Faculty Bibliography

Purpose:To assess diagnostic sensitivity of radial T1-weighted gradient-echo (radial volumetric interpolated breath-hold examination [VIBE]) magnetic resonance (MR) imaging, positron emission tomography (PET), and combined simultaneous PET and MR imaging with an integrated PET/MR system in the detection of lung nodules, with combined PET and computed tomography (CT) as a reference.Materials and Methods:In this institutional review board-approved HIPAA-compliant prospective study, 32 patients with tumors who underwent clinically warranted fluorine 18 (18F) fluorodeoxyglucose (FDG) PET/CT followed by PET/MR imaging were included. In all patients, the thorax station was examined with free-breathing radial VIBE MR imaging and simultaneously acquired PET data. Presence and size of nodules and FDG avidity were assessed on PET/CT, radial VIBE, PET, and PET/MR images. Percentage of nodules detected on radial VIBE and PET images was compared with that on PET/MR images by using generalized estimating equations. Maximum standardized uptake value (SUVmax) in pulmonary nodules with a diameter of at least 1 cm was compared between PET/CT and PET/MR imaging with Pearson rank correlation.Results:A total of 69 nodules, including 45 FDG-avid nodules, were detected with PET/CT. The sensitivity of PET/MR imaging was 70.3% for all nodules, 95.6% for FDG-avid nodules, and 88.6% for nodules 0.5 cm in diameter or larger. PET/MR imaging had higher sensitivity than PET for all nodules (70.3% vs 61.6%, P = .002) and higher sensitivity than MR imaging for FDG-avid nodules (95.6% vs 80.0%, P = .008). There was a significantly strong correlation between SUVmax of pulmonary nodules obtained with PET/CT and that obtained with PET/MR imaging (r = 0.96, P < .001).Conclusion:Radial VIBE and PET data acquired simultaneously with PET/MR imaging have high sensitivity in the detection of FDG-avid nodules and nodules 0.5 cm in diameter or larger, with low sensitivity for small non-FDG-avid nodules.(c) RSNA, 2013.

BACKGROUND: Surgical correction of hiatal hernia (HH) during bariatric surgery has been found to improve patient outcomes and decrease reoperation rate. Although barium esophagram is more sensitive than endoscopy for detection of HH, accurate preoperative diagnosis remains a challenge. The aim of this study is to determine whether diagnostic accuracy improves by utilizing right anterior oblique (RAO) esophagram technique instead of the commonly used upright technique when comparing to the gold standard of intraoperative detection. METHODS: All patients undergoing bariatric surgery were prospectively evaluated for HH by barium esophagram. After the first 69 patients, the technique was changed from upright to RAO. Hiatal hernia was assessed intraoperatively by laxity of the phrenoesophageal ligament and, if present, was repaired posteriorly. Two board-certified radiologists specializing in gastrointestinal radiology, who were blinded to the intraoperative results, retrospectively reviewed the esophagrams. Consensus reads were utilized for divergent opinions. Sensitivity and specificity were calculated for each technique. RESULTS: Between 2008 and 2010, a total of 388 patients underwent preoperative esophagrams (69 upright, 388 RAO). For upright esophagram, sensitivity was 50 % and specificity was 97 %. For RAO esophagram, sensitivity was 70 % and specificity was 77 %. RAO had a lower percentage of false negatives (11 vs. 21 %) than upright esophagram. CONCLUSIONS: The use of RAO technique for preoperative esophagram is more sensitive for diagnosis of hiatal hernia than upright esophagram. If surgeons desire routine preoperative esophagram, RAO technique is the best.

BACKGROUND: Weight regain after Roux-en-Y gastric bypass (RYGB) is increasingly reported in the bariatric literature. Laparoscopic sleeve reduction of the gastrojejunal complex is a surgical option to revise a dilated gastric pouch. We report our short-term results. METHODS: Sleeve reduction entails serial firing of a linear stapler along the jejunal alimentary limb, across the gastric pouch and towards the left crus, with a bougie in place, thus, creating a new 20-25-cm reduced gastrojejunal complex. Data analyzed included age, body mass index (BMI), excess weight loss (EWL), comorbidity resolution, and any other simultaneous operative procedures. RESULTS: Fourteen patients were identified, all done laparoscopically. Nine underwent gastrojejunal sleeve reduction alone and five underwent additional lengthening of the Roux limb. There were no mortalities. Mean age at revision was 43 years (31-59). Mean BMI and EWL prior to revision were 35.5 +/- 4.0 kg/m(2) and 48.9 +/- 15.8%, respectively. Nine of 14 patients (64%) had obesity-related comorbidities prior to the revision. Average BMI decrease was 2.7 kg/m(2). Post-revision mean BMI and %EWL were 32.9 +/- 4.7 kg/m(2) and 12.0 +/- 13.9%, respectively, with mean follow-up of 12 months. Three of nine patients (33%) experienced improvement and/or resolution of comorbidities. We did not find a significant difference between pre-and post-revision mean BMI and %EWL (p = 0.13) even after separately evaluating those patients who underwent Roux limb lengthening (p = 0.16). CONCLUSION: For RYGB patients who regained weight, laparoscopic gastrojejunal sleeve reduction does not seem to offer a major therapeutic benefit. Additional malabsorptive Roux lengthening also does not provide a significant benefit. Other options should be considered, such as placing a band on the gastric pouch or conversion to duodenal switch.

Background: Hiatal hernia repair at the time of bariatric surgery improves patient outcome, decreases GERD symptoms and reduces the need for reoperation. The aim of this report is twofold: first, to compare the sensitivity of esophagram with surgical findings at the time of bariatric surgery, and second, to compare the sensitivities of upright versus right anterior oblique (RAO) recumbent esophagram in predicting the presence of hiatal hernia intraoperatively. Methods: Between 2008 and 2010, 389 patients undergoing bariatric surgery were prospectively evaluated for hiatal hernia by barium esophagram. 70 (18%) were performed only in the upright position and 319 (82%) only in the RAO recumbent position. Esophagram technique was changed from upright to recumbent because we hypothesized that we would be able to better detect hiatal hernia utilizing RAO recumbent technique. Hiatal hernia was assessed intraoperatively by laxity/dimpling of the phrenoesophageal ligament and, when present, was repaired posteriorly with permanent sutures. Results: Compared with the surgical findings, the sensitivity and specificity for upright esophagram was 50% and 97%, respectively. For recumbent esophagram, sensitivity was 70% and specificity was 77%. Recumbent esophagram had a lower percentage of false negatives than upright esophagram (11% vs. 21%). Conclusions: Use of a recumbent technique for preoperative esophagram has a higher sensitivity for diagnosis of hiatal hernia than upright esophagram. Routine use of recumbent esophagram results in increased preoperative detection of hiatal hernia and facilitates planning of crural closure

BACKGROUND:The incidence and pattern of delirium recorded in a broad spectrum of American hospitalizations has not been well described. The National Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project is an administrative database of hospitalizations in the US that affords an opportunity to examine for International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes relating to delirium. OBJECTIVE:To examine the prevalence of delirium diagnoses and associated clinical factors, including adverse drug effects, in a broad spectrum of hospitalizations in the US. Delirium was grouped into three categories: drug-induced delirium, dementia-associated delirium, and non-dementia, non-drug (NDND). METHODS:Hospitalizations during the years 1998-2005 in the NIS databases were examined. These databases represent samples of hospitalizations that allow for national prevalence estimates. ICD-9 codes for drug-induced, dementia-associated and NDND delirium were identified in the hospitalizations for each year. Delirium tremens was not considered in this classification, and paediatric and psychiatric admissions were excluded. Yearly prevalence for drug-induced, dementia-associated and NDND delirium were tabulated, and time trends were analysed with negative binomial regression. A hospitalization subset cohort with urinary tract/kidney infection, pneumonia, heart failure and lower extremity orthopaedic surgery diagnosis-related group categories was also analysed for clinical associations with the presence of the three categories of delirium using multinomial logistic regression. ICD-9 E codes (external causes of injury) constituting adverse drug effects were identified and considered as clinical predictors. RESULTS:Delirium was recorded in 1 269 185 (0.54%) non-psychiatric adult hospitalizations during the study years. Whereas the overall prevalence of dementia-associated delirium and NDND delirium decreased over time, drug-induced delirium prevalence increased (p < 0.0001). As expected, the presence of dementia and adverse drug effects had the strongest associations with dementia-associated and drug-induced delirium, respectively, in the cohort hospitalizations. CONCLUSIONS:Drug-induced delirium and NDND delirium had the strongest associations with lower extremity orthopaedic surgery hospitalizations and urinary tract/kidney infection hospitalizations, respectively. Among the NDND co-morbid conditions, volume depletion and sodium imbalance had the strongest, albeit modest, associations with delirium. The association between decade of age and delirium was strongest for NDND delirium (adjusted odds ratio 1.53; 95% CI 1.52, 1.53), but age had significant associations with drug-induced and dementia-associated delirium as well. In the cohort, the most frequent adverse effects codes were for opioids and for benzodiazepines or other sedatives, which were noted in 21.3% and 15.2% of drug-induced delirium hospitalizations, respectively. Drug-induced delirium is being increasingly identified in hospitalized patients. Administrative hospitalization databases constitute a resource to explore factors and trends associated with delirium. The findings suggest that interventions focusing on adverse drug effects have the greatest potential for preventing delirium.

OBJECTIVE:To describe clinical associations of delirium in hospitalized patients and relationships to on admission presentation. DESIGN/METHODS:Retrospective analysis of an administrative hospitalization database 1998-2007. SETTING/METHODS:Acute care hospitalizations in the New York State (NYS). MEASUREMENTS/METHODS:Four categories of diagnosis related group (DRG) hospitalizations were extracted from a NYS administrative database: pneumonia, congestive heart failure, urinary tract/kidney infection (UTI), and lower extremity orthopedic surgery (LEOS) DRGs. These hospitalizations were examined for clinical associations with delirium coding both on and after admission. RESULTS:Delirium was coded in 0.8% of the cohort, of which an on admission diagnosis was present in 59%. On admission delirium was strongly associated with dementia (adjusted odds ratio 0, 95%CI 5.8-6.3) and with adverse drug effects (ADEs) (adjusted odds ratio 4.6, 95%CI 4.3, 5.0). After admission delirium was even more highly associated with ADEs (adjusted odds ratio 22.2, 95%CI 20.7-23.7). The UTI DRG category had the greatest proportion of on admission delirium. However after admission delirium was more common in the LEOS DRG category. Over time, there was a greater increase in delirium proportions in the UTI DRG category, and an overall increase in coding for encephalopathy states (potential alternative delirium descriptors). CONCLUSION/CONCLUSIONS:ADEs play an important role in delirium regardless of whether or not it is present on admission. While the finding that most delirium hospitalizations presented on admission suggests that delirium impacts more as a clinical admitting determinant, in-hospital prevention strategies may still have benefit in targeted settings where after admission delirium is more frequent, such as patients with LEOS.