Publications by authors named "Kimberly Lind"

37 Publications

The effect of direct cognitive assessment in the Medicare annual wellness visit on dementia diagnosis rates.

Health Serv Res 2021 Apr 22;56(2):193-203. Epub 2021 Jan 22.

Colorado School of Public Health, University of Colorado, Aurora, Colorado, USA.

Objective: To evaluate the relationship between direct cognitive assessment introduced with the Medicare Annual Wellness Visit (AWV) and new diagnoses of dementia, and to determine if effects vary by race.

Data Sources: Medicare Limited Data Set 5% sample claims 2003-2014 and the HRSA Area Health Resources Files.

Study Design: Instrumental Variable approach estimating the relationship between AWV utilization and new diagnoses of dementia using county-level Welcome to Medicare Visit rates as an instrument.

Data Collection/extraction Methods: Three hundred twenty-four thousand three hundred and eighty-five fee-for-service Medicare beneficiaries without dementia when the AWV was introduced in 2011.

Principal Findings: Annual Wellness Visit utilization was associated with an increased probability of new dementia diagnosis with effects varying by racial group (categorized as white, black, Hispanic/Latino, or Asian based on Social Security Administration data). Hazard ratios (95% confidence intervals) for new dementia diagnosis within 6 months of AWV utilization were as follows: 2.34 (2.13, 2.58) white, 2.22 (1.71, 2.89) black, 4.82 (2.94, 7.89) Asian, and 6.14 (3.70, 10.19) Hispanic (P < .001 for each). Our findings show that estimates that do not control for selection underestimate the effect of AWV on new diagnoses.

Conclusions: Dementia diagnosis rates increased with AWV implementation with heterogenous effects by race and ethnicity. Current recommendations by the United States Preventive Services Task Force state that the evidence is insufficient to recommend for or against screening for cognitive impairment in older adults.
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http://dx.doi.org/10.1111/1475-6773.13627DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968942PMC
April 2021

Measuring the prevalence of 60 health conditions in older Australians in residential aged care with electronic health records: a retrospective dynamic cohort study.

Popul Health Metr 2020 10 8;18(1):25. Epub 2020 Oct 8.

Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia.

Background: The number of older Australians using aged care services is increasing, yet there is an absence of reliable data on their health. Multimorbidity in this population has not been well described. A clear picture of the health status of people using aged care is essential for informing health practice and policy to support evidence-based, equitable, high-quality care. Our objective was to describe the health status of older Australians living in residential aged care facilities (RACFs) and develop a model for monitoring health conditions using data from electronic health record systems.

Methods: Using a dynamic retrospective cohort of 9436 RACF residents living in 68 RACFs in New South Wales and the Australian Capital Territory from 2014 to 2017, we developed an algorithm to identify residents' conditions using aged care funding assessments, medications administered, and clinical notes from their facility electronic health record (EHR). We generated age- and sex-specific prevalence estimates for 60 health conditions. Agreement between conditions recorded in aged care funding assessments and those documented in residents' EHRs was evaluated using Cohen's kappa. Cluster analysis was used to describe combinations of health conditions (multimorbidity) occurring among residents.

Results: Using all data sources, 93% of residents had some form of circulatory disease, with hypertension the most common (62%). Most residents (93%) had a mental or behavioural disorder, including dementia (58%) or depression (54%). For most conditions, EHR data identified approximately twice the number of people with the condition compared to aged care funding assessments. Agreement between data sources was highest for multiple sclerosis, Huntington's disease, and dementia. The cluster analysis identified seven groups with distinct combinations of health conditions and demographic characteristics and found that the most complex cluster represented a group of residents that had on average the longest lengths of stay in residential care.

Conclusions: The prevalence of many health conditions among RACF residents in Australia is underestimated in previous reports. Aged care EHR data have the potential to be used to better understand the complex health needs of this vulnerable population and can help fill the information gaps needed for population health surveillance and quality monitoring.
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http://dx.doi.org/10.1186/s12963-020-00234-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7545887PMC
October 2020

HealthPathways: a detailed analysis of utilisation trends in the northern Sydney region.

Aust J Prim Health 2020 Aug;26(4):338-343

Northern Sydney Local Health District, Douglas Building, Level 5 Reserve Road, St Leonards, NSW 2065, Australia.

This study developed a model for using Google Analytics (GA) data to evaluate utilisation trends of the Sydney North HealthPathways portal. HealthPathways GA data merged with dates of page localisations and promotional events from March 2017 through June 2018 were analysed to evaluate engagement and use of HealthPathways, integration into clinical practice and how HealthPathways is used. Descriptive statistics and plots were generated for each clinical stream and page for the number of users per month (total, new and return users), mean time on page, navigation and search terms. The number of page views, new users and return users increased during the study period. Each clinical stream had between 26 and 2508 views, with a median of 199 views (interquartile range 84-461 views). Individual pages had 0-12388 total views. Return users visited seven times on average. Most usage occurred between mid-morning and mid-afternoon. Diabetes was the most frequently viewed and searched clinical stream, followed by palliative care. These streams had the greatest number of promotional events. Increasing use of and interaction with HealthPathways suggests that it is a useful tool to support clinical practice among northern Sydney primary care providers.
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http://dx.doi.org/10.1071/PY20010DOI Listing
August 2020

Radiculopathy Following Vertebral Body Compression Fracture: The Role of Percutaneous Cement Augmentation.

Pain Physician 2020 06;23(3):315-324

University of Colorado, Aurora, Colorado.

Background: Vertebral cement augmentation is a commonly used procedure in patients with vertebral body compression fractures from primary or secondary osteoporosis, metastatic disease, or trauma. Many of these patients present with radiculopathy as a presenting symptom, and can experience symptomatic relief following the procedure.

Objectives: To determine the incidence of preprocedural radiculopathy in patients with vertebral body compression fractures presenting for cement augmentation, and present their postoperative outcomes.

Study Design: Retrospective cohort study.

Setting: Interventional pain practice in a tertiary care university hospital.

Methods: In this cohort study, all patients who underwent kyphoplasty (KP) or vertebroplasty (VP) procedures in a 7-year period within our practice were evaluated through a search of the electronic medical records. The primary endpoint was to evaluate the prevalence of noncompressive preprocedural radiculopathy in our patients. Evaluation of each patient's relative improvement following the procedure, respective to the initial presence or absence of radicular symptoms (including and above T10, above and below T10, and below T10) was included as a secondary endpoint. Additional subanalysis was performed with respect to patients demographics, fracture location, and primary indication for the procedure (osteoporosis, trauma, etc.).

Results: A total of 302 procedures were performed during this time period, encompassing 544 total vertebral body levels. After exclusion criteria were applied to this cohort, 31.6% of patients demonstrated radiculopathy prior to the procedure that could not be explained by nerve impingement. Nearly half of patients demonstrated an optimal clinical outcome (48.5% nearly complete/complete resolution of symptoms, 40.1% partial resolution of symptoms, 11.4% little to no resolution of symptoms). Patients with fractures above T10 were more likely to see complete resolution, whereas patients with fractures above and below T10 were likely to not see any resolution. Men and women without initial radiculopathy symptoms were more likely to see little to no resolution, regardless of fracture location.

Limitations: This retrospective study used an electronic chart review of clinicians' notes to determine the presence of radiculopathy and their relative improvement following the procedure.

Conclusions: Preprocedural radiculopathy is a common symptom of patients presenting for the evaluation of VP or KP. The presence of radiculopathy in the absence of nerve impingement may be an important marker for those patients who may experience greater benefit from the procedure.

Key Words: Radiculopathy, kyphoplasty, vertebroplasty, osteoporosis, compression fracture, spine, cement augmentation.
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June 2020

Highlighting the Need for Action Regarding Persistent Sex Bias in Research.

Authors:
Kimberly E Lind

JAMA Intern Med 2020 01;180(1):164-165

Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia.

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http://dx.doi.org/10.1001/jamainternmed.2019.5673DOI Listing
January 2020

Persistent Disparities in Medicare's Annual Wellness Visit Utilization.

Med Care 2019 12;57(12):984-989

Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO.

Introduction: The Medicare Annual Wellness Visit (AWV) is a preventive care visit introduced in 2011 as part of the Affordable Care Act provided without cost to beneficiaries. The AWV is associated with higher preventive services utilization. Although AWV utilization increased during 2011-2013, utilization was lower among ethnoracial minority beneficiaries who may benefit the most.

Objectives: To determine if AWV utilization disparities have persisted using the most recent data available.

Research Design: The authors analyzed AWV utilization in 2011-2013 and 2015-2016 by beneficiary-reported race and ethnicity, adjusting for potential confounders.

Subjects: Weighted sample of 78,639,501 fee-for-service Medicare beneficiaries aged 66 years and older who participated in the Medicare Current Beneficiary Survey 2011-2013 or 2015-2016.

Measures: AWV utilization was identified using Medicare claims.

Results: AWV utilization increased from 8.1% to 23.0% of all beneficiaries between 2011 and 2016. Compared with non-Hispanic white beneficiaries, utilization was significantly lower among non-Hispanic Black and non-Hispanic other race beneficiaries in both the minimally and fully-adjusted models. Hispanic/Latino beneficiaries had lower utilization in the minimally adjusted model, but not in the fully-adjusted model. In 2016, compared with non-Hispanic white beneficiaries, AWV utilization was 10.2 points lower for non-Hispanic black, 11.6 points lower for Hispanic/Latino, and 8.6 points lower for non-Hispanic other race beneficiaries, and these differences were attenuated after adjusting for all covariates to 6.8 points lower, 9.4 points lower, and 7.2 points lower, respectively.

Conclusions: The AWV has the potential to increase the use of preventive care, improve health, and reduce ethnoracial disparities among Medicare beneficiaries, but realizing these goals will require increasing utilization by minority groups. If ethnoracial minority beneficiaries had used the AWV at the same rate as non-Hispanic white beneficiaries during the study period, then ~1.6 million additional AWVs would have been used.
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http://dx.doi.org/10.1097/MLR.0000000000001229DOI Listing
December 2019

A profile of health status and demographics of aged care facility residents with gout.

Australas J Ageing 2020 Mar 21;39(1):e153-e161. Epub 2019 Aug 21.

Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia.

Objective: To estimate gout prevalence and examine associated factors in residential aged care facilities.

Methods: Electronic data from 11 548 residents aged 65+ during 2014-2017 from 68 residential aged care facilities in Australia were analysed. Gout prevalence was estimated, and regression was used to assess differences in comorbidities, sociodemographic factors and health status between residents with and without gout.

Results: Over 10% of residents had gout. Most common comorbidities in these residents were hypertension (71.3%), heart disease (37.9%) and diabetes (33.0%) and they were more likely to have renal disease and historical myocardial infarction. The interaction between comorbid gout had complex interactions between age, sex and comorbidities for diabetes and depression was complex.

Conclusions: Gout is common among older people in residential care but may be under-recognised. Holistic management of gout is needed in this population, with careful consideration of chronic comorbidities and treatments.
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http://dx.doi.org/10.1111/ajag.12716DOI Listing
March 2020

NSAID use among residents in 68 residential aged care facilities 2014 to 2017: An analysis of duration, concomitant medication use, and high-risk conditions.

Pharmacoepidemiol Drug Saf 2019 11 6;28(11):1480-1488. Epub 2019 Aug 6.

Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia.

Purpose: People in residential aged care are at increased risk of adverse events from nonsteroidal anti-inflammatory drugs (NSAIDs) due to their age and health status, but little is known about use of NSAIDs in this setting. We aimed to estimate the prevalence of NSAID use by route, differences by high-risk conditions, prevalence of concurrent proton pump inhibitor (PPI) use, and prevalence of the "triple whammy" combination (oral NSAID, diuretic, and angiotensin-converting-enzyme inhibitor or angiotensin receptor antagonist).

Methods: We conducted a dynamic cohort study using medication administration data from 68 residential aged care facilities (RACFs) during 2014 to 2017. Descriptive statistics and regression were used to estimate the proportion of residents who used NSAIDs, NSAIDs long term, NSAIDs with PPIs, and the triple whammy combination.

Results: Ten thousand three hundred sixty-seven residents were included. Two thousand four hundred fourteen (23.3%) used at least one NSAID: 756 (7.3%) used only oral, 1326 (12.8%) used only topical, and 332 (3.2%) used both topical and oral NSAIDs. One thousand five hundred forty two (14.8%) used an NSAID long term, a majority of which only used topical NSAIDs 933/1542 (60.5%). Age, sex, and health status were associated with greater variation in long-term topical use relative to oral NSAID use. A majority of oral NSAID users concomitantly used a PPI, which varied according to age, sex, and health status. Among residents with any oral NSAID use, 182/1088 (16.7%) had triple whammy medication use.

Conclusions: Targeted interventions to reduce NSAID use among RACF residents, to reduce triple whammy medication use, and increase PPI use for long-term oral NSAID users are warranted.
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http://dx.doi.org/10.1002/pds.4866DOI Listing
November 2019

Clearing the air: why a link between Alzheimer's disease and air quality cannot be validly determined using prescription data in Australia.

Health Place 2020 03 24;62:102169. Epub 2019 Jul 24.

Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Australia.

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http://dx.doi.org/10.1016/j.healthplace.2019.102169DOI Listing
March 2020

Duration of Antipsychotic Medication Use by Aged Care Facility Residents With Dementia.

Alzheimer Dis Assoc Disord 2019 Oct-Dec;33(4):331-338

Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia.

Introduction: Guidelines recommend short-term targeted use of antipsychotic medications for behavioral and psychological symptoms of dementia only when other strategies have failed. Antipsychotic prescribing in dementia is common internationally, but data on duration of use are limited. Our objectives were to determine duration, time to initiation, and prevalence of antipsychotic use among people with dementia.

Methods: This work was a retrospective dynamic cohort study of people aged 65 years or above with dementia in 68 residential aged facilities during the period spanning from 2014 to 2017. Medication administration records were used to identify antipsychotic medication use. Medication outcomes (prevalence, duration, and time to initiation) were estimated using regression. Covariates included comorbidities and sociodemographic and facility characteristics.

Results: A total of 5825 residents with dementia were identified. The annual prevalence of antipsychotic use ranged from 27.6% to 32.6%. Mean time to initiation after admission was 308.4 days (for female individuals) and 173.2 days (for male individuals). An overall 65% of people who used antipsychotics did so for >3 months even without psychiatric comorbidities; mean durations were 212.74 (95% confidence interval: 170.24, 255.25) days (for female individuals) and 216.10 (95% confidence interval: 165.31, 266.89) days (for male individuals) at median ages.

Discussion: Antipsychotics are often used longer than recommended. Current guidelines and restrictions may be insufficient to limit antipsychotic medication use. Further efforts are needed to ensure that antipsychotic medications are used as recommended in dementia.
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http://dx.doi.org/10.1097/WAD.0000000000000336DOI Listing
July 2020

Anti-osteoporosis Medication Use in a High Fracture-Risk Population: Contemporary Trends in Australian Residential Aged Care Facilities.

Health Serv Insights 2019 2;12:1178632919852111. Epub 2019 Jun 2.

Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia.

Osteoporotic fractures impose substantial morbidity and mortality among older adults. Undertreatment is an ongoing concern; treatment rates declined following reports of adverse effects of guideline-recommended bisphosphonates, but new antiresorptives have since become available. Our goal was to identify contemporary trends in osteoporosis treatment guideline adherence in a high fracture-risk population. We conducted a secondary data analysis using electronic health record data of adults aged ⩾65 years from 68 residential aged care facilities in Australia during 2014-2017 (n = 9094). Using medication administration data, we identified antiresorptive (bisphosphonates and denosumab) and vitamin D supplement use among residents with osteoporosis. Regression was used to evaluate temporal trends, and resident and facility characteristics associated with antiresorptive use and vitamin D use. In 2014, 34% of women and 42% of men with osteoporosis used antiresorptives; this decreased 8 percentage points by 2017. Antiresorptive use was higher among those with a history of fracture and lower in the last year of life. Denosumab use increased but did not substitute for the continued decline in bisphosphonate use. Vitamin D was consistently used by more than 60% of residents and was higher among those with fracture history. Greater attention to the treatment of osteoporosis treatment rates among this high fracture-risk population is warranted.
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http://dx.doi.org/10.1177/1178632919852111DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6547170PMC
June 2019

Sociodemographic Variation in the Use of Conservative Therapy Before MRI of the Lumbar Spine for Low Back Pain in the Era of Public Reporting.

J Am Coll Radiol 2019 Apr;16(4 Pt B):560-569

Mayo Clinic Arizona, Department of Radiology, Phoenix, Arizona.

Purpose: To evaluate the relationship between use of MRI of the lumbar spine for low back pain without prior conservative therapy and sociodemographic factors after the implementation of public reporting for Medicare's Hospital Outpatient Imaging Efficiency Measure for MRI Lumbar Spine for Low Back Pain (OP-8) metric.

Materials And Methods: We conducted a secondary data analysis using a nationally representative sample of 2009 to 2014 Medicare claims to evaluate trends in use of conservative therapy before MRI of the lumbar spine. Continuously enrolled fee-for-service Medicare beneficiaries were included. We applied the same criteria used by Medicare to generate a measure consistent with OP-8. Regression was used to evaluate trends in OP-8 by reporting status (outpatient hospital or clinic) and beneficiary characteristics. Age, sex, and race from the Medicare denominator and area-level socioeconomic measures from the Area Health Resource File were used as covariates.

Results: Use of conservative therapy before MRI increased regardless of OP-8 reporting status. Several sociodemographic characteristics were associated with the likelihood of receiving conservative therapy before MRI; beneficiaries were less likely to receive conservative therapy before MRI if they were male, older, black, Hispanic or Latino; if they lived in the West or in an area with more college graduates; or if they had low incomes. Beneficiaries were more likely to receive conservative therapy before MRI if they had poorer health or lived in areas with higher home values.

Conclusion: Variations in use of conservative therapy according to factors other than clinically relevant factors, such as health status, are worrying. Further strategies are needed to improve appropriateness and equity in the provision of diagnostic imaging.
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http://dx.doi.org/10.1016/j.jacr.2018.12.047DOI Listing
April 2019

Antidementia medication use by aged care facility residents with dementia.

Int J Geriatr Psychiatry 2019 07 25;34(7):1029-1040. Epub 2019 Apr 25.

Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia.

Objectives: Little is known about the use of antidementia medications in Australia. Other countries have reported sociodemographic disparities in use. Our objective was to estimate prevalence, duration, and time to initiation of antidementia medication (cholinesterase inhibitors or memantine) among Australians with dementia in residential aged care facilities and to evaluate resident and facility factors associated with use.

Methods: Dynamic retrospective cohort study of people with dementia in 68 residential aged care facilities during 2014 to 2017 using electronic health record and medication administration data. Regression evaluated relationships between medication use (prevalence, duration, and time to initiation) and resident and facility characteristics.

Results: Five thousand three hundred fifty-four residents with dementia were included in the analyses. Annual prevalence of antidementia medication use was less than 10% each year and decreased during the study period by 2-percentage points by 2017 (relative to 2014). Antidementia medication use varied by sociodemographic characteristics (3-points lower for single, 4-points lower for divorced relative to married residents, and 3-points higher for Australian-born). Each point in ADL score was associated with 0.1-point lower medication use. Antidementia medication use was lower in outer regional facilities. Most comorbidities were associated with lower antidementia medication use (myocardial infarction, cerebrovascular disease and heart failure 3-points lower, respiratory disease, and diabetes 2-points lower). Age had a complex relationship with antidementia medication use that varied by sex and if medication was started before or after admission. After admission, males initiated antidementia medication earlier than females.

Conclusions: Antidementia medication use in Australian facilities was lower than in other countries and varied by clinical and sociodemographic factors.
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http://dx.doi.org/10.1002/gps.5105DOI Listing
July 2019

Patient Perceptions of CT Imaging in a Diverse Patient Sample.

J Am Coll Radiol 2019 Oct 2;16(10):1401-1408. Epub 2019 Mar 2.

University of Colorado Denver, School of Medicine, Department of Radiology, Aurora, Colorado.

Objective: To describe patient perceptions related to CT and evaluate variation related to patient sociodemographic characteristics.

Methods: Institutional review board-approved survey of adult patients undergoing outpatient CT at a large academic hospital administered May 2016 to March 2017. The survey included questions about participant demographic and socioeconomic characteristics as well as scales that addressed five perceptual constructs related to their CT examination: knowledge, benefits, barriers, expectations, and trust. Two of these constructs use the Health Belief Model as a conceptual framework, and questions were adapted from the Benefits and Barriers Scale for Screening Mammography. Descriptive statistics were calculated for all variables. Heterogeneous choice models were used to evaluate associations between participant characteristics and the perceptual constructs.

Results: In all, 302 surveys were completed by a diverse patient sample (33% non-Hispanic white, 29% Hispanic or Latino, 24% black, 8% mixed or other race, 5% Asian or Pacific Islander, 2% American Indian or Alaska Native). A large majority of participants responded positively to CT examination perceptions for each item with: high knowledge (71%-97%), positive expectations (94%-98%), high trust (92%) and benefits (67%-93%), and low barriers (only 9%-17% reported). In addition, 26% of participants reported seeking information about the CT before their appointment, with calling their physician's office the most common approach. The heterogeneous choice models found that responses to nearly all of the scale questions did not vary by sociodemographic characteristics, although in a larger sample some associations may be significant.

Conclusions: Among a diverse sample of patients, perceptions of CT examination were highly positive and similar according to sociodemographic characteristics.
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http://dx.doi.org/10.1016/j.jacr.2018.12.027DOI Listing
October 2019

Effect of Arrival of Prior Mammograms on Recall Negation for Screening Mammograms Performed With Digital Breast Tomosynthesis in a Clinical Setting.

J Am Coll Radiol 2018 Sep 29;15(9):1293-1299. Epub 2018 Jun 29.

University of Colorado Anschutz Medical Campus School of Public Health, Aurora, Colorado.

Purpose: This retrospective study evaluates the effect of comparison with prior mammograms on recall negation for screening mammography performed with digital breast tomosynthesis (DBT) in a clinical setting and compares it with that performed without DBT.

Methods: This is an Institutional Review Board-approved, HIPAA-compliant retrospective review of the electronic medical record for all nonbaseline screening mammograms performed in clinical practice over 13 months. For each mammogram, we recorded if DBT were used, the BI-RADS assigned at initial interpretation, and whether prior mammograms were available at initial interpretation. If prior mammograms arrived later for comparison, the final BI-RADS assigned after comparison was recorded. A mammogram assigned a BI-RADS 0 at initial interpretation and assigned a BI-RADS 1 or BI-RADS 2 after prior mammograms arrived for comparison was labeled as a recall that was negated by the arrival of prior mammograms. The number of recalls negated for mammograms that used DBT was compared with that for mammograms that did not use DBT.

Results: Arrival of prior mammograms for comparison negated the need for recall for mammograms performed with DBT by 67.67% and negated the need for recall for mammograms performed without DBT by 55.80%. After adjusting for age, density, and time between mammograms, the percentage of recalls negated by comparison with prior mammograms was not significantly different for mammograms performed with DBT than it was for those performed without DBT.

Conclusion: Comparison with prior mammograms remains important for the minimization of recall rates during the use of DBT for screening mammography in the clinical setting.
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http://dx.doi.org/10.1016/j.jacr.2018.05.003DOI Listing
September 2018

Assessment of PI-RADS v2 categories ≥ 3 for diagnosis of clinically significant prostate cancer.

Abdom Radiol (NY) 2019 02;44(2):705-712

Department of Radiology, University of Colorado SOM, 12401 East 17th Avenue, Mail Stop L954, Aurora, CO, 80045, USA.

Purpose: To assess the diagnostic accuracy of PI-RADS v2 categories ≥ 3 to detect clinically significant prostate cancer (csPCa) against histopathology of Transperineal Mapping Biopsy (TPMB).

Materials And Methods: IRB-approved retrospective cohort study included 47 men who had 3.0 T multi-parametric MRI (mpMRI) and TPMB of prostate. Two radiologists independently evaluated T2, DWI, ADC map, and DCE images using PI-RADS v2 categories. A third radiologist served as tie-breaker. PI-RADS v2 score (PS) ≥ 3 lesions were correlated with 3D model of TPMB (3DTPMB) results based on prostate sectors. Two groups of csPCa status were separately analyzed for accuracy measures at lesion and person levels: Group 1 with GS (Gleason Score) ≥ 7 and group 2 with tumor volume ≥ 0.5 cc. Inter-rater reliability for PS and MR lexicon was calculated.

Results: Forty-seven patients with 3DTPMB had at least one lesion with PS ≥ 3 on mpMRI. PS of 5 had high PPV and high specificity of 100% at the lesion and person levels. Sensitivity of a PS ≥ 3 was 68.27% for group 1 and was 48.39% for group 2. Specificity was 93.56% for group 1 and was 95.53% for group 2. At the person level, sensitivity of PS ≥ 3 was 81.25% for group 1 and was 82.35% for group 2. Specificity was 32.26% for group 1 and was 53.85% for group 2.

Conclusion: PI-RADS v2 category of 5 had high PPV and specificity; however, combined PS ≥ 3 had mixed performance in detection of csPCa.
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http://dx.doi.org/10.1007/s00261-018-1751-5DOI Listing
February 2019

Effect of Medicare Part D on Ethnoracial Disparities in Antidementia Medication Use.

J Am Geriatr Soc 2018 09 10;66(9):1760-1767. Epub 2018 Aug 10.

Department of Health Systems, Management and Policy, Colorado School of Public Health, Aurora, Colorado.

Objectives: To examine ethnoracial disparities in antidementia medication use, accounting for implementation of Part D, and to evaluate the role of prescription drug coverage as a cause of antidementia medication disparities.

Design: Rotating panel of Medicare beneficiaries who participated in the Medicare Current Beneficiary Survey from 2003 to 2013.

Setting: Nationally representative sample of Medicare fee-for-service (FFS) beneficiaries with dementia.

Participants: Community-dwelling FFS Medicare beneficiaries with dementia (N=4,304).

Measurements: Antidementia medication use, defined as at least one prescription fill in a given year.

Results: Unadjusted antidementia medication use was 10-percentage points lower for ethnoracial minority beneficiaries before Part D was implemented in 2006 (p=.01). This difference was attenuated after adjusting for demographic and socioeconomic factors (6-percentage points; p=.10). Part D was associated with a 6-percentage point increase in use (p<.01). The increase in use associated with Part D was higher although not statistically significantly so in ethnoracial minority beneficiaries (8-percentage points, p=.08). Analyses of each ethnoracial group found a significant effect of Part D only in Hispanic/Latino beneficiaries (18-percentage points; p<.01, adjusted).

Conclusion: Antidementia medication disparities were reduced with expanded prescription drug coverage through Medicare Part D. Increases in antidementia medication use for minority beneficiaries started after Part D was implemented, with the largest increases in use observed in Hispanic/Latino beneficiaries.
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http://dx.doi.org/10.1111/jgs.15494DOI Listing
September 2018

Ethnoracial Disparities in Medicare Annual Wellness Visit Utilization: Evidence From a Nationally Representative Database.

Med Care 2018 09;56(9):761-766

Department of Health Systems, Management, and Policy, Colorado School of Public Health, Aurora, CO.

Introduction: In 2011, Medicare began offering annual preventive care visits (annual wellness visit; AWV) to beneficiaries at no charge. Providing free preventive care supports primary and secondary prevention of chronic disease and may reduce ethnoracial disparities in health outcomes.

Objectives: To estimate AWV utilization trends by ethnoracial group in a nationally representative sample of the Medicare population.

Research Design: We estimated the probability of AWV utilization using probit regression models with beneficiary-reported ethnoracial group as the primary predictor and demographics, socioeconomic indicators, and factors related to access and utilization of health care as covariates.

Subjects: In total, 14,687 fee-for-service Medicare beneficiaries aged 66 years or older who participated in the Medicare Current Beneficiary Survey 2011-2013.

Measures: AWV utilization was identified using procedure codes.

Results: Overall AWV utilization increased from 8.1% (2011) to 13.4% (2013). In 2011, utilization was highest in non-Hispanic white (8.5%) and lowest in non-Hispanic black (4.5%) beneficiaries. Utilization increased the most in non-Hispanic black beneficiaries, to 15.4% in 2013. Significant differences in AWV utilization by non-Hispanic black and Hispanic/Latino beneficiaries were found in unadjusted models, but did not persist after controlling for income and education. Having a usual (nonemergent) place of care and a nonrural residence were strong predictors of utilization.

Conclusions: Utilization of the AWV has increased modestly since its introduction, but remains low. Utilization varies by ethnoracial group, with disparities largely explained by differences in income and education. Further efforts are needed to evaluate AWV utilization and effectiveness, especially among low socioeconomic status ethnoracial minorities.
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http://dx.doi.org/10.1097/MLR.0000000000000962DOI Listing
September 2018

Ultrasound and Dual-Energy X-Ray Absorptiometry Report Transcription Error Rates and Strategies for Reduction.

J Am Coll Radiol 2018 Dec 20;15(12):1784-1790. Epub 2018 Mar 20.

Department of Radiology, University of Colorado School of Medicine, Aurora, Colorado.

Purpose: Radiologists play an essential role in patient care by providing accurate and timely results. An error-free radiology report is an expectation of both patients and referring physicians. Software is currently available that can eliminate measurement and side types of errors while saving radiologists and sonographers time. The objectives of this study were to evaluate the potential reduction in report errors, estimate the potential time savings associated with implementation, and conduct a cost-benefit analysis of implementing two software programs.

Methods: Data on the number of measurement errors and side errors in ultrasound and dual-energy x-ray absorptiometry reports were collected, and the time required for data entry that the software would reduce was measured by report type. Generalized estimating equations regression was used to estimate error rates and data entry times and corresponding 95% confidence intervals by report type for radiologists and sonographers. Current wages and report volumes were then applied to the time savings to estimate the annual wage savings. Projected volume increases were applied to the annual estimates to generate a 5-year savings estimate.

Results: Overall, measurement errors occurred in 6% to 28% of ultrasound reports, depending on the report type. Side errors were rare. It was estimated that over 5 years, the software could save $693,777 in radiologist wages and $130,771 in sonographer wages, a total of $824,548 (range, $621,866-$1,039,714).

Conclusions: The use of data integration software would both significantly reduce errors in ultrasound and dual-energy x-ray absorptiometry reports and save a considerable amount of time and money.
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http://dx.doi.org/10.1016/j.jacr.2018.01.020DOI Listing
December 2018

Validity of Measures Assessing Oral Health Beliefs of American Indian Parents.

J Racial Ethn Health Disparities 2018 12 5;5(6):1254-1263. Epub 2018 Mar 5.

Colorado School of Public Health, University of Colorado Anschutz Medical Campus, 13199 E. Montview Blvd, Suite 300, W359-G, Aurora, CO, 80045, USA.

Objectives: This aimed to validate measures of constructs included in an extended Health Belief Model (EHBM) addressing oral health beliefs among American Indian (AI) parents.

Methods: Questionnaire data were collected as part of a randomized controlled trial (n = 1016) aimed at reducing childhood caries. Participants were AI parents with a preschool-age child enrolled in the Navajo Nation Head Start program. Questionnaire items addressed five EHBM constructs: perceived susceptibility, severity, barriers, benefits, and parental self-efficacy. Subscales representing each construct underwent reliability and validity testing. Internal consistency reliability of each subscale was evaluated using Cronbach's alpha. Convergent validity was assessed using linear regression to evaluate the association of each EHBM subscale with oral health-related measures.

Results: Internal consistency reliability was high for self-efficacy (α = 0.83) and perceived benefits (α = 0.83) compared to remaining EHBM subscales (α < 0.50). Parents with more education (p < 0.0001) and income (p = 0.0002) perceived dental caries as more severe younger parents (ps = 0.02) and those with more education (ps < 0.0001) perceived greater benefits and fewer barriers to following recommended oral health behavior. Female parents (p < 0.0001) and those with more education (p = 0.02) had higher levels of self-efficacy. Parental knowledge was associated with all EHBM measures (ps < 0.0001) excluding perceived susceptibility (p > 0.05). Parents with increased self-efficacy had greater behavioral adherence (p < 0.0001), whereas lower behavioral adherence was associated with parents who reported higher perceived barriers (p < 0.0001). Better pediatric oral health outcomes were associated with higher levels of self-efficacy (p < 0.0001) and lower levels of perceived severity (p = 0.02) and barriers (p = 0.05).

Conclusions: Results support the value of questionnaire items addressing the EHBM subscales, which functioned in a manner consistent with the EHBM theoretical framework in AI participants.
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http://dx.doi.org/10.1007/s40615-018-0472-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6123310PMC
December 2018

Race and Sex Disparities in Outcomes of Dialysis Access Maintenance Interventions.

J Vasc Interv Radiol 2018 04 17;29(4):476-481.e1. Epub 2018 Jan 17.

Department of Radiology, University of Colorado Hospital, Aurora, Colorado.

Purpose: To determine whether utilization and outcomes of dialysis access maintenance interventions vary by patient race or sex.

Materials And Methods: Data for this retrospective cohort study of first-time arteriovenous (AV) access recipients were drawn from a 5% sample of Medicare beneficiaries, containing claims from all clinical settings (2009-2014) in 2,693 patients who received their first AV fistula/graft in 2009. Maintenance interventions-angiography, angioplasty, thrombolysis, stent placement, and venous embolization-were identified by corresponding Current Procedural Terminology codes. Outcomes of primary patency (PP), postinterventional primary patency (PIPP), and postinterventional secondary patency (PISP) were calculated with utilization records. Associations between demographic data and patency times were evaluated by a multivariate survival approach, controlling for baseline differences in patient age, comorbid disease, type of dialysis access, and interventionist specialty.

Results: AV grafts (AVGs) were created with greater frequency in women (32% vs 23% in men; P < .001) and minority patients (39% in black, 32% in Hispanic, and 29% in Asian patients vs 21% in white patients; P < .001). Women were at greater hazards for loss of PP (hazard ratio [HR], 1.49; 95% confidence interval [CI], 1.09-2.14) and PIPP (HR, 1.42; 95% CI, 1.01-2.00). Black patients were at greater hazards for loss of PP (HR, 1.37; 95% CI, 1.23-1.54) and PISP (HR, 1.29; 95% CI, 1.01-1.65). AVG creation predisposed patients to patency loss in all models (P < .001).

Conclusions: Dialysis access patency rates are lower for women and black patients. More frequent primary AVG creation in women and minority patients additionally predisposes these patients to patency loss.
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http://dx.doi.org/10.1016/j.jvir.2017.10.018DOI Listing
April 2018

Physician Knowledge of Radiation Exposure and Risk in Medical Imaging.

J Am Coll Radiol 2018 01 1;15(1 Pt A):34-43. Epub 2017 Nov 1.

University of Colorado Anschutz Medical Campus, Aurora, Colorado.

Purpose: Medical imaging is an increasingly important source of radiation exposure for the general population, and there are risks associated with such exposure; however, recent studies have demonstrated poor understanding of medical radiation among various groups of health care providers. This study had two aims: (1) analyze physicians' knowledge of radiation exposure and risk in diagnostic imaging across multiple specialties and levels of training, and (2) assess the effectiveness of a brief educational presentation on improving physicians' knowledge.

Methods: From 2014 to 2016, 232 health care providers from multiple departments participated in an educational presentation and pre- and postpresentation tests evaluating knowledge of radiation exposure and risk at a large academic institution.

Results: Knowledge of radiation exposure and risk was relatively low on the prepresentation test, including particularly poor understanding of different imaging modalities, with 26% of participants unable to correctly identify which modalities expose patients to ionizing radiation. Test scores significantly increased after the educational presentation. Radiologists had higher prepresentation test scores than other specialties, and therefore less opportunity for improvement, but also demonstrated improvement in radiation safety knowledge after education. Aside from radiology, there was no significant difference in initial knowledge of radiation exposure and risk among the other specialties.

Conclusions: Providers' knowledge of radiation exposure and risk was low at baseline but significantly increased after a brief educational presentation. Efforts to educate ordering providers about radiation exposure and risk are needed to ensure that providers are appropriately weighing the risks and benefits of medical imaging and to ensure high-quality, patient-centered care.
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http://dx.doi.org/10.1016/j.jacr.2017.08.034DOI Listing
January 2018

Public Reporting of MRI of the Lumbar Spine for Low Back Pain and Changes in Clinical Documentation.

J Am Coll Radiol 2017 Dec 31;14(12):1545-1551. Epub 2017 Aug 31.

Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Health Systems, Management, and Policy, Colorado School of Public Health, Aurora, Colorado.

Objective: OP-8 is the Medicare imaging efficiency metric for MRI of the lumbar spine for low back pain in the outpatient hospital. We studied trends in exclusion criteria coding over time by site of service after implementation of OP-8 to evaluate provider's response to public reporting.

Materials And Methods: We conducted a secondary data analysis using the Medicare Limited Data Set 5% sample for beneficiaries with MRI lumbar spine and lower back pain during 2009 to 2014. We evaluated the association between excluding condition prevalence and site by using generalized estimating equations regression. We produced model-based estimates of excluding condition prevalence by site and year. As a sensitivity analysis, we repeated the analysis while including additional conditions in the outcome measure.

Results: We included 285,911 MRIs of the lumbar spine for low back pain. Generalized estimating equations regression found that outpatient hospitals had a higher proportion of MRIs with at least one excluding condition documented compared with outpatient clinics (P < .05), but increases in excluding condition prevalence were similar across all sites during 2009 to 2014. Our results were not sensitive to the inclusion of additional conditions.

Conclusion: Documentation of excluding conditions and other clinically reasonable exclusions for OP-8 increased over time for outpatient hospitals and clinics. Increases in documentation of comorbidities may not translate to actual improvement in imaging appropriateness for low back pain. When accounting for all relevant conditions, the proportion of patients with low back pain considered uncomplicated and being measured by OP-8 would be small, reflecting a small proportion of patients with low back pain.
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http://dx.doi.org/10.1016/j.jacr.2017.07.012DOI Listing
December 2017

3D Morphometric Analysis of Normal Sacroiliac Joints: A New Classification of Surface Shape Variation and the Potential Implications in Pain Syndromes.

Pain Physician 2017 07;20(5):E701-E709

Department of Orthopedics, University of Colorado, Aurora, CO.

Background: Normal sacroiliac (SI) joints vary widely in shape, and it is unclear whether SI joint morphology plays a role in the development of pain. To answer this question, we used 3D-CT surface rendering to image healthy study participants and used the resulting images to develop a classification system for SI joint morphology. In a case-control study comparing health research participants to patients with SI pain, we assessed whether the classification of SI joint morphology was associated with pain.

Objectives: We aimed to define normal variation in area and shape of the synovialized SI joint. We also aimed to determine interactions between joint area and shape and SI pain in men and women.

Study Design: A retrospective cohort study.

Setting: University hospital tertiary care center.

Methods: We conducted a retrospective case-control study. We acquired 3D-CT surface rendered images of the SI joint in 223 normal controls and 34 patients with SI pain syndrome. We measured the sacral and iliac surface areas and performed morphologic 3D assessment of both articular surfaces. We classified SI joints into 3 types based on morphology (types one, 2, and 3). We used descriptive statistics to provide a reference standard for normal SI joints. We used multivariate models to assess whether articular surface area differed between study participants with and without SI pain. We also assessed the association between morphology type and the presence of pain.

Results: Sacral and iliac surface areas differ by participant gender. Sacral and iliac surface area was associated with SI joint pain in both men (P = 0.0007) and in women (P = 0.02). In women (P = 0.04), but not in men (P = 0.11), joint shape was associated with pain.

Limitations: A retrospective study may create potential for misclassification bias if SI joint symptoms/histories were present but not well-documented in the electronic medical record. A lack of clinical standardization in the pre-procedural assessment of SI joint pain via provocative maneuvers (FABER, etc.) is also a limitation.

Conclusions: Our study provides insight into the association between shape and joint surface area and SI joint pain. Further, prospective studies will allow us to determine the role of joint shape and surface area in the patho-etiology of SI joint pain, and thus provide information for patients and physicians about prevention or treatment.

Key Words: Sacroiliac joint, spine pain, 3D reformation, SI joint area, SI joint shape, SI joint pain syndrome.
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July 2017

Corrigendum to Sex disparities in substance abuse research: Evaluating 23 years of structural neuroimaging studies [Drug Alcohol Depend. 173 (2017) 92-98].

Drug Alcohol Depend 2017 07 6;176:181-184. Epub 2017 May 6.

Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA. Electronic address:

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http://dx.doi.org/10.1016/j.drugalcdep.2017.04.002DOI Listing
July 2017

Sex disparities in substance abuse research: Evaluating 23 years of structural neuroimaging studies.

Drug Alcohol Depend 2017 Apr 31;173:92-98. Epub 2017 Jan 31.

Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA. Electronic address:

Background: Sex differences in brain structure and clinical course of substance use disorders underscores the need to include women in structural brain imaging studies. The NIH has supported the need for research to address sex differences. We evaluated female enrollment in substance abuse structural brain imaging research and the methods used to study sex differences in substance effects.

Methods: Structural brain imaging studies published through 2016 (n=230) were evaluated for number of participants by sex and substance use status and methods used to evaluate sex differences. Temporal trends in the numbers of participants by sex and substance use status were analyzed. We evaluated how often sex effects were appropriately analyzed and the proportion of studies that found sex by substance interactions on volumetric measures.

Results: Female enrollment increased over time, but remained significantly lower than male enrollment (p=0.01), with the greatest bias for alcohol and opiate studies. 79% of studies included both sexes; however, 74% did not evaluate sex effects or used an analytic approach that precluded detection of sex by substance use interactions. 85% of studies that stratified by sex reported different substance effects on brain volumes. Only 33% of studies examining two-way interactions found significant interactions, highlighting that many studies were underpowered to detect interactions.

Conclusions: Although female participation in substance use studies of brain morphometry has increased, sex disparity persists. Studying adequate numbers of both sexes and employing correct analytic approaches is critical for understanding sex differences in brain morphometric changes in substance abuse.
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http://dx.doi.org/10.1016/j.drugalcdep.2016.12.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5581940PMC
April 2017

Medical Student Satisfaction and Performance Using an Innovative Radiology Education Laboratory.

J Am Coll Radiol 2017 03 28;14(3):404-408. Epub 2017 Jan 28.

Department of Radiology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.

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http://dx.doi.org/10.1016/j.jacr.2016.10.019DOI Listing
March 2017

Dural sinus stenting for idiopathic intracranial hypertension: factors associated with hemodynamic failure and management with extended stenting.

J Neurointerv Surg 2017 Sep 8;9(9):867-874. Epub 2016 Nov 8.

Department of Ophthalmology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.

Background: Some patients undergoing dural sinus stenting for idiopathic intracranial hypertension (IIH) develop clinical and hemodynamic failure (recurrence of the pressure gradient) owing to stent-adjacent stenosis.

Objective: To characterize factors associated with hemodynamic failure, and to describe outcomes of patients after repeat stenting.

Materials And Methods: We reviewed the initial and follow-up clinical, venographic, and hemodynamic data in 39 patients with IIH treated over 17 years with stenting. Thirty-two had follow-up angiographic and hemodynamic data at 1-99 months (mean 27.6, median 19.5 months). Eight patients were treated with 12 repeat stenting procedures, including extended stenting into the superior sagittal sinus (SSS).

Results: All patients had an initial successful hemodynamic result with the pressure gradient reduced from 10-43 to 0-7 mm Hg. 10/32 patients (31.3%), all women, developed new stenoses in the transverse sinus or posterior SSS above the stent with a recurrent pressure gradient. 7/9 patients with pure extrinsic stenosis of the transverse-sigmoid junction pre-stenting developed new stenoses and hemodynamic failure. All patients with hemodynamic failure who were restented had early and mid-term documented hemodynamic success at 1.7-50 months. They were free from papilledema at 3.8-50 months after the last restenting, and 11.5-99.5 months after initial stent placement (mean 45.3, median 38.5 months).

Conclusions: Pure extrinsic compression of the transverse-sigmoid junction and female gender were strongly associated with hemodynamic failure. Eight patients with hemodynamic failure who were restented had successful control of papilledema, including 4/4 who had extended stenting into the SSS.
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http://dx.doi.org/10.1136/neurintsurg-2016-012810DOI Listing
September 2017

Effect of Change in Portal Vein Flow Rates on Hepatic Ablations Created with a Bipolar Radiofrequency Ablation Device.

Radiology 2017 05 19;283(2):399-407. Epub 2016 Oct 19.

From the Department of Radiology, School of Medicine, University of Colorado, Mail Stop L954, 12401 E 17th Ave, PO Box 6510, Aurora, CO 80045.

Purpose To investigate the effect of change in portal vein flow rates on the size and shape of ablations created by a bipolar radiofrequency (RF) ablation device. Materials and Methods This study was exempt from institutional animal care and use committee review. An in vitro bovine liver model perfused with autologous blood via the portal vein at three flow rates (60, 80, 100 mL/min per 100 g of liver) was used. Four ablations, two bipolar and two monopolar (control probe), were made in each of five livers perfused at each flow rate. Short- and long-axis diameters were measured from gross specimens, and volume and sphericity index were calculated for each ablation. A general linear mixed model accounting for correlation within the liver was used to evaluate the effects of flow on ablations. Analyses were performed by using software. Results There was no significant difference in the size or shape of ablations created by the bipolar device at the different flow rates (P > .05 for all outcomes). The monopolar device demonstrated the expected inverse association between ablation size and change in flow (P < .01 for all outcomes). The mean ± standard deviation of short-axis diameter, long-axis diameter, volume, and sphericity index of the bipolar ablations was 4.3 cm ± 0.1, 4.2 cm ± 0.1, 41.0 cm ± 1.8, and 1.1 ± 0.1, respectively. Conclusion Unlike monopolar RF ablation, change in portal vein flow rates does not have a statistically significant effect on the size or shape of ablations created by the bipolar RF ablation device tested. RSNA, 2016.
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http://dx.doi.org/10.1148/radiol.2016152562DOI Listing
May 2017

Normal main portal vein diameter measured on CT is larger than the widely referenced upper limit of 13 mm.

Abdom Radiol (NY) 2016 10;41(10):1931-6

Department of Biostatistics, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, 13001 East 17th Place, MS C245, Aurora, CO, 80045, USA.

Objective: We determined mean main portal vein diameter in healthy patients evaluated with CT, compared this value to the "upper limit of normal" reported previously, and evaluated effects of age, sex, height, and BMI on portal vein diameter.

Materials And Methods: Our cohort of healthy patients underwent abdominal CT as potential renal donors. We excluded patients with evidence of liver or severe cardiac disease. We recorded patients' age, sex, height, weight, and BMI. Patients' main portal vein diameters were measured by fellowship-trained abdominal imagers on non-contrast and post-contrast images in axial and coronal projections at a defined location. A general linear mixed model was used for analysis.

Results: 191 patients with 679 main portal vein measurements were included in the analysis. Mean main portal vein diameter was 15.5 ± 1.9 mm; this value was significantly different from the upper limit of normal of 13 mm commonly referenced in the literature (95% CI: 2.22-2.69 mm higher, p < 0.0001). Portal vein diameter does not vary significantly when measured on axial vs. coronal images. On average, post-contrast main portal veins were 0.56 mm larger compared to non-contrast, (95% CI: 0.40-0.71 mm, p < 0.0071). Patient height and BMI are positively correlated with MPV diameter.

Conclusions: Normal mean portal vein diameter measured on CT was significantly larger (mean 15.5 mm) than the accepted upper limit of 13 mm. Contrast-enhanced main portal veins are significantly larger (0.56 mm) than unenhanced. Sex, height, and BMI significantly affect main portal vein diameter.
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http://dx.doi.org/10.1007/s00261-016-0785-9DOI Listing
October 2016
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