Assessing AI-Powered Patient Education: A Case Study in Radiology.

RATIONALE AND OBJECTIVES: With recent advancements in the power and accessibility of artificial intelligence (AI) Large Language Models (LLMs) patients might increasingly turn to these platforms to answer questions regarding radiologic examinations and procedures, despite valid concerns about the accuracy of information provided. This study aimed to assess the accuracy and completeness of information provided by the Bing Chatbot-a LLM powered by ChatGPT-on patient education for common radiologic exams. MATERIALS AND METHODS: We selected three common radiologic examinations and procedures: computed tomography (CT) abdomen, magnetic resonance imaging (MRI) spine, and bone biopsy. For each, ten questions were tested on the chatbot in two trials using three different chatbot settings. Two reviewers independently assessed the chatbot's responses for accuracy and completeness compared to an accepted online resource, radiologyinfo.org. RESULTS: Of the 360 reviews performed, 336 (93%) were rated "entirely correct" and 24 (7%) were "mostly correct," indicating a high level of reliability. Completeness ratings showed that 65% were "complete" and 35% were "mostly complete." The "More Creative" chatbot setting produced a higher proportion of responses rated "entirely correct" but there were otherwise no significant difference in ratings based on chatbot settings or exam types. The readability level was rated eighth-grade level. CONCLUSION: The Bing Chatbot provided accurate responses answering all or most aspects of the question asked of it, with responses tending to err on the side of caution for nuanced questions. Importantly, no responses were inaccurate or had potential to cause harm or confusion for the user. Thus, LLM chatbots demonstrate potential to enhance patient education in radiology and could be integrated into patient portals for various purposes, including exam preparation and results interpretation.

Ultrasound-guided nerve block prior to biopsy of suspected neurogenic tumors: safety and feasibility in a pilot study.

OBJECTIVE: The aim of this study is to investigate the safety and feasibility of ultrasound-guided nerve block prior to biopsy of potentially neurogenic tumors. MATERIALS AND METHODS: A retrospective review of the medical record from June 2017 to June 2022 identified ultrasound-guided biopsies of potentially neurogenic tumors that were performed with a pre-procedural nerve block. Patient demographics, biopsy site, number of passes, needle gauge, use of sedation, pathology results, and procedural complications were recorded and summarized. RESULTS: The structured search found 16 patients that underwent biopsies of 18 potentially neurogenic tumors with the use of a pre-procedural nerve block at a variety of upper and lower extremity locations. Average patient age was 52 (range 18-78) and 9 patients (56%) were female. Of the 16 patients, 10 were performed without intravenous sedation. Three patients were unable to tolerate biopsy until a nerve block was used. All biopsies yielded a diagnostic sample with 13 of the tumors neurogenic in origin. One patient reported mild postprocedural pain which resolved with conservative treatment; no other complications were reported. CONCLUSION: Nerve block prior to ultrasound-guided biopsy of potentially neurogenic tumors is a safe and feasible technique. Further study is needed to determine the extent to which nerve block can decrease intra-procedural pain and reduce or eliminate the need for sedation during biopsy.

Ultrasound-guided temporomandibular joint aspiration: technique and results in six cases of suspected septic arthritis.

OBJECTIVE: The aim of this study is to describe an ultrasound (US)-guided temporomandibular joint (TMJ) arthrocentesis technique and determine its microbial yield in the workup of suspected TMJ septic arthritis. MATERIALS AND METHODS: A retrospective review of US-guided TMJ arthrocentesis for the work-up of septic arthritis performed by radiologists at two institutions was performed. Patient demographics, risk factors for septic arthritis, blood culture results, and pre-procedural imaging findings were recorded. Procedural data included fluid aspirate quantity, needle gauge and length, and any immediate complications. Post-procedural data included synovial fluid analysis including culture, final diagnosis of TMJ disease, type of treatment, and any delayed complications from arthrocentesis. RESULTS: A total of six US-guided TMJ arthrocenteses were identified, all of which yielded at least 1 mL of synovial fluid. Five patients were subsequently diagnosed with septic arthritis, and one patient was diagnosed with GVHD arthritis. The synovial fluid in four out of five patients with a final diagnosis of septic arthritis produced positive cultures. There were no immediate or delayed complications from arthrocentesis. CONCLUSION: Basic US-guided procedural skills are transferrable to TMJ arthrocentesis, which is a low-risk procedure with a high microbial yield in our small series of patients with septic arthritis.

Cost-effectiveness Analysis in Diagnostic Musculoskeletal Radiology: A Systematic Review.

Diagnostic musculoskeletal imaging represents a large economic expenditure within the health care system. Cost-effectiveness analysis can identify the most efficient use of imaging resources, but the literature is not well summarized. The purpose of this study was to summarize the existing literature on this topic and identify areas for future research. A systematic review of the literature was performed for 1995 - 2020. Data was extracted and summarized from those studies meeting inclusion criteria including publication and analysis characteristics and clinical topics. The search found 27 studies meeting inclusion criteria of which 16 (59%) were published in the last 5 years. Studies were clustered around specific topics with 21 (78%) of studies analyzing either osteoporosis screening (n = 9, 33%), cancer imaging (n = 4, 15%), inflammatory arthritis (n = 4, 15%), or spinal trauma (n = 4, 15%). Only 4 studies (15%) were published in radiology journals. Although 12 studies (44%) had a radiologist author, only 8 (30%) had a radiologist as first or senior author. Existing cost-effectiveness analyses in musculoskeletal radiology are clustered around a small number of topics and few studies are led by radiologists. Future research should target under-represented clinical topics and radiologists should actively pursue involvement in this field to apply their unique expertise and understanding of imaging.

ACR Appropriateness Criteria® Osteonecrosis: 2022 Update.

Osteonecrosis is defined as bone death due to inadequate vascular supply. It is sometimes also called "avascular necrosis" and "aseptic necrosis" when involving epiphysis, or "bone infarct" when involving metadiaphysis. Common sites include femoral head, humeral head, tibial metadiaphysis, femoral metadiaphysis, scaphoid, lunate, and talus. Osteonecrosis is thought to be a common condition most commonly affecting adults in third to fifth decades of life. Risk factors for osteonecrosis are numerous and include trauma, corticosteroid therapy, alcohol use, HIV, lymphoma/leukemia, blood dyscrasias, chemotherapy, radiation therapy, Gaucher disease, and Caisson disease. Epiphyseal osteonecrosis can lead to subchondral fracture and secondary osteoarthritis whereas metadiaphyseal cases do not, likely explaining their lack of long-term sequelae. Early diagnosis of osteonecrosis is important: 1) to exclude other causes of patient's pain and 2) to allow for possible early surgical prevention to prevent articular collapse and need for joint replacements. Imaging is also important for preoperative planning. 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 in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Predictors of CT Colonography Use: Results From the 2019 National Health Interview Cross-Sectional Survey.

PURPOSE: CT colonography (CTC) is a minimally invasive screening test with high sensitivity for colonic polyps (>1 cm). Prior studies suggest that CTC utilization remains low. However, there are few studies evaluating recent CTC utilization and predictors of CTC utilization. Our purpose was to estimate recent nationwide CTC utilization and evaluate predictors of CTC utilization using 2019 nationally representative cross-sectional survey data. METHODS: Participants between ages 50 and 75 without colorectal cancer history in the 2019 National Health Interview Survey cross-sectional data were included. The proportion of participants reporting utilization of CTC was estimated, accounting for complex survey design elements. Multiple variable logistic regression analyses evaluated predictors of CTC utilization. Analyses were conducted accounting for complex survey design elements to obtain valid estimates for the civilian, noninstitutionalized US population. RESULTS: In all, 13,709 respondents were included, and 1.4% reported undergoing CTC, of whom 39.9% underwent CTC within the last year, 18.5% within the last 2 years, 13.0% within the last 3 years, 7.8% within the last 5 years, 11.2% within the last 10 years, and 9.6% underwent CTC 10 years ago or more. Multiple variable logistic regression analyses revealed that Hispanic (odds ratio 2.67, 95% confidence interval 1.66-4.29, P < .001) and Black (odds ratio 2.47, 95% confidence interval 1.60-3.82, P < .001) participants were more likely than White participants to undergo CTC. CONCLUSION: Survey results suggest that nationwide utilization of CTC remains low. Black and Hispanic participants were more likely than White participants to report undergoing CTC. Promotion of CTC may reduce racial and ethnic disparities in colorectal cancer screening.

Patient Race or Ethnicity and the Use of Diagnostic Imaging: A Systematic Review.

OBJECTIVE: To summarize the existing literature evaluating differences in imaging use based on patient race and ethnicity. METHODS: The authors performed a structured search of four databases for the dates January 1, 2000, to April 13, 2021, using key words and derivatives focused on imaging and patient race. Retrieved citations were reviewed by abstract and then full text to identify articles that evaluated the likelihood of imaging use by patient race or ethnicity controlling for sociodemographic factors. Data regarding publication characteristics, study population, clinical setting, and results was extracted and summarized. RESULTS: The structured search identified 2,938 articles, of which 206 met inclusion criteria. Most studies (87%, 179 of 206) were conducted in the United States, and the majority (72%, 149 of 206) found decreased or inappropriate imaging use in minority groups. Breast cancer screening was the most common clinical setting (50%, 104 of 206), followed by cancer care (10%, 21 of 206) and general imaging use (9%, 19 of 206). Government-administered surveys were the most common data source (40%, 82 of 206). Only a small minority of studies (8%, 17 of 206) evaluated strategies to mitigate the unequal use of imaging based on patient race and ethnicity. DISCUSSION: The existing literature shows decreased or inappropriate use of diagnostic imaging for minority patients across a wide variety of clinical settings. Although the number of articles on the topic is large, the majority are clustered around specific topics, and few articles evaluate potential strategies to reduce the inequitable use of diagnostic imaging.

Ultrasound-Guided Injection Treatments Versus Surgical Neurectomy for Morton Neuroma: A Cost-Effectiveness Analysis.

BACKGROUND. Morton neuroma is a common, painful disorder of the foot with multiple treatment options of varying cost and effectiveness. OBJECTIVE. The aim of this study was to determine the most cost-effective treatment pathway for symptomatic Morton neuromas when conservative management has failed. METHODS. An incremental cost-utility analysis was performed comparing a direct to surgical neurectomy strategy with three selective injection strategies in which one or more ultrasound-guided injection therapies was tried first before surgery for patients who did not respond to treatment. The three selective injection strategies were selective steroid injection, selective alcohol injection, and selective steroid/alcohol injection in which both steroid injections and alcohol sclerosing injections were trialed successively before surgical neurectomy. The direct-to-surgery approach was compared with the three different selective injection strategies and with a no-treatment strategy in a decision-analytic model for a hypothetical group of patients with symptomatic Morton neuroma in whom conservative management had failed. Model parameters, including treatment costs, effectiveness, complication rates, and health utility states, were estimated from the literature, reimbursement databases, and expert opinion. The outcome was cost per quality-adjusted life year (QALY) with a time horizon of 3 years. A societal cost perspective was adopted with a willingness-to-pay threshold of $100,000/QALY. Sensitivity analyses for key model parameters were performed. RESULTS. For the base input values, the steroid/alcohol selective injection strategy was dominant and yielded an incremental cost-effectiveness ratio of $4401.61/QALY compared with no treatment. The probabilistic sensitivity analysis supported this strategy in 74% of 10,000 simulated trials. Results were robust with low sensitivity to most input parameters. However, when the probability of successful alcohol injection treatment dropped below 40%, the steroid selective injection strategy became most cost-effective. CONCLUSION. A trial of ultrasound-guided injection therapies for Morton neuroma is a cost-effective strategy compared with proceeding directly to surgical neurectomy. CLINICAL IMPACT. Ultrasound-guided injection therapies are indicated as first-line treatment of patients with symptomatic Morton neuromas when conservative management fails.

Influence of augmentation of biochar during anaerobic co-digestion of Chlorella vulgaris and cellulose.

The anaerobic co-digestion (AcoD) of microalgae is a prospective option for generating biomethane from renewable sources. This study investigates the effects of inoculum-to-substrate ratio (ISR), C/N ratio and biochar (BC) load on the AcoD of Chlorella vulgaris and cellulose. An initial augmentation of BC at ISR 0.5-0.9 and C/N ratio 10-30 offered a pH buffering effect and resulted in biomethane yields of 233-241 mL CH4/g VS, corresponding to 1.8-4.6 times the controls. BC addition ameliorated significantly AcoD, supporting the digestate stability at less favourable conditions. The effect of the process variables was further studied with a 23 factorial design and response optimisation. Under the design conditions, the variables had less influence over methane production. Higher ISRs and C/N ratios favoured AcoD, whereas increasing amounts of BC reduced biomethane yield but enhanced production rate. The factorial design highlighted the importance of BC-load on AcoD, establishing an optimum of 0.58 % (w/v).

Intravenous contrast does not improve detection of nerve lesions or active muscle denervation changes in MR neurography of the common peroneal nerve.

OBJECTIVE: To evaluate the effect of intravenous (IV) contrast on sensitivity, specificity, and accuracy of magnetic resonance (MR) neurography of the knee with attention to the common peroneal nerve (CPN) in identifying nerve lesions and active muscle denervation changes. MATERIALS AND METHODS: A retrospective search for contrast-enhanced MR neurography cases evaluating the CPN at the knee was performed. Patients with electrodiagnostic testing (EDX) within 3 months of imaging were included and those with relevant prior surgery were excluded. Two radiologists independently reviewed non-contrast sequences and then 4 weeks later evaluated non-contrast and contrast sequences. McNemar's tests were performed to detect a difference between non-contrast only and combined non-contrast and contrast sequences in identifying nerve lesions and active muscle denervation changes using EDX as the reference standard. RESULTS: Forty-four exams in 42 patients (2 bilateral) were included. Twenty-eight cases had common peroneal neuropathy and 29, 21, and 9 cases had active denervation changes in the anterior, lateral, and posterior compartment/proximal muscles respectively on EDX. Sensitivity, specificity, and accuracy of non-contrast versus combined non-contrast and contrast sequences for common peroneal neuropathy were 50.0%, 56.2%, and 52.3% versus 50.0%, 56.2%, and 52.3% for reader 1 and 57.1%, 50.0%, and 54.5% versus 64.3%, 56.2%, and 61.4% for reader 2. Sensitivity, specificity, and accuracy of non-contrast and combined non-contrast and contrast sequences in identifying active denervation changes for anterior, lateral, and posterior compartment muscles were not significantly different. McNemar's tests were all negative. CONCLUSION: IV contrast does not improve the ability of MR neurography to detect CPN lesions or active muscle denervation changes.

Contrast-enhanced ultrasound-guided musculoskeletal biopsies: our experience and technique.

OBJECTIVE: To present our experience with contrast-enhanced ultrasound (CEUS)-guided musculoskeletal soft tissue biopsies in a busy interventional clinic. MATERIALS AND METHODS: After IRB approval was obtained and informed consent was waived, we retrospectively reviewed all CEUS-guided musculoskeletal biopsies performed from December 1, 2018 to March 2, 2020. Relevant pre-procedure imaging was reviewed. Number of samples, suspected necrosis on pre-procedure imaging, specimen adequacy for pathologic analysis, correlation with pathologic diagnosis of surgical resection specimens, and procedural complications were recorded. RESULTS: Thirty-six CEUS-guided musculoskeletal biopsies were performed in 32 patients (mean age 57, range 26-88; 22 males, 10 females). All procedures were performed using 16-gauge biopsy needles, and all procedures provided adequate samples for pathologic analysis as per the final pathology report. Between two and seven core specimens were obtained (mean 3.7). In 30/36 cases (83%), a contrast-enhanced MRI was obtained prior to biopsy, and 10/30 (33%) of these cases showed imaging features suspicious for necrosis. In 15/36 cases, surgical resection was performed, and the core biopsy and surgical resection specimens were concordant in 14/15 cases (93%). One patient noted transient leg discomfort at the time of microbubble bursting. Otherwise, no adverse reactions or procedural complications were observed. CONCLUSION: CEUS is an accurate way to safely target representative areas of soft tissue lesions for biopsy and can be implemented in a busy interventional clinic. Our early experience has shown this to be a promising technique, especially in targeting representative areas of heterogeneous lesions and lesions with areas of suspected necrosis on prior imaging.

The effect of augmentation of biochar and hydrochar in anaerobic digestion of a model substrate.

The augmentation of biochar produced at 450 and 600-650 °C and hydrochar produced at 250 °C has been investigated using biochemical methane potential experiments of cellulose. The feedstocks used for the char production included the lignocellulosic (oak wood), macroalgae (Fucus serratus) and aquatic plant (water hyacinth). Biomethane production was improved with the addition of lower-temperature biochars from oak wood (285 mL CH4/g VS) and water hyacinth (294 mL CH4/g VS), corresponding to 7 and 11% more than the control. The addition of these two biochars increased the methane production rate of 2.4 and 2.3 times the control, respectively. Higher temperature biochars showed no difference. Conversely, all hydrochars and macroalgae biochars augmentation reduced methane generation by 57-86 %. The chemical and structural composition of each of the chars differed significantly. Surface oxygen functionality appears to be the most important property of the biochars that improved digestion performance.

Fluoroscopy-guided percutaneous needle aspiration of posterior epidural abscesses: a report of two cases.

Introduction: Spinal epidural abscesses are most commonly treated with surgical decompression and antibiotics or in specific instances managed medically with antibiotic therapy alone. Image-guided percutaneous aspiration as an alternative to surgery has only rarely been reported in the literature. Case presentation: We report two cases of successful fluoroscopy-guided needle aspiration of posterior epidural abscesses. Case 1 is a 48-year-old man who presented with several days of escalating back pain and constitutional symptoms with MRI showing a posterior epidural abscess at L2-L3 causing spinal stenosis. The patient remained neurologically intact. Percutaneous needle aspiration of the collection provided dramatic pain relief with the aspirate growing methicillin sensitive Staphylococcus aureus. The patient made a full recovery on antibiotic therapy. Case 2 is an 81-year-old man who presented with worsening upper back pain and was found to have osteomyelitis/discitis with a large posterior epidural abscess in the thoracic spine. Needle drainage was performed with the sample growing Bacteroides fragilis. This patient also responded successfully to nonsurgical management with full recovery after appropriate antibiotic therapy. Discussion: In carefully selected patients, image-guided needle aspiration of posterior epidural abscesses may be a viable and less invasive alternative to surgery.