Impact of automated alerts on discharge opioid overprescribing after general surgery.

DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: The objectives of this study were to identify the most performed surgical procedures associated with the highest rates of discharge opioid overprescribing and to implement an electronic health record (EHR) alert to reduce discharge opioid overprescribing. METHODS: This quality improvement, before-and-after study included patients undergoing one of the identified target procedures-laparoscopic cholecystectomy, unilateral open inguinal hernia repair, and laparoscopic appendectomy-at an academic medical center. The alert notified providers when the prescribed opioid quantity exceeded guideline recommendations. The preimplementation cohort included surgical encounters from January 2020 to December 2021. The EHR alert was implemented in May 2022 following provider education via email and in-person presentations. The postimplementation cohort included surgical encounters from May to August 2022. The primary outcome was the proportion of patients with a discharge opioid supply exceeding guideline recommendations (overprescribing). RESULTS: A total of 1,478 patients were included in the preimplementation cohort, and 141 patients were included in the postimplementation cohort. The rate of discharge opioid overprescribing decreased from 48% in the preimplementation cohort to 3% in the postimplementation cohort, with an unadjusted absolute reduction of 45% (95% confidence interval, 41% to 49%; P < 0.001) and an adjusted odds ratio of 0.03 (95% confidence interval, 0.01 to 0.08; P < 0.001). Among patients who received opioids, the mean (SD) opioid supply at discharge decreased from 92 (43) oral morphine milligram equivalents (MME) (before implementation) to 57 (20) MME (after implementation) (P < 0.001). The proportion of patients who received additional opioid prescriptions within 1 to 14 days of hospital discharge did not change (P = 0.76). CONCLUSION: Implementation of an EHR alert along with provider education can reduce discharge opioid overprescribing following general surgery.

A practical approach to nutritional intervention for people with chronic kidney disease in Vietnam.

BACKGROUND AND OBJECTIVES: A comprehensive nutritional management is necessary for favourable outcomes in patients with chronic kidney disease (CKD). We aimed to assess the changes in nutritional status and disease progression with nutritional management where renal replacement therapy (RRT) was not in place. METHODS AND STUDY DESIGN: A quasi-experiment intervention was conducted on 70 CKD patients at stages 3-5 from July to December 2022. Participants were excluded if they underwent RRT, including dialy-sis (hemodialysis or peritoneal dialysis), or kidney transplantation. The nutritional regimen covered nutrition-al counseling, samples of the dietary menu, and supplement products. We evaluated nutritional status using Subjective Global Assessment (SGA) scale and sub-clinical blood test at T0 (hospital admission) and T1 (two weeks after the admission or 24 hours before the discharge). RESULTS: After the intervention, the number of patients classified as malnutrition or at risk of malnourished reduced significantly (65.7% to 54.3% and 25.7% and 5.7%, respectively). The serum concentration of urea, creatinine and parathyroid hormone decreased remarkably, especially in patients receiving nutritional management. In the intervention group, the dietary pattern provided increased intakes of calcium and iron at T1, while phosphorus, sodium and potassium decreased after follow-up. Nausea/vomiting, loss of appetite, tiredness and sleep disorders were improved in the intervention compared to the control group. CONCLUSIONS: Nutritional therapy enhanced the nutritional sta-tus, and quality of dietary and renal function in CKD patients without RRT. Applying nutrition education and treatment at an early stage can slow CKD progression, which should be applicable elsewhere in Vietnam.

Generalizing Diffusion Tensor Imaging of the Physis and Metaphysis.

BACKGROUND: Current methods to predict height potential are inaccurate. Predicting height by using MRI of the physeal cartilage has shown promise but the applicability of this technique in different imaging setups has not been well-evaluated. PURPOSE: To assess variability in diffusion tensor imaging of the physis and metaphysis (DTI-P/M) of the distal femur between different scanners, imaging parameters, tractography software, and resolution. STUDY TYPE: Prospective. POPULATION/SUBJECTS: Eleven healthy subjects (five males and six females ages 10-16.94). FIELD STRENGTH/SEQUENCE: 3 T; DTI single shot echo planar sequences. ASSESSMENT: Physeal DTI tract measurements of the distal femur were compared between different scanners, imaging parameters, tractography settings, interpolation correction, and tractography software. STATISTICAL TESTS: Bland-Altman, Spearman correlation, linear regression, and Shapiro-Wilk tests. Threshold for statistical significance was set at P = 0.05. RESULTS: DTI tract values consistently showed low variability with different imaging and analysis settings. Vendor to vendor comparison exhibited strong correlation (ρ = 0.93) and small but significant bias (bias -5.76, limits of agreement [LOA] -24.31 to 12.78). Strong correlation and no significant difference were seen between technical replicates of the General Electric MRI scanner (ρ = 1, bias 0.17 [LOA -1.5 to 1.2], P = 0.42) and the Siemens MRI scanner (ρ = 0.89, bias = 0.56, P = 0.71). Different voxel sizes (1 × 1 × 2 mm3 vs. 2 × 2 × 3 mm3) did not significantly affect DTI values (bias = 1.4 [LOA -5.7 to 8.4], P = 0.35) but maintained a strong correlation (ρ = 0.82). Gap size (0 mm vs. 0.6 mm) significantly affects tract volume (bias = 1.8 [LOA -5.4 to 1.8]) but maintains a strong correlation (ρ = 0.93). Comparison of tractography algorithms generated significant differences in tract number, length, and volume while maintaining correlation (ρ = 0.86, 0.99, 0.93, respectively). Comparison of interobserver variability between different tractography software also revealed significant differences while maintaining high correlation (ρ = 0.85-0.98). DATA CONCLUSION: DTI of the pediatric physis cartilage shows high reproducibility between different imaging and analytic parameters. EVIDENCE LEVEL: 2 TECHNICAL EFFICACY: Stage 1.

Enhancing Nutritional Status and Addressing Micronutrient Deficiencies: Evaluating the Impact of Workplace Nutrition Program on Female Workers in Vietnam.

This randomized controlled clinical study aimed to assess the effectiveness of a nutrition intervention program for non-pregnant female workers in Vietnam. A total of 500 female workers were randomly assigned to the intervention and control groups. Participants in the intervention group were provided nutrition education, personalized specific dietary, and received oral nutrition supplements (ONS)-which contained multi-minerals and vitamins according to recommendations for adults for a duration of 12 wk, while participants in the control group received only nutrition education. The result shows the percentage of malnutrition by BMI in the control group rose from 15.6% to 21.3% after 12 wk; the figure for counterpart experienced a remain unchanged (p<0.05). Additionally, the mean of serum zinc in the intervention group significantly increased from 49.0±21.2 µg/dL to 53.6±19.5 µg/dL after 12 wk. Moreover, the intervention group demonstrated significant increases in serum iron and total serum calcium levels (p<0.05), with from 13.9±5.6 µmol/L to 15.3±5.8 µmol/L, and from 2.36±0.15 mmol/L to 2.4±0.09 mmol/L, respectively. The participants of the intervention group were more likely to have higher total serum calcium (Coef=0.04, p<0.05), serum iron (Coef=1.99, p<0.05), and serum zinc (Coef=18.9, p<0.05), which presents a reduce micronutrient deficiency. In conclusion, workplace nutrition interventions effectively mitigate micronutrient deficiencies and improve the nutritional status of female workers.

Quality Improvement Report: Improving Retrieval Time for CT Supplies by Using 5S.

The CT supply room is a critical resource in the imaging workflow. However, the supply room for the two CT scanners at our cancer center, one of which is used for our busy interventional service, was disorganized, and the time spent searching for the appropriate equipment could potentially lead to delays in service and contribute to patient safety risks. The purpose of this project was to reduce the time to find supplies and to increase the satisfaction of CT technologists and medical providers by reorganizing and clearly labeling supplies using "lean" principles. A multidisciplinary team was assembled to reorganize the CT storage using lean 5S methodology (sort, set in order, shine, standardize, and sustain). Baseline and postintervention analysis of the impact of supply reorganization and labeling was performed using three methods: (a) the time recorded for a supply retrieval scavenger hunt, (b) a spaghetti diagram of participant movement during the scavenger hunt, and (c) satisfaction surveys of radiologists and staff. Seven radiology residents participated in the timed supply retrieval scavenger hunt before and after the intervention. Spaghetti diagrams demonstrated a reduction in redundant foot traffic for supply retrieval after the intervention. There was a 61.7% decrease in the average time to retrieve the 10 items in the scavenger hunt (P < .01). Satisfaction surveys after the intervention had statistically significant positive responses compared with those before the intervention. ©RSNA, 2024.

Deep Learning-Assisted Diffusion Tensor Imaging for Evaluation of the Physis and Metaphysis.

Diffusion tensor imaging of physis and metaphysis can be used as a biomarker to predict height change in the pediatric population. Current application of this technique requires manual segmentation of the physis which is time-consuming and introduces interobserver variability. UNET Transformers (UNETR) can be used for automatic segmentation to optimize workflow. Three hundred and eighty-five DTI scans from 191 subjects with mean age of 12.6 years ± 2.01 years were retrospectively used for training and validation. The mean Dice correlation coefficient was 0.81 for the UNETR model and 0.68 for the UNET. Manual extraction and segmentation took 15 min per volume, whereas both deep learning segmentation techniques took < 1 s per volume and were deterministic, always producing the same result for a given input. Intraclass correlation coefficient (ICC) for ROI-derived femur diffusion metrics was excellent for tract count (0.95), volume (0.95), and FA (0.97), and good for tract length (0.87). The results support the hypothesis that a hybrid UNETR model can be trained to replace the manual segmentation of physeal DTI images, therefore automating the process.

Preventing Static Biofilm Formation of Staphylococcus aureus on Different Types of Surfaces Using Microbubbles.

Bacterial fouling and biofilm formation on surfaces have been ongoing problems in real life as well as in the medical field. Different approaches have been taken to tackle the issues, from costly surface modification to antibiotic-delivering strategies. In this study, we examined the potential of using stabilized microbubbles (MBs) to shield against bacterial adhesion. Three types of surfaces were tested: hydrophilic glass (hydrophilic surface), neutral hydrophobic polystyrene (PS)-coated surfaces, and negatively charged hydrophobic octadecyltrichlorosilane (OTS)-coated surfaces. By evaluating the colony-forming unit (CFU) values from each surface, MBs stabilized by 0.05 mM SDS were shown to only produce significant reduction of Staphylococcus aureus adhesion on PS surfaces, up to 60.29 and 82.32% compared to no-MB PS surfaces, and no-MB uncoated surfaces, correspondingly, due to the appropriate size, stability, and negative charges of the MB shielding layer. On the other hand, OTS coatings had an intrinsic antiadhesion effect (69.83% compared to uncoated surface), given that the negatively charged OTS-aqueous interface or surface porosity nature of the coating prohibited the attachment of MBs, leading to the elimination of the antifouling effect of MBs. Ultimately, MBs gave better shielding results than surface modification when compared to uncoated surfaces and hence can be applied more widely.

Large variation in radiation dose for routine abdomen CT: reasons for excess and easy tips for reduction.

OBJECTIVE: To characterize the use and impact of radiation dose reduction techniques in actual practice for routine abdomen CT. METHODS: We retrospectively analyzed consecutive routine abdomen CT scans in adults from a large dose registry, contributed by 95 hospitals and imaging facilities. Grouping exams into deciles by, first, patient size, and second, size-adjusted dose length product (DLP), we summarized dose and technical parameters and estimated which parameters contributed most to between-protocols dose variation. Lastly, we modeled the total population dose if all protocols with mean size-adjusted DLP above 433 or 645 mGy-cm were reduced to these thresholds. RESULTS: A total of 748,846 CTs were performed using 1033 unique protocols. When sorted by patient size, patients with larger abdominal diameters had increased dose and effective mAs (milliampere seconds), even after adjusting for patient size. When sorted by size-adjusted dose, patients in the highest versus the lowest decile in size-adjusted DLP received 6.4 times the average dose (1680 vs 265 mGy-cm) even though diameter was no different (312 vs 309 mm). Effective mAs was 2.1-fold higher, unadjusted CTDIvol 2.9-fold, and phase 2.5-fold for patients in the highest versus lowest size-adjusted DLP decile. There was virtually no change in kV (kilovolt). Automatic exposure control was widely used to modulate mAs, whereas kV modulation was rare. Phase was the strongest driver of between-protocols variation. Broad adoption of optimized protocols could result in total population dose reductions of 18.6-40%. CONCLUSION: There are large variations in radiation doses for routine abdomen CT unrelated to patient size. Modification of kV and single-phase scanning could result in substantial dose reduction. CLINICAL RELEVANCE: Radiation dose-optimization techniques for routine abdomen CT are routinely under-utilized leading to higher doses than needed. Greater modification of technical parameters and number of phases could result in substantial reduction in radiation exposure to patients. KEY POINTS: • Based on an analysis of 748,846 routine abdomen CT scans in adults, radiation doses varied tremendously across patients of the same size and optimization techniques were routinely under-utilized. • The difference in observed dose was due to variation in technical parameters and phase count. Automatic exposure control was commonly used to modify effective mAs, whereas kV was rarely adjusted for patient size. Routine abdomen CT should be performed using a single phase, yet multi-phase was common. • kV modulation by patient size and restriction to a single phase for routine abdomen indications could result in substantial reduction in radiation doses using well-established dose optimization approaches.

Review on the Significant Interactions between Ultrafine Gas Bubbles and Biological Systems.

Having sizes comparable with living cells and high abundance, ultrafine bubbles (UBs) are prone to inevitable interactions with different types of cells and facilitate alterations in physiological properties. The interactions of four typical cell types (e.g., bacterial, fungal, plant, and mammalian cells) with UBs have been studied over recent years. For bacterial cells, UBs have been utilized in creating the capillary force to tear down biofilms. The release of high amounts of heat, pressure, and free radicals during bubble rupture is also found to affect bacterial cell growth. Similarly, the bubble gas core identity plays an important role in the development of fungal cells. By the proposed mechanism of attachment of UBs on hydrophobin proteins in the fungal cell wall, oxygen and ozone gas-filled ultrafine bubbles can either promote or hinder the cell growth rate. On the other hand, reactive oxygen species (ROS) formation and mass transfer facilitation are two means of indirect interactions between UBs and plant cells. Likewise, the use of different gas cores in generating bubbles can produce different physical effects on these cells, for example, hydrogen gas for antioxidation against infections and oxygen for oxidation of toxic metal ions. For mammalian cells, the importance of investigating their interactions with UBs lies in the bubbles' action on cell viability as membrane poration for drug delivery can greatly affect cells' survival. UBs have been utilized and tested in forming the pores by different methods, ranging from bubble oscillation and microstream generation through acoustic cavitation to bubble implosion.

Specification, validation, and adherence of quality indicators to optimize the safe use of nonsteroidal anti-inflammatory drugs for knee osteoarthritis pain in the primary care setting.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) used for osteoarthritis (OA) in primary care may cause gastrointestinal or renal injury. This study estimated adherence to two quality indicators (QIs) to optimize NSAID safety: add proton pump inhibitors (PPI) to NSAIDs for patients with gastrointestinal (GI) risk (QI #1 NSAID-PPI) and avoid oral NSAIDs in chronic kidney disease (CKD) stage G4 or G5 (QI #2 NSAID-CKD). METHODS: This retrospective study included index primary care clinic visits for knee OA at our health system in 2019. The validation cohort consisted of a random sample of 60 patients. The remainder were included in the expanded cohort. Analysis of structured data extracts was validated against chart review of clinic visit notes (validation cohort) and estimated QI adherence (expanded cohort). RESULTS: Among 60 patients in the validation cohort, analysis of data extracts was validated against chart review for QI #1 NSAID-PPI (100% sensitivity and 91% specificity) and QI #2 NSAID-CKD (100% accuracy). Among 335 patients in the expanded cohort, 44% used NSAIDs, 27% used PPIs, 73% had elevated GI risk, and only 2% had CKD stage 4 or 5. Twenty-one percent used NSAIDs and had elevated GI risk but were not using PPIs. Therefore, adherence to QI #1 NSAID-PPI was 79% (95% CI, 74-83%). No patients with CKD stage 4 or 5 used NSAIDs. Therefore, adherence to QI #2 NSAID-CKD was 100%. CONCLUSION: A substantial proportion of knee OA patients with GI risk factors did not receive PPI with NSAID therapy during primary care visits.

PET/CT and SPECT/CT Imaging of HER2-Positive Breast Cancer.

HER2 (Human Epidermal Growth Factor Receptor 2)-positive breast cancer is characterized by amplification of the HER2 gene and is associated with more aggressive tumor growth, increased risk of metastasis, and poorer prognosis when compared to other subtypes of breast cancer. HER2 expression is therefore a critical tumor feature that can be used to diagnose and treat breast cancer. Moving forward, advances in HER2 in vivo imaging, involving the use of techniques such as positron emission tomography (PET) and single-photon emission computed tomography (SPECT), may allow for a greater role for HER2 status in guiding the management of breast cancer patients. This will apply both to patients who are HER2-positive and those who have limited-to-minimal immunohistochemical HER2 expression (HER2-low), with imaging ultimately helping clinicians determine the size and location of tumors. Additionally, PET and SPECT could help evaluate effectiveness of HER2-targeted therapies, such as trastuzumab or pertuzumab for HER2-positive cancers, and specially modified antibody drug conjugates (ADC), such as trastuzumab-deruxtecan, for HER2-low variants. This review will explore the current and future role of HER2 imaging in personalizing the care of patients diagnosed with breast cancer.

Deep Learning Approaches with Digital Mammography for Evaluating Breast Cancer Risk, a Narrative Review.

Breast cancer remains the leading cause of cancer-related deaths in women worldwide. Current screening regimens and clinical breast cancer risk assessment models use risk factors such as demographics and patient history to guide policy and assess risk. Applications of artificial intelligence methods (AI) such as deep learning (DL) and convolutional neural networks (CNNs) to evaluate individual patient information and imaging showed promise as personalized risk models. We reviewed the current literature for studies related to deep learning and convolutional neural networks with digital mammography for assessing breast cancer risk. We discussed the literature and examined the ongoing and future applications of deep learning techniques in breast cancer risk modeling.

Facilitate or Inhibit: Corporate Environmental Performance and Financing Costs.

The proposed carbon peak and carbon neutralization goals have ushered China into an era of emissions reduction and a climate-oriented economy. With the proposed double carbon goal, China has formulated many environmental protection and green credit policies. This paper aims to assess the impact of corporate environmental performance (CEP) on financing costs, using a panel dataset of companies in China's heavily polluting industries from 2010 to 2019. We employed fixed-effect models, moderating-effect models, and panel quantile regression (PQR) to analyze the impact, underlying mechanisms, and asymmetric features of CEP on financing costs. Our results indicate that CEP has an inhibitory effect on financing costs, with political connections strengthening this effect and GEA weakening it. Moreover, the impact exhibits asymmetry at different levels of financing costs, wherein lower financing costs see a greater weakening effect from CEP. Improved CEP helps to optimize the financing performance of companies and reduce financing costs. Therefore, policy makers and regulatory authorities should work to unblock financing channels for companies, encourage environmental investment, and remain flexible in implementing environmental policies.

Crucial Role of Surfactants in Improving the Extraction Efficiency of ß-Amyrin from Dischidia major Using Ultrasound-Assisted Extraction Coupled with Gas Bubble Flotation.

Ultrasound-assisted extraction coupled with gas bubble flotation was developed as a green method for extracting ß-amyrin fromDischidia major. The solvent system was water:ethanol (9:1). To improve the adsorption of ß-amyrin onto the air/liquid interface during flotation, surfactants were employed; however, the positive effect was only observed with cationic surfactants. High-performance liquid chromatography with spectrophotometric detection (HPLC-PDA) was, for the first time, applied to quantify the ß-amyrin content in D. major and its extracts. With the assistance of surfactants, the foam layer collected from flotation showed high selectivity toward ß-amyrin. The product content was notably increased after surfactants had been removed from the solution.

REFLACX, a dataset of reports and eye-tracking data for localization of abnormalities in chest x-rays.

Deep learning has shown recent success in classifying anomalies in chest x-rays, but datasets are still small compared to natural image datasets. Supervision of abnormality localization has been shown to improve trained models, partially compensating for dataset sizes. However, explicitly labeling these anomalies requires an expert and is very time-consuming. We propose a potentially scalable method for collecting implicit localization data using an eye tracker to capture gaze locations and a microphone to capture a dictation of a report, imitating the setup of a reading room. The resulting REFLACX (Reports and Eye-Tracking Data for Localization of Abnormalities in Chest X-rays) dataset was labeled across five radiologists and contains 3,032 synchronized sets of eye-tracking data and timestamped report transcriptions for 2,616 chest x-rays from the MIMIC-CXR dataset. We also provide auxiliary annotations, including bounding boxes around lungs and heart and validation labels consisting of ellipses localizing abnormalities and image-level labels. Furthermore, a small subset of the data contains readings from all radiologists, allowing for the calculation of inter-rater scores.

Diffusion Tensor Imaging of the Knee to Predict Childhood Growth.

Background Accurate and precise methods to predict growth remain lacking. Diffusion tensor imaging (DTI) depicts the columnar structure of the physis and metaphyseal spongiosa and provides measures of tract volume and length that may help predict growth. Purpose To validate physeal DTI metrics as predictors of height velocity (1-year height gain from time of MRI examination) and total height gain (height gain from time of MRI examination until growth stops) and compare the prediction accuracy with bone age-based models. Materials and Methods Femoral DTI studies (b values = 0 and 600 sec/mm2; directions = 20) of healthy children who underwent MRI of the knee between February 2012 and December 2016 were retrospectively analyzed. Children with height measured at MRI and either 1 year later (height velocity) or after growth cessation (total height gain, mean = 34 months from MRI) were included. Physeal DTI tract volume and length were correlated with height velocity and total height gain. Multilinear regression was used to assess the potential of DTI metrics in the prediction of both parameters. Bland-Altman plots were used to compare root mean square error (RMSE) and bias in height prediction using DTI versus bone age methods. Results Eighty-nine children (mean age, 13 years ± 3 [SD]; 47 boys) had height velocity measured, and 70 (mean age, 14 years ± 1; 36 girls) had total height gain measured. Tract volumes correlated with height velocity (r2 = 0.49) and total height gain (r2 = 0.46) (P < .001 for both) after controlling for age and sex. Tract volume was the strongest predictor for height velocity and total height gain. An optimal multilinear model including tract volume improved prediction of height velocity (R2 = 0.63, RMSE = 1.7 cm) and total height gain (R2 = 0.59, RMSE = 1.8 cm) compared with bone age-based methods (height velocity: R2 = 0.32, RMSE = 2.9 cm; total height gain: R2 = 0.42, RMSE = 5.0 cm). Conclusion Models using tract volume derived from diffusion tensor imaging may perform better than bone age-based models in children for the prediction of height velocity and total height gain. © RSNA, 2022.

Implementing a Novel Through-Glass Chest Radiography Technique for COVID-19 Patients: Image Quality, Radiation Dose Optimization, and Practical Considerations.

RATIONALE AND OBJECTIVES: The novel coronavirus (COVID-19) pandemic has presented many logistical challenges, including unprecedented shortages of personal protective equipment (PPE). A technique of obtaining portable chest radiographs (pCXR) through glass doors or windows to minimize technologist-patient contact and conserve PPE has gained popularity, but remains incompletely evaluated in the literature. Our goal was to quickly implement this technique and evaluate image quality and radiation dose. MATERIALS AND METHODS: An infographic and video were developed to educate nurses and technologists on the through-glass pCXR technique. Imaging parameters were optimized using a phantom and scatter radiation was measured. Three reviewers independently evaluated 100 conventionally obtained and 100 through-glass pCXRs from March 13, 2020 to April 30, 2020 on patients with suspected COVID-19, using criteria for positioning and sharpness/contrast on a 1 (confident criteria not met) to 5 (confident criteria met) scale. Imaging parameters, including deviation index (DI) were recorded for all radiographs. RESULTS: The through-glass method was rapidly adopted and conserved one isolation gown per interaction. Although there was a statistically significant difference in the positioning (P value 0.018) and sharpness/contrast (P value 0.016), the difference in mean ratings was small: 4.82 vs 4.65 for positioning and 4.67 vs 4.50 (conventional vs modified) for sharpness/contrast. Scatter radiation was measured using a thorax phantom and found to be acceptable for the patient and nearby personnel. Standard deviation was higher for the DI for the through-glass technique (2.8) compared to the conventional technique (1.8), although the means were similar. CONCLUSION: The through-glass technique was quickly implemented, producing diagnostic quality chest radiographs while conserving PPE and reducing risks to radiology staff. There was more variability with imaging technique and DI using the through-glass technique, likely due to technologist uncertainty regarding technical modifications. Further work to reduce this variation is necessary to optimize quality and dose.

Revisiting racial disparities in ED CT utilization during the Affordable Care Act era: 2009-2018 data from the NHAMCS.

OBJECTIVE: To examine the trends in CT utilization in the emergency department (ED) for different racial and ethnic groups, factors that may affect utilization, and the effects of increased insurance coverage since passage of the Affordable Care Act in 2010. MATERIALS AND METHODS: Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for the years 2009-2018 were used for the analysis. The NHAMCS is a cross-sectional survey which has random and systematical samples of more than 200,000 visits to over 250 hospital EDs in the USA. Patient demographic characteristics, source of payment/insurance, clinical presentation, and disposition from the ED were recorded. Descriptive statistics and multivariate logistic regression were performed. RESULTS: Between 2009 and 2018, the rate of uninsured patients in the ED decreased from 18.1% to as low as 9.9%, but this was not associated with a decrease in the disparity in CT utilization between non-Hispanic Black and non-Hispanic White patients. CT use rate increased 38% over the study period. Factors strongly associated with CT utilization include age, source of payment, triage category, disposition from the ED, and residence. After controlling for these factors, non-Hispanic White patients were 21% more likely to undergo CT than non-Hispanic Black patients, though no disparity was seen for Hispanic or Asian/other groups. CONCLUSION: Despite increased insurance coverage over the sample period, racial disparities between non-Hispanic Black and non-Hispanic White patients persist in CT utilization, though no disparity was seen for Hispanic or Asian/other patients. The source of this disparity remains unclear and is likely multifactorial.

Diagnostic reference levels and median doses for common clinical indications of CT: findings from an international registry.

OB JECTIVES: The European Society of Radiology identified 10 common indications for computed tomography (CT) as part of the European Study on Clinical Diagnostic Reference Levels (DRLs, EUCLID), to help standardize radiation doses. The objective of this study is to generate DRLs and median doses for these indications using data from the UCSF CT International Dose Registry. METHODS: Standardized data on 3.7 million CTs in adults were collected between 2016 and 2019 from 161 institutions across seven countries (United States of America (US), Switzerland, Netherlands, Germany, UK, Israel, Japan). DRLs (75th percentile) and median doses for volumetric CT-dose index (CTDIvol) and dose-length product (DLP) were assessed for each EUCLID category (chronic sinusitis, stroke, cervical spine trauma, coronary calcium scoring, lung cancer, pulmonary embolism, coronary CT angiography, hepatocellular carcinoma (HCC), colic/abdominal pain, appendicitis), and US radiation doses were compared with European. RESULTS: The number of CT scans within EUCLID categories ranged from 8,933 (HCC) to over 1.2 million (stroke). There was greater variation in dose between categories than within categories (p < .001), and doses were significantly different between categories within anatomic areas. DRLs and median doses were assessed for all categories. DRLs were higher in the US for 9 of the 10 indications (except chronic sinusitis) than in Europe but with a significantly higher sample size in the US. CONCLUSIONS: DRLs for CTDIvol and DLP for EUCLID clinical indications from diverse organizations were established and can contribute to dose optimization. These values were usually significantly higher in the US than in Europe. KEY POINTS: • Registry data were used to create benchmarks for 10 common indications for CT identified by the European Society of Radiology. • Observed US radiation doses were higher than European for 9 of 10 indications (except chronic sinusitis). • The presented diagnostic reference levels and median doses highlight potentially unnecessary variation in radiation dose.