National Trends in Lumbar Puncture from 2010 to 2018: A Shift Reversal from the Emergency Department to the Hospital Setting for Radiologists and Advanced Practice Providers.

BACKGROUND AND PURPOSE: Prior research has shown substantial shifts in procedure shares between specialty groups providing lumbar punctures. Our aim was to analyze national trends in lumbar punctures among the Medicare population from 2010 to 2018. MATERIALS AND METHODS: Medicare Part B Physician/Supplier Procedure Summary Master Files from 2010 to 2018 were analyzed for all Current Procedural Terminology, Version 4 codes related to lumbar punctures (62270 and 62272). Lumbar puncture procedure volume and utilization rates were assessed and stratified by place of service and specialty background of the providers. RESULTS: From 2010 to 2018, the overall number of lumbar puncture procedures essentially has not changed (92,579 versus 92,533). Radiologists hold the largest and an increasing procedure share of diagnostic and overall lumbar punctures (overall share, 45.7% in 2010 [n = 42,296] versus 52.3% in 2018 [n = 48,414]). Advanced practice providers have increased their procedure share (3.7% in 2010 [n = 3388] versus 8.4% in 2018 [n = 7785], + 129.8% procedure volume). Emergency medicine physicians and neurologists have a decreasing procedure share (21.8% versus 15.3% and 12.5% versus 8.8%, respectively). The inpatient hospital setting remains the largest place of service for lumbar punctures, recording a 5.3% increase in procedure share. The emergency department lumbar puncture volume has declined, with a 7.4% decrease in the overall procedure share. Similarly, the hospital outpatient department procedure volume has increased (+4%), while the private office volume has decreased (-1.7%). CONCLUSIONS: During the past decade, lumbar puncture procedures among the Medicare population have remained stable, with a shift in procedure volume from the emergency department and private offices to the hospital setting, which has mainly affected radiologists and advanced practice providers.

Pathologic changes of the lateral pterygoid muscle in patients with derangement of the temporomandibular joint disk: objective measures at MR imaging.

BACKGROUND AND PURPOSE: The superior head of the lateral pterygoid muscle (SHLP), which inserts on the anterior disk of the temporomandibular joint (TMJ), can spasm, contracting and exerting forward traction on the disk. This mechanism can lead to anterior displacement. In TMJ dysfunction, it is hypothesized that the SHLP will demonstrate morphologic changes with measurable changes in signal intensity related to atrophy or muscular edema, or both. The goal of this study was to evaluate the lateral pterygoid muscle (LPM) in patients with TMJ dysfunction. MATERIALS AND METHODS: Patients with displacement of the TMJ disk with and without reduction were identified through a review of radiology reports. Absolute measurements of thickness as well as region-of-interest measurements were placed over the 2 heads of the LPM bilaterally on sagittal T1- and T2-weighted images. Statistically significant differences between the superior and inferior heads of the LPM were calculated with use of a 1-tailed Student t test and were correlated with the degree of disk derangement. RESULTS: In patients with disk derangement, significantly increased region-of-interest values on T2- and T1-weighted images were demonstrated within the SHLP. No patients with anatomically normal disks demonstrated a statistically significant difference in region-of-interest values between the superior and inferior heads of the LPMs. CONCLUSION: Correlation between increased region-of-interest values and pathologic alteration of the relationship between the condylar head and disk was identified. In patients with displacement of the anterior disk with and without reduction, region-of-interest values were significantly increased, which indicates abnormal signal intensity involving the superior head of the LPM.

Use trends and geographic variation in neuroimaging: nationwide medicare data for 1993 and 1998.

BACKGROUND AND PURPOSE: Powerful tools, including CT and MR imaging, have revolutionized neuroimaging. These are routinely used, but the extent and variation of use has not been studied. Our purposes were to determine the use rates of MR imaging and CT (of spine, brain, or head and neck), myelography, conventional angiography, and MR angiography in diagnosing neurologic disorders; to study trends in use; and to determine regional variations in use. METHODS: We used the National Part B Medicare Database for 1993 and 1998 to compare rates of use for these procedures in 10 geographic regions. RESULTS: In 1993 and 1998, respectively, 13,897 and 19,431 (39.8% increase) neuroimaging procedures were performed per 100,000 Medicare beneficiaries nationwide. Use of brain or head and neck CT (30.4%) and MR imaging (43.6%), spinal CT (3.5%) and MR imaging (83.0%), myelography (56.6%), and conventional angiography (24.3%) increased in 1998 versus 1993. Increases in MR angiography were not assessed, because this procedure was not reimbursable in 1993. Regional use of brain or head and neck and spinal CT and MR studies varied considerably; ratios of highest and lowest rates were 1.38-1.56. Use of MR angiography, myelography, and conventional angiography varied three- to fourfold. CONCLUSION: Use of MR and CT studies of the brain or head and neck and of the spine increased considerably in the Medicare population between 1993 and 1998. Use of conventional invasive procedures such as myelography and angiography increased strikingly, contrary to the expected decline. Regional use varied substantially.

Granular cell tumor of the parotid: a case report and literature review.

Granular cell tumors are relatively uncommon soft tissue lesions that originate in Schwann's cells. Although these tumors can occur at any site, their presence in the parotid gland is very unusual. This article describes one such case in a 48-year-old woman, followed by a brief review of the literature on this subject.

Controlled and complete release of a model poorly water-soluble drug, prednisolone, from hydroxypropyl methylcellulose matrix tablets using (SBE)(7m)-beta-cyclodextrin as a solubilizing agent.

Sustained-release formulations such as hydroxypropyl methylcellulose (HPMC)-based hydrophilic matrix tablets of poorly water-soluble drugs often result in incomplete release because of the poor solubility and dissolution rate of the drug in the hydrophilic matrix. Sulfobutylether-beta-cyclodextrins ((SBE)(7M)-beta-CDs) have been known to improve the solubility of such drugs by forming inclusion complexes. The present paper deals with the modification of drug release from an HPMC-based matrix tablet of a sparingly water-soluble drug, prednisolone (PDL), using (SBE)(7M)-beta-CD as a solubilizing agent. Tablets were prepared by direct compression of a physically mixed PDL, (SBE)(7M)-beta-CD, and polymer. On exposure to water, an in situ PDL:(SBE)(7M)-beta-CD complex was formed in the gel layer, and enhanced drug release relative to a control formulation was observed (lactose used as the excipient instead of (SBE)(7M)-beta-CD ). Other possible changes due to the incorporation of (SBE)(7M)-beta-CD in the formulation were also probed. Incorporation of (SBE)(7M)-beta-CD lead to a higher water uptake relative to the control (lactose) formulation. For a fixed total tablet weight, polymer type, and loading, the drug release rate appeared to depend on the molar ratio of (SBE)(7M)-beta-CD to PDL and not the absolute amount of (SBE)(7M)-beta-CD present in the matrix tablet. This work shows that incorporation of (SBE)(7M)-beta-CD into the matrix tablets could be considered in designing a sustained-release tablet of poorly water-soluble drugs.

Imaging of frontal sinus disease: concepts, interpretation, and technology.

Imaging of the frontal sinus is an integral part of patient evaluation. High-resolution computed tomography (CT) imaging is the preferred modality for evaluation of sinus inflammatory disease. Magnetic resonance (MR) imaging plays an important role in differentiating tumors from inflammatory diseases and serves as a problem-solving tool.

Frequency of cochlear enhancement on magnetic resonance imaging in patients with autoimmune sensorineural hearing loss.

OBJECTIVE: To evaluate magnetic resonance imaging (MRI) scans for enhancement of inner ear structures of patients with sensorineural hearing loss and documented antibodies to the 68-kd inner ear antigen. STUDY DESIGN: Retrospective case review with reexamination of MRI scans. SETTING: Outpatient office. PATIENTS: Thirty-five patients with autoimmune sensorineural hearing loss defined by audiograms documenting a sensorineural hearing deficit in one or both ears and the presence of an anti-inner ear antibody (68-kd band) in serum samples who underwent precontrast and postcontrast T1-weighted axial and coronal MRI scans of the inner ear, which were performed concurrently with the hearing loss. INTERVENTIONS: Diagnostic. MAIN OUTCOME MEASURES: Frequency and intensity of cochlear enhancement on MRI scans. RESULTS: One patient demonstrated +2 cochlear enhancement. However, that finding was thought to represent postoperative inflammatory change. CONCLUSION: No correlation was found between the presence of antibodies to inner ear antigen in patients with hearing loss and cochlear enhancement on MRI scans.

Leiomyosarcoma of the larynx: diagnosis aided by advances in immunohistochemical staining.

We present only the 12th reported case of a laryngeal leiomyosarcoma. This tumor was diagnosed with the aid of the newer immunohistochemical stains on archival paraffin-embedded tissue. The diagnosis and management of these tumors is based largely on the patterns seen in the small number of earlier reported cases of head and neck leiomyosarcomas and laryngeal sarcomas.

Aqueous solubility and dissolution rate does not adequately predict in vivo performance: a probe utilizing some N-acyloxymethyl phenytoin prodrugs.

Some physicochemical properties of N-acyloxyalkyl prodrugs of phenytoin were reported previously.(1,2) It was shown that despite their lower aqueous solubilities relative to phenytoin, these lower-melting prodrugs with apparently disrupted crystalline structures gave either comparable or enhanced in vitro solubility and dissolution rate in simulated intestinal media made up of bile salts and lecithin (SIBLM).(2) The current objective was to compare the in vivo behavior of two of these prodrugs to phenytoin in dogs and attempt to correlate the in vitro behavior to their in vivo behavior. The oral bioavailability of phenytoin after administration of phenytoin (1) and the selected prodrugs, 3-pentanoyloxymethyl 5, 5-diphenylhydantoin (2) and 3-octanoyloxymethyl 5, 5-diphenylhydantoin (3), in fed and fasted beagle dogs were compared to intravenously administered phenytoin. Phenytoin and its prodrugs showed improvement in fed-state phenytoin bioavailability relative to the fasted state indicating that food enhanced the delivery of phenytoin from phenytoin and its prodrugs. The increased bioavailability in the fed state may be due to stimulation of bile release by food and, for the prodrugs, possible catalysis of their dissolution by lipases.(3) In both, fasted and fed states, prodrugs 2 and 3 gave higher AUC values of phenytoin than the parent compound. The enhanced bioavailability of phenytoin after oral administration were more obvious in fed dogs. Although enhanced, AUC values of phenytoin from the prodrugs relative to phenytoin were not statistically different (at 95% confidence level) in fasted state, but were different in fed state. Although the aqueous solubilities and dissolution of both prodrugs were lower than phenytoin, dissolution of 2 and 3 was equivalent and greater, respectively, relative to phenytoin in SIBLM. As expected, the in vivo behavior correlated better with the in vitro SIBLM dissolution behavior. These results indicate that aqueous solubility per se does not adequately predict in vivo behavior.

Clinical impact of sonographically guided biopsy of salivary gland masses and surrounding lymph nodes.

Although fine-needle aspiration biopsy of salivary gland masses has been reported in the otolaryngology literature, the use of sonography to guide the biopsy of nonpalpable masses and masses seen on other cross-sectional imaging studies has not been described. Our goal was to evaluate sonographically guided biopsy of masses and lymph nodes related to the salivary glands. We analyzed the records of 18 patients who had undergone fine-needle aspiration biopsy of a salivary gland mass or lymph node with a 25-, 22-, or 20-gauge needle. A definitive cytologic diagnosis was made for 13 of the 18 patients (72%); cytology was suggestive but not definitive in three patients (17%) and insufficient in two (11%). Definitive diagnoses were made in three cases of reactive lymph node, in two cases each of lymph node metastasis and Warthin's tumor, and in one case each of pleomorphic adenoma, adenoid-cystic carcinoma, schwannoma-neurofibroma, parotid metastasis, parotid lymphoma, and Sjögren's-related lymphoid-epithelial lesion. Sonographically guided biopsy allows for confident needle placement in masses seen on computed tomography and magnetic resonance imaging. Sonography can usually distinguish a perisalivary lymph node from true intrasalivary masses, and it can help the surgeon avoid the pitfall of a nondiagnostic aspiration of the cystic component of masses. We conclude that sonographically guided biopsy of salivary gland masses can provide a tissue diagnosis that can have a direct impact on clinical decision making.

Some relationships between the physical properties of various 3-acyloxymethyl prodrugs of phenytoin to structure: potential in vivo performance implications.

Physicochemical properties of neutral N-acyloxyalkyl derivatives of phenytoin in aqueous, organic solvents and simulated intestinal fluid were evaluated. Based on the hypothesis that these low melting prodrugs may have improved physical properties such as solubility and dissolution rate in gastrointestinal fluid, an enhanced bioavailability of these prodrugs may be observed relative to phenytoin. Melting points, aqueous solubilities, and octanol-water (Poct) and cylcohexane-water (Pcyc) partition coefficients of phenytoin and its prodrugs were determined. A simulated intestinal bile salts-lecithin mixture (SIBLM) was also prepared to possibly mimic the intestinal fluid content. Solubility and dissolution rates of phenytoin and its prodrugs were conducted in aqueous buffer and SIBLM. Apparent micelle-water partition coefficients (Kapp) were calculated by using the aqueous and SIBLM equilibrium solubility data. These properties were qualitatively or quantitatively correlated to the alkyl chain length of the prodrugs. The melting points and aqueous solubilities of all the prodrugs were lower than that of the parent compound, phenytoin. The apparent micelle-water partition coefficient increased with an increase in chain length but unlike the octanol-water and cyclohexane-water partition coefficients the relationship was complex. There was a disproportionate increase in the interaction between the micelle and the prodrug with the prodrugs with alkyl groups larger than four carbons. In SIBLM, the solubilities and dissolution rates were increased to a greater extent for the prodrugs than that for phenytoin. The implications are that the bioavailability of phenytoin from these prodrugs may be comparable to or higher than that of phenytoin despite having lower aqueous solubilities, especially after a meal inducing bile flow.

Sinonasal imaging. Anatomy and pathology.

This article provides a clear understanding of the pathophysiology of sinonasal inflammatory diseases and the rationale behind endoscopic surgery. Normal anatomy and pertinent anatomic variants that should be included in the radiology report are described. The relative role of CT and MR imaging in evaluation of inflammatory and neoplastic lesions is emphasized.

Practice patterns of radiologists and nonradiologists: nationwide Medicare data on the performance of chest and skeletal radiography and abdominal and pelvic sonography.

OBJECTIVE: We assessed the relative roles of radiologists and nonradiologists in performing chest and skeletal radiography and nonobstetric abdominal and pelvic sonography. MATERIALS AND METHODS: Information was extracted from the 1993 Medicare file on procedure volume for 65 imaging procedures. Claims were categorized by the specialty of the physician and the location (office or hospital) where the service was performed. RESULTS: In hospitals, radiologists performed virtually all chest and skeletal radiography and nonobstetric abdominal and pelvic sonography. In nonhospital settings such as offices or imaging centers, nonradiologists performed approximately two thirds of the chest and spinal radiography and nonobstetric abdominal and pelvic sonography and larger percentages (78-86%) of the pelvic, hip, lower extremity, and upper extremity radiography. CONCLUSION: Although radiologists perform virtually all chest and skeletal radiographs and abdominal and pelvic sonograms obtained in hospitals, they perform a distinct minority of these procedures in nonhospital settings. The data we present have certain implications for the amount of training nonradiologists receive in diagnostic imaging.

Effect of levamisole on the immune status of malnourished children.

Levamisole is known to enhance an impaired immune response. Its function as an immunostimulant was assessed in malnourished children. A total of 26 children suffering from severe protein-calorie malnutrition were selected for the study. Serum immunoglobulins were estimated in these subjects and to assess cell-mediated immunity, enumeration of T lymphocytes and the lymphocyte proliferative response were carried out. The results show an increase in the cell-mediated immunity response in the levamisole-treated group, thereby suggesting that levamisole may help to speed the recovery of malnourished children suffering from various infections.

Cricothyroid joint injury.

Cricothyroid joint injuries may result in severe voice dysfunction and may be associated with laryngeal pain. Otolaryngologists and radiologists should be familiar with this rarely recognized injury.