Local and Systemic Side Effects of Corticosteroid Injections for Musculoskeletal Indications.

Corticosteroid injections can be associated with a range of potential side effects, which may be classified as local or systemic and further stratified as immediate or delayed in onset. Radiologists performing image-guided musculoskeletal injections should recognize the potential side effects of corticosteroid medication when counseling patients before injection and consider such side effects in planning individual injections. This Review summarizes the available evidence regarding the local and systemic side effects of corticosteroid injections performed for musculoskeletal indications. Local side effects include postinjection flare, skin hypopigmentation and atrophy, infection, tendon rupture, accelerated progression of osteoarthritis, and osseous injury. Systemic side effects include adrenal suppression or insufficiency, facial flushing, hypertension, hyperglycemia, and osteoporosis. Additional targeted counseling is warranted regarding side effects that are specific to certain patient populations (i.e., premenopausal women, patients with diabetes, athletes, and pediatric patients). Corticosteroid injections are contraindicated in the presence of superficial or deep infection, fracture, or a prosthetic joint. Guidelines on the frequency, duration, and maximal lifetime use of corticosteroid injections are currently lacking. Further research is needed regarding the long-term complications of continuous corticosteroid use, particularly with regard to osseous effects.

Percutaneous Interventions for Injuries in Athletes: Implications on Return to Play.

For nonsurgical musculoskeletal (MSK) injuries in athletes, image-guided percutaneous intervention may aid in recovery and decrease return to play (RTP) time. These interventions fall into two major categories: to reduce inflammation (and therefore alleviate pain) or to promote healing. This review describes the risks and benefits of the various percutaneous interventions in MSK athletic injury and surveys the literature regarding the implication of these interventions on RTP.

Presence of subchondral fracture in cases diagnosed as transient osteoporosis of the hip: a retrospective independent reader-based study.

OBJECTIVE: Transient osteoporosis of the hip (TOH) is an uncommon, typically self-limited diagnosis of uncertain etiology. We hypothesize that TOH represents an underlying subchondral fracture, and a discrete fracture line can often be detected on high-resolution MRI. MATERIALS AND METHODS: A retrospective PACS query identified patients meeting imaging criteria for TOH with intense bone marrow edema (BME) in the femoral head on MRI. Those with poor quality studies, other underlying pathologies, or antecedent trauma were excluded. Three musculoskeletal radiologists independently reviewed each case for presence of a definite subchondral fracture line on small field of view (FOV) MR images of the affected hip. Extent of BME, reciprocal acetabular BME, and joint effusion size were also recorded. Binomial logistic regression was performed to determine statistically significant predictors of subchondral fracture. RESULTS: Fifty patients met inclusion criteria (29 females, 0 pregnant). Mean age was 62±12 years (range 35-84). Average duration of symptoms before MRI was 102±135 days. Ten patients had bone densitometry within 2 years of MRI, six demonstrating osteopenia or osteoporosis. Subchondral fractures were unanimously identified in 44/50 (88%). Interclass correlation coefficient with absolute agreement was 0.73, 95% CI (0.57-0.84), indicating near-excellent agreement. Most cases demonstrated a large joint effusion (23/50, 46%) and acetabular BME (31/50, 62%). Increasing size of joint effusion was a statistically significant predictor of subchondral fracture (p=0.05), with 6.9 higher odds. There was a strong correlation with osteopenia/osteoporosis and fracture (p<0.001). CONCLUSION: Discrete subchondral fractures were identified unanimously on small FOV imaging in the majority of TOH cases.

Minimally Invasive Ultrasound-Guided Carpal Tunnel Release Improves Long-Term Clinical Outcomes in Carpal Tunnel Syndrome.

BACKGROUND. Ultrasound guidance allows performance of carpal tunnel release with smaller incisions and quicker recovery than traditional open or endoscopic surgery. OBJECTIVE. The purpose of this study was to evaluate the long-term effectiveness of ultrasound-guided carpal tunnel release in improving function and discomfort in patients with carpal tunnel syndrome. METHODS. Retrospective review was conducted of 61 ultrasound-guided carpal tunnel release procedures performed on 46 patients (15 bilateral procedures) with clinically diagnosed carpal tunnel syndrome. The procedures were performed with a single-use transection device and local anesthesia at an outpatient radiology office. Patients answered three questionnaires (Quick Disabilities of the Arm, Shoulder, and Hand [QDASH] and two parts of the Boston Carpal Tunnel Syndrome Questionnaire-the symptom severity [BCTSQ-SS] and functional status [BCTSQ-FS] scales) to assess the function of and discomfort in the affected wrist immediately before and 2 weeks and at least 1 year after the procedure. Higher scores indicated increasing disability. Patients also answered a global satisfaction question at follow-up. Preprocedure and postprocedure scores were compared by paired Wilcoxon signed rank tests. RESULTS. The 46 patients (25 women, 21 men; mean age, 60.6 years; range, 21-80 years) had median preprocedure scores of 45.4 for QDASH, 3.2 for BCTSQ-SS, and 2.5 for BCTSQ-FS. The median scores 2 weeks after the procedure were 22.5 for QDASH, 1.7 for BCTSQ-SS, and 1.9 for BCTSQ-FS. All scores decreased (p < .001) from preprocedure scores and surpassed reference standards for clinically important difference in scores. Follow-up questionnaires obtained for 90% (55/61) of wrists a median of 1.7 years (range, 1.0-2.8 years) after the procedure showed further declines (p < .001) in median scores: 2.3 for QDASH, 1.2 for BCTSQ-SS, and 1.1 for BCTSQ-FS. At long-term follow-up evaluation, 96% (52/54) of wrists had lower QDASH and 98% (53/54) had lower BCTSQ (average of BCTSQ-SS and BCTSQ-FS) scores compared with the preprocedure scores. Among the patients who participated in the survey, 93% (37/40) were satisfied or very satisfied with the long-term outcomes. No immediately postoperative complications occurred. Two patients needed surgical intervention 8 and 10 days after surgery, one for infection after injury and one for posttraumatic compartment syndrome. CONCLUSION. Ultrasound-guided carpal tunnel release quickly improves hand function and reduces hand discomfort; improvement persists beyond 1 year. CLINICAL IMPACT. Ultrasound-guided carpal tunnel release may be a safe, effective, and less invasive alternative to traditional surgery.

Establishing a Women-in-Radiology Group: A Toolkit From the American Association for Women in Radiology.

Despite increasing representation in medical schools and surgical specialties, recruitment of women into radiology has failed to exhibit commensurate growth. Furthermore, women are less likely than men to advance to leadership roles in radiology. A women-in-radiology (WIR) group provides a robust support system that has been shown to produce numerous benefits to the group's individual participants as well as the group's institution or practice. These benefits include development of mentor-ship relationships, guidance of career trajectories, improved camaraderie, increased participation in scholarly projects, and increased awareness of gender-specific issues. This article describes a recommended pathway to establishing a WIR group, with the goal of fostering sponsorship and promoting leadership, recruitment, and advancement of women in radiology. We consider barriers to implementation and review resources to facilitate success, including a range of resources provided by the American Association for Women in Radiology. By implementing the provided framework, radiologists at any career stage can start a WIR group, to promote the advancement of their female colleagues.

The Evolving Roles of MRI and Ultrasound in First-Line Imaging of Rotator Cuff Injuries.

Rotator cuff tears are the most likely source of shoulder pain in adults and may cause protracted disability. Management of rotator cuff tears is associated with considerable costs. Accurate diagnosis can guide surgical planning and help achieve a favorable clinical outcome. Although radiography remains the initial imaging test for shoulder injury, the roles of MRI and ultrasound (US) as first-line imaging after radiography are evolving. This article leverages current literature and the practical experience of subspecialty musculoskeletal radiologists from different institutions in describing a practical approach to imaging rotator cuff pathology. Both MRI and US are accurate for identifying rotator cuff tears, but each has advantages and shortcomings. As both modalities currently represent reasonable first-line approaches, considerable practice variation has evolved. Given the low cost of US, imagers should strive to optimize the quality of shoulder US examinations and to build referrer confidence in this modality. The roles of direct CT and MR arthrography as well as imaging evaluation of the postoperative rotator cuff are also considered. Through careful selection among the available imaging modalities and optimal performance and interpretation of such examinations, radiologists can positively contribute to the diagnosis and treatment of patients with rotator cuff injuries.

Potential clinical impact of reporting breast arterial calcifications on screening mammograms in women without known coronary artery disease.

Cardiovascular disease remains a leading cause of death in women. 10-year likelihood for a cardiovascular event is determined by the American College of Cardiology Atherosclerotic Cardiovascular disease risk score calculator (ASVCD); however, this does not encompass risk factors unique to women. Breast arterial calcifications (BAC) detected on screening mammography may serve as a proxy for coronary atherosclerosis (CAC) in women. Our purpose was to investigate the correlation between BAC and CAC on imaging in women without a diagnosis of atherosclerosis to determine the potential clinical impact. Retrospective review was performed on a cohort of females evaluated by internists at our institution in 2019. Study patients had a screening mammogram within 1 year of a noncardiac chest CT. Clinical data were collected to determine ASCVD risk score. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of BAC in detecting CAC were determined. 222 women met inclusion criteria, ranging from 41 to 77 years of age, among which 25% (56/222) had BAC. 84% (47/56) of women with BAC had CAC on CT, yielding a sensitivity, specificity, PPV, and NPV of 51%, 93%, 84%, and 72%, respectively. Of the 47 patients who had both BAC and CAC, 66% had an unknown or low-to-borderline ASCVD score. Women with BACs have a high specificity for CAC. The reporting of BACs should prompt clinicians to risk stratify women for atherosclerotic disease. These women may otherwise be undetected by conventional risk calculators.

Prevalence of lateral patellofemoral maltracking and associated complications in patients with Osgood Schlatter disease.

OBJECTIVE: To evaluate adults with history of Osgood Schlatter disease (OSD) for imaging features of lateral patellofemoral maltracking. METHODS: In a span of four years, 10,181 unique non-contrast knee MRIs were performed on patients aged 20-50. Patients with acute trauma, prior surgery, and synovial pathologies were excluded. 171 exams had imaging findings of OSD, and an age-matched control group of 342 patients without OSD was randomly selected. Two radiologists retrospectively reviewed MRIs for features of lateral patellofemoral maltracking. Maltracking was defined as edema in superolateral Hoffa's fat or a tibial tuberosity-trochlear groove (TT-TG) distance ≥20 mm with either patellar tilt/translation. Binomial logistic regression identified predictors of maltracking in OSD. Optimal TT-TG distance to indicate maltracking was determined by receiver operating characteristic curve. RESULTS: 59% (101/171) of the knees with OSD showed findings of maltracking, with patella alta, trochlear dysplasia, and quadriceps tendinosis as significant predictors of maltracking (p < 0.001). Patellofemoral chondrosis was present in 63% (107/171), with maltracking contributing to higher grade chondrosis more so than increasing age (OR 8.4 versus 1.07). 13 mm was the optimal cut-off TT-TG distance to indicate maltracking (sensitivity 83%, specificity 80%). The prevalence of maltracking in the control group was 15% (p < 0.001 compared with the OSD group). CONCLUSION: Adults with sequelae of OSD are at high risk of maltracking and are likely to develop patellofemoral chondrosis. A lower threshold for identifying maltracking patients, including a lower cut-off TT-TG distance can help identify those at risk. Radiologists should maintain a high index of suspicion for maltracking in adults with OSD to guide clinical intervention.

Painful type II os naviculare: introduction of a standardized, reproducible classification system.

OBJECTIVE: To provide a novel MRI classification system for the symptomatic type II os naviculare by creating a standardized grading of associated bone marrow edema (BME) and correlating with patient symptoms. METHODS: BME was classified on an ordinal scale: grade 1, faint signal immediately adjacent to the synchondrosis; grade 2, intermediate signal within the os and navicular tuberosity without extending to the navicular body; grade 3, intense signal extending to the navicular body. BME on 59 MRIs was independently graded by three radiologists. Inter- and intra-observer agreement was analyzed using intraclass correlation coefficient. Univariate and multivariate analyses assessed for patient and imaging characteristics predictive of subjective pain score. A cohort of 82 patients without BME represented a control group. RESULTS: Inter-observer agreement of BME grade was 0.95 (CI 0.93-0.97) and intra-observer was 0.92 (CI 0.87-0.96), indicating excellent agreement. In patients with BME, predictors of more severe pain were longer duration of pain (p = 0.02) and presence of soft tissue edema overlying the os naviculare (p < 0.001). One hundred percent of subjects with BME localized their pain to the medial midfoot (59/59) versus 25.6% (21/82) of controls (p < 0.001). CONCLUSIONS: This novel grading system provides reliable quantification of BME associated with os naviculare, which is a specific cause of medial foot/ankle pain. Early diagnosis is important as pain severity worsens with longer duration of symptoms. Pain severity is correlated with soft tissue edema overlying the os, which may be secondary to extrinsic compression, reactive to biomechanical stress, or reflect direct trauma.

Effect of Preoperative MRI Coracoid Dimensions on Postoperative Outcomes of Latarjet Treatment for Anterior Shoulder Instability.

Background: Preoperative coracoid dimensions may affect the size of the bone graft transferred to the glenoid rim and thus the postoperative outcomes of Latarjet coracoid transfer. Purpose: To determine the effect of coracoid length and width as measured on preoperative magnetic resonance imaging (MRI) on outcomes after Latarjet treatment of anterior shoulder instability. Study Design: Cohort study; Level of evidence, 3. Methods: Included were patients who underwent primary Latarjet surgery between 2009 and 2019 and had preoperative MRI scans and minimum 2-year postoperative outcomes. Longitudinal coracoid length was measured on axial MRI sequences as the distance from the coracoclavicular ligament insertion to the distal tip. Comparisons were made between shorter and longer coracoids and between narrower and wider coracoids. The outcomes of interest were recurrent instability, reoperation, complications, return to sport (RTS), and American Shoulder and Elbow Surgeons (ASES) score. Independent-samples t test, Mann-Whitney test, chi-square test, and Fisher exact test were used to compare outcomes between groups, and univariate correlation coefficients were calculated to evaluate the relationships between demographics and coracoid dimensions. Results: Overall, 56 patients were included (mean age, 28.4 years). The mean ± SD coracoid length was 21.6 ± 2.4 mm and width 10.0 ± 1.0 mm. Relative to patients with a longer coracoid (≥22 mm; n = 26), patients with a shorter coracoid (<22 mm; n = 30) had similar rates of recurrent instability (shorter vs longer; 6.7% vs 3.8%), complications (10.0% vs 15.4%), reoperation (3.3% vs 7.7%), and RTS (76.5% vs 58.8%) and similar postoperative ASES scores (85.0 vs 81.6) (P ≥ .05 for all). Likewise, relative to patients with a wider coracoid (≥10 mm; n = 27), patients with a narrower coracoid (<10 mm; n = 29) had similar prevalences of recurrent instability (narrower vs wider; 6.9% vs 3.7%), complications (17.2% vs 7.4%), reoperation (3.5% vs 7.4%), and RTS (66.7% vs 68.4%) and similar postoperative ASES scores (87.1 vs 80.0) (P ≥ .05 for all). Conclusion: Patients undergoing Latarjet coracoid transfer had similar postoperative outcomes regardless of preoperative coracoid dimensions. These findings should be confirmed in a larger cohort before further clinical recommendations are made.

The role of liver-directed surgery in patients with hepatic metastasis from a gynecologic primary carcinoma.

BACKGROUND: The management of patients with liver metastasis from a gynecologic carcinoma remains controversial, as there is currently little data available. We sought to determine the safety and efficacy of liver-directed surgery for hepatic metastasis from gynecologic primaries. METHODS: Between 1990 and 2010, 87 patients with biopsy-proven liver metastasis from a gynecologic carcinoma were identified from an institutional hepatobiliary database. Fifty-two (60%) patients who underwent hepatic surgery for their liver disease and 35 (40%) patients who underwent biopsy only were matched for age, primary tumor characteristics, and hepatic tumor burden. Clinicopathologic, operative, and outcome data were collected and analyzed. RESULTS: Of the 87 patients, 30 (34%) presented with synchronous metastasis. The majority of patients had multiple hepatic tumors (63%), with a median size of the largest lesion being 2.5 cm. Of those patients who underwent liver surgery (n=52), most underwent a minor hepatic resection (n=44; 85%), while 29 (56%) patients underwent concurrent lymphadenectomy and 45 (87%) patients underwent simultaneous peritoneal debulking. Postoperative morbidity and mortality were 37% and 0%, respectively. Median survival from time of diagnosis was 53 months for patients who underwent liver-directed surgery compared with 21 months for patients who underwent biopsy alone (n=35) (p=0.01). Among those patients who underwent liver-directed surgery, 5-year survival following hepatic resection was 41%. CONCLUSIONS: Hepatic surgery for liver metastasis from gynecologic cancer can be performed safely. Liver surgery may be associated with prolonged survival in a subset of patients with hepatic metastasis from gynecologic primaries and therefore should be considered in carefully selected patients.

The Relationship Between Discoid Meniscus and Articular Cartilage Thickness: A Quantitative Observational Study With MRI.

BACKGROUND: Several cadaveric imaging studies have demonstrated that the articular cartilage thickness on the tibial plateau varies depending on coverage by native meniscal tissue. These differences are thought to partially contribute to the rates of cartilage degeneration and development of osteoarthritis after meniscectomy. Because there is greater tibial plateau coverage with meniscal tissue in the setting of a discoid meniscus, these findings may also have implications for the long-term health of the knee after saucerization of a torn discoid meniscus. PURPOSE: To evaluate the relationship between lateral compartment articular cartilage thickness and the presence or absence of a discoid meniscus. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Included in the study were 25 patients younger than 40 years of age who had undergone a 1.5-T or 3-T knee magnetic resonance imaging (MRI) between 2010 and 2016 at a single institution and had an intact, lateral discoid meniscus. Only patients with an otherwise asymptomatic lateral compartment were included. The authors then identified 35 age-matched controls with a nondiscoid, intact lateral meniscus who underwent knee MRI at the same institution and during the same period. The articular cartilage thicknesses in 6 zones of the lateral femoral condyle (LFC) and lateral tibial plateau (LTP) were measured for each patient by 2 musculoskeletal radiologists, and the mean thicknesses were compared between the study and control groups. RESULTS: The average age at MRI was 22.63 years (range, 8.30-35.90 years) for the discoid group and 20.93 years (range, 8.43-34.99 years) for the nondiscoid group. The nondiscoid group had significantly greater mean articular cartilage thickness in all 6 zones of the LTP (P < .05 for all). When comparing the zones of the LFC, there was no significant difference in the mean thickness in any zone between the 2 groups. CONCLUSION: Patients with discoid menisci had thinner baseline articular cartilage thickness in the LTP compared with those patients without discoid menisci.

Recent Trends in Medicare Reimbursements to Nonradiologist Physicians for In-Office MRI and CT.

PURPOSE: Previous studies demonstrated rapid growth in payments to nonradiologist providers (NRPs) for MRI and CT in their private offices. In this study, we re-examine the trends in these payments. METHODS: The nationwide Medicare Part B master files from 2004 to 2016 were accessed. They provide payment data for all Current Procedural Terminology codes. Codes for MRI and CT were selected. Global and technical component claims were counted. Medicare specialty codes identified payments made to NRPs and radiologists, and place-of-service codes identified payments directed to their private offices. RESULTS: Medicare MRI payments to NRPs peaked in 2006 at $247.7 million. As a result of the Deficit Reduction Act, there was a sharp drop to $189.5 million in 2007, eventually declining to $101.6 million by 2016 (-59% from peak in 2006). The NRP specialty groups with the highest payments for MRI ownership include orthopedists, neurologists, primary care physicians, and hospital-based specialists (pathology, physiatry, and hospitalists). Medicare CT payments to NRPs peaked in 2008 at $284.1 million and declined to $94.7 million in 2016 (-67% from peak). Cardiologists, primary care physicians, internal medicine specialists, urologists, and medical oncologists accounted for the most payments made to NRPs. Dollars paid to radiologists for private office MRI and CT dropped substantially since they peaked in 2006. CONCLUSIONS: NRP private offices (and radiology offices also) experienced massive decreases in Medicare payments for MRI and CT since peaking in 2006 and 2008, respectively. These trends suggest the financial viability of private office practice may be in jeopardy. However, certain recent policy changes could promote a resurgence.

Impact of the Closure of a Large, Urban Safety-Net Hospital on a Neighboring Academic Center: A Philadelphia Case Study.

OBJECTIVES: We examined how the closure of 496-bed Hahnemann University Hospital (HUH), a level I trauma and stroke center and safety-net hospital in Philadelphia, Pennsylvania, impacted the emergency department (ED) and radiology workflow in our neighboring hospital (Thomas Jefferson University Hospital) located <1 mile away. METHODS: On June 30, 2019, HUH announced its imminent closure and began diverting trauma patients, with its ED officially closing in mid-August. Trends of our ED and radiology workflow were analyzed using QlikView analytics software for 3 months before and after the closure. Data were compared to workflow from the same time period in 2018. RESULTS: The average monthly number of patients presenting to our ED after the closure increased 20.2% with a corresponding 16% increase in ED imaging studies, primarily in radiographs (+16%) and CT (+20%). Radiology orders by advanced practice providers increased 74%. Turnaround time from imaging order placed to final diagnostic radiology report did not change substantially after the closure. CONCLUSION: Workflow in our ED and radiology department was significantly impacted by the closure of HUH. This study provides insight into how our practice patterns changed and compensated after the closure of a neighboring, large, urban safety-net hospital; it is important for radiologists to be aware of citywide practice patterns to adapt to acute change.

Recent Trends Suggest Possible Inappropriate Utilization of Myocardial Perfusion Imaging.

PURPOSE: The aim of this study was to analyze the utilization of elective stress nuclear myocardial perfusion imaging (MPI) in the Medicare population. METHODS: Nationwide Medicare Part B fee-for-service databases for 2004 to 2016 were reviewed. Current Procedural Terminology codes for stress MPI were selected: standard planar and single-photon emission computed tomography (STD) and PET. Utilization rates per 1,000 Medicare beneficiaries were calculated. Elective examinations were identified using place-of-service codes for private offices and hospital outpatient departments (HOPDs). Medicare physician specialty codes identified the performing physician. Because Medicare Part B databases are complete population counts, sample statistics were not required. RESULTS: Elective STD MPI utilization peaked in 2006 at 74 studies/1,000 and had declined by 36% by 2016. Cardiologists' share of STD MPI grew from 79% to 87% between 2004 and 2016. Cardiologists perform STD MPI primarily in private offices, where utilization peaked in 2008 and then demonstrated an absolute decline of 28 studies/1,000 by 2016. During this same time period, cardiologists' use of STD MPI in HOPDs demonstrated an absolute increase of 8.1 studies/1,000. From 2004 to 2016, STD MPI use by radiologists declined by 58%. Elective PET MPI maintained an upward trend, reflecting increasing use by cardiologists in private offices. CONCLUSIONS: Elective STD MPI use is declining, but cardiologists are performing an increasing share in outpatient settings. The drop in private office STD MPI among cardiologists was far greater than the corresponding increase in its use in HOPDs, suggesting that many studies previously performed in private offices were unindicated. Self-referred PET MPI utilization has rapidly grown in cardiology private offices.

Prostate Contrast Enhanced Transrectal Ultrasound Evaluation of the Prostate With Whole-Mount Prostatectomy Correlation.

OBJECTIVE: To investigate the diagnostic accuracy of contrast enhanced transrectal ultrasound (CE-TRUS) in comparison with whole-mount radical prostatectomy specimens. METHOD AND MATERIALS: Fifty-eight subjects who underwent CE-TRUS and subsequent radical prostatectomy with whole-mount pathology were included in the study. Each patient underwent evaluation with baseline TRUS and again during CE-TRUS with intravenous infusion of perflutren lipid microsphere (Definity, Lantheus Medical Imaging, N Billerica, MA). A subjective 5 point scale was used to rate each sextant of the prostate in 3 baseline imaging modes and in 5 contrast-enhanced imaging modes. Baseline TRUS and CE-TRUS findings were compared with digitized whole-mount findings. A clustered logistic regression model was computed to compare the area under the receiver operating characteristic curve (Az) for detection of prostate cancer by various modes of ultrasound imaging. RESULTS: Among the 58 whole-mount specimens, a maximum Gleason score of 6 was identified in 29 subjects, a score of 7 was identified in 24 and a score of 8 was identified in 5. The Az for baseline TRUS parameters was 0.55 for grayscale, 0.61 for color Doppler and 0.59 for power Doppler. CE-TRUS parameters demonstrated significant increases in Az with the highest Az for CE-power Doppler (0.66) and flash replenishment imaging (0.64) (P = .04 for comparison to baseline). The combination of CE-power Doppler and flash replenishment imaging resulted in improved Az compared with baseline imaging (0.70 vs 0.59, P= .006). CONCLUSION: Contrast-enhanced ultrasonography demonstrates greater diagnostic accuracy than baseline imaging. Diagnostic accuracy is further improved for "clinically significant" tumor volumes >1 cc.

Utilization Trends in Noncardiac Thoracic Imaging, 2002-2014.

PURPOSE: To analyze recent trends in utilization of the various noncardiac thoracic imaging modalities in the Medicare population. METHODS: The Medicare Part B databases for 2002 through 2014 were reviewed. All CPT codes pertaining to noninvasive imaging of the thorax were selected and grouped into seven categories: x-ray, CT, computed tomographic angiography (CTA), nuclear scans (noncardiac), MRI, MR angiography, and ultrasound. Yearly utilization rates per 1,000 Medicare beneficiaries were calculated. Medicare physician specialty codes were used to determine how many studies were performed by radiologists versus nonradiologist physicians. RESULTS: The total utilization rate of all chest imaging peaked at 1,090 per 1,000 in 2005, then progressively declined to 913 by 2014 (-16%). In 2002, radiologists' share of thoracic imaging was 87% and increased to 91% by 2014. Among all providers, the total utilization rate of chest CT rose sharply, peaked at 100 in 2007, and has remained steady at around 89-91 in more recent years. The CTA utilization rate rose progressively from 2 in 2002 to 23 in 2014. Utilization rates of nuclear chest imaging decreased steadily after 2002. Chest x-ray rates reached a peak of 976 in 2005 but then declined to 790 in 2014; this change was largely responsible for the decline in total thoracic imaging. CONCLUSION: Overall thoracic imaging utilization rates have declined in recent years, despite an increase in use of CT and CTA. The decline largely resulted from a decrease in use of chest x-rays.