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## Complete Summary

#### GUIDELINE TITLE

Acute respiratory illness in HIV-positive patients.

#### BIBLIOGRAPHIC SOURCE(S)

Haramati LB, Davis SD, Goodman PC, Khan A, Leung AN, McLoud TC, Rosado
de Christenson ML, Rozenshtein A, White CS, Kaiser LR, Raoof S, Expert
Panel on Thoracic Imaging. Acute respiratory illness in HIV-positive
patients. \[online publication\]. Reston (VA): American College of
Radiology (ACR); 2005. 6 p. \[34 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American College of Radiology
(ACR), Expert Panel on Thoracic Imaging. Acute respiratory illness in
HIV-positive patients. Reston (VA): American College of Radiology (ACR);
2003. 5 p. (ACR appropriateness criteria).

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Acute respiratory illness (including *Pneumocystis jiroveci*
    pneumonia, bacterial and viral pneumonia, tuberculosis, Kaposi
    sarcoma, and lymphadenopathy)

-   Human immunodeficiency virus (HIV) infection

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation

#### CLINICAL SPECIALTY

Family Practice\
Infectious Diseases\
Internal Medicine\
Nuclear Medicine\
Pulmonary Medicine\
Radiology

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of initial radiologic examinations of
acute respiratory illness in human immunodeficiency virus (HIV)-positive
patients

#### TARGET POPULATION

Human immunodeficiency virus (HIV)-positive patients with acute
respiratory illness

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  X-ray

2.  Computer tomography (CT)

3.  Nuclear medicine (NUC)

    -   Gallium 67 scan

    -   Diethylene triamine pentaacetic acid-Technetium (DTPA-Tc) scan

    -   Thallium scan

#### MAJOR OUTCOMES CONSIDERED

Utility (i.e., sensitivity, specificity) of radiologic examination
procedures in differential diagnosis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of peer-reviewed
medical journals, and the major applicable articles were identified and
collected.

#### NUMBER OF SOURCE DOCUMENTS

The total number of source documents identified as the result of the
literature search is not known.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed to reach agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by the participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1 to 9, indicating the most to the least appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by the Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**[Clinical Condition]{.underline}: Acute Respiratory Illness in HIV +
Patient**

**[Variant 1]{.underline}: Asymptomatic.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, chest         2                    

  CT, chest            2                    

  NUC, lung, gallium   2                    
  67 scan                                  

  NUC, lung, DTPA-Tc   2                    
  scan                                     

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**[Variant 2]{.underline}: Cough, dyspnea, chest pain, fever.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, chest         9                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

**[Variant 3]{.underline}: Negative, equivocal, or nonspecific chest
radiograph.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, chest            8                    

  NUC, lung, gallium   2                    
  67 scan                                  

  NUC, lung, DTPA-Tc   2                    
  scan                                     

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**[Variant 4]{.underline}: Positive chest radiograph, diffuse
infiltrates.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, chest            4                    

  NUC, lung, gallium   2                    
  67 scan                                  

  NUC, lung, DTPA-Tc   2                    
  scan                                     

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**[Variant 5]{.underline}: Positive chest radiograph, infection other
than PCP suspected.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, chest            4                    

  NUC, lung, gallium   2                    
  67 scan                                  

  NUC, lung, DTPA-Tc   2                    
  scan                                     

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**[Variant 6]{.underline}: Positive chest radiograph, noninfectious
disease suspected.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, chest            8                    

  NUC, lung, thallium  2                    
  scan                                     

  NUC, lung, gallium   2                    
  67 scan                                  

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

Acute respiratory illness (ARI) constitutes a group of signs and
symptoms that develop over a brief interval (hours to weeks), some of
which are constitutional such as fever, chills, and weight loss, and
some of which are organ specific such as cough, shortness of breath, and
chest pain. In human immunodeficiency virus (HIV)-infected individuals
with ARI, a wide variety of diseases can have similar presentation.
Clinical and demographic factors that help to rank the differential
diagnosis include the degree of immunosuppression as reflected by the
patients\' CD4 cell count, whether or not they are being treated with
highly active antiretroviral therapy (HAART), their country or region of
origin and travel history, and their HIV risk factor. Radiographic
findings play a role in narrowing the differential diagnosis and in
guiding further diagnostic testing or procedures.

The chest radiograph is a basic and widely accepted diagnostic imaging
tool in HIV-infected patients. When an HIV-infected patient presents
with ARI, after obtaining the history and performing a physical
examination, obtaining a chest radiograph is usually the next step. The
vast majority of processes that cause ARI in HIV-infected individuals
are associated with chest radiographic abnormalities, and several
studies support obtaining an initial chest radiograph in HIV-infected
patients with an ARI.

The nature and distribution of pulmonary findings on the chest
radiograph will often suffice in suggesting a diagnosis or differential
diagnosis. Bacterial pneumonia caused by infection with the usual
organisms is the most common cause of ARI in acquired immune deficiency
syndrome (AIDS) patients. The chest radiographic finding of focal or
multifocal consolidation associated with fever, sputum production, and
leukocytosis is usually diagnostic. Viral pneumonia can also present
with bilateral reticular opacities on chest radiographs. If the viral
infection is cytomegalovirus, there will often be cytomegalovirus
infection in other organs (e.g., retinitis, esophagitis), and the
patients will have very low CD4 counts (less than 50/mm^3^). On CT,
cytomegalovirus will often demonstrate small, ill-defined nodules,
peribronchial thickening, and foci of bronchiectasis. Congestive heart
failure due to AIDS cardiomyopathy can also show reticular interstitial
opacities. If bilateral nodular or reticular opacities are present
without lymphadenopathy or pleural effusion and the CD4 count is less
than 200/mm^3^, a diagnosis of Pneumocystis jiroveci pneumonia (PCP) can
be suggested. Several studies found that the severity of the
radiographic abnormality correlated with both severity of illness and
mortality in patients with PCP.

It is now accepted that a normal or only subtly abnormal chest
radiograph can occasionally occur in patients with tuberculosis,
cytomegalovirus pneumonia, and PCP among other processes. If there is a
high clinical suspicion of a pulmonary infection in the setting of a
normal chest radiograph, a CT may be warranted to assess for subtle
abnormalities. Miliary or disseminated tuberculosis or nodal disease can
be readily evident on CT in the face of a normal or near-normal chest
radiograph. Small airways disease with mild bronchiectasis,
peribronchial thickening, foci of mucoid impaction, and air trapping may
be evident only on CT. Patients who have a normal chest radiograph and
PCP will usually have focal areas of ground glass opacity evident on CT.

Exercise desaturation, an elevated lactate dehydrogenase (LDH), and a
low diffusion capacity are all associated with PCP and add supportive
evidence to a typical chest radiographic appearance. Sputum induction
will often confirm the diagnosis. In the setting of a negative sputum
induction, some practices treat empirically for PCP if the chest
radiographic and clinical findings are typical. Otherwise, fiberoptic
bronchoscopy (FOB) with bronchoalveolar lavage and/or biopsy is the
usual practice. One group of researchers proposed some compelling
arguments for using CT early in the diagnostic evaluation of PCP. When
the presence or absence of ground glass opacity on CT was used as the
diagnostic criterion, patients were classified as \"possible PCP\" or
\"not PCP.\" CT had a high sensitivity and specificity. This is
supported by the findings of one study that found ground glass,
reticular, and cystic changes in the lung on high resolution CT (HRCT)
in patients with PCP. In contrast, those with tree-in-bud nodules had
other diagnoses. The authors concluded that patients with \"possible
PCP\" should go on to direct testing, (induced sputum, bronchoalveolar
lavage) whereas a diagnosis of \"not PCP\" can be used to avoid empiric
treatment and direct testing. They also point out that CT has higher
sensitivity and specificity and is cheaper than gallium scanning and
provides an immediate result, in contrast to the 48 to 72-hour delay for
gallium. There is, however, literature supporting the utility of
performing DTPA-Tc and gallium 67 lung scans in patients with suspected
PCP and negative or atypical chest radiographs. In two different
studies, gallium lung scans were positive (94% and 100%, respectively)
in patients with PCP. In another study, the researchers noninvasively
detected 34 of 36 patients with PCP using a combination of DTPA lung
scanning while inducing sputum and were thus able to reduce the need for
bronchoscopy.

CT is widely accepted when noninfectious AIDS-related intrathoracic
diseases are suspected, when the chest radiograph shows findings
atypical for PCP, or when FOB is not diagnostic. The CT findings can
frequently suggest the diagnosis or at least limit the diagnostic
possibilities, and may identify optimal sites for obtaining a biopsy.
According to another group of researchers, in a series of 128 AIDS
patients, they found that CT was 93% accurate in excluding disease and
94% and 93% accurate in rendering confident diagnoses of PCP and Kaposi
sarcoma, respectively. Another study demonstrated the utility of
thallium and gallium scanning for diagnosing Kaposi sarcoma. In this
series, a thallium-positive, gallium-negative pattern had a high
specificity of 95% for the diagnosis of Kaposi sarcoma. However, the
sensitivity decreased from 89% to 37% in patients who had opportunistic
infections.

If lung nodules or masses with or without cavitation are present on the
chest radiograph and the sputum is unrevealing, a chest CT should be
performed. CT better delineates the distribution and morphology of the
parenchymal disease. CT also has an advantage in demonstrating
associated hilar and mediastinal lymphadenopathy, which may alter the
differential diagnosis. The differential diagnosis for lung nodules and
masses depends in part on the patient\'s immune status and HIV risk
factors. Bacterial infection can occur at any level of immunity,
although its frequency increases as CD4 declines, and it occurs more
often in HIV-infected patients whose risk factor was intravenous drug
use. In one series of studies, bacterial infection was the most common
etiology of lung nodules seen on CT. Tuberculosis was second. In areas
where fungal infections are endemic, that diagnosis rises in the
differential diagnosis. The authors noted that nodule size less than
1cm, fever, and cough favored an infectious etiology for the nodules.
Neoplasms also can cause nodules and masses. Kaposi sarcoma has its
highest prevalence in HIV-infected gay men. In that population,
especially if the patient has a low CD4 count and cutaneous or
oropharyngeal Kaposi sarcoma, lung nodules and masses will often be due
to Kaposi sarcoma. The radiographic findings can mimic infection.
Acutely, patients with Kaposi sarcoma can present with hemoptysis. FOB
with bronchial inspection will reveal the typical violaceous
endobronchial Kaposi sarcoma lesions in most cases. AIDS-related
lymphoma is predominantly an extranodal disease. Lung nodules and masses
are often present if there is thoracic involvement. These patients are
often acutely ill with \"B\" symptoms. CT will often show
lymphadenopathy or abdominal visceral involvement that is not evident on
the chest radiograph.

Lymphadenopathy may be evident on chest radiographs, although CT is much
more sensitive in its detection. When an HIV-infected patient is acutely
ill and has lymphadenopathy, the differential diagnosis includes
tuberculosis, other mycobacterial infections, fungal infection, and
lymphoma among more common etiologies. In patients with tuberculosis who
are evaluated with contrast-enhanced CT, central low attenuation
lymphadenopathy is highly suggestive of the correct diagnosis. The
pattern of associated parenchymal and pleural disease, described above,
will also help prioritize the differential diagnosis.

Pleural effusions are rarely present in patients with PCP. Bacterial
pneumonia, tuberculosis, and fungal infections all can be associated
with pleural effusions. Kaposi sarcoma may have effusions in the later
stages. Kaposi sarcoma effusions are often hemorrhagic. Pleural
involvement with AIDS-related lymphoma is not rare. Patients may have
effusions or masses. While the chest radiograph is usually adequate to
demonstrate the presence of a pleural effusion, if the patient does not
respond to antibiotic therapy or develops a complicated effusion, CT may
be helpful in guiding the choice of a site for biopsy or drainage.

**Recommendation**

Chest radiography is indicated early in the evaluation of AIDS patients
with ARI. Most respiratory diseases will be associated with abnormal
chest radiographic findings. If the radiograph is normal or equivocal
and clinical suspicion for disease is high, CT can be performed to
evaluate for subtle pulmonary abnormalities and lymphadenopathy. CT also
plays a role in weighting a differential diagnosis and guiding
diagnostic and therapeutic procedures in those with abnormal chest
radiographs. Nuclear scintigraphy, including gallium 67 and DTPA-Tc, can
be helpful in diagnosing PCP, and the combination of thallium and
gallium scanning has shown utility in the diagnosis of Kaposi sarcoma.

**Abbreviations**

-   CT, computed tomography

-   NUC, nuclear medicine

-   DTPA-Tc, Diethylenetriamine pentaacetic acid-Technetium

-   PCP, *Pneumocystis jiroveci* pneumonia

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Selection of appropriate radiographic imaging procedures for evaluation
of human immunodeficiency virus (HIV)-positive patients with acute
respiratory illness

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (ACR) Committee on Appropriateness
Criteria and its expert panels have developed criteria for determining
appropriate imaging examinations for diagnosis and treatment of
specified medical condition(s). These criteria are intended to guide
radiologists, radiation oncologists, and referring physicians in making
decisions regarding radiologic imaging and treatment. Generally, the
complexity and severity of a patient\'s clinical condition should
dictate the selection of appropriate imaging procedures or treatments.
Only those exams generally used for evaluation of the patient\'s
condition are ranked. Other imaging studies necessary to evaluate other
co-existent diseases or other medical consequences of this condition are
not considered in this document. The availability of equipment or
personnel may influence the selection of appropriate imaging procedures
or treatments. Imaging techniques classified as investigational by the
U.S. Food and Drug Administration (FDA) have not been considered in
developing these criteria; however, study of new equipment and
applications should be encouraged. The ultimate decision regarding the
appropriateness of any specific radiologic examination or treatment must
be made by the referring physician and radiologist in light of all the
circumstances presented in an individual examination.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Haramati LB, Davis SD, Goodman PC, Khan A, Leung AN, McLoud TC, Rosado
de Christenson ML, Rozenshtein A, White CS, Kaiser LR, Raoof S, Expert
Panel on Thoracic Imaging. Acute respiratory illness in HIV-positive
patients. \[online publication\]. Reston (VA): American College of
Radiology (ACR); 2005. 6 p. \[34 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 (revised 2005)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

The American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Thoracic Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Linda B. Haramati, MD (*Principal Author*); Sheila D.
Davis, MD (*Panel Chair*); Philip C. Goodman, MD; Arfa Khan, MD; Ann N.
Leung, MD; Theresa C. McLoud, MD; Melissa L. Rosado de Christenson, MD;
Anna Rozenshtein, MD; Charles S. White, MD; Larry R. Kaiser, MD; Suhail
Raoof, MBBS

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American College of Radiology
(ACR), Expert Panel on Thoracic Imaging. Acute respiratory illness in
HIV-positive patients. Reston (VA): American College of Radiology (ACR);
2003. 5 p. (ACR appropriateness criteria).

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonThoracicImaging/AcuteRespiratoryIllnessinHIVPositivePatientsDoc2.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on November 12, 2004. The
information was verified by the guideline developer on December 21,
2004. This summary was updated by ECRI on March 22, 2006.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008