Publications by authors named "Michael J Reiter"

34 Publications

Transpedicular-Transdiscal Cement Augmentation Treatment of Thoracolumbar Fusion Proximal Junctional Failure.

Int J Spine Surg 2019 Oct 31;13(5):470-473. Epub 2019 Oct 31.

University of Colorado, Aurora, Colorado.

Background: Long instrumented fusions for adult deformity have a proximal junction kyphosis rate between 20% and 40%. When symptomatic, proximal junctional failure (PJF) often requires revision surgery and is associated with significant morbidity. Vertebral cement augmentation (VCA) has been used for prophylaxis against PJF but has not been previously described as treatment after onset of PJF has occurred. We describe a series of patients with PJF of long posterior spinal fusions that were treated at our institution using a novel VCA technique.

Methods: Three patients with PJF above thoracolumbopelvic fusions were retrospectively reviewed following treatment with transpedicular-transdiscal VCA. The medical record was reviewed for demographic data, outcomes scores, and radiographic images.

Results: Mean age was 69.3 years. Mean follow-up was 13.3 months. Mean preprocedure visual analog scale score was 8.67, and postprocedure visual analog scale score was 4.00. Mean preprocedure sagittal balance was 9.7 cm, and postprocedure sagittal balance was 5.8 cm. No patients required revision surgery for PJF in the follow-up period.

Conclusions: Transpedicular-transdiscal VCA treatment for PJF is safe and may have the potential to prevent the need for revision surgery.

Level Of Evidence: 4.
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http://dx.doi.org/10.14444/6062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6833968PMC
October 2019

The many faces of cirrhosis.

Abdom Radiol (NY) 2020 10;45(10):3065-3080

Department of Radiology, Brooke Army Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, San Antonio, TX, 78234, USA.

There are many different imaging features of cirrhosis, some of which are less commonly recognized. It is important that the radiologist is familiar with these features as cirrhosis can be first discovered on imaging performed for other indications, thus alerting the clinician for the need to screen for complications of cirrhosis and referral for potential treatment. This article reviews the various imaging findings of cirrhosis seen on cross-sectional imaging of the abdomen and pelvis.
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http://dx.doi.org/10.1007/s00261-019-02095-zDOI Listing
October 2020

Postoperative CT of the Mandible Following Trauma: Review of Normal Appearances and Common Complications.

Acad Radiol 2019 05 30;26(5):686-698. Epub 2018 Jul 30.

Department of Otolaryngology, Brooke Army Medical Center, San Antonio, Texas.

Rationale And Objectives: Surgeons aim to restore occlusion and jaw function to baseline status for patients with mandibular fractures using either closed treatment or reduction and fixation.

Materials And Methods: Occlusion is defined as the relationship between the maxillary and mandibular teeth as they approach each other.

Results: Radiologists should be familiar with the goals of repair to help identify which treatment is adequate as well as to diagnose potential complications. Some of the more common complications encountered are infection, nonunion or malunion, and malocclusion.

Conclusion: We provide a comprehensive review of both the desired and untoward CT findings after surgical repair of traumatic mandibular injuries.
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http://dx.doi.org/10.1016/j.acra.2018.06.009DOI Listing
May 2019

Frequency and distribution of incidental findings deemed appropriate for S modifier designation on low-dose CT in a lung cancer screening program.

Lung Cancer 2018 06 20;120:1-6. Epub 2018 Mar 20.

Department of Radiology, Stony Brook University Medical Center, Stony Brook, NY, United States.

Purpose: To describe the frequency, distribution and reporting patterns of incidental findings receiving the Lung-RADS S modifier on low-dose chest computed tomography (CT) among lung cancer screening participants.

Methods: This retrospective investigation included 581 individuals who received baseline low-dose chest CT for lung cancer screening between October 2013 and June 2017 at a single center. Incidental findings resulting in assignment of Lung-RADS S modifier were recorded as were incidental abnormalities detailed within the body of the radiology report only. A subset of 60 randomly selected CTs was reviewed by a second (blinded) radiologist to evaluate inter-rater variability of Lung-RADS reporting.

Results: A total of 261 (45%) participants received the Lung-RADS S modifier on baseline CT with 369 incidental findings indicated as potentially clinically significant. Coronary artery calcification was most commonly reported, accounting for 182 of the 369 (49%) findings. An additional 141 incidentalomas of the same types as these 369 findings were described in reports but were not labelled with the S modifier. Therefore, as high as 69% (402 of 581) of participants could have received the S modifier if reporting was uniform. Inter-radiologist concordance of S modifier reporting in a subset of 60 participants was poor (42% agreement, kappa = 0.2).

Conclusions: Incidental findings are commonly identified on chest CT for lung cancer screening, yet reporting of the S modifier within Lung-RADS is inconsistent. Specific guidelines are necessary to better define potentially clinically significant abnormalities and to improve reporting uniformity.
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http://dx.doi.org/10.1016/j.lungcan.2018.03.017DOI Listing
June 2018

Postoperative CT of the Midfacial Skeleton After Trauma: Review of Normal Appearances and Common Complications.

AJR Am J Roentgenol 2017 Oct 13;209(4):W238-W248. Epub 2017 Jul 13.

4 Department of Otolaryngology, Brooke Army Medical Center, San Antonio, TX.

Objective: The objective of this article is to describe the CT appearance of the midfacial skeleton after surgical repair of posttraumatic Le Fort, nasoorbitoethmoidal (NOE), and frontal sinus fractures. Several of the more commonly encountered complications will also be described.

Conclusion: Surgery after midfacial trauma is aimed at restoring both form and function. Knowledge of the principal tenets of Le Fort, NOE, and frontal sinus fracture repair is vital for radiologists to accurately assess the adequacy of treatment on postoperative CT and provide meaningful reports for the surgeon.
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http://dx.doi.org/10.2214/AJR.17.17875DOI Listing
October 2017

Dual-energy Computed Tomography for the Evaluation of Enhancement of Pulmonary Nodules≤3 cm in Size.

J Thorac Imaging 2017 May;32(3):189-197

*Department of Radiology, Stony Brook University Medical Center, Stony Brook, NY †Department of Radiology, Brooke Army Medical Center, San Antonio, TX ‡Uniformed Services University of the Health Sciences, Bethesda, MD.

Purpose: The aim of the study was to compare the accuracies of 4 different methods of assessing pulmonary nodule enhancement to distinguish benign from malignant solid pulmonary nodules using nondynamic contrast-enhanced dual-energy computed tomography.

Materials And Methods: Seventy-two patients (mean age, 62 y) underwent dual-energy chest computed tomography 3 minutes after intravenous contrast administration. Each of 118 pulmonary nodules (9±5.9 mm) were evaluated for enhancement by 4 methods: visual assessment, 3-dimensional automated postprocessing measurement tool, manually drawn region of interest with calculated iodine-related attenuation, and measurement of iodine concentration. The optimal cutoff for enhancement was defined as having the largest specificity among all cutoffs while maintaining 100% sensitivity. Accuracy of the methods was assessed with receiver operating characteristic curves.

Results: Ninety-three of 118 pulmonary nodules were benign (79%). Visual assessment of enhancement had sensitivity and specificity of 100% and 44%, respectively. For the automated 3-dimensional measurement tool, 20 HU was found to be the optimal threshold for defining enhancement, resulting in a specificity of 71% and a sensitivity of 100%, as well as an area under the curve (AUC) of 0.87 (95% confidence interval [CI], 0.82-0.92). The AUC was 0.79 (95% CI, 0.73-0.85) for the measured enhancement using a manually drawn region of interest. When a threshold of 21 HU was used for defining enhancement, maximum specificity was obtained (56%) while maintaining 100% sensitivity. The AUC for measured iodine concentration was 0.79 (95% CI, 0.77-0.85). At a cutoff iodine concentration of 0.6 mg/mL, the sensitivity was 100% with a specificity of 57%.

Conclusions: Although use of automated postprocessing had the highest specificity while maintaining 100% sensitivity, there were only minor clinically relevant differences between measurement techniques given that no single technique misclassified a malignant nodule as nonenhancing.
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http://dx.doi.org/10.1097/RTI.0000000000000263DOI Listing
May 2017

Magnetic Resonance Imaging Characteristics of a Baerveldt Glaucoma Implant.

J Glaucoma 2017 Jun;26(6):534-540

San Antonio Military Medical Center, Fort Sam Houston, San Antonio, TX.

Purpose: Evaluate for normative postoperative magnetic resonance imaging (MRI) characteristics of a Baerveldt Glaucoma Implant (BGI).

Design: Prospective case series.

Participants: Seven subjects with uncontrolled glaucoma requiring a primary superotemporal BGI.

Methods: Subjects prospectively underwent sequential MRI orbital scans without contrast at 0 to 2 weeks, 6 to 8 weeks, and 4 to 6 months after implantation of a BGI model 103-250. Masked to the postoperative time course, a radiologist measured bleb and implant characteristics.

Main Outcome Measures: Linear measurements of the maximum bleb height at the anterior, middle, and posterior sections of the endplate were measured. Intraocular pressure (IOP) was correlated to bleb height.

Results: On axial T2-weighted images, the height of fluid below and above the BGI endplate increased from the initial to the final MRI images: 0.49 mm to 1.83 mm and 0.57 mm to 1.08 mm (middle 1/3), respectively. On coronal T2-weighted images, fluid below and above the BGI endplate increased from 0.47 mm to 1.53 mm and 0.49 mm to 1.38 mm, respectively. Maximum inverse correlation between bleb height and IOP was observed at the 6 to 8 week coronal T2 images (r=-0.963, P=0.002).

Conclusions: Fluid collections and endplate characteristics are easily visualized with MRI. Dynamic changes occur over the early postoperative time course. Bleb height is inversely correlated to IOP at 6 to 8 weeks, but disappears at 4 to 6 months.
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http://dx.doi.org/10.1097/IJG.0000000000000658DOI Listing
June 2017

Mild asymptomatic intrahepatic biliary dilation after cholecystectomy, a common incidental variant.

Abdom Radiol (NY) 2017 05;42(5):1408-1414

Department of Radiology, Stony Brook University Medical Center, HSC Level 4, Room 120 East Loop Road, Stony Brook, NY, 11794, USA.

Objective: The purpose of this study is to evaluate the prevalence of intra- and extrahepatic ductal dilatation in asymptomatic individuals after cholecystectomy.

Methods And Materials: This IRB-approved retrospective cohort study evaluated the prevalence of intra- and extrahepatic biliary dilation in 77 consecutive post cholecystectomy patients who had CT obtained in the portal venous phase. These were then compared to age and sex matched control patients. Two radiologists in consensus blinded to surgical history evaluated the intrahepatic ducts qualitatively for dilatation. A single radiologist using the best of three orthogonal planes measured the extrahepatic ducts. Extrahepatic ducts were considered dilated if >7 mm plus 1 mm/decade after 60 years. T tests and chi-squared tests were performed.

Results: Cholecystectomy patient duct patterns: normal ducts 26% (20/77); intra- and extrahepatic dilation 31.2% (24/77); intrahepatic dilation only 18.2% (14/77); extrahepatic dilation only 24.7% (19/77). Control patient duct patterns: normal ducts 88.3% (68/77); intra- and extrahepatic dilation 2.6% (2/77); intrahepatic dilation only 2.6% (2/77); extrahepatic dilation only 6.5% (5/77). All intrahepatic ductal dilatation was mild. Total intrahepatic dilation: 49.4% (cholecystectomy); 5.2% (control patients). The relative risk of intrahepatic ductal dilation in cholecystectomy patients was 9.5:1. Increased prevalence of intra- and extrahepatic dilation in cholecystectomy patients was statistically significant (p < 0.0001). Average extrahepatic duct was 7.8 mm (cholecystectomy) and 5.3 mm (control patients) (p < 0.001).

Conclusion: Mild intrahepatic biliary dilation in the setting of cholecystectomy is very common, and if not associated with clinical or biochemical evidence of obstruction is likely of no clinical significance.
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http://dx.doi.org/10.1007/s00261-016-1017-zDOI Listing
May 2017

Uterine Incarceration: Imaging Findings on Magnetic Resonance Imaging.

J Emerg Med 2016 Sep 25;51(3):e49-50. Epub 2016 May 25.

Department of Radiology, Stony Brook University Medical Center, Stony Brook, New York.

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http://dx.doi.org/10.1016/j.jemermed.2016.04.006DOI Listing
September 2016

Postoperative CT of the Orbital Skeleton After Trauma: Review of Normal Appearances and Common Complications.

AJR Am J Roentgenol 2016 Jun 24;206(6):1276-85. Epub 2016 Mar 24.

4 Department of Otolaryngology, Brooke Army Medical Center, San Antonio, TX.

Objective: The purpose of this article is to describe both the expected and unexpected imaging features of posttraumatic defects of the orbital skeleton after surgical repair.

Conclusion: The goal of surgery is to restore the preinjury orbital anatomy to improve function and prevent enophthalmos. Radiologists need to be cognizant of the more frequently encountered operative procedures used for orbital fracture repair, the desired goals of treatment, and common complications. This will permit accurate interpretation of postoperative CT and provide surgeons with clinically useful results.
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http://dx.doi.org/10.2214/AJR.15.15477DOI Listing
June 2016

Improving Patient Satisfaction Through Computer-Based Questionnaires.

Orthopedics 2016 Jan-Feb;39(1):e31-5. Epub 2015 Dec 23.

Patient-reported outcome measures are helping clinicians to use evidence-based medicine in decision making. The use of computer-based questionnaires to gather such data may offer advantages over traditional paper-based methods. These advantages include consistent presentation, prompts for missed questions, reliable scoring, and simple and accurate transfer of information into databases without manual data entry. The authors enrolled 308 patients over a 16-month period from 3 orthopedic clinics: spine, upper extremity, and trauma. Patients were randomized to complete either electronic or paper validated outcome forms during their first visit, and they completed the opposite modality at their second visit, which was approximately 7 weeks later. For patients with upper-extremity injuries, the Penn Shoulder Score (PSS) was used. For patients with lower-extremity injuries, the Foot Function Index (FFI) was used. For patients with lumbar spine symptoms, the Oswestry Disability Index (ODI) was used. All patients also were asked to complete the 36-Item Short Form Health Survey (SF-36) Health Status Survey, version 1. The authors assessed patient satisfaction with each survey modality and determined potential advantages and disadvantages for each. No statistically significant differences were found between the paper and electronic versions for patient-reported outcome data. However, patients strongly preferred the electronic surveys. Additionally, the paper forms had significantly more missed questions for the FFI (P<.0001), ODI (P<.0001), and PSS (P=.008), and patents were significantly less likely to complete these forms (P<.0001). Future research should focus on limiting the burden on responders, individualizing forms and questions as much as possible, and offering alternative environments for completion (home or mobile platforms).
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http://dx.doi.org/10.3928/01477447-20151218-07DOI Listing
September 2016

Effect of Low-Osmolar Intravenous Contrast on Renal Length.

J Comput Assist Tomogr 2016 Jan-Feb;40(1):167-71

From the *Department of Radiology, San Antonio Military Medical Center, Ft. Sam Houston, TX; †Department of Radiology, Uniformed Services University of the Health Sciences, Bethesda, MD; ‡Resource Management Division, Brooke Army Medical Center, Houston, TX; and §Department of Radiology, Stony Brook University Medical Center, Stony Brook, NY.

Objective: The purpose was to study the effect of low-osmolar nonionic contrast on renal length.

Material And Methods: This study included 56 patients (4-phase renal computed tomography [CT] and 4-phase CT urogram [CTU], 19 patients each; split-phase CTU, 18 patients). Three radiologists created the best off-axis plane and renal lengths measured on a postprocessing workstation. Two-way analysis of variance with Bonferroni corrections was performed along with single-sample t tests.

Results: Four-phase renal CT and CTU average differences from unenhanced phases were 0.30/0.16 mm (corticomedullary), 0.88/1.33 mm (nephrographic), and 2.17/2.22 mm (delayed). The nephrographic and delayed phases were significantly different from their unenhanced phase (P < 0.01). Nonsignificant differences between the corticomedullary phase and the unenhanced phase were observed (P = 0.217, 4-phase renal CT; P = 0.232, 4-phase CTU). The split-phase CTU average difference in the enhanced phase was 1.36 mm (P < 0.001).

Conclusion: Renal length increases 1 to 2 mm with low-osmolar nonionic contrast.
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http://dx.doi.org/10.1097/RCT.0000000000000345DOI Listing
May 2016

Multiplanar Reformations in the Measurement of Renal Length on CT: Is It Plain Which Plane to Use?

AJR Am J Roentgenol 2015 Oct;205(4):797-801

1 Department of Radiology, San Antonio Military Medical Center, 3851 Roger Brooke Dr, #3600, San Antonio, TX 78234.

Objective: The objective of this study was to determine the accuracy of renal measurement on CT in multiple imaging planes.

Materials And Methods: In this study, three board-certified radiologists retrospectively measured 110 kidneys on CT in 55 consecutive patients. Five measurement methods were used: axial, coronal single image, coronal multiimage, sagittal single image, and sagittal multiimage. The coronal database was sent to a postprocessing workstation, and each radiologist performed a maximum renal measurement using a best off-axis plane that was our reference standard. An ANOVA test with repeated measures and posthoc Bonferroni corrected t tests were performed.

Results: The mean differences (± standard error) compared with the reference standard method were as follows: axial, 7.7 ± 0.7 mm; coronal single image, 13.1 ± 1.4 mm; coronal multiimage, 6.4 ± 0.8 mm; sagittal single image, 6.4 ± 0.6 mm; and sagittal multiimage, 2.8 ± 0.3 mm. The reference standard measurement was larger (p < 0.001), whereas the coronal single-image measurement (p ≤ 0.006) was smaller than all other methods. The sagittal multiimage (p ≤ 0.005) was statistically significantly different from all other methods. There were no statistically significant differences among the axial, coronal multiimage, and sagittal single-image methods (p ≥ 0.088).

Conclusion: The single-image coronal method is the least accurate, with an error of approximately 13 mm. The axial, multiimage coronal, and single-image sagittal methods underestimate renal size by approximately 6-8 mm. Multiimage sagittal is the most accurate method for measuring kidneys with an error of approximately 3 mm.
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http://dx.doi.org/10.2214/AJR.14.14248DOI Listing
October 2015

Review of Commonly Used Serum Tumor Markers and Their Relevance for Image Interpretation.

J Comput Assist Tomogr 2015 Nov-Dec;39(6):825-34

From the *Department of Radiology, Stony Brook University Medical Center, Stony Brook, NY; †Department of Radiology, Brooke Army Medical Center, San Antonio, TX; ‡Uniformed Services University of the Health Sciences, Bethesda, MD; and §Department of Oncology, Brooke Army Medical Center, San Antonio, TX.

Serum tumor markers are firmly entrenched as one of the primary tools in an oncologist's armamentarium. They can be implemented in a broad range of applications from diagnostic assistance, assessing prognosis, or guiding therapeutic decisions. However, tumor markers also have limitations, which significantly impact how they should be used. Radiologists should be familiar with the following most prevalent tumor markers, which will all be discussed here: prostate-specific antigen (prostate), carcinoembryonic antigen (colon), α-fetoprotein (hepatocellular and testicular), carbohydrate antigen 19.9 (pancreas), cancer antigen 125 (ovarian), human chorionic gonadotropin/lactic dehydrogenase (testicular), and chromogranin A (neuroendocrine). This knowledge should avoid needless intervention, enhance image interpretation, and ultimately provide optimal patient care.
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http://dx.doi.org/10.1097/RCT.0000000000000297DOI Listing
February 2016

Can a T2 hyperintense rim sign differentiate uterine leiomyomas from other solid adnexal masses?

Abdom Imaging 2015 Oct;40(8):3182-90

Department of Pathology, Brooke Army Medical Center, San Antonio, TX, USA.

Purpose: To investigate the incidence of high T2 signal rims surrounding leiomyomas, evaluate if a particular T2-weighted sequence is more effective in depicting this rim, and determine if this sign is useful in differentiating pedunculated leiomyomas from other solid adnexal masses.

Materials And Methods: In this retrospective study, two radiologists evaluated 233 T2 dark pelvic masses (223 uterine leiomyomas and 10 ovarian fibromas) in 60 women (mean age 47) on Magnetic resonance imaging for the presence of a high signal rim. Three different T2-weighted sequences were reviewed independently for uterine leiomyomas: half-Fourier acquisition single-shot turbo spin echo (HASTE), SPACE, and T2 with fat saturation (T2 FS). Only T2 FS images were available for 10 fibromas. A consensus review was conducted for discrepant cases. Statistical analyses were performed using Fisher's exact test, kappa test, and ANOVA RESULTS: For 223 uterine leiomyomas, 23% (95% CI 17.8-28.9%) demonstrated a high T2 signal rim sign on T2 FS compared with 4.9% (95% CI 2.6-8.9%) for HASTE and 6.7% (95% CI 3.9-11.1%) for SPACE. The difference between the number of positive rims on T2 FS relative-HASTE and SPACE was statistically significant (p < 0.001). For ovarian fibromas, 40% (95% CI 16.9-68.8%) were classified positive for a rim sign.

Conclusion: A high T2 signal rim sign was present for up to 23% of uterine leiomyomas and the T2 FS sequence detected this rim sign most frequently. Up to 40% of ovarian fibromas can also have a T2 rim sign and, therefore, a solid adnexal mass with a T2 rim sign cannot be assumed to represent a pedunculated leiomyoma.
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http://dx.doi.org/10.1007/s00261-015-0510-0DOI Listing
October 2015

Role of imaging for patients with colorectal hepatic metastases: what the radiologist needs to know.

Abdom Imaging 2015 Oct;40(8):3029-42

Department of Surgery, Brooke Army Medical Center, San Antonio, TX, USA.

Surgical resection of colorectal metastatic disease has increased as surgeons have adopted a more aggressive ideology. Current exclusion criteria are patients for whom a negative resection margin is not feasible or a future liver remnant (FLR) of greater than 20% is not achievable. The goal of preoperative imaging is to identify the number and distribution of liver metastases, in addition to establishing their relation to relevant intrahepatic structures. FLR can be calculated utilizing cross-sectional imaging to select out patients at risk for hepatic dysfunction after resection. MRI, specifically with gadoxetic acid contrast, is currently the preferred modality for assessment of hepatic involvement for patients with newly diagnosed colorectal cancer, to include those who have undergone neoadjuvant chemotherapy. Employment of liver-directed therapies has recently expanded and they may provide an alternative to hepatectomy in order to obtain locoregional control in poor surgical candidates or convert patients with initially unresectable disease into surgical candidates.
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http://dx.doi.org/10.1007/s00261-015-0507-8DOI Listing
October 2015

Surgical management of retrorectal lesions: what the radiologist needs to know.

AJR Am J Roentgenol 2015 Feb;204(2):386-95

1 Department of Radiology, Brooke Army Medical Center, 3551 Roger Brooke Dr, San Antonio, TX 78234.

OBJECTIVE. The purpose of this article is to highlight the most salient imaging features of retrorectal masses with regard to surgical planning, preoperative biopsy, and identification of nonneoplastic mimickers of malignancy. CONCLUSION. Retrorectal tumors are associated with high morbidity. CT and MRI aid in preoperative planning because surgical resection is the treatment of choice for both benign and malignant entities. Radiologists need to understand the operative techniques currently used for retrorectal tumors because the first attempt at excision is the best chance for complete resection and optimal outcome.
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http://dx.doi.org/10.2214/AJR.14.12791DOI Listing
February 2015

Gadoxetic acid: pearls and pitfalls.

Abdom Imaging 2015 Aug;40(6):2012-29

Department of Radiology, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio, TX, 78234, USA,

Gadoxetic acid is a hepatocyte-specific magnetic resonance imaging contrast agent with the ability to detect and characterize focal liver lesions and provide structural and functional information about the hepatobiliary system. Knowledge of the pharmacokinetics of gadoxetic acid is paramount to understanding imaging protocol and lesion appearance and facilitates identification and avoidance of undesired effects with use of this intravenous contrast agent. This article reviews the utility of gadoxetic acid in liver and biliary imaging, with emphasis on the hepatobiliary phase.
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http://dx.doi.org/10.1007/s00261-015-0354-7DOI Listing
August 2015

Postoperative imaging of the orbital contents.

Radiographics 2015 Jan-Feb;35(1):221-34

From the Departments of Radiology (M.J.R., R.B.S., J.A.K., G.E.Y.) and Ophthalmology (A.W.S.), Brooke Army Medical Center, 3851 Roger Brooke Dr, San Antonio, TX 78234.

Ophthalmologists perform a wide array of interventions on the orbital contents. The surgical treatment of glaucoma, cataracts, retinal detachment, and ocular trauma or malignancy results in alteration of the standard anatomy, which is often readily evident at radiologic examinations. The ability to accurately recognize the various imaging manifestations after orbital surgery is critical for radiologists to avoid misdiagnosis. Of particular importance is familiarity with the numerous types of implanted devices, such as glaucoma drainage devices, orbital implants, and eyelid weights. Although knowledge of patients' surgical history is helpful, this information is often not available at the time of interpretation. Fortunately, there are characteristic posttreatment findings that enable diagnosis. The imaging features of the most commonly performed ophthalmologic procedures are highlighted, with emphasis on computed tomography and magnetic resonance (MR) imaging, because they are currently the primary modalities involved in evaluating the orbits. Glaucoma drainage devices and orbital implants after enucleation are two of the more pertinent implanted devices because their composition has substantially evolved over the past 2 decades, which affects their imaging appearance. Some devices, such as the Baerveldt Glaucoma Implant and platinum-weighted eyelid implants, may distort radiologic images. The MR imaging safety profiles of numerous implanted devices are also reported.
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http://dx.doi.org/10.1148/rg.351140008DOI Listing
December 2015

Subtrochanteric femur fractures: review of the complete pathologic spectrum with emphasis on distinguishing imaging features.

J Comput Assist Tomogr 2015 Jan-Feb;39(1):47-56

From the *Department of Radiology, Brooke Army Medical Center, San Antonio, TX; †Uniformed Services University of the Health Sciences, Bethesda, MD; and ‡Department of Orthopedic Surgery, Brooke Army Medical Center, San Antonio, TX.

Subtrochanteric femur fractures result from a variety of mechanisms of injury and underlying pathologies. Radiologists can play a pivotal role by differentiating the etiology of a subtrochanteric femur fracture, which assists the orthopedic surgeon in choosing the correct method of treatment. To provide this valuable service, one must be familiar with the characteristic radiologic features of the numerous causative etiologies, ranging from Paget disease to underlying bone lesions to iatrogenic fractures.
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http://dx.doi.org/10.1097/RCT.0000000000000158DOI Listing
March 2015

Mimickers of neoplasm on abdominal and pelvic CT.

Abdom Imaging 2015 Feb;40(2):400-10

Department of Radiology, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX, 78234, USA,

Purpose: The radiologist can encounter benign significant imaging findings on computed tomography that can be incorrectly interpreted as neoplasm. The authors review several benign findings and demonstrate several methods to differentiate these findings from more sinister pathology.

Conclusion: It is imperative for the radiologist to be cognizant of and how to correctly identify mimickers of pathology so that unnecessary interventions and surgeries are avoided.
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http://dx.doi.org/10.1007/s00261-014-0216-8DOI Listing
February 2015

Computed tomography imaging manifestations of commonly used materials in posttraumatic craniofacial repair.

J Comput Assist Tomogr 2014 Nov-Dec;38(6):890-7

From the *Department of Radiology, Brooke Army Medical Center, San Antonio, TX; †Uniformed Services University of the Health Sciences, Bethesda, MD; and ‡Department of Otolaryngology, Brooke Army Medical Center, San Antonio, TX.

An expansive array of materials exists within the armamentarium of craniofacial surgeons. For patients undergoing repair of posttraumatic injuries, computed tomography is the imaging modality of choice in the postoperative setting. Therefore, radiologists will invariably encounter implants constructed with various materials, depending on the surgeon's preference. The appearance of these materials on computed tomography is broad, ranging from hyperdense to radiolucent. To avoid misdiagnosis, radiologists should be familiar with all of the materials currently in use.
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http://dx.doi.org/10.1097/RCT.0000000000000138DOI Listing
January 2015

Algorithmic approach to solid adnexal masses and their mimics: utilization of anatomic relationships and imaging features to facilitate diagnosis.

Abdom Imaging 2014 Dec;39(6):1284-96

Department of Radiology, Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX, 78234, USA,

Solid adnexal masses, while less common than their cystic counterparts, may present a challenge for radiologists given the wide range of histologic entities that occur in this region. Pelvic masses, especially when large, can seem overwhelming at first but application of an algorithmic approach allows for more confident assessment. This approach focuses first on the use of anatomic relationships and interactions of various pelvic structures to localize the mass' origin. For instance, the directionality of ureteral displacement can suggest if a mass is intra or extraperitoneal. Then, key discriminating imaging features, such as the presence of fat, hypervascularity, or low T2 signal on magnetic resonance imaging (MRI) can be applied to further narrow the list of diagnostic possibilities. Entities such as leiomyomas, nerve sheath tumors, congenital uterine anomalies, and vascular abnormalities (ovarian torsion or iliac vessel aneurysm) in particular are often accurately characterized with sonography and/or MRI. For solid adnexal masses in which a definitive diagnosis by imaging is not reached, information germane to clinicians regarding further management can still be provided, principally with regard to surgical vs. nonsurgical treatment.
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http://dx.doi.org/10.1007/s00261-014-0163-4DOI Listing
December 2014

Influence of intracardiac pressure on spontaneous ventricular arrhythmias in patients with systolic heart failure: insights from the REDUCEhf trial.

Circ Arrhythm Electrophysiol 2013 Apr 20;6(2):272-8. Epub 2013 Mar 20.

University of Colorado Medical Center, Aurora, CO, USA.

Background: The implantation of a combination hemodynamic monitor-cardioverter-defibrillator in the Reducing Decompensation Events Utilizing Intracardiac Pressures in Patients with Chronic Heart Failure (REDUCEhf) study allowed assessment of the relationship between daily intracardiac pressure and occurrence of ventricular arrhythmic (VT/VF) events.

Methods And Results: Median estimated pulmonary artery diastolic pressures (ePAD) were calculated every 24 hours in 378 subjects with New York Heart Association functional class II-III heart failure who had at least 60 days of hemodynamic data. Forty-six subjects experienced 140 VT/VF events on 80 unique study days in which daily median ePAD was available. The incidence of days with VT/VF events was significantly higher when the daily median ePAD for a subject was elevated, defined as >1 SD above that subject's average median ePAD for the whole study: (2.8 episode days per patient-year compared with 1.7 episode days per patient-year; P=0.040). However, the incidence of days with VT/VF events was not significantly different on days when ePAD was >25 mm Hg compared with days when ePAD was <25 mm Hg. For all 378 subjects, the risk of VT/VF increased with average median ePAD calculated over the whole follow-up period (odds ratio, 1.072 for a 1-mm Hg increase; 95% confidence interval, 1.023-1.124; P=0.003).

Conclusions: There is significant positive association between average daily median ePAD and risk for VT/VF. Among patients with VT/VF, elevated intracardiac pressures are associated with higher VT/VF risk only when the definition of increased pressure is subject specific.
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http://dx.doi.org/10.1161/CIRCEP.113.000223DOI Listing
April 2013

Thiazolidinedione drugs promote onset, alter characteristics, and increase mortality of ischemic ventricular fibrillation in pigs.

Cardiovasc Drugs Ther 2012 Jun;26(3):195-204

Cardiology Section, VA Medical Center and University of Colorado, Denver, CO, USA.

Purpose: Despite favorable metabolic and vascular effects, thiazolidinedione (TZD) drugs have not convincingly reduced cardiovascular mortality in clinical trials, raising the possibility of countervailing, off-target effects. We previously showed that TZDs block cardiac ATP-sensitive potassium (K(ATP)) channels in pigs. In this study, we investigated whether TZDs affect onset, spectral characteristics, and mortality of ischemic ventricular fibrillation (VF) and whether such effects are recapitulated by a non-selective K(ATP) blocker (glyburide) or a mitochondrial K(ATP) blocker (5-hydroxydecanoate).

Methods: A total of 121 anesthetized pigs were pre-treated with TZD (pioglitazone or rosiglitazone, 1 mg/kg IV, resulting in clinically relevant plasma concentrations), glyburide (1 mg/kg IV), 5-hydroxydecanoate (5 mg/kg IV) or inert vehicle. Ischemia was produced by occlusion of the left anterior descending coronary artery. In a subset of pigs treated with rosiglitazone or vehicle, ischemic preconditioning was performed.

Results: VF developed in all but 6 pigs. In non-preconditioned pigs, onset of VF occurred sooner with pioglitazone (11±3 min, p<0.05) or rosiglitazone (14±3 min, p=0.06) than with vehicle (20±2 min). Defibrillation of VF was successful in 44% of pigs treated with vehicle, compared with 0% with pioglitazone (p=0.057) and 33% with rosiglitazone (NS). After ischemic preconditioning, defibrillation was successful in 62% of pigs treated with vehicle, compared with 26% treated with rosiglitazone (p=0.03). TZDs attenuated slowing of conduction due to ischemia and shifted ECG power spectra during VF toward higher frequencies. All effects of TZDs were recapitulated by glyburide, but not by 5-hydroxydecanoate, supporting an interaction of TZDs with the sarcolemmal K(ATP) channel.

Conclusion: In a porcine model, TZDs promote onset and increase mortality of ischemic VF, associated with alterations of conduction and VF spectral characteristics. Similar effects in a clinical setting might adversely impact cardiovascular mortality.
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http://dx.doi.org/10.1007/s10557-012-6384-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5027884PMC
June 2012

The impact of stored atrial rhythm diagnostics in permanent pacemakers and the management of atrial fibrillation: the Vitatron Selection AFm Registry study.

J Interv Card Electrophysiol 2010 Sep 4;28(3):227-34. Epub 2010 Jun 4.

Northwestern University Feinberg School of Medicine, Cardiac Electrophysiology, 251 E. Huron St., Suite 8-503, Chicago, IL 60611, USA.

Introduction: The Selection AFm Registry investigated the impact of pacemaker diagnostic data on the clinical management of patients with atrial arrhythmias, specifically atrial fibrillation (AF) through the use of advanced atrial arrhythmia monitoring features. Very few data on the clinical impact of such data has been reported in a real world setting.

Methods: Patients with known or suspected AF with a Class I or Class II indication for a dual-chamber pacemaker received the Selection AFm pacemaker. These patients were prospectively followed at pacemaker follow-up visits, and data were collected on medications and device programming. Physicians identified which therapy changes were based upon the stored data within the pacemaker.

Results: Two hundred eighty-two patients were enrolled. A total of 119 patients had 311 changes made to either their medications or device programming after review of diagnostic pacemaker data. Changes involved rate and rhythm control, warfarin anticoagulation, and pacemaker programmed settings. Significantly, more changes were made in patients with documented atrial arrhythmias at follow-up.

Conclusions: The atrial arrhythmia recording features were used by clinicians to guide therapy-related decisions in patients with paroxysmal AF. Such data represent an additional source of clinical information for AF disease management.
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http://dx.doi.org/10.1007/s10840-010-9492-6DOI Listing
September 2010

Warfarin and aspirin use in atrial fibrillation among practicing cardiologist (from the AFFECTS Registry).

Am J Cardiol 2010 Apr 20;105(8):1130-4. Epub 2010 Feb 20.

Jefferson Medical College, Philadelphia, Pennsylvania, USA.

Among patients with atrial fibrillation (AF), the risk of thromboembolism is a significant concern. However, the reported use of warfarin among patients with AF at elevated risk of stroke remains low. In the present study, we have provided information on anticoagulation use reported during the recent Atrial Fibrillation: Focus on Effective Clinical Treatment Strategies (AFFECTS) Registry. Among patients identified by their physician at baseline to be at an increased risk of stroke, as determined from an assessment of the medical history, 74% received warfarin and 29% received aspirin. Post hoc analysis of warfarin use stratified by Congestive heart failure, Hypertension, Age, Diabetes, Stroke, (CHADS(2)) doubled score revealed that at the end of the study, warfarin use was 73% (155 of 213) and 66% (185 of 280) in the rate- and rhythm-control patients with a score of > or = 2, respectively, compared to 60% (183 of 306) and 49% (322 of 662) in the rate- and rhythm-control patients with a score of <2, respectively. The practicing cardiologists who participated in this registry initiated anticoagulation therapy in most of their patients with AF. However, warfarin use is not yet in line with the guidelines and evidence-based recommendations. Patients considered at no risk of stroke appear to have been overprescribed anticoagulant agents, and a considerable portion of high-risk patients did not receive warfarin. In conclusion, these results suggest that continued physician education of appropriate anticoagulation use in patients with AF is needed.
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http://dx.doi.org/10.1016/j.amjcard.2009.11.047DOI Listing
April 2010

Practice patterns among United States cardiologists for managing adults with atrial fibrillation (from the AFFECTS Registry).

Am J Cardiol 2010 Apr 20;105(8):1122-9. Epub 2010 Feb 20.

Columbia University, New York, NY, USA.

The Atrial Fibrillation: Focus on Effective Clinical Treatment Strategies (AFFECTS) Registry was designed to examine atrial fibrillation (AF) treatment by United States cardiologists in the context of the American College of Cardiology, American Heart Association, and European Society of Cardiology guidelines after recent landmark clinical trials. Most patients in AFFECTS had AF without clinically significant structural heart disease or only uncomplicated hypertension. Among the all-enrolled population (n = 1,461), initial treatment strategies assigned were rhythm control in 64% and rate control in 36%. Among patients with either paroxysmal (n = 1,165) or persistent (n = 273) AF, 67% and 55%, respectively, were assigned rhythm control. The trend to assign rhythm control as the initial treatment goal decreased with age. In the rhythm-control group, most patients (74%) also received a rate-control agent during the registry, while 25% of those assigned to rate control received antiarrhythmic drugs. Most first prescriptions of antiarrhythmic drugs were for first-line therapy compliant with 2001 (76%) and 2006 (86%) guidelines. Most second prescriptions were for first-line therapies as well. Rates of serious adverse events were low. In conclusion, data from this study provide insight into community treatment patterns in patients with AF, most without clinically significant structural heart disease or with only uncomplicated hypertension.
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http://dx.doi.org/10.1016/j.amjcard.2009.11.046DOI Listing
April 2010

Influence of structural heart disease on characteristics of atrial fibrillation recurrence in patients with dual-chamber pacemakers.

J Electrocardiol 2009 Mar-Apr;42(2):128-35. Epub 2008 Oct 30.

Department of Medicine, University of Colorado Health Sciences Center, Denver, CO, USA.

Aims: The aim of the study was to prospectively examine the influence of structural heart disease (SHD) and sinus node dysfunction (SND) on the frequency and duration of atrial fibrillation (AF) episodes in patients with implanted pacemakers.

Methods: We examined episodes of AF in 207 patients (93 with SHD; 165 with SND) with known or suspected paroxysmal AF who underwent dual-chamber pacing.

Results: Seventy-one percent of all patients experienced at least one episode of AF during follow-up, with a mean burden of 3.3 +/- 6.4 h/d (median, 0.2 hours) and a mean frequency of 11.7 +/- 26.0 episodes per day (median, 1.4). The proportion of episodes longer than 6 hours was greater in patients with SHD when compared to patients without SHD. In a logistic regression model adjusted for SND, gender, and the 2-way interactions of SND, sex, and SHD, SHD was a significant factor (P = .0188) with the odds ratio of having an episode longer than 6 hours 3.4 times higher for patients with SHD than for patients without SHD. Older patients with SHD had less frequent but longer episodes compared to younger patients. In patients without SHD, there was no comparable age difference. Burden, frequency, and average episode length were not influenced by the presence or absence of SND.

Conclusions: Patients with SHD have longer episodes of AF supporting the concept that SHD influences the underlying substrate to favor perpetuation.
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http://dx.doi.org/10.1016/j.jelectrocard.2008.09.002DOI Listing
May 2009

Value of pacemaker atrial diagnostic data in patients with paroxysmal atrial fibrillation: an opportunity to improve rates of warfarin utilization.

Pacing Clin Electrophysiol 2007 Apr;30(4):580-3

University of Minnesota, Minneapolis, Minnesota, USA.

Atrial diagnostic data within implantable devices provide an opportunity to assess the frequency and quantity of atrial fibrillation (AF) episodes (AF burden) and its impact on appropriate warfarin anticoagulation. Cardiologists were given clinical scenarios to review with different types of pacemaker diagnostic data in an elderly patient with risk factors for stroke. AF specific data was associated with increased warfarin utilization, but only at intermediate rates. Potential reasons and clinical implications are discussed.
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http://dx.doi.org/10.1111/j.1540-8159.2007.00714.xDOI Listing
April 2007
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