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Rationale and Objectives Standardized Uptake Value (SUV) is an important semiquantitative measurement used in the clinical and research domains to assess radiopharmaceutical concentration in tumors versus normal organs, but is susceptible to many factors beyond the tumor biological environment. So, the aim of this study is to identify the optimum internal reference among organs with physiological uptake in 68Ga-DOTATATE PET/CT (DOTA PET/CT) scans. Materials and Methods This HIPAA-compliant, IRB-approved study with waiver of consent included retrospective imaging review of 180 consecutive patients with neuroendocrine tumors presenting for DOTA PET/CT image acquisition: Ga-68 DOTATATE dose was reported as (0.054 mCi/Kg) scans between September 2018 and May 2019. Mean value of body weight normalized SUV (SUVbw) and lean body mass normalized SUV (SUL) of liver and spleen were measured. Information about the patients and scan characteristics were collected. The paired Grambsch test was used to compare variance among the measured SUVs. Spearman's rank correlation coefficient was used to assess correlation between SUVs and potential patient- and scan-specific confounding factors. Results Variance of SUL was significantly lower than variance of SUVbw in both liver and spleen (p-value Conclusion SUL is a more reproducible, less variable, and therefore more reliable quantitative measure in DOTA PET/CT scans, compared SUVbw. Among the available organs with physiological uptake, liver SUL is the optimum internal reference given the liver's larger size and uniform SUL values resulting in lower variability and better reproducibility.

This section focuses on the professional workforce comprised of the primary medical specialties that utilize ionizing radiation in their practices. Those discussed include the specialties of radiology and radiation oncology, as well as the subspecialties of radiology, namely diagnostic radiology, interventional radiology, nuclear radiology, and nuclear medicine. These professionals provide essential health care services, for example, the interpretation of imaging studies, the provision of interventional procedures, radionuclide therapeutic treatments, and radiation therapy. In addition, they may be called on to function as part of a radiologic emergency response team to care for potentially exposed persons following radiation events, for example, detonation of a nuclear weapon, nuclear power plant accidents, and transportation incidents. For these reasons, maintenance of an adequate workforce in each of these professions is essential to meeting the nation's future needs. Currently, there is a shortage for all physicians in the medical radiology workforce.

Background Nuclear medicine (NM) is a multidisciplinary field. Its overlap with nuclear radiology (NR) creates unique training considerations, opportunities, and challenges. Various factors impact the workforce, training needs, and training pathways. This state of flux may be perplexing to prospective NM/NR trainees. Purpose To evaluate the state of NM/NR training by assessing the (1) workforce trends and job prospects for NM/NR trainees, (2) NM and NR training pathways, and (3) applicant-accessible online presence of training programs. Methods Workforce trends were analyzed using data collected from the 2017 American College of Radiology Commission on Human Resources Workforce Survey. Information regarding the training pathways leading to board certification(s) for NM and NR physicians were obtained through the American Board of Nuclear Medicine, the American Board of Radiology (ABR), and the Society of Nuclear Medicine and Medical Imaging. Each Accreditation Council for Graduate Medical Education-accredited NM residency or NR fellowship training program's website was reviewed for 20 content items to assess its comprehensiveness for those seeking information regarding eligibility, applications, training curriculum, and program characteristics. Results Number of hires for NM/NR physicians has exceeded the projected number of hires from 2014 to 2017. In the last decade, there has been a greater than 25% decrease in the combined number of traditional NM residencies and NR fellowships (79–58 programs) and a greater than 50% decrease in the combined number of NM and NR trainees (173–82 trainees). In 2017, the ABR redesigned its 16-month pathway leading to specialty certification in diagnostic radiology and subspecialty certification in NR. As of March 24, 2019, there are 36 diagnostic radiology or IR residency programs with 64 trainees participating in this redesigned NR pathway. Of the 93.1% (54/58) of traditional Accreditation Council for Graduate Medical Education-accredited NM and NR training programs having websites in the 2017–2018 academic year, the mean number of online criteria met per program was 7.74 ± 3.2 of 20 (38.7%). Conclusion Recruitment into the traditional NM/NR training pathways has been steadily declining, but there has been a renewed interest with the redesigned ABR 16-month pathway. There is a paucity of online information available to prospective NM/NR applicants. In this rapidly evolving and unique field, it is important to streamline NM/NR training and bolster the information accessible to potential NM/NR applicants as they weigh career options.

Despite widespread interest in creating a more equitable and inclusive culture, a lack of workforce diversity persists in Radiology, in part due to a lack of universal and longitudinal metrics across institutions. In an attempt to establish benchmarks, a subset of the Society of Chairs of Academic Radiology Departments (SCARD) Diversity, Equity and Inclusion (DEI) Committee volunteered to design a DEI dashboard as a potential tool for academic radiology programs to use to document and track their progress. This freely-available, modular dashboard includes suggested (plus optional department-defined) DEI activities/parameters and suggested assessment criteria across three domains: faculty, residentsfellows, and medical students; it can be completed, in whole or in part, by departmental leaders annually. The suggested metrics and their associated rubrics were derived from the collective experiences of the five working group members, all of whom are chairs of academic radiology departments. The resulting dashboard was unanimously approved by the remaining 14 DEI committee members and endorsed by the SCARD board of directors.

Rationale and Objectives The American Board of Radiology Core Examination integrates assessment of physics knowledge into its overall testing of clinical radiology, with an emphasis on understanding image quality and artifacts, radiation dose, and patient safety for each modality or subspecialty organ system. Accordingly, achieving a holistic approach to physics education of radiology residents is a huge challenge. The traditional teaching of radiological physics—simply through didactic lectures—was not designed for such a holistic approach. Admittedly, time constraints and clinical demands can make incorporation of physics teaching into clinical practice problematic. We created and implemented a week-long, intensive physics rotation for fledgling radiology residents and evaluated its effectiveness. Materials and Methods The dedicated physics rotation is held for 1 week during the first month of radiology residency. It comprises three components: introductory lectures, hands-on practical clinical physics operations, and observation of clinical image production. A brief introduction of the physics pertinent to each modality is given at the beginning of each session. Hands-on experimental demonstrations are emphasized, receiving the greatest allotment of time. The residents perform experiments such as measuring radiation dose, studying the relationship between patient dose and clinical practice (eg, fluoroscopy technique), investigating the influence of acquisition parameters (kV, mAs) on radiographs, and evaluating image quality using computed tomography, magnetic resonance imaging, ultrasound, and gamma camera/single-photon emission computed tomography/positron emission tomography phantoms. Quantitative assessment of the effectiveness of the rotation is based on an examination that tests the residents' grasp of basic medical physics concepts along with written course evaluations provided by each resident. Results The pre- and post-rotation tests show that after the physics rotation, the average correct score of 25 questions improved from 13.6 ± 2.4 to 19 ± 1.2. The survey shows that the physics rotation during the first week of residency is favored by all residents and that 1 week's duration is appropriate. All residents are of the opinion that the intensive workshop would benefit them in upcoming clinical rotations. Residents acknowledge becoming more comfortable regarding the use of radiation and providing counsel regarding radiation during pregnancy. Conclusions An immersive, short-duration, clinically oriented physics rotation is well received by new or less experienced radiology trainees, correlates basic physics concepts with their relevance to clinical imaging, and more closely parallels expectations of the American Board of Radiology Core Examination.

Existing surveys of radiopharmaceutical doses for U.S. nuclear medicine laboratories are of limited scope and size. Dose data are important because they can be used to benchmark individual laboratories, understand geographic variations in practice, and provide source data for societal guidelines and appropriateness criteria. Diagnostic reference levels (DRLs) and achievable administered activities (AAAs) for 13 noncardiac adult gamma camera and PET/CT examinations were derived retrospectively from American College of Radiology accreditation data (January 1, 2015, to December 31, 2017). The calculated DRL and AAA are consistent with previously published surveys. The distributions of radiopharmaceutical doses across facilities are in general consistent but show variation within a particular examination. Analysis of dose distribution suggests this variation results from differences in clinical protocols, educational gaps, and/or equipment factors. The AAA for the surveyed facilities exceeds dose ranges proposed in societal practice guidelines for several common nuclear medicine studies. Compared with similar surveys from Europe and Japan, geographic variation is observed, with some doses greater and others lower than used in the United States. Overall, radiopharmaceutical dose variation within the United States and internationally, and deviation from societal guidelines, imply that these dose-related benchmarks may be used to further standardize and improve clinical practice.

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

Women are, and have always been, underrepresented in radiology. This gender disparity must be addressed. Women bring a different perspective to the workplace; and their collaborative, empathetic, and compassionate approach to patient care and education is an asset that the radiology community should embrace and leverage. Radiologic organizations should focus on removing barriers to the entry of women physicians into radiology as a specialty and to their career advancement. Organizations should address bias, promote physician well-being, and cultivate a safe and positive work environment. Radiology leaders committed to increasing gender diversity and fostering an inclusive workplace have the opportunity to strengthen their organizations. This article outlines the key steps that practice leaders can take to address the needs of women in radiology: (a) marketing radiology to talented women medical students, (b) addressing recruitment and bias, (c) understanding and accommodating the provisions of the Family and Medical Leave Act of 1993 and the Fair Labor Standards Act for both trainees and radiologists in practice, (d) preventing burnout and promoting well-being, (e) offering flexible work opportunities, (f) providing mentorship and career advancement opportunities, and (g) ensuring equity. ©RSNA, 2018.

Founded in 1951, the Joint Commission, formerly known as the Joint Commission on Accreditation of Healthcare Organizations and, previous to that, the Joint Commission on Accreditation of Hospitals, is a United States–based nonprofit organization that accredits more than 20,000 health care

Purpose In 2011, the ACGME Nuclear Medicine (NM) Residency Review Committee revised the NM program requirements, which increased CT training for NM residents. This article examines the effect of this revision. Methods Requests were e-mailed to all NM program directors asking that their residents be given the opportunity to complete an online survey regarding their CT training. Subsequently, an identical online survey regarding CT training was e-mailed directly to all members of the NM Residents Organization of the American College of NM asking that they complete the survey regarding their CT training if they had not already done so. Results Resident responses, compared with those from a similar 2011 survey, indicate a perception that CT training and CT expertise gained in ACGME-accredited NM programs have improved. However, some NM residents are not provided with the opportunity to develop critical skills in interpreting and dictating CT scans during their time on dedicated CT services. The survey indicates that experience gained during NM residency in head and neck/neuroradiology, emergency, and musculoskeletal CT is marginal at best. A slight majority felt that CT training should be further increased. Conclusions Compared with a 2011 survey of NM residents and the 2011 implementation of expanded CT training requirements, a follow-up survey seems to indicate improvement in CT training for most NM residents. Nevertheless, an opportunity clearly remains to further improve the breadth and depth of CT skills during NM residency. However, whether such an improvement will result in a reversal of multiyear downward trends in the number of NM residents and training programs in the United States is not clear.

Processes for credentialing physicians and criteria used for delineating their practice-specific clinical privileges vary widely across the United States. The ACR and the ABR have jointly developed this resource document to define the requisite credentials for specialty board-certified diagnostic radiologists and subspecialty board-certified nuclear radiologists to be privileged to practice therapeutic nuclear medicine. Through its initial specialty and subspecialty certification processes and its maintenance of certification programs for practicing certificate holders, the ABR assures the competence of its professional diplomates for clinical practice. On the basis of their education, training, and clinical work experience, board-certified radiologists have the qualifications to supervise and perform therapies using unsealed radioisotopes. Optimum patient care is best served by a physician with training and expertise in supervising and performing radioisotope therapies in conjunction with multimodality imaging technologies for initial diagnosis and follow-up.

There has been much consternation in the nuclear medicine (NM) community in recent years regarding the difficulty many NM graduates experience in securing initial employment. A survey designed to determine the extent and root causes behind the paucity of career opportunities was sent to all 2010-2011 NM residency program directors. The results of that survey and its implications for NM trainees and the profession are presented and discussed in this article.

OBJECTIVE. During the 20th century, radiologists enjoyed relationships with clinicians and patients through daily face-to-face communication. As specialist consultants, radiologists were naturally integral members of the care team. CONCLUSION. The widespread availability of information technology, notably PACS, has disrupted the fundamental radiologist-clinician axis. New generations of radiologists must respond to this disturbing trend by (re)learning how to “add value” by rekindling personal professional relationships, developing global leadership skills, and becoming involved in health care system design and implementation.

The reader should now be familiar with the technical principles behind image acquisition and should understand the general guidelines regarding interpretation of noncardiac findings during SPECT MPI. Section IV contains 36 challenging cases that the reader can use for reinforcement of learned knowledge and application of interpretative skills. Within this self-assessment section, there are three chapters, each with 12 cases, which have increasing levels of complexity and difficulty: basic (Chap. 27), intermediate (Chap. 28), and advanced (Chap. 29).

The small intestine is always visualized due to the normal hepatobiliary clearance of the99mTc MPI radiopharmaceuticals. Duodenogastric reflux of radioactive bile and “hot” jejunal activity can cause reconstruction processing artifacts. The large intestine may be seen if intestinal motility is relatively rapid, or there is a long interval between injection and imaging.

A pericardial effusion often appears as a “cold halo” surrounding the heart. Visualization of a pericardial effusion should prompt personal communication with the referring physician and be included in the report.

Uptake of SPECT MPI radiopharmaceuticals within the thin-walled right atrium itself, and more focally within the right auricular appendage, is normal. Avid uptake within the right ventricular free wall, particularly when associated with a flattened septum and D-shaped left ventricle, is consistent with pulmonary hypertension and RV hypertrophy. Prominent uptake within the right ventricular myocardium after exercise stress could signify RV strain and left heart failure due to severe multivessel CAD.

The gallbladder should fill with radioactive bile and appear “hot”; it is often the “hottest” finding in the field-of-view. When superiorly displaced, the “hot” gallbladder can create a processing artifact on the reconstructed SPECT MPI. The degree of gallbladder visualization can vary between rest and stress imaging on both 1-day and 2-day protocols and is dependent on the fasting state of the patient. The gallbladder is usually well-distended in the fasting state; a contracted gallbladder is considered abnormal. Non-visualization of the gallbladder, if not surgically absent, or a distended “cold” gallbladder signifies underlying gallbladder disease; such findings warrant clinical correlation and communication with the referring physician. Radioactivity in the small intestine excludes high-grade or complete common bile duct obstruction.

The reader should now be familiar with the technical principles behind image acquisition and should understand the general guidelines regarding interpretation of noncardiac findings during SPECT MPI. Section IV contains 36 challenging cases that the reader can use for reinforcement of learned knowledge and application of interpretative skills. Within this self-assessment section, there are three chapters, each with 12 cases, which have increasing levels of complexity and difficulty: basic (Chap. 27), intermediate (Chap. 28), and advanced (Chap. 29).

The reader should now be familiar with the technical principles behind image acquisition and should understand the general guidelines regarding interpretation of noncardiac findings during SPECT MPI. Section IV contains 36 challenging cases that the reader can use for reinforcement of learned knowledge and application of interpretative skills. Within this self-assessment section, there are three chapters, each with 12 cases, which have increasing levels of complexity and difficulty: basic (Chap. 27), intermediate (Chap. 28), and advanced (Chap. 29).

A least a portion of the left kidney is generally included in the field-of-view and readily visualized; the right kidney is often difficult to visualize on a 180° acquisition. Increased renal activity is associated with liver failure because the kidneys are the secondary route of clearance of the99mTc MPI radiopharmaceuticals. “Hot” or “cold” defects within the kidneys are abnormal and require correlative imaging. Displacement of neighboring organs can result from large renal or pelvic masses.