Publications by authors named "Ghaneh Fananapazir"

67 Publications

Consensus report from the 9 International Forum for Liver Magnetic Resonance Imaging: applications of gadoxetic acid-enhanced imaging.

Eur Radiol 2021 Feb 1. Epub 2021 Feb 1.

Department of Diagnostic, Molecular, and Interventional Radiology, BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Objectives: The 9th International Forum for Liver Magnetic Resonance Imaging (MRI) was held in Singapore in September 2019, bringing together radiologists and allied specialists to discuss the latest developments in and formulate consensus statements for liver MRI, including the applications of gadoxetic acid-enhanced imaging.

Methods: As at previous Liver Forums, the meeting was held over 2 days. Presentations by the faculty on days 1 and 2 and breakout group discussions on day 1 were followed by delegate voting on consensus statements presented on day 2. Presentations and discussions centered on two main meeting themes relating to the use of gadoxetic acid-enhanced MRI in primary liver cancer and metastatic liver disease.

Results And Conclusions: Gadoxetic acid-enhanced MRI offers the ability to monitor response to systemic therapy and to assist in pre-surgical/pre-interventional planning in liver metastases. In hepatocellular carcinoma, gadoxetic acid-enhanced MRI provides precise staging information for accurate treatment decision-making and follow-up post therapy. Gadoxetic acid-enhanced MRI also has potential, currently investigational, indications for the functional assessment of the liver and the biliary system. Additional voting sessions at the Liver Forum debated the role of multidisciplinary care in the management of patients with liver disease, evidence to support the use of abbreviated imaging protocols, and the importance of standardizing nomenclature in international guidelines in order to increase the sharing of scientific data and improve the communication between centers.

Key Points: • Gadoxetic acid-enhanced MRI is the preferred imaging method for pre-surgical or pre-interventional planning for liver metastases after systemic therapy. • Gadoxetic acid-enhanced MRI provides accurate staging of HCC before and after treatment with locoregional/biologic therapies. • Abbreviated protocols for gadoxetic acid-enhanced MRI offer potential time and cost savings, but more evidence is necessary. The use of gadoxetic acid-enhanced MRI for the assessment of liver and biliary function is under active investigation.
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http://dx.doi.org/10.1007/s00330-020-07637-4DOI Listing
February 2021

Can the American Thyroid Association, K-Tirads, and Acr-Tirads Ultrasound Classification Systems Be Used to Predict Malignancy in Bethesda Category IV Nodules?

Endocr Pract 2020 Sep;26(9):945-952

From the University of California, Davis Medical Center, Sacramento, California.. Electronic address:

Objective: Management of thyroid nodules with Bethesda category III and IV cytology on fine needle aspiration (FNA) is challenging as they cannot be adequately classified as benign or malignant. Ultrasound (US) patterns have demonstrated the utility in evaluating the risk of malignancy (ROM) of Bethesda category III nodules. This study aims to evaluate the value of 3 well-established US grading systems (American Thyroid Association [ATA], Korean Thyroid Imaging Reporting and Data System [Korean-TIRADS], and The American College of Radiology Thyroid Imaging Reporting and Data System [ACR-TIRADS]) in determining ROM in Bethesda category IV nodules.

Methods: Ninety-two patients with 92 surgically resected thyroid nodules who had Bethesda category IV cytology on FNA were identified. Nodule images were retrospectively graded using the 3 systems in a blinded manner. Associations between US risk category and malignant pathology for each system were analyzed.

Results: Of the 92 nodules, 56 (61%) were benign and 36 (39%) were malignant. Forty-seven per cent of ATA high risk nodules, 53% of K-TIRADS category 5 nodules, and 50% of ACR-TIRADS category 5 nodules were malignant. The ATA high-risk category had 25% sensitivity, 82% specificity, 47% positive predictive value (PPV) for malignancy. K-TIRADS category 5 had 25% sensitivity, 85% specificity, 53% PPV for malignancy. ACR-TIRADS category 5 had 25% sensitivity, 84% specificity, 50% PPV for malignancy. None of the 3 grading systems yielded a statistically significant correlation between US risk category and the ROM (P = .30, .72, .28).

Conclusion: The ATA, Korean-TIRADS, and ACR-TIRADS classification systems are not helpful in stratifying ROM in patients with Bethesda category IV nodules. Clinicians should be cautious of using ultra-sound alone when deciding between therapeutic options for patients with Bethesda category IV thyroid nodules.
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http://dx.doi.org/10.4158/EP-2020-0024DOI Listing
September 2020

Accuracy of focal cystic appearance within adrenal nodules on contrast-enhanced CT to distinguish pheochromocytoma and malignant adrenal tumors from adenomas.

Abdom Radiol (NY) 2021 Jan 8. Epub 2021 Jan 8.

Department of Radiology, Davis Medical Center, University of California, 4860 Y Street, Suite 3100, Sacramento, CA, 95817, USA.

Purpose: To determine the accuracy of cystic appearance within adrenal masses on contrast-enhanced CT in distinguishing pheochromocytomas and malignant adrenal tumors from adenomas.

Methods: We performed a retrospective review of adult patients with pathologically proven adrenal tumors who underwent contrast-enhanced abdominal CT. There were 92 patients (mean age 64.7 years, 52 men) with 22 pheochromocytomas, 34 malignant masses, and 36 adenomas. Two abdominal radiologists independently reviewed CT images to determine the presence of cystic appearance within the adrenal masses, defined as focal regions of low attenuation within the tumor that subjectively had fluid density.

Results: Cystic appearance was present in 12/22 (55%, 95% CI 32-76%) pheochromocytomas (mean size 5.3 cm), 15/34 (44%, 95% CI 27-62%) malignant masses (mean size 5.8 cm), and 2/36 (5.6%, 95% CI 0.7-9%) adenomas (mean size 3.2 cm). Sensitivity and specificity of cystic appearance for distinguishing pheochromocytoma or malignant masses from adenomas were 48.2% (95% CI 34.7-62.0%) and 94.4% (95% CI 81.3-99.3%), respectively. Cystic appearance was a significant predictor of tumor type (p = 0.015) even after controlling for tumor size. Reader agreement for cystic appearance was almost perfect with a kappa of 0.85.

Conclusion: Cystic appearance in adrenal tumors on contrast-enhanced CT has high specificity and low sensitivity for distinguishing pheochromocytoma and malignant adrenal masses from adenomas.
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http://dx.doi.org/10.1007/s00261-020-02925-5DOI Listing
January 2021

Functional Adrenal Collision Tumor in a Patient with Cushing's Syndrome.

Case Rep Endocrinol 2020 14;2020:7415762. Epub 2020 Dec 14.

Department of Surgery, University of California, Davis Medical Center, Sacramento, CA, USA.

Adrenal collision tumors are rare and produce unique diagnostic challenges for clinicians. We report the case of a 45-year-old woman with obesity and diabetes mellitus and an incidentally-discovered adrenal mass containing macroscopic fat, thought to be a myelolipoma. A functional workup confirmed adrenocorticotropic hormone- (ACTH-) independent Cushing's syndrome. The patient underwent a successful laparoscopic adrenalectomy with pathology showing an adrenal collision tumor consisting of an adrenocortical adenoma and a myelolipoma. Postoperatively, the clinical symptoms, body mass index, and hemoglobin A1C all improved. Clinicians should consider a functional workup in patients with radiographically diagnosed myelolipomas as some may prove to be hormonally active collision tumors.
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http://dx.doi.org/10.1155/2020/7415762DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7752288PMC
December 2020

Abdominal radiology involvement in image-guided procedures: a perspective from the society of abdominal radiology Cross-Sectional Interventional Radiology Emerging Technology Commission.

Abdom Radiol (NY) 2021 Jan 7. Epub 2021 Jan 7.

Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Shapiro 4, Boston, MA, 02215-5400, USA.

Abdominal radiology as a field has historically played an important role in the training, research, and performance of image-guided procedures. With the emphasis on increased subspecialization and the more formal and rigorous interventional radiology training programs, the question of the future of image-guided procedures within abdominal radiology is explored. A survey conducted by the Cross-Sectional Interventional Radiology Emerging Technology Commission on members of the Society of Abdominal Radiology showed that image-guided procedures are overwhelmingly being performed by abdominal radiology groups, and the vast majority of programs are training their fellows in this regard. We explore some of the challenges radiology and health care in general may face should abdominal radiologists no longer perform procedures and outline strategies departments can employ to meet the needs of both abdominal and interventional radiologists.
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http://dx.doi.org/10.1007/s00261-020-02869-wDOI Listing
January 2021

Imaging of the Non-Obstetric Acute Abdomen in Pregnancy.

Semin Roentgenol 2020 Oct 24;55(4):364-372. Epub 2020 Jun 24.

University of California, Davis, Department of Radiology, Sacramento, CA. Electronic address:

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http://dx.doi.org/10.1053/j.ro.2020.06.016DOI Listing
October 2020

Right-sided scrotal varicocele and its association with malignancy: a multi-institutional study.

Abdom Radiol (NY) 2021 05 5;46(5):2140-2145. Epub 2020 Nov 5.

Department of Radiology, University of California Davis Medical Center, Sacramento, CA, USA.

Purpose: To determine the prevalence of isolated right-sided varicocele due to an obstructing malignancy in patients with no other evidence of malignancy.

Methods: This retrospective, multi-institutional study included a text search for right-sided varicocele in consecutive reports of scrotal ultrasound studies performed between 4/22/1999 and 06/24/2018. Diagnosis was confirmed by a radiologist based on the following criteria: pampiniform plexus vein diameter of ≥ 2 mm, which has augmented flow or increases by ≥ 1 mm on Valsalva. Inclusion criteria for adequate follow-up were (1) abdominopelvic CT or MRI performed within 3 months prior to, or any time after, the ultrasound study; or (2) presence of clinical documentation more than 2 years after the ultrasound date. Exclusion criteria were existing cancer diagnosis in the abdomen or pelvis, epididymo-orchitis, intratesticular or intrascrotal mass, and prior scrotal surgery. Images of available CT or MRI studies were reviewed for presence of any explanation of right-sided varicocele.

Results: 210 patients with right-sided varicocele met inclusion and exclusion criteria. 118/210 had abdominopelvic CT or MRI in the assigned timeframe. Of these, no patients had malignancy that could account for right-sided varicoceles. Of the 92/210 patients without CT or MRI but with available clinical follow-up, none had a malignancy that could have caused an isolated right-sided varicocele. There was no underlying malignancy to explain the right-sided varicocele in any of the patients, 0/210, 95% CI [0.0-1.4%].

Conclusion: No associated malignancy was found in patients with isolated right-sided varicoceles to support additional imaging for malignancy screening.
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http://dx.doi.org/10.1007/s00261-020-02840-9DOI Listing
May 2021

Clinical Importance of Incidental Homogeneous Renal Masses That Measure 10-40 mm and 21-39 HU at Portal Venous Phase CT: A 12-Institution Retrospective Cohort Study.

AJR Am J Roentgenol 2021 May 12:1-6. Epub 2021 May 12.

Department of Radiology, Michigan Medicine, Ann Arbor, MI.

Incidental homogeneous renal masses are frequently encountered at portal venous phase CT. The American College of Radiology Incidental Findings Committee's white paper on renal masses recommends additional imaging for incidental homogeneous renal masses greater than 20 HU, but single-center data and the Bosniak classification version 2019 suggest the optimal attenuation threshold for detecting solid masses should be higher. The purpose of this article is to determine the clinical importance of small (10-40 mm) incidentally detected homogeneous renal masses measuring 21-39 HU at portal venous phase CT. We performed a 12-institution retrospective cohort study of adult patients who underwent portal venous phase CT for a nonrenal indication. The date of the first CT at each institution ranged from January 1, 2008, to January 1, 2014. Consecutive reports from 12,167 portal venous phase CT examinations were evaluated. Images were reviewed for 4529 CT examinations whose report described a focal renal mass. Eligible masses were 10-40 mm, well-defined, subjectively homogeneous, and 21-39 HU. Of these, masses that were shown to be solid without macroscopic fat; classified as Bosniak IIF, III, or IV; or confirmed to be malignant were considered clinically important. The reference standard was renal mass protocol CT or MRI, ultrasound of definitively benign cysts or solid masses, single-phase contrast-enhanced CT or unenhanced MRI showing no growth or morphologic change for 5 years or more, or clinical follow-up 5 years or greater. A reference standard was available for 346 masses in 300 patients. The 95% CIs were calculated using the binomial exact method. Eligible masses were identified in 4.2% of patients (514/12,167; 95% CI, 3.9-4.6%). Of 346 masses with a reference standard, none were clinically important (0%; 95% CI, 0-0.9%). Mean mass size was 17 mm; 72% (248/346) measured 21-30 HU, and 28% (98/346) measured 31-39 HU. Incidental small homogeneous renal masses measuring 21-39 HU at portal venous phase CT are common and highly likely benign. The change in attenuation threshold signifying the need for additional imaging from greater than 20 HU to greater than 30 HU proposed by the Bosniak classification version 2019 is supported.
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http://dx.doi.org/10.2214/AJR.20.24245DOI Listing
May 2021

Utilization and Yield of CT Urography: Are the American Urological Association Guidelines for Imaging of Patients With Asymptomatic Microscopic Hematuria Being Followed?

AJR Am J Roentgenol 2021 01 5;216(1):106-110. Epub 2020 Nov 5.

Department of Radiology, University of California, Davis Medical Center, 4860 Y St, Ste 3100, Sacramento, CA 95817.

Objective: The purposes of this study were to determine whether patients with asymptomatic microscopic hematuria undergoing CT urography (CTU) meet the American Urological Association criteria for radiologic evaluation and to determine the yield of CTU for upper tract malignancy.

Materials And Methods: A retrospective review was conducted of consecutive CTU examinations performed for asymptomatic microscopic hematuria in adult patients. Patients with clinical evidence suggestive of a benign cause of hematuria (stone, urinary tract infection, trauma) or prior urologic malignancy were excluded. The study group included 419 patients (173 men, 246 women). CT reports were reviewed to identify causes of hematuria in all cases. Evaluate for appropriateness was conducted with 200 randomly allocated patients. Urinalysis results were reviewed, and appropriate use of CTU was defined as more than 3 RBCs per high-power field in the absence of urinary tract infection. Cystoscopy results after CTU were noted.

Results: In total, 58 of 200 patients (29.0%; 95% CI, 23.2-35.6%) did not meet American Urological Association criteria for radiologic evaluation. Fifteen (7.5%) received dipstick analysis only. Thirty-eight (19.0%) had urinalysis results showing 0-2 RBCs per high-power field. Five patients (2.5%) were found to have urinary tract infections. No upper tract urothelial neoplasms were identified (0/419; 95% CI, 0.0-0.9%). One solid renal mass was identified without pathologic confirmation. One possible bladder mass was seen at CTU but not visualized at subsequent cystoscopy.

Conclusion: In 29.0% of examinations, CTU is performed for patients who do not meet the criteria for radiologic evaluation. The yield of CTU for upper urinary tract malignancy is low.
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http://dx.doi.org/10.2214/AJR.20.22998DOI Listing
January 2021

Association of adipose tissue and skeletal muscle metrics with overall survival and postoperative complications in soft tissue sarcoma patients: an opportunistic study using computed tomography.

Quant Imaging Med Surg 2020 Aug;10(8):1580-1589

Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC, USA.

Background: To determine the relationship between adipose tissue and skeletal muscle measurements on computed tomography (CT) and overall survival and major postoperative complications in patients with soft-tissue sarcoma (STS).

Methods: The retrospective study included 137 STS patients (75 men, 62 women; mean age, 53 years, SD 17.7; mean BMI, 28.5, SD 6.6) who had abdominal CT exams. On a single CT image, at the L4 pedicle level, measurements of visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), and skeletal muscle area and attenuation were obtained using clinical PACS and specialized segmentation software. Clinical information was recorded, including STS characteristics (size, depth, grade, stage, and site), overall survival, and postoperative complications. The relationships between CT metrics and survival were analyzed using Cox proportional hazard models and those between CT metrics and postoperative complications using logistic regression models.

Results: There were 33 deaths and 41 major postoperative complications. Measured on clinical PACS, the psoas area (P=0.003), psoas index (P=0.006), psoas attenuation (P=0.011), and total muscle attenuation (P=0.023) were associated with overall survival. Using specialized software, psoas attenuation was also associated with overall survival (P=0.018). Adipose tissue metrics were not associated with survival or postoperative complications.

Conclusions: In STS patients, CT-derived muscle size and attenuation are associated with overall survival. These prognostic biomarkers can be obtained using specialized segmentation software or routine clinical PACS.
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http://dx.doi.org/10.21037/qims.2020.02.09DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7378098PMC
August 2020

Reorganizing Cross-Sectional Interventional Procedures Practice During the Coronavirus Disease (COVID-19) Pandemic.

AJR Am J Roentgenol 2020 12 22;215(6):1499-1503. Epub 2020 May 22.

Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA.

The purpose of this article is to present strategies and guidelines that can be implemented in the performance of cross-sectional interventional procedures during the coronavirus disease (COVID-19) pandemic. Radiologists who perform cross-sectional interventional procedures can take several steps to minimize the risks to patients and radiology personnel, including screening referred patients to decide which procedures can be postponed, using appropriate personal protective equipment (PPE), minimizing the number of people involved in procedures, preserving PPE when possible, and applying proper room and equipment cleaning measures.
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http://dx.doi.org/10.2214/AJR.20.23227DOI Listing
December 2020

CAN THE AMERICAN THYROID ASSOCIATION, K-TIRADS AND ACR-TIRADS ULTRASOUND CLASSIFICATION SYSTEMS BE USED TO PREDICT MALIGNANCY IN BETHESDA CATEGORY IV NODULES?

Endocr Pract 2020 May 14. Epub 2020 May 14.

From: University of California, Davis Medical Center, Sacramento, CA.

Management of thyroid nodules with Bethesda Category III and IV cytology on fine needle aspiration (FNA) is challenging as they cannot be adequately classified as benign or malignant. Ultrasound (US) patterns have demonstrated utility in evaluating the risk of malignancy (ROM) of Bethesda Category III nodules. This study aims to evaluate the value of three well established US grading systems (ATA, Korean-TIRADS, and ACR-TIRADS) in determining ROM in Bethesda Category IV nodules. 92 patients with 92 surgically resected thyroid nodules who had Bethesda Category IV cytology on FNA were identified. Nodule images were retrospectively graded using the three systems in a blinded manner. Associations between US risk category and malignant pathology for each system were analyzed. Of the 92 nodules, 56 (61%) were benign and 36 (39%) were malignant. 47% of ATA high risk nodules, 53% of K-TIRADS category 5 nodules, and 50% of ACR-TIRADS category 5 nodules were malignant. The ATA high-risk category had 25% sensitivity, 82% specificity, 47% PPV for malignancy. K-TIRADS category 5 had 25% sensitivity, 85% specificity, 53% PPV for malignancy. ACR-TIRADS category 5 had 25% sensitivity, 84% specificity, 50% PPV for malignancy. None of the three grading systems yielded statistically significant correlation between US risk category and the ROM ( =0.30, 0.72, 0.28). The ATA, Korean-TIRADS, and ACR-TIRADS classification systems are not helpful in stratifying ROM in patients with Bethesda Category IV nodules. Clinicians should be cautious of using ultrasound alone when deciding between therapeutic options for patients with Bethesda Category IV thyroid nodules.
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http://dx.doi.org/10.4158/EP-2020-0024DOI Listing
May 2020

Adherence to guidelines for hormonal evaluation in patients with incidentally detected adrenal nodules: effects of radiology report wording and standardized reporting.

Abdom Radiol (NY) 2020 09;45(9):2910-2915

Department of Surgery, University of California, Davis Medical Center, 2221 Stockton Blvd., Sacramento, CA, 95817, USA.

Objective: To compare the rates of hormonal evaluation in patients who had CT reports describing adrenal incidentalomas with and without a specific recommendation for hormonal evaluation.

Materials And Methods: We performed a retrospective review of adult outpatients without a history of cancer who had a CT report describing an incidental adrenal nodule. Radiology reports were reviewed to determine whether a standardized macro was used which gave specific recommendations for hormonal evaluation and endocrinology consultation. If no macro was used it was determined whether the report had a recommendation for hormonal evaluation and endocrinology consultation.

Results: A standardized macro recommending hormonal evaluation and endocrinology referral was used in 45/129 (34.8%) reports that described an incidental adrenal nodule. A recommendation for hormonal evaluation was made in 5/84 (6.0%) reports without a macro. Hormonal evaluation was performed in 24/50 (48.0%) patients whose reports recommended it and in 11/79 (13.9%) patients whose reports did not (p < 0.0001). A recommendation for endocrinology referral was made in 2/84 (2.4%) reports without a macro. Patients were seen by endocrinology in 12/47 (25.5%) patients whose reports recommended an endocrinology referral evaluation and 5/82 (6.1%) patients whose reports did not (p < 0.0001). Hormonal evaluation was performed in 17/17 (100%) patients who were seen by endocrinology and 18/112 (16.1%) patients who were not (p < 0.0001). Eleven patients (8.5%) had an evaluation suggesting hyperfunctioning nodules (4 cortisol producing, 6 aldosterone producing, and 1 pheochromocytoma).

Conclusions: Utilizing standardized macros that make specific recommendations for hormonal evaluation in patients with adrenal incidentalomas leads to improved adherence to clinical guidelines.
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http://dx.doi.org/10.1007/s00261-020-02517-3DOI Listing
September 2020

Short- and Long-term Outcomes of Kidney Transplants From Very Small (≤15 kg) Pediatric Donors With Acute Kidney Injury.

Transplantation 2021 02;105(2):430-435

Department of Surgery, University of California, Davis School of Medicine, Sacramento, CA.

Background: Kidneys from small deceased pediatric donors with acute kidney injury (AKI) are commonly discarded owing to transplant centers' concerns regarding potentially inferior short- and long-term posttransplant outcomes.

Methods: We retrospectively analyzed our center's en bloc kidney transplants performed from November 2007 to January 2015 from donors ≤15 kg into adult recipients (≥18 y). We pair-matched grafts from 27 consecutive donors with AKI versus 27 without AKI for donor weight, donation after circulatory death status, and preservation time.

Results: For AKI versus non-AKI donors, median weight was 7.5 versus 7.1 kg; terminal creatinine was 1.7 (range, 1.1-3.3) versus 0.3 mg/dL (0.1-0.9). Early graft loss rate from thrombosis or primary nonfunction was 11% for both groups. Delayed graft function rate was higher for AKI (52%) versus non-AKI (15%) grafts (P = 0.004). Median estimated glomerular filtration rate was lower for AKI recipients only at 1 and 3 months (P < 0.03). Graft survival (death-censored) at 8 years was 78% for AKI versus 77% for non-AKI grafts. Late proteinuria rates for AKI versus non-AKI recipients with >4 years follow-up were not significantly different.

Conclusions: Small pediatric donor AKI impacted early posttransplant kidney graft function, but did not increase risk for early graft loss and decreased long-term function. The presently high nonutilization rates for en bloc kidney grafts from very small pediatric donors with AKI appear therefore unjustified. Based on the outcomes of the present study, we infer that the reluctance to transplant single kidneys from larger pediatric donors with AKI lacks a rational basis as well. Our findings warrant further prospective study and confirmation in larger study cohorts.
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http://dx.doi.org/10.1097/TP.0000000000003230DOI Listing
February 2021

Adrenal Tumors Found During Staging and Surveillance for Colorectal Cancer: Benign Incidentalomas or Metastatic Disease?

World J Surg 2020 07;44(7):2282-2287

Department of Surgery, University of California, Davis, Davis Medical Center, Comprehensive Cancer Center, 4501 X St, Sacramento, CA, 95817, USA.

Objective: To evaluate the incidence of adrenal metastases in patient with colorectal cancer (CRC) and determine the clinical and radiographic features associated metastatic CRC to the adrenal glands.

Materials And Methods: The review of consecutive adults with newly diagnosed CRC found to have adrenal tumors > 1 cm in size on staging or surveillance CT scans with at least two scans to evaluate progression or stability of disease.

Results: Fifty-eight of 856 (6.8%) CRC patients had an adrenal tumor. Forty-three patients (74%) with 46 adrenal tumors had benign adrenal tumors, and 15 (26%) patients with 17 adrenal tumors had metastatic disease. On univariate analysis, patients with metastatic CRC had larger adrenal tumors (26.7 mm vs 12.4 mm, p < 0.01), a higher mean CEA (239 ng/mL vs 14.2 ng/mL, p = 0.03), and were more likely to have other sites of metastatic disease seen on imaging 8/43 (19%) vs 14/15 (93%), p < 0.01. On multivariable analysis, adrenal tumor size > 1.8 cm (OR 49.6 CI 8-306), CEA > 2.5 ng/mL (OR 15.8 CI 1.7-144) and other metastatic disease seen on imaging (OR 68.1 CI 7-661) were independently associated with adrenal metastases.

Conclusion: CRC patients with small adrenal tumors, normal CEA levels and no evidence of other metastatic disease are unlikely to have spread to the adrenal glands. Adrenal tumors found during staging and surveillance of CRC patients should be evaluated with appropriate imaging and biochemical analysis.
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http://dx.doi.org/10.1007/s00268-020-05479-1DOI Listing
July 2020

Sonographically Diagnosed Urothelial Thickening in Kidney Allografts: A Noninvasive and Clinically Highly Relevant Marker for the Detection of Acute Rejection.

AJR Am J Roentgenol 2020 07 25;215(1):148-152. Epub 2020 Feb 25.

Department of Radiology, University of California Davis Medical Center, 4860 Y St, Ste 3100, Sacramento, CA 95817.

The objective of our study was to investigate the significance of sonographic features in assessing for acute kidney allograft rejection in the modern era. In this retrospective study, 107 adult patients with a kidney allograft biopsy performed between 2015 and 2018 and diagnostic ultrasound performed within 2 weeks of the biopsy were included. Acute rejection was diagnosed on the basis of biopsy tissue sample results using the Banff criteria. The following ultrasound features were assessed: perfusion, cortical echogenicity, corticomedullary differentiation, urothelial thickening, change in renal length, renal artery velocity, and intraparenchymal arterial resistive index. Subjective measures of perfusion, echogenicity, corticomedullary differentiation, and urothelial thickening were assessed independently and in consensus by three abdominal radiologists; multirater kappa values were calculated for interobserver variability. The Wilcoxon rank sum test and chi-square test were used to evaluate the differences between two groups (rejection vs no rejection) and the sonographic features. Sensitivity, specificity, positive predictive value, and negative predictive value (NPV) were calculated for sonographic features that are associated with acute rejection. Of the sonographic features, only the presence of urothelial thickening was significantly associated with acute rejection ( < 0.001) and had substantial agreement (κ = 0.61) among readers. Urothelial thickening was highly sensitive (96%; 95% CI, 79-100%) with a high NPV (98%; 95% CI, 86-100%). Urothelial thickening on ultrasound is a highly sensitive finding for acute kidney rejection with a high NPV and thus may play a role in sonographic prebiopsy screening. Other historically associated sonographic features seem to play little, if any, role in the screening and assessment for kidney allograft rejection in the modern era.
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http://dx.doi.org/10.2214/AJR.19.22128DOI Listing
July 2020

Urologic complications after transplantation of 225 en bloc kidneys from small pediatric donors ≤20 kg: Incidence, management, and impact on graft survival.

Am J Transplant 2020 08 18;20(8):2126-2132. Epub 2020 Feb 18.

Department of Surgery, University of California Davis Medical Center, Sacramento, California.

Pediatric en bloc kidney transplants (EBKs) from small deceased pediatric donors are associated with increased early graft loss and morbidity. Yet, urologic complications post-EBK and their potential impact on graft survival have not been systematically studied. We retrospectively studied urological complications requiring intervention for 225 EBKs performed at our center January 2005 to September 2017 from donors ≤20 kg into recipients ≥18 years. Overall ureteral complication incidence after EBK was 9.8% (n = 22) (12% vs 2% for EBK donors 10 vs 10 kg, respectively [P = .031]). The most common post-EBK urologic complication was a stricture (55%), followed by urine leak (41%). In all, 95% of all urologic complications occurred early within 5 months posttransplant (median, 138 days). Urologic complications could be successfully managed nonoperatively in 50% of all cases and had no impact on graft or patient survival. In summary, urologic complications after EBK were common, associated with lower donor weights, occurred early posttransplant, and were often amenable to nonoperative treatment, without adversely affecting survival. We conclude that the higher urologic complication rate after EBK (1) should not prevent increased utilization of small pediatric donor en bloc kidneys for properly selected recipients, and (2) warrants specific discussion with EBK recipients during the preoperative consent process.
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http://dx.doi.org/10.1111/ajt.15792DOI Listing
August 2020

Incidentally detected biliary ductal dilatation on contrast-enhanced CT: what is the incidence of occult obstructing malignancy?

Abdom Radiol (NY) 2019 12;44(12):4022-4027

Department of Radiology, Davis Medical Center, University of California, 4860 Y Street, Suite 3100, Sacramento, CA, 95817, USA.

Purpose: The purpose of this study was to determine the incidence of occult obstructing malignancy in the setting of asymptomatic biliary ductal dilatation incidentally detected and without identifiable cause on contrast-enhanced CT.

Methods: A retrospective search identified patients with biliary ductal dilatation on contrast-enhanced CT from March 30, 2007 to November 1, 2017. Patients with biliary symptomatology or clinical concern for an obstructing process, an explanation for biliary ductal dilatation on index CT, intrahepatic without extrahepatic biliary ductal dilatation, concurrent pancreatic ductal dilatation, and inadequate follow-up were excluded. A reference standard of at least 1 year of imaging follow-up or 2 years of clinical follow-up was used to exclude occult obstructing malignancy.

Results: 156 patients were included; 120 patients met imaging follow-up criteria and 36 patients met clinical follow-up criteria. No cases of occult malignancy were identified as the source of biliary ductal dilatation (95% CI 0.0-1.9%). LFTs were available for 131 patients, of which 36 were elevated (27%). One case demonstrated a 1.2-cm ampullary adenoma on endoscopic retrograde cholangiopancreatography (occult on follow-up MRI, normal LFTs at the time of the index CT).

Conclusion: Asymptomatic biliary ductal dilatation incidentally detected and without identifiable cause on contrast-enhanced CT is likely benign in patients with normal LFTs, and further workup may not be warranted.
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http://dx.doi.org/10.1007/s00261-019-02217-7DOI Listing
December 2019

Is Ultrasound-Guided Core Biopsy as Safe as Fine-Needle Aspiration, and Does It Add Significantly to the Diagnosis of Suspected Peritoneal Malignancy?

J Ultrasound Med 2020 Feb 22;39(2):239-245. Epub 2019 Jul 22.

Department of Radiology, University of California, Davis Medical Center, Sacramento, California, USA.

Objectives: We undertook this retrospective review to compare the safety and diagnostic yield of core biopsy (CB) compared to fine-needle aspiration (FNA) in patients with suspected peritoneal malignancy.

Methods: This retrospective study included 35 patients who underwent ultrasound (US)-guided percutaneous biopsy of a peritoneal mass. Success rates of US-guided biopsy of these masses using the CB technique, FNA, or the combination of the two were compared. Outcomes of tissue adequacy, the final pathologic diagnosis, and complications were recorded. The binary outcome variable was adequate tissue obtained.

Results: Adequate specimens were obtained in 94% (33 of 35) of the cases. There were 19 CBs, with 100% of samples sufficient for diagnosis (19 of 19). Thirty-one FNAs were performed, of which 7 were insufficient, with a diagnostic yield of 77% (24 of 31). There was a statistically significant difference between FNA and CB in providing more adequate tissue for diagnosis in our population (P = .035). There were no significant complications in either group.

Conclusions: The use of the CB technique when performing US-guided percutaneous biopsy of peritoneal masses provides better tissue for diagnosis compared to FNA. Additional benefits of CB, including genomic testing and tumor subtyping, make this technique a good addition to FNA, without significant complications.
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http://dx.doi.org/10.1002/jum.15095DOI Listing
February 2020

Differences in Growth Rate on CT of Adrenal Adenomas and Malignant Adrenal Nodules.

AJR Am J Roentgenol 2019 09 30;213(3):632-636. Epub 2019 Apr 30.

Department of Surgery, University of California, Davis Medical Center, Sacramento, CA.

The purpose of this study is to determine the differences in growth rate of adrenal adenomas and malignant adrenal nodules. This was a retrospective review of adults with an adrenal nodule seen at two different abdominal or chest CT examinations or PET/CT examinations. Patients in the adenoma group were included if they had a CT, MRI, or pathologic diagnosis of an adrenal adenoma. Patients in the malignant group were included if they had a pathologically proven malignant adrenal nodule. Nodule growth was defined as a change in the largest axial diameter greater than or equal to 3 mm. Growth rate was calculated by dividing the change in the longest axial diameter by the time between the first and last imaging examination. There were 105 adenomas and 26 malignant nodules. Of the 105 adenomas, 34 (32.4%; 95% CI, 23.6-42.2%) grew, three (2.9%; 95% CI, 0.6-8.1%) became smaller, and 68 (64.8%; 95% CI, 54.8-73.8%), were unchanged in size. All 26 (100%; 95% CI, 89.1-100%) malignant nodules grew. The mean (± SD) growth rate of adenomas was 1.0 ± 0.67 mm/year (range, 0.3-2.8 mm/year), compared with 58.4 ± 78.5 mm/year (range, 5.8-395.4 mm/year) for malignant nodules ( < 0.001). A growth rate of 3 mm/year distinguished adenomas from malignant nodules with a sensitivity of 100% (95% CI, 86.8-100%) and a specificity of 100% (95% CI, 96.6-100%). Approximately one-third of radiologically proven adrenal adenomas grew, all of which grew at a rate less than 3 mm/year. All malignant adrenal nodules grew, and all at a rate greater than 5 mm/year.
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http://dx.doi.org/10.2214/AJR.19.21342DOI Listing
September 2019

Radiation Dose Reduction of Unenhanced CT Limited to the Kidneys for Follow-Up of Patients With Known Nephrolithiasis Without Symptoms.

AJR Am J Roentgenol 2019 Jul 11;213(1):123-126. Epub 2019 Apr 11.

Department of Radiology, University of California, Davis, 4860 Y St, Ste 3100, Sacramento, CA 95817.

The purpose of this study is to identify the landmarks and associated radiation dose reduction for limited CT of the kidneys of patients requiring follow-up for known nephrolithiasis. This retrospective study included all adult patients who underwent CT examination type "CT abdomen + pelvis renal stone" at our institution during 2017. Several exclusion criteria were identified, including scoliosis and congenital renal abnormalities. A total of 299 patients met the inclusion and exclusion criteria. The radiation dose and -axis length associated with the original CT scan were recorded. The upper and lower limits of both kidneys in relation to the vertebral body endplates were recorded, to determine the -axis length for a CT scan limited to the kidneys. A commercially available radiation dose analytics software package was used to provide estimates of whole-body-and individual organ-equivalent doses for the original CT scan and the limited range CT scan. The superior endplate of T11 and the inferior endplate of L5 are landmarks that will include both kidneys on almost all scans. A limited -axis range leads to a mean scan length reduction of 50%. The whole-body mean effective dose is reduced by 41.5%, and the doses to the breast and the gonadal and bladder organs are reduced by 71.7%, 73.8%, and 81.8%, respectively. For patients without symptoms who are undergoing CT surveillance to evaluate renal calculi growth, new stone formation, or both, a limited-range scan extending from the superior endplate of T11 to the inferior endplate of L5 results in a significant reduction in radiation dose.
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http://dx.doi.org/10.2214/AJR.18.20805DOI Listing
July 2019

Incidentally Detected Focal Fundal Gallbladder Wall Thickening at Contrast-Enhanced Computed Tomography: Prevalence and Computed Tomography Features of Malignancy.

J Comput Assist Tomogr 2019 Jan/Feb;43(1):149-154

Department of Public Health Sciences, University of California, Davis, Davis, CA.

Objective: The aim of this study was to determine the prevalence and computed tomography (CT) features of malignancy in incidental focal fundal gallbladder wall thickening.

Methods: Patients with incidental focal fundal gallbladder wall thickening on CT were included if they had an ultrasound or magnetic resonance imaging diagnostic of the etiology (n = 19), stability on CT for 1 year (n = 84), or pathological correlation (n = 13). Morphologies were classified as type 1 (nodular/pinched intramural low attenuation), type 2 (intramural low attenuation), type 3 (homogeneous enhancement), type 4 (nodular/pinched homogeneous enhancement), type 5 (intramural cystic spaces), or type 6 (hyperenhancing/heterogeneous enhancement).

Results: One hundred sixteen patients had the following morphologies: type 1 (n = 57), type 2 (n = 10), type 3 (n = 6), type 4 (n = 19), type 5 (n = 14), and type 6 (n = 10). Four cases (3.4%; 95% confidence interval, 0.9%-8.6%) of malignancy were identified (type 6 in 3 and type 3 in 1).

Conclusions: Incidental focal fundal gallbladder wall thickening is usually benign. Computed tomography features help distinguish benign from malignant etiologies.
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http://dx.doi.org/10.1097/RCT.0000000000000802DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6331261PMC
January 2019

Both Ultrasound Features and Nuclear Atypia are Associated with Malignancy in Thyroid Nodules with Atypia of Undetermined Significance.

Ann Surg Oncol 2018 Dec 9;25(13):3913-3918. Epub 2018 Oct 9.

Department of Surgery, University of California, Davis Medical Center, Sacramento, CA, USA.

Background: The optimal management of thyroid nodules that undergo fine-needle aspiration (FNA) with findings of atypia of undetermined significance (AUS) is unclear. Categorizing nodules by AUS subtype and ultrasound characteristics may improve risk stratification. Therefore, the purpose of this study is to evaluate the association between AUS subtype and ultrasound features on risk of malignancy (ROM).

Methods: We performed a review of all patients with a thyroid nodule who underwent an FNA at our institution between January 2010 and November 2015. Patients with AUS were divided into groups with (1) nuclear atypia, (2) architectural atypia, or (3) Hurthle cell atypia. Their ultrasound features were assessed using the American Thyroid Association (ATA) thyroid nodule sonographic patterns. We conducted a univariate and multivariable analysis to determine the association between AUS subtype and other variables of interest with ROM.

Results: Of the 3428 thyroid nodules that underwent FNA, 237 (6.9%) had AUS. Of the 97 surgically resected nodules, 67 (69%) were benign and 30 (31%) were malignant. On univariate analysis nuclear atypia (p < 0.01) was associated with a thyroid malignancy. On multivariable analysis, both ATA high-risk ultrasound features (p = 0.04, odds ratio [OR] 3.68) and nuclear atypia (p < 0.01, OR 11.8) were independently associated with a final diagnosis of thyroid carcinoma.

Conclusions: Nuclear atypia and ATA high-risk ultrasound features are useful in identifying patients with AUS that are at a higher risk of thyroid malignancy. Surgeons should take these factors into consideration when evaluating patients with AUS.
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http://dx.doi.org/10.1245/s10434-018-6826-6DOI Listing
December 2018

Optimizing renal transplant Doppler ultrasound.

Abdom Radiol (NY) 2018 10;43(10):2564-2573

Department of Radiology, University of Alabama at Birmingham, 619 19th St South, JTN 314, Birmingham, AL, 35249, USA.

Doppler ultrasound is routinely used for the post-operative evaluation of renal transplant patients. Knowledge of the surgical anatomy and application of a robust technique are important for appropriate evaluation of a transplanted kidney. In this review article, we discuss the surgical anatomy of renal transplantation, techniques to optimize image acquisition, as well as commonly associated pitfalls with Doppler ultrasound evaluation of renal grafts.
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http://dx.doi.org/10.1007/s00261-018-1731-9DOI Listing
October 2018

Introduction to the special section on kidney transplantation.

Abdom Radiol (NY) 2018 10;43(10):2545

University of California Davis Medical Center, Sacramento, CA, USA.

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http://dx.doi.org/10.1007/s00261-018-1692-zDOI Listing
October 2018

Prevalence of Solid Tumors in Incidentally Detected Homogeneous Renal Masses Measuring > 20 HU on Portal Venous Phase CT.

AJR Am J Roentgenol 2018 09 11;211(3):W173-W177. Epub 2018 Jul 11.

1 Department of Radiology, University of California, Davis Medical Center, 4860 Y St, Ste 3100, Sacramento, CA 95817.

Objective: The purpose of this study was to determine the prevalence of solid tumors in incidental homogeneous renal masses with attenuation greater than 20 HU on portal venous phase CT images.

Materials And Methods: In this retrospective study, the records of patients with incidental indeterminate (> 20 HU) homogeneous renal masses on portal venous phase CT scans from September 11, 2007, through March 18, 2017, were identified. Adult patients were included if they had undergone follow-up ultrasound, contrast-enhanced MRI, multiphase contrast-enhanced CT, or pathologic analysis alone to confirm the solid or cystic nature of the lesion. A single ROI was placed in the center of the mass, and lesions were characterized as ≥ 50% exophytic, < 50% exophytic, or entirely surrounded by renal parenchyma.

Results: There were 322 masses in 267 patients. The mean lesion size was 16.6 (SD, 9.8) mm (range, 9-45 mm). Lesions were ≥ 50% exophytic in 92 cases, < 50% exophytic in 111 cases, and completely surrounded by renal parenchyma in 119 cases. All nonsolid lesions were characterized as benign cysts. The numbers of solid lesions per total number of lesions in each attenuation group were: 20-30 HU (0/140), 30-40 HU (0/67), 40-50 HU (1/38), 50-60 HU (3/24), 60-70 HU (5/17), 70-80 HU (5/17), and > 80 HU (8/19). All 207 lesions in the 20- to 40-HU range were benign cysts with no solid lesions (0%; 95% CI, 0.0-1.4%).

Conclusion: Small homogeneous renal masses measuring 20-40 HU on portal venous phase CT images are highly likely to be benign cysts.
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http://dx.doi.org/10.2214/AJR.17.19351DOI Listing
September 2018

Pediatric en bloc kidney transplantation from very small (≤10 kg) donation after circulatory death (versus brain death) donors: Single-center matched-pair analysis of 130 transplants.

Am J Transplant 2018 11 4;18(11):2811-2817. Epub 2018 Jun 4.

Department of Surgery, University of California, Davis, School of Medicine, Sacramento, CA, USA.

En bloc kidney transplants (EBK) from very small pediatric donation after circulatory death (DCD) donors are infrequent because of the perception that DCD adversely impacts outcomes. We retrospectively studied 130 EBKs from donors ≤10 kg (65 consecutive DCD vs 65 donation after brain death [DBD] transplants; pair-matched for donor weight and terminal creatinine, and for preservation time). For DCD vs DBD, median donor weight was 5.0 vs 5.0 kg; median recipient age was 57 vs 48 years (P = .006). Graft losses from thrombosis (DCD, 5%; DBD, 7%) or primary nonfunction (DCD, 3%; DBD, 0%) were similar in both groups (P = .7). Delayed graft function rate was higher for DCD (25%) vs DBD (14%) (P = .2). Graft survival (death-censored) for DCD vs DBD at 5 years was 87% vs 91% (P = .3). Median estimated GFR (mL/min per 1.73 m ) was significantly lower for DCD recipients at 1 and 3 months; at 6 years it remained stable at 100 (DCD) and 99 (DBD). DCD impacted early posttransplant graft function, but did not appear to impart added risk for graft loss and long-term function. Very small (≤10 kg) DCD EBK donors should be considered as an option to augment the deceased kidney donor pool; larger studies with longer follow-up must confirm these findings.
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http://dx.doi.org/10.1111/ajt.14914DOI Listing
November 2018

Predonation Volume of Future Remnant Cortical Kidney Helps Predict Postdonation Renal Function in Live Kidney Donors.

Radiology 2018 Jul 20;288(1):153-157. Epub 2018 Mar 20.

From the Departments of Radiology (G.F., R.B., M.T.C), Internal Medicine (L.X.C), Surgery (J.S., C.T.), and Public Health Sciences (S.L.S), University of California Davis Medical Center, 4860 Y Street, Suite 3100, Sacramento, CA 95817.

Purpose To determine whether the predonation computed tomography (CT)-based volume of the future remnant kidney is predictive of postdonation renal function in living kidney donors. Materials and Methods This institutional review board-approved, retrospective, HIPAA-compliant study included 126 live kidney donors who had undergone predonation renal CT between January 2007 and December 2014 as well as 2-year postdonation measurement of estimated glomerular filtration rate (eGFR). The whole kidney volume and cortical volume of the future remnant kidney were measured and standardized for body surface area (BSA). Bivariate linear associations between the ratios of whole kidney volume to BSA and cortical volume to BSA were obtained. A linear regression model for 2-year postdonation eGFR that incorporated donor age, sex, and either whole kidney volume-to-BSA ratio or cortical volume-to-BSA ratio was created, and the coefficient of determination (R) for the model was calculated. Factors not statistically additive in assessing 2-year eGFR were removed by using backward elimination, and the coefficient of determination for this parsimonious model was calculated. Results Correlation was slightly better for cortical volume-to-BSA ratio than for whole kidney volume-to-BSA ratio (r = 0.48 vs r = 0.44, respectively). The linear regression model incorporating all donor factors had an R of 0.66. The only factors that were significantly additive to the equation were cortical volume-to-BSA ratio and predonation eGFR (P = .01 and P < .01, respectively), and the final parsimonious linear regression model incorporating these two variables explained almost the same amount of variance (R = 0.65) as did the full model. Conclusion The cortical volume of the future remnant kidney helped predict postdonation eGFR at 2 years. The cortical volume-to-BSA ratio should thus be considered for addition as an important variable to living kidney donor evaluation and selection guidelines. RSNA, 2018.
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http://dx.doi.org/10.1148/radiol.2018171642DOI Listing
July 2018

Vascular complications in kidney transplant recipients.

Abdom Radiol (NY) 2018 10;43(10):2546-2554

Department of Surgery, University of California Davis Medical Center, 2315 Stockton Blvd # 1018, Sacramento, CA, 95817, USA.

Vascular complications are a significant source of morbidity and mortality among renal transplant recipients. Imaging using ultrasound, CT, and MRI plays a key role in diagnosing such complications. This review focuses on the major vascular complications of renal grafts, which include transplant renal arterial and venous stenoses, arterial and venous thromboses, arteriovenous fistulas, and pseudoaneurysms. Etiology, diagnostic modalities useful for diagnosis, and imaging appearance will be presented.
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http://dx.doi.org/10.1007/s00261-018-1529-9DOI Listing
October 2018

Bladder debris on ultrasound in the emergency department: correlation with urinalysis.

Abdom Radiol (NY) 2018 09;43(9):2462-2466

University of California Davis Medical Center, 4860 Y Street Suite 3100, Sacramento, CA, 95817, USA.

Purpose: To evaluate the correlation between the presence of bladder debris on ultrasound and urinalysis results in the emergency department setting.

Methods: Adult patients presenting to the emergency department with an ultrasound of the bladder and a urinalysis performed within 24 h of the ultrasound were included in this retrospective study. Two radiologists in consensus evaluated for the presence or absence of debris within the bladder. Urinalysis results were recorded including continuous variables (specific gravity and pH) and categorical variables (presence of occult blood, bilirubin, ketones, glucose, protein, urobilinogen, nitrite, leukocyte esterase, white blood cells, and red blood cells). The presence and absence of white and red blood cells were defined as > 5 cells/high-powered field. To control the experimentwise type I error rate at 0.05, a Bonferroni-corrected significance level of 0.0042 was used to determine significant associations.

Results: The presence of bladder debris was associated with the presence of urobilinogen, nitrite, and white blood cells (p = < 0.0001, 0.0005, and 0.0004, respectively).

Conclusions: Bladder debris in the emergency department setting correlates with urinalysis laboratory values suggesting a urinary tract infection. Therefore, the presence of bladder debris should elicit the recommendation of a urinalysis in such a setting.
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http://dx.doi.org/10.1007/s00261-018-1513-4DOI Listing
September 2018