesions depicted by imaging.

Improving Sensitivity for Liver Cancer Diagnosis with HBAs

HBAs are gadolinium-based intravenous MR contrast agents that permit hepatobiliary phase (HBP) imaging, in addition to conventional dynamic post-contrast phases. Gadoxetate disodium is the most commonly utilized HBA, due to high hepatobiliary excretion and convenient HBP timing of 10–30 minutes.

Gadoxetate offers several advantages for patients with cirrhosis. Of all available modalities, gadoxetate-enhanced MRI has the highest overall per-lesion sensitivity (86%) and positive predictive value (94%) for diagnosis of HCC, as well as the highest sensitivity (84–96%) for detection of ≤ 2 cm HCCs. Unlike APHE, reduced gadoxetate uptake is an early event in hepatocarcinogenesis: up to 38% of early HCCs may be seen only on the HBP, and 82% of high-grade dysplastic nodules (DN) and 76% of early HCCs are hypointense on the HBP.

HBP hypointense nodules without APHE are unique to HBA MRI. If sampled histologically, 74% of such nodules are HCCs, and 10% are DN, although these numbers may be inflated by selection bias; if followed, 16–43% progress to hypervascular HCC within 24 months. Nakamura S, Nouso K, Kobayashi Y, et al. The diagnosis of hypovascular hepatic lesions showing hypo-intensity in the hepatobiliary phase of Gd-EOBDTPA-enhanced MR imaging in high-risk patients for hepatocellular carcinoma. Acta Med Okayama 2013; 67:239–244

Cho YK, Kim JW, Kim MY, Cho HJ. Non-hypervascular hypointense nodules on hepatocyte phase gadoxetic acid-enhanced MR images: transformation of MR hepatobiliary hypointense nodules into hypervascular hepatocellular carcinomas. Gut and Liver 2018; 12:79–85

Saitoh T, Sato S, Yazaki T, et al. Progression of hepatic hypovascular nodules with hypointensity in the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI in hepatocellular carcinoma cases. Intern Med 2018; 57:165–171

Yang HJ, Song JS, Choi EJ, Choi H, Yang JD, Moon WS. Hypovascular hypointense nodules in hepatobiliary phase without T2 hyperintensity: longterm outcomes and added value of DWI in predicting hypervascular transformation. Clin Imaging 2018; 50:123–129

Hwang JA, Kang TW, Kim YK, et al. Association between non-hypervascular hypointense nodules on gadoxetic acid-enhanced MRI and liver stiffness or hepatocellular carcinoma. Eur J Radiol 2017; 95:362–369

Briani C, Di Pietropaolo M, Marignani M, et al. Non-hypervascular hypointense nodules at gadoxetic acid MRI: hepatocellular carcinoma risk assessment with emphasis on the role of diffusion-weighted imaging. J Gastrointest Cancer 2018; 49:302–310

Kim YS, Song JS, Lee HK, Han YM. Hypovascular hypointense nodules on hepatobiliary phase without T2 hyperintensity on gadoxetic acid-enhanced MR images in patients with chronic liver disease: long-term outcomes and risk factors for hypervascular transformation. Eur Radiol 2016; 26:3728–3736

Rosenkrantz AB, Pinnamaneni N, Kierans AS, Ream JM. Hypovascular hepatic nodules at gadoxetic acid-enhanced MRI: whole-lesion hepatobiliary phase histogram metrics for prediction of progression to arterial-enhancing hepatocellular carcinoma. Abdom Radiol (NY) 2016; 41:63–70 In patients who undergo resection for early-stage HCC, the presence of HBP hypointense nodules predicts high HCC recurrence risk and lower overall survival. Toyoda H, Kumada T, Tada T, Sone Y, Maeda A, Kaneoka Y. Nonhypervascular hypointense nodules on Gd-EOB-DTPA-enhanced MRI as a predictor of outcomes for early-stage HCC. Hepatol Int 2015; 9:84–92 Intermediate to long-term recurrence-free survival may be improved, if these nodules are treated concomitantly at the time of HCC resection. Matsuda M, Ichikawa T, Amemiya H, et al. Preoperative gadoxetic acid-enhanced MRI and simultaneous treatment of early hepatocellular carcinoma prolonged recurrence-free survival of progressed hepatocellular carcinoma patients after hepatic resection. HPB Surg 2014; 2014:641685

HBP hypointense nodules without APHE are also markers of increased HCC risk elsewhere in the liver: the cumulative three year rate of HCC elsewhere in the liver is 22%, compared to 6% in patients with no such nodules. Komatsu N, Motosugi U, Maekawa S, et al. Hepatocellular carcinoma risk assessment using gadoxetic acid-enhanced hepatocyte phase magnetic resonance imaging. Hepatol Res 2014; 44:1339–1346 Presence of these nodules in patients with early HCC is associated with decreased recurrence-free survival and higher intrahepatic recurrence rates following resection or ablation. Inoue M, Ogasawara S, Chiba T, et al. Presence of non-hypervascular hypointense nodules on gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging in patients with hepatocellular carcinoma. J Gastroenterol Hepatol 2017; 32:908–915

Lee DH, Lee JM, Lee JY, et al. Non-hypervascular hepatobiliary phase hypointense nodules on gadoxetic acid-enhanced MRI: risk of HCC recurrence after radiofrequency ablation. J Hepatol 2015; 62:1122–1130

Song KD, Rhim H, Lee MW, Kim YS, Kang TW. Intrahepatic distant recurrence after radiofrequency ablation for hepatocellular carcinoma: precursor nodules on pre-procedural gadoxetic acid-enhanced liver magnetic resonance imaging. Acta Radiol 2017; 58:778–785

The degree of gadoxetate uptake may predict tumor differentiation: poorly-differentiated HCCs are more frequently HBP hypointense (98%), compared with well- or moderately-differentiated HCCs (86%). Erra P, Puglia M, Ragozzino A, et al. Appearance of hepatocellular carcinoma on gadoxetic acid-enhanced hepatobiliary phase MR imaging: a systematic review. La Radiol Med 2015; 120:1002–1011 Up to 15% of HCCs may be iso- or hyperintense on the HBP, and such HCCs have more favorable outcomes, including improved recurrence-free and overall survival. Kim JY, Kim MJ, Kim KA, Jeong HT, Park YN. Hyperintense HCC on hepatobiliary phase images of gadoxetic acid-enhanced MRI: correlation with clinical and pathological features. Eur J Radiol 2012; 81:3877–3882

Kitao A, Matsui O, Yoneda N, et al. Hypervascular hepatocellular carcinoma: correlation between biologic features and signal intensity on gadoxetic acid-enhanced MR images. Radiology 2012; 265:780–789

Kitao A, Zen Y, Matsui O, et al. Hepatocellular carcinoma: signal intensity at gadoxetic acid-enhanced MR Imaging–correlation with molecular transporters and histopathologic features. Radiology 2010; 256:817–826

Use of gadoxetate in patients with cirrhosis is associated with several important pitfalls. Smaller contrast dose and volume affect timing of the arterial phase (AP) and may lead to reduced peak enhancement of HCC in the AP. Fujinaga Y, Ohya A, Matsushita T, Kurozumi M, Ueda K, Kitou Y, et al. Effect of hepatobiliary uptake of Gd-EOB-DTPA on the hepatic venous phase of dynamic magnetic resonance imaging on a 3.0-T apparatus: comparison between Gd-EOB-DTPA and Gd-DTPA. Jpn J Radiol 2011; 29:695–700

Tirkes T, Mehta P, Aisen AM, Lall C, Akisik F. Comparison of dynamic phase enhancement of hepatocellular carcinoma using gadoxetate disodium vs gadobenate dimeglumine. J Comput Assist Tomogr 2015; 39:479–482 Furthermore, gadoxetate is associated with higher incidence (5–22%) of transient severe motion, which occurs at or around the time of the late AP and leads to image degradation. Davenport MS, Viglianti BL, Al-Hawary MM, et al. Comparison of acute transient dyspnea after intravenous administration of gadoxetate disodium and gadobenate dimeglumine: effect on arterial phase image quality. Radiology 2013; 266:452–461

Davenport MS, Bashir MR, Pietryga JA, Weber JT, Khalatbari S, Hussain HK. Dose-toxicity relationship of gadoxetate disodium and transient severe respiratory motion artifact. AJR 2014; 203:796–802

Kim SY, Park SH, Wu EH, et al. Transient respiratory motion artifact during arterial phase MRI with gadoxetate disodium: risk factor analyses. AJR 2015; 204:1220–1227 Poor quality of the AP may affect depiction of APHE, a feature that is required for noninvasive HCC diagnosis. Chernyak V, Fowler KJ, Kamaya A, et al. Liver imaging reporting and data system (LI-RADS) version 2018: imaging of hepatocellular carcinoma in at-risk patients. Radiology 2018; 289:816–830

Portal venous phase (PVP) “washout” appearance in combination with APHE allows for nearly 100% specificity of HCC diagnosis. Marrero JA, Hussain HK, Nghiem HV, Umar R, Fontana RJ, Lok AS. Improving the prediction of hepatocellular carcinoma in cirrhotic patients with an arterially-enhancing liver mass. Liver Transpl 2005; 11:281–289 Parenchymal uptake of gadoxetate starting as early as the PVP results in observations potentially appearing relatively hypointense to the parenchyma, due to lower uptake of gadoxetate rather than true “washout.” As a result, hypointensity in the transitional phase (TP) is not equivalent to hypointensity during the PVP or delayed phases with extracellular agents: if hypointensity in the TP is considered “washout,” the specificity for HCC decreases from 98–100% to 86–95%. Choi SH, Lee SS, Kim SY, Park SH, Park SH, Kim KM, et al. Intrahepatic cholangiocarcinoma in patients with cirrhosis: differentiation from hepatocellular carcinoma by using gadoxetic acid-enhanced MR imaging and dynamic CT. Radiology 2017; 282:771–781 Therefore, LI-RADS restricts assessment of “washout” with gadoxetate to the PVP. Santillan C, Fowler K, Kono Y, Chernyak V. LI-RADS major features: CT, MRI with extracellular agents, and MRI with hepatobiliary agents. Abdom Radiol (NY) 2018; 43:75–81 Another effect of the early parenchymal enhancement with gadoxetate is the potential to obscure enhancement of the “capsule.”

In patients with decompensated cirrhosis, diminished parenchymal uptake of gadoxetate results in less enhancement during the TP and the HBP. Motosugi U, Ichikawa T, Sou H, et al. Liver parenchymal enhancement of hepatocyte-phase images in Gd-EOB-DTPA-enhanced MR imaging: which biological markers of the liver function affect the enhancement? J Magn Reson Imaging 2009; 30:1042–1046 As a result, conspicuity of HCC in the HBP is decreased in patients with poor hepatic function. Kim JY, Lee SS, Byun JH, et al. Biologic factors affecting HCC conspicuity in hepatobiliary phase imaging with liver-specific contrast agents. AJR 2013; 201:322–331 Additionally, interpretation of HBP intensity of liver observations—particularly if iso- or hyperintense to the background— may be unreliable in the setting of suboptimal HBP enhancement.

Although HBP hypointensity improves detection of HCC and high-grade DN, TP and HBP hypointensity are not specific to HCC, as any lesion without functional hepatocytes (e.g., cysts, hemangiomas, non-HCC malignancies, etc.) will appear hypointense in the HBP. Joo I, Lee JM, Lee DH, Jeon JH, Han JK, Choi BI. Noninvasive diagnosis of hepatocellular carcinoma on gadoxetic acid-enhanced MRI: can hypointensity on the hepatobiliary phase be used as an alternative to washout? Eur Radiol 2015; 25:2859–68

In conclusion, use of gadoxetate in patients with cirrhosis offers certain advantages—particularly higher sensitivity for HCC, if liver function is preserved and AP quality is adequate—but radiologists should be aware of the various pitfalls of gadoxetate to optimize patient selection and image interpretation.

Acknowledgements
Kathryn Fowler, Claude Sirlin, and Victoria Chernyak also contributed to this article.

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The opinions expressed in InPractice magazine are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher.

How often does gender or sex come up in your daily practice? In a publication or article you read? In your daily interactions with your family or colleagues?

Based on your answers to the above questions, suffice it to say that although gender is arguably a core piece of each individual’s identity, it variably affects one’s daily lived experience. For example, do you experience your gender differently in different contexts—such as when you were eight years old vs as a 45-year-old, or in different settings like a black-tie event? Just from these instances, it is clear that many factors influence our experience of gender, including language, societal norms, cultural background, etc. A recent article in the Journal of the American College of Radiology (JACR) excellently described basic gender terminology and definitions, emphasizing the need for greater gender inclusivity in radiology.

Whereas radiologists are not expected to be gender studies experts, there are several key aspects of gender that radiologists should be aware of in daily practice.

1. Be able to clearly and accurately describe imaging findings of physical anatomy, including gender affirmation therapy and surgeries, which we described in our original article in AJR, “Gender Affirmation Surgery: A Primer on Imaging Correlates for the Radiologist”. Gender affirmation therapy is multidisciplinary by nature; as radiologists, we are part of the team providing necessary care for individuals experiencing gender incongruence.
2. Consider adjusting protocols for relevant anatomy: training staff to allow self-insertion of transvaginal probes; utilizing an endovaginal, rather than transrectal, approach for prostate cancer screening in transwomen who have undergone gender affirmation surgery; and correctly evaluating atrophied structures secondary to hormone therapy.
3. Study developing educational cases and share research in transgender health and imaging. Our colleagues (Maglione, Margolies, Jaffer, et al.) published one of the first descriptions of imaging findings of breast cancer in transgender women in AJR, and others have proposed adapting breast cancer screening guidelines for transgender women. More investigations with outcomes-based research are needed to improve understanding of transgender healthcare, including developing screening guidelines and protocols.
4. Collaborate with counselors, pediatricians, endocrinologists, general practitioners, surgeons (breast, plastic, maxillofacial, gynecologic, general, etc.), and allied health professionals who specialize in gender affirmation therapy, as there are treatment options (i.e., hormonal therapy) and ongoing advancements that may impact imaging interpretation.
5. Be aware of your local facility and institution’s Human Rights Commission “Healthcare Equality Index” score, and how you may either maintain or improve that score. Our own institution, Mount Sinai Health System, is fortunate to have a 100/100 score and a strong multidisciplinary team at the Center for Transgender Medicine and Surgery.
   
   What is the experience of LGBTQ+ patients in your facility? Are all staff trained? Two separate studies in 2015 and 2017 found that almost a quarter of transgender people said they avoided doctors or health care for fear of being discriminated against. The 2017 study, which detailed LGBTQ+ American experiences, showed that 33% had one or more negative experiences with a health care provider.
6. Assess workplace and educational climates for colleagues and trainees, who may face invisible or systemic barriers, even if not addressed explicitly in the scoring system. A 2015 study of medical students showed that approximately 43% of sexual and gender minorities concealed their identities, due to fear of discrimination. Do you consider your workplace gender diverse? Have you personally advocated for gender inclusivity, or defended someone from discriminatory attitudes, remarks, or behaviors? How are issues reported and addressed individually and systemically?
7. Encourage your professional society and journal publications to be aware of sex and gender terminology. Many journals, including AJR, require sex to be labelled on image captions. This posed an interesting dilemma, particularly in our recent article, as “sex assigned at birth” (SAAB) and “anatomical sex” are not necessarily equivalent, and anatomical sex may change. And, of course, these labels do not necessarily match the patient’s gender identity or chosen pronouns. These guidelines should be contextualized when publishing articles on transgender imaging.

8. Examine your local, state, and national policies regarding gender rights and safety protections. As described in a recent call to action published in JACR, the Association of University Radiologists moved its annual meeting location, in part, due to California’s Assembly Bill 1887, which prohibited California state employees (including those at medical centers) from state-funded travel to states that have discriminatory laws in place. Other radiology organizations should be encouraged to follow this example. Only half of the United States has state or local laws protecting LGBTQ+ workers. Is your state one of them?

9. Survey identification (ID) laws, as well as how difficult it may be to correct identification to reflect gender identity. The National Center for Transgender Equality’s 2015 study also revealed that 32% of transgender individuals who have shown an ID with a name or gender that did not match their gender presentation were verbally harassed, denied benefits or services, asked to leave, or assaulted. What are the requirements for ID in your institution, and how are staff trained to respond?

Imaging is simply one, albeit vital, facet in the overall care that we provide to our patients. The landscape of gender and sex, both inside and outside of radiology, continues to evolve, as we improve our individual understanding and address systemic flaws. All of us—ourselves, our healthcare providers, our patients, and our society—benefit by respectfully recognizing our individual identities. Let us be allies for one another.

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The opinions expressed in InPractice magazine are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher.