Publications by authors named "Andrew J Degnan"

55 Publications

Progression of Plaque Burden of Intracranial Atherosclerotic Plaque Predicts Recurrent Stroke/Transient Ischemic Attack: A Pilot Follow-Up Study Using Higher-Resolution MRI.

J Magn Reson Imaging 2021 Feb 18. Epub 2021 Feb 18.

Department of Radiology, University of Washington, Seattle, Washington, USA.

Background: Patients with intracranial atherosclerotic disease (ICAD) have a high frequency of stroke recurrence. However, there has been little investigation into the prognostic value of higher-resolution magnetic resonance imaging (HR-MRI).

Purpose: To investigate the use of intracranial atherosclerotic plaques features in predicting risk of recurrent cerebrovascular ischemic events using HR-MRI.

Study Type: Prospective.

Population: Fifty-eight patients with acute/subacute stroke (N = 46) or transient ischemic attack (N = 12).

Field Strength/sequence: A 3.0 T, 3D time-of-flight gradient echo sequence and T1- and T2-weighted fast spin echo sequences with 0.31 x 0.39 mm in-plane resolution, twice (with >3 months between scans) following the initial event.

Assessment: Patients were also followed clinically for recurrent ischemic events for up to 48 months or until a subsequent event occurred. The degree of stenosis, plaque burden (PB), minimal lumen area (MLA), and contrast enhancement ratio were assessed at each scanning session and the percentage change of each over time was calculated.

Statistical Tests: Univariable and multivariable Cox regression analyses were used to calculate the hazard ratio (HR) and 95% confidence interval (CI) for predicting recurrent events.

Results: The mean time interval between baseline and follow-up MRI scans was 6.2 ± 4.1 months. After the second MRI scan, 20.7% of patients (N = 12) had experienced ipsilateral recurrent TIA/stroke within 10.9 ± 9.2 months. Univariable analyses showed that baseline triglyceride, percentage change of PB, and progression of PB were significantly associated with recurrent events (all P < 0.05). Multivariable Cox regression indicated that progression of PB (HR, 6.293; 95% CI, 1.620-24.444; P < 0.05) was a significant independent imaging feature for recurrent ischemic events.

Data Conclusion: Progression of PB was independently associated with recurrent ischemic cerebrovascular events. HR-MRI may help risk stratification of patients at risk of recurrent stroke.

Level Of Evidence: 2 TECHNICAL EFFICACY: Stage 4.
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http://dx.doi.org/10.1002/jmri.27561DOI Listing
February 2021

Diagnostic journey and impact of enzyme replacement therapy for mucopolysaccharidosis IVA: a sibling control study.

Orphanet J Rare Dis 2020 11 30;15(1):336. Epub 2020 Nov 30.

Abington Hospital - Jefferson Health, Abington, PA, USA.

Background: Mucopolysaccharidosis (MPS) IVA, also known as Morquio A syndrome, is a rare autosomal recessive lysosomal storage disorder caused by a deficiency in the enzyme N-acetylgalactosamine-6-sulfatase. Early recognition, diagnosis, and treatment of this progressive, multisystem disease by enzyme replacement therapy (ERT) can lead to improved outcomes and reduced mortality.

Methods: This report documents the diagnostic journey and treatment with ERT of three siblings with MPS IVA. Clinical outcome measures included growth, endurance, imaging, cardiac, respiratory, ophthalmology, and laboratory evaluations.

Results: Three siblings, diagnosed at 14.7, 10.1, and 3.2 years of age, demonstrated clinical improvement with weekly infusions of 2.0 mg/kg elosulfase alfa (Vimizim, BioMarin Pharmaceutical, Novato, CA, USA). Patient 1 (oldest sibling) and Patient 2 (middle sibling) experienced a diagnostic delay of 8 years 7 months and 4 years after symptom onset, respectively. All three patients demonstrated improvements in growth, 6-min walk distance, joint range of motion, and respiratory function after 30 months of ERT. The treatment was well tolerated without any adverse events.

Conclusions: This case series highlights the importance of early recognition of the clinical and imaging findings that are initially subtle in MPS IVA. Early treatment with ERT is necessary to slow irreversible disease progression and improve patient outcomes. The oldest sibling experienced improvements in mobility despite severe symptoms resulting from a late diagnosis. When evaluating patients with skeletal anomalies, imaging multiple body regions is recommended. When findings such as anterior beaking of vertebrae or bilateral femoral head dysplasia are present, MPS IVA should be included in the differential diagnosis. Newborn screening must be considered for early detection, accurate diagnosis, and initiation of treatment to reduce morbidity.
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http://dx.doi.org/10.1186/s13023-020-01618-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7706253PMC
November 2020

Lipoblastoma: computed tomographic and magnetic resonance imaging features correlate with tumor behavior and pathology.

Pediatr Radiol 2020 Nov 5. Epub 2020 Nov 5.

American Institute for Radiologic Pathology, Silver Spring, MD, USA.

Background: Lipoblastoma is a rare benign neoplasm of immature fat cells in children. Imaging appearances are frequently complex, sometimes simulating liposarcoma.

Objective: To characterize features of lipoblastoma on MRI and CT in comparison with recurrence risk.

Materials And Methods: We identified cases via retrospective review of histopathology-proven lipoblastoma cases in a large referral database and a pediatric medical center. Two radiologists scored CT and MRI on the basis of lesion features.

Results: We included a total of 56 children (32 boys and 24 girls) with a mean age of 2.6 years (range 0.1-13 years). Extremity lesions were most common (27%), followed by neck (19%), gluteal region (18%), chest (14%) and mesentery (14%). Children most commonly presented with painless masses (73%), followed by dyspnea (9%), distension (9%) and pain (7%). Non-adipose soft-tissue components were identified on CT and MRI in 78% of cases. Significant (moderate or marked) septations were noted in 59% and enhancement in 35%. Compartmental invasion was present in 43% of cases. Of paraspinal cases, 38% involved the neural foramina or central canal. Lesion complexity did not significantly correlate with age. Recurrence was observed in 9% of cases and was significantly correlated with compartmental invasion (correlation: 0.303, P=0.009) and septation complexity (correlation: 0.227, P=0.038) on initial imaging.

Conclusion: Although lipoblastoma is a fat-containing entity, many lesions demonstrate marked complexity and local infiltration that resemble liposarcoma, which is exceedingly rare in younger children. Compartmental invasion and thicker septations appear to confer greater risk of recurrence following resection.
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http://dx.doi.org/10.1007/s00247-020-04882-zDOI Listing
November 2020

Optimizing Radiology Reading Room Design: The Eudaimonia Radiology Machine.

J Am Coll Radiol 2021 Jan 13;18(1 Pt A):108-120. Epub 2020 Oct 13.

Associate Radiologist in Chief, Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

Physical and mental stressors on radiologists can result in burnout. Although current efforts seek to target the issues of burnout and stress for radiologists, the impact of their physical workspace is often overlooked. By combining evidence-based design, human factors, and the architectural concept of the Eudaimonia Machine, we have developed a redesign of the radiology reading room that aims to create an optimal workspace for the radiologist. Informed by classical principles of well-being and contemporary work theory, Eudaimonia integrates concerns for individual wellness and efficiency to create an environment that fosters productivity. This layout arranges a work environment into purposeful spaces, each hosting tasks of varying degrees of intensity. The improved design addresses the radiologist's work requirements while also alleviating cognitive and physical stress, fatigue, and burnout. This new layout organizes the reading room into separate areas, each with a distinct purpose intended to support the range of radiologists' work, from consultation with other health care providers to reading images without interruption. The scientific principles that undergird evidence-based design and human factors considerations ensure that the Eudaimonia Radiology Machine is best suited to support the work of the radiologists and the entire radiology department.
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http://dx.doi.org/10.1016/j.jacr.2020.09.041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7553105PMC
January 2021

Solitary long-bone epiphyseal lesions in children: radiologic-pathological correlation and epidemiology.

Pediatr Radiol 2020 11 7;50(12):1724-1734. Epub 2020 Jul 7.

Department of Pediatric Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.

Background: Solitary epiphyseal lesions are rare and present with nonspecific imaging features. Knowledge regarding etiologies of pediatric epiphyseal lesions is limited to small studies.

Objective: The purpose of this study was to determine the relative incidence of pathologies affecting the pediatric epiphysis based on biopsy-proven cases with imaging.

Materials And Methods: We conducted a retrospective review of imaging studies including the terms "biopsy" or "resection" and entities known to affect the epiphysis and cross-referenced these with pathology reports, recording the relevant clinical data. Two radiologists performed comprehensive imaging review and recorded relevant features.

Results: Forty-nine children and adolescents met inclusion criteria. The long-bone epiphyseal lesion etiologies included chondroblastoma (n=22, 45%), nonspecific nonmalignant pathology (n=11, 22%), osteomyelitis (n=9, 18%), lymphoma (n=2, 4%) and 1 case of each of aneurysmal bone cyst, chondrosarcoma, enchondroma, hemangioendothelioma, and non-Langerhans cell histiocytosis. Median age was 13.1 years old (range 1.5-18.6 years). We performed comparative analysis of the two most common lesions in our series, chondroblastoma and osteomyelitis. Chondroblastoma was significantly more likely to be peripherally located (94% vs. 33%, P=0.002) and to demonstrate a discrete T1-weighted hypointense rim (94% vs. 33%, P=0.002); there were no significant differences in enhancement or intrinsic signal properties. Children with chondroblastoma were older (15.1 years vs. 7.3 years, P=0.001), and chondroblastoma lesions were significantly larger, with mean maximum lesion diameter of 25 mm (interquartile range [IQR] 20-30) vs. 12 mm (IQR 11-18) (P=0.001) and lesion volumes of 4.4 mL (IQR 2.4-7.9) vs. 0.4 mL (IQR 0.2-1.4) (P=0.01).

Conclusion: This study reports the relative frequency of pathology of pediatric solitary epiphyseal lesions and describes several features that might assist in differentiating between chondroblastoma and osteomyelitis.
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http://dx.doi.org/10.1007/s00247-020-04752-8DOI Listing
November 2020

Evaluation of chronic carotid artery occlusion by non-contrast 3D-MERGE MR vessel wall imaging: comparison with 3D-TOF-MRA, contrast-enhanced MRA, and DSA.

Eur Radiol 2020 Nov 11;30(11):5805-5814. Epub 2020 Jun 11.

Department of Radiology, University of Washington, Seattle, WA, USA.

Objectives: To analyze the accuracy of a non-contrast MR vessel wall imaging technique, three-dimensional motion-sensitized driven equilibrium prepared rapid gradient echo (3D-MERGE) for diagnosing chronic carotid artery occlusion (CCAO) characteristics compared with 3D time-of-flight (TOF) MRA, and contrast-enhanced MRA (CE-MRA), using digital subtraction angiography (DSA) as a reference standard.

Methods: Subjects diagnosed with possible CCAO by ultrasound were retrospectively analyzed. Patients underwent 3.0-T MR imaging with 3D-MERGE, 3D-TOF-MRA, and CE-MRA followed by DSA within 1 week. Diagnostic accuracy of occlusion, occlusion site, and proximal stump condition were assessed independently on 3 MRI sequences and DSA. Agreement of the above indicators was evaluated in reference to DSA.

Results: One hundred twenty-four patients with 129 suspected CCAO (5 with bilateral occlusions) met the inclusion criteria for our study. 3D-MERGE demonstrated a sensitivity, specificity, and accuracy of 97.0%, 86.7%, and 94.6%, respectively, with excellent agreement (Cohen's κ = 0.85; 95% CI, 0.71, 0.94) for diagnosing CCAO in reference to DSA. 3D-MERGE was superior in diagnosing CCAO compared with 3D-TOF-MRA (Cohen's κ = 0.61; 95% CI, 0.42, 0.77) and similar to CE-MRA (Cohen's κ = 0.93; 95% CI, 0.86, 1.00). 3D-MERGE also had excellent agreement compared with DSA for assessing occlusion sites (Cohen's κ = 0.85; 95% CI, 0.71, 0.97) and stump condition (Cohen's κ = 0.83; 95% CI, 0.71, 0.94). Moreover, 3D-MERGE provided additional information regarding the occluded segment, such as distal lumen collapse and vessel wall lesion components.

Conclusion: 3D-MERGE can reliably assess chronic carotid occlusive characteristics and has the ability to identify other vessel wall features of the occluded segment. This non-contrast MR vessel wall imaging technique is promising for assessment of CCAO.

Key Points: • Excellent agreement was found between 3D-MERGE and DSA for assessing chronic carotid artery occlusion, occlusion site, and proximal stump condition. • 3D-MERGE was shown to be a more accurate and efficient tool than 3D-TOF-MRA to detect the characteristics of the occluded segment. • 3D-MERGE provides not only luminal images for characterizing the proximal characteristics of occlusion but also vessel wall images for assessing the distal lumen and morphology of occlusion segment, which might help clinicians to optimize the treatment strategy for patients with chronic carotid artery occlusion.
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http://dx.doi.org/10.1007/s00330-020-06989-1DOI Listing
November 2020

Gaucher disease status and treatment assessment: pilot study using magnetic resonance spectroscopy bone marrow fat fractions in pediatric patients.

Clin Imaging 2020 Jul 22;63:1-6. Epub 2020 Feb 22.

Department of Radiology, Columbia University Medical Center, 622 West 168th Street, PH1-301, New York, NY 10032, USA. Electronic address:

Objective: To assess magnetic resonance spectroscopy (MRS) bone marrow fat fractions' ability to discern between untreated Gaucher disease patients and healthy controls based on assessment of bone marrow infiltration and evaluate response to enzyme replacement therapy (ERT) on serial imaging.

Methods: This retrospective case-controlled study compared conventional MRI and bone marrow MRS findings in six pediatric and young adult Gaucher disease patients with age- and sex-matched controls, examining femoral neck and lumbar spine bone marrow fat fractions and bone marrow burden (BMB) scores. Separate analysis of six patients with serial imaging on ERT was performed with analysis of fat fractions, BMB scores, organ volumes, and serum chitotriosidase.

Results: Untreated patients had significantly lower femoral and lumbar spine fat fractions than controls (0.32 versus 0.67, p = 0.041 and 0.17 versus 0.34, p = 0.041, respectively). Total BMB scores were significantly higher in patients (8.0 versus 3.5, p = 0.015). In patients on ERT with average follow-up of 3.5 years, femoral neck fat fraction was the sole significant predictor of treatment duration (R square: 0.804, p < 0.001) when adjusted for age. Femoral neck fat fraction also correlated with lumbar spine fat fraction, liver volume and chitotriosidase (p < 0.05). MRS test-retest reliability was excellent (Pearson correlations: 0.96, 0.99; p-values <0.001). BMB inter-rater reliability was good overall with an intra-class correlation coefficient of 0.79 for total score, although lumbar spine score reliability was poor at 0.45.

Conclusion: MRS-derived bone marrow fat fractions appear capable of detecting Gaucher disease severity and monitoring treatment-related changes as a predictor of ERT duration in pediatric and young adult patients.
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http://dx.doi.org/10.1016/j.clinimag.2020.02.009DOI Listing
July 2020

Cost-Effectiveness Analysis in Pediatric Imaging: The Evidence (or Lack Thereof) Thus Far.

J Am Coll Radiol 2020 Apr 30;17(4):452-461. Epub 2019 Nov 30.

Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts.

Objective: To systematically review all published cost-effectiveness analyses (CEAs) of imaging technologies in children.

Methods: We identified all CEAs involving fetal and pediatric imaging included in a publicly available repository of CEAs published since 1976. Information on publication characteristics, methods, costs, quality of life weights, and incremental cost-effectiveness ratios (ICERs) was recorded for each article.

Results: Of 480 diagnostic CEAs, only 10 focused on fetal and pediatric imaging. The 10 studies reported 43 quality of life weights based on previously published adult data (n = 20, 46.5%); pregnant women perspective (n = 11, 25.6%), and treating physician perspective (n = 12, 27.9%). None of the studies elicited quality of life weights from children nor took into consideration the postnatal impact of disease on family's quality of life. All studies used a health care payer perspective without incorporating patients' incurred cost such as loss wages or travel related cost. Of 37 ICERs, 7 (18.9%) were cost saving and 6 (16.2%) were more expensive and less effective. The remaining ICERs ranged from $1,400 per quality-adjusted life-year (MRI versus ultrasound in newborns with moderate risk of occult spinal dysraphism) to $10,000,000 per quality-adjusted life-year (CT versus no imaging in children at low risk for craniosynostosis).

Conclusion: There is a striking paucity of cost-effectiveness studies evaluating imaging technologies in children. Existing studies do not incorporate the patient and family perspectives regarding utilities (eg, impact of child's disease on families' quality of life) or cost (eg, loss wages, travel, time off). Future studies should elicit and incorporate the impact of disease on families to better reflect real-world scenarios.
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http://dx.doi.org/10.1016/j.jacr.2019.10.005DOI Listing
April 2020

Whole-body magnetic resonance imaging of pediatric cancer predisposition syndromes: special considerations, challenges and perspective.

Pediatr Radiol 2019 10 16;49(11):1506-1515. Epub 2019 Oct 16.

Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.

Cancer predisposition syndromes increase the incidence of tumors during childhood and are associated with significant morbidity and mortality. Imaging is paramount for ensuring early detection of neoplasms, impacting therapeutic interventions and potentially improving outcome. While conventional imaging techniques involve considerable exposure to ionizing radiation, whole-body MRI is a radiation-free modality that allows continuous imaging of the entire body and has increasingly gained relevance in the surveillance, diagnosis, staging and monitoring of pediatric patients with cancer predisposition syndromes. Nevertheless, widespread implementation of whole-body MRI faces several challenges as a screening tool. Some of these challenges include developing clinical indications, variability in protocol specifications, image interpretation as well as coding and billing practices. These factors impact disease management, patient and family experience and research collaborations. In this discussion we review the aforementioned special considerations and the potential direction that might help overcome these challenges and promote more widespread use of whole-body MRI in children with cancer predisposition syndromes.
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http://dx.doi.org/10.1007/s00247-019-04431-3DOI Listing
October 2019

Osteochondritis Dissecans of the Elbow in Children: MRI Findings of Instability.

AJR Am J Roentgenol 2019 11 28;213(5):1145-1151. Epub 2019 Aug 28.

Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI.

The purpose of this study was to investigate the performance of MRI criteria for predicting instability of osteochondritis dissecans (OCD) lesions of the elbow in children. This retrospective study included 41 children with 43 OCD lesions of the elbow who underwent an MRI examination between April 1, 2010, and May 31, 2018. Two radiologists blinded to clinical outcomes reviewed MRI studies to determine the presence or absence of joint effusion, osteochondral defect, intraarticular body, overlying cartilage changes, subchondral bone disruption, rim of high signal intensity on T2-weighted images, cysts, marginal sclerosis, and perilesional bone marrow edema. The stability of OCD lesions was determined with clinical follow-up and surgical findings as reference standards. Mann-Whitney , chi-square, Fisher exact, and Cochran-Armitage tests were used to compare MRI findings between stable and unstable OCD lesions. There were 20 stable and 23 unstable OCD lesions. An osteochondral defect ( = 0.01), intraarticular body ( < 0.001), overlying cartilage changes ( = 0.001), subchondral bone plate disruption ( = 0.02), and hyperintense rim ( = 0.01) were significantly more common in unstable than stable OCD lesions. However, only osteochondral defect and intraarticular body were 100% specific for OCD instability. There was no significant difference between stable and unstable OCD lesions in the presence of joint effusion ( = 0.10), cysts ( = 0.45), marginal sclerosis ( = 0.70), or perilesional bone marrow edema ( = 1.00). MRI findings of OCD instability of the elbow include an osteochondral defect, intraarticular body, overlying cartilage changes, subchondral bone disruption, and rim of high signal intensity on T2-weighted MR images.
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http://dx.doi.org/10.2214/AJR.19.21855DOI Listing
November 2019

Imaging of non-neuronopathic Gaucher disease: recent advances in quantitative imaging and comprehensive assessment of disease involvement.

Insights Imaging 2019 Jul 10;10(1):70. Epub 2019 Jul 10.

Division of Human Genetics, The Children's Hospital of Philadelphia, Colket Translational Research Building, 3501 Civic Center Blvd, Floor 9, Philadelphia, PA, 19104, USA.

Gaucher disease is an inherited metabolic disorder resulting in deficiency of lysosomal enzyme β-glucocerebrosidase causing the accumulation of abnormal macrophages ("Gaucher cells") within multiple organs, most conspicuously affecting the liver, spleen, and bone marrow. As the most common glycolipid metabolism disorder, it is important for radiologists encountering these patients to be familiar with advances in imaging of organ and bone marrow involvement and understand the role of imaging in clinical decision-making. The recent advent of commercially available, reliable, and reproducible quantitative MRI acquisitions to measure fat fractions prompts revisiting the role of quantitative assessment of bone marrow involvement. This manuscript reviews the diverse imaging manifestations of Gaucher disease and discusses more optimal quantitative approaches to ascertain solid organ and bone marrow involvement with an emphasis on future applications of other quantitative methods including elastography.
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http://dx.doi.org/10.1186/s13244-019-0743-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6616606PMC
July 2019

Culprit intracranial plaque without substantial stenosis in acute ischemic stroke on vessel wall MRI: A systematic review.

Atherosclerosis 2019 08 20;287:112-121. Epub 2019 Jun 20.

Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA. Electronic address:

Background And Aims: Intracranial atherosclerotic plaque is associated with ischemic strokes without substantial stenosis, and needs better characterization. We aim to investigate the clinical significance of intracranial plaque without substantial stenosis by high resolution vessel wall MRI (vwMRI) through a systematic review of existing studies.

Methods: Studies investigating intracranial arterial atherosclerotic plaques without substantial stenosis in acute ischemic stroke patients using vwMRI were systematically identified by searching the PubMed and Medline database and article reference lists. Study characteristics were recorded, the methodological quality of eligible studies was assessed, relevant clinical data were extracted, and collective data was analyzed.

Results: Twenty-one studies were identified as eligible. 463 patients were included without stenosis of the intracranial arteries, and 651 patients were included with stenosis <50%. The prevalence of intracranial plaque revealed by vwMRI among acute/subacute ischemic stroke patients with non-stenotic Magnetic Resonance Angiography (MRA) was 50.6% (95% confidence interval (CI), 46.1%-55.1%). The prevalence of <50% MRA stenotic culprit plaque among acute/subacute ischemic stroke patients with a clinical diagnosis of intracranial atherosclerosis was 51.2% (95% CI, 38.4%-64.0%). Plaques features, including wall enhancement, positive remodeling, intraplaque hemorrhage, plaque location and eccentricity, were associated with acute stroke, progressive motor deficits and unfavorable overall functional outcomes.

Conclusions: Intracranial high-risk plaque with zero or mild degree of stenosis is more prevalent than previously acknowledged, and is associated with ischemic stroke and unfavorable outcome. VwMRI can identify the high-risk plaque features, which may act as a promising tool to better risk stratify these patients.
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http://dx.doi.org/10.1016/j.atherosclerosis.2019.06.907DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6707846PMC
August 2019

Proximal radius fractures in children: evaluation of associated elbow fractures.

Pediatr Radiol 2019 08 8;49(9):1177-1184. Epub 2019 Jun 8.

Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19122, USA.

Background: Additional fractures occur in association with proximal radius fractures, but the extent of these secondary injuries has not been systematically assessed.

Objective: To ascertain the frequency and nature of additional fractures associated with proximal radius injuries in a large pediatric cohort.

Materials And Methods: Radiographs meeting search criteria for proximal radius fracture during a 5-year period were reviewed. Fracture characteristics and the coexistence of additional elbow fractures were recorded and analyzed. The retrospective review was compared with initial interpretation and a blinded review by two pediatric musculoskeletal radiologists.

Results: Four hundred ninety-four proximal radius fractures were included. The radial neck was the most common fracture site (89%). Neck fractures occurred in younger patients (mean: 7.3 years) than head fractures (mean: 13.3 years) (P<0.001). Additional elbow fractures occurred in 39%, most commonly at the olecranon (22%). Additional fractures occurred in younger patients (mean: 7.2 years) than isolated proximal radius fractures (mean: 8.5 years) (P<0.001). Elbow joint effusion and complete or displaced radius fractures were each associated with additional elbow fractures (P<0.001). When compared with initial interpretation, 25% of additional fractures were not identified on initial radiographs, of which 44% were occult retrospectively. Fracture identification demonstrated excellent inter-reader reliability (interclass correlation coefficient [ICC]: 0.88, 0.94), but joint effusion interobserver agreement was only fair (ICC: 0.52, 0.41).

Conclusion: Proximal radius fractures in children often occur in association with other elbow fractures, most commonly involving the olecranon. Enhanced awareness of these fracture patterns, especially in the setting of joint effusion or complete and displaced radius fractures, may improve detection to guide appropriate management.
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http://dx.doi.org/10.1007/s00247-019-04445-xDOI Listing
August 2019

Imaging Assessment of Partial Liquid Ventilation in Bronchopulmonary Dysplasia.

Curr Probl Diagn Radiol 2019 May - Jun;48(3):247-250. Epub 2018 Dec 7.

Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.

Partial liquid ventilation is proposed as an alternative ventilation strategy to reduce surface tension, increase alveolar recruitment, and decrease inflammation. Studied in acute respiratory distress and other indications, liquid ventilation is being revisited for infants with bronchopulmonary dysplasia. Perfluorooctyl bromide used for liquid ventilation is radiopaque, allowing radiographic visualization of lung liquid ventilation patterns that may provide additional insight into pulmonary pathophysiology. Current protocols utilize reduced liquid dosing, resulting in unique imaging features. We discuss optimal radiographic technique and report initial ultrasound evaluation results. With renewed interest in partial liquid ventilation, it may be helpful for pediatric radiologists to familiarize themselves with the clinical use and radiographic appearance of liquid ventilation material.
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http://dx.doi.org/10.1067/j.cpradiol.2018.12.005DOI Listing
August 2019

Radiology Research Funding: Current State and Future Opportunities.

Acad Radiol 2018 01 1;25(1):26-39. Epub 2017 Sep 1.

Department of Radiology & Imaging Sciences, Emory University, Atlanta, Georgia.

Funding for research has become increasingly difficult to obtain in an environment of decreasing clinical revenue, increasing research costs, and growing competition for federal and nonfederal funding sources. This paper identifies critical requirements to build and sustain a successful radiology research program (eg, key personnel and leadership, research training and mentorship, infrastructure, institutional and departmental funding or support), reviews the current state of available funding for radiology (including federal, nonfederal, philanthropy, crowdfunding, and industry), and describes promising opportunities for future funding (eg, health services, comparative effectiveness, and patient-centered outcomes research). The funding climate, especially at the federal level, changes periodically, so it is important to have radiology-specific organizations such as the American College of Radiology and the Academy of Radiology Research serving as our key advocates. Key to obtaining any funding, no matter what the source, is a well-formulated grant proposal, so a review of opportunities specifically available to radiologists to develop and hone their grant-writing skills is provided. Effective and sustained funding for radiology research has the potential to cultivate young researchers, bolster quality research, and enhance health care. Those interested in pursuing research need to be aware of the ever-changing funding landscape, research priority areas, and the resources available to them to succeed. To succeed, radiology researchers need to think about diversification and flexibility in their interests, developing multidisciplinary and multi-institutional projects, and engaging a broader base of stakeholders that includes patients.
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http://dx.doi.org/10.1016/j.acra.2017.07.013DOI Listing
January 2018

Perceptual and Interpretive Error in Diagnostic Radiology-Causes and Potential Solutions.

Acad Radiol 2019 06 14;26(6):833-845. Epub 2018 Dec 14.

Department of Radiology and Imaging Sciences, University of Utah School of Medicine, 30 North 1900 East, Rm # 1A71, Salt Lake City, UT 84132, USA. Electronic address:

Interpretation of increasingly complex imaging studies involves multiple intricate tasks requiring visual evaluation, cognitive processing, and decision-making. At each stage of this process, there are opportunities for error due to human factors including perceptual and ergonomic conditions. Investigation into the root causes of interpretive error in radiology first began over a century ago. In more recent work, there has been increasing recognition of the limits of human image perception and other human factors and greater acknowledgement of the role of the radiologist's environment in increasing the risk of error. This article reviews the state of research on perceptual and interpretive error in radiology. This article focuses on avenues for further error examination, and strategies for mitigating these errors are discussed. The relationship between artificial intelligence and interpretive error is also considered.
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http://dx.doi.org/10.1016/j.acra.2018.11.006DOI Listing
June 2019

Diagnostic and Interventional Imaging Services are Significant Sources of Medicare Revenue for Highly Reimbursed Nonradiologist Providers.

Curr Probl Diagn Radiol 2020 Jan - Feb;49(1):17-22. Epub 2018 Nov 2.

Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA.; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.

Introduction: Nonradiologist providers increasingly perform diagnostic imaging examinations and imaging-guided interventions traditionally performed by radiologists, which have raised concerns regarding appropriate utilization and self-referral. The purpose of this study was to assess the contribution of imaging studies to Medicare reimbursements for highly compensated nonradiologist providers in specialties often performing imaging studies.

Methods: The Medicare Provider Utilization and Payment Database was queried for provider information regarding overall reimbursement for providers in anesthesiology, cardiology, emergency medicine, neurology, obstetrics and gynecology, orthopedic surgery, neurology, and vascular surgery. Information regarding imaging studies reported and payment amounts were extracted for the 25 highest-reimbursed providers. Data were analyzed for relative contribution of imaging payments to overall medical Medicare payments.

Results: Significant differences between numbers of imaging studies, types of imaging, and payment amounts were noted based on provider specialty (p < 0.001). Highest-reimbursed cardiologists received the greatest percentage of Medicare payments from imaging (18.3%) followed by vascular surgery (11.6%), obstetrics and gynecology (10.9%), orthopedic surgery (9.6%), emergency medicine (8.7%), neurology (7.8%), and anesthesiology (3.2%) providers. Mean imaging payments amongst highly reimbursed nonradiologists were greatest for cardiology ($578,265), vascular surgery ($363,912), and orthopedic surgery ($113,634). Amongst highly reimbursed specialists, most common nonradiologist imaging payments were from ultrasound (45%) and cardiac nuclear medicine studies (40%).

Conclusions: Nonradiologist performed imaging payments comprised substantial proportions of overall Medicare reimbursement for highly reimbursed physicians in several specialties, especially cardiology, vascular surgery, and orthopedic surgery. Further investigation is needed to better understand the wider economic implications of nonradiologist imaging study performance and self-referral beyond the Medicare population.
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http://dx.doi.org/10.1067/j.cpradiol.2018.10.009DOI Listing
June 2020

Partial liquid ventilation for bronchopulmonary dysplasia: Visualizing ventilation patterns on chest radiographs.

Pediatr Neonatol 2019 10 1;60(5):587-588. Epub 2018 Nov 1.

Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.

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http://dx.doi.org/10.1016/j.pedneo.2018.10.004DOI Listing
October 2019

Variability in billing practices for whole-body magnetic resonance imaging.

Pediatr Radiol 2019 01 7;49(1):153. Epub 2018 Sep 7.

Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA.

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http://dx.doi.org/10.1007/s00247-018-4255-0DOI Listing
January 2019

More Than Epiphyseal Osteochondromas: Updated Understanding of Imaging Findings in Dysplasia Epiphysealis Hemimelica (Trevor Disease).

AJR Am J Roentgenol 2018 10 30;211(4):910-919. Epub 2018 Aug 30.

1 Department of Radiology, The Children's Hospital of Philadelphia, 3NW39, 3401 Civic Center Blvd, Philadelphia, PA 19104.

Objective: The purpose of this article is to discuss approaches to imaging dysplasia epiphysealis hemimelica in the context of recent advances in the understanding of the underlying pathophysiologic profile of this entity, which may result in pain, growth disturbance, and early development of osteoarthritis.

Conclusion: Dysplasia epiphysealis hemimelica was first characterized as a skeletal disorder with osteochondromas characteristically involving epiphyses on one side of the same lower extremity. Upper extremity involvement was subsequently recognized. Previously conceptualized as epiphyseal osteochondromatosis, recent investigations have uncovered differences between these osteocartilaginous lesions and osteochondromas.
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http://dx.doi.org/10.2214/AJR.18.19712DOI Listing
October 2018

Knowledge-based iterative model reconstruction: Comparative image quality with low tube voltage cerebral CT angiography.

Medicine (Baltimore) 2018 Jul;97(30):e11514

From the Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, China From the Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA From the Department of Radiology, University of Pittsburgh, Pittsburgh, PA.

The aim of this study was to compare image quality of low tube voltage cerebral computed tomography angiography (CTA) reconstructed with knowledge-based iterative model reconstruction (IMR), filtered back projection (FBP), and hybrid iterative reconstruction (HIR).A total of 101 patients with suspected cerebrovascular diseases were enrolled and randomized into 2 groups, 100 kVp tube voltage (n = 53) and reduced tube voltage (80 kVp) (n = 48). Computed tomography data were reconstructed with IMR, FBP, and HIR algorithms. The image noise, vascular attenuation, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were measured and calculated. Two blinded radiologists independently evaluated image quality based on diagnostic confidence on a 3-point scale. Quantitative and qualitative assessments were compared between different groups and reconstruction subgroups.Vascular attenuation was higher in the reduced tube voltage group than in 100-kVp tube voltage group, but showed no significant difference within each group. In both groups, the image noise, vascular SNR, and CNR were significantly improved by IMR as compared with FBP and HIR. Inter-group comparison indicated that IMR with reduced tube voltage showed better image quality with lower image noise and higher vascular SNR and CNR than FBP and HIR at 100 kVp, but slightly inferior to IMR at 100 kVp. IMR also yields the best qualitative image quality, and improves the diagnostic confidence of atherosclerosis and aneurysm. Compared with the standard 120-kVp protocol (1.86mSv), the radiation doses of 100 kVp (1.13mSv) and 80 kVp (0.56mSv) were 39% and 70% less, respectively.The quantitative and qualitative image quality obtained by IMR was superior to that obtained by FBP and HIR for low tube voltage cerebral CTA.
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http://dx.doi.org/10.1097/MD.0000000000011514DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6078758PMC
July 2018

Intracranial Aneurysm Wall Enhancement Associated with Aneurysm Rupture: A Systematic Review and Meta-analysis.

Acad Radiol 2019 05 13;26(5):664-673. Epub 2018 Jun 13.

Department of Radiology, Changhai Hospital, Shanghai, China. Electronic address:

Rationale And Objectives: Aneurysm wall enhancement (AWE) on magnetic resonance vessel wall imaging has been proposed as an imaging marker of aneurysm wall inflammation and instability. We performed a systematic review and meta-analysis to summarize the association between AWE and aneurysm rupture.

Materials And Methods: We performed a comprehensive literature search of studies evaluating the association between AWE and aneurysm rupture. We abstracted the following study data: study design, patient demographics, aneurysm characteristics, MRI protocols, and AWE assessment. We performed meta-analysis using a random-effects model. Study heterogeneity was assessed by using the Cochrane Q and I statistic, and publication bias was examined by using the Begg-Mazumdar test.

Results: Five studies with 492 subjects met eligibility for systematic review. We found a significant positive overall association between AWE and aneurysm rupture, with an odds ratio (OR) of 34.26 (95% confidence interval [CI] 10.20-115.07, p < 0.001). No significant heterogeneity (Q = 5.38, p = 0.25; I = 26%) or publication bias (p = 1.000) was present. In the separate analysis of circumferential AWE and aneurysm rupture, we identified marked heterogeneity across studies (Q = 21.23, p < 0.001; I = 86%). Further subgroup analysis considering the effect of aneurysm size showed that the strength of association between circumferential AWE and aneurysm rupture was significant in small aneurysms (<7 mm), with an OR of 26.12 (95% CI 6.11-111.75, p < 0.001), but limited in large aneurysms (OR = 0.56, 95% CI [0.21, 1.44], p = 0.23).

Conclusion: AWE on magnetic resonance vessel wall imaging is significantly and independently associated with aneurysm rupture and may become a promising imaging marker to predict aneurysm behavior and identify high-risk aneurysms.
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http://dx.doi.org/10.1016/j.acra.2018.05.005DOI Listing
May 2019

Wall enhancement of intracranial unruptured aneurysm is associated with increased rupture risk and traditional risk factors.

Eur Radiol 2018 Dec 5;28(12):5019-5026. Epub 2018 Jun 5.

Department of Radiology, Changhai Hospital, Shanghai, China.

Objective: Aneurysm wall enhancement (AWE) on MRI has been considered an imaging marker to indicate active aneurysm inflammation, but no prospective studies have assessed the ability of AWE to predict rupture risk or growth. We aim to study the association of AWE with traditional risk factors and the estimated rupture risk.

Methods: Seventy-seven patients (mean age, 58.4 ± 10.8 years; 57% female) with 88 asymptomatic intracranial saccular aneurysms underwent both 3-T high-resolution MRI and three-dimensional (3D) rotational digital subtraction angiography (DSA). Geometric and morphologic parameters were measured on DSA, and the degree of AWE on MRI was graded. One- and 5-year rupture risks of aneurysms were estimated using the UCAS and PHASES calculator. Parameters associated with AWE were analyzed using uni- and multivariate logistic regression.

Results: Non-internal carotid artery location (OR 3.4, 95% CI 1.6-7.1) and aneurysm size (OR 1.9, 95% CI 1.3-2.7) were independently associated with AWE (p < 0.05). Aneurysms with AWE had significantly higher estimated rupture risk (1 and 5 year, 1.9% and 5.8%) than aneurysms without AWE (0.5% and 2.1%) (p < 0.001). Stronger and larger areas of AWE were correlated with the aneurysm size, size ratio and estimated rupture risk (R ≥ 0.30) (p < 0.01).

Conclusions: Prospective assessment of asymptomatic intracranial aneurysms with MRI suggests that AWE is associated with traditional risk factors and estimated short- and medium-term rupture risk.

Key Points: • AWE independently associates with aneurysm location and size. • Aneurysms with AWE have higher rupture risk than aneurysms without AWE. • Stronger and larger areas of AWE correlated with the aneurysm size, size ratio and rupture risk.
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http://dx.doi.org/10.1007/s00330-018-5522-zDOI Listing
December 2018

Bilateral absence of the cruciate ligaments with meniscal dysplasia: Unexpected diagnosis in a child with juvenile idiopathic arthritis.

Clin Imaging 2018 May - Jun;49:193-197. Epub 2018 Mar 26.

Department of Radiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States. Electronic address:

Bilateral agenesis of the cruciate ligaments is a rare congenital anomaly. We report a unique case of a young girl who had congenital short femur and diagnosed with polyarticular juvenile idiopathic arthritis (JIA) and later discovered to have congenital absence of both anterior and posterior cruciate ligaments and meniscal dysplasia in both the knees when MRI was performed at 11 years of age. The MRI was performed to evaluate knee laxity and persistent symptoms despite medical management and multiple steroid injections for arthritis treatment. This patient is one of the youngest with congenital absence of both the cruciate ligaments to be treated with ACL reconstruction. We highlight the unique radiographic imaging manifestations of congenital cruciate ligament agenesis and emphasize the role of MRI to confirm and depict additional intraarticular abnormalities.
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http://dx.doi.org/10.1016/j.clinimag.2018.03.015DOI Listing
September 2018

Identification of high-risk plaque features in intracranial atherosclerosis: initial experience using a radiomic approach.

Eur Radiol 2018 Sep 9;28(9):3912-3921. Epub 2018 Apr 9.

Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China.

Objectives: To evaluate a quantitative radiomic approach based on high-resolution magnetic resonance imaging (HR-MRI) to differentiate acute/sub-acute symptomatic basilar artery plaque from asymptomatic plaque.

Methods: Ninety-six patients with basilar artery stenosis underwent HR-MRI between January 2014 and December 2016. Patients were scanned with T1- and T2-weighted imaging, as well as T1 imaging following gadolinium-contrast injection (CE-T1). The stenosis value, plaque area/burden, lumen area, minimal luminal area (MLA), intraplaque haemorrhage (IPH), contrast enhancement ratio and 94 quantitative radiomic features were extracted and compared between acute/sub-acute and asymptomatic patients. Multi-variate logistic analysis and a random forest model were used to evaluate the diagnostic performance.

Results: IPH, MLA and enhancement ratio were independently associated with acute/subacute symptoms. Radiomic features in T1 and CE-T1 images were associated with acute/subacute symptoms, but the features from T2 images were not. The combined IPH, MLA and enhancement ratio had an area under the curve (AUC) of 0.833 for identifying acute/sub-acute symptomatic plaques, and the combined T1 and CE-T1 radiomic approach had a significantly higher AUC of 0.936 (p = 0.01). Combining all features achieved an AUC of 0.974 and accuracy of 90.5%.

Conclusions: Radiomic analysis of plaque texture on HR-MRI accurately distinguished between acutely symptomatic and asymptomatic basilar plaques.

Key Points: • High-resolution magnetic resonance imaging can assess basilar artery atherosclerotic plaque. • Radiomic features in T1 and CE-T1 images are associated with acute symptoms. • Radiomic analysis can accurately distinguish between acute symptomatic and asymptomatic plaque. • The highest accuracy may be achieved by combining radiomic and conventional features.
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http://dx.doi.org/10.1007/s00330-018-5395-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6081255PMC
September 2018

From imaging to reimbursement: what the pediatric radiologist needs to know about health care payers, documentation, coding and billing.

Pediatr Radiol 2018 07 19;48(7):904-914. Epub 2018 Mar 19.

Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.

Medical coding and billing processes in the United States are complex, cumbersome and poorly understood by radiologists. Despite the direct implications of radiology documentation on reimbursement, trainees and practicing radiologists typically receive limited relevant training. This article summarizes the payer structure including the state-based Children's Health Insurance Programs, discusses the essential processes by which radiologists request and receive reimbursement, details the mechanisms of coding diagnoses using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes and imaging services using Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes, and explores reimbursement and coding-related issues specific to pediatric radiology. Appropriate documentation, informed by knowledge of coding, billing and reimbursement fundamentals, facilitates appropriate payment for clinically relevant services provided by pediatric radiologists.
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http://dx.doi.org/10.1007/s00247-018-4104-1DOI Listing
July 2018

Quantitative diffusion-weighted magnetic resonance imaging assessment of chemotherapy treatment response of pediatric osteosarcoma and Ewing sarcoma malignant bone tumors.

Clin Imaging 2018 Jan - Feb;47:9-13. Epub 2017 Aug 5.

Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States; Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States. Electronic address:

Objective: Assessment of tumor response to chemotherapy is essential in managing malignant pediatric bone tumors prior to resection.

Subjects And Methods: Pre-chemotherapy and post-chemotherapy osteosarcoma and Ewing sarcoma cases (n=18) were analyzed with apparent diffusion coefficient (ADC) values measured by two readers.

Results: Treated tumors demonstrated significantly greater ADC values compared to untreated tumors (p<0.001). Intraclass correlation coefficients ranged between 0.858 and 0.935. No significant tumor volume differences were observed. Regression analysis demonstrated average ADC as the best predictor of treatment.

Conclusions: Our study suggests that ADC values may be useful for evaluating chemotherapeutic response of malignant pediatric bone tumors.
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http://dx.doi.org/10.1016/j.clinimag.2017.08.003DOI Listing
May 2018

Medicare Utilization of Vertebral Augmentation 2001 to 2014: Effects of Randomized Clinical Trials and Guidelines on Vertebroplasty and Kyphoplasty.

J Am Coll Radiol 2017 Aug;14(8):1001-1006

Harvey L. Neiman Health Policy Institute, Reston, Virginia; Department of Health Administration and Policy, George Mason University, Fairfax, Virginia.

Purpose: Vertebral fractures have a substantial impact on the health and quality of life of elderly individuals as one of the most common complications of osteoporosis. Vertebral augmentation procedures including vertebroplasty and kyphoplasty have been supported as means of reducing pain and mitigating disability associated with these fractures. However, use of vertebroplasty is debated, with negative randomized controlled trials published in 2009 and divergent clinical guidelines. The effect of changing evidence and guidelines on different practitioners' utilization of both kyphoplasty and vertebroplasty in the years after these developments and publication of data supporting their use is poorly understood.

Methods: Using national aggregate Medicare claims data from 2002 through 2014, vertebroplasty and kyphoplasty procedures were identified by provider type. Changes in utilization by procedure type and provider were studied.

Results: Total vertebroplasty billing increased 101.6% from 2001 (18,911) through 2008 (38,123). Total kyphoplasty billing frequency increased 17.2% from 2006 (54,329) through 2008 (63,684). Vertebroplasty billing decreased 60.9% from 2008 through 2014 to its lowest value (14,898). Kyphoplasty billing decreased 8.4% from 2008 (63,684) through 2010 (58,346), but then increased 7.6% from 2010 to 2013 (62,804).

Conclusions: Vertebroplasty billing decreased substantially beginning in 2009 and continued to decrease through 2014 despite publication of more favorable studies in 2010 to 2012, suggesting studies published in 2009 and AAOS guidelines in 2010 may have had a persistent negative effect. Kyphoplasty did not decrease as substantially and increased in more recent years, suggesting a clinical practice response to favorable studies published during this period.
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http://dx.doi.org/10.1016/j.jacr.2017.04.026DOI Listing
August 2017

Documentation, coding, and billing: what abdominal radiologists need to know.

Abdom Radiol (NY) 2018 03;43(3):734-741

Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, 30322, USA.

This article reviews basic concepts of report documentation for abdominal imaging examinations, focusing on practical elements for ensuring appropriate physician reimbursement. Nuances of abdominal radiography, CT, MRI, and ultrasonography codes are highlighted. Special considerations for the coding of 3D-rendering and contrast administration are also described. Greater abdominal radiologist awareness of these codes and their reporting requirements can help ensure proper documentation within radiology reports, thereby optimizing legitimate reimbursement.
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http://dx.doi.org/10.1007/s00261-017-1235-zDOI Listing
March 2018

Metastatic extrapleural malignant solitary fibrous tumor presenting with hypoglycemia (Doege-Potter syndrome).

Radiol Case Rep 2017 Mar 23;12(1):113-119. Epub 2016 Nov 23.

Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite, Pittsburgh, PA 15213, USA.

We report a rare case of metastatic malignant solitary fibrous tumor (SFT) that presented with hypoglycemia because of insulin growth factor-2 production. Initial workup included computed tomography imaging that revealed a large, partially necrotic liver mass, a hypervascular pancreatic head lesion, and 2 renal lesions. Following hepatic resection, pancreatic head resection and nephrectomy, all these lesions demonstrated pathological findings that were consistent with SFT. The patient also had a history of an intracranial mass that had been previously resected and treated with gamma knife therapy at an outside institution, which was found to also be SFT. Six months after initial pancreatic head resection, the patient developed a new lesion involving the pancreatic tail that was found to represent recurrent metastatic SFT. This case emphasizes the highly aggressive nature of extrapleural SFT, while rare, and the role of imaging in follow-up for disease recurrence.
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http://dx.doi.org/10.1016/j.radcr.2016.10.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5310265PMC
March 2017