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Purpose of review Late-onset Fuchs endothelial corneal dystrophy (FECD) is seen in approximately 4% of individuals over the age of 40. With the growing population of adults over the age of 65, ophthalmologists need to be aware of the preoperative, perioperative, and postoperative considerations involved in cataract surgery in Fuchs patients. Recent findings Management of cataract patients with FECD requires preoperative assessment of endothelial cell size, density, and morphology. Considerations for perioperative endothelial cell loss include patients with hyperopia and shallow anterior chambers, phacoemulsification technique, transfer of ultrasonic energy to the cornea, corneal-protective perioperative agents, as well as thermal and mechanical damage. Summary Ophthalmologists performing cataract surgery on patients with FECD must carefully consider the risks of endothelial cell loss during surgery and minimize the risk of corneal decompensation after surgery. Preoperative management should evaluate the severity of the FECD as well as individual factors such as cataract density, the health and thickness of the cornea, and the anterior chamber depth. Perioperative techniques, adjustments to biometry calculations, and intraocular lens (IOL) selection may help optimize visual outcomes and recovery time.

Majid Moshirfar,1– 3 James Ellis,4 Daniel Beesley,5 Shannon E McCabe,1,6 Adam Lewis,7 William B West Jnr,4 Yasmyne Ronquillo,1 Phillip Hoopes Snr1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4University of Utah School of Medicine, Salt Lake City, UT, USA; 5Brigham Young University, Provo, UT, USA; 6Mission Hills Eye Center, Pleasant Hill, CA, USA; 7Kansas City University College of Osteopathic Medicine, Kansas City, MO, USACorrespondence: Majid MoshirfarHoopes Vision Research Center, Hoopes Vision, Draper, UT, USATel +1 801-568-0200Fax +1 801-563-0200Email cornea2020@me.comPurpose: To compare the visual performance of the AcrySof IQ PanOptix trifocal intraocular lens and the TECNIS Symfony extended depth-of-focus lens at near and distance visual ranges.Methods: A total of 146 patients (221 eyes) who underwent phacoemulsification and cataract extraction and received either a PanOptix or Symfony lens from January 2019 to July 2020 were included in the study (83 PanOptix non-toric, 30 PanOptix toric, 70 Symfony non-toric, and 38 Symfony toric). Uncorrected distance (UDVA), uncorrected near (UNVA), and corrected distance (CDVA) visual acuity were assessed at one-day, one-month, and three-months postoperatively. Averages of UDVA, UNVA, and CDVA were taken to evaluate which lens was superior at near and distance visual ranges. Secondary outcome measures including glare, halo, dryness, and problems with night vision were documented at each postoperative visit.Results: At one month postoperatively, the average UNVA was 0.16 ± 0.14 logMAR in the PanOptix group and 0.21 ± 0.14 logMAR in the Symfony group (P=0.007); the average UDVA for the PanOptix group was 0.09 ± 0.13 logMAR compared to the Symfony group at 0.10 ± 0.14 logMAR (P=0.67); and the average CDVA was 0.02 ± 0.05 logMAR in the PanOptix group and 0.00 ± 0.04 logMAR in the Symfony group (P=0.11). At three months postoperatively, there were no statistically significant differences in UNVA, UDVA, or CDVA between the two groups (P=0.18, 0.79, 0.68 respectively). There was no statistically significant difference in secondary outcome measures at one- and three-months (P=0.49, 0.10 respectively).Conclusion: The AcrySof IQ PanOptix trifocal intraocular lens appears to afford better UNVA compared to the TECNIS Symfony extended depth-of-focus intraocular lens at one-month postoperatively, though this difference was not seen at three months postoperatively. There is no statistically significant difference in UDVA and CDVA between the two groups at postoperative day one, one-month, and three-months.Keywords: visual acuity, intraocular lens, trifocal lens, extended depth-of-focus lens

Majid Moshirfar,1– 3 Nour Bundogji,4 Alyson N Tukan,4 James H Ellis,5 Shannon E McCabe,1,6 Ayesha Patil,5 Yasmyne C Ronquillo,1 Phillip C Hoopes1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, 84020, USA; 2John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA; 5University of Utah School of Medicine, Salt Lake City, UT, USA; 6Mission Hills Eye Center, Pleasant Hill, CA, USACorrespondence: Majid MoshirfarMedical Director Hoopes Vision Research Center, Hoopes Vision Research Center, 11820 S. State Street Suite #200, Draper, UT, 84020, USATel +1 801-568-0200Fax +1 801-563-0200Email cornea2020@me.comPurpose: To report visual outcomes following surgical correction of myopic astigmatism with Visian Toric implantable collamer lens (ICL) (STAAR Surgical, Monrovia, CA, USA) at a single tertiary refractive center in the United States.Patients and Methods: Toric ICL was implanted in 96 eyes (55 patients) with mean preoperative sphere of − 8.98 ± 3.04 diopters (D) and cylinder of − 2.67 ± 1.02 D from December 2018 to February 2021. Primary visual outcomes of efficacy, safety, stability, predictability of refractive correction, and astigmatic analysis were reported at three and twelve months postoperatively. Secondary subjective outcomes included patient-reported dry eye symptoms and glare/halos at postoperative visits. Other secondary outcomes were biometric data and postoperative vault over time.Results: At three and twelve months, 75 and 46 eyes were evaluated, respectively. At twelve months, the mean manifest refraction spherical equivalent (MRSE) was − 0.23 ± 0.47 D with 93% achieving within ± 1.00 D of target refraction. The manifest refractive cylinder (MRC) at twelve months was − 0.73 ± 0.51 D, with 86% within ± 1.00 D of target. Uncorrected distance visual acuity (UDVA) was 20/20 or better in 74% of eyes at twelve months. No patients lost ≥ 2 lines of corrected distance visual acuity (CDVA) at twelve months. The mean angle of error was − 0.9 ± 10.2° at three months and − 1.6 ± 12.8° at twelve months. One patient required bilateral lens rotation, four patients underwent secondary enhancement with LASIK/PRK, and seven patients underwent postoperative limbal relaxing incisions.Conclusion: This initial single-site experience finds Toric ICL implantation for myopic astigmatism to be safe and effective. Patients can achieve markedly improved UDVA in a single surgery with stable vision over time and minimal adverse subjective symptoms.Keywords: Toric ICL, visian, myopic astigmatism, visual outcomes

Cystic renal cell carcinoma (RCC) is almost certainly overdiagnosed and overtreated. Efforts to diagnose and treat RCC at a curable stage result in many benign neoplasms and indolent cancers being resected without clear benefit. This is especially true for cystic masses, which compared with solid masses are more likely to be benign and, when malignant, less aggressive. For more than 30 years, the Bosniak classification has been used to stratify the risk of malignancy in cystic renal masses. Although it is widely used and still effective, the classification does not formally incorporate masses identified at MRI or US or masses that are incompletely characterized but are highly likely to be benign, and it is affected by interreader variability and variable reported malignancy rates. The Bosniak classification system cannot fully differentiate aggressive from indolent cancers and results in many benign masses being resected. This proposed update to the Bosniak classification addresses some of these shortcomings. The primary modifications incorporate MRI, establish definitions for previously vague imaging terms, and enable a greater proportion of masses to enter lower-risk classes. Although the update will require validation, it aims to expand the number of cystic masses to which the Bosniak classification can be applied while improving its precision and accuracy for the likelihood of cancer in each class.

Majid Moshirfar,1– 3 Adam L Lewis,4 James H Ellis,5 Shannon E McCabe,1,6 Yasmyne C Ronquillo,1 Phillip C Hoopes Sr1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4Kansas City University, Kansas City, MO, USA; 5University of Utah School of Medicine, Salt Lake City, UT, USA; 6Mission Hills Eye Center, Pleasant Hill, CA, USACorrespondence: Majid MoshirfarMedical Director Hoopes Vision Research Center, Hoopes Vision, 11820 S. State Street Suite #200, Draper, UT, 84020, USATel +1 801-568-0200Fax +1 801-563-0200Email cornea2020@me.comIntroduction: Retained lens fragments in the anterior chamber following cataract extraction (CE) with phacoemulsification are rare but can lead to significant patient morbidity. Our study aimed to identify risk factors associated with retained lens fragments.Methods: Patients who underwent cataract surgery and subsequently identified to have retained lens fragments in the anterior segment were included. Incidence per year, patient demographics, visual acuity, ocular biometrics, surgical technique, surgeon performing CE, and outcomes were collected retrospectively and compared to a control group.Results: Twenty-four patients were identified with retained lens fragments, with an incidence of 0.10%. The mean age was 76 years ± 6.72 (60– 80) compared to 63 ± 11.41 (22– 86) in the control group (p < 0.001). Patients with UDVA 20/150 or worse experienced a greater average improvement in visual acuity compared to patients with UDVA better than 20/150 (logMAR 0.46 vs logMAR 0.05). The mean intraocular pressures before (CE), after CE but before fragment removal, and following fragment removal were 14 mmHg ± 2.59, 19 mmHg ± 8.20, and 11 mmHg ± 2.75, respectively. Twenty-two patients presented with inferiorly located fragments. Statistically significant biometrics include mean anterior chamber depth (3.1 mm ± 0.37 vs 3.33 mm ± 0.39, p = 0.01) and lens thickness (4.77 mm ± 0.44 vs 4.35 mm ± 0.44, p = < 0.001). Yearly incidence rates per surgeon ranged from 0.00% to 0.85%. In 2003 and 2004, one surgeon had significantly higher incidence rates (0.31 and 0.40%) compared to the average combined rate of all surgeons throughout the study (0.10), with p values of 0.001 and 0.003, respectively. The mean number of days between CE and fragment removal was 26 ± 40 (1– 138).Conclusion: Increased patient age, shallow anterior chamber depth, and thick lens may be risk factors for retained lens fragments. There may be additional surgeon-specific risk factors. Phacoemulsification technique (Divide-and-Conquer versus Horizontal Chop) showed no significant difference.Keywords: retained lens fragments, phacoemulsification, cataract surgery, complications of cataract surgery, refractory corneal edema

Purpose The purpose of this study was to evaluate the frequency, indications, and findings of abdominal CTs ordered in the initial evaluation of patients who had a positive COVID-19 test performed in our institution. Methods Retrospective chart review was performed on all patients who had a positive test for COVID-19 performed at a single quaternary care center from 1/20/2020 through 5/8/2020. In a subset of patients undergoing abdominal CT as part of the initial evaluation, the demographics, suspected COVID-19 status at the time of scan, presenting complaints, and abdominal CT findings were recorded. Cardiothoracic radiologists reviewed and scored the visualized lung bases for the likelihood of COVID-19. Results Only 43 (4.1%) of 1057 COVID-19 patients presented with abdominal complaints sufficient to warrant an abdominal CT. Of these 43 patients, the vast majority (39, 91%) were known or suspected to have COVID-19 at the time of the scan. Most (27/43, 63%) scans showed no acute abdominal abnormality, and those that were positive did not share a discernable pattern of abnormalities. Lung base abnormalities were common, and there was moderate inter-reviewer reliability. Conclusion A minority of COVID-19 patients present with abdominal complaints sufficient to warrant a dedicated CT of the abdomen, and most of these studies will be negative or have abdominal findings not associated with COVID-19. Appropriate lung base findings are a more consistent indication of COVID-19 infection than abdominal findings.

Gadolinium-based contrast agents (GBCAs) have revolutionized MRI, enabling physicians to obtain crucial life-saving medical information that often cannot be obtained with other imaging modalities. Since initial approval in 1988, over 450 million intravenous GBCA doses have been administered worldwide, with an extremely favorable pharmacologic safety profile; however, recent information has raised new concerns over the safety of GBCAs. Mounting evidence has shown there is long-term retention of gadolinium in human tissues. Further, a small subset of patients have attributed a constellation of symptoms to GBCA exposure, although the association of these symptoms with GBCA administration or gadolinium retention has not been proven by scientific investigation. Despite evidence that macrocyclic GBCAs show less gadolinium retention than linear GBCAs, the safety implications of gadolinium retention are unknown. The mechanism and chemical forms of gadolinium retention, as well as the biologic activity and clinical importance of these retained gadolinium species, remain poorly understood and underscore the need for additional research. In February 2018, an international meeting was held in Bethesda, Md, at the National Institutes of Health to discuss the current literature and knowledge gaps about gadolinium retention, to prioritize future research initiatives to better understand this phenomenon, and to foster collaborative standardized studies. The greatest priorities are to determine (a) if gadolinium retention adversely affects the function of human tissues, (b) if retention is causally associated with short- or long-term clinical manifestations of disease, and (c) if vulnerable populations, such as children, are at greater risk for experiencing clinical disease. The purpose of the research roadmap is to highlight important information that is not known and to identify and prioritize needed research. ©RSNA, 2018 Online supplemental material is available for this article .

The purpose of this study was to determine whether individual radiologists are predictive of important relevant health outcomes among emergency department (ED) patients undergoing abdominopelvic CT for right lower quadrant pain.This single-institution retrospective cohort study included 2169 patients undergoing abdominopelvic CT for right lower quadrant pain in the ED from February 1, 2012, through August 31, 2016. CT examinations were interpreted by 15 radiologists (four emergency, 11 abdominal) who each reported on more than 70 CT examinations in the cohort. After risk adjustment for covariates thought to influence outcome, including baseline risk (demographics, 30 Elixhauser comorbidities, number of previous ED visits), clinical factors (vital signs, triage and pain scores, laboratory data), and system factors (time of CT, resident involvement, attending physician experience), multivariable models were built to analyze the effect of individual radiologists on four important health outcomes: hospital admission (primary outcome), readmission within 30 days, abdominal surgery, and image-guided percutaneous aspiration or drainage.Radiologists had a mean experience of 14 years (range, 2-36 years) and read a mean of 145 CT examinations in the study cohort (range, 73-253 examinations). Unadjusted event rates across the 15 radiologists were 38-55% (admission), 11-21% (readmission), 10-26% (surgery), and 0-3% (aspiration or drainage). After risk adjustment, individual radiologists were not a significant multivariable predictor of hospital admission, readmission within 30 days, abdominal surgery, or image-guided abdominal percutaneous aspiration or drainage (all p0.05).Individual radiologists were indistinguishable both within group and between group by emergency and abdominal specialization for the prediction of major patient outcomes after abdominopelvic CT performed for right lower quadrant pain in the ED.

Rationale and Objective We aimed to determine the frequency and clinical significance of homogeneous renal masses measuring 21–39 Hounsfield units on contrast-enhanced computed tomography (CT). Methods Subjects 40–69 years old undergoing portal-venous-phase contrast-enhanced abdominal CT from January 1, 2006 to December 31, 2010 with slice thickness ≤5 mm and no prior CT or magnetic resonance imaging were identified (n = 1387) for this institutional review board-approved retrospective cohort study. Images were manually reviewed by three radiologists in consensus to identify all circumscribed homogeneous renal masses (maximum of three per subject) ≥10 mm with a measured attenuation of 21–39 Hounsfield units. Exclusion criteria were known renal cancer or imaging performed for a renal indication. The primary outcome was retrospective characterization as a clinically significant mass, defined as a solid mass, a Bosniak IIF/III/IV mass, or extirpative therapy or metastatic renal cancer within 5 years' follow-up. Results Eligible masses (n = 74) were found in 5% (63/1387) of subjects. Of those with a reference standard (n = 42), none (0% [95% CI: 0.0%–8.4%]) were determined to be clinically significant. Conclusion Incidental renal masses on contrast-enhanced CT that are homogeneous and display an attenuation of 21–39 Hounsfield units are uncommon in patients 40–69 years of age, unlikely to be clinically significant, and may not need further imaging evaluation. If these results can be replicated in an independent and larger population, the practical definition of a benign cyst on imaging may be able to be expanded.

Purpose To determine if the allergic-like breakthrough reaction rate of intravenous corticosteroid prophylaxis administered 5 hours before contrast material-enhanced computed tomography (CT) is noninferior to that of a traditional 13-hour oral regimen. Materials and Methods Institutional review board approval was obtained and informed consent waived for this retrospective noninferiority cohort study. Subjects (n = 202) who completed an accelerated 5-hour intravenous corticosteroid premedication regimen before low-osmolality contrast-enhanced CT for a prior allergic-like or unknown-type reaction to iodine-based contrast material from June 1, 2008, to June 30, 2016, were identified. The breakthrough reaction rate was compared by using the Farrington and Manning noninferiority likelihood score to test subjects premedicated with a traditional 13-hour oral regimen (2.1% [13 of 626]). All subjects were premedicated for a prior allergic-like or unknown-type reaction to iodine-based contrast material. A noninferiority margin of 4.0% was selected to allow for no more than a clinically negligible 6.0% breakthrough reaction rate in the cohort that received 5-hour intravenous corticosteroid prophylaxis. Results The breakthrough reaction rate for 5-hour intravenous prophylaxis was 2.5% (five of 202 patients; 95% confidence interval: 0.8%, 5.7%), which was noninferior to the 2.1% (13 of 626 patients; 95% confidence interval: 1.1%, 3.5%) rate for the 13-hour regimen (P = .0181). The upper limits of the confidence interval for the difference between the two rates was 3.7% (0.4%; 95% confidence interval: -1.6%, 3.7%), which was within the 4.0% noninferiority margin. All breakthrough reactions were of equal or lesser severity to those of the index reactions (two severe, one moderate, and one mild reaction). Conclusion Accelerated intravenous premedication with corticosteroids beginning 5 hours before contrast-enhanced CT has a breakthrough reaction rate noninferior to that of a 13-hour oral premedication regimen. © RSNA, 2017.

Purpose To determine the magnitude of subject-level and population-level cost savings that could be realized by moving from fixed-volume low-osmolality iodinated contrast material administration to an effective weight-based dosing regimen for contrast-enhanced abdominopelvic CT. Methods HIPAA-compliant, institutional review board–exempt retrospective cohort study of 6,737 subjects undergoing contrast-enhanced abdominopelvic CT from 2014 to 2015. Subject height, weight, lean body weight (LBW), and body surface area (BSA) were determined. Twenty-six volume- and weight-based dosing strategies with literature support were compared with a fixed-volume strategy used at the study institution: 125 mL 300 mgI/mL for routine CT, 125 mL 370 mgI/mL for multiphasic CT (single-energy, 120 kVp). The predicted population- and subject-level effects on cost and contrast material utilization were calculated for each strategy and sensitivity analyses were performed. Results Most subjects underwent routine CT (91% [6,127/6,737]). Converting to lesser-volume higher-concentration contrast material had the greatest effect on cost; a fixed-volume 100 mL 370 mgI/mL strategy resulted in $132,577 in population-level savings with preserved iodine dose at routine CT (37,500 versus 37,000 mgI). All weight-based iodine-content dosing strategies (mgI/kg) with the same maximum contrast material volume (125 mL) were predicted to contribute mean savings compared with the existing fixed-volume algorithm ($4,053-$116,076/strategy in the overall study population, $1-$17/strategy per patient). Similar trends were observed in all sensitivity analyses. Conclusions Large cost and material savings can be realized at abdominopelvic CT by adopting a weight-based dosing strategy and lowering the maximum volume of administered contrast material.

Objective To review our clinical T1a renal mass active surveillance (AS) cohort to determine whether renal mass biopsy was associated with maintenance of AS. Materials and Methods From our prospectively maintained database we identified patients starting AS from June 2009 to December 2011 who had at least 5 months of radiologic follow-up, unless limited by unexpected death or delayed intervention. The primary outcome was delayed intervention. Clinical, radiologic, and pathologic variables were compared. We constructed Kaplan-Meier survival curves for maintenance of AS. Cox multivariable regression analysis was performed to assess predictors of delayed intervention. Results We identified 118 patients who met criteria for inclusion with a median radiologic follow-up of 29.5 months. The delayed intervention group had greater initial mass size and faster growth rate compared to those who continued AS. Rate of renal mass biopsy was similar between the 2 groups. In the multivariable analysis, size >2 cm (hazard ratio [HR] 3.65, 95% confidence interval [CI] 1.28-10.38, P = .015), growth rate (continuous by mm/year: HR 1.26, 95% CI 1.12-1.41, P P = .29), were associated with increased risk of delayed intervention. Time-to-event curves also showed that size was closely associated with delayed intervention whereas renal mass biopsy was not. Conclusion At our institution, growth rate and initial tumor size appear to be more influential than renal mass biopsy results in determining delayed intervention after a period of AS. Further analysis is required to determine the role of renal biopsy in the management of patients being considered for AS.

OBJECTIVE. The objective of our study was to explore whether clinical factors historically associated with contrast material-causative kidney injury (contrast-induced nephrotoxicity [CIN]) increase risk after use of IV iodinated low-osmolality contrast material (LOCM) in patients with stage IIIb-V chronic kidney disease. MATERIALS AND METHODS. In this retrospective hypothesis-generating study, 1:1 propensity score matching was used to assess post-CT acute kidney injury (AKI) after unenhanced or contrast-enhanced CT in patients with stable estimated glomerular filtration rate (eGFR; 1112 patients with an eGFR = 30-44 mL/min/1.73 m2 and 86 patients with an eGFR < 30 mL/min/1.73 m2 and no dialysis). Historical risk factors including diabetes mellitus, age more than 60 years, hypertension, loop diuretic use, hydrochlorothiazide use, and cardiovascular disease were evaluated for modulation of CIN risk. Stepwise multivariable logistic regression was performed. RESULTS. Overall IV LOCM was an independent risk factor for post-CT AKI in patients with an eGFR of less than 30 mL/min/1.73 m2 (odds ratio, 3.96 [95% CI, 1.29-12.21]; p = 0.016) but not in those with an eGFR of 30-44 mL/min/1.73 m2 (p = 0.24). In patients with an eGFR of less than 30 mL/min/1.73 m2, the tested covariates did not significantly modify the risk of CIN (p = 0.096-0.832). In patients with an eGFR of 30-44 mL/min/1.73 m2, risk of CIN emerged in those with cardiovascular disease (p = 0.015; number needed to harm from LOCM = 11 patients); the other tested cofactors had no significant effect (p = 0.108-0.822). CONCLUSION. CIN was observed when eGFR was less than 30 mL/min/1.73 m2. In those with an eGFR of 30-44 mL/min/1.73 m2, CIN was not observed with LOCM alone but was observed in the presence of cardiovascular disease. Other cofactors historically thought to increase CIN risk (e.g., diabetes mellitus) did not increase risk of CIN. Further study is needed to determine whether these exploratory results are true associations.

To compare the accuracies of renal mass biopsy (RMB) and R.E.N.A.L. nephrometry score (RNS) nomograms for predicting benign vs malignant disease, and low- vs high-risk renal tumors.We included 281 renal masses in 277 patients who had complete RNS, preoperative RMB, and final pathology from renal surgery for clinically localized renal tumors. RMB and final pathology were determined to be benign or malignant, and malignancies were classified as low-risk (Fuhrman grade I/II) or high-risk (Fuhrman grade III/IV) (benign included in low-risk group). Previously published RNS nomograms were used to determine probabilities of any cancer and high-risk cancer. The gamma statistic was used to assess strength of association between RMB or RNS with final pathology.Of the 281 masses, 13 (5%) and 268 (95%) were confirmed benign and malignant, respectively, and 155 (55%) and 126 (45%) were confirmed low-risk and high-risk, respectively, on final pathology. The areas under the curve of the RNS nomograms for benign vs malignant disease and for low-risk vs high-risk renal tumors were 0.56 and 0.64, respectively. Concordances for predicting benign vs malignant disease were 99% for RMB (P .01, gamma 0.99) and 29% for RNS nomogram (P = .16, gamma 0.38). Concordances for predicting low-risk vs high-risk renal tumors were 67% for RMB (P .01, gamma 0.97) and 61% for RNS nomogram (P .01, gamma 0.47), respectively.Although RNS nomograms are useful for discriminating between benign vs malignant renal masses, and low-risk vs high-risk renal tumors, they are outperformed by RMB.

PurposeThe purpose of this study was to determine the frequency in which the pelvis component of an abdominopelvic CT provides information that would influence clinical management in two separate groups of patients: those with previously resected pancreatic ductal adenocarcinoma (PDA) and those with locally advanced unresectable PDA.MethodsThis institutional review-board approved HIPAA compliant retrospective study with waived informed consent included 247 subjects with histologically proven PDA, including 153 subjects post-pancreaticoduodenectomy and 94 subjects with locally advanced unresectable disease. Imaging reports interpreted between January 2005 and December 2013 were obtained from our institution's Radiology Information System by searching a Cancer Registry database of PDA patients separately for the words "whipple" and "unresectable." CT findings were separated by location in the abdomen or pelvis, and subsequently reviewed and graded for their likelihood of representing metastatic disease. The probability of pelvic CT influencing clinical management-i.e., of finding isolated pelvic metastatic disease-was determined using 95% binomial proportion confidence intervals for both the post-pancreaticoduodenectomy and locally advanced unresectable groups.ResultsNo subjects who had undergone pancreaticoduodenectomy had an isolated pelvic metastasis on follow-up imaging (0%; 95% CI 0-2.38, p=0.0004); 33 had metastatic disease in the abdomen, and 120 had no or equivocal evidence of abdominopelvic metastatic disease. One subject with locally advanced unresectable PDA had a possible isolated pelvic metastasis on follow-up imaging (1.1%; 95% CI 0.03-5.79, p=0.048); 20 had metastatic disease in the abdomen, and 73 had no or equivocal evidence of abdominopelvic metastatic disease.ConclusionIsolated pelvic metastatic disease rarely occurs in patients with PDA who have had prior pancreaticoduodenectomy or have a locally advanced unresectable primary tumor, suggesting routine pelvic CT in follow-up imaging of these patients may not be necessary.

To estimate the effect of an oral 13-hour inpatient corticosteroid premedication regimen on length of stay, hospital cost, and hospital-acquired infections (HAIs) by using a combination of real and hypothetical study populations.Institutional review board approval was obtained and informed consent waived for this HIPAA-compliant retrospective study. Inpatients who received an oral 13-hour corticosteroid premedication regimen before contrast material-enhanced CT (n = 1424) from 2008 to 2013 were matched by age, sex, and year when CT was performed to a control cohort (n = 1425) of patients who underwent contrast-enhanced CT without premedication and who had similar rates of 13 comorbid diseases. Length of stay in the hospital and time from admission to CT were compared by using the Mann-Whitney U test. Rates of prospectively reported HAIs were compared by using χ(2) tests. The indirect cost and risk of HAI with premedication were estimated by using published data.Premedicated inpatients had a significantly longer median length of stay (+25 hours; 158 vs 133 hours, P.001), a significantly longer median time to CT (+25 hours, 42 vs 17 hours, respectively; P.001), and a significantly greater risk of HAI (5.1% [72 of 1424] vs 3.1% [44 of 1424], respectively; P = .008) compared with nonpremedicated control subjects. On the basis of these data and existing references, the prolonged length of stay was estimated to result in 0.04 HAI-related deaths and a cost of $159 131 (in U.S. dollars) for each prevented reaction of any severity and 32 HAI-related deaths and a cost of $131 211 400 for each prevented reaction-related death.Oral 13-hour inpatient corticosteroid prophylaxis is associated with substantial cost relative to its modest benefit, and may cause more indirect harm than the direct harm that it prevents.

The purpose of this study was to assess the effect of model-based iterative reconstruction (MBIR) on CT number measurements within small (10-29 mm) low-attenuation renal masses.One hundred 10- to 29-mm exophytic or endophytic low-attenuation renal lesions imaged with CT (unenhanced and nephrographic [100 seconds] phases, 120 kVp, variable mA, 2.5-mm slice thickness) were identified in 100 patients. The raw CT source data were prospectively reconstructed twice: once using Veo MBIR and once using a blend of 30% adaptive statistical iterative reconstruction (ASiR) and filtered back projection (FBP). Lesions were chosen to form four equal-sized (n = 25) groups stratified by lesion size (10-19 or 20-29 mm) and growth pattern (endophytic or exophytic). Attenuation (in HU) was measured using identical ROIs and compared with two-tailed t tests. The effects of patient diameter and lesion anatomy on attenuation discrepancies of 5 HU or more were assessed using binary logistic regression.Mean MBIR attenuation was not significantly different than mean 30% ASiR/FBP attenuation in the overall study population (unenhanced phase, 17 ± 13 vs 17 ± 13 HU, p = 0.74; nephrographic phase, 31 ± 27 vs 30 ± 26 HU, p = 0.89) or in any subgroup (p = 0.63-0.95). Only lesion size predicted discrepancies of 5 HU or more (p = 0.008; odds ratio, 1.20 [95% CI, 1.05-1.34] per 1 mm decrease) (p = 0.19-0.98 for the other variables). Seven lesions had enhancement of 20 HU or more with only one reconstruction method (MBIR = 4; 30% ASiR = 3).Veo MBIR has no significant or consistent effect on attenuation measurements within small (10-29 mm) low-attenuation renal masses and is therefore unlikely to change clinically accepted attenuation thresholds for renal mass characterization.

The purpose of this study was to determine the rate of allergiclike breakthrough reactions among inpatients at high risk receiving premedication before undergoing CT with IV iodinated low-osmolality contrast material (LOCM).Inpatients (n = 1051) completing a 13-hour corticosteroid and diphenhydramine premedication regimen before LOCM-enhanced CT from January 1, 2010, through December 31, 2013, were included in the study. Breakthrough reaction rates were compared with the ordinary allergiclike reaction rate in the general population (0.6% [545/84,928]) by use of chi-square tests. Multivariate logistic regression was performed. Number needed to treat (NNT) was calculated for patients premedicated for a previous contrast reaction.Sixty percent (626/1051) of premedicated patients had had a previous reaction to iodinated contrast material, and 40% (425/1051) were premedicated for other reasons. The overall breakthrough reaction rates were 1.2% (13/1051) (p0.0001 vs the general population), 2.1% (13/626) for those with a previous iodinated contrast reaction (p0.0001), and 0% (0/425) for those premedicated for other reasons (p = 0.18). There were no severe breakthrough reactions. Younger age (p = 0.046; odds ratio, 1.03 per year; 95% CI, 1.001-1.07) and multiple indications for premedication (p0.0001; odds ratio, 2.7 per indication; 95% CI, 1.5-4.8) significantly increased the likelihood of a breakthrough reaction. The estimated NNTs were 69 (95% CI, 39-304) to prevent a reaction of any severity and 569 (95% CI, 389-1083) to prevent a severe reaction.Patients premedicated for a previous reaction to iodinated contrast material have a breakthrough reaction rate 3-4 times the ordinary reaction rate in the general population. Patients receiving premedication for other reasons have a breakthrough reaction rate near 0%. Many patients must receive premedication to prevent one reaction.

OBJECTIVE. The incidence and significance of complications related to intravascular contrast material administration have become increasingly controversial. This review will highlight current thinking regarding the imaging of patients with renal impairment and those at risk for an allergiclike contrast reaction. CONCLUSION. The risk of contrast-induced acute kidney injury remains uncertain for patients with an estimated glomerular filtration rate (GFR) less than 45 mL/min/1.73m2, but if there is a risk, it is greatest in those with estimated GFR less than 30 mL/min/1.73m2. In this population, low-risk gadolinium-based contrast agents appear to have a large safety margin. Corticosteroid prophylaxis remains the standard of care in the United States for patients identified to be at high risk of a contrast reaction, but it has an incomplete mitigating effect on contrast reaction rates and the number needed to treat is large.

Purpose To identify computed tomographic (CT) findings that are predictive of recurrence of colonic diverticulitis. Materials and Methods Institutional review board approval was obtained for this HIPAA-compliant, retrospective cohort study. Six abdominal fellowship-trained radiologists reviewed the CT studies of 440 consecutive subjects diagnosed with acute colonic diverticulitis between January 2004 and May 2008 to determine the involved segments, maximum wall thickness in the inflamed segment, severity of diverticulosis, presence of complications (abscess, fistula, stricture, or perforation), and severity of the inflammation. Electronic medical records were reviewed for a 5-year period after the patients' first CT study to determine clinical outcomes. Predictors of diverticulitis recurrence were assessed with univariate and multiple Cox proportional hazard regression models. Results Colonic diverticulitis most commonly involved the rectosigmoid (70%, 309 of 440) and descending (30%, 133 of 440) colon segments. Complicated diverticulitis was present in 22% (98 of 440) of patients. On the basis of the results of univariate analysis, significant predictors of diverticulitis recurrence were determined to be maximum colonic wall thickness in the inflamed segment (hazard ratio [HR], 1.07 per every millimeter of increase in wall thickness; P < .001), presence of a complication (HR, 1.75; P = .002), and subjective severity of inflammation (HR, 1.36 for every increase in severity category; P value for linear trend = .003). The difference in maximum wall thickness in the inflamed segment (HR, 1.05 per millimeter; P = .016) and subjective inflammation severity (HR, 1.29 per category; P = .018)remained statistically significant in a Cox multiple regression model. Conclusion Maximum colonic wall thickness and subjective severity of acute diverticulitis allow prediction of recurrent diverticulitis and may be useful for stratifying patients according to the need for elective partial colectomy. © RSNA, 2017 Online supplemental material is available for this article.

We aimed to determine the frequency and clinical significance of homogeneous renal masses measuring 21-39 Hounsfield units on contrast-enhanced computed tomography (CT).Subjects 40-69 years old undergoing portal-venous-phase contrast-enhanced abdominal CT from January 1, 2006 to December 31, 2010 with slice thickness ≤5 mm and no prior CT or magnetic resonance imaging were identified (n = 1387) for this institutional review board-approved retrospective cohort study. Images were manually reviewed by three radiologists in consensus to identify all circumscribed homogeneous renal masses (maximum of three per subject) ≥10 mm with a measured attenuation of 21-39 Hounsfield units. Exclusion criteria were known renal cancer or imaging performed for a renal indication. The primary outcome was retrospective characterization as a clinically significant mass, defined as a solid mass, a Bosniak IIF/III/IV mass, or extirpative therapy or metastatic renal cancer within 5 years' follow-up.Eligible masses (n = 74) were found in 5% (63/1387) of subjects. Of those with a reference standard (n = 42), none (0% [95% CI: 0.0%-8.4%]) were determined to be clinically significant.Incidental renal masses on contrast-enhanced CT that are homogeneous and display an attenuation of 21-39 Hounsfield units are uncommon in patients 40-69 years of age, unlikely to be clinically significant, and may not need further imaging evaluation. If these results can be replicated in an independent and larger population, the practical definition of a benign cyst on imaging may be able to be expanded.

The purpose of this study was to quantify changes in renal length, volume, and function over time after upper abdominal radiation therapy.Imaging and clinical data were retrospectively reviewed for 27 adults with abdominal radiation therapy between 2001 and 2012. All had two kidneys, radiation exposure to one kidney, and survival of at least 1 year after therapy. Mean prescribed dose was 52 ± 9 Gy to extrarenal targets. Length and volume of exposed and unexposed kidneys were measured on CT scans before treatment (baseline) and at intervals 0-3, 3-6, 6-12, 12-24, 24-36, and more than 36 months after completion of radiotherapy. Serum creatinine was correlated at each interval. Mixed-models ANOVA was used to test renal length and volume, serum creatinine, and time against multiple models to assess for temporal effects; specific time intervals were compared in pairwise manner.Mean follow-up duration was 35 months (range, 5-94 months). Exposed kidney length and volume progressively decreased from baseline throughout follow-up, with mean loss of 23% (p0.001) and 47% (p0.001), respectively. Slight increase in unexposed kidney length was not significant. Mean serum creatinine increased from 0.86 ± 0.18 mg/dL at baseline to 1.12 ± 0.27 mg/dL at 12-24 months (p0.001), then stabilized.Kidneys exposed to radiation during therapy of adjacent malignancies exhibited continuous progressive atrophy for the entire follow-up period, nearly 8 years. Volume changes were twice as great as length changes. Renal function also declined. To accurately interpret follow-up studies in cancer survivors, radiologists should be aware of the potential for progressive renal atrophy, even many years after radiation therapy.

To determine whether the frequency of intra-observer measurement discrepancies ≥5 mm for solid renal masses varies by renal mass characteristics and CT contrast phase.This HIPAA-compliant retrospective study was approved by our IRB. We selected single CT images performed during the nephrographic phase (NP) of renal enhancement in 97 patients, each with a single solid renal mass. Mass location, margin, heterogeneity, and growth pattern were assessed. Six readers measured each mass on two occasions3 weeks apart. Readers also measured the masses on images in 50 patients who had corticomedullary phase (CMP) images obtained during the same study. Results were assessed using Chi-square/Fisher's exact and Wilcoxon Signed Rank tests, and logistic regression analyses.For NP to NP comparisons, intra-reader measurement differences ≥5 mm were seen for 3.7% (17/463) of masses4 cm, but increased to 16.8% (20/119) for masses4 cm (p0.0001). Masses with poorly defined margins (15.9% [22/138] vs. 3.4% [15/444] for well-defined margins, p0.0001) and heterogeneity (15.3% [22/144], vs. 5.0% [14/282] for minimally heterogeneous, vs. 0.6% [1/156] for homogeneous, p0.0001), were more frequently associated with measurement differences ≥5 mm. Differences ≥5 mm were more frequent when only CMP images were utilized (14% [42/299]), or when CMP images were compared with NP images (26% [77/299]).A ≥5 mm intra-reader variation in measured size of solid renal masses4 cm is uncommon for NP to NP comparisons. Variation increases when masses are ≥4 cm, poorly defined, or heterogeneous; or when CMP images are utilized.

To compare serum creatinine (SCr) level- and estimated glomerular filtration rate (eGFR)-based screening methods for identifying adult inpatients at risk for contrast medium-induced nephrotoxicity (CIN).Institutional review board approval was obtained; informed consent was waived for this HIPAA-compliant retrospective study. Computed tomographic examinations performed during 10 years in adult inpatients with stable renal function were identified (n = 28 390). The proportion of inpatients meeting various eGFR (≥60,60,45,30, 30-44, 45-59 mL/min/1.73 m(2)) and SCr (1.5, ≥1.5, ≥1.6, ≥1.7, ≥1.8, ≥1.9, ≥2.0 mg/dL) thresholds were contrasted with each other and with published guidelines (≥2.0 mg/dL [SCr] and45 mL/min/1.73 m(2) [eGFR]) using McNemar and binomial tests.Most inpatients were considered low risk for CIN with commonly used thresholds: 92.6% (26 285 of 28 390) had SCr1.5 mg/dL; 91.3% (25 922 of 28 390) had eGFR of ≥45 mL/min/1.73 m(2). Using SCr threshold of ≥1.5 mg/dL, identified inpatients had the following eGFRs: 19.6% (413 of 2105), 45-59 mL/min/1.73 m(2); 51.1% (1075 of 2105), 30-44 mL/min/1.73 m(2); 28.6% (603 of 2105),30 mL/min/1.73 m(2); and 0.7% (14 of 2105), ≥60 mL/min/1.73 m(2) . Using SCr threshold of ≥2.0 mg/dL, identified inpatients had the following eGFRs: 100% (658 of 658),45 mL/min/1.73 m(2); 74.6% (491 of 658),30 mL/min/1.73 m(2). Threshold of SCr ≥2.0 mg/dL could not be used to identify eGFR30 mL/min/1.73 m(2) in 0.4% (112 of 28 390) and45 mL/min/1.73 m(2) in 6.4% (1810 of 28 390) of all inpatients. Using eGFR45 mL/min/1.73 m(2) instead of SCr of ≥1.5 mg/dL would result in a significant but small increase in identified inpatients (8.7% [2468 of 28 390; 95% confidence interval: 8.4%, 9.0%] vs 7.4% [2105 of 28 390; 95% confidence interval: 7.1%, 7.7%]; P.0001).Screening using eGFR45 mL/min/1.73 m(2) instead of common SCr thresholds would significantly increase the number of inpatients identified to be at risk for CIN but would reduce misidentification of a large number of inpatients at low risk according to eGFR criteria.

Mucin-related carbohydrates are overexpressed on the surface of cancer cells, providing a disease-specific target for cancer immunotherapy. Here, we describe the design and construction of peptide-free multivalent glycosylated nanoscale constructs as potential synthetic cancer vaccines that generate significant titers of antibodies selective for aberrant mucin glycans. A polymerizable version of the Tn-antigen glycan was prepared and converted into well-defined glycopolymers by Reversible Addition–Fragmentation chain Transfer (RAFT) polymerization. The polymers were then conjugated to gold nanoparticles, yielding ‘multicopy-multivalent’ nanoscale glycoconjugates. Immunological studies indicated that these nanomaterials generated strong and long-lasting production of antibodies that are selective to the Tn-antigen glycan and cross-reactive toward mucin proteins displaying Tn. The results demonstrate proof-of-concept of a simple and modular approach toward synthetic anticancer vaccines based on multivalent glycosylated nanomaterials without the need for a typical vaccine protein component.

To evaluate the effect of available intravenous (IV) access on the accuracy and timeliness of epinephrine administration during a surprise mock severe contrast reaction.Informed consent was waived for this prospective randomized IRB-approved study. Radiology trainees with previous annual hands-on contrast reaction training (n = 46) were randomized to one of two surprise mock contrast reactions over a 23-month period: Group 1-severe laryngeal edema with IV access present (n = 27) or Group 2-severe laryngeal edema without IV access present (n = 19). Both intramuscular (IM, Epi-Pen(®)) and IV epinephrine were available in both scenarios. Time-to-treat and epinephrine administration error rates were compared by study group and by route of administration using two-tailed Student's t test or χ (2) test. Epinephrine administration errors were correlated with training experience using Pearson's correlation.Mean time to epinephrine administration was significantly faster for scenarios without IV access (Group 2: 35 ± 16 s vs. Group 1: 62 ± 49 s, p = 0.03), and for intramuscular administrations overall (IM: 42 ± 34 s vs. IV: 98 ± 46 s, p 0.001). Epinephrine administration errors were common: (63% [17/27, Group 1] vs. 61% [11/18, Group 2], p = 1.00), had no relationship with time to most recent hands-on training (r = 0.24, p = 0.11), and were not predicted by year of post-graduate training (r = 0.04, p = 0.79).Lack of IV access is associated with a faster epinephrine administration time but no improvement in epinephrine administration error rate among radiology trainees responding to a surprise mock severe contrast reaction. Annual hands-on training appears to have little effect on epinephrine administration accuracy.

The purpose of this study was to determine the clinical effectiveness of prospectively reported sonographic twinkling artifact for the diagnosis of renal calculus in patients without known urolithiasis.All ultrasound reports finalized in one health system from June 15, 2011, to June 14, 2014, that contained the words "twinkle" or "twinkling" in reference to suspected renal calculus were identified. Patients with known urolithiasis or lack of a suitable reference standard (unenhanced abdominal CT with ≤ 2.5-mm slice thickness performed ≤ 30 days after ultrasound) were excluded. The sensitivity, specificity, and positive likelihood ratio of sonographic twinkling artifact for the diagnosis of renal calculus were calculated by renal unit and stratified by two additional diagnostic features for calcification (echogenic focus, posterior acoustic shadowing).Eighty-five patients formed the study population. Isolated sonographic twinkling artifact had sensitivity of 0.78 (82/105), specificity of 0.40 (26/65), and a positive likelihood ratio of 1.30 for the diagnosis of renal calculus. Specificity and positive likelihood ratio improved and sensitivity declined when the following additional diagnostic features were present: sonographic twinkling artifact and echogenic focus (sensitivity, 0.61 [64/105]; specificity, 0.65 [42/65]; positive likelihood ratio, 1.72); sonographic twinkling artifact and posterior acoustic shadowing (sensitivity, 0.31 [33/105]; specificity, 0.95 [62/65]; positive likelihood ratio, 6.81); all three features (sensitivity, 0.31 [33/105]; specificity, 0.95 [62/65]; positive likelihood ratio, 6.81).Isolated sonographic twinkling artifact has a high false-positive rate (60%) for the diagnosis of renal calculus in patients without known urolithiasis.

Rationale and Objectives Knowledge of the management of acute contrast reactions is lacking among radiologists. Training in the management of acute contrast reactions occurs at the investigators’ institution and others, but the durability of that training and the need for refresher training have not been assessed. Materials and Methods A prospective assessment of changes in trainees’ knowledge and confidence following a required educational course concerning reactions to contrast material was conducted. Assessments were performed prior to and immediately following the course and at 1, 3, 6, and 9 months after the course. Results Trainees’ knowledge significantly improved following the course and remained improved for 6 months (P Conclusions These data suggest the need for biannual refresher training in the management of acute contrast reactions to maintain trainees’ knowledge and confidence.

The purpose of our study was to compare the effects of i.v. iohexol and iopamidol on renal function in outpatients undergoing CT.We performed a prospective, double-blind, randomized clinical trial of 389 adults with low risk for contrast-induced nephropathy, comparing i.v. iohexol with iopamidol (300 mg I/mL). Serum creatinine (SCr) concentration was measured at baseline and 2 and 3 days after contrast administration. A noninferiority analysis was planned to compare the mean maximum SCr change from baseline between subject groups. Contrast-induced nephropathy rates (three definitions) for both contrast agents were compared as a secondary end point.One hundred ninety and 199 subjects received iohexol and iopamidol, respectively. The mean change in SCr from baseline using the maximum day 2 or 3 measurement was 0.07 ± 0.12 mg/dL (95% CI, 0.05-0.09 mg/dL) for the iohexol group and 0.05 ± 0.12 mg/dL (95% CI, 0.03-0.07 mg/dL) for the iopamidol group. The difference between contrast agents with respect to the mean change in SCr from baseline was -0.02 ± 0.12 mg/dL (95% CI, -0.045 to 0.003 mg/dL; p = 0.08). Contrast-induced nephropathy rates were not statistically different using any definition.Although our results were unable to show absolute noninferiority of iohexol compared with iopamidol because of a very small difference in increase in mean SCr from baseline (using a noninferiority margin of 0.04 mg/dL), this difference is likely of minimal or no clinical importance in outpatients undergoing CT with low risk for contrast-induced nephropathy.

The aim of this study was to identify the rate of discrepancies between radiology residents and faculty radiologists at an academic hospital and to determine the distribution across subspecialties and modalities, specifically CT, MR, and ultrasound.Consecutive CT, MR, and ultrasound preliminary interpretations rendered by on-call second-year through fourth-year radiology residents for 9 months on emergency department patients, inpatients, and urgent outpatients formed the study population. All preliminary interpretations were graded using a modified RADPEER(®) system (scores 0 and 1 = concordance; score 2 = minor, clinically insignificant discordance; scores 3 and 4 = clinically significant discordance) by the subspecialty faculty members who rendered the final interpretation.There were 158 clinically significant discrepancies out of 21,482 preliminary interpretations, for a discrepancy rate of 0.7%. There was no statistically significant difference in rates across subspecialties or between adult and pediatric examinations (cardiothoracic, 1%; abdominal, 0.7%; neuroradiology, 0.6%; musculoskeletal, 0.7%; pediatrics, 0.8%). MR and CT interpretations had significantly higher rates than ultrasound (MR, 1.4%; CT, 0.9%; ultrasound, 0.2%; P.001). Within neuroradiology, there was a significantly higher rate for MR than CT (1.5% vs 0.6%, P.01), and within abdominal radiology, there was a significantly higher rate for CT than ultrasound (1.1% vs 0.2%, P.01).Discrepancy rates in this study were less than or comparable with those reported previously and within or lower than rates for practicing radiologists. Discrepancy rates varied among subspecialties and modalities, suggesting the use of a RADPEER system with attention to modality and subspecialty as a methodology for identifying areas for targeted resident education.

There are few data available concerning the use of intravenous contrast materials in children. To assess patterns of intravenous iodinated/gadolinium-based contrast material (ICM/GBCM) use in children. Society of Chairs of Radiology in Children’s Hospitals (SCORCH) members were invited to complete a Web-based survey regarding intravenous contrast material use at their institutions. Sixty-six percent (42/64) of SCORCH member institutions responded, 76% of which are academic hospitals. Ioversol and gadopentetate dimeglumine are the most commonly used ICMs and GBCMs (52% and 81%, respectively). Premedication policies to mitigate risk of allergic-like contrast reactions are more common for ICMs than GBCMs (71% vs. 32%). For both ICMs and GBCMs, most institutions premedicate or avoid contrast material in the setting of a prior allergic-like contrast reaction of any severity. Policies regarding ICM and GBCM use in children with renal insufficiency are in place at 74% and 88% of institutions, respectively, but are variable. Policies concerning premedication for prevention of allergic-like contrast agent reactions and administration of contrast materials in children with renal insufficiency are variable and not consistently present at all pediatric institutions. This highlights the need for standardization of practice patterns and pediatric-specific research on these topics.

Purpose The aim of the study was to prospectively assess the utility of quantitative enhancement washout method in the differentiation of benign solid renal masses from various subtypes of malignant masses using multidetector computed tomography. Methods In a prospective investigation from January 2009 to May 2010, 97 patients with solid renal masses underwent CT scan examination with unenhanced, arterial, parenchymal, and delayed phases. The following features were analyzed: the maximum attenuation value in each phase, attenuation difference (enhancement) of the mass in each phase from the unenhanced phase (ΔH), and parenchymal and delayed phases' washout. Of these patients, 82 (85%) underwent unilateral radical nephrectomy, 15 (15%) underwent partial nephrectomy. Group comparison was performed with the Kruskal-Wallis test and Mann-Whitney U test. Results The masses included in our study were 45 clear cell renal cell carcinomas (CCRCCs); 18 chromophobe renal cell carcinomas, 16 papillary (PRCC), 14 oncocytomas, and 4 minimal fat containing angiomyolipomas. In the arterial phase, the CCRCC was the most enhancing type and could be differentiated from other renal masses (benign or malignant) with high sensitivity and specificity. In the parenchymal phase, the CCRCCs demonstrated the highest washout. Chromophobe renal cell carcinomas showed the second highest washout in this phase. Benign lesions and PRCCs did not exhibit significant washout in this phase. In the delayed phase, the malignant lesions (with the exception of PRCCs) showed the highest washout. Benign lesions showed significant washout but less than malignant lesions. Conclusions Multiphasic multidetector CT utilizing arterial-phase attenuation and quantitative enhancement washout method could help in the preoperative differentiation of various types of solid renal masses.

Purpose The aim of this study was to assess Society of Uroradiology member use of premedication before the intravenous administration of low-osmolality iodinated contrast materials (LOCM) and gadolinium-based contrast materials (GBCM). Methods Society of Uroradiology members were invited to complete a Web-based survey concerning the use of premedication. The survey included scenarios concerning intravenous LOCM or GBCM injection in which respondents were asked whether they would recommend premedication or withhold contrast material injection. Results for LOCM questions were compared with those for GBCM questions. Question responses for LOCM were also compared with those from a similar Society of Uroradiology survey published in 1995. Results Sixty-two of 72 respondents (86%) used standardized premedication regimens. Fifty-nine of 61 described regimens (97%) included oral corticosteroids and 48 (79%) antihistamines. Twenty of 69 respondents (29%) had separate urgent premedication regimens. There was general agreement concerning premedication use; however, responses were inconsistent in patients with severe food or medication allergies, severe symptomatic asthma, or prior mild urticarial reactions. More respondents recommended premedication before LOCM than GBCM administration. More respondents recommended premedication or avoidance of contrast material injection in patients with prior contrast reactions in the current study compared with the 1995 study. Conclusions There is frequent agreement among uroradiologists concerning the use of corticosteroid prophylaxis, but there is inconsistency in some clinical situations. The threshold for premedication is often lower for LOCM than GBCM. Since 1995, recommendations for use of premedication have become more widespread.

The diagnostic yield was evaluated of percutaneous image-guided tissue biopsy of hepatic lesions identified on computed tomography performed for staging of a primary malignancy, and it was determined how often the biopsy result was unexpectedly negative, benign, or secondary to a second unknown malignancy.In a retrospective investigation from 1998 through 2008, 580 patients with primary malignancies had indeterminate focal hepatic lesions and underwent percutaneous image-guided biopsy; 369 patients had lesions in their liver at first cross-sectional imaging, performed for staging; 211 patients had a negative liver imaging study, followed by the subsequent appearance of at least 1 indeterminate suspicious lesion. The results of percutaneous image-guided tissue biopsies were compared with the histology of the primary malignancy.Liver biopsies were performed in 580 patients (288 men and 292 women; age, 25-92 years; mean age, 61 years). The most common primary malignancies were pancreatic (n = 96), breast (n = 85), melanoma (n = 57), esophageal (n = 51), lung (n = 47), colorectal (n = 37), and urothelial tumors (n = 26). Biopsy results were positive for malignancy in 528 (91%) cases. Among the positive biopsies, 29 (5%) cases had pathology results different from the primary tumor. Of the 52 biopsies negative for malignancy, 20 yielded a specific benign diagnosis, and 32 were nondiagnostic.If all liver lesions had been assumed to be metastases, as expected secondary to the known primary tumor, then the true or presumed alternate diagnosis would have been missed in 60 (10.3%) of the 580 cases. The authors did not attempt to determine whether actual clinical management changed based on these 60 liver biopsy results, so this number is an upper bound on management change. On the basis of these results, and given the minimal complication rate of liver biopsy, the authors suggest that liver biopsy should still be performed in the types of cases studied here, despite the finding that the vast majority of biopsies produced the expected result and presumably did not change patient management.

To analyze the independent effects of multiple variables on resident call performance.Independent radiology resident "on call" cross-sectional imaging interpretation quality assurance (QA) data obtained during a 171-day period at a single tertiary care Level 1 trauma teaching institution was reviewed. Clinically significant resident-faculty discrepancies were compared among three different call types: traditional single-day overnight call (OC, 15 hours/night after 9 daytime hours on weekdays), 7-night nightfloat (NF, 9 hours/night), and weekend day call (WD, 10 hours/day). Logistic regression analyses were performed to evaluate associations.There were 119 (0.89%) clinically significant resident-faculty discordances from 13,424 cross-sectional interpretations: 56 (0.79%) from 7102 interpretations on 172 OC shifts, 39 (0.85%) from 4567 interpretations on 165 NF shifts, and 24 (1.4%) from 1755 interpretations on 49 WD shifts. Individual residents (n = 20) had a mean discrepancy rate of 0.9% (0.45%-1.9%). Overall, 102 (26.2%) of the shifts had at least one discordance. The following were associated with significantly (P.001) increased discrepancy rates: junior vs. senior residents (odds ratio [OR] = 1.3 [1.2-1.4]), OC vs. NF (OR = 1.5 [1.3-1.6], WD vs. NF (OR = 1.4 [1.2-1.6]), weekend vs. weekday (OR = 1.3 [1.2-1.4]), and increasing cases/hour (OR = 1.6 [1.5-1.7]). Weekend OC shifts had a higher discrepancy rate (OR 1.3[1.2-1.5], P.001) than weekday OC shifts despite a shorter workday (15 vs. 24 hours).Increasing caseload, junior residents, and weekends are associated with a significantly higher discrepancy rate. OC is associated with a significantly higher discrepancy rate than NF. Measured discrepancy rates are low, regardless of call type.

Although most cases of acute pancreatitis are uncomplicated and resolve spontaneously, the presence of complications has significant prognostic importance. Necrosis, hemorrhage, and infection convey up to 25%, 52%, and 80% mortality, respectively. Other complications such as pseudocyst formation, pseudoaneurysm formation, or venous thrombosis increase morbidity and mortality to a lesser degree.We review the computed tomographic findings of complications associated with acute pancreatitis with emphasis on their prognostic significance and impact on clinical management.

The purpose of our study was to assess the glycemic risk of a 13-hour corticosteroid premedication regimen in outpatients.Clinical documentation for 216 outpatients premedicated with a 13-hour corticosteroid regimen before an abdominopelvic CT examination between February 20, 2009, and September 15, 2009, was reviewed. Periprocedural serum glucose obtained between 2 hours before and 72 hours after CT was compared with baseline serum glucose.Serum glucose was available for 46 premedication episodes in 43 patients (10 with type 2 diabetes and 33 without diabetes). Mean baseline nonfasting serum glucose was 177 mg/dL (range, 110-290 mg/dL) for diabetic patients and 117 mg/dL (range, 85-190 mg/dL) for those without diabetes. The mean rise in serum glucose was 58 mg/dL at +/-2-24 hours, 10 mg/dL at 25-48 hours, and -2 mg/dL at 49-72 hours. Mean maximal change in serum glucose was greater (p = 0.02) in diabetic patients (mean, 87 mg/dL; range, -134 to 295) than in those without diabetes (mean, 27 mg/dL; range, -35 to 172 mg/dL). No patient developed a hyperglycemia-related hospital admission or complication. One diabetic patient required a temporary increase in daily insulin dose.An outpatient 13-hour corticosteroid premedication regimen is associated with a short-term rise in serum glucose that is greater in type 2 diabetic patients but unlikely to result in a clinically significant outcome.

Many unknowns remain concerning how best to reduce a patient's risk of contrast-induced nephropathy (CIN). Many interventions have been proposed, but few have gone unchallenged, and new questions have arisen from analysis of serum creatinine variations in patients who have not been exposed to radiographic iodinated contrast media (RICM). Use of alternate imaging tests that do not use RICM is the most direct way to avoid CIN. Hydration remains the bulwark of intervention when RICM must be administered. The administration of N-acetylcysteine is a popular pharmacologic prophylaxis against CIN but its efficacy is unclear. Hemodialysis has not been effective, but hemofiltration has shown good results in limited series.

The objective of our study was to evaluate the evolution of the appearances of successfully ablated renal masses on CT and MRI.We conducted a retrospective review of 28 solid renal masses in 25 patients who underwent percutaneous radiofrequency ablation (RFA) between July 2003 and July 2006 in whom there was no evidence of residual tumor during at least 1 year of imaging follow-up and there was postablation biopsy proof of nonviable tissue within the ablation cavity. Three radiologists assessed the size, morphology, and CT or MRI characteristics of the initial tumor and of the ablated tumor or ablation cavity at imaging follow-up 1-2, 3-5, 6-11, and 12-24 months after RFA.The mean initial tumor volume was 5.5 cm(3) (range, 0.3-22.3 cm(3)). Within 1-2 months, the postablation beds of small masses (or = 3 cm(3)) were larger than the volume of the initial tumor. Large masses (3 cm(3)) did not show this increase in volume. At 12 months after RFA, the postablation beds had decreased in size but had not disappeared. On CT, the postablation beds did not show enhancement at any time. On MRI, the postablation beds often showed a thin rim of peripheral enhancement. Imaging follow-up often revealed local stranding in the perinephric fat adjacent to the ablation site. Exophytic tumors were more likely to separate from the renal parenchyma as they contracted toward their epicenter and were more likely to reveal a complete halo of soft-tissue attenuation in the adjacent perinephric fat, which became more apparent on the longer-term follow-up imaging studies.Successfully ablated tumors show predictable imaging features that can be used to guide interpretation of CT and MRI surveillance examinations.

The objective of our study was to evaluate the frequency, outcome, and appropriateness of treatment of adults with acute allergiclike reactions related to IV-administered nonionic iodinated contrast media.For IV injections of nonionic iodinated contrast media between January 1, 1999, and December 31, 2005, contrast reaction reports and medical records of patients in whom contrast reactions occurred were reviewed. Data collected included patient sex and age, symptoms, reaction manifestations, treatment, and long-term sequelae. The appropriateness and efficacy of patient management were assessed.Allergic-type reactions occurred in 545 (0.6%) of patients injected with nonionic iodinated contrast media: 418 (77%) reactions were mild, 116 (21%) were moderate, and 11 (2%) were severe. Two hundred twenty-one patients (41%) received treatment. The most commonly administered medication was diphenhydramine (145 patients or 27%). Corticosteroids were administered to 17 patients, nebulized albuterol to 16, and epinephrine to 15. Although 99% of the treatments did not result in any complication, three patients may have had short-term sequelae as a result of receiving a nonrecommended treatment.Patients usually do well after developing acute allergiclike reactions to nonionic iodinated contrast media. Fortunately, in our series, this was true even in the rare cases in which the instituted treatment was considered to be inappropriate. Reacting patients rarely develop serious long-term sequelae.

OBJECTIVE. This commentary deals with the study by Newhouse and colleagues in this issue of the AJR discussing the implications of a lack of a control group in previously published studies on contrast-induced nephropathy (CIN).CONCLUSION. Until more rigorous studies including an appropriate control group address the issue of CIN, our understanding of the actual risk of CIN when administering IV contrast media is limited.

The purpose of our study was to determine the sensitivity of 16-row multi-detector computed tomography urography (CTU) axial, coronal reformatted, and curved-planar reformatted image-types for upper tract urothelial neoplasm detection. Twenty-one CTU examinations were identified that contained one or more pathology-proven upper tract urothelial neoplasms during our study period. Two readers independently reviewed 1.25 and 2.5 mm axial, coronal reformatted, and curved-planar reformatted excretory phase CTU images. Each reader then documented the location and appearance of lesions suspicious for upper tract urothelial neoplasm. These results were correlated with relevant endoscopic/surgical procedure notes as well as pathology results. Reader #1 detected 72%, 63%, 75%, and 72% of the known 32 upper tract urothelial neoplasms using 1.25 mm axial, 2.5 mm axial, coronal reformatted, and curved-planar reformatted image-types, respectively. Reader #2 detected 72% of the known neoplasms using each of the four image-types. No significant difference in sensitivity between image-types was identified. After combining the results for all four image-types, readers #1 and #2 had overall sensitivities of 94% and 91%. Axial, coronal reformatted, and curved-planar reformatted image-types have similar sensitivities for the detection of upper tract urothelial neoplasm in 16-row multi-detector CTU. Reviewing multiple image-types increases the sensitivity of urothelial lesion detection.

The objective of our study was to determine the number and severity of allergic-like breakthrough reactions to i.v. gadolinium-containing contrast agents in children and adults after premedication with corticosteroids and antihistamines.Contrast material reaction forms from the department of radiology for pediatric (under 19 years old) and adult patients were reviewed for the time period from January 1, 2001, through December 31, 2006. All documented allergic-like reactions to i.v. gadolinium-containing contrast media after premedication with corticosteroids and antihistamines were identified. Forms were evaluated for reaction manifestations, management, and patient outcome. Our institutional electronic medical record system was accessed for each individual patient to identify pertinent medical history, including demographic information, history of allergic-like reaction to contrast media (gadolinium- or iodine-containing), and additional factors that led to prophylactic premedication.Eight patients experienced nine allergic-like reactions after the i.v. administration of gadolinium-containing contrast media despite premedication. A single patient had two breakthrough reactions. Six breakthrough reactions were mild, and three were moderate. No severe or fatal breakthrough reaction occurred. Eight of nine breakthrough reactions occurred in adults. All patients who experienced breakthrough reactions had a history of allergic-like reaction to either gadolinium- or iodine-containing contrast media.Allergic-like reactions to gadolinium-containing contrast media can occur despite premedication with corticosteroids and antihistamines.