Racial and Ethnic Differences in Diagnostic Imaging Utilization During Adult Emergency Department Visits in the United States, 2005 to 2014

ObjectiveTo compare the use of medical imaging (x-ray [XR], CT, ultrasound, and MRI) in the emergency department (ED) for adult patients of different racial and ethnic groups in the United States from 2005 to 2014.MethodsWe performed a multilevel stratified regression analysis of the National Hospital Ambulatory Medical Care Survey ED Subfile, a nationally representative database of hospital-based ED visits. We examined race (white, black, Asian, other) and ethnicity (Hispanic versus non-Hispanic) as the primary exposures for the outcomes of ED medical imaging use (XR, CT, ultrasound, MRI, and any imaging). We controlled for other potential patient-level and facility-level determinants of ED imaging use.ResultsApproximately half (48.8%) of the 225,037 adult patient ED visits underwent imaging; 36.1% underwent XR, 16.4% CT, 4.1% ultrasound, and 0.8% MRI. White patients received imaging during 51.3% of their encounters, black patients received imaging during 43.6% of their encounters, Asians received imaging during 50.8% of their encounters, and other races received imaging during 46% of their encounters. As compared with white patients, black patients had decreased adjusted odds of receiving imaging in the ED (odds ratio [OR] = 0.86, 95% confidence interval [CI]: 0.84-0.89). Comparatively, black patients had a lower odds of CT scan (OR = 0.80, 95% CI: 0.77-0.83) or MRI (OR = 0.74, 95% CI: 0.65-0.85). Hispanic patients and Asian patients had a higher odds of receiving ultrasound (OR = 1.36, 95% CI: 1.27-1.44 and OR = 1.25, 95% CI: 1.10-1.42), respectively.ImplicationsWe observed significant racial and ethnic differences in medical imaging use in the ED even after controlling for patient- and facility-level factors.     

Definitive chemoirradiation for resectable head and neck cancer: treatment outcome and prognostic significance of MRI findings

The aim of this study was to evaluate the outcome and prognosticators for patients with resectable head and neck cancer (RHNC) undergoing definitive concurrent chemotherapy and radiotherapy (CCRT). In total, 110 RHNC patients receiving definitive CCRT to defer radical surgery were enrolled. Radiotherapy was given as either 2 Gy once daily with 70 Gy, or 1.2 Gy twice daily with 74.4 Gy. Chemotherapy involved the administration of 5-fluorouracil and cisplatin in two concomitant and two post-radiotherapy adjuvant cycles. 3 months after CCRT, MRI was performed to evaluate the response and determine further treatment plans. Survival outcome was calculated by the Kaplan-Meier method. Log-rank test and Cox regression analyses were used to estimate the significance of prognosticators. 4-year local-regional control, distant metastasis-free survival, disease-free survival and overall survival rates were 76.1%, 85.6%, 67.5% and 53.2%, respectively. Local recurrence (odds ratio = 4.09; p < 0.0001) and T3/T4 stage (odds ratio = 2.34; p = 0.01) were the independent factors associated with poor survival. T stage (odds ratio = 3.29; p = 0.03) and/or remission status on post-CCRT MRI (odds ratio = 7.22; p < 0.0001) were significantly associated with local control, distant metastasis-free survival and disease-free survival. 13 of 20 patients with imaging residuum had local recurrence, compared with 12 of 89 with complete remission (4-year local control rate of 27% vs 86%; p < 0.0001). Post-CCRT MRI may thus be used to predict the chance of a successful non-surgical approach.     

Functional evaluation of myocardial viability by99mTc tetrofosmin gated SPECT —A quantitative comparison with18F fluorodeoxyglucose positron emission CT (18F FDG PET)—

To validate functional analysis of gated SPECT in detecting myocardial viability, seventeen patients (male 15, female 2, mean age 58) with angiographically proven chronic ischemic heart disease (RCA 6, LAD 10, LCX 1) and eight normal volunteers (all male) were studied. All patients underwent 18F FDG PET and 99mTc tetrofosmin (TF) gated SPECT within a week. After being displayed in a polar map, myocardial perfusion was regionally determined by the mean count in 9 segments at end diastole (ED) and end systole (ES) in gated SPECT. Systolic function was determined by the count increase ratio from ED to ES (WTI: ES - ED/ED). Glucose metabolism was assessed by 18F FDG PET in the segments correspondent to those defined for SPECT. TF %uptake of < 60% was defined as hypoperfusion, and FDG %uptake of < 50% was defined as reduced glucose metabolism. RESULTS: The myocardial segments were classified into 3 categories: "normal" perfusion (n = 85), "mismatch" (reduced perfusion with reserved FDG uptake, n = 25) and "matched" reduced perfusion and metabolic reduction (n = 26). Mean WTI in "mismatch" segment was 0.38 +/- 0.21, and was significantly greater than that in "matched reduced" segments, 0.15 +/- 0.20 (p < 0.001). It was also greater than that in "normal" segments, 0.27 +/- 0.16. Regression analysis showed that association between WTI and FDG %uptake was significant (r = 0.57, p < 0.0005) for the ischemic segments ("mismatch" + "matched", n = 51), but the association was weak for the entire segments although it was statistically significant (r = 0.26, p = 0.02, n = 136). CONCLUSION: For the segments determined as infarct by perfusion image, systolic functional analysis by gated SPECT is helpful in differentiation of a viable myocardial region or artifact from a scar. Nevertheless, further clinical and technical assessment is required for ECG gating to eliminate overestimation of viability and to warrant clinical use.     

The usefulness of dipyridamole thallium-201 single photon emission computed tomography for predicting perioperative cardiac events in patients undergoing non-cardiac vascular surgery

The aim of this study was to evaluate the usefulness of dipyridamole Tl-201 myocardium single photon emission computed tomography (201Tl-SPECT) for predicting perioperative cardiac events in patients with arteriosclerosis obliterans (ASO) and abdominal aortic aneurysm (AAA) undergoing non-cardiac vascular surgery. METHODS: Preoperative dipyridamole 201Tl-SPECT imaging in association with clinical risk assessment was performed in 224 consecutive patients (97 ASO and 127 AAA). RESULTS: The patients were classified into three groups, including low-risk (n = 173, 77%), intermediate-risk (n = 39, 18%), and high-risk (n = 12, 5%) groups according to the clinical risk stratification. The prevalence of reversible Tl-201 defect was significantly higher in the high-risk group than that in the low-risk group (83% vs. 14%, p < 0.001). In 180 patients who underwent vascular surgery, 9 patients (5.0%) had perioperative cardiac events, including heart failure (n = 1), unstable angina (n = 2), and other cardiac events such as arrhythmias (n = 6). The clinical variables including the clinical risk stratification did not significantly correlate with the perioperative cardiac events. In contrast, the reversible defect on 201Tl-SPECT was the only variable to predict perioperative cardiac events by a stepwise logistic regression analysis (odds ratio 7.0, 95% confidence interval 1.7-28.0, p = 0.007). It was also a significant predictor of perioperative cardiac events in a subgroup of low risk patients (odds ratio 11.6, 95% confidence interval 2.3-57.4, p = 0.004). The sensitivity and specificity of the reversible defect for predicting perioperative cardiac events were 55.6% and 84.8% in all operated patients, and 57.1% and 89.7% in low risk patients, respectively. CONCLUSIONS: The preoperative dipyridamole 201Tl-SPECT was useful for predicting perioperative cardiac events in patients with vascular diseases, even in patients identified as having a low risk based on the clinical risk assessment.     

Is functional improvement after myocardial infarction predicted with myocardial enhancement patterns at multidetector CT?

PURPOSE: To prospectively evaluate the sensitivity of myocardial early perfusion defects (EDs) and late enhancement (LE) at multidetector computed tomography (CT) following acute myocardial infarction (AMI) to predict segment myocardial dysfunction and myocardial functional recovery (MFR), by using echocardiography as the reference standard. MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained. Twenty-six patients (25 men, one woman; mean age, 53 years+/-9 [standard deviation]), underwent baseline multidetector CT, coronary angiography, and echocardiography within a week of AMI and a follow-up echocardiography at 3 months. ED, LE, and late hypoattenuation were compared with regional left ventricular function and MFR. A logistic regression model and generalized estimating equation analysis were applied to estimate the predictive effect of ED and LE. Differences between groups were evaluated by using nonpaired Student t tests. RESULTS: All EDs and LE corresponded with AMI location determined by using angiography and echocardiography. For occluded arteries (n=5), no relationship was found between the presence of ED or LE and MFR. For patent arteries (n=21), presence of LE had a respective sensitivity and specificity of 73% and 85% for predicting follow-up segment dysfunction, compared with 57% and 90% for ED. In abnormal baseline segments, nonrecovery was clearly related to the presence and size of segment defect area for both ED (odds ratio: 1.95 [95% confidence interval: 0.9, 4.1] per square centimeter) and LE (odds ratio: 1.85 [95% confidence interval: 1.2, 2.9] per square centimeter). Segments that recovered had significantly lower prevalence of ED and LE, and if present, were significantly smaller than in segments remaining abnormal (P<.05). CONCLUSION: The presence and size of ED and LE at multidetector CT is closely related to follow-up segment myocardial dysfunction and MFR.     

Subclinical inflammation as a predictor for erectile dysfunction after brachytherapy for localized prostate cancer

PURPOSE: Neutrophil-to-lymphocyte ratio (NLR), a marker for subclinical inflammation, has been previously shown to be associated with erectile dysfunction (ED). We studied the potential predictive value of the NLR on ED after prostate brachytherapy (PB) for PCa.METHODS AND MATERIALS: Between July 2005 and January 2021, 842 patients were included in this retrospective study of a prospectively maintained database. ED was assessed using the Common Terminology Criteria for Adverse Events (CTCAE) physician-reported scale. ED was defined as a Grade 2 or 3 function. NLR count was determined 1–2 months before PB and separated into values PB <2 and ≥2. Patient characteristics and erectile function at last follow-up were compared for patients with a Univariate and multivariate analyses were performed to evaluate the predictive value of baseline NLR ≥2 on post-PB ED.RESULTS: Baseline NLR ≥2 was found to be a statistically significant predictor of post-PB ED on both univariate (p = 0.002) and multivariate analyses (p = 0.008). Furthermore, the difference in ED prevalence between the NLR <2 and NLR ≥2 groups became more pronounced with longer follow-up after PB. The ED rate at 5 years post-PB was 43% for the NLR ≥2 groups, compared to 29% for the NLR <2 groups.CONCLUSIONS: Subclinical systemic inflammation is a potentially important factor for predicting sexual toxicity after pelvic radiotherapy. NLR may be used as a proxy for predicting post-PB ED.     

Acute wrist trauma: value of a short dedicated extremity MR imaging examination in prediction of need for treatment

PURPOSE: To assess predictive value of a short magnetic resonance (MR) imaging examination in addition to or instead of radiography in patients with acute wrist trauma to identify patients who require additional treatment versus those who do not and can be discharged without further follow-up. MATERIALS AND METHODS: Informed consent was obtained from all participating patients; the institutional review board approved the randomized controlled trial and use of data to create prediction models. Of 90 patients (37 female, 53 male; mean age, 40.0 years), 87 with acute wrist trauma were randomized to undergo radiography (n = 43) or radiography and a short MR imaging examination with low-field-strength dedicated extremity MR system (n = 44). Age, sex, trauma mechanism, presence of tenderness of the anatomic snuffbox, radiographic results, MR imaging results, and treatment data were collected. Univariable and multivariable logistic regression analysis was used to create four models for prediction of treatment need. RESULTS: Thirty-six patients had one or more fractures; one patient had a marked soft-tissue lesion. In univariable analysis, age (odds ratio, 1.02; 95% confidence interval: 1.00, 1.05), anatomic snuffbox tenderness (odds ratio, 2.31; 95% confidence interval: 0.90, 5.96), radiographic results (odds ratio, 31.2; 95% confidence interval: 8.90, 109), and positive MR imaging results versus MR imaging not performed (odds ratio, 1.86; 95% confidence interval: 0.57, 6.06) were significantly predictive of treatment need. In multivariable analysis, radiographic results (odds ratio, 24.7; 95% confidence interval: 6.59, 93.1) and positive MR imaging results (odds ratio, 6.28; 95% confidence interval: 1.27, 31.0) were significantly predictive of treatment need. Negative MR imaging results were not significantly predictive (odds ratio, 0.87; 95% confidence interval: 0.20, 3.82). CONCLUSION: A short MR imaging examination with a low-field-strength MR imaging system following radiography in initial evaluation of patients with acute wrist trauma has additional value in prediction of treatment need; it does not have value in identification of patients who can be discharged without further follow-up.     

Assessment of therapeutic effect in patients with secondary hyperparathyroidism using bone scintigraphy

OBJECTIVE: The semi-quantitative method of bone scintigraphy [bone to soft tissue (B/ST) ratio] has been used in diagnosing and evaluating systemic metabolic bone diseases. The aim of this study is to evaluate of the therapeutic effect of secondary hyperparathyroidism (SHP). METHODS: The subjects were ten hemodialysis patients with SHP. Seven patients underwent parathyroidectomy (PTX), and 22-Oxacalcitoriol (derivative of 1,25-dihydroxyvitamin D3) (OCT) was given to three patients. Bone scintigraphy and blood tests [intact parathyroid hormone (PTH), alkaline phosphatase (ALP), calcium (Ca), phosphorus (P), bone alkaline phosphatase (BALP), and deoxypridinoline (DPYD)] were performed before and after treatment. Regions of interest were drown around cranium, lumbar vertebrae, femoral neck and soft tissue of left medial thigh to calculate the B/ST ratio. RESULT: The B/ST ratios of cranium, lumbar vertebrae, and femoral neck were reduced significantly after PTX (cranium, p = 0.0079, lumbar vertebrae, p = 0.0282, femoral neck, p = 0.0252). Intact PTH, ALP, Ca, P, BALP and DPYD levels were reduced significantly after PTX (intact PTH, p = 0.003, Ca, p = 0.0005, P, p = 0.0393, ALP, p = 0.0051, DPYD, p = 0.0232, BALP, p = 0.0324). After OCT administration, the B/ST ratio of each bony region showed tendency to diminish, although not significantly. Intact PTH levels were reduced significantly, although ALP, BALP, and DPYD levels were not. Ca and P levels were increased significantly because of the medicinal action of OCT. CONCLUSION: The B/ST ratio of cranium may be non-invasive method and have potential in evaluating the therapeutic effect of SHP.     

Association of stressful life events with acute myocardial infarction in population in the city of Nis within the period from 1998-2000

BACKGROUND/AIM: Stressful life events present a very important category of psychosocial stress. A few studies have showed that a psychosocial stress represents a very important risk factor for acute myocardial infarction (AMI), but measures of stress may not be suitable for different countries, cultures and ethnic groups. The aim of this study was to investigate the relation of stressful life events with AMI in the period of 1998-2000 in the population of the city of Nis. METHODS: A case-control study included 100 patients with the first MI (in the period 1998-2000) and 100 healthy subjects, matched with respect to sex and age (+/- 2 years) from the city of Nis. The data of stressful life events were obtained by the Scaling of life events by Paykel ES, modified by the authors consistent with the examined population and the period of investigation. The Yates chi2 test, odds ratio - OR and their 99% interval of confidence were used as statistical procedures. RESULTS: The results showed that stressful life events in the period of investigation were very important risk factors for AMI with a statistically significant level (p = 0.000). Huge financial problems (OR = 202.36, Ci = 24.82-4387.58), violation of law (OR = 168.00, Ci = 10.66-6658.96) and serious illness of family members (OR = 159.60, Ci = 19.05- 3514.81) were the highest risk for AMI. The patients who reported that his/her son or other member of family had been gone to the army (or mobilization) before the illness onset, had 138 times higher risk of AMI (Ci = 14.98-3222.47, chi2 = 40.95, p = 0.000), while the patients who had mobilized themselves had 84 times higher risk (Ci = 7.00-2363.06, chi2= 23.87, p = 0.000). Effect of several stressful life events lead to significantly increased risk of AMI andthat significance is larger as the number of life events is more frequent (one life event: OR = 28.41, Ci = 3.73-593.52; chi2 = 17.40, p = 0.000; ? 4: OR = 336.00, Ci = 28.31-9760.28, chi2 = 50,43, p = 0,000). CONCLUSION: These findings indicate that stressful life events are associated with AMI and that they are very important for further epidemiological investigation of the triggering mechanisms and should improve preventive strategies of this serious disorder.     

In vitro differentiation characteristics of human skin fibroblasts: correlations with radiotherapy-induced breast fibrosis in patients

PURPOSE: To determine whether there is an association between dermal fibroblast differentiation characteristics in vitro and breast fibrosis developing in patients following radiotherapy for breast cancer. MATERIALS AND METHODS: Three hundred and eighty-five patients had been characterized for the degree of breast fibrosis and the level of clinical risk factors for fibrosis as established by logistic regression. Early-passage fibroblasts from 79 patients with a high (HR) or low (LR) level of risk factors were studied in vitro. The percentage differentiated cells (%DC) 7 days after 0 and 8 Gy was scored, and unirradiated colonies were scored for the ratio of early:late fibroblast differentiation stages (E:L ratio). RESULTS: %DC: For the 0 Gy data there was a significant interpatient variation (CoV = 55%, p = 0.0001). HR patients with breast fibrosis had a higher %DC compared with patients without (p = 0.017). E:L ratio: for HR patients there was a significant interpatient variation (82%, p = 0.0030) and a lower E:L ratio for patients with fibrosis compared with those without (p = 0.086), but for LR patients this relationship was reversed (p = 0.079) CONCLUSIONS: There was a true interpatient variation in the in vitro parameters of fibroblast differentiation but insufficient correlation with observed fibrosis after radiotherapy for use as a predictive test.     

Developing a prediction rule to assess hepatic malignancy in patients with cirrhosis

OBJECTIVE: The objectives of our study were to identify independent clinical, demographic, and MR imaging correlates of malignancy in patients with cirrhosis and to develop a predictive model based on identified correlates of malignancy. MATERIALS AND METHODS: Sixty examinations of 58 patients with biopsy proof of lesions suggestive of hepatocellular carcinoma on MR imaging were retrospectively reviewed. The signal intensity of the lesion on T2-weighted imaging and dynamic gadolinium-enhanced imaging, the size of the lesion, and the number of suspicious lesions were recorded; in addition, patient age and sex, alpha-fetoprotein level, and hepatitis C viral genotype were noted. The association between malignancy and each predictor variable was evaluated using the chi-square test or the two-group t test. The final logistic regression model included the variables that were shown to have a significant association with malignancy and the clinically relevant predictors. We used the adjusted odds ratios to measure the strength of each association. The discriminant ability of the model for detecting hepatic malignancy was assessed using receiver operating characteristic curve analysis. RESULTS: The prevalence of hepatic malignancy in our study population was 64%. The area under the receiver operating characteristic curve for the logistic regression model was 0.82. Venous washout (odds ratio = 9.2), alpha-fetoprotein level (odds ratio = 3.2), and number of lesions (odds ratio = 1.5) were significant predictors for malignancy (p < 0.05). When arterial enhancement and venous washout were either both present or both absent, alpha-fetoprotein level contributed little to the prediction of malignancy. CONCLUSION: The MR characteristics of hepatic lesions during the dynamic venous phase in conjunction with the serum alpha-fetoprotein level and number of lesions are predictors of hepatic malignancy. The use of these predictors can facilitate explicit estimation of malignancy in individuals with underlying cirrhosis, potentially improving clinical decision-making.     

Patient satisfaction with the communication of mammographic results before and after the Mammography Quality Standards Reauthorization Act of 1998.

OBJECTIVE: The goal of this study was to evaluate the difference in patient satisfaction, timeliness of reporting, patient recollection of recommendations, and patient anxiety before and after passage of the Mammography Quality Standards Reauthorization Act of 1998, which requires written notification of all mammographic results. MATERIALS AND METHODS: We used a telephone survey with sampling that was stratified to reflect patients with normal and abnormal findings who had screening and diagnostic mammograms. Patients with visits before the mandate became effective (April 1999, n = 298) and after (January 2000, n = 316) were interviewed about the average time to receive results, satisfaction with communication about results, anxiety, and perceived follow-up recommendations. Multiple logistic regression was used to test the association of time period with patient dissatisfaction, controlling for age, anxiety level (considerable or extreme vs none or moderate), examination type (screening vs diagnostic), and examination result (normal vs abnormal findings). RESULTS: No significant difference was found between periods in anxiety about results or agreement with documented radiology recommendations, but we found a substantial increase in the number of screening patients who reported timely receipt of results. Significantly fewer patients were dissatisfied with mammographic results communication after the mandate (multivariable odds ratio = 0.46, p = 0.006). Screening examination patients and patients who reported considerable or extreme anxiety about test results were more likely to be dissatisfied in both periods. CONCLUSION: By standardizing results notification, the Mammography Quality Standards Reauthorization Act improved patient satisfaction and reporting timeliness among screening examination patients, but did little to improve anxiety or recollection of recommendations. Future quality improvement efforts should focus on improving patients' understanding of follow-up recommendations.     

Reduced emergency department stabilization time before cranial computed tomography in patients undergoing air medical transport

INTRODUCTION: Advanced patient stabilization skills provided by air medical providers were hypothesized to result in streamlined emergency department (ED) stabilization of patients with head injuries requiring urgent cranial computed tomography (CCT). The goal of this study was to compare initial ED stabilization times between air- and ground-transported patients requiring urgent CCT and emergency neurosurgical hematoma evacuation. SETTING: Academic Level trauma center (annual ED census 60,000) receiving patients from ground EMS and a nurse/paramedic air medical transport team. METHODS: This retrospective study identified, from a database of 15 months of ED visits, consecutive group of adults who had CCT performed within 60 minutes of ED arrival and underwent emergent craniotomy for intracranial hematoma. Demographics, hemodynamic status, patient acuity, and time intervals between ED and CCT suite arrivals were compared between air and ground patients using chi-square, Fisher's exact, and t-tests (p = 0.05). RESULTS: Eleven air- and 39 ground-transported patients were eligible. All patient acuity data were similar between groups. Air patients were more likely to be intubated (100% versus 71.8%, p = .04) and had shorter mean ED stabilization times (29 versus 40 minutes, p = .02) than the ground. CONCLUSION: This study suggests that advanced patient stabilization offered by air medical transport may result in reduced ED stabilization time for patients requiring urgent craniotomy.     

Self-efficacy of knee function as a pre-operative predictor of outcome 1 year after anterior cruciate ligament reconstruction

The knee self-efficacy scale (K-SES) has been shown to have good reliability, validity and responsiveness during rehabilitation for patients' perceived self-efficacy of knee function. Determinants of self-efficacy of knee function 1 year after ACL reconstruction have been found to be the patients' internal locus of control and knee symptoms in sports and recreation. The predictive ability of perceived self-efficacy of knee function measured by the K-SES has not been studied in terms of patient outcome after an ACL reconstruction. The purpose of this study was to explore the potential for pre-operative self-efficacy of knee function measured by the K-SES to predict patient outcome in terms of physical activity, knee symptoms and muscle function 1 year after an ACL reconstruction. Thirty-eight patients were evaluated for outcome in terms of physical activity with the Tegner activity scale and the physical activity scale (PAS), knee symptoms with the Lysholm knee scoring scale and the knee injury and osteoarthritis outcome score (KOOS) and knee function with ability tests for muscle function 1 year after ACL reconstruction. Multiple regression and logistic multiple regression analysis were used to evaluate the K-SES as a possible predictor of outcome. The patients' present perceived self-efficacy of knee function (K-SES(Present)) pre-operatively was a significant predictor (P = 0.016) of the patients returning to their intensity and frequency of physical activity (PAS) 1 year after ACL reconstruction, when adjusted for age, gender and pre-injury physical activity level (Tegner(Pre-injury)) (odds ratio = 2.1). The patients' perceived future self-efficacy of knee function (K-SES(Future)) pre-operatively was a significant predictor (P = 0.045) of their self-rated knee function in sports/recreational activities (KOOS(Sports/recreation)) at the 1-year follow-up, when adjusted for age, gender and Tegner(Pre-injury )(R (2 )=0.25). The pre-operative K-SES(Future) was also a significant predictor (P = 0.023) of the patients' knee-related quality of life (KOOS(Qol)), at the 1-year follow-up, when adjusted for age, gender and Tegner(Pre-injury) (R (2 )=0.23). The pre-operative K-SES(Future) was furthermore a significant predictor of an acceptable outcome 1 year after surgery, on the Lysholm knee scoring scale (P = 0.003, odds ratio = 1.7), as well as on KOOS(Sports/recreation) (P = 0.002, odds ratio = 1.6) and knee-related quality of life (KOOS(Qol)) (P = 0.037, odds ratio = 1.4), when adjusted for age, gender and Tegner(Pre-injury). The pre-operative K-SES(Future) was also a significant predictor (P = 0.04) of an acceptable outcome 1 year after surgery, on the one-leg hop for distance (odds ratio = 2.2), when adjusted for age, gender and Tegner(Pre-injury). In conclusion, this study indicates that patients' perceived self-efficacy of knee function pre-operatively is of predictive value for their return to acceptable levels of physical activity, symptoms and muscle function 1 year after ACL reconstruction.     

Validation of a clinical decision rule: chest X-ray in patients with chest pain and possible acute coronary syndrome

Current literature suggests that a large proportion of chest X-rays (CXRs) performed in emergency department (ED) patients with chest pain and suspected acute coronary syndrome (ACS) are unnecessary. The Canadian ACS Guidelines aim to guide clinicians in the appropriate use of CXR within this patient population. This study determined the prevalence of clinically significant CXR abnormalities and assessed the utility of the guidelines in a population of ED patients with chest pain and suspected ACS. Included in the study were participants over the age of 18 who presented to an Australian metropolitan ED, over a 1-year period, with a primary complaint of chest pain and who had a CXR and troponin level ordered in the ED (N?=?760). We retrospectively compared their radiographic findings with their recommendations for CXR according to the ACS Guidelines. We found that 12 % of the participants had a clinically significant chest X-ray. The guidelines had a sensitivity of 80 % (95 % CI 0.70–0.87) and specificity of 50 % (95 % CI 0.47–0.54). The positive predictive value was 18 % (95 % CI 0.15–0.22) with a 95 % negative predictive value (95 % CI 0.92–0.97). Had the ACS guidelines been applied to our patient population, the number of CXR performed would have been reduced by 47 %. This study suggests that the ACS Guidelines has the potential to reduce the numbers of unnecessary CXR performed in ED patients. However, this would come at the expense of missing a minority of significant CXR abnormalities.     

Low-level Irradiation

Purpose : To determine whether there is an association between dermal fibroblast differentiation characteristics in vitro and breast fibrosis developing in patients following radiotherapy for breast cancer. Materials and methods : Three hundred and eighty-five patients had been characterized for the degree of breast fibrosis and the level of clinical risk factors for fibrosis as established by logistic regression. Early-passage fibroblasts from 79 patients with a high (HR) or low (LR) level of risk factors were studied in vitro. The percentage differentiated cells (%DC) 7 days after 0 and 8 Gy was scored, and unirradiated colonies were scored for the ratio of early:late fibroblast differentiation stages (E:L ratio). Results : %DC: For the 0 Gy data there was a significant interpatient variation (CoV=55%, p=0.0001). HR patients with breast fibrosis had a higher %DC compared with patients without (p =0.017). E:L ratio: for HR patients there was a significant interpatient variation (82%, p =0.0030) and a lower E:L ratio for patients with fibrosis compared with those without (p =0.086), but for LR patients this relationship was reversed (p =0.079) Conclusions : There was a true interpatient variation in the in vitro parameters of fibroblast differentiation but insufficient correlation with observed fibrosis after radiotherapy for use as a predictive test.     

MR imaging of pancreatic changes in patients with transfusion-dependent beta-thalassemia major.

OBJECTIVE: The aim of this study was to evaluate MR imaging changes of the pancreas in patients with transfusion-dependent beta-thalassemia major. SUBJECTS AND METHODS: Twenty patients with transfusion-dependent beta-thalassemia major were examined using MR imaging at 0.5 T, with spin-echo T1-weighted, fast spin-echo T2-weighted, and gradient-echo T2*-weighted sequences. Image analysis was performed to assess pancreas-to-fat signal intensity ratios for all pulse sequences. Pancreatic exocrine and endocrine function and serum ferritin levels were assessed. Twenty healthy volunteers underwent MR imaging with the same three sequences and served as a control group. RESULTS: The pancreas-to-fat signal intensity ratio was significantly decreased in 17 (85%) of the 20 patients on spin-echo T1-weighted images (p < .05), fast spin-echo T2-weighted images (p < .01), and gradient-echo T2*-weighted images (p < .01) when compared with the 20 volunteers in the control group. The pancreas-to-fat signal intensity ratio was significantly increased in three (15%) of the 20 patients on spin-echo T1-weighted images (p < .01) and fast spin-echo T2-weighted images (p < .05). In addition, in the 20 patients, we found a significant correlation between increased pancreas-to-fat signal intensity ratios and decreased serum trypsin levels (r = -.77, p < .01 for spin-echo T1-weighted sequences; r = -.75, p < .05 for fast spin-echo T2-weighted sequences; and r = -.74, p < .05 for gradient-echo T2*-weighted sequences). Likewise, for the 20 patients, we found a significant correlation between decreased pancreas-to-fat signal intensity ratios and increased serum ferritin levels for gradient-echo T2*-weighted images (r = -.65, p < .01). No correlation was found for the other clinical parameters evaluated. CONCLUSION: MR imaging revealed signal intensity changes in the pancreas of patients with transfusion-dependent beta-thalassemia major. Patients with a major impairment of the exocrine pancreatic function had higher signal intensity of the pancreas because of fatty replacement of the parenchyma.     

Lost to Follow-Up: A Nationwide Analysis of Patients With Transient Ischemic Attack Discharged From Emergency Departments With Incomplete Imaging

PurposeImaging guidelines for transient ischemic attack (TIA) recommend that patients undergo urgent brain and neurovascular imaging within 48 hours of symptom onset. Prior research suggests that most patients with TIA discharged from the emergency department (ED) do not complete recommended TIA imaging workup during their ED encounters. The purpose of this study was to determine the nationwide percentage of patients with TIA discharged from EDs with incomplete imaging workup who complete recommended imaging after discharge.MethodsPatients discharged from EDs with the diagnosis of TIA were identified from the Medicare 5% sample for 2017 and 2018 using International Classification of Diseases, tenth rev, Clinical Modification codes. Imaging performed was identified using Current Procedural Terminology codes. Incomplete imaging workup was defined as a TIA encounter without cross-sectional brain, brain-vascular, and neck-vascular imaging performed within the subsequent 30 days of the initial ED encounter. Patient- and hospital-level factors associated with incomplete TIA imaging were analyzed in a multivariable logistic regression.ResultsIn total, 6,346 consecutive TIA encounters were analyzed; 3,804 patients (59.9%) had complete TIA imaging workup during their ED encounters. Of the 2,542 patients discharged from EDs with incomplete imaging, 761 (29.9%) completed imaging during the subsequent 30 days after ED discharge. Among patients with TIA imaging workup completed after ED discharge, the median time to completion was 5 days. For patients discharged from EDs with incomplete imaging, the odds of incomplete TIA imaging at 30 days after discharge were highest for black (odds ratio, 1.84; 95% confidence interval, 1.27-2.66) and older (≥85 years of age; odds ratio, 2.41; 95% confidence interval, 1.78-3.26) patients. Reference values were age cohort 65 to 69 years; male gender; white race; no co-occurring diagnoses of hypertension, hyperlipidemia, or diabetes mellitus; household income > $63,029; hospital in the Northeast region; urban hospital location; hospital size > 400 beds; academically affiliated hospital; and facility with access to MRI.ConclusionsMost patients discharged from EDs with incomplete TIA imaging workup do not complete recommended imaging within 30 days after discharge.     

A multicenter evaluation of the appropriate use of single-photon emission tomography myocardial perfusion imaging in Greece

Background

This study evaluates the appropriate use of myocardial perfusion imaging (MPI) and determines patterns and variables associated with inappropriate testing.

Methods

Over a 10-month period data were collected prospectively from consecutive patients referred for MPI in four academic departments and an appropriate use grade was assigned (appropriate, uncertain, inappropriate, and unclassifiable scans) according to established criteria.

Results

Among 3,032 referrals appropriate MPI had 72.8% of patients and 19.2% of studies were inappropriate, the remaining being uncertain (7.2%) or unclassifiable (0.8%). In multivariate analysis the asymptomatic status (odds ratio 10.7, P < .001), good functional capacity (odds ratio 1.9, P < .001), an interpretable resting electrocardiogram (odds ratio 1.8, P = .004), an age <65 years (odds ratio 1.5, P = .001) and the absence of diabetes (odds ratio 1.7, P < .001) or dyslipidemia (odds ratio 1.3, P = .014) were independent predictors of inappropriate scintigraphy. The most common indication for inappropriate testing was the assessment of asymptomatic patients <2 years after percutaneous coronary intervention (PCI) (38.9%).

Conclusions

The appropriate use of MPI is relatively high, but a considerable proportion of inappropriate scans is noted which is associated with markers of lower risk. The most common source of inappropriate testing is the assessment of asymptomatic patients <2 years after PCI.     

Creutzfeldt-Jakob disease and blood transfusions: a meta-analysis of case-control studies.

A meta-analysis of five published case-control studies that examined the association between previous blood transfusions and Creutzfeld-Jakob disease was performed. The results demonstrated that controls were more likely (p < 0.001, odds ratio = 1.56, 95% confidence interval, 1.22-1.98) to have received previous blood transfusions (18.7%) than Creutzfeld-Jakob disease patients (12.9%), suggesting that selection bias of the control populations had occurred.