Utilization Of Advanced Imaging Research Articles

What is the Utilization and Impact of Advanced Imaging for Tibial Tubercle Fractures? An Analysis of 598 Patients From the Tibial Tubercle Study (TITUS) Group.

Given the rare nature of tibial tubercle fractures, previous studies are mostly limited to small, single-center series. This results in practice variation. Previous research has shown poor surgeon agreement on utilization of advanced imaging, but improved evidence-based indications may help balance clinical utility with resource utilization. The purpose of this study is to quantify diagnostic practices for tibial tubercle fractures in a large, multicenter cohort, with attention to the usage and impact of advanced imaging. This is a retrospective series of pediatric tibial tubercle fractures from 7 centers between 2007 and 2022. Exclusion criteria were age above 18 years, missing demographic and pretreatment data, closed proximal tibial physis and tubercle apophysis, or a proximal tibia fracture not involving the tubercle. Demographic and injury data were collected. Fracture classifications were derived from radiographic evaluation. The utilization of advanced imaging was recorded as well as the presence of findings not identified on radiographs. Standard descriptive statistics were reported, and χ2 tests were performed (means reported±SD). A total of 598 patients satisfied the inclusion criteria, of which 88.6% (530/598) were male with a mean age of 13.8±1.9 years. Internal oblique x-rays were obtained in 267 patients (44.6%), computed tomography (CT) in 158 (26.4%), and magnetic resonance imaging (MRI) in 64 (10.7%). There were significant differences in the frequency at which CT (7.2% to 79.4%, P<0.001) and MRI were obtained (1.5% to 54.8%, P<0.001). CT was obtained most frequently for Ogden type IV fractures (50/99, 50.5%), and resulted in novel findings that were not visualized on radiographs in a total of 37/158 patients (23.4%). The most common finding on CT was intra-articular fracture extension (25/37). MRI was obtained most frequently for Ogden type V fractures (13/35, 37.1%), and resulted in novel findings in a total of 31/64 patients (48.4%). The most common finding was patellar tendon injury (11/64), but only 3 of these patients required tendon repair. Substantial variation exists in the diagnostic evaluation of tibial tubercle fractures. CT was most helpful in clarifying intra-articular involvement, while MRI can identify patellar tendon injury, periosteal sleeve avulsion, or a nondisplaced fracture. This study quantifies variation in diagnostic practices for tibial tubercle fractures, highlighting the need for evidence-based indications for advanced imaging. Level III.

Emergency physician resource utilization varies by years of experience.

One of the most pivotal decisions an emergency physician (EP) makes is whether to admit or discharge a patient. The emergency department (ED) work-up leading to this decision involves several resource-intensive tests. Previous studies have demonstrated significant differences in EP resource utilization, measured by lab tests, advanced imaging (magnetic resonance imaging [MRI], computed tomography [CT], ultrasound), consultations, and propensity to admit a patient. However, how an EP's years of experience may impact their resource utilization and propensity to admit patients has not been well characterized. This study seeks to better understand how EPs' years of experience, post-residency, relates to their use of advanced imaging and patient disposition. Ten years of ED visits were analyzed for this study from a single, academic tertiary care center in the urban Northeast United States. The primary outcomes were utilization of advanced imaging during the visit (CT, MRI, or formal ultrasound) and whether the patient was admitted. EP years of experience was categorized into 0-2years, 3-5years, 6-8years, 9-11years, and 12 or more years. Patient age, sex, Emergency Severity Index (ESI), and the attending EP's years of experience were collected. The relationship between EP years of experience and each outcome was assessed with a linear mixed model with a random effect for provider and patient age, sex, and ESI as covariates. A total of 460,937 visits seen by 65 EPs were included in the study. Over one-third (37.6%) of visits had an advanced imaging study ordered and nearly half (49.5%) resulted in admission. Compared to visits with EPs with 0-2years of experience, visits with EPs with 3-5 or 6-8years of experience had significantly lower odds of advanced imaging occurring. Visits seen by EPs with more than 2 years of experience had lower odds of admission than visits by EPs with 0-2years of experience. More junior EPs tend to order more advanced imaging studies and have a higher propensity to admit patients. This may be due to less comfort in decision-making without advanced imaging or a lower risk tolerance. Conversely, the additional clinical experience of the most senior EPs, with greater than 9years of experience,likely impacts their resource utilization patterns such that their use of advanced imaging does not significantly differ from the most junior EPs.

The Neiman Imaging Comorbidity Index Predicts Advanced Imaging Utilization, But Reducing Overutilization Is the Goal

The Neiman Imaging Comorbidity Index Predicts Advanced Imaging Utilization, But Reducing Overutilization Is the Goal

Association of Case Duration with Late vs. Early Physical Therapy Initiation in Treatment of Work-Related Musculoskeletal Injuries: A Retrospective Analysis

Background:Occupational medicine providers treat patients who are injured while working. Conservative management with over-the-counter anti-inflammatory medicines, physical modalities (ice/heat), and activity restrictions are first-line treatment strategies. Physical therapy (PT) is often added to assist with patients’ return to baseline through symptom reduction and restoration of function. PT efficacy on outcomes and healthcare costs has been described in other patient populations but less described in injured worker populations. This study focused on associations between PT timing and case duration for treating musculoskeletal injuries in a regional injured workerpopulation.&#x0D; Methods:A retrospective chart review of 795 patients receiving care at Parkview Occupational Health (POH) for musculoskeletal injuries from 2017-2023 was conducted to determine if early PT was associated with case duration. Patients employed in Indiana and referred to PT within Parkview were included in the study. Age, BMI, and case duration were compared between early vs. late PT groups using two-sampled t-test. Race, sex, smoking status, and injury type were compared using chi-squared tests.&#x0D; Results:The mean case duration (73.41 days) when PT was initiated early (≤ 30 days after date of injury, DOI) was significantly shorter compared to the mean case duration (104.21 days) when PT was initiated late (p&lt;0.0001). Case duration was even shorter (67.61 days) when early PT was defined as ≤14 days after injury (p=0.001). There was no significant difference in case duration (mean difference=9.5 days) between patients initiating PT within 14 days and within 15-30 days (p=0.15). Injury type (back vs. other musculoskeletal injuries) was significantly associated with PT timing (p=0.002).&#x0D; Conclusion/Implications:Future analysis should compare case duration, days of restricted work, advanced imaging utilization, and specialist referral rate between patients with early and late PT initiation. This comparison will aid in development of best practice guidance for treatment of work-related musculoskeletal injuries at POH.

Low Back Pain: Utilization of Urgent Cares Relative to Emergency Departments.

Retrospective study. To understand why patients utilize emergency departments (EDs) versus urgent care centers for low back pain (LBP). LBP is a common reason for ED visits. In the setting of trauma or recent surgery, the resources of EDs may be needed. However, urgent care centers may be appropriate for other cases. Adult patients below 65 years of age presenting to the ED or urgent care on the day of diagnosis of LBP were identified from the 2019 PearlDiver M151 administrative database. Exclusion criteria included history of radiculopathy or sciatica, spinal surgery, spinal cord injury, other traumatic, neoplastic, or infectious diagnoses in the 90 days prior, or Medicare insurance. Patient age, sex, Elixhauser comorbidity index, geographic region, insurance, and management strategies were extracted. Factors associated with urgent care relative to ED utilization were assessed using multivariable analysis. Of 356,284 LBP patients, ED visits were identified for 345,390 (96.9%) and urgent care visits for 10,894 (3.1%). Factors associated with urgent care use relative to the ED were: geographic region [relative to Midwest; Northeast odds ratio (OR): 5.49, South OR: 1.54, West OR: 1.32], insurance (relative to Medicaid; commercial OR: 4.06), lower Elixhauser comorbidity index (OR: 1.28 per two-point decrease), and higher age (OR: 1.10 per decade), female sex (OR: 1.09), and use of advanced imaging (OR: 0.08) within 1 week ( P <0.001 for all). Most patients presenting for a first diagnosis of isolated LBP went to the ED relative to urgent care. The greatest drivers of urgent care versus ED utilization for LBP were insurance type and geographic region. Utilization of advanced imaging was higher among ED patients, but rates of surgical intervention were similar between those seen in the ED and urgent care.

Ten-Year Trend in Advanced Imaging Utilization for Suspected Pulmonary Embolism in Pregnancy

PurposeAdvanced imaging is essential to diagnose pulmonary embolism (PE) in pregnancy, but there are associated maternal and fetal radiation risks. The purpose of this study was to evaluate the 10-year trend in advanced imaging utilization for the evaluation of suspected PE in pregnancy. MethodsThe authors evaluated pregnant women with advanced imaging using CT pulmonary angiography (CTPA) or lung scintigraphy (LS) for evaluation of suspected PE presenting to two tertiary hospitals from 2007 to 2016. The rate of imaging was evaluated relative to positive PE rate and local pregnancy rate. positive PE was defined as a new acute PE finding on any advanced imaging within 3 days of first advanced imaging test. Local pregnancy rates were defined per 1,000 pregnancies in the county serviced by both hospitals. Chi-square testing was used to evaluate statistical significance (P < .05) in the utilization trend of advanced imaging and relative to local pregnancy rates and evaluations positive for PE. ResultsA total of 707 pregnant patients were identified, of whom 92.5% (n = 654) underwent CTPA and 7.5% (n = 53) underwent LS. Regression analysis showed an average increase of 5.2 advanced imaging studies per year (P < .001), with 61 and 105 studies performed in 2007 and 2016, respectively. Additionally, there was an average increase of 0.08 (P < .001) advanced imaging studies per 1,000 local pregnancies per year, doubling from 0.7 in 2007 to 1.4 in 2016 (P < .001). Finally, there was a decrease of 0.004 (P = .009) in advanced imaging positive for PE, from 3% (2 of 61) in 2007 to 0% (0 of 100) in 2016. ConclusionsAdvanced imaging utilization increased by 72% over the 10-year window, driven by higher use of CTPA. Although the detection rate of PE on advanced imaging has decreased, the utilization rate among pregnant patients doubled during this period. These results highlight the need to consider the radiation risks and costs of advanced imaging in specific patient populations.

Diagnostic Imaging Utilization in the Emergency Department: Recent Trends in Volume and Radiology Work Relative Value Units

PurposeThe aim of this study was to quantify and characterize the recent trend in emergency department (ED) imaging volumes and radiology work relative value units (wRVUs) at level I and level III trauma centers. MethodsTotal annual diagnostic radiology imaging volumes and wRVUs were obtained from level I and level III trauma centers from January 2014 to December 2021. Imaging volumes were analyzed by modality type, examination code, and location. Total annual patient ED encounters (EDEs), annual weighted Emergency Severity Index, and patient admissions from the ED were obtained. Data were analyzed using annual imaging volume or wRVUs per EDE, and percentage change was calculated. ResultsAt the level I trauma center, imaging volumes per EDE increased for chest radiography (5.5%), CT (35.5%), and MRI (56.3%) and decreased for ultrasound (−5.9%) from 2014 to 2021. Imaging volumes per EDE increased for ultrasound (10.4%), CT (74.6%), and MRI (2.0%) and decreased for chest radiography (−4.4%) at the level III trauma center over the same 8-year period. Total wRVUs per EDE increased at both the level I (34.9%) and level III (76.6%) trauma centers over the study period. ConclusionsED imaging utilization increased over the 8-year study period at both level I and level III trauma centers, with an increase in total wRVUs per EDE. There was a disproportionate increased utilization of advanced imaging, such as CT, over time. ED utilization trends suggest that there will be a continued increase in demand for advanced imaging interpretation, including at lower acuity hospitals, so radiology departments should prepare for this increased work demand.

Association of Patient English Proficiency and Diagnostic Imaging Acquisition in Emergency Department Patients with Abdominal Symptoms

BackgroundPatients with limited English proficiency (LEP) are at risk for communication barriers during medical care in the United States compared with English-proficient (EP) patients. It is unknown how EP affects the utilization of advanced diagnostic imaging (ADI) in the emergency department (ED). ObjectiveThe aim of this study was to compare the acquisition and findings of ADI in EP and LEP patients with abdominal symptoms. MethodsWe conducted a retrospective analysis of adult ED patients from January 2015 to January 2016. Patients were divided into EP and LEP cohorts. Logistic regression models incorporated language proficiency, interpretation method, and demographic characteristics. We determined crude and adjusted odds ratios (ORs) for the acquisition of ADI, defined as either computed tomography or ultrasound, and the proportion with actionable findings. ResultsIn 3324 encounters (2134 EP; 1190 LEP), LEP patients were older (46.3 years vs. 43.8 years), more likely to be female (66.7% vs. 51.5%), and preferred Spanish (91.4%). ADI was obtained in 43.5% of EP and 48.1% of LEP. Adjusting for age, sex, and interpretation method, the OR was 1.09 (95% CI 0.90–1.32). There were no significant associations between interpretation type and acquisition of ADI. The proportion with actionable findings were similar in EP and LEP cohorts (29.6% vs. 26.7%). ConclusionsAccounting for demographic differences, ADI acquisition was similar for ED patients with and without LEP. Further research is needed to determine optimal interpretation modalities in this setting to prevent unnecessary imaging.

Analysis of Advanced Imaging Utilization in Low National Institutes of Health Stroke Scale Score and Rate of Large Vessel Occlusion Detection in Large Telestroke Database (S24.009)

<h3>Objective:</h3> Analyze the rate of large vessel occlusion (LVO) detection in low National Institutes of Health Stroke Scale (NIHSS) score patients in a large multicenter database. <h3>Background:</h3> The benefits of mechanical thrombectomy in low NIHSS score (&lt;6) is unclear and undergoing investigation. Currently, great variation exists in practice patterns of computed tomography angiography (CTA) for patients with low NIHSS. Current guidelines do not address low NIHSS largely owing to a paucity of data. Better understanding of the rate of LVO associated with low NIHSS could help guide clinical practice and pave the way for expanding guideline recommendations. <h3>Design/Methods:</h3> Acute stroke consultations seen in the emergency department in 227 facilities (27 states) from July 1, 2021 to December 31, 2021 were extracted from the TeleCare™ database. The encounters seen within 24 hours of last known normal were reviewed for CTA performed, LVO detected, and NIHSS score. Multivariate analysis was performed to determine the odds ratio (OR) for CTA performed, and LVO found at each NIHSS score of 0–5 with reference of ≥6. <h3>Results:</h3> 23,166 acute stroke encounters were included and 10,507 had CTA performed. There were lesser odds for CTA being performed among patients with an NIHSS of: 0 (OR=0.14, [0.13,0.15]); 1 (OR=0.16, [0.15,0.18]); 2 (OR=0.27, [0.24,0.3]); 3 (OR=0.33, [0.3,0.37]); 4 (OR=0.49, [0.43,0.55]); and 5 (OR=0.71, [0.61,0.82]). In addition, there were lesser odds of an LVO detected among patients with an NIHSS of: 0 (OR=0.1, [0.07,0.13]); 1 (OR=0.09, [0.06,0.12]); 2 (OR=0.16, [0.12,0.22]); 3 (OR=0.14, [0.1,0.2]); 4 (OR=0.24, [0.18,0.32]), and 5 (OR=0.27, [0.2,0.37]). <h3>Conclusions:</h3> Analysis of our large telemedicine database demonstrated a significant number of LVOs detected with NIHSS &lt;6, supporting lowering the minimum NIHSS score for emergent CTA. The cutoff of ≥4 may be optimal threshold for LVO capture. We suggest a rational approach to CTA performance to include patients with NIHSS ≥4 or cortical symptoms. <b>Disclosure:</b> Dr. Sevilis has stock in Moderna. Dr. Fowler has nothing to disclose. Dr. Avila has nothing to disclose. Ms. Boyd has nothing to disclose. Mr. Collins has nothing to disclose. Dr. Gao has nothing to disclose. Dr. Heath has received personal compensation in the range of $0-$499 for serving as a Epidemiologic analysis consultant with Neuroscience Innovation Foundation . Dr. Devlin has received personal compensation for serving as an employee of Neuroscience Innovation Foundation. Dr. Devlin has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Nova Signal. Dr. Devlin has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Viz.ai. Dr. Devlin has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Medtronic. Dr. Devlin has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Medtronic. Dr. Devlin has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Viz,ai. Dr. Devlin has received personal compensation in the range of $5,000-$9,999 for serving as an officer or member of the Board of Directors for Neuroscience Innovation Foundation. Dr. Devlin has stock in Nova Signal. Dr. Devlin has stock in Viz.ai. The institution of Dr. Devlin has received research support from Viz.ai. Dr. Devlin has received research support from Nova Signal. Dr. Devlin has received intellectual property interests from a discovery or technology relating to health care.

April 2023 Stroke Highlights.

April 2023 Stroke Highlights.

Trends in Disparities in Advanced Neuroimaging Utilization in Acute Stroke: A Population-Based Study.

Our primary objective was to evaluate if disparities in race, sex, age, and socioeconomic status (SES) exist in utilization of advanced neuroimaging in year 2015 in a population-based study. Our secondary objective was to identify the disparity trends and overall imaging utilization as compared with years 2005 and 2010. This was a retrospective, population-based study that utilized the GCNKSS (Greater Cincinnati/Northern Kentucky Stroke Study) data. Patients with stroke and transient ischemic attack were identified in the years 2005, 2010, and 2015 in a metropolitan population of 1.3 million. The proportion of imaging use within 2 days of stroke/transient ischemic attack onset or hospital admission date was computed. SES determined by the percentage below the poverty level within a given respondent's US census tract of residence was dichotomized. Multivariable logistic regression was used to determine the odds of advanced neuroimaging use (computed tomography angiogram/magnetic resonance imaging/magnetic resonance angiogram) for age, race, gender, and SES. There was a total of 10 526 stroke/transient ischemic attack events in the combined study year periods of 2005, 2010, and 2015. The utilization of advanced imaging progressively increased (48% in 2005, 63% in 2010, and 75% in 2015 [P<0.001]). In the combined study year multivariable model, advanced imaging was associated with age and SES. Younger patients (≤55 years) were more likely to have advanced imaging compared with older patients (adjusted odds ratio, 1.85 [95% CI, 1.62-2.12]; P<0.01), and low SES patients were less likely to have advanced imaging compared with high SES (adjusted odds ratio, 0.83 [95% CI, 0.75-0.93]; P<0.01). A significant interaction was found between age and race. Stratified by age, the adjusted odds of advanced imaging were higher for Black patients compared with White patients among older patients (>55 years; adjusted odds ratio, 1.34 [95% CI, 1.15-1.57]; P<0.01), but no racial differences among the young. Racial, age, and SES-related disparities exist in the utilization of advanced neuroimaging for patients with acute stroke. There was no evidence of a change in trend of these disparities between the study periods.

Does Additional Review of Initial Radiographs by Musculoskeletal Specialists Limit Additional Advanced Imaging in Suspected Hip Fractures?

AbstractPatients with suspected fractures of the hip usually require significant time and resources for care, sometimes including advanced imaging. Optimizing care may improve patient outcomes and reduce the financial burden of hip fractures. Few studies have investigated approaches to reduce the utilization of additional imaging to diagnose hip fractures. The objective of this study was to determine if the utilization of computed tomography and magnetic resonance imaging can be reduced for suspected hip fracture patients via additional review of initial hip radiographs by musculoskeletal specialists. This may aid imaging referral guidelines for patients with a clinical suspicion of a hip fracture and reduce the amount of costly additional imaging. A retrospective multicenter study was conducted of hip fracture patients from five hospitals in an academic health system from 2015 to 2018. The study included initial radiographs of 108 patients, all of which were considered inconclusive at the time of service by radiologist reports and subsequently diagnosed with a hip fracture after receiving additional imaging. Four musculoskeletal specialists were asked to evaluate if the radiographs were positive for hip fracture, negative for hip fracture, or required additional imaging. A positive hip fracture was correctly identified by musculoskeletal specialists from the initial radiograph in 37 to 50% of cases. There was no statistically significant difference between reviewers of different levels of training in identifying hip fractures (p = 0.19) or ordering additional imaging (p = 0.235). There was a moderately positive interclass correlation across reviewers who correctly identified a hip fracture (interclass correlation coefficients [ICC] = 0.59, 95% confidence interval [CI]: 0.45–0.70), as well as reviewers who requested additional imaging (ICC = 0.45, 95% CI: 0.25–0.60). Review of initial radiographs by musculoskeletal specialists could reduce the utilization of additional advanced imaging by up to 50% in patients with a suspected hip fracture. This is a level III evidence study.

Abstract WP42: Real-world Utilization Of Advanced Imaging Based Patient Selection For Thrombectomy

Introduction: Multiple clinical trials support an extended treatment window for thrombectomy for large vessel occlusions (LVO) and the treatment of distal occlusions, leading to increased numbers of patients requiring advanced imaging during acute stroke evaluation. Across hospital systems, there is great variation in advanced imaging protocols for acute stroke patients. The goal of this study is to provide a descriptive analysis of the real-world practices in facilities across the United States. Methods: Acute stroke consultations seen by TeleSpecialists, LLC physicians in the emergency department in 227 facilities (27 states) from July 1, 2021 to December 31, 2021 were extracted from the TeleCare TM database. The encounters were reviewed for age, ethnicity, stroke risk factors, last known normal (LKN), arrival time, thrombolytics candidate, door to needle (DTN) time, advanced imaging, LVO, if Neurointerventionalist (NIR) accepted case, premorbid modified Rankin Score (p-mRS), and NIHSS score. Comparison of baseline characteristics and time benchmarks between advanced imaging group (computed tomography angiography (CTA) with optional CT perfusion (CTP)) vs no advanced imaging group (CT only) was performed. Analysis of the location of the occlusion and of the specific vessels being accepted for intervention was performed. Results: There were 29,187 acute stroke consultations seen with 12,641 (43.3%) receiving advanced imaging. The median DTN time for advanced imaging group was 44 minutes (33, 59) vs 41 minutes (30.5, 54) with no advanced imaging group, p = 0.158. There was a higher NIHSS score and lower p-mRS in the advanced imaging group. Analysis of patients with LVO showed lower DTN times, higher NIHSS scores, lower p-mRS, and shorter LKN to arrival times in the patients accepted for thrombectomy. Majority of cases accepted for thrombectomy were left M1 (31.4%) or right M1 (26.6%) occlusions. A significantly lower percentage of patients accepted for intervention had left M2 (10%) and right M2 (6%) occlusions. Conclusion: Advanced imaging in a large real-world data set of acute stroke patients did not significantly delay DTN times. The ability to maintain DTN times is likely related to thrombolytics being prioritized and a parallel process.

Enhanced Global Disease Assessment with Advanced Imaging and Targeted Myeloma Lesion Biopsy Highlights Spatial Heterogeneity and Detects Residual Disease in Multiple Myeloma

Background: Multiple myeloma (MM) is a biologically complex disease with marked heterogeneity; limitations remain in our standard myeloma disease assessment at diagnosis and in response to therapy. In this study, we aimed to prospectively investigate the utilization of advanced imaging and targeted focal lesion (FL) biopsies to augment global disease evaluation, detect residual tumor burden, and explore the diverse histologic and molecular landscape of this multifocal neoplasm. Herein, we present our final analysis of this clinical trial. Methods: Adult patients with newly diagnosed clinical MM (NDMM) and bone or extramedullary (EM) FL were eligible to participate in this prospective study. Advanced imaging with positron emission tomography/computed tomography (PET/CT) or whole body magnetic resonance imaging (WB-MRI), standard bone marrow (BM) biopsy and aspiration, and targeted FL biopsy were performed at enrollment and after four 28-day cycles of induction therapy with carfilzomib (36 mg/m2 intravenously twice weekly), lenalidomide (25 mg orally days 1-21), and dexamethasone (40 mg orally weekly) (KRd), with dose modifications as needed. Conventional clinical response, using IMWG Response Criteria (Kumar S et al, 2016), was also measured after each cycle of treatment. Patients were followed for 12 months after end of treatment or until data cutoff on February 23rd, 2022. Results: 27 patients were enrolled in this study between June 2018 and August 2021, with 25 evaluable for global response assessment. Median age was 61 years (range, 42-76 years) and 14.8% of patients were of Black or African American race. 85.2% of patients had Revised International Staging System (R-ISS) stage II or III disease. 51.9% of patients were identified as having EM disease arising out of bone or soft tissue and 44.4% of patients had high risk cytogenetics inclusive of chromosome 1 abnormalities. In sum, 70.4% of our cohort had at least 1 high risk feature at diagnosis (Table 1). 80% of patients had myeloma FL identified on advanced imaging that were missed on conventional skeletal survey. Of the 7 patients with cytogenetic and fluorescence in situ hybridization (FISH) testing performed on initial FL biopsy, 6 (85.7%) had findings discrepant from those seen on cytogenetic testing from standard BM samples. 9 patients had cytogenetic and FISH studies on repeat myeloma FL biopsy after KRd induction with 2 showing residual FISH abnormalities that were not detected on standard BM obtained for response assessment. Clinical response rates after 4 cycles of KRd were high in our study population with 88% of patients achieving a very good partial response (VGPR) or better and 20% with a stringent complete response (sCR) with minimal residual disease (MRD) negativity by flow cytometry. However, of the 22 patients with ≥VGPR by IMWG response assessment, 18 had residual disease on advanced imaging with WB-MRI (10 patients), PET/CT (7 patients), or MRI total spine (1 patient), including 3 of the 5 patients with sCR (Figure 1). 2 patients experienced disease progression during the study period with median progression free survival not reached by the patient cohort. Both patients with progression had a VGPR by conventional response assessment, though with residual FL on advanced imaging post-KRd induction. Conclusions: While tumor spatial differences in MM have been observed retrospectively, prospective data on this important component of myelomagenesis is limited. In our cohort of high risk NDMM, we demonstrated spatial heterogeneity both at diagnosis and after KRd induction. Despite the deep clinical responses observed by IMWG response assessment, 81.8% of patients with ≥VGPR had ongoing abnormalities on advanced imaging which could potentially serve as disease reservoirs for future progression and development of treatment resistance. A novel assessment method in MM, inclusive of advanced imaging and targeted FL biopsies, may overcome the limitations of our standard response assessment with resultant improved knowledge of the varied intra-tumor disease biology as well as development of more refined treatment approaches. A potential limitation of our study is the smaller sample size with underrepresentation of minority populations. Data on whole exome sequencing of paired BM and FL biopsies will be reported separately. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

The pivot fracture: an unusual tibial plateau fracture found in association with acute ACL injury.

Tibial plateau fractures are common fractures which are often associated with concurrent soft tissue injury and for which accurate preoperative diagnosis is important for development of an appropriate treatment plan and outcome prediction. Here, we present an extreme manifestation of the pivot shift phenomenon with an unusual tibial plateau fracture with flipped component not described by any existing tibial plateau fracture classification system and never reported previously in conjunction with an anterior cruciate ligament injury. We describe the utilization of advanced imaging not typically utilized in the management of tibial plateau fractures in combination with clinical suspicion to diagnose the associated soft tissue injuries and develop an appropriate management plan.

Advanced imaging use and payment trends in a large pediatric accountable care organization.

Pediatric imaging use and payment trends in accountable care organizations (ACOs) are seldom studied but are important for health policy decisions and resource allocation. To evaluate patterns of advanced imaging use and associated payments over a 7-year period at a large ACO in the USA serving a Medicaid population. We reviewed paid claims data from 2011 through 2017 from an ACO, analyzing the MRI, CT and US use trends and payments from emergency department (ED) and outpatient encounters. We defined "utilization rate" as the number of advanced imaging procedures per 100 enrolled children per calendar year. Average yearly utilization and payments trends were analyzed using Pearson correlation. Across 7years, 186,552 advanced imaging procedures were performed. The average overall utilization rate was 6.99 (95% confidence interval [CI]: 6.9-7.1). In the ED this was 2.7 (95% CI: 2.6-2.8) and in outpatients 4.3 (95% CI: 4.2-4.3). The overall utilization rate grew by 0.7% yearly (P=0.077), with US growing the most at 4.0% annually (P=0.0005), especially in the ED in the US, where it grew 10.8% annually (P=0.000019). The overall payments were stable from 2011 to 2017, with outpatient MRI seeing the largest payment decrease at 1.8% (P=0.24) and ED US showing the most growth at 3.3% (P=0.00016). Head CT and abdominal US were the two most common procedures. Over the study period, advanced imaging utilization at this large pediatric ACO serving the Medicaid population increased, especially with US use in the ED. Overall payments related to advanced imaging remained stable over this period.

Use of advanced cardiac imaging in congenital heart disease: growth, indications and innovations.

Significant improvements in the diagnosis and management of patients with congenital heart disease (CHD) have led to improved survival. These patients require life-long noninvasive evaluation. The use of advanced imaging such as cardiac magnetic resonance imaging (CMR) and cardiac computed tomography (CCT) has increased to support this need. The purpose of this review is to discuss the basics of advanced cardiac imaging, indications and review the recent innovations. Recent literature has demonstrated the increasing reliance of advanced imaging for CHD patients. In addition, research is focusing on CMR techniques to shorten scan time and address previous limitations that made imaging younger and sicker patients more challenging. CCT research has involved demonstrating high-quality images with low radiation exposure. Advances in digital technology have impacted the interactivity of 3D imaging through the use of virtual and augmented reality platforms. With the increased reliance of advanced imaging, appropriate use criteria have been developed to address possible under or over utilization. The utilization of advanced cardiac imaging continues to increase. As CMR and CCT continue to grow, increased knowledge of these modalities and their usage will be necessary for clinicians caring for CHD patients.

Use of preoperative advanced imaging for reverse total shoulder arthroplasty

BackgroundIn order to avoid implant related complications related to glenosphere malposition, there has been an increased interest in the use of advanced imaging, including computed tomography (CT) and magnetic resonance imaging (MRI) for preoperative planning and patient-specific instrumentation for reverse shoulder arthroplasty (RSA). While recent literature has demonstrated improved component position when this technology is applied, the clinical benefits remain largely hypothetical and unproven. Thus, the goals of the current study were to utilize a national database to describe current trends in the use of preoperative advanced imaging and investigate the relationship between such imaging and postoperative complications compared to matched controls without any preoperative imaging. MethodsPatients undergoing RSA for non-fracture indications were identified within the Mariner dataset within the PearlDiver database from 2010 to 2018Q2. Patients who underwent preoperative advanced imaging (MRI and/or CT) within a year prior to surgery were then identified as study cohorts. A matched cohort undergoing RSA without preoperative advanced imaging was created for comparison purposes. The incidence of imaging over time and rates of loosening/osteolysis, periprosthetic fracture, prosthetic dislocation, and revision shoulder arthroplasty of all groups were compared using a regression analysis. ResultsThe percentage of patients who underwent preoperative CT (141% increase, P < .0001), and either MRI or CT (107% increase, P = .002) increased significantly during the study period, while there was no significant increase in MRI utilization (P = .122). Patients who underwent preoperative CT experienced significantly lower rates of revision shoulder arthroplasty (2.4% vs. 3.3%, OR = 0.72, P = .004) and periprosthetic dislocation (2.8% vs. 3.3%, OR 0.80, P = .039) within 2 years of RSA compared to patients who did not undergo preoperative CT, while preoperative MRI was associated with significantly lower rates of periprosthetic fracture (0.2% vs. 0.4%, OR 0.44, P = .005), revision shoulder arthroplasty (2.1% vs. 2.6%, OR = 0.75, P = .006), and periprosthetic dislocation (2.5% vs. 3.2%, OR 0.78, P = .003) within 2 years of RSA compared to patients without an MRI. ConclusionThere has been a significant increase in the utilization of preoperative CT as compared to MRI for RSA during the time period studied. The utilization of preoperative advanced imaging may be associated with a statistically significant reduction in multiple implant related complications following RSA for non-fracture indications, although these findings are of unclear clinical significance given limitations of the database and low percentage difference in complication rates.Level of Evidence: Level III

Utilization and Availability of Advanced Imaging in Patients With Acute Ischemic Stroke.

Recent clinical trials have established the efficacy of endovascular stroke therapy and intravenous thrombolysis using advanced imaging, particularly computed tomography perfusion (CTP). The availability and utilization of CTP for patients and hospitals that treat acute ischemic stroke (AIS), however, is uncertain. We performed a retrospective cross-sectional analysis using 2 complementary Medicare datasets, full sample Texas and 5% national fee-for-service data from 2014 to 2017. AIS cases were identified using International Classification of Diseases, NinthRevision and International Classification of Diseases, Tenth Revision coding criteria. Imaging utilization performed in the initial evaluation of patients with AIS was derived using Current Procedural Terminology codes from professional claims. Primary outcomes were utilization of imaging in AIS cases and the change in utilization over time. Hospitals were defined as imaging modality-performing if they submitted at least 1 claim for that modality per calendar year. The National Medicare dataset was used to validate state-level findings, and a local hospital-level cohort was used to validate the claims-based approach. Among 50 797 AIS cases in the Texas Medicare fee-for-service cohort, 64% were evaluated with noncontrast head CT, 17% with CT angiography, 3% with CTP, and 33% with magnetic resonance imaging. CTP utilization was greater in patients treated with endovascular stroke therapy (17%) and intravenous thrombolysis (9%). CT angiography (4%/y) and CTP (1%/y) utilization increased over the study period. These findings were validated in the National dataset. Among hospitals in the Texas cohort, 100% were noncontrast head CT-performing, 77% CT angiography-performing, and 14% CTP-performing in 2017. Most AIS cases (69%) were evaluated at non-CTP-performing hospitals. CTP-performing hospitals were clustered in urban areas, whereas large regions of the state lacked immediate access. In state-wide and national Medicare fee-for-service cohorts, CTP utilization in patients with AIS was low, and most patients were evaluated at non-CTP-performing hospitals. These findings support the need for alternative means of screening for AIS recanalization therapies.

Diagnostic Performance and Advanced Imaging Reduction With Digital Tomosynthesis in Scaphoid Fracture Management.

Management of scaphoid fractures often requires advanced imaging to achieve accurate diagnoses and appropriate treatment. Digital tomosynthesis (DTS) is a cross-sectional imaging modality that may be used to substitute magnetic resonance imaging or computed tomographic scans. The purpose of this study is to: (1) determine the diagnostic accuracy of DTS in occult scaphoid fractures; and (2) report on the reduction of other advanced imaging when using DTS. From May 2014 to October 2017, the charts of all patients who underwent scaphoid tomogram were retrospectively reviewed. The diagnostic accuracy of DTS for occult fracture was compared with 2-week follow-up plain films. To measure the reduction in utilization of advanced imaging, it was determined whether DTS eliminated the need for advanced imaging by providing adequate information regarding the clinical question. A total of 78 patients underwent scaphoid tomography in this time frame: 39 for occult fracture, 33 for fracture union, 5 for fracture morphology, and 1 for hardware positioning. For the detection of occult fracture, DTS had a sensitivity of 100%, specificity of 83%, positive predictive value of 64%, and negative predictive value of 100%. Advanced imaging was not used in 35 of the remaining 39 patients based on the results obtained by DTS. In patients who did receive advanced imaging, 83% of tomograms provided conclusive diagnostic information. Digital tomosynthesis increases the diagnostic sensitivity of occult scaphoid fractures, reducing unnecessary immobilization and advanced imaging. Digital tomosynthesis provides clinical detail beyond plain film, which reduces the need to obtain advanced imaging when assessing union, fracture pattern, and hardware placement.