Accuracy of Medical Student Measurements of CT Right-to-Left Ventricular Diameter in Patients with Acute Pulmonary Embolism.

Objectives: Acute pulmonary embolism (PE) is a common disease, necessitating risk stratification to determine management. A right ventricle (RV) to left ventricle (LV) diameter ratio ≥1.0 on computed tomography pulmonary angiography (CTPA) suggests RV strain, which may indicate a worse prognosis. Two prior studies showed that residents with brief training by a radiologist could accurately measure RV/LV ratio. We assessed whether medical students could accurately measure RV dilatation. Methods: We conducted a post hoc analysis of a retrospective cohort study of adults undergoing management for acute PE at 21 community emergency departments across Kaiser Permanente Northern California from 2013 to 2015. We created a sample, stratified to contain an equal number of patients from each of the 5 PE Severity Index classes. Four medical students measured RV and LV diameter on CTPA after training from an emergency medicine physician and an interventional radiologist. We used Cohen's kappa statistics, Bland-Altman plots, and Pearson correlation coefficients to assess interrater reliability. Results: Of the 108 CTPAs reviewed, 79 (73%) showed RV dilatation and 29 (27%) did not. The kappa statistic for the presence of RV dilatation of the medical students compared to the radiologist showed moderate agreement for 3 medical students (kappa (95% CI): 0.46 (0.21-0.70), 0.49 (0.31-0.68), 0.50 (0.32-0.68)) and fair agreement for 1 medical student (kappa (95% CI): 0.29 (0.10-0.47)). The average interrater differences in RV/LV ratio between a radiologist and each of the 4 medical students were -0.04, -0.05, 0.04, and 0.24. Pearson correlation coefficients were 0.87, 0.80, 0.74, and 0.78, respectively, indicating moderate correlation (P < .001 for all). Conclusion: Medical students were able to identify RV dilatation on CTPA in moderate agreement with that of a radiologist. Further study is needed to determine whether medical student accuracy could improve with additional training.

Computational Modeling of the Liver Arterial Blood Flow for Microsphere Therapy: Effect of Boundary Conditions.

Transarterial embolization is a minimally invasive treatment for advanced liver cancer using microspheres loaded with a chemotherapeutic drug or radioactive yttrium-90 (90Y) that are injected into the hepatic arterial tree through a catheter. For personalized treatment, the microsphere distribution in the liver should be optimized through the injection volume and location. Computational fluid dynamics (CFD) simulations of the blood flow in the hepatic artery can help estimate this distribution if carefully parameterized. An important aspect is the choice of the boundary conditions imposed at the inlet and outlets of the computational domain. In this study, the effect of boundary conditions on the hepatic arterial tree hemodynamics was investigated. The outlet boundary conditions were modeled with three-element Windkessel circuits, representative of the downstream vasculature resistance. Results demonstrated that the downstream vasculature resistance affected the hepatic artery hemodynamics such as the velocity field, the pressure field and the blood flow streamline trajectories. Moreover, the number of microspheres received by the tumor significantly changed (more than 10% of the total injected microspheres) with downstream resistance variations. These findings suggest that patient-specific boundary conditions should be used in order to achieve a more accurate drug distribution estimation with CFD in transarterial embolization treatment planning.

Evaluation of the Statewide Variability in the Current Role of Different Specialties in Lower Extremity Endovascular Revascularization for Medicare Beneficiaries.

PURPOSE: To evaluate the statewide variability in the role of different specialties in lower extremity endovascular revascularization (LEER) and associated submitted charges of care and actual reimbursement for Medicare beneficiaries. METHODS: The 2015 "Medicare Provider Utilization and Payment Data: Physician and Other Supplier" data includes provider-specific information regarding the type of service, submitted average charges of care, and actual average Medicare reimbursements per Healthcare Common Procedure Coding System (HCPCS) code per provider. All HCPCS codes related to LEER were identified. The role of vascular surgery (VS), interventional cardiology (IC), and interventional radiology (IR) in each HCPCS-specific intervention was investigated. RESULTS: In 2015, 4113 providers submitted claims for iliac (n = 13,659), femoropopliteal (n = 52,344), and tibioperoneal (n = 32,688) endovascular revascularizations. In the facility setting, VS performed most of these procedures (52%), followed by IC (32%) and IR (8%). In the outpatient-based lab setting, the proportions were 46%, 36%, and 13%, respectively. Substantial statewide variability in the role of different specialties in LEER was noted. In Maine, Vermont, and Hawaii, all facility claims were submitted by VS, while more than 70% of the claims in Arizona and Utah were submitted by IC. The highest share of LEER for IR was observed in Montana and North Dakota (50%). There was substantial statewide variability in the submitted charges. CONCLUSION: Currently, less than 10% of LEER procedures are being performed by IR. The statewide variability in the submitted charges of care by providers and actual reimbursement for Medicare beneficiaries were investigated in this study.

Introduction to Cost Analysis in IR: Challenges and Opportunities.

Demonstration of value has become increasingly important in the current health care system. This review summarizes four of the most commonly used cost analysis methods relevant to IR that could be adopted to demonstrate the value of IR interventions: the cost minimization study, cost-effectiveness assessment, cost-utility analysis, and cost-benefit analysis. In addition, the issues of true cost versus hospital charges, modeling in cost studies, and sensitivity analysis are discussed.

Digital pressure and oxygen saturation measurements in the diagnosis of chronic hemodialysis access-induced distal ischemia.

OBJECTIVE: Hemodialysis access-induced distal ischemia (HAIDI) can be classified as acute (on the first postoperative day), subacute (≤1 month), or chronic (>1 month), based on the time of onset after access creation. The diagnosis is mainly clinical. However, performing additional tests is beneficial in further assessment of patients. The purpose of this study was to evaluate the use of finger pressure and oxygen saturation measurements for the diagnosis of chronic HAIDI. METHODS: A total of 20 patients with chronic HAIDI (cases) and 40 asymptomatic hemodialysis patients (controls) were matched for age, sex, etiology of end-stage renal disease, and type of arteriovenous access. Basal digital pressure (BDP), digital pressure during manual compression of access, digital brachial index (DBI), change in digital pressure with access compression (CDP), digital pressure of the contralateral side, and bilateral oxygen saturation (O2 Sat) were measured in all patients. RESULTS: In the case group, compression of the arteriovenous fistula (AVF) increased mean BDP from 61 ± 26 to 118 ± 28 mm Hg (P < .001), which failed to reach the non-AVF side mean digital pressure of 151 ± 25 mm Hg (P < .001). In addition, O2 Sat of the AVF side was significantly lower than the contralateral side (92.9% ± 2.1% vs 95.6% ± 1.4%; P = .001). Among the controls, manual AVF compression raised the mean BDP from 114 ± 36 mm Hg to 133 ± 29 mm Hg (P < .001), which was still significantly lower than the contralateral side mean digital pressure of 141 ± 30 mm Hg (P = .002). In addition, O2 Sat values of the two sides were different (96.7% ± 2.1% vs 97.1% ± 1.9%; P = .01). Comparing the cases and controls, the mean BDP (61 ± 26 mm Hg vs 114 ± 36 mm Hg; P < .001), DBI (0.44 ± 0.16 vs 0.82 ± 0.19; P < .001), and O2 Sat (92.9% ± 2.1% vs 96.7% ± 2.1%; P < .001) were significantly lower and CDP (57 ± 24 mm Hg vs 19 ± 17 mm Hg; P < .001) was significantly higher in the cases than in the controls. The optimal discriminatory thresholds of 80 mm Hg for BDP, 0.7 for DBI, 40 mm Hg for CDP, and 94% for O2 Sat were determined. CONCLUSIONS: Digital pressure and O2 Sat measurements are useful additional methods to assist in the clinical evaluation of hemodialysis patients with access-related hand ischemia. BDP <80 mm Hg, DBI <0.7, CDP >40 mm Hg, and O2 Sat <94% are associated with chronic HAIDI.

Utilization of angiography and embolization for abdominopelvic trauma: 14 years' experience at a level I trauma center.

OBJECTIVE: The objective of our study was to evaluate the long-term trends in the use of angiography and embolization for abdominopelvic injuries. MATERIALS AND METHODS: Utilization rates for pelvic and abdominal angiography, arterial embolization, and CT were analyzed for trauma patients with pelvic fractures and liver and kidney injuries admitted to a level 1 trauma center from 1996 to 2010. Multivariable linear regression was used to evaluate trends in the use of angioembolization. RESULTS: A total of 9145 patients were admitted for abdominopelvic injuries during the study period. Pelvic angiography decreased annually by 5.0% (95% CI, -6.4% to -3.7%) from 1996 to 2002 and by 1.8% (-2.4% to -1.2%) from 2003 to 2010. Embolization rates for these patients varied from 49% in 1997 to 100% in 2010. Utilization of pelvic CT on the day of admission increased significantly during this period. Abdominal angiography for liver and kidney injuries decreased annually by 3.3% (95% CI, -4.8% to -1.8%) and 2.0% (-4.3% to 0.3%) between 1996 and 2002 and by 0.8% (95% CI, -1.4% to -0.1%) and 0.9% (-2.0% to 0.1%) from 2003 to 2010, respectively. Embolization rates ranged from 25% in 1999 to 100% in 2010 for liver injuries and from 0% in 1997 to 80% in 2002 for kidney injuries. Abdominal CT for liver and kidney injuries on the day of admission also increased. CONCLUSION: A significant decrease in angiography use for trauma patients with pelvic fractures, liver injuries, and kidney injuries from 1996 to 2010 and a trend toward increasing embolization rates among patients who underwent angiography were found. These findings reflect a declining role of angiography for diagnostic purposes and emphasize the importance of angiography as a means to embolization for management.

Superselective yttrium-90 radioembolization for hepatocellular carcinoma yields high response rates with minimal toxicity.

PURPOSE: To assess the safety and efficacy of yttrium-90 ((90)Y) radioembolization when performed in a superselective fashion for patients with unresectable hepatocellular carcinoma (HCC). MATERIALS AND METHODS: This retrospective study included 20 patients with unresectable HCC. Median Model for End-Stage Liver Disease score was 10.5 (range, 6-25), with 8 of 20 patients (40%) classified Child-Pugh class B and 1 of 20 patients (5%) classified class C cirrhosis. Segmental tumor-associated portal vein thrombus was present in 12 patients (60%), and a transjugular intrahepatic portosystemic shunt was present in 4 patients (20%). Median tumor diameter was 3.9 cm (range, 2.5-7.1 cm). All patients underwent superselective (90)Y radioembolization targeted to a single liver segment using glass microspheres. RESULTS: Median dose to the treated segment was 254 Gy, and median dose to the tumor was 536 Gy. No grade 3-4 hepatotoxicity occurred. The most common clinical toxicities were fatigue (30%), abdominal pain (10%), and postembolization syndrome (10%). Follow-up imaging demonstrated complete European Association for the Study of the Liver response of the index tumor in 19 of 20 patients (95%) and stable disease in 1 of 20 patients (5%). In patients with complete response, local tumor recurrence rate was 5.3% (1 of 19 patients). Median time to progression was 319 days. Overall survival was 90% (18 of 20 patients) with a median follow-up period of 275 days (range, 32-677 d). CONCLUSIONS: When performed in a segmental fashion, (90)Y radioembolization demonstrates high response rates and low local tumor recurrence rates. Complete imaging response can be achieved in patients with locally aggressive disease. This study demonstrates no clinically significant hepatotoxicity, despite moderate liver dysfunction in many patients.

Outcomes and resource utilization associated with underage drinking at a level I trauma center.

PURPOSE: To examine the association of blood alcohol content (BAC) on hospital-based outcomes and imaging utilization for patients <21 years admitted to a level I trauma center. METHODS: Retrospective analysis of alcohol-involved injuries in patients 13-20 years, admitted to a level I trauma center from 1996 to 2010. An injury was considered alcohol involved if the patient had a BAC > 0. Multivariable logistic regression was used to compare mortality, discharge destination (home and skilled nursing facility), intensive care unit admission, and operating room use between patients with and without positive BAC for patients 13-15, 16-17, and 18-20 years. Multivariable linear regression was used to compare length of hospitalization. Finally, multivariable negative binomial regression evaluated radiology resource utilization (x-ray, computed tomography [CT], and magnetic resonance imaging). RESULTS: A total of 7,663 patients, 13-20 years old, were admitted over the study period. A positive BAC was reported in 19% of these patients. In general, the presence of alcohol was not associated with mortality rate, length of hospitalization, intensive care unit, and operating room use or discharge status for any age group. However, the presence of alcohol was associated with higher utilization of head (incidence rate ratio [IRR] 1.13, 95% confidence interval [CI] 1.02-1.26), cervical spine (IRR 1.10, 95% CI 1.01-1.22), and thoracic (IRR 1.30, 95% CI 1.05-1.63) CTs in young adults 18-20 years. No differences in CT use were observed in patients 13-15 or 16-17 years. CONCLUSIONS: Positive BAC was not significantly associated with adverse outcomes or resource utilization in younger trauma patients. However, the use of certain body region CTs was associated with positive BAC in patients 18-20 years.

Biostatistics primer for the radiologist.

OBJECTIVE: The purpose of this article is to review the most common data analysis methods encountered in radiology-based studies. Initially, description of variable types and their corresponding summary measures are provided; subsequent discussion focuses on comparison of these summary measures between groups, with a particular emphasis on regression analysis. CONCLUSION: Knowledge of statistical applications is critical for radiologists to accurately evaluate the current literature and to conduct scientifically rigorous studies. Misapplication of statistical methods can lead to inappropriate conclusions and clinical recommendations.

Effect of an image-sharing network on CT utilization for transferred trauma patients: a 5-year experience at a level I trauma center.

PURPOSE: The aim of this study was to evaluate the influence of an image-sharing network established between referring hospitals and a level I trauma center on CT utilization at the trauma center. METHODS: This retrospective study was approved by the local institutional review board. The requirement for informed consent was waived. Harborview Medical Center's trauma registry was linked to billing department data, and detailed information on all resources utilized during each patient's hospitalization was obtained. Negative binomial regression was used to evaluate body region-specific CT utilization between direct-admit and transfer patients after adjustment for potential confounding variables. Special attention was paid to 2005 as the year internet-based image sharing between Harborview Medical Center and referring hospitals was established. RESULTS: A total of 81,159 trauma patients were admitted to Harborview Medical Center (44% transfers) during the study period. The utilization of head CT slightly increased from 1996 to 2005, with no significant difference between direct-admit and transfer patients. Between 2005 and 2010, utilization remained relatively unchanged; however, significantly higher utilization rates were observed for direct-admit patients. A relatively similar pattern was observed for pelvic CT; however, between 2005 and 2010, CT use was greater for direct-admit compared with transfer patients. Abdominal and thoracic CT was relatively unchanged between 2005 and 2010. However, both studies had significantly higher utilization rates for direct-admit patients. CONCLUSIONS: The utilization rates of CT of different body regions have been higher for direct-admit trauma patients compared with transfer patients since 2005; however, decreasing utilization trends have been observed in recent years.

CT use in hospitalized pediatric trauma patients: 15-year trends in a level I pediatric and adult trauma center.

PURPOSE: To evaluate the 15-year trend in the use of computed tomography (CT) in hospitalized pediatric trauma patients admitted to Harborview Medical Center (HMC) from 1996 to 2010. MATERIALS AND METHODS: This Health Insurance Portability and Accountability Act-compliant retrospective study was approved by the institutional review board. The requirement for informed consent was waived. The HMC trauma registry was linked to the billing department data, and patient and injury-related characteristics were extracted, in addition to type and frequency of CT procedures. Patients discharged from the emergency department and patients hospitalized for less than 24 hours were not included in this study. Patients were classified into three categories according to age: 0-14 years, 15-18 years, and 19-54 years (reference group). Multivariate negative binomial regression was used to compare CT usage among different age groups by adjusting for patient sex, race and/or ethnicity, insurance status, mechanism of injury, injury severity, final disposition (dead vs alive), and year of admission. The trend for CT use in children and teenagers was also evaluated. RESULTS: A total of 64 425 trauma patients 0-54 years of age were admitted during the study period. Compared with CT usage in adults 19-54 years old, usage in children up to 15 years of age was significantly lower for spine (incidence rate ratio [IRR], 0.89; 95% confidence interval [CI]: 0.85, 0.92), maxillofacial (IRR, 0.89; 95% CI: 0.81, 0.97), and thoracic (IRR, 0.91; 95% CI: 0.84, 0.99) CT. Increased use of head CT was observed in children up to 15 years old (IRR, 1.09; 95% CI: 1.05, 1.13) and 15-18 years old (IRR, 1.08; 95% CI: 1.04, 1.13). From 2008 to 2010, usage rates in children up to 15 years old and 15-18 years old was relatively unchanged or slightly decreased for almost all CT types. CONCLUSION: A decreasing or unchanged trend was observed in CT usage in hospitalized pediatric trauma patients in recent years. © RSNA, 2013.

Declining trend in the use of repeat computed tomography for trauma patients admitted to a level I trauma center for traffic-related injuries.

OBJECTIVE: To evaluate the trend in utilization of repeat (i.e. ≥2) computed tomography (CT) and to compare utilization patterns across body regions for trauma patients admitted to a level I trauma center for traffic-related injuries (TRI). MATERIALS AND METHODS: We linked the Harborview Medical Center trauma registry (1996-2010) to the billing department data. We extracted the following variables: type and frequency of CTs performed, age, gender, race/ethnicity, insurance status, injury mechanism and severity, length of hospitalization, intensive care unit (ICU) admission and final disposition. TRIs were defined as motor vehicle collisions, motorcycle, bicycle and pedestrian-related injuries. Logistic regression was used to evaluate the association between utilization of different body region repeat (i.e. ≥2) CTs and year of admission, adjusting for patient and injury-related characteristics that could influence utilization patterns. RESULTS: A total of 28,431 patients were admitted for TRIs over the study period and 9499 (33%) received repeat CTs. From 1996 to 2010, the proportion of patients receiving repeat CTs decreased by 33%. Relative to 2000 and adjusting for other covariates, patients with TRIs admitted in 2010 had significantly lower odds of undergoing repeat head (OR=0.61; 95% CI: 0.49-0.76), pelvis (OR=0.37; 95% CI: 0.27-0.52), cervical spine (OR=0.23; 95% CI: 0.12-0.43), and maxillofacial CTs (OR=0.24; 95% CI: 0.10-0.57). However, they had higher odds of receiving repeat thoracic CTs (OR=1.86; 95% CI: 1.02-3.38). CONCLUSION: A significant decrease in the utilization of repeat CTs was observed in trauma patients presenting with traffic-related injuries over a 15-year period.

Burden of alcohol-related injuries on radiology services at a level I trauma center.

OBJECTIVE: The purpose of our study was to evaluate the burden of alcohol-related injuries on a radiology department at a level 1 trauma center. MATERIALS AND METHODS: We linked the trauma registry (2005-2009) of Harborview Medical Center to billing department data and extracted patient demographic and injury-related characteristics and the radiology services provided. Multivariate negative binomial analysis was used to evaluate the association between blood alcohol concentration (BAC) and CT and MRI utilization rates. RESULTS: A total of 125,776 CT and 4681 MRI examinations were performed on 27,274 patients during the study period. Higher BAC was generally associated with higher utilization rates for all types of CT even after adjusting for potential confounding variables. Compared with patients with a BAC of 0, the greatest increases in utilization were observed in individuals with a BAC of 240 mg/dL or more for head CT (incidence rate ratio [IRR], 1.43; 95% CI, 1.32-1.54), cervical spine (IRR, 1.45; 95% CI, 1.32-1.58), and maxillofacial (IRR, 1.66; 95% CI, 1.42-1.95), with no increase observed for MRI. This association was more prominent in less severely injured patients with utilization rates for head CT (IRR, 1.83; 95% CI, 1.56-2.13), abdomen (IRR, 1.46; 95% CI, 1.32-1.63), and thorax (IRR, 1.57; 95% CI, 1.30-1.89) in individuals with a BAC of 240 mg/dL or more compared with those with a BAC of 0. CONCLUSION: Higher BAC was associated with increased CT utilization for most body region-specific CT scans and was more strongly associated in patients with less severe injuries. Any guideline that could potentially decrease unnecessary imaging for patients with alcohol-involved injuries would represent a cost-saving strategy.

Falls, older adults, and the trend in utilization of CT in a level I trauma center.

OBJECTIVE: The purpose of this article is to evaluate the trend in the utilization of CT for fall victims older than 55 years admitted to a level I trauma center. MATERIALS AND METHODS: We used trauma registry data (1996-2006) of a level I trauma center. By using the International Classification of Disease, Ninth Revision (Clinical Modification) codes, we identified the type and frequency of CT examinations for each patient. We used negative binomial regression to evaluate the association between CT utilization rates and age, year of admission, sex, insurance status, ethnicity, ICU admission status, injury severity score, and final disposition (i.e., deceased vs alive). We used logistic regression to evaluate predictors of repeat (i.e., ≥ 2) CT scans. RESULTS: During the study period, the utilization rate of head, abdomen, thorax, and other body region (including spine and extremities) CT examinations increased, on average, by 7%, 16%, 14%, and 15% per year, respectively. Older age was associated with a higher utilization of head CT. Male sex and ICU admission were associated with higher utilization for all types of CT examinations. Repeat head and abdominal CT scans increased, on average, by 28% (95% CI, 20-36%) and 24% (95% CI, 2-51%) per year, respectively. CONCLUSION: We quantified the increase in utilization rates of all types of CT scans for fall victims admitted to a level I trauma center. We found a marked increase in CT use over time, both for initial as well as repeat studies, and an association between CT use and variables such as sex. Future studies should focus on the evaluation of CT appropriateness and their influence on patient outcomes.

Methodologic challenges in the analysis of count data in radiology health services research.

PURPOSE: The authors explain that negative binomial (NB) and zero-inflated NB (ZINB) distributions are probably the most commonly seen distributions of outcomes in radiology health services research. Using simulation data, the authors demonstrate the potential errors in adopting an inappropriate model in the analysis of count outcomes in this field of research. METHODS: A hypothetical database with 5,000 records was generated to evaluate the associations between the number of head CT studies (with Poisson, NB, and ZINB distributions) and age, gender, mechanism of injury, and injury severity. Linear, Poisson, NB, and ZINB regression models were used to analyze these hypothetical data. RESULTS: For analysis of the number of head CT studies with an NB distribution, using linear regression resulted in biased estimates. Poisson regression resulted in artificially narrow confidence intervals. For the analyses of the number of head CT studies with a ZINB distribution, Poisson and NB regression models overestimated the association between the number of head CT studies and the predictors, while linear regression resulted in incorrect point estimates. CONCLUSIONS: With substantial increases in health care costs and the upcoming health care overhaul, pressure on radiology health services research will increase. To provide valid estimates of the predictors of utilization pattern, researchers should adopt models that appropriately deal with the skewed count outcomes, or the results might be incorrect.

Is qualitative research second class science? A quantitative longitudinal examination of qualitative research in medical journals.

BACKGROUND: Qualitative research appears to be gaining acceptability in medical journals. Yet, little is actually known about the proportion of qualitative research and factors affecting its publication. This study describes the proportion of qualitative research over a 10 year period and correlates associated with its publication. DESIGN: A quantitative longitudinal examination of the proportion of original qualitative research in 67 journals of general medicine during a 10 year period (1998-2007). The proportion of qualitative research was determined by dividing original qualitative studies published (numerator) by all original research articles published (denominator). We used a generalized estimating equations approach to assess the longitudinal association between the proportion of qualitative studies and independent variables (i.e. journals' country of publication and impact factor; editorial/methodological papers discussing qualitative research; and specific journal guidelines pertaining to qualitative research). FINDINGS: A 2.9% absolute increase and 3.4-fold relative increase in qualitative research publications occurred over a 10 year period (1.2% in 1998 vs. 4.1% in 2007). The proportion of original qualitative research was independently and significantly associated with the publication of editorial/methodological papers in the journal (b = 3.688, P = 0.012); and with qualitative research specifically mentioned in guidelines for authors (b = 6.847, P<0.001). Additionally, a higher proportion of qualitative research was associated only with journals published in the UK in comparison to other countries, yet with borderline statistical significance (b = 1.776, P = 0.075). The journals' impact factor was not associated with the publication of qualitative research. CONCLUSIONS: Despite an increase in the proportion of qualitative research in medical journals over a 10 year period, the proportion remains low. Journals' policies pertaining to qualitative research, as expressed by the appearance of specific guidelines and editorials/methodological papers on the subject, are independently associated with the publication of original qualitative research; irrespective of the journals' impact factor.

Alcohol intoxication/dependence, ethnicity and utilisation of health care resources in a level I trauma center.

OBJECTIVE: To evaluate the potential influence of acute intoxication and dependence to alcohol on extrautilisation of health care resources by ethnic minority trauma patients in a level I trauma center. METHODS: We analysed the data of 1493 patients enrolled in a study that evaluated the effectiveness of brief alcohol intervention among ethnic minority trauma patients. The database included detailed demographic, injury-related and drinking-related characteristics (including acute intoxication and alcohol dependency status). Patients were categorised into the following groups: non-intoxicate/nondependent(NI/ND), non-intoxicated/dependent (NI/D), intoxicated/non-dependent (I/ND) and intoxicated/dependent (I/D). We compared utilisation of several diagnostic and therapeutic procedures among these four categories. We placed special emphasis on ethnicity as a potential effect modifier. RESULTS: Relative to NI/ND trauma patients, I/ND patients (relative risk (RR): 1.8, 95% CI: 1.2­2.8) and I/D patients (RR: 2.4, 95% CI: 1.6­3.6) had significantly higher chance of being evaluated by abdominal ultrasound during the first 24 h of hospital arrival. Similar pattern was observed for head CT scan (with the corresponding RRs of 2.1 and 2.6, respectively). Chance of admission to the intensive care unit (ICU)was not associated with intoxication/dependence status. Length of hospital stay was negatively associated with drinking status with the shortest length of stay for I/D. Including ethnicity in the models,did not change the results and conclusions. DISCUSSION: Acute intoxication and dependence to alcohol are both associated with more frequent utilisation of selected health care resources and the utilisation pattern was not associated with patient ethnicity. This emphasises on the importance of routine screening for drinking problems among all trauma patients, regardless of their blood alcohol level in the ED.

Trend in the utilization of CT for adolescents admitted to an adult level I trauma center.

PURPOSE: The aims of this study were to evaluate the trend in the utilization of CT for adolescents admitted to an adult level I trauma center and to compare the utilization pattern between adolescents and adults during the past 11 years. METHODS: Trauma registry data (1996-2006) from an adult level I trauma center were used. Patients aged ≥13 years were eligible to be admitted to this hospital. From this trauma registry, the following variables were extracted: age; sex; ethnicity; insurance status; mechanism of injury; injury severity score; length of hospital and intensive care unit stay; International Classification of Diseases, Ninth Revision (ICD-9), codes; and patient disposition. Patients were categorized on the basis of their age in the following groups: 13 to 18, 19 to 55, and ≥56 years. ICD-9 procedure codes were used to create new variables that were reflective of the frequency of use of head CT (ICD-9 code 87.03), abdominal CT (ICD-9 code 88.01), thoracic CT (ICD-9 code 87.41), and other CT studies, including CT of the extremities and spine (ICD-9 code 88.38). RESULTS: All age groups experienced substantial increases in the utilization of CT, and there were minimal differences in crude utilization rates among different age categories. After adjustment for potential confounders, adolescents had a slightly higher chance of being evaluated by head CT (incident risk ratio [IRR], 1.16; 95% confidence interval [CI], 1.11-1.22) and a significantly lower chance of undergoing thoracic CT (IRR, 0.54; 95% CI, 0.48-0.61) in comparison with adults aged 19 to 55 years. Among adolescents, the chance of undergoing head CT was significantly higher in 2006 relative to 1996 (IRR, 1.50; 95% CI, 1.20-1.86). However, there was no linear increase in utilization pattern from 1996 to 2006. Abdominal CT demonstrated a similar pattern. Thoracic CT and other CT studies demonstrated the most drastic increases in utilization pattern among adolescents. The IRR for the use of thoracic CT increased from 1.15 (95% CI, 0.26-5.20) in 1997 (relative to 1996) to 10.53 (95% CI, 3.24-34.26) in 2006. The IRRs for other CT studies in 2005 and 2006, relative to 1996, were 7.24 and 6.91, respectively. CONCLUSIONS: Treatment of adolescents in adult level I trauma centers is challenging. Trauma centers should adopt strategies that could potentially decrease unnecessary utilization, especially among adolescents. To do this, these facilities should be familiar with patient-related and system-related characteristics that might influence overutilization. Furthermore, physicians in adult trauma centers should be reeducated with regard to potential hazardous consequences of CT for adolescents.

Lumbar spine MRI for low back pain: indications and yield.

OBJECTIVE: Low back pain is one of the most common causes of physician visits in the United States with an enormous socioeconomic burden. Because of this burden, numerous studies have focused on its diagnosis and management. New technologies have been quickly adopted with the hope that they will improve our understanding of the physiopathology of the disease and assist us in alleviating patients' pain and discomfort. Unfortunately, previous studies have not been able to show that higher utilization of advanced imaging technology is associated with improvements in patient outcome. This article highlights practices that are evidence-based versus those that are common, or heterogeneous, but not supported by existing evidence. We also highlight outstanding areas for further research. CONCLUSION: Clinicians and researchers should be encouraged to follow standardized practices in accordance with evidence-based medicine guidelines. The use of such guidelines will decrease variation in care, allowing researchers to more easily design and conduct comparative effectiveness studies of diagnostic imaging.