Imaging Among the Underserved: Utilization and Expenditures in a Student-Run Free Clinic.

OBJECTIVE: To determine imaging utilization and expenditures among an underserved population at a student-run free clinic. METHODS: This was a retrospective review of billing records for all radiology studies performed over a 4-year period at a student-run free clinic supervised by physician faculty. All imaging services were outsourced through either direct payment by the clinic to a local imaging group or through in-kind donations. Radiology studies were grouped by modality and diagnostic category. Data were analyzed to determine overall and average imaging utilization and expenditures. RESULTS: Across the 4-year study period, 413 radiology studies were performed with a yearly average of 103 (SD = 16). During this time, 192 (46%) ultrasounds, 123 (30%) radiographic studies, 40 (10%) MRIs, 37 (9%) CTs, 8 (2%) interventional procedures, and 5 (1%) nuclear imaging studies were obtained. Overall, expenditures were $157,888 with a yearly average of $39,472 (SD = $1982). In-kind donations accounted for $138,508 (88%) of expenditures. Across the 4-year study period, utilization increased by 15% with less than 1% increase in expenditures. DISCUSSION: Ultrasound was the most common imaging modality used. Overall imaging utilization was considerably less than that of published data in an ambulatory setting.

Starting a Free Ultrasound Clinic for the Underserved: Considerations and Overcoming Challenges.

Many radiologists are interested in providing affordable care to underserved populations but are unsure how to accomplish it. We present a model for providing imaging services to the underserved with an emphasis on the challenges we encountered and strategies we used to overcome them. In partnership with our medical school's student-run free clinic, we developed a community-based ultrasound service that provides diagnostic ultrasound examinations to an uninsured urban population to address the need of timely access to care and integrated follow-up care. Image storage and reporting were fully integrated with our existing imaging informatics and electronic medical record systems. Radiology residents play a central role in the operation of the service while gaining hands-on ultrasound experience, in partnership with volunteer sonographers, radiology attendings, and medical students.

Quantitative magnetic resonance imaging of meniscal pathology ex vivo.

OBJECTIVE: To determine the ability of conventional spin echo (SE) T2 and ultrashort echo time (UTE) T2* relaxation times to characterize pathology in cadaveric meniscus samples. MATERIALS AND METHODS: From 10 human donors, 54 triangular (radially cut) meniscus samples were harvested. Meniscal pathology was classified as normal (n = 17), intrasubstance degenerated (n = 33), or torn (n = 4) using a modified arthroscopic grading system. Using a 3-T MR system, SE T2 and UTE T2* values of the menisci were determined, followed by histopathology. Effect of meniscal pathology on relaxation times and histology scores were determined, along with correlation between relaxation times and histology scores. RESULTS: Mean ± standard deviation UTE T2* values for normal, degenerated, and torn menisci were 3.6 ± 1.3 ms, 7.4 ± 2.5 ms, and 9.8 ± 5.7 ms, respectively, being significantly higher in degenerated (p < 0.0001) and torn (p = 0.0002) menisci compared to that in normal. In contrast, the respective mean SE T2 values were 27.7 ± 9.5 ms, 25.9 ± 7.0 ms, and 35.7 ± 10.4 ms, without significant differences between groups (all p > 0.14). In terms of histology, we found significant group-wise differences (each p < 0.05) in fiber organization and inner-tip surface integrity sub-scores, as well as the total score. Finally, we found a significant weak correlation between UTE T2* and histology total score (p = 0.007, Rs2 = 0.19), unlike the correlation between SE T2 and histology (p = 0.09, Rs2 = 0.05). CONCLUSION: UTE T2* values were found to distinguish normal from both degenerated and torn menisci and correlated significantly with histopathology.

ACR Appropriateness Criteria® Chronic Ankle Pain.

Chronic ankle pain is a common clinical problem whose cause is often elucidated by imaging. The ACR Appropriateness Criteria for chronic ankle pain define best practices of image ordering. Clinical scenarios are followed by the imaging choices and their appropriateness. The information is in ordered tables with an accompanying narrative explanation to guide physicians to order the right test. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Muscle-Tendon-Enthesis Unit.

Injuries to the muscle-tendon-enthesis unit are common and a significant source of pain and loss of function. This article focuses on the important anatomical and biomechanical considerations for each component of the muscle-tendon-enthesis unit. We review normal and pathologic conditions affecting this unit, illustrating the imaging appearance of common disorders on magnetic resonance imaging and ultrasound. Knowledge of the anatomy and biomechanics of these structures is crucial for the radiologist to make accurate diagnoses and provide clinically relevant assessments.

Endovascular Interventions for the Morbidly Adherent Placenta.

Morbidly adherent placentas are a spectrum of abnormalities ranging from placental invasion of the myometrium to invasion past the myometrium and muscular layers into adjacent structures. This entity is becoming more prevalent recently with increased number of cesarean deliveries. Given the high risk of morbidity and mortality, this was traditionally treated with pre-term planned cesarean hysterectomy. However, recently, uterine preservation techniques have been implemented for those women wishing to preserve future fertility or their uterus. Early identification is crucial as studies have shown better outcomes for women treated at tertiary care facilities by a dedicated multidisciplinary team. Interventional radiologists are frequently included in the care of these patients as there are several different endovascular techniques which can be implemented to decrease morbidity in these patients both in conjunction with cesarean hysterectomy and in the setting of uterine preservation. This article will review the spectrum of morbidly adherent placentas, imaging, as well as the surgical and endovascular interventions implemented in the care of these complex patients.

Bleeding after Percutaneous Transhepatic Biliary Drainage: Incidence, Causes and Treatments.

Of all procedures in interventional radiology, percutaneous transhepatic biliary drainage (PTBD) is amongst the most technically challenging. Successful placement requires a high level of assorted skills. While this procedure can be life-saving, it can also lead to significant iatrogenic harm, often manifesting as bleeding. Readers of this article will come to understand the pathophysiology and anatomy underlying post-PTBD bleeding, its incidence, its varied clinical manifestations and its initial management. Additionally, a structured approach to its treatment emphasizing endovascular and percutaneous methods is given.

Quantitative two-dimensional ultrashort echo time magnetization transfer (2D UTE-MT) imaging of cortical bone.

PURPOSE: To investigate quantitative 2D ultrashort echo time magnetization transfer (UTE-MT) imaging in ex vivo bovine cortical bone and in vivo human tibial cortical bone. METHODS: Data were acquired from five fresh bovine cortical bone samples and five healthy volunteer tibial cortical bones using a 2D UTE-MT sequence on a clinical 3T scanner. The 2D UTE-MT sequence used four or five MT powers with five frequency offsets. Results were analyzed with a two-pool quantitative MT model, providing measurements of macromolecular fraction (f), macromolecular proton transverse relaxation times (T2m ), proton exchange rates from water/macromolecular to the macromolecular/water pool (RM0m /RM0w ), and spin-lattice relaxation rate of water pool (R1w ). A sequential air-drying study for a small bovine cortical bone chip was used to investigate whether above MT modeling parameters were sensitive to the water loss. RESULTS: Mean fresh bovine cortical bone values for f, T2m , R1w , RM0m , and RM0w were 59.9 ± 7.3%, 14.6 ± 0.3 µs, 9.9 ± 2.4 s-1 , 17.9 ± 3.6 s-1 , and 11.8 ± 2.0 s-1 , respectively. Mean in vivo human cortical bone values for f, T2m , R1w , RM0m and RM0w were 54.5 ± 4.9%, 15.4 ± 0.6 µs, 8.9 ± 1.1 s-1 , 11.5 ± 3.5 s-1 , and 9.5 ± 1.9 s-1 , respectively. The sequential air-drying study shows that f, RM0m , and R1w were increased with longer drying time. CONCLUSION: UTE-MT two-pool modeling provides novel and useful quantitative information for cortical bone. Magn Reson Med 79:1941-1949, 2018. © 2017 International Society for Magnetic Resonance in Medicine.

Three-dimensional ultrashort echo time cones T1ρ (3D UTE-cones-T1ρ ) imaging.

We report a novel three-dimensional (3D) ultrashort echo time (UTE) sequence employing Cones trajectory and T1ρ preparation (UTE-Cones-T1ρ ) for quantitative T1ρ assessment of short T2 tissues in the musculoskeletal system. A basic 3D UTE-Cones sequence was combined with a spin-locking preparation pulse for T1ρ contrast. A relatively short TR was used to decrease the scan time, which required T1 measurement and compensation using 3D UTE-Cones data acquisitions with variable TRs. Another strategy to reduce the total scan time was to acquire multiple Cones spokes (Nsp ) after each T1ρ preparation and fat saturation. Four spin-locking times (TSL = 0-20 ms) were acquired over 12 min, plus another 7 min for T1 measurement. The 3D UTE-Cones-T1ρ sequence was compared with a two-dimensional (2D) spiral-T1ρ sequence for the imaging of a spherical CuSO4 phantom and ex vivo meniscus and tendon specimens, as well as the knee and ankle joints of healthy volunteers, using a clinical 3-T scanner. The CuSO4 phantom showed a T1ρ value of 76.5 ± 1.6 ms with the 2D spiral-T1ρ sequence, as well as 85.7 ± 3.6 and 89.2 ± 1.4 ms for the 3D UTE-Cones-T1ρ sequences with Nsp of 1 and 5, respectively. The 3D UTE-Cones-T1ρ sequence provided shorter T1ρ values for the bovine meniscus sample relative to the 2D spiral-T1ρ sequence (10-12 ms versus 16 ms, respectively). The cadaveric human Achilles tendon sample could only be imaged with the 3D UTE-Cones-T1ρ sequence (T1ρ  = 4.0 ± 0.9 ms), with the 2D spiral-T1ρ sequence demonstrating near-zero signal intensity. Human studies yielded T1ρ values of 36.1 ± 2.9, 18.3 ± 3.9 and 3.1 ± 0.4 ms for articular cartilage, meniscus and the Achilles tendon, respectively. The 3D UTE-Cones-T1ρ sequence allows volumetric T1ρ measurement of short T2 tissues in vivo.

Long head of the biceps brachii tendon: unenhanced MRI versus direct MR arthrography.

OBJECTIVE: We sought to determine the diagnostic accuracy of unenhanced MRI and direct MR arthrography (MRA) for evaluation of the intra-articular long head of the biceps brachii tendon (LHBT) using arthroscopy as the gold standard. MATERIALS AND METHODS: A retrospective review of patients who underwent shoulder MRI (n = 132) and MRA (n = 67) within 12 months prior to arthroscopy was performed. MR images were independently reviewed by two blinded musculoskeletal radiologists. Routinely recorded arthroscopic photos/videos were reviewed by an orthopedic surgeon. The LHBT was graded as normal, tendinosis, partial thickness tear less or greater than 50%, and complete tear. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for tendinosis and tear detection were calculated. RESULTS: MRI correctly diagnosed fewer normal LHBTs compared to MRA (39-54% versus 74-84%, respectively; p < 0.005). MRI and MRA did not differ significantly in the diagnosis of tendinosis (18-36% and 15-38%, respectively; p > 0.05) and tears (75-83% and 64-73%, respectively; p > 0.05). For tendinosis, MRI versus MRA showed 18-36% and 15-38% sensitivity, 69-79% and 83-91% specificity, 22-28% and 18-50% PPV, 74-76% and 80-86% NPV, and 61-64% and 70-81% accuracy; respectively. For tears, MRI versus MRA showed 75-83% and 64-73% sensitivity, 73-75% and 82-91% specificity, 66-69% and 41-62% PPV, 82-87% and 92-94% NPV, and 74-78% and 79-88% accuracy; respectively. CONCLUSIONS: No significant difference was found between unenhanced MRI and direct MRA for the detection of tendinosis and tears of LHBTs.

Effects of an emergency medical services-based resource access program on frequent users of health services.

BACKGROUND: A small group of adults disproportionately and ineffectively use acute services including emergency medical services (EMS) and emergency departments (EDs). The resulting episodic, uncoordinated care is of lower quality and higher cost and simultaneously consumes valuable public safety and acute care resources. OBJECTIVE: To address this issue, we measured the impact of a pilot, EMS-based case management and referral intervention termed the San Diego Resource Access Program (RAP) to reduce EMS, ED, and inpatient (IP) visits. METHODS: This was a historical cohort study of RAP records and billing data of EMS and one urban hospital for 51 individuals sequentially enrolled in the program. The study sample consisted of adults with ≥ 10 EMS transports within 12 months and others reported by prehospital personnel with significant recent increases in transports. Data were collected over a 31-month time period from December 2006 to June 2009. Data were collected for equal pre- and postenrollment time periods based on date of initial RAP contact, and comparisons were made using the Wilcoxon signed-rank test. Overall use for subjects is reported. RESULTS: The majority of subjects were male (64.7%), homeless (58.8%), and 40 to 59 years of age (72.5%). Between the pre and post periods, EMS encounters declined 37.6% from 736 to 459 (p = 0.001), resulting in a 32.1% decrease in EMS charges from $689,743 to $468,394 (p = 0.004). The EMS task time and mileage decreased by 39.8% and 47.5%, respectively, accounting for 262 (p = 0.008) hours and 1,940 (p = 0.006) miles. The number of ED encounters at the one participating hospital declined 28.1% from 199 to 143, which correlated with a 12.7% decrease in charges from $413,410 to $360,779. The number of IP admissions declined by 9.1% from 33 to 30, corresponding to a 5.9% decrease in IP charges from $687,306 to $646,881. Hospital length of stay declined 27.9%, from 122 to 88 days. Across all services, total charges declined by $314,406. CONCLUSIONS: This pilot study demonstrated that an EMS-based case management and referral program was an effective means of decreasing EMS transports by frequent users, but had only a limited impact on use of hospital services.

Lower iodine load in routine contrast-enhanced CT: an alternative imaging strategy.

OBJECTIVE: To demonstrate an alternative imaging strategy for routine thoracic computed tomography using low intravenous contrast volume. METHODS: Based on radiologists' clinical judgment, 61 thoracic computed tomographic examinations were performed using 15 mL of iohexol intravenous contrast. Indications included patients with relative con traindications to contrast, American College of Radiology appropriateness rating of 1 to 6 for contrast, rating of 7 or greater for contrast with a modifying condition, and cases without specific rating in which contrast may have been useful although not mandatory. Images were retrospectively reviewed to determine adequacy as part of an American Board of Radiology Practice Quality Improvement project. Ascending aorta and right and left pulmonary artery enhancement was measured and compared to most recent routine contrast protocol examination if available. RESULTS: All studies were adequate for evaluation of the given indication. Degree of vascular opacification was sufficient for discriminating between mediastinal structures. Computed tomography number (Hounsfield units) ± standard deviation using 15 mL of contrast compared to routine protocol was 134 ± 47.8 and 240.8 ± 86.6 in ascending aorta, 109.6 ± 47.6 and 185 ± 59.3 in right pulmonary artery, and 112 ± 50 and 186 ± 56.3 in left pulmonary artery, respectively. Mean difference in computed tomography number was significant. Low contrast dose studies demonstrated relatively decreased soft tissue enhancement. CONCLUSIONS: The 15-mL protocol results in reduced vascular and soft tissue enhancement; however, reasonable-quality images are obtained that are diagnostic for a wide range of indications, namely, those involving thoracic inlet, mediastinal, and hilar structures.

Real-time inter-rater reliability of the Council of Emergency Medicine residency directors standardized direct observation assessment tool.

OBJECTIVES: Developed by the Council of Emergency Medicine Residency Directors (CORD), the standardized direct observation assessment tool (SDOT) is an evaluation instrument used to assess residents' clinical skills in the emergency department (ED). In a previous study examining the inter-rater agreement of the tool, faculty scored simulated resident-patient encounters. The objective of the present study was to evaluate the inter-rater agreement of the SDOT in real-time evaluations of residents in the ED. METHODS: This was a multi-center, prospective, observational study in which faculty raters were paired to simultaneously observe and independently evaluate a resident's clinical performance using the SDOT. Data collected from eight emergency medicine (EM) residency programs produced 99 unique resident-patient encounters and reported on 26 individual behaviors related to specific core competencies, global evaluation scores for each core competency, and an overall clinical competency score. Inter-rater agreement was assessed using percentage agreement analyses with three constructs: exact agreement, liberal agreement, and binary (pass/fail) agreement. RESULTS: Inter-rater agreement between faculty raters varied according to category of measure used. Exact agreement ranged from poor to good, depending on the measure: the overall competency score (good), the competency score for each of the six core competencies (poor to good), and the individual item scores (fair to very good). Liberal agreement and binary agreement were excellent for the overall competency score and the competency score for each of the six core competencies and very good to excellent for the individual item scores. CONCLUSIONS: The SDOT demonstrated excellent inter-rater agreement when analyzed with liberal agreement and when dichotomized as a pass/fail measure and fair to good agreement for most measures with exact agreement. The SDOT can be useful and reliable when evaluating residents' clinical skills in the ED, particularly as it relates to marginal performance.