Management options for pediatric venous thromboembolic disease: Beyond anticoagulation with endovascular therapies.

Venous thromboembolism (VTE) in pediatric patients is an uncommon but serious diagnosis that has an array of therapeutic options and challenges. An assessment of the existing literature on management of pediatric patients with VTE was conducted. The interventions reviewed include anticoagulation, thrombolysis, thrombectomy, inferior vena cava (IVC) filters, and venous stenting. For each intervention, a discussion of mechanism of action, indications, contraindications, and potential complications was performed. While anticoagulants are considered the first-line pediatric VTE treatment, many drugs remain investigational in this patient population and treatment recommendations are extrapolated from adult practice. Thrombolysis may be indicated in cases of acute thrombosis requiring more rapid clot resolution but presents a greater bleeding risk than anticoagulation. Similarly, thrombectomy also provides rapid clot resolution and offers a larger therapeutic window and usage in more mature thrombi than thrombolysis. In select patient groups, IVC filters may be indicated in the prevention of PE but present with inherent thrombogenicity and risk of migration. The data regarding pediatric VTE treatment options, monitoring, and long term outcomes is limited compared to the adult population. The relatively few clinical trials including pediatric patients have a relatively small sample size and are heterogenous with regards to predisposing factors that further exacerbate generalizability. Additional research is needed to help construct and evaluate a robust treatment algorithm for pediatric patients with VTE.

Same-day discharge after percutaneous renal cryoablation and its effect on 30 day hospital re-admission rates and post-procedural complications.

PURPOSE: The purpose of this study is to identify if the local institutional shift from routine overnight observation to same-day discharge following percutaneous cryoablation (PCA) of renal tumors increases 30 day re-admission rates or serious adverse events (AEs). MATERIALS AND METHODS: This retrospective study included 133 adult patients. PCA patients in calendar years 2018-2019 were routinely observed overnight in the hospital, comprising the control group (Group A). PCA patients in calendar years 2021-2022 were routinely discharged the same day, comprising the test group (Group B). Relevant demographic information, tumor characteristics, technical outcomes, and clinical outcomes were recorded. RESULTS: 15 patients (11.3 %) from the total cohort were re-admitted to the hospital within 30 days of PCA for any reason. Seven patients (10.4 %) and eight patients (12.1 %) were re-admitted for any reason within 30 days in Group A and Group B, respectively, with no difference between the two groups (p = 0.76). Nine patients (6.8 %) from the total cohort were re-admitted to the hospital within 30 days for a diagnosis secondary to the procedure. Four patients (6 %) and five patients (7.6 %) were re-admitted within 30 days for reasons related to PCA in Group A and Group B, respectively, with no significant difference between the groups (p = 0.71). Eight patients (12 %) and four patients (6 %) had major AEs following PCA in Group A and Group B, respectively, with no difference between the two groups (p = 0.43). CONCLUSION: Overall, the change in post-procedural care after PCA did not have a deleterious effect on 30 day re-admission rates or rates of major AEs.

Non-operating room anesthesia workflow (NORA) implementation to improve start times in interventional radiology.

BACKGROUND: Non-OR Anesthesia (NORA) is rapidly becoming standard in many high-volume institutions and efficiency in these spaces has yet to be optimized. On-time first start percentage has been suggested to correlate with more efficient flow, and this correlation is established within the surgical space. PURPOSE: To investigate the effects of timetable targets on first case on-time first start percentage within a NORA setting. MATERIALS AND METHODS: A retrospective study of anesthesia-supported first start cases from October 2022 to April 2023 was performed to analyze the effect of timetable targets on on-time first-case starts for planned cases. Statistical analysis was calculated using Student's t-tests with statistical significance defined as p < 0.05. Additionally, analysis of variance was used to compare three or more groups, and Tukey Kramer was used to evaluate groups pairwise. RESULTS: One hundred twenty-four first start cases were included in the evaluation. After intervention with timetable targets, average patient arrival to the room time improved from 7:49 AM to 7:40 AM (p < 0.05) and procedure start time improved from 8:31 AM to 8:20 AM (p < 0.01). The percentage of procedure start times occurring prior to the goal time increased from 35 % to 58 % after the implementation (p < 0.05). With exception of Tuesdays (Anesthesia Late Start Day), on-time starts improved from 17 % to 48 % (p < 0.01) and sustained this improvement throughout the post-implementation period. CONCLUSION: Implementation of novel timetable targets yielded statistically significant improvement in first case start times. This improvement in efficiency and throughput results in increased room utilization, improved case throughput, and decreased block overrun times, all of which contribute toward increased revenues, decreased costs, and thus improved return on investment.

Characterising the distribution of mangroves along the southern coast of Vietnam using multi-spectral indices and a deep learning model.

Mangroves are an ecologically and economically valuable ecosystem that provides a range of ecological services, including habitat for a diverse range of plant and animal species, protection of coastlines from erosion and storms, carbon sequestration, and improvement of water quality. Despite their significant ecological role, in many areas, including in Vietnam, large scale losses have occurred, although restoration efforts have been underway. Understanding the scale of the loss and the efficacy of restoration requires high resolution temporal monitoring of mangrove cover on large scales. We have produced a time series of 10-m-resolution mangrove cover maps using the Multispectral Instrument on the Sentinel 2 satellites and with this tool measured the changes in mangrove distribution on the Vietnamese Southern Coast (VSC). We extracted the annual mangrove cover ranging from 2016 to 2023 using a deep learning model with a U-Net architecture based on 17 spectral indices. Additionally, a comparison of misclassification by the model with global products was conducted, indicating that the U-Net architecture demonstrated superior performance when compared to experiments including multispectral bands of Sentinel-2 and time-series of Sentinel-1 data, as shown by the highest performing spectral indices. The generated performance metrics, including overall accuracy, precision, recall, and F1-score were above 90 % for entire years. Water indices were investigated as the most important variables for mangrove extraction. Our study revealed some misclassifications by global products such as World Cover and Global Mangrove Watch and highlighted the significance of our study for local analysis. While we did observe a loss of 34,778 ha (42.2 %) of mangrove area in the region, 47,688 ha (57.8 %) of new mangrove area appeared, resulting in a net gain of 12,910 ha (15.65 %) over the eight-year period of the study. The majority of new mangrove areas were concentrated in Ca Mau peninsulas and within estuaries undergoing recovery programs and natural recovery processes. Mangrove loss occurred in regions where industrial development, wind farm projects, reclaimed land, and shrimp pond expansion is occurring. Our study provides a theoretical framework as well as up-to-date data for mapping and monitoring mangrove cover change that can be readily applied at other sites.

Flawed MIREC fluoride and intelligence quotient publications: A failed attempt to undermine community water fluoridation.

OBJECTIVE: To assess the evidence presented in a set of articles that use the Canadian Maternal-Infant Research on Environmental Chemicals (MIREC) study database to claim that community water fluoridation (CWF) is associated with harm to foetal and infant cognitive development. METHODS: Critical appraisal of measurements and processes in the MIREC database, and articles derived therefrom. MIREC's cohort is approximately 2000 pregnant women recruited in 10 centres across Canada, 2008-2011, leading to measuring 512 children aged 3-6 years in six cities. Fluoride exposure was measured by city fluoridation status, self-reports and maternal spot urine samples. Intelligence Quotient (IQ) was measured using the Wechsler Preschool and Primary Scale of Intelligence (WPPSI-III) by different assessors in each city. RESULTS: MIREC's fluoride and IQ measurements are invalid and therefore cannot support the claim that CWF is associated with IQ decline in children. CONCLUSIONS: The MIREC fluoride-IQ articles' results should be considered unacceptable for legal and policy purposes; other water fluoridation studies and systematic reviews show no effect of fluoridation on cognition.

NCCN Guidelines® Insights: Kidney Cancer, Version 2.2024.

The NCCN Guidelines for Kidney Cancer provide multidisciplinary recommendations for diagnostic workup, staging, and treatment of patients with renal cell carcinoma (RCC). These NCCN Guidelines Insights focus on the systemic therapy options for patients with advanced RCC and summarize the new clinical data evaluated by the NCCN panel for the recommended therapies in Version 2.2024 of the NCCN Guidelines for Kidney Cancer.

Safety and Technical Feasibility of Percutaneous Renal Cryoablation of Central Tumors without Pyeloperfusion.

PURPOSE: To assess the safety and technical success of percutaneous cryoablation (PCA) without pyeloperfusion in 94 patients with central renal tumors. MATERIALS AND METHODS: A retrospective review of all central renal tumors treated by PCA without pyeloperfusion was performed. Central tumors were defined as those involving the renal sinus fat on preprocedural cross-sectional imaging. Patient demographics and baseline tumor characteristics were recorded. The details of the PCA procedure, primary and secondary technical success, rates of local recurrence, adverse events (AEs), cancer-specific survival (CSS), and overall survival (OS) were compiled. RESULTS: Ninety-four patients (48 females [51%]; mean age, 68.2 years [range, 38-87 years]) with 94 central renal tumors were included. The mean maximal tumor diameter and mean RENAL nephrometry score were 37 mm (range, 15-67 mm) and 8 (range, 4-11), respectively. Primary technical success was achieved in 94% (n = 88) of procedures. Of the patients who did not achieve primary technical success, 3 underwent successful repeat PCA (secondary technical success, 97%; n = 91/94). The other 3 patients were surveilled for residual disease. Twenty-four patients (26%) required hydrodissection during PCA. Six patients (6%) experienced major AEs after PCA including hemorrhage requiring embolization (n = 3), hemorrhage requiring transfusions with admission (n = 2), and perinephric abscess necessitating drain placement (n = 1). Twenty-two patients (23%) experienced minor AEs. Nine patients (10%) experienced local recurrence during the follow-up period. OS was 94% (n = 88/94), whereas CSS was 98% (n = 92/94) during the study follow-up period (mean, 16 months [range, 1-102 months]). CONCLUSIONS: PCA of central renal tumors appears to be safe with high rates of technical success, even without the use of pyeloperfusion.

Mass-Balance-Consistent Geological Stock Accounting: A New Approach toward Sustainable Management of Mineral Resources.

Global resource extraction raises concerns about environmental pressures and the security of mineral supply. Strategies to address these concerns depend on robust information on natural resource endowments, and on suitable methods to monitor and model their changes over time. However, current mineral resources and reserves reporting and accounting workflows are poorly suited for addressing mineral depletion or answering questions about the long-term sustainable supply. Our integrative review finds that the lack of a robust theoretical concept and framework for mass-balance (MB)-consistent geological stock accounting hinders systematic industry-government data integration, resource governance, and strategy development. We evaluate the existing literature on geological stock accounting, identify shortcomings of current monitoring of mine production, and outline a conceptual framework for MB-consistent system integration based on material flow analysis (MFA). Our synthesis shows that recent developments in Earth observation, geoinformation management, and sustainability reporting act as catalysts that make MB-consistent geological stock accounting increasingly feasible. We propose first steps for its implementation and anticipate that our perspective as "resource realists" will facilitate the integration of geological and anthropogenic material systems, help secure future mineral supply, and support the global sustainability transition.

Percutaneous cryoablation of 100 anterior renal tumors: safety and technical success.

PURPOSE: To assess the safety, technical success, and clinical outcomes of percutaneous cryoablation (PCA) in patients with anterior renal tumors. METHODS: A retrospective analysis of patients with anterior renal tumors, defined as tumors at or anterior to the level of the renal pelvis, treated with CT-guided PCA from 2008 to 2022. Summary statistics included demographics and baseline tumor attributes. Treatment and follow-up metrics included primary and secondary technical success, adverse events (AEs) according to the SIR classification, local recurrence, overall survival (OS), and cancer-specific survival (CSS)). 100 patients (60 males; mean age: 63, mean BMI: 33, mean Charlson comorbidity index:6) with 100 anterior renal tumors were included. RESULTS: 78% of tumors were T1a and 22% T1b with mean maximal tumoral dimension of 29 mm (range: 6-62 mm) and mean distance to nearest critical structure 9 mm (range: 0-40 mm). Mean follow-up was 20.9 months (range: 3-103). 28% of PCAs required hydrodissection. Technical success was achieved in 92% of patients; with six remaining patients undergoing successful repeat PCA (secondary technical success: 98%). The remaining two patients without primary technical success were either surveilled or had a benign pathology on resulted concomitant biopsy. Four patients (4%) had major AEs (hemorrhage requiring prolonged admission, transfusion, or embolization (n = 3), perinephric abscess requiring drainage (n = 1)) and 27% had minor AEs. Eight patients (8%) had recurrence with a one-year OS of 94% and CSS of 100%. All recurrences underwent repeat ablation without additional recurrence and 3/8 (38%) were T1b and 5/8 (63%) were T1a tumors. CONCLUSION: PCA of anterior renal tumors can be performed safely with high rates of technical and oncologic success.

ACR Appropriateness Criteria® Pulsatile Abdominal Mass, Suspected Abdominal Aortic Aneurysm: 2023 Update.

Abdominal aortic aneurysm (AAA) is defined as abnormal dilation of the infrarenal abdominal aortic diameter to 3.0 cm or greater. The natural history of AAA consists of progressive expansion and potential rupture. Although most AAAs are clinically silent, a pulsatile abdominal mass identified on physical examination may indicate the presence of an AAA. When an AAA is suspected, an imaging study is essential to confirm the diagnosis. This document reviews the relative appropriateness of various imaging procedures for the initial evaluation of suspected AAA. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Sudden Onset of Cold, Painful Leg: 2023 Update.

Acute onset of a cold, painful leg, also known as acute limb ischemia, describes the sudden loss of perfusion to the lower extremity and carries significant risk of morbidity and mortality. Acute limb ischemia requires rapid identification and the management of suspected vascular compromise and is inherently driven by clinical considerations. The objectives of initial imaging include confirmation of diagnosis, identifying the location and extent of vascular occlusion, and preprocedural/presurgical planning. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Comments on recent community water fluoridation studies.

Water fluoridation is a public health measure to reduce levels of dental caries in populations. A report of the recently completed CATFISH study has been published. This was the first UK evaluation of fluoridation introduction for many years; it was carefully designed and executed and is welcomed. The purpose of this article is to highlight the 180-page report of the study and comment on some aspects to aid interpretation of the findings. Significant features were that two cohorts, from birth and from five years, were followed for six years in a fluoridated and a non-fluoridated area, and clinical and cost analyses were reported. Areas of the report which deserve comment are: a) interruption of fluoridation for a year for half the children in the intervention area and its effect; b) clinical results were reported as absolute reduction in caries prevalence, with the preventive fraction for caries severity downplayed; c) the power of the study was diminished by an unexpected lower caries increment; and d) control for differences in diet was not possible. Nevertheless, this major UK study showed clinical and cost benefits of water fluoridation. The risk of cessation of water fluoridation is highlighted in examples of three recently published studies.

Eye Motion Tracking for Medical Image Interpretation Training.

INTRODUCTION: The significance of Eye Motion Tracking in aiding learners in training search patterns, pattern recognition, and efficiently using their gaze in terms of time and scanning distribution has been highlighted in the USAF Pilot Training Next initiative. METHODS: The innovation described further builds on this concept in the realm of medical imaging and the provision of real-time feedback of eye direction and gaze duration. RESULTS: This real-time indicator enables the trainer to adapt verbal queueing of the trainee in a personalized manner to improve knowledge transfer, and to increase the confidence of the trainer and trainee in the competency of the trainee. The initial experiment data set included bone radiographs, digital subtraction angiograms, and computed tomography images. DISCUSSION: Preliminary results and formative feedback from participants was encouraging with expert viewers able to use Eye Motion Tracking to successfully guide novice readers through search and gaze protocol patterns of the medical images.

Short-term outcomes of uterine artery embolization for urgent or emergent abnormal uterine bleeding.

PURPOSE: To evaluate the outcomes of uterine artery embolization (UAE) for patients with urgent or emergent abnormal uterine bleeding (AUB). MATERIALS AND METHODS: Retrospective review of all patients from 1/2009-12/2020 who were treated urgently or emergently with UAE for AUB. Urgent and emergent cases were defined as those requiring inpatient admissions. Demographic data were collected for each patient including hospitalizations related to bleeding and length of stay (LOS) for each hospitalization. Hemostatic interventions other than UAE were collected. Hematologic data were collected before and after UAE including hemoglobin, hematocrit, and transfusion products. Data specific to the UAE procedure included complication rates, 30-day readmission, 30-day mortality, embolic agent, site of embolization, radiation dose, and procedure time. RESULTS: 52 patients (median age: 39) underwent 54 urgent or emergent UAE procedures. The most common indications for UAE were malignancy (28.8%), post-partum hemorrhage (21.2%), fibroids (15.4%), vascular anomalies (15.4%), and post-operative bleeding (9.6%). There were no procedure-related complications. Following UAE, 44 patients (84.6%) achieved clinical success and required no additional intervention. Packed red blood cell transfusion decreased from a mean of 5.7 to 1.7 units (p < 0.0001). Fresh frozen plasma transfusion decreased from a mean of 1.8 to 0.48 units (p = 0.012). 50% of patients received a transfusion prior to UAE, while only 15.4% were transfused post-procedure (p = 0.0001). CONCLUSIONS: Emergent or urgent UAE is a safe and effective procedure to control AUB hemorrhage secondary to a variety of etiologies.

Limited ability of the renal ablation-specific (MC)2 risk scoring system to predict major adverse events from percutaneous renal microwave ablation.

PURPOSE: To access if the (MC)2 scoring system can identify patients at risk for major adverse events following percutaneous microwave ablation of renal tumors. METHODS: Retrospective review of all adult patients who underwent percutaneous renal microwave ablation at two centers. Patient demographics, medical histories, laboratory work, technical details of the procedure, tumor characteristics, and clinical outcomes were collected. The (MC)2 score was calculated for each patient. Patients were assigned to low-risk (<5), moderate-risk (5-8) and high-risk (>8) groups. Adverse events were graded according to the criteria from the Society of Interventional Radiology guidelines. RESULTS: A total of 116 patients (mean age = 67.8 [95%CI 65.5-69.9], 66 men) were included. 10 (8.6%) and 22 (19.0%) experienced major or minor adverse events, respectively. The mean (MC)2 score for patients with major adverse events (4.6 [95%CI 3.3-5.8]) was not higher than those with either minor adverse events (4.1 [95%CI 3.4-4.8], p = 0.49) or no adverse events (3.7 [95%CI 3.4-4.1], p = 0.25). However, mean tumor size was greater in those with major adverse events (3.1 cm [95%CI 2.0-4.1]) than minor adverse events (2.0 cm [95%CI 1.8-2.3], p = 0.01). Patients with central tumors were also more likely to experience major adverse events compared to those without central tumors (p = 0.02). The area under the receiver operator curve to predict major adverse events was 0.61 (p = 0.15), indicating a poor ability of the (MC)2 score to predict major adverse events. CONCLUSION: The (MC)2 risk scoring system does not accurately identify patients at risk for major adverse events from percutaneous microwave ablation of renal tumors. The mean tumor size and central tumor location may serve as a better indicator for risk assessment of major adverse events.

ACR Appropriateness Criteria® Thoracoabdominal Aortic Aneurysm or Dissection: Treatment Planning and Follow-Up.

As the incidence of thoracoabdominal aortic pathology (aneurysm and dissection) rises and the complexity of endovascular and surgical treatment options increases, imaging follow-up of patients remains crucial. Patients with thoracoabdominal aortic pathology without intervention should be monitored carefully for changes in aortic size or morphology that could portend rupture or other complication. Patients who are post endovascular or open surgical aortic repair should undergo follow-up imaging to evaluate for complications, endoleak, or recurrent pathology. Considering the quality of diagnostic data, CT angiography and MR angiography are the preferred imaging modalities for follow-up of thoracoabdominal aortic pathology for most patients. The extent of thoracoabdominal aortic pathology and its potential complications involve multiple regions of the body requiring imaging of the chest, abdomen, and pelvis in most patients. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Transarterial embolization of T1b and T2a renal cell carcinoma prior to percutaneous cryoablation: a retrospective comparative study.

PURPOSE: To compare outcomes in patients with T1b and T2a renal cell carcinoma (RCC) treated with percutaneous cryoablation (PCA) who underwent transarterial embolization (TAE) of the RCC prior to PCA (TAE + PCA) to patients who were treated with PCA alone. METHODS: Retrospective review of all adult patients with T1b (4.1-7 cm) and T2a (7.1-10 cm) RCC treated with PCA from 2008 to 2021. Data collected included age, sex, tumor diameter, RENAL nephrometry score, technical success, adverse events (AEs), changes in serum creatinine, local control, and recurrence rates. A p value of 0.05 was considered the threshold for statistical significance. RESULTS: 13 patients with 13 RCCs (mean age: 72.7 ± 10.4; 54% male) and 35 patients with 37 RCCs (mean age: 66.7 ± 10.6; 60% male) were included in the TAE + PCA and PCA groups, respectively. The TAE + PCA group had larger mean tumor diameter (5.7 ± 1.1 cm vs. 4.7 ± 0.6 cm; p < 0.0001) and higher mean RENAL nephrometry score (8.9 ± 1.1 vs. 7.8 ± 1.5; p = 0.02). There were no differences between the groups with respect to technical success of PCA (p = 0.46), local tumor control (p = 0.3), or mean number of procedures to achieve local tumor control (p = 0.85). Mean increase in serum creatinine was not significantly different between the two groups (p = .63). Major AEs were similar between the groups (p = 1); however, the TAE + PCA group had no major hemorrhagic AEs while the PCA alone group had three (8.3%). CONCLUSION: TAE + PCA in patients with T1b or T2 RCC is technically feasible without significant added detriment to renal function. This combined approach may help to reduce hemorrhagic AEs but larger patient cohorts are needed.

Patient Engagement with Online Portals and Online Radiology Results.

The purpose of this study was to examine patient portal enrollment and the usage with a specific focus on the utilization of on-line radiology reports by patients. Oracle SQL (Austin, TX, USA) queries were used to extract portal enrollment data over a 13-month period from March 1, 2017 through March 31, 2018 from the hospital system's EMR. Patient enrollment was collected as was patient information including basic demographics and utilization patterns. For enrolled patients, interaction within the portal with the "Radiology" work tab (RADTAB) was used as a surrogate for review of radiology results. As a comparator, interaction within the portal with the "Laboratory" work tab (LABTAB) was used as a surrogate for review of laboratory results. Statistical analysis on the data was performed using Chi-squared, Student's t-test, Logistic regression and multivariate analysis where appropriate. The population for analysis included 424,422 patients. Overall, 138,783 patients (32.7%) were enrolled in the portal. Patients enrolled in the portal were older (P < 0.0001), female (P < 0.0001) and Caucasian (P < 0.0001). Patients enrolled in the portal had higher levels of educational attainment (p < 0.0001), higher annual household income (P < 0.0001), and more outpatient clinic visits (P < 0.0001). The proportion of enrolled patients that interacted with the LABTAB (47.2%) was significantly higher than those that interacted with the RADTAB (27.1%) (P < 0.0001; Table 2). Patients that utilize the portal are more likely to utilize the Laboratory tab than the Radiology tab, and demographic differences do not account for this difference in usage. Further investigation is needed to better understand the reasons for the differing usage trends of Laboratory and Radiology tabs.