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1.
J Neuroimaging ; 22(2): 118-21, 2012 Apr.
Article in English | MEDLINE | ID: mdl-21281379

ABSTRACT

Patients with symptomatic intracranial neuropathology such as atherosclerotic occlusive disease or unruptured aneurysms face high risks for morbidity and mortality. Magnetic resonance angiography of the circle of Willis is an important tool used to detect and diagnose intracranial neuropathology; however, recent changes to the Medicare local coverage determinations for this procedure threaten to compromise the physician's ability to deliver this current standard of care. Physicians can assume an important role in advocating for this lifesaving procedure on behalf of this vulnerable patient population.


Subject(s)
Cerebral Angiography , Circle of Willis/pathology , Intracranial Aneurysm/diagnosis , Magnetic Resonance Angiography , Diagnosis, Differential , Humans , Medicare , United States
2.
J Neurosurg Sci ; 55(2): 85-8, 2011 Jun.
Article in English | MEDLINE | ID: mdl-21623319

ABSTRACT

AIM: A variety of magnetic resonance imaging (MRI)-compatible skin-marker localization devices are available on the market. MRI protocols call for the liberal use of the skin markers over the specific site of symptoms or over any palpable mass. This study investigates the usefulness of patient-assisted placement of 1 000-mg fish oil capsules as skin markers over the area of maximum localized pain, signs, or symptoms and correlates this placement with any potential underlying neuropathology or potential pain generator. METHODS: One-hundred symptomatic patients undergoing MRI were assessed for focal or localized signs or symptoms. Under the direction of a physician and with guidance from the patient, the MRI technician placed a 1 000-mg fish-oil capsule over the area of maximum pain or signs and symptoms. Patients with poorly localized, diffuse symptoms or an area of maximal signs and symptoms outside the field of view of the MRI were not included in this study. All MRI exams were reviewed by clinical physicians and radiologists or neuroimaging physicians. RESULTS: In all 100 cases, the images show clearly visible MRI-compatible skin-surface markers that correlate with potential underlying neuropathology. CONCLUSION: Our results show that 1 000-mg fish-oil capsules can be used as MRI localization devices as a cost-effective alternative to more expensive commercially available devices.


Subject(s)
Fish Oils , Magnetic Resonance Imaging/methods , Neurosurgery , Preoperative Care/methods , Spinal Diseases/pathology , Anthropometry/instrumentation , Anthropometry/methods , Back Pain/pathology , Back Pain/surgery , Capsules , Humans , Skin , Spinal Diseases/surgery
3.
Pain Physician ; 13(2): 187-94, 2010.
Article in English | MEDLINE | ID: mdl-20309384

ABSTRACT

BACKGROUND: Because the symptoms of drug misuse are nonspecific and difficult to detect, pain physicians have relied heavily on the results of urine drug tests to diagnose and treat chronic noncancer pain in patients who are prescribed controlled substances. However, changes in Medicare local carrier determinations for Medicare Part B providers in Connecticut, Indiana, Kentucky, and New York went into effect on July 1, 2009, whereby qualitative drug screening was no longer recognized as medically reasonable and necessary in the treatment of patients with chronic noncancer pain unless the patient presents with suspected drug overdose. STUDY DESIGN: A retrospective review of urine drug testing services. OBJECTIVE: To determine the extent of urine drug testing in patients with chronic noncancer pain in a large, Kentucky neuroscience practice offering pain management services combined with neurologic and neurosurgical services to better understand the potential effects of recent changes to Medicare benefits. METHODS: An audit of services provided during 2007 was conducted using computer software. OUTCOME MEASURES: Outcome measures included the number of practice services, number of urine drug tests by payor, and the number of noncompliant patients by payor who self-released from care. RESULTS: Urine drug tests represented approximately 18.2% of professional medical services rendered in 2007 to patients with a diagnosis of chronic noncancer pain. Of these, UDTs represented approximately 22.2% of services provided to Medicare patients and 24.6% of services provided to Medicaid patients. In 2007, 2,081 patients with noncompliant UDTs self released from the practice against medical advice. Of these, 23.1% were enrolled in Medicare and 47.5% were enrolled in Medicaid. Approximately 40% of patients were referred to the CARE Clinic on the basis of noncompliance as indicated by UDT and/or behavioral health issues. Of these, approximately 50% remained in treatment. Urine drug tests were also instrumental in revealing that 19.6% of patients showed signs of drug abuse or addiction. Of these patients, approximately 60% were government insured. LIMITATIONS: Not a prospective, double-blinded study. We approximated the proportion of patients potentially affected by drug abuse or addiction as the percentage of patients self releasing from medical care. CONCLUSION: In 2007, UDTs were used as an effective tool in adherence monitoring in a private neuroscience practice in Kentucky that offers pain management services combined with neurologic and neurosurgical services. UDTs were instrumental in referring 40% of patients for evaluation and treatment by behavioral health and addiction medicine specialists. UDTs were also instrumental in discovering signs of drug abuse or addiction in 19.6% of patients. Of these patients, approximately 60% were government insured. Should the objective and reliable sign offered by UDTs be eliminated from the physician's toolbox, the physician's ability to accurately diagnose and treat these patients could be impaired.


Subject(s)
Medicare/trends , Opioid-Related Disorders/diagnosis , Opioid-Related Disorders/urine , Pain Clinics/statistics & numerical data , Pain, Intractable/drug therapy , Reimbursement Mechanisms/trends , Substance Abuse Detection/statistics & numerical data , Analgesics, Opioid/administration & dosage , Analgesics, Opioid/adverse effects , Humans , Kentucky , Opioid-Related Disorders/epidemiology , Pain Clinics/economics , Pain Clinics/standards , Patient Acceptance of Health Care , Patient Compliance , Practice Patterns, Physicians'/statistics & numerical data , Predictive Value of Tests , Retrospective Studies , Sensitivity and Specificity , Substance Abuse Detection/economics , Substance Abuse Detection/standards , United States , Urinalysis/standards , Urinalysis/statistics & numerical data
4.
Pain Physician ; 13(2): 167-86, 2010.
Article in English | MEDLINE | ID: mdl-20309383

ABSTRACT

BACKGROUND: Urine drug testing has become a widely used tool in American society for deterring illicit drug use. In the practice of medicine, urine drug testing is commonly used to help diagnose substance misuse, abuse, or addiction. OBJECTIVE: This narrative review provides an informed perspective on the importance of urine drug testing in the medical treatment of chronic noncancer pain. The history and current uses of urine drug tests in the United States are reviewed, the prevalence and nature of prescription drug misuse is described as is related to chronic noncancer pain, and implications and considerations for practitioners are presented related to the noncancer pain diagnosis and treatment. DISCUSSION: Practitioners are confronted with the ethical and legal dilemma of being called to adequately treat chronic pain in a culture with a high prevalence of prescription drug abuse. Yet the symptoms of drug abuse are nonspecific and therefore of limited value to the practitioner in determining patient compliance to drug treatment regimens. In contrast, urine drug testing has a reliable history, both in and out of medicine, as an independent sign of drug misuse. This sign can be used to aid in the diagnosis and treatment of drug misuse and underlying addictions to improve patient outcomes. CONCLUSION: Regular urine drug testing should be a part of acute and chronic pain management whether or not the patient has any signs or symptoms of drug misuse.


Subject(s)
Legislation, Drug/trends , Medicare/trends , Opioid-Related Disorders/diagnosis , Opioid-Related Disorders/urine , Pain, Intractable/drug therapy , Substance Abuse Detection/standards , Urinalysis/standards , History, 20th Century , Humans , Kentucky , Opioid-Related Disorders/prevention & control , Pain, Intractable/prevention & control , Practice Patterns, Physicians'/legislation & jurisprudence , Practice Patterns, Physicians'/standards , Practice Patterns, Physicians'/trends , Prescriptions/standards , Substance Abuse Detection/history , Substance Abuse Detection/legislation & jurisprudence , United States , Urinalysis/history
5.
J Magn Reson Imaging ; 11(6): 655-64, 2000 Jun.
Article in English | MEDLINE | ID: mdl-10862065

ABSTRACT

To evaluate the effect of contrast dose using gadobenate dimeglumine, 30 patients with focal liver lesions documented by computed tomography or ultrasound were studied by magnetic resonance imaging at 1.5 T. Patients received one of four doses of gadobenate dimeglumine (0.025, 0.05, 0.1, or 0.2 mmol/kg) or saline. The order of dosage was randomized, with both the physician and patient blinded to the administered dose. Scans were obtained before, immediately following injection, and after 80 minutes of delay. Enhancement effects were quantified by region of interest measurements. Films were also reviewed in a randomized prospective fashion by an abdominal radiologist blinded to contrast dose and diagnosis. Higher doses led to a statistically significant improvement in enhancement of normal liver, both on immediate (P = 0.01 for the comparison of 0.1 and 0.2 mmol/kg immediately post-contrast) and delayed scans (P = 0.003 for the same comparison). Liver-lesion contrast-to-noise ratio also increased with dose, although results for most comparisons by dose were not statistically significant. Scans following gadobenate dimeglumine injection were judged to provide additional diagnostic confidence sufficient to affect patient management in 10 of 24 cases. In seven cases this information was provided by dynamic scans, in one case by delayed scans, and in two cases by both dynamic and delayed scans. In 2 of the 10 cases the dose was 0.025 mmol/kg, in 2 cases 0.05 mmol/kg, in 3 cases 0.1 mmol/kg, and in 3 cases 0.2 mmol/kg. Gadobenate dimeglumine is effective for imaging of focal liver lesions at a range of doses, with trends toward improved diagnostic information at higher doses.


Subject(s)
Contrast Media , Image Enhancement , Liver Diseases/diagnosis , Liver/pathology , Magnetic Resonance Imaging/methods , Meglumine/analogs & derivatives , Organometallic Compounds , Adult , Aged , Aged, 80 and over , Analysis of Variance , Dose-Response Relationship, Drug , Double-Blind Method , Female , Humans , Male , Middle Aged , Probability , Sensitivity and Specificity , Time Factors
6.
Radiographics ; 16(2): 321-34, 1996 Mar.
Article in English | MEDLINE | ID: mdl-8966290

ABSTRACT

Detection and characterization of pelvic masses are universal and vital applications of sonography. Despite the considerable overlap in the morphologic patterns of different pelvic masses, a characteristic sonographic appearance frequently allows at least a narrow differential diagnosis and often allows a specific diagnostic choice, particularly when the imaging findings are coupled with sufficient clinical data. Color flow and spectral Doppler techniques are evolving and have promising roles in diagnosis of pelvic masses; however, basic sonographic morphology coupled with the necessary clinical input remains the mainstay of sonographic differential diagnosis of pelvic masses. Considerable research is being done on enhancing sonographic differentiation between benign and malignant neoplasms. The most common sonographic features of benign pelvic masses should permit clinically useful characterization. Benign pelvic masses include uterine masses (leiomyoma, hematometra, hematocolpometra), ovarian masses (functional cysts, polycystic ovaries, parovarian cyst, endometrioma, epithelial tumors, dermoid cyst), and miscellaneous masses (pelvic inflammatory disease, ectopic pregnancy).


Subject(s)
Genital Diseases, Female/diagnostic imaging , Pelvic Inflammatory Disease/diagnostic imaging , Pelvic Neoplasms/diagnostic imaging , Pregnancy, Ectopic/diagnostic imaging , Adult , Diagnosis, Differential , Female , Humans , Middle Aged , Pregnancy , Ultrasonography
7.
AJNR Am J Neuroradiol ; 17(1): 61-70, 1996 Jan.
Article in English | MEDLINE | ID: mdl-8770251

ABSTRACT

PURPOSE: To present characteristic MR findings of developmental venous anomalies (DVAs) in terms of location of caput and draining veins, to correlate these findings with normal medullary venous anatomy, and to suggest an approach to the evaluation of DVAs by means of MR imaging. METHODS: We reviewed the contrast-enhanced MR examinations of 61 patients with DVA, which were selected from 4624 consecutive cranial MR examinations. Site of the DVA and size and direction of draining veins were recorded. RESULTS: Seventy-two DVAs with 78 draining veins were located: 18 were juxtacortical, 13 were subcortical, and 41 were periventricular or deep. Twenty-six of the DVA caputs were frontal, 16 were parietal, 13 were in the brachium pontis/dentate, seven were in the temporal lobe, three were in the cerebellar hemisphere, three were in the occipital lobe, three were in the basal ganglia, and one was in the pons. The draining veins were superficial in 29 cases and deep in 49. Of the 36 supratentorial deep draining veins, 16 were in the trigone/occipital horn, 11 were in the mid-body of the lateral ventricle, seven were in the frontal horn, and two were in the temporal horn. Among the 14 infratentorial deep draining veins, five were in the lateral recess of the fourth ventricle, four were anterior transpontine veins, three were lateral transpontine veins, and two were precentral cerebellar veins. CONCLUSION: The DVA caputs and their draining veins occurred in typical locations that could be predicted from the normal medullary venous anatomy, with the frontal, parietal, and brachium pontis/dentate being the most common locations. Drainage can occur in superficial cortical veins or sinuses or in deep ventricular veins or in both, no matter where the caput is located. Whether drainage was superficial or deep could not be predicted on the basis of the site of the DVA caput. Contrast-enhanced T1-weighted MR images showed the DVAs best, but diagnosis could be made from T2-weighted MR images.


Subject(s)
Brain Neoplasms/diagnosis , Hemangioma/diagnosis , Intracranial Arteriovenous Malformations/diagnosis , Magnetic Resonance Imaging , Adolescent , Adult , Aged , Brain Neoplasms/congenital , Cerebellum/blood supply , Cerebral Cortex/blood supply , Cerebral Veins/abnormalities , Cerebral Veins/pathology , Cerebral Ventricles/blood supply , Child , Child, Preschool , Female , Hemangioma/congenital , Humans , Infant , Magnetic Resonance Angiography , Male , Middle Aged
8.
J Comput Assist Tomogr ; 16(4): 660-2, 1992.
Article in English | MEDLINE | ID: mdl-1629432

ABSTRACT

We report the MR appearance of a rare case of sarcoidosis of the spine presenting as spondylodiskitis. Vertebral and disk signal changes were typical for diskitis. In the appropriate clinical setting the differential diagnosis of diskitis should include sarcoidosis.


Subject(s)
Discitis/diagnosis , Lumbar Vertebrae/diagnostic imaging , Magnetic Resonance Imaging , Sarcoidosis/diagnosis , Spondylitis/diagnosis , Adolescent , Discitis/etiology , Female , Humans , Radiography , Spondylitis/etiology
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