Publications by authors named "James H Ellis"

79 Publications

Toric Implantable Collamer Lens for the Treatment of Myopic Astigmatism.

Clin Ophthalmol 2021 6;15:2893-2906. Epub 2021 Jul 6.

Hoopes Vision Research Center, Hoopes Vision, Draper, UT, 84020, USA.

Purpose: 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.
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http://dx.doi.org/10.2147/OPTH.S321095DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8274236PMC
July 2021

Anterior Chamber Retained Lens Fragments After Cataract Surgery: A Case Series and Narrative Review.

Clin Ophthalmol 2021 21;15:2625-2633. Epub 2021 Jun 21.

Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA.

Introduction: 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.
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http://dx.doi.org/10.2147/OPTH.S314148DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8232887PMC
June 2021

Abdominal CT in COVID-19 patients: incidence, indications, and findings.

Abdom Radiol (NY) 2021 03 19;46(3):1256-1262. Epub 2020 Sep 19.

Department of Radiology, Michigan Medicine, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5030, USA.

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.
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http://dx.doi.org/10.1007/s00261-020-02747-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7501764PMC
March 2021

Influence of Clinical Factors on Risk of Contrast-Induced Nephrotoxicity From IV Iodinated Low-Osmolality Contrast Material in Patients With a Low Estimated Glomerular Filtration Rate.

AJR Am J Roentgenol 2019 11 3;213(5):W188-W193. Epub 2019 Jul 3.

Department of Radiology, Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5030.

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. 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 m and 86 patients with an eGFR < 30 mL/min/1.73 m 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. 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 m (odds ratio, 3.96 [95% CI, 1.29-12.21]; = 0.016) but not in those with an eGFR of 30-44 mL/min/1.73 m ( = 0.24). In patients with an eGFR of less than 30 mL/min/1.73 m, the tested covariates did not significantly modify the risk of CIN ( = 0.096-0.832). In patients with an eGFR of 30-44 mL/min/1.73 m, risk of CIN emerged in those with cardiovascular disease ( = 0.015; number needed to harm from LOCM = 11 patients); the other tested cofactors had no significant effect ( = 0.108-0.822). CIN was observed when eGFR was less than 30 mL/min/1.73 m. In those with an eGFR of 30-44 mL/min/1.73 m, 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.
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http://dx.doi.org/10.2214/AJR.19.21424DOI Listing
November 2019

Benign diseases of the urinary tract at CT and CT urography.

Abdom Radiol (NY) 2019 12;44(12):3811-3826

Department of Radiology, Michigan Medicine, Ann Arbor, MI, 48109-5030, USA.

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http://dx.doi.org/10.1007/s00261-019-02108-xDOI Listing
December 2019

Bosniak Classification of Cystic Renal Masses, Version 2019: An Update Proposal and Needs Assessment.

Radiology 2019 08 18;292(2):475-488. Epub 2019 Jun 18.

From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (S.G.S., A.B.S.); Disease-Focused Panel on Renal Cell Carcinoma, Society of Abdominal Radiology, Houston, Tex (S.G.S., I.P., N.M.H., N.S., A.D.S., E.M.R., A.B.S., N.E.C., S.S.R., S.A.W., S.D.K., Z.J.W., H.C., M.S.D.); Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Tex (I.P.); Departments of Radiology and Urology, Michigan Medicine, University of Michigan, 1500 E Medical Center Dr, B2-A209A, Ann Arbor, MI 48109 (J.H.E., N.E.C., S.D.K., M.S.D.); Department of Radiology, New York University Langone Medical Center, New York, NY (N.M.H., H.C.); Department of Radiology, University of Ottawa, Ottawa, Canada (N.S.); Department of Radiology, University of Alabama School of Medicine, Birmingham, Ala (A.D.S.); Imaging Institute and Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio (E.M.R.); Department of Radiology, David Geffen School of Medicine, UCLA Center for the Health Sciences, Los Angeles, Calif (S.S.R.); Department of Radiology, University of Wisconsin Hospital and Clinics, Madison, Wis (S.A.W.); and Department of Radiology, UCSF Medical Center, San Francisco, Calif (Z.J.W.).

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.
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http://dx.doi.org/10.1148/radiol.2019182646DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6677285PMC
August 2019

Approach to Evaluation of Multiple Liver Lesions.

Authors:
James H Ellis

JAMA 2019 05;321(20):2031

Department of Radiology, University of Michigan, Ann Arbor.

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http://dx.doi.org/10.1001/jama.2019.2728DOI Listing
May 2019

Gadolinium Retention: A Research Roadmap from the 2018 NIH/ACR/RSNA Workshop on Gadolinium Chelates.

Radiology 2018 11 11;289(2):517-534. Epub 2018 Sep 11.

From the Division of Neuroradiology, Department of Radiology, Mayo Clinic, Rochester, Minn (R.J.M.); Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215 (D.L., H.Y.K.); Department of Radiology & Biomedical Imaging, Yale School of Medicine, New Haven, Conn (J.W.); Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pa (E.K.); Department of Radiology, University of Michigan Health System, Ann Arbor, Mich (M.S.D., J.H.E.); Cancer Imaging Program, National Institutes of Health, National Cancer Institute, Bethesda, Md (P.M.J.); Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (R.E.L.); Department of Radiology, University of Washington, Seattle, Wash (K.R.M.); Department of Radiology, Cornell and Columbia Universities, New York, NY (M.R.P.); Department of Radiology, University of Wisconsin, Madison, Wis (H.A.R.); and Department of Radiology, The Ohio State University, Columbus, Ohio (M.F.T.).

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 .
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http://dx.doi.org/10.1148/radiol.2018181151DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6209069PMC
November 2018

Novel Quality Indicators for Radiologists Interpreting Abdominopelvic CT Images: Risk-Adjusted Outcomes Among Emergency Department Patients With Right Lower Quadrant Pain.

AJR Am J Roentgenol 2018 Jun 18;210(6):1292-1300. Epub 2018 Apr 18.

5 Department of Emergency Medicine, Michigan Medicine, Ann Arbor, MI.

Objective: 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.

Materials And Methods: 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.

Results: 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 p > 0.05).

Conclusion: 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.
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http://dx.doi.org/10.2214/AJR.17.19163DOI Listing
June 2018

Expanding the Definition of a Benign Renal Cyst on Contrast-enhanced CT: Can Incidental Homogeneous Renal Masses Measuring 21-39 HU be Safely Ignored?

Acad Radiol 2018 02 23;25(2):209-212. Epub 2017 Nov 23.

Department of Radiology, University of Michigan Health System, 1500 E. Medical Center Dr B2-A209P, Ann Arbor, MI 48109; Michigan Radiology Quality Collaborative, Ann Arbor, Michigan; Department of Urology, University of Michigan Health System, Ann Arbor, Michigan. Electronic address:

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.
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http://dx.doi.org/10.1016/j.acra.2017.09.021DOI Listing
February 2018

Recurrence of Colonic Diverticulitis: Identifying Predictive CT Findings-Retrospective Cohort Study.

Radiology 2017 12 24;285(3):850-858. Epub 2017 Aug 24.

From the Division of Abdominal Radiology, Department of Radiology (E.C.D., J.H.E., M.S.D., M.A., R.H.C.); Division of Emergency Radiology, Department of Radiology (S.T.C., M.B.M.), Michigan Institute for Clinical and Health Research (K.W.), Department of Biostatistics, School of Public Health (B.N.), Division of Gastroenterology, Department of Internal Medicine (R.R.), and Division of Colorectal Surgery, Division of General Surgery, Department of Surgery (A.M.M.), University of Michigan Health System, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5030.

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.
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http://dx.doi.org/10.1148/radiol.2017161374DOI Listing
December 2017

Intravenous Corticosteroid Premedication Administered 5 Hours before CT Compared with a Traditional 13-Hour Oral Regimen.

Radiology 2017 11 26;285(2):425-433. Epub 2017 Jul 26.

From the Departments of Radiology (B.M.M., R.H.C., J.H.E., M.S.D.) and Urology (J.H.E., M.S.D.), University of Michigan Health System, 1500 E Medical Center Dr, Room B2 A209P, Ann Arbor, MI 48109-5030; and Michigan Institute for Clinical and Health Research (S.K.) and Michigan Radiology Quality Collaborative (M.S.D.), University of Michigan, Ann Arbor, Mich.

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.
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http://dx.doi.org/10.1148/radiol.2017170107DOI Listing
November 2017

Effect of Fixed-Volume and Weight-Based Dosing Regimens on the Cost and Volume of Administered Iodinated Contrast Material at Abdominal CT.

J Am Coll Radiol 2017 Mar 21;14(3):359-370. Epub 2016 Dec 21.

Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan.

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.
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http://dx.doi.org/10.1016/j.jacr.2016.09.001DOI Listing
March 2017

Predictors of Delayed Intervention for Patients on Active Surveillance for Small Renal Masses: Does Renal Mass Biopsy Influence Our Decision?

Urology 2016 Dec 19;98:88-96. Epub 2016 Jul 19.

Department of Urology, University of Michigan Health System, Ann Arbor, MI.

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 < .001), but not renal biopsy (HR 1.52, 95% CI 0.70-3.30, 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.
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http://dx.doi.org/10.1016/j.urology.2016.04.067DOI Listing
December 2016

Effect of delayed resection after initial surveillance and tumor growth rate on final surgical pathology in patients with small renal masses (SRMs).

Urol Oncol 2016 11 28;34(11):486.e9-486.e15. Epub 2016 Sep 28.

Department of Urology, University of Michigan, Ann Arbor, MI. Electronic address:

Objective: To understand potential harms associated with delaying resection of small renal masses (SRMs) in patients ultimately treated, and whether these patients have factors associated with adverse pathology.

Methods: Patients with SRMs (≤4cm) who underwent surgical resection at our institution (2009-2015) were classified as undergoing early resection or initial surveillance with delayed resection (defined by a time from presentation to intervention of at least 6mo). Demographic and clinical variables were compared among groups. Using multivariable logistic regression, we examined the association between delayed resection and adverse pathology (Fuhrman grade 3-4, papillary type 2, sarcomatoid histology, angiomyolipoma with epithelioid features, or stage≥pT3). For patients who underwent delayed intervention, we used similar methods to examine the association between SRM growth rate and adverse pathology.

Results: Overall, 401 (81%) and 94 (19%) patients underwent early and delayed resection, respectively. Median time to resection was 84 days (interquartile range: 59-121) and 386 days (interquartile range: 272-702) (P<0.001). Patients undergoing delayed resection were older (62 vs. 58y, P = 0.01) and had smaller masses (2.3 vs. 2.7cm, P<0.001) at initial presentation. Utilization of partial vs. radical nephrectomy was similar regardless of resection timing (P = 0.5). Delayed resection was not associated with adverse pathology (P = 0.8); however, male sex was independently associated with adverse pathology (odds ratio: 1.7, 95% CI: 1.1-2.4, P = 0.009). In patients on surveillance, increasing annual SRM growth rate was associated with adverse pathology (odds ratio: 1.2, 95% CI: 1.03-1.3mm/y, P = 0.02).

Conclusions: Delayed resection was not associated with adverse pathology. Patients on surveillance with increased SRM growth rates had a modest but significant increase in the risk of adverse pathology.
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http://dx.doi.org/10.1016/j.urolonc.2016.05.032DOI Listing
November 2016

Value of pelvis CT during follow-up of patients with pancreatic adenocarcinoma.

Abdom Radiol (NY) 2017 01;42(1):211-215

Department of Radiology, University of Michigan Medical Center, UH B1-D502, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.

Purpose: The 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.

Methods: This 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.

Results: No 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.

Conclusion: Isolated 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.
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http://dx.doi.org/10.1007/s00261-016-0869-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5247305PMC
January 2017

"Concordance" Revisited: A Multispecialty Appraisal of "Concordant" Preliminary Abdominopelvic CT Reports.

J Am Coll Radiol 2016 Sep 20;13(9):1111-7. Epub 2016 Jun 20.

Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan; Michigan Radiology Quality Collaborative, Ann Arbor, Michigan. Electronic address:

Purpose: To determine whether resident abdominopelvic CT reports considered prospectively concordant with the final interpretation are also considered concordant by other blinded specialists and abdominal radiologists.

Methods: In this institutional review board-approved retrospective cohort study, 119 randomly selected urgent abdominopelvic CT examinations with a resident preliminary report deemed prospectively "concordant" by the signing faculty were identified. Nine blinded specialists from Emergency Medicine, Internal Medicine, and Abdominal Radiology reviewed the preliminary and final reports and scored the preliminary report with respect to urgent findings as follows: 1.) concordant; 2.) discordant with minor differences; 3.) discordant with major differences that do not alter patient management; or 4.) discordant with major differences that do alter patient management. Predicted management resulting from scores of 4 was recorded. Consensus was defined as majority agreement within a specialty. Consensus major discrepancy rates (ie, scores 3 or 4) were compared to the original major discrepancy rate of 0% (0/119) using the McNemar test.

Results: Consensus scores of 4 were assigned in 18% (21/119, P < .001, Emergency Medicine), 5% (6/119, P = .03, Internal Medicine), and 13% (16/119, P < .001, Abdominal Radiology) of examinations. Consensus scores of 3 or 4 were assigned in 31% (37/119, P < .001, Emergency Medicine), 14% (17/119, P < .001, Internal Medicine), and 18% (22/119, P < .001, Abdominal Radiology). Predicted management alterations included hospital status (0-4%), medical therapy (1%-4%), imaging (1%-10%), subspecialty consultation (3%-13%), nonsurgical procedure (3%), operation (1%-3%), and other (0-3%).

Conclusions: The historical low major discrepancy rate for urgent findings between resident and faculty radiologists is likely underreported.
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http://dx.doi.org/10.1016/j.jacr.2016.04.019DOI Listing
September 2016

Comparison of Percutaneous Renal Mass Biopsy and R.E.N.A.L. Nephrometry Score Nomograms for Determining Benign Vs Malignant Disease and Low-risk Vs High-risk Renal Tumors.

Urology 2016 Oct 1;96:87-92. Epub 2016 Jun 1.

Department of Urology, University of Michigan Health System, Ann Arbor, MI.

Objective: 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.

Materials And Methods: 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.

Results: 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.

Conclusion: 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.
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http://dx.doi.org/10.1016/j.urology.2016.05.044DOI Listing
October 2016

Effect of available intravenous access on accuracy and timeliness of epinephrine administration.

Abdom Radiol (NY) 2016 06;41(6):1133-41

Division of Abdominal Imaging, Department of Radiology, University of Michigan Health System, 1500 E. Medical Center Dr. B1-D502H, Ann Arbor, MI, 48109, USA.

Purpose: To evaluate the effect of available intravenous (IV) access on the accuracy and timeliness of epinephrine administration during a surprise mock severe contrast reaction.

Methods: 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.

Results: 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).

Conclusions: 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.
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http://dx.doi.org/10.1007/s00261-016-0660-8DOI Listing
June 2016

Clinical Effectiveness of Prospectively Reported Sonographic Twinkling Artifact for the Diagnosis of Renal Calculus in Patients Without Known Urolithiasis.

AJR Am J Roentgenol 2016 Feb;206(2):326-31

1 Department of Radiology, University of Michigan Health System, 1500 E Medical Center Dr, B2-A209P, Ann Arbor MI, 48109.

Objective: 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.

Materials And Methods: 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).

Results: 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).

Conclusion: Isolated sonographic twinkling artifact has a high false-positive rate (60%) for the diagnosis of renal calculus in patients without known urolithiasis.
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http://dx.doi.org/10.2214/AJR.15.14998DOI Listing
February 2016

Indirect Cost and Harm Attributable to Oral 13-Hour Inpatient Corticosteroid Prophylaxis before Contrast-enhanced CT.

Radiology 2016 May 4;279(2):492-501. Epub 2015 Nov 4.

From the Department of Radiology (M.S.D., B.M.M., .H.E., J.R.D., N.R.D., R.H.C.), Division of Abdominal Imaging (M.S.D., J.H.E., N.R.D., R.H.C.); Section of Pediatric Imaging (J.R.D.), and Michigan Radiology Quality Collaborative (M.S.D.), University of Michigan Health System, 1500 E Medical Center Dr, Ann Arbor, MI 48108.

Purpose: 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.

Materials And Methods: 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.

Results: 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.

Conclusion: 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.
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http://dx.doi.org/10.1148/radiol.2015151143DOI Listing
May 2016

Age, Gender and R.E.N.A.L. Nephrometry Score do not Improve the Accuracy of a Risk Stratification Algorithm Based on Biopsy and Mass Size for Assigning Surveillance versus Treatment of Renal Tumors.

J Urol 2016 Mar 30;195(3):574-80. Epub 2015 Oct 30.

Department of Urology, University of Michigan Health System, Ann Arbor, Michigan. Electronic address:

Purpose: A previously published risk stratification algorithm based on renal mass biopsy and radiographic mass size was useful to designate surveillance vs the need for immediate treatment of small renal masses. Nonetheless, there were some incorrect assignments, most notably when renal mass biopsy indicated low risk malignancy but final pathology revealed high risk malignancy. We studied other factors that might improve the accuracy of this algorithm.

Materials And Methods: For 202 clinically localized small renal masses in a total of 200 patients with available R.E.N.A.L. (radius, exophytic/endophytic, nearness of tumor to collecting system or sinus, anterior/posterior, hilar tumor touching main renal artery or vein and location relative to polar lines) nephrometry score, preoperative renal mass biopsy and final pathology we assessed the accuracy of management assignment (surveillance vs treatment) based on the previously published risk stratification algorithm as confirmed by final pathology. Logistic regression was used to determine whether other factors (age, gender, R.E.N.A.L. score, R.E.N.A.L. score components and nomograms based on R.E.N.A.L. score) could improve assignment.

Results: Of the 202 small renal masses 53 (26%) were assigned to surveillance and 149 (74%) were assigned to treatment by the risk stratification algorithm. Of the 53 lesions assigned to surveillance 25 (47%) had benign/favorable renal mass biopsy histology while in 28 (53%) intermediate renal mass biopsy histology showed a mass size less than 2 cm. Nine of these 53 masses (17%) were incorrectly assigned to surveillance in that final pathology indicated the need for treatment (ie intermediate histology and a mass greater than 2 cm or unfavorable histology). Final pathology confirmed a correct assignment in all 149 masses assigned to treatment. None of the additional parameters assessed improved assignment with statistical significance.

Conclusions: Age, gender, R.E.N.A.L. nephrometry score, R.E.N.A.L. score components and nomograms or combinations of these factors do not improve the predictive performance of a small renal mass management risk stratification algorithm based on renal mass biopsy and radiographic mass size.
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http://dx.doi.org/10.1016/j.juro.2015.10.137DOI Listing
March 2016

Renal Masses: Imaging Evaluation.

Radiol Clin North Am 2015 Sep;53(5):985-1003

Department of Radiology, University of Michigan Hospital, University of Michigan Health System, Room B1-D502, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5030, USA.

This article illustrates the imaging characteristics of cystic and solid renal masses, along with a summary of identified imaging criteria that may be of use to differentiate masses that are more likely to be benign from those that are more likely to be malignant. In addition, important features of known or suspected renal cancers that should be identified before treatment are summarized, including staging of renal cancer and RENAL nephrometry. Finally, the imaging appearance of patients following treatment of renal cancer, including after partial or total nephrectomy, thermal ablation, or chemotherapy for metastatic disease, is reviewed.
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http://dx.doi.org/10.1016/j.rcl.2015.05.003DOI Listing
September 2015

Effect of Model-Based Iterative Reconstruction on CT Number Measurements Within Small (10-29 mm) Low-Attenuation Renal Masses.

AJR Am J Roentgenol 2015 Jul;205(1):85-9

1 Department of Radiology, University of Michigan Health System, 1500 E Medical Center Dr, B2-A209P, Ann Arbor, MI 48109.

Objective: 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.

Materials And Methods: 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.

Results: 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).

Conclusion: 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.
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http://dx.doi.org/10.2214/AJR.14.13835DOI Listing
July 2015

Rates of Breakthrough Reactions in Inpatients at High Risk Receiving Premedication Before Contrast-Enhanced CT.

AJR Am J Roentgenol 2015 Jul;205(1):77-84

1 Department of Radiology, University of Michigan Health System, 1500 E Medical Center Dr, B2-A209P, Ann Arbor, MI 48109.

Objective: 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).

Materials And Methods: 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.

Results: 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) (p < 0.0001 vs the general population), 2.1% (13/626) for those with a previous iodinated contrast reaction (p < 0.0001), 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 (p < 0.0001; 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.

Conclusion: 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.
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http://dx.doi.org/10.2214/AJR.14.13810DOI Listing
July 2015

Contrast media controversies in 2015: imaging patients with renal impairment or risk of contrast reaction.

AJR Am J Roentgenol 2015 Jun 2;204(6):1174-81. Epub 2015 Mar 2.

1 Department of Radiology, University of Michigan Health System, 1500 E Medical Center Dr, B2-A209P, Ann Arbor, MI 48109-5030.

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/1.73 m(2), but if there is a risk, it is greatest in those with estimated GFR less than 30 mL/min/1.73 m(2). 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.
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http://dx.doi.org/10.2214/AJR.14.14259DOI Listing
June 2015

Abdominopelvic hemorrhage: correlation of CT positivity with the subsequent decision to perform blood transfusion.

Abdom Imaging 2015 Oct;40(8):3348-53

Michigan Institute for Clinical and Health Research (MICHR), University of Michigan Medical Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.

The purpose of this study is to determine the role of computed tomography (CT) on the decision to administer blood transfusions in patients with abdominopelvic hemorrhage (trauma, surgery, invasive procedure, and spontaneous) and to determine the clinical parameters most likely to influence the decision to administer blood transfusions in patients with spontaneous abdominopelvic hemorrhage. In this IRB approved and HIPPA compliant study, retrospective analysis was performed on 298 patients undergoing abdominal and pelvic CT for suspected abdominopelvic hemorrhage and the CT reports and electronic medical records were reviewed. Odds ratios and 95% CI were calculated to compare the odds of abdominopelvic hemorrhage and transfusion for categorical and continuous predictors. The presence of abdominopelvic hemorrhage by CT was significantly associated with blood transfusions for trauma patients (p-value <0.0001) only. 106 patients with suspected spontaneous abdominopelvic hemorrhage had the lowest CT positivity rate (n = 23, 21.7%) but the highest blood transfusion rate (n = 62, 58.5%) compared to the patients with abdominopelvic hemorrhage from known preceding causes. In patients with spontaneous abdominopelvic hemorrhage, low hemoglobin and hematocrit levels immediately prior to obtaining the CT study were more predictive for receiving a blood transfusion (p-value <0.0001) than the presence of hemorrhage by CT. CT positivity is strongly correlated with the decision to administer blood transfusions for patients with abdominopelvic hemorrhage from trauma, indicating that CT studies play a significant role in determining the clinical management of trauma patients. For patients with spontaneous abdominopelvic hemorrhage, the decision to transfuse depends not on the CT study but on the patient's hemoglobin and hematocrit levels. CT studies should therefore not be performed for the sole purpose of determining the need for blood transfusion in patients with spontaneous abdominopelvic hemorrhage.
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http://dx.doi.org/10.1007/s00261-015-0377-0DOI Listing
October 2015

Assessment of 1 mSv urinary tract stone CT with model-based iterative reconstruction.

AJR Am J Roentgenol 2014 Dec;203(6):1230-5

1 Department of Radiology, University of Michigan Health System, UH B1 D502, 1500 E Medical Center Dr, Ann Arbor, MI 48109.

Objective: The purpose of this study was to evaluate stone detection, assessment of secondary signs of stone disease, and diagnostic confidence utilizing submillisievert CT with model-based iterative reconstruction (MBIR) in a North American population with diverse body habitus.

Materials And Methods: Fifty-two adults underwent stone CT using a split-dose protocol; weight-based projected volume CT dose index (CTDIvol) and dose-length product (DLP) were divided into two separate acquisitions at 80% and 20% dose levels. Images were reconstructed with MBIR. Five blinded readers counted stones in three size categories and rated "overall diagnostic confidence" and "detectability of secondary signs of stone disease" on a 0-4 scale at both dose levels. Effective dose (ED) in mSv was calculated as DLP multiplied by conversion coefficient, k, equal to 0.017.

Results: Mean ED (80%, 3.90±1.44 mSv; vs 20%, 0.97±0.34 mSv [p<0.001]) and number of stones detected (80%, 193.6±25.0; vs 20%, 154.4±15.4 [p=0.03]) were higher in scans at 80% dose level. Intrareader correlation between scans at 80% and 20% dose levels was excellent (0.83-0.97). With 80% scans as reference standard, mean sensitivity and specificity at 20% varied with stone size (<3 mm, 74% and 77%; ≥3 mm, 92% and 82%). The 20% scans scored lower than 80% scans in diagnostic confidence (2.46±0.50; vs 3.21±0.36 [p<0.005]) and detectability of secondary signs (2.41±0.39; vs 3.19±0.29 [p<0.005]).

Conclusion: Aggressively dose-reduced (~1 mSv) MBIR scans detected most urinary tract stones of 3 mm or larger but underperformed the low-dose reference standard (3-4 mSv) scans in small (<3 mm) stone detection and diagnostic confidence.
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http://dx.doi.org/10.2214/AJR.13.12271DOI Listing
December 2014

Renal remodeling after abdominal radiation therapy: parenchymal and functional changes.

AJR Am J Roentgenol 2014 Aug;203(2):W192-8

1 University of Michigan Medical School, M4101 Medical Science Bldg, I-C Wing, 1301 Catherine Rd, Ann Arbor, MI 48109-5624.

Objective: The purpose of this study was to quantify changes in renal length, volume, and function over time after upper abdominal radiation therapy.

Materials And Methods: 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.

Results: 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% (p < 0.001) and 47% (p < 0.001), 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 (p < 0.001), then stabilized.

Conclusion: 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.
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http://dx.doi.org/10.2214/AJR.13.12149DOI Listing
August 2014

Response.

Radiology 2014 Mar;270(3):938

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March 2014
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