Severe emphysematous pyelonephritis as a complication of klebsiella pneumonia and uncontrolled diabetes mellitus.

A female in her 40s, with poorly controlled Type I diabetes mellitus, was brought to our tertiary hospital by ambulance after being found drowsy. Six days prior, she had self-discharged from the Intensive Care Unit whilst being treated for a Klebsiella pneumonia. At re-admission, she had an acute kidney injury with abdominal pain and clinical features of sepsis. Her presentation was attributed to ongoing Klebsiella pneumoniae infection; however, a chest radiograph showed marked improvement of pulmonary consolidations and an unusual subdiaphragmatic gas pattern. A CT scan demonstrated severe bilateral emphysematous pyelonephritis. The patient was unfit for bilateral nephrectomy and was medically managed in the Intensive Care Unit for 41 days, before transfer to a specialist renal unit for life-long haemodialysis. This case highlights the importance of considering emphysematous pyelonephritis in patients presenting with uncontrolled diabetes mellitus and acute kidney injury and/or infection, the role of imaging in its diagnosis, and the challenges of complex social circumstances in health management.

Impact of Artificial Intelligence-Assisted Indication Selection on Appropriateness Order Scoring for Imaging Clinical Decision Support.

PURPOSE: The aim of this study was to assess appropriateness scoring and structured order entry after the implementation of an artificial intelligence (AI) tool for analysis of free-text indications. METHODS: Advanced outpatient imaging orders in a multicenter health care system were recorded 7 months before (March 1, 2020, to September 21, 2020) and after (October 20, 2020, to May 13, 2021) the implementation of an AI tool targeting free-text indications. Clinical decision support score (not appropriate, may be appropriate, appropriate, or unscored) and indication type (structured, free-text, both, or none) were assessed. The χ2 and multivariate logistic regression adjusting for covariables with bootstrapping were used. RESULTS: In total, 115,079 orders before and 150,950 orders after AI tool deployment were analyzed. The mean patient age was 59.3 ± 15.5 years, and 146,035 (54.9%) were women; 49.9% of orders were for CT, 38.8% for MR, 5.9% for nuclear medicine, and 5.4% for PET. After deployment, scored orders increased to 52% from 30% (P < .001). Orders with structured indications increased to 67.3% from 34.6% (P < .001). On multivariate analysis, orders were more likely to be scored after tool deployment (odds ratio [OR], 2.7, 95% CI, 2.63-2.78; P < .001). Compared with physicians, orders placed by nonphysician providers were less likely to be scored (OR, 0.80; 95% CI, 0.78-0.83; P < .001). MR (OR, 0.84; 95% CI, 0.82-0.87) and PET (OR, 0.12; 95% CI, 0.10-0.13) were less likely to be scored than CT (; P < .001). After AI tool deployment, 72,083 orders (47.8%) remained unscored, 45,186 (62.7%) with free-text-only indications. CONCLUSIONS: Embedding AI assistance within imaging clinical decision support was associated with increased structured indication orders and independently predicted a higher likelihood of scored orders. However, 48% of orders remained unscored, driven by both provider behavior and infrastructure-related barriers.

De novo motor learning of a bimanual control task over multiple days of practice.

Although much research on motor learning has focused on how we adapt our movements to maintain performance in the face of imposed perturbations, in many cases, we must learn new skills from scratch or de novo. Compared with adaptation, relatively little is known about de novo learning. In part, this is because learning a new skill can involve many challenges, including learning to recognize new patterns of sensory input and generate new patterns of motor output. However, even with familiar sensory cues and well-practiced movements, the problem of quickly selecting the appropriate actions in response to the current state is challenging. Here, we devised a bimanual hand-to-cursor mapping that isolates this control problem. We find that participants initially struggled to control the cursor under this bimanual mapping, despite explicit knowledge of the mapping. Performance improved steadily over multiple days of practice, however. Participants exhibited no aftereffects when reverting to a veridical cursor, confirming that participants learned the new task de novo, rather than through adaptation. Corrective responses to mid-movement perturbations of the target were initially weak, but with practice, participants gradually became able to respond rapidly and robustly to perturbations. After 4 days of practice, participants' behavior under the bimanual mapping almost matched performance using a veridically mapped cursor. However, there remained a small but persistent difference in performance level. Our findings illustrate the dynamics and limitations of learning a novel controller and introduce a promising paradigm for tractably investigating this aspect of motor skill learning.NEW & NOTEWORTHY We examine motor learning in a novel task in which participants must use both hands to control an on-screen cursor via a nonintuitive interface. Participants gradually improved their ability to control the cursor over multiple practice sessions, but their control was worse than baseline even after 4 days. These results reveal the timescale and limitations of de novo learning-an important but understudied form of learning.

Lessons From the Free-Text Epidemic: Opportunities to Optimize Deployment of Imaging Clinical Decision Support.

OBJECTIVE: The Protecting Access to Medicare Act of 2014 requires clinicians to consult Appropriate Use Criteria (AUC) when ordering advanced imaging procedures. Free-text order indications are available when there is no applicable structured indication but are unscored by the AUC. We determined the proportion of free-text indications among all advanced imaging orders and the proportion of free-text indications that could be mapped to a single structured indication. METHODS: All outpatient advanced diagnostic imaging orders placed in a large multisite health system were recorded after initial AUC deployment (November 20, 2017, to December 19, 2017). Clinicians were prompted upon order entry to select a structured indication or enter a free-text indication. We manually reviewed the two imaging examinations with the highest rate of free-text indications: enhanced CT abdomen/pelvis and unenhanced CT head. Regression analysis examined differences in patient-, imaging-, context-, and provider-level characteristics between scored and unscored examinations. RESULTS: Among all 39,533 orders for advanced imaging procedures, 59% (23,267 of 39,533) were unscored by the system. The regression model c-statistic (0.50-0.55) demonstrated poor model fit to evaluate for differences between scored and unscored examinations. Free-text indications were found in 71% (16,440 of 23,267) of unscored examinations and 42% (16,440 of 39,533) of all examinations. Manual review of all 1,693 CT abdomen/pelvis and 1,527 CT head examinations with free-text indications revealed that 3,132 free-text indications (97%) could be mapped to a single existing structured indication. DISCUSSION: Of all initially placed outpatient advanced imaging procedure orders, 42% included free-text indications and 97% of manually reviewed free-text indications could be mapped to a single structured indication.

Annual Trends and Geographic Variation in the Utilization of Imaging in Pediatric Patients with Low Back Pain in the United States.

BACKGROUND: Low back pain (LBP) is increasing in the pediatric population. Advanced imaging, such as computed tomography and magnetic resonance imaging, performed for LBP imposes significant costs with little benefit. We investigated annual trends and demographic and geographic variation in spinal imaging for first-time pediatric presenters with LBP in primary care clinics. METHODS: We queried a private administrative claims database for patients presenting with LBP who underwent plain radiography, computed tomography, and magnetic resonance imaging from 2011 to 2017. We used a Cochrane Armitage test of trend to determine significant annual variation in diagnostic imaging utilization during the study period. The χ2 test was used to determine demographic and geographic variation. RESULTS: The study included 67,423 patients with mean age 15.2 ± 3 years. There was no significant change in radiography (34.8% in 2011 vs. 35.5% in 2017, P = 0.795) or computed tomography (1.6% in 2011 vs. 1.1% in 2017, P = 0.073), but there was a significant increase in magnetic resonance imaging (3.3% in 2011 vs. 4.5% in 2017, P = 0.017). Overall, there was no significant change in total imaging use (P = 0.895). Boys had higher rates of imaging compared with girls (40.2% vs. 35.6%, P < 0.001). Imaging rates significantly varied between regions across the United States (P < 0.001). The Midwest had the highest imaging rates (41%), while the Northeast had the lowest rates (31%). CONCLUSIONS: There was significant demographic and geographic variation but no significant annual change in total diagnostic spinal imaging for pediatric patients with LBP between 2011 and 2017, with rates of advanced imaging remaining relatively low.

Harnessing Augmented Reality and CT to Teach First-Year Medical Students Head and Neck Anatomy.

RATIONALE AND OBJECTIVES: Three-dimensional (3D) visualization has been shown to benefit new generations of medical students and physicians-in-training in a variety of contexts. However, there is limited research directly comparing student performance after using 3D tools to those using two-dimensional (2D) screens. MATERIALS AND METHODS: A CT was performed on a donated cadaver and a 3D CT hologram was created. A total of 30 first-year medical students were randomly assigned into two groups to review head and neck anatomy in a teaching session that incorporated CT. The first group used an augmented reality headset, while the second group used a laptop screen. The students were administered a five-question anatomy test before and after the session. Two-tailed t-tests were used for statistical comparison of pretest and posttest performance within and between groups. A feedback survey was distributed for qualitative data. RESULTS: Pretest vs. posttest comparison of average percentage of questions answered correctly demonstrated both groups showing significant in-group improvement (p < 0.05), from 59% to 95% in the augmented reality group, and from 57% to 80% in the screen group. Between-group analysis indicated that posttest performance was significantly better in the augmented reality group (p = 0.022, effect size = 0.73). CONCLUSION: Immersive 3D visualization has the potential to improve short-term anatomic recall in the head and neck compared to traditional 2D screen-based review, as well as engage millennial learners to learn better in anatomy laboratory. Our findings may reflect additional benefit gained from the stereoscopic depth cues present in augmented reality-based visualization.

Vascular imaging in the initial evaluation of embolic stroke source.

PURPOSE: During acute ischemic stroke evaluations, neurovascular imaging is commonly performed to localize the source of a thromboembolus and to identify vascular stenoses. In this study, we aimed to analyze 1) the usefulness of intracranial and/or cervical CTA and MRA and carotid doppler ultrasound (DUS) for identifying the stroke source and 2) the incidence of vascular stenoses across stroke etiologies. METHODS: We retrospectively reviewed intracranial and/or cervical CTA, DUS and MRA studies to identify the source of the acute stroke by Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria for 200 consecutive patients admitted with a stroke to our tertiary hospital. Stroke etiologies were ascertained and the rates of intracranial and cervical vascular stenoses were stratified by stroke type. RESULTS: Of 200 patients, the most probable sources of stroke were small vessel disease (29%), cardioembolic (26.0%) and atheroembolic (23.5%). Across all groups, 27.5% of patients had ≥70% stenosis on neurovascular imaging. The rate of ≥70% vascular stenosis in the neck was 6.9% and 5.8% in the small vessel and cardioembolic categories, respectively. CONCLUSIONS: The TOAST etiologies of strokes were nearly equally distributed. Neurovascular imaging was of high utility for identifying large vessel intracranial stenoses in patients presenting with acute stroke across all etiologies, although neck CTA/MRA had a lower rate of positive studies with cardiogenic and small vessel strokes. These findings have implications on the use of CTA/MRA in acute stroke work-up.

Recent Advances in Computed Tomography and MR Imaging.

Numerous advanced MR imaging and computed tomographic techniques have been developed and implemented in clinical practice over the past several years resulting in increased diagnostic accuracy and improved patient care. In this article, the authors highlight recent and emerging imaging techniques in functional and structural MR imaging, perfusion and vascular imaging, standardization of imaging practices, and selected applications of artificial intelligence in clinical practice.

Preoperative and Postoperative Spending Among Working-Age Adults Undergoing Posterior Spinal Fusion Surgery for Degenerative Disease.

OBJECTIVE: To investigate the health care resource utilization and the associated 6 months preoperative and 6 months postoperative spending among patients undergoing posterior lumbar fusion. METHODS: We retrospectively reviewed a private insurance claims database for patients who underwent single-level posterior spinal fusion from January 2011 to December 2015. Outpatient health services, prescription pain medications, and inpatient admissions were assessed. RESULTS: Among 25,401 patients (mean age, 52 years; 58% female) in the final cohort, median spending during the period from 6 months before surgery to 6 months after surgery was $60,714 (interquartile range [IQR], $46,961-$79,892)/patient. Preoperative spending accounted for 7% ($121 million) of the total costs, and postoperative spending accounted for 8% ($135 million). Median preoperative spending was $3566 (IQR, $2144-$5857) per patient, with imaging accounting for the highest proportion (33%) of preoperative spending. In the 6 months period preceding surgery, 46% patients received injections and 47% received physical therapy. The median postoperative spending was $1954/patient (IQR, $735-$4416). Total postoperative spending was significantly higher among those not discharged home (median, $7525; IQR, $6779-$19,602) compared with those discharged home (median, $1617/patient; IQR, $648-$4033) and home with home care services (median, $2921; IQR, $1406-$5662) (P < 0.001). CONCLUSIONS: Unplanned readmission after posterior spinal fusion was the highest contributor to postoperative spending and the second highest contributor to overall costs. Understanding factors that contribute to the costs in the preoperative and postoperative period in patients undergoing single-level posterior lumbar fusion for degenerative pathology is essential to identify targets for cost containment.

Opioid Prescriptions for New Low Back Pain: Trends and Variability by State.

BACKGROUND: The United States is facing a widespread opioid epidemic that disproportionately affects the working-age population. In the clinical setting, new low back pain is one of the most common reasons for opioid prescriptions, despite national recommendations advising against their use until nonopioid treatments have been trialed. In this study, we aimed to examine national opioid prescribing practices among primary care physicians after the evaluation of low back pain in working-age patients. METHOD: This study used a national claims database's billing codes to identify patients in the outpatient setting with a new encounter for isolated low back pain following a 1-year look-back period. The primary outcome was whether an opioid prescription was filled within 30 days after the encounter. Patients with a daily morphine milligram equivalence (MME/day) known to be associated with a higher risk of overdose were also analyzed. RESULTS: A total of 418,565 patients between January 1, 2011 and November 30, 2016 were included. The proportion of patients with filled opioid prescriptions declined significantly between 2011 and 2016 (P < .01; 28.5% in 2011, 27.6% in 2012, 26.3% in 2013, 25.5% in 2014, 23.5% in 2015, and 20.4% in 2016). Nationally, the proportion of patients with a filled opioid prescription varied significantly between states (P < .01), ranging from 12.9% in Hawaii to 33.6% in Arkansas. DISCUSSION: We found that the overall frequency of opioid prescriptions for low back pain is decreasing nationally, which speaks favorably for future initiatives to change physician prescribing patterns. However, we identified that there is large variation in prescribing patterns among physicians in different states.

Use of Imaging During Emergency Department Visits for Low Back Pain.

OBJECTIVE. Back pain is one of the most common reasons for adult patients 18-65 years old to seek emergency care. Use of imaging for patients without so-called red flags (trauma, malignancy, or infection) may result in potentially unnecessary costs and radiation exposure. The aim of this study was to investigate the use of imaging for patients with emergency visits for low back pain. MATERIALS AND METHODS. Emergency department visits for patients with low back pain billed to insurance were identified by querying a national commercial claims and encounters database for patients 18-64 years old. Patients with concomitant encounter diagnoses suggestive of trauma or those with prior visits for back pain were excluded. Imaging modalities (radiography, CT, and MRI) were identified by Current Procedural Terminology codes. RESULTS. A total of 134,624 encounters met inclusion criteria. Imaging was obtained in 44,405 (33.7%) visits and decreased from 34.4% to 31.9% between 2011 and 2016 (odds ratio per year, 0.98 [95% CI, 0.98-0.99]; p < 0.001). During the study period, 30.9% of patients underwent radiography, 2.7% of patients underwent CT, and 0.8% of patients underwent MRI for evaluation of low back pain. The use of imaging varied significantly by geographic region (p < 0.001), with patients in the southern United States undergoing 10% more imaging than patients in the western United States. CONCLUSION. The use of imaging for the initial evaluation of patients with low back pain in the emergency department continues to occur at a high rate, in approximately one in three new emergency visits for low back pain in the United States.

Diagnostic Imaging Use for the Initial Evaluation of Low Back Pain by Primary Care Providers in the United States: 2011-2016.

OBJECTIVE: High-value care guidelines from multiple medical societies recommend against imaging for the initial evaluation of low back pain in the absence of red flag symptoms. We aimed to determine the current temporal and geographic landscape of imaging ordering patterns for this indication among US primary care providers. METHODS: Using a national commercial insurance claims database, we identified patients between 18 and 64 years old who presented to a primary care provider for an initial evaluation of low back pain between 2011 and 2016. Patients were identified via International Classification of Diseases codes, and the use of diagnostic imaging was identified by Current Procedural Terminology codes. Geographic regions were based on the location of patient residence. RESULTS: Overall, 627,118 encounters met inclusion criteria. Imaging acquisitions increased over time, from 14% of encounters in 2011 to 16% in 2016 (P < .01). Radiographs represented 96% of ordered imaging, CT 2%, and MRI 3%. The likelihood of having any imaging for low back pain varied significantly by US census region and by US state (P < .01). The greatest use of imaging was in the Midwest (13.9%) and the South (18.5%), and lowest in the Northeast and West (6.2% and 13.6%). DISCUSSION: Imaging utilization for the initial evaluation of low back pain by primary care providers has increased on a national level from 2011 to 2016, largely represented by radiographs. Significant regional variation also exists. Encouragingly, the use of advanced imaging has remained at a low level in the primary care setting (<1.0%).

Virtual Reality in Neurointervention.

OBJECTIVES: Virtual reality (VR) allows users to experience realistic, immersive 3D virtual environments with the depth perception and binocular field of view of real 3D settings. Newer VR technology has now allowed for interaction with 3D objects within these virtual environments through the use of VR controllers. This technical note describes our preliminary experience with VR as an adjunct tool to traditional angiographic imaging in the preprocedural workup of a patient with a complex pseudoaneurysm. METHODS: Angiographic MRI data was imported and segmented to create 3D meshes of bilateral carotid vasculature. The 3D meshes were then projected into VR space, allowing the operator to inspect the carotid vasculature using a 3D VR headset as well as interact with the pseudoaneurysm (handling, rotation, magnification, and sectioning) using two VR controllers. RESULTS: 3D segmentation of a complex pseudoaneurysm in the distal cervical segment of the right internal carotid artery was successfully performed and projected into VR. Conventional and VR visualization modes were equally effective in identifying and classifying the pathology. VR visualization allowed the operators to manipulate the dataset to achieve a greater understanding of the anatomy of the parent vessel, the angioarchitecture of the pseudoaneurysm, and the surface contours of all visualized structures. CONCLUSION: This preliminary study demonstrates the feasibility of utilizing VR for preprocedural evaluation in patients with anatomically complex neurovascular disorders. This novel visualization approach may serve as a valuable adjunct tool in deciding patient-specific treatment plans and selection of devices prior to intervention.

A 35-year analysis of sex differences in neurology authorship.

Career progression in academic medicine is partly influenced by publication productivity. There has been a significant increase in female authorship over a 35-year time period at both the first and senior authorship positions in 3 high impact factor neurology journals in the United States. While these trends are encouraging, a sex gap remains. Institutions/departments may wish to consider further strategies for trainees and faculty that can help to maintain momentum and narrow the gap further.

Follow-Up of Emergency Department MRI Scans Suggesting New Diagnosis of CNS Demyelination.

OBJECTIVE: The literature has shown that new cases of multiple sclerosis (MS) can be missed in the emergency department (ED), causing unnecessary delays for patients. In 2012, an MRI scanner was introduced into the ED of our institution. This study examines the potential value of the radiologists' MRI reports for patients with previously undiagnosed MS who presented to the ED. MATERIALS AND METHODS: In this retrospective study, electronic medical records were reviewed for patients without a prior diagnosis of a demyelinating disorder, who underwent imaging on the ED's MRI scanner between March 1, 2014, and March 1, 2016, and for whom the radiologist reported a possible demyelinating disorder. RESULTS: Patient encounters of 61 women and 31 men (mean age, 41.2 years) met the inclusion criteria. In 48 of 92 (52.2%) cases where the radiology report suggested a demyelinating diagnosis, the patient was also given such a diagnosis as the final outcome. Where a demyelinating disorder was placed as the only, first, second, or third (or later) differential diagnosis, the final diagnosis was concordant with demyelination in 84.3% (43/51), 37.5% (3/8), 18.2% (2/11), and 0% (0/22) of cases, respectively (p < 0.01). CONCLUSION: Radiologist-suggested demyelinating disease as the top differential diagnosis after MRI showed a high concordance rate with demyelinating disease being the final diagnosis. Scans in the ED for neurologic deficits can lead to early guidance for a diagnosis of demyelination to be made. Downstream effects may include reduced admission rates, avoidance of unnecessary use of other procedures, and early commencement of disease-modifying therapy.

Independence of Movement Preparation and Movement Initiation.

Initiating a movement in response to a visual stimulus takes significantly longer than might be expected on the basis of neural transmission delays, but it is unclear why. In a visually guided reaching task, we forced human participants to move at lower-than-normal reaction times to test whether normal reaction times are strictly necessary for accurate movement. We found that participants were, in fact, capable of moving accurately ∼80 ms earlier than their reaction times would suggest. Reaction times thus include a seemingly unnecessary delay that accounts for approximately one-third of their duration. Close examination of participants' behavior in conventional reaction-time conditions revealed that they generated occasional, spontaneous errors in trials in which their reaction time was unusually short. The pattern of these errors could be well accounted for by a simple model in which the timing of movement initiation is independent of the timing of movement preparation. This independence provides an explanation for why reaction times are usually so sluggish: delaying the mean time of movement initiation relative to preparation reduces the risk that a movement will be initiated before it has been appropriately prepared. Our results suggest that preparation and initiation of movement are mechanistically independent and may have a distinct neural basis. The results also demonstrate that, even in strongly stimulus-driven tasks, presentation of a stimulus does not directly trigger a movement. Rather, the stimulus appears to trigger an internal decision whether to make a movement, reflecting a volitional rather than reactive mode of control.