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Background Obesity is considered a major cardiovascular risk factor. The excess of pericardial fat (PF) in patients with obesity has been associated with a variety of electrocardiographic alterations. In previous studies, we demonstrated that rapid weight loss and bariatric interventions result in decreased PF. Objectives The aim of this study is to report the changes in PF after bariatric surgery and its effect on ventricular conduction. Setting US hospital, academic institution. Methods A linear measurement of PF thickness on computed tomography scans was obtained for 81 patients, as well as a retrospective review of electrocardiographic changes before and after bariatric surgery. We compared the changes in PF thickness and electrocardiographic components before and after procedures. Common demographics and co-morbidities were collected along with lipid profiles preoperative and postoperative. Results A total of 81 patients had electrocardiograms done before and 1 year after bariatric surgery. Females comprised 67.9% (n = 55), and the average age for our population was 55.07 ± 14.17 years. Pericardial fat thickness before surgery was 5.6 ± 1.84 and 4.5 ± 1.62 mm after surgery (P = .0001). Ventricular conduction (QT and QT corrected [QTc] intervals) showed a significant improvement from 438.7 + 29 before to 426.8 + 25.3 after bariatric surgery (P = .006). We found a statistically significant association between the decrease in PF and the decrease in QTc intervals (P = .002). Conclusion Obesity is a risk factor for arrhythmias and sudden cardiac death. Bariatric surgery and its effect on PF produce an improvement in ventricular conduction, which may reduce the ventricular electrical instability in patients with obesity.

Aim Treatment of transsphincteric fistulas (TSFs) with fistulotomy after an indwelling seton is tempered by risks of incontinence and litigation. Thus, ligation of the TSF tract has been popularized as an alternative option. We previously reported on 107 patients who underwent ligation of the intersphincteric fistula tract (LIFT), with a 46% failure rate. Posterior fistula was the only predictor of recurrence. The aim of the present work was to investigate whether the length, width or depth of the fistula measured on preoperative MRI was correlated with recurrence. Method Following institutional review board approval, a retrospective analysis of our prospective Complex Anal Fistula Database from 1 January 2011 to 31 August 2019 was performed. Patients with TSF who underwent preoperative MRI and LIFT were included. Fistula location was classified as anterior, posterior or lateral. MRI measurements of fistula length, width and depth (in the intersphincteric groove) were performed. The type and rate of postoperative recurrence were analysed. Results 173 patients underwent MRI for an anal fistula; of these 40 underwent LIFT and 22/40 (55%) had preoperative MRI. There was no difference in the length, width or depth of anterior (n = 9), posterior (n = 7) or lateral (n = 6) fistula tracts. The overall recurrence rate was 9/22 (41%). Posterior TSFs had the highest recurrence rate (5/7, 71%). Conclusion The mean length, width, and depth of the fistula tract, measured at the preoperative site of LIFT in the intersphincteric groove, did not correlate with recurrence regardless of fistula location.

Background Pericardial fat has a local atherosclerotic effect and is associated with both metabolic syndrome (MetS) and coronary artery disease (CAD). Objectives The aim of this study is to report changes in pericardial fat thickness (PFT) after bariatric surgery, and to investigate its significance on the risk of developing coronary artery disease (CAD). Setting Academic institution. Methods We retrospectively measured the linear pericardial thickness from patients’ computed tomography (CT) scans within 5 years preoperatively and compared to any available CT scan within 5 years postoperatively. The PFT was measured at the right ventricular wall, perpendicular to the myocardium, at the level of the sternum. The risk of developing CAD was estimated by calculating the Framingham risk score (FRS). We divided the patients into 2 groups: laparoscopic sleeve gastrectomy (SG, Group 1), and laparoscopic gastric Roux-en-Y gastric bypass (LRYGB, Group 2). Common demographic characteristics and co-morbidities were collected along with the preoperative and postoperative lipid profiles. Results A total of 113 patients met the inclusion criteria, with 64 (56.6%) patients in group 1 and 49 (43.3%) patients in group 2. Group 1 consisted of 83.6% (n = 53) female patients versus 75.5% (n = 37) in group 2. The percent excess body mass index loss (%EBMIL) at 12 months was 74.4 ± 35.8% for group 1 versus 67 ± 30.1% for group 2 (P = .292). Pericardial thickness before surgery was 5.6 ± 1.9 mm and 4.6 ± 1.6 mm after surgery (P = .0001). The risk of CAD in females was 9.1% before and 6.6% after surgery. We found statistically significant linear association between pericardial thickness after surgery and a lower risk of CAD (P = .001). Conclusion Bariatric surgery decreases the PFT lowering risk of developing CAD. Further studies may be needed to better assess these findings.

BACKGROUND The observation of inferior oncologic outcomes after surgery for proximal colon cancers has led to the investigation of alternative treatment strategies, including surgical procedures and neoadjuvant systemic chemotherapy in selected patients. OBJECTIVE The purpose of this study was to determine the accuracy of CT staging in proximal colon cancer in detecting unfavorable pathologic features that may aid in the selection of ideal candidates alternative treatment strategies, including extended lymph node dissection and/or neoadjuvant chemotherapy. DESIGN This was a retrospective consecutive series. SETTINGS Trained abdominal radiologists from 2 centers performed a blinded review of CT scans obtained to locally stage proximal colon cancer according to previously defined prognostic groups, including T1/2, T3/4, N+, and extramural venous invasion. CT findings were compared with histopathologic results as a reference standard. Unfavorable pathologic findings included pT3/4, pN+, or extramural venous invasion. PATIENTS Consecutive patients undergoing right colectomy in 2 institutions between 2011 and 2016 were retrospectively reviewed from a prospectively collected database. MAIN OUTCOME MEASURES T status, nodal status, and extramural venous invasion status comparing CT with final histologic findings were measured. RESULTS Of 150 CT scans reviewed, CT failed to identify primary cancer in 18%. Overall accuracy of CT to identify unfavorable pathologic features was 63% with sensitivity, specificity, positive predictive value, and negative predictive value of 63% (95% CI, 54%-71%), 63% (95% CI, 46%-81%), 87% (95% CI, 80%-94%) and 30% (95% CI, 18%-41%). Only cT3/4 (55% vs 45%; p = 0.001) and cN+ (42% vs 58%; p = 0.02) were significantly associated with correct identification of unfavorable features at final pathology. CT scans overstaged and understaged cT in 23.7% and 48.3% and cN in 28.7% and 53.0% of cases. LIMITATIONS The study was limited by its retrospective design, relatively small sample size, and heterogeneity of CT images performed in different institutions with variable equipment and technical details. CONCLUSIONS Accuracy of CT scan for identification of pT3/4, pN+, or extramural venous invasion was insufficient to allow for proper identification of patients at high risk for local recurrence and/or in whom to consider alternative treatment strategies. Locoregional overstaging and understaging resulted in inappropriate treatment strategies in

Renal masses found to contain macroscopic fatty elements on CT or MRI imaging can generally be classified as benign angiomyolipomas. Rarely, renal cell carcinomas may also contain evidence of macroscopic fat. When true adipocytic elements are present, this is generally due to a process of osseous metaplasia in which both fat cells and calcification are co-localized within the mass. We present a patient with a large papillary renal cell carcinoma containing abundant fat with sparse, punctate calcification remote from the fatty elements on imaging. This report highlights the need for radiologists to maintain caution when diagnosing renal angiomyolipomas on the basis of macroscopic fat and reviews the current literature on fat-containing renal masses.

Purpose To identify malfunction of implanted cardiac devices during or after thermal ablation of tumors in lung, kidney, liver or bone, using radiofrequency (RF) or microwave (MW) energy. Materials and methods After providing written consent, 19 patients (15 men and 4 women; mean age 78 years) with pacemakers or pacemaker/defibrillators underwent 22 CT image-guided percutaneous RF or MW ablation of a variety of tumors. Before and after each procedure, cardiac devices were interrogated and reprogrammed by a trained cardiac electrophysiology fellow. Possible pacer malfunctions included abnormalities on electrocardiographic (EKG) monitoring and alterations in device settings. Our institutional review board approved this Health Insurance Portability and Accountability Act-compliant study. Informed consent for participation in this retrospective study was deemed unnecessary by our review board. Results During 20 of 22 sessions, no abnormalities were identified in continuous, EKG tracings or pacemaker functions. However, in two sessions significant changes, occurred in pacemaker parameters: inhibition of pacing during RF application in one, session and resetting of mode by RF energy in another session. These changes did not, result in hemodynamic instability of either patient. MW ablation was not associated with, any malfunction. In all 22 sessions, pacemakers were undamaged and successfully reset to original parameters. Conclusion RF or MW ablation of tumors in liver, kidney, bone and lung can be performed safely in patients with permanent intra-cardiac devices, but careful planning between radiology and cardiology is essential to avoid adverse outcomes.

To review the recurrence patterns in patients with primary non-small cell lung cancer (NSCLC) treated with percutaneous image-guided radiofrequency (RF) ablation.This retrospective review was institutional review board approved and HIPAA compliant. Informed consent was waived. Data from all patients with primary NSCLC who underwent lung RF ablation from January 1998 to January 2008 were reviewed. Ninety-one patients were identified. Ten patients with no posttreatment imaging results and two patients with multiple treated lung cancers were excluded. There were 79 tumors in 79 patients (mean age, 75 years). Mean tumor size was 2.5 cm (range, 1-5.5 cm). Fifteen (19%) tumors were central, and 64 (81%) tumors were peripheral. Nineteen (24%) patients underwent adjuvant external beam radiation, and nine (11%) patients underwent concomitant brachytherapy. Correlation of computed tomography and positron emission tomography imaging studies with biopsy results, tumor size, location, and stage was performed. Patterns of recurrence were classified as local, intrapulmonary, nodal, mixed (local and nodal), and distant.Forty-five (57%) patients demonstrated no evidence of recurrence at follow-up imaging (range, 1-72 months; mean, 17 months). Recurrence was seen in 34 (43%) patients (range, 2-48 months; mean, 14 months). Recurrence after RF ablation was local in 13 (38%), intrapulmonary in six (18%), nodal in six (18%), mixed in two (6%), and distant metastases in seven (21%) cases. Median disease-free survival was 23 months. Sex, tumor location, and radiation therapy were not associated with risk of recurrence. Increasing tumor size (P = .02) and stage (P = .007) were related to risk of recurrence.The most common pattern of recurrence was local, which suggests that more aggressive initial RF ablation and adjuvant radiation may offer improvement in outcomes. Continued follow-up imaging is needed because new recurrences were seen throughout the 2 years following treatment.

The purpose of this study is to quantify the time expenditure associated with radiologist ordering of CT oral contrast media when using an integrated protocoling portal and to determine radiologists' perceptions of the ordering process.This prospective study was performed at a large academic tertiary care facility. Detailed timing information for CT inpatient oral contrast orders placed via the computerized physician order entry (CPOE) system was gathered over a 14-day period. Analyses evaluated the amount of physician time required for each component of the ordering process. Radiologists' perceptions of the ordering process were assessed by survey. Descriptive statistics and chi-square analysis were performed.A total of 96 oral contrast agent orders were placed by 13 radiologists during the study period. The average time necessary to create a protocol for each case was 40.4 seconds (average range by subject, 20.0-130.0 seconds; SD, 37.1 seconds), and the average total time to create and sign each contrast agent order was 27.2 seconds (range, 10.0-50.0 seconds; SD, 22.4 seconds). Overall, 52.5% (21/40) of survey respondents indicated that radiologist entry of oral contrast agent orders improved patient safety. A minority of respondents (15% [6/40]) indicated that contrast agent order entry was either very or extremely disruptive to workflow.Radiologist e-prescribing of CT oral contrast agents using CPOE can be embedded in a protocol workflow. Integration of health IT tools can help to optimize user acceptance and adoption.

The large-scale automated creation of radiation exposure databases from unstructured nuclear medicine reports is possible by using informatics tools and may potentially enhance patient safety efforts for both nuclear medicine quality assurance and radiation dose monitoring.

Aim To assess the incidence, appropriateness, and outcomes of recommendations for additional imaging tests (RAI) in oncological combined 2-[ 18 F]-fluoro-2-deoxy- d- glucose positron-emission tomography and computed tomography (FDG-PET/CT) reports. Material and methods In this retrospective study, conducted with institutional review board approval, the first oncological FDG-PET/CT reports in 2008 for 250 consecutive patients were reviewed to identify RAI. PET/CT reports containing RAI were retrospectively reviewed by two blinded readers. PET/CT findings prompting RAI, appropriateness of RAI, results of additional imaging tests actually performed, and the ultimate clinical significance of findings prompting RAI were recorded. Confirmation of clinical significance required pathology confirmation, unequivocal imaging progression, imaging stability for 12 months, or clinical follow-up for 24 months or end of life. Results Eighty-four RAI were identified for 88 PET/CT findings in 29.6% (74/250) of PET/CT reports, of which 51.2% (43/84) were deemed unnecessary by reviewers. Referring clinicians only followed 31% (26/84) of RAI by requesting additional imaging tests, and these tests resolved the PET/CT question in 76.9% (20/26) of those cases. Only 11.4% (10/88) of all findings prompting RAI proved to be clinically significant. Only 4.7% (2/43) of RAI deemed unnecessary by reviewers and 5.2% (3/58) of RAI not pursued by clinicians were found to be clinically significant; however, PET/CT alone was sufficient for diagnosis or guiding appropriate clinical management in each of these cases. Conclusion RAI were found in 29.6% of oncological PET/CT reports. No potential adverse impact on patient management or outcome, by not issuing or following RAI, was identified in the 51.2% of RAI deemed unnecessary by study readers or in the 69% of RAI not pursued by referring clinicians.

Recent years have witnessed the refinement and significant growth of several new, minimally invasive approaches for the nonsurgical treatment of primary lung malignancies. For select patients, these technologies offer an attractive treatment option given their availability in the outpatient setting and low associated morbidity and mortality. Microwave ablation represents the most recent addition to the growing armamentarium of available ablative technologies. Administered in a manner similar to radiofrequency ablation, the lung tumor is localized under imaging guidance, and a microwave antenna is placed directly into the tumor bed. In contrast to existing thermoablative technologies, however, microwave treatment offers several key theoretical advantages. These include consistently higher intratumoral temperatures, larger ablation volumes, reduced treatment times, and improved convection profile. As a nascent technology, efficacy and outcomes data for microwave ablation of pulmonary malignancies remain relatively lacking compared with other thermoablative techniques; however, early trials have demonstrated promising results. It is hoped that further refinements in the clinical application of this technology will continue to improve the care of patients with lung cancer.

The use of high-cost imaging modalities is rising rapidly. From 1995 through 2007, use of computed tomographic (CT) scans in the United States increased more than 4-fold1,2; by 2006, CT and magnetic resonance imaging examinations were the fastest-growing physician-directed Medicare expenditure.3,4 An uncertain proportion of these examinations represent overuse.5 There are little published data on the frequency of duplicated high-cost imaging examinations,6 but economic modeling suggests that cost savings from reducing redundant radiologic testing would be substantial.7 Because unnecessary duplication of CT examinations contributes to an increasingly strained medical payment system and exposes patients to unnecessary potential risks of radiation and intravenous contrast,2,8,9 we sought to determine whether alerting an ordering health care provider to the presence of a potentially redundant recent CT examination via decision support in a computerized physician order entry system (CPOE) can reduce repeated testing.