An exercise stress test for contrast-enhanced duplex ultrasound assessment of lower limb muscle perfusion in patients with peripheral arterial disease.

OBJECTIVE: The aim of the present study was to develop a standardized contrast-enhanced duplex ultrasound (CE-DUS) protocol to assess lower-extremity muscle perfusion before and after exercise and determine relationships of perfusion with clinical and functional measures. METHODS: CE-DUS (EPIQ 5G, Philips) was used before and immediately after a 10-minute, standardized bout of treadmill walking to compare microvascular perfusion of the gastrocnemius muscle in older (55-82 years) patients with peripheral arterial disease (PAD) (n = 15, mean ankle-brachial index, 0.78 ± 0.04) and controls (n = 13). Microvascular blood volume (MBV) and microvascular flow velocity (MFV) were measured at rest and immediately following treadmill exercise, and the Modified Physical Performance Test (MPPT) was used to assess mobility function. RESULTS: In the resting state (pre-exercise), MBV in patients with PAD was not significantly different than normal controls (5.17 ± 0.71 vs 6.20 ± 0.83 arbitrary units (AU) respectively; P = .36); however, after exercise, MBV was ∼40% lower in patients with PAD compared with normal controls (5.85 ± 1.13 vs 9.53 ± 1.31 AU, respectively; P = .04). Conversely, MFV was ∼60% higher in patients with PAD compared with normal controls after exercise (0.180 ± 0.016 vs 0.113 ± 0.018 AU, respectively; P = .01). There was a significant between-group difference in the exercise-induced changes in both MBV and MFV (P ≤ .05). Both basal and exercise MBV directly correlated with MPPT score in the patients with PAD (r = 0.56-0.62; P < .05). CONCLUSIONS: This standardized protocol for exercise stress testing of the lower extremities quantifies calf muscle perfusion and elicits perfusion deficits in patients with PAD. This technique objectively quantifies microvascular perfusion deficits that are related to reduced mobility function and could be used to assess therapeutic efficacy in patients with PAD.

Changes in the Radiology Practice Landscape and Indicators of Practice Consolidation From 2014 to 2023.

BACKGROUND. A range of economic and health policy incentives are leading to ongoing consolidation among payers, hospitals, and physician practices. OBJECTIVE. The purpose of the present study was to evaluate consolidation among radiologists' affiliated practices through 2023, analyze the impact of consolidation on such practices' specialty mix and size, and assess radiologists' new affiliations after prior practices cease. METHODS. CMS data from 2014 to 2023 were used to identify all radiologists nationally along with their affiliated practices. Based on the specialty mix of all affiliated physicians, practices were categorized as radiology only or multispecialty; multispecialty practices were further categorized as radiology majority, other specialty majority, or no majority specialty. Practices that ceased (i.e., became absent within CMS data) were identified. Temporal shifts were assessed to infer consolidation patterns. RESULTS. From 2014 to 2023, the number of radiologists enrolled in Medicare increased 17.3% (from 30,723 to 36,024), whereas the number of affiliated practices decreased 14.7% (from 5059 to 4313). The number of radiology-only, radiology-majority, other-specialty-majority, and no-majority-specialty practices changed by -31.8% (from 3104 to 2118), 10.9% (from 402 to 446), -5.7% (from 615 to 580), and 24.6% (from 938 to 1169), respectively. The number of practices with one to two, three to nine, 10-24, 25-49, 50-99, and 100 or more radiologists changed by -18.7% (from 2233 to 1815), -34.4% (from 1406 to 923), -25.2% (from 910 to 681), 33.2% (from 352 to 469), 121.6% (from 125 to 277), and 348.5% (from 33 to 148). A total of 3494 practices ceased, including 2281 radiology-only practices. Among 3854 radiologists whose only affiliation was a ceased radiology-only practice, their subsequent-year affiliation was a radiology-only practice in 54.3% and a multispecialty practice type in the remaining instances. CONCLUSION. An overall decrease in the number of radiology practices and concurrent growth in the number of radiologists was mirrored by shifts from small toward large practices and from radiology-only toward multispecialty practices, consistent with ongoing practice consolidation. Although determining the causes of consolidation was beyond this scope of this study, the shifts may relate to economic incentives and legislative changes favoring large multispecialty practices. CLINICAL IMPACT. The continued consolidation of radiologists into large multispecialty practices may facilitate subspecialization and greater negotiating power in payer contracting. However, radiologists may prefer smaller and/or radiology-only practices for reasons of autonomy and influence on practice structure.

Sociodemographic Factors and Screening CT Colonography Use Among Medicare Beneficiaries.

BACKGROUND. Approximately one-third of the eligible U.S. population have not undergone guideline-compliant colorectal cancer (CRC) screening. Guidelines recognize various screening strategies to increase adherence. CMS provides coverage for all recommended screening tests except CT colonography (CTC). OBJECTIVE. The purpose of this study was to compare CTC and other CRC screening tests in terms of associations of utilization with income, race and ethnicity, and urbanicity in Medicare fee-for-service beneficiaries. METHODS. This retrospective study used CMS Research Identifiable Files from January 1, 2011, through December 31, 2020. These files contain claims information for 5% of Medicare fee-for-service beneficiaries. Data were extracted for individuals 45-85 years old, and individuals with high CRC risk were excluded. Multivariable logistic regression models were constructed to determine the likelihood of undergoing CRC screening tests (as well as of undergoing diagnostic CTC, a CMS-covered test with similar physical access as screening CTC) as a function of income, race and ethnicity, and urbanicity while controlling for sex, age, Charlson comorbidity index, U.S. census region, screening year, and related conditions and procedures. RESULTS. For 12,273,363 beneficiary years (mean age, 70.5 ± 8.2 [SD] years; 2,436,849 unique beneficiaries: 6,774,837 female beneficiaries, 5,498,526 male beneficiaries), there were 785,103 CRC screenings events, including 645 for screening CTC. Compared with individuals living in communities with per capita income of less than US$25,000, individuals in communities with income of US$100,000 or more had OR for undergoing screening CTC of 5.73, optical colonoscopy (OC) of 1.36, sigmoidoscopy of 1.03, guaiac fecal occult blood test or fecal immunochemical test of 1.50, stool DNA of 1.43, and diagnostic CTC of 2.00. The OR for undergoing screening CTC was 1.00 for Hispanic individuals and 1.08 for non-Hispanic Black individuals compared with non-Hispanic White individuals. Compared with the OR for undergoing screening CTC for residents of metropolitan areas, the OR was 0.51 for residents of micropolitan areas and 0.65 for residents of small or rural areas. CONCLUSION. The association with income was substantially larger for screening CTC than for other CRC screening tests or for diagnostic CTC. CLINICAL IMPACT. Medicare's noncoverage for screening CTC may contribute to lower adherence with CRC screening guidelines for lower-income beneficiaries. Medicare coverage of CTC could reduce income-based disparities for individuals avoiding OC owing to invasiveness, need for anesthesia, or complication risk.

Financial Viability of the No Surprises Act Independent Dispute Resolution Process: Radiology and Other Hospital-Based Specialties.

BACKGROUND. The federal No Surprises Act (NSA), designed to eliminate surprise medical billing for out-of-network (OON) care for circumstances beyond patients' control, established the independent dispute resolution (IDR) process to settle clinician-payer payment disputes for OON care. OBJECTIVE. The purpose of our study was to assess the fraction of OON claims for which radiologists and other hospital-based specialists can expect to at least break even when challenging payer-determined payments through the NSA IDR process, as a measure of the process's financial viability. METHODS. This retrospective study extracted claims from a national commercial database (Optum's deidentified Clinformatics Data Mart) for hospital-based specialties occurring on the same day as in-network emergency department (ED) visits or inpatient stays from January 2017 to December 2021. OON claims were identified. OON claims batching was simulated using IDR rules. Maximum potential recovered payments from the IDR process were estimated as the difference between the charges and the allowed amount. The percentages of claims for which the maximum potential payment and one-quarter of this amount (a more realistic payment recovery estimate) would exceed IDR fees were determined, using US$150 and US$450 fee thresholds to approximate the range of final 2024 IDR fees. These values represented the percentage of OON claims that would be financially viable candidates for IDR submission. RESULTS. Among 76,221,264 claims for hospital-based specialties associated with in-network ED visits or inpatient stays, 1,482,973 (1.9%) were OON. The maximum potential payment exceeded fee thresholds of US$150 and US$450 for 55.0% and 32.1%, respectively, of batched OON claims for radiologists and 76.8% and 61.3% of batched OON claims for all other hospital-based specialties combined. At payment of one-quarter of that amount, these values were 26.9% and 10.6%, respectively, for radiologists and 56.6% and 38.4% for all other hospital-based specialties combined. CONCLUSION. The IDR process would be financially unviable for a substantial fraction of OON claims for hospital-based specialists (more so for radiology than for other such specialties). CLINICAL IMPACT. Although the NSA enacted important patient protections, IDR fees limit clinicians' opportunities to dispute payer-determined payments and potentially undermine their bargaining power in contract negotiations. Therefore, IDR rulemaking may negatively impact patient access to in-network care.

Dual-energy X-ray Absorptiometry Trends Among US Medicare Beneficiaries: 2005-2019.

INTRODUCTION: Bone density measured using dual-energy X-ray absorptiometry (DXA) volume, performance site and interpreters have changed in the US since 2005. The purpose of this report is to provide updated trends in DXA counts, rates, place of service and interpreter specialty for the Medicare fee-for-service population. METHODS: The 100 % Medicare Physician/Supplier Procedure Summary Limited Data Set between 2005-2019 was used. DXA counts and annual rates per 10,000 Medicare beneficiaries were calculated. Annual distributions of scan performance location, provider type and interpreter specialty were described. Place of service trends (significance assigned at p < 0.05) of the mean annual share of DXA utilization were identified using linear regression. RESULTS: Annual DXA use per 10,000 beneficiaries peaked in 2008 at 832, declined to 656 in 2015 then increased (p < 0.001) by 38 per year to 807 in 2019. From 2005 to 2019 DXA performance in office settings declined from 70.7 % to 47.2 %. Concurrently, outpatient hospital (OH) DXA increased from 28.6 % to 51.7 %. In 2005, 43.5 % of DXAs were interpreted by radiologists. This increased (p < 0.001) in the office and OH, averaging 0.3 and 2.0 percentage points per year respectively, reaching 73.5 % in 2019. Interpretation by most non-radiologist specialties declined (p < 0.001). CONCLUSIONS: From 2005-2019, total DXA use among Medicare beneficiaries declined reaching a nadir in 2015 then returned to 2005 levels by 2019. Office DXA declined since 2005 with 51.7 % of all scans now occurring in an OH setting. The proportion of DXAs interpreted by radiologists increased over time, reaching 73.5 % in 2019.

Relationship between Race and Access to Newer Mammographic Technology in Women with Medicare Insurance.

Background Racial disparities in breast cancer mortality have been reported. Mammographic technology has undergone two major technology transitions since 2000: first, the transition from screen-film mammography (SFM) to full-field digital mammography (FFDM) and second, the transition to digital breast tomosynthesis (DBT). Purpose To examine the relationship between use of newer mammographic technology and race in women receiving mammography services. Materials and Methods This was a multiyear (January 2005 to December 2020) retrospective study of women aged 40-89 years with Medicare fee-for-service insurance who underwent mammography. Data were obtained using a 5% research identifiable sample of all Medicare fee-for-service beneficiaries. Within-institution and comparable-institution use of mammographic technology between Black women or women of other races and White women were assessed with multivariable logistic and linear regression, respectively, adjusted for age, race, Charlson comorbidity index, per capita income, urbanicity, and institutional capability. Results Between 2005 and 2020, there were 4 028 696 institutional mammography claims for women (mean age, 72 years ± 8 [SD]). Within an institution, the odds ratio (OR) of Black women receiving digital mammography rather than SFM in 2005 was 0.80 (95% CI: 0.70, 0.91; P < .001) when compared with White women; these differences remained until 2009. Compared with White women, the use of DBT within an institution was less likely for Black women from 2015 to 2020 (OR, 0.84; 95% CI: 0.81, 0.87; P < .001). Across institutions, there were racial differences in digital mammography use, which followed a U-shaped pattern, and the differences peaked at 3.8 percentage points less for Black compared with White women (95% CI: -6.1, -1.6; P = .001) in 2011 and then decreased to 1.2 percentage points less (95% CI: -2.2, -0.2; P = .02) in 2016. Conclusion In the Medicare population, Black women had less access to new mammographic imaging technology compared with White women for both the transition from screen-film mammography to digital mammography and then for the transition to digital breast tomosynthesis. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Lee and Lawson in this issue.

Humanizing the intensive care unit experience in a comprehensive cancer center: A patient- and family-centered improvement study.

OBJECTIVES: Improving family-centered outcomes is a priority in oncologic critical care. As part of the Intensive Care Unit (ICU) Patient-Centered Outcomes Research Collaborative, we implemented patient- and family-centered initiatives in a comprehensive cancer center. METHODS: A multidisciplinary team was created to implement the initiatives. We instituted an open visitation policy (OVP) that revamped the use of the two-way communication boards and enhanced the waiting room experience by hosting ICU family-centered events. To assess the initiatives' effects, we carried out pre-intervention (PRE) and post-intervention (POST) family/caregiver and ICU practitioner surveys. RESULTS: A total of 159 (PRE = 79, POST = 80) family members and 147 (PRE = 95, POST = 52) ICU practitioners participated. Regarding the decision-making process, family members felt more included (40.5% vs. 68.8%, p < 0.001) and more supported (29.1% vs. 48.8%, p = 0.011) after the implementation of the initiatives. The caregivers also felt more control over the decision-making process in the POST survey (34.2% vs. 56.3%, p = 0.005). Although 33% of the ICU staff considered OVP was beneficial for the ICU, 41% disagreed and 26% were neutral. Only half of them responded that OVP was beneficial for patients and 63% agreed that OVP was beneficial for families. Half of the practitioners agreed that OVP resulted in additional work for staff. SIGNIFICANCE OF RESULTS: Our project effectively promoted patient- and family-centered care. The families expressed satisfaction with the communication of information and the decision-making process. However, the ICU staff felt that the initiatives increased their work load. Further research is needed to understand whether making this project universal or introducing additional novel practices would significantly benefit patients admitted to the ICU and their family.

A possible close supermassive black-hole binary in a quasar with optical periodicity.

Quasars have long been known to be variable sources at all wavelengths. Their optical variability is stochastic and can be due to a variety of physical mechanisms; it is also well-described statistically in terms of a damped random walk model. The recent availability of large collections of astronomical time series of flux measurements (light curves) offers new data sets for a systematic exploration of quasar variability. Here we report the detection of a strong, smooth periodic signal in the optical variability of the quasar PG 1302-102 with a mean observed period of 1,884 ± 88 days. It was identified in a search for periodic variability in a data set of light curves for 247,000 known, spectroscopically confirmed quasars with a temporal baseline of about 9 years. Although the interpretation of this phenomenon is still uncertain, the most plausible mechanisms involve a binary system of two supermassive black holes with a subparsec separation. Such systems are an expected consequence of galaxy mergers and can provide important constraints on models of galaxy formation and evolution.

The impact and recovery of asteroid 2018 LA.

The June 2, 2018, impact of asteroid 2018 LA over Botswana is only the second asteroid detected in space prior to impacting over land. Here, we report on the successful recovery of meteorites. Additional astrometric data refine the approach orbit and define the spin period and shape of the asteroid. Video observations of the fireball constrain the asteroid's position in its orbit and were used to triangulate the location of the fireball's main flare over the Central Kalahari Game Reserve. 23 meteorites were recovered. A consortium study of eight of these classifies Motopi Pan as a HED polymict breccia derived from howardite, cumulate and basaltic eucrite, and diogenite lithologies. Before impact, 2018 LA was a solid rock of ~156 cm diameter with high bulk density ~2.85 g/cm3, a relatively low albedo pv ~ 0.25, no significant opposition effect on the asteroid brightness, and an impact kinetic energy of ~0.2 kt. The orbit of 2018 LA is consistent with an origin at Vesta (or its Vestoids) and delivery into an Earth-impacting orbit via the v6 resonance. The impact that ejected 2018 LA in an orbit towards Earth occurred 22.8 ± 3.8 Ma ago. Zircons record a concordant U-Pb age of 4563 ± 11 Ma and a consistent 207Pb/206Pb age of 4563 ± 6 Ma. A much younger Pb-Pb phosphate resetting age of 4234 ± 41 Ma was found. From this impact chronology, we discuss what is the possible source crater of Motopi Pan and the age of Vesta's Veneneia impact basin.

Discriminative Accuracy of Procalcitonin and Traditional Biomarkers in Pediatric Acute Musculoskeletal Infection.

OBJECTIVES: Septic arthritis (SA) is responsible for 20% of pediatric musculoskeletal infections (MSKI) and can have significant consequences. Early detection of SA is critical, and procalcitonin (PCT) has emerged as a promising biomarker. This study assessed the test performance of PCT and traditional biomarkers for suspected SA. METHODS: We conducted a prospective study at two pediatric emergency departments (ED). Data collected measured serum levels of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell (WBC) count, and PCT. Box and whisker plots were generated to compare the of the biomarkers by positive MSKI or a non-MSKI diagnosis. The diagnostic performance of biomarkers was examined using the area under the receiver operating characteristic curve (AUC), and optimal cut -points were identified using the Liu method. RESULTS: Procalcitonin performed reasonably well for detection of MSKI (AUC, 0.72; confidence interval [95% CI], 0.59-0.84). However, CRP and ESR performed better (AUC, 0.88 and 0.78, respectively). White blood cell count was not predictive of MSKI. Patients with a PCT value >0.1 ng/mL, ESR values >19.5 mm/h, and a temperature higher than 99.0°F were more than twice as likely to have acute MSKI. A high CRP level was most predictive of acute MSKI, and patients with levels >2.38 mg/dL were 3.5 times more likely to have acute MSKI. CONCLUSIONS: Procalcitonin is a potential biomarker for the clinical differential of MSKI in the pediatric ED. Additional research is warranted to establish the optimal diagnostic level for PCT, to increase sample size, and to examine any impact on cost.

Resuscitation With Ringer's Lactate Compared With Normal Saline for Pediatric Diabetic Ketoacidosis.

OBJECTIVE: The aims of this study were to describe the use of Ringer's lactate (LR) or normal saline (NS) for resuscitation among children with diabetic ketoacidosis (DKA) and compare the effect of fluid type on cost, length of stay, and rate of cerebral edema (CE). METHODS: This is a retrospective study of 49,737 children aged 0 to 17 years with DKA between January 1, 2005, and September 30, 2015, using data from the Pediatric Health Information System. Treatment with LR or NS was identified. Our primary outcomes were total adjusted cost and length of stay. Our secondary outcome was CE rate per 1000 episodes. RESULTS: The majority of patients were treated with NS (n = 43,841 [88%]) compared with LR (n = 1762 [4%]) or both NS and LR (n = 4134 [8%]). Hospital-year-specific practice patterns were used to investigate the effect of fluid type across resuscitation fluid groups. Total adjusted cost was $1160 less (95% confidence interval, -1468 to -852), or -14.2%, for cases with any episode of LR compared with NS only. Length of stay was not different across groups. The rate of cerebral edema per 1000 episodes was 12.7 for cases with any episode of LR compared with 34.6 NS only (difference, -21.9; 95% confidence interval, -30.4 to -13.3). CONCLUSIONS: Ringer's lactate was infrequently used for resuscitation of pediatric DKA patients. However, resuscitation with LR compared with NS was associated with lower total cost and rates of CE. Further investigation using patient-level clinical and laboratory data is needed to evaluate factors that drive cost and risk of CE development with each fluid.

Ultrasound Utilization Among Medicare Beneficiaries From 2009 to 2021 by Billing Specialty and Place of Service.

Patterns of ultrasound utilization in the national Medicare population shifted from 2009 to 2021. Office ultrasound services were increasingly performed by radiologists, whereas hospital outpatient and inpatient services were increasingly performed by cardiologists/cardiac surgeons; ultrasound services in other places of service were increasingly performed by nonphysician practitioners.

Trends in Medical Claims and Utilization of Limited Ultrasonography Among Emergency Physicians and Radiologists Within a Large Health Plan Provider.

OBJECTIVES: The goal of this study was to evaluate trends in medical claim submissions for limited ultrasound studies performed (1) during emergency department (ED) encounters and (2) by ED providers compared to radiologists. METHODS: We conducted a retrospective, descriptive study using medical claims data from Medica Health Plans from January 1, 2011 to December 31, 2015. Current procedural terminology codes were abstracted for limited ultrasound applications performed during an ED visit and further stratified by studies performed by ED providers compared with radiologists. We excluded claims for which we could not determine provider specialty. RESULTS: We identified 42,576 encounters with limited US claims, of which, 32,666 were submitted by ED providers (N = 9649) or radiologists (N = 23,017). Among ED providers, there was a significant linear increase in the annual number of claims for retroperitoneal (P < .001) and nonlinear increases for thoracic, soft tissue, cardiac, transvaginal genitourinary (GU) and transabdominal GU claims (all P < .001). Compared with radiologists, there was a linear increase in the annual proportion of claims submitted for retroperitoneal (P = .023), transabdominal GU (P = .003), and transvaginal GU (P < .001) studies by ED providers. There was a nonlinear decrease in the annual proportion of limited abdomen claims (P < .001) submitted by ED providers compared with radiologists. CONCLUSIONS: Using data from a large health plan provider, we show that medical claims for many limited ultrasound studies are increasing among ED providers. Compared with radiologists, ED providers are increasingly submitting claims for retroperitoneal, soft tissue, and transabdominal GU studies.

Multi-Year Microbial Source Tracking Study Characterizing Fecal Contamination in an Urban Watershed.

Microbiological and hydrological data were used to rank tributary stream contributions of bacteria to the Little Blue River in Independence, Missouri. Concentrations, loadings and yields of E. coli and microbial source tracking (MST) markers, were characterized during base flow and storm events in five subbasins within Independence, as well as sources entering and leaving the city through the river. The E. coli water quality threshold was exceeded in 29% of base-flow and 89% of storm-event samples. The total contribution of E. coli and MST markers from tributaries within Independence to the Little Blue River, regardless of streamflow, did not significantly increase the median concentrations leaving the city. Daily loads and yields of E. coli and MST markers were used to rank the subbasins according to their contribution of each constituent to the river. The ranking methodology used in this study may prove useful in prioritizing remediation in the different subbasins.

Pediatric Inpatient Readmissions in an Accountable Care Organization.

OBJECTIVE: To assess the association between the length of consistent primary care as part of an accountable care organization (attribution length) and population-level and same-hospital readmissions. Readmission studies are generally focused on same-hospital readmissions rather than readmissions to any hospital (population-level readmissions). STUDY DESIGN: A retrospective study of Medicaid claims data for 28,794 unique pediatric patients attributed to a single children's hospital between September 2013 and May 2015. Study used logistic regression to estimate the impact of attribution length on readmissions and a zero-inflated Poisson model to assess the impact of attribution length on readmission cost and readmission days. RESULTS: The study showed attribution length was associated with a significant reduction in the population-level 30-day readmission rate from 8.9%-6.2% (P = .010) primarily by reducing readmissions that occurred at hospitals other than the discharging hospital. There was no significant reduction in the same-hospital readmission rate. Readmissions to a different hospital occurred in 37% of readmissions. Although not significant at the P = .05 level, attribution length was associated with a 44% reduction (P = .100) in 30-day readmission costs or a 5.0% reduction in the cost of an inpatient episode of care and a 53% reduction (P = .019) in readmission days. CONCLUSIONS: Consistent primary care (attribution length) may be able to reduce 30-day, pediatric Medicaid patients' readmissions at the population level. The decrease occurred primarily in readmissions to hospitals other than the discharging hospital. There was no decrease in the rate of same-hospital readmissions.

Improved Cardiorespiratory Fitness With Aerobic Exercise Training in Individuals With Traumatic Brain Injury.

OBJECTIVE: To examine cardiorespiratory fitness in individuals with traumatic brain injury (TBI), before and following participation in a supervised 12-week aerobic exercise training program. METHODS: Ten subjects with nonpenetrating TBI (TBI severity: mild, 50%; moderate, 40%; severe, 10%; time since injury [mean ± SD]: 6.6 ± 6.8 years) performed exercise training on a treadmill 3 times a week for 30 minutes at vigorous intensity (70%-80% of heart rate reserve). All subjects completed a cardiopulmonary exercise test, with pulmonary gas exchange measured and a questionnaire related to fatigue (Fatigue Severity Scale) at baseline and following exercise training. RESULTS: After training, increases (P < .01) in peak oxygen consumption ((Equation is included in full-text article.); +3.1 ± 2.4 mL/min/kg), time to volitional fatigue (+1.4 ± 0.8 minutes), and peak work rate (+59 ± 43 W) were observed. At the anaerobic threshold, (Equation is included in full-text article.)(+3.6 ± 2.1 mL/kg/min), treadmill time (+1.8 ± 1.1 minutes), and work rate (+37 ± 39 W) were higher (P < .01) following exercise training. Subjects also reported significantly lower (P < .05) Fatigue Severity Scale composite scores (-0.9 ± 1.3) following exercise training. CONCLUSION: These findings suggest that individuals with TBI may benefit from participation in vigorous aerobic exercise training with improved cardiorespiratory fitness and diminished fatigue.

Clinical Feasibility of 2-Dimensional Video Analysis of Active Cervical Motion in Congenital Muscular Torticollis.

PURPOSE: The purpose of this study was to evaluate the clinical feasibility of using a 2-dimensional (2D) video analysis (VA) system compared with visual estimation (VE) for measurement of active cervical rotation and lateral flexion in infants with congenital muscular torticollis. METHODS: Twelve infants participated in this study. Active cervical motion in rotation and lateral flexion was measured by VE and 2D VA. RESULTS: Significant differences between VE and VA were found for left lateral flexion, right lateral flexion, and right rotation. Average total time for VA was 23.96 minutes. CONCLUSIONS: This study suggests that the use of VA may improve the measurement of active cervical motion to improve clinical assessment of infants with congenital muscular torticollis. However, VA time is excessive and, therefore, not clinically feasible. Further studies are indicated to explore other software for this application.

Antineutrino monitoring for heavy water reactors.

In this Letter we discuss the potential application of antineutrino monitoring to the Iranian heavy water reactor at Arak, the IR-40, as a nonproliferation measure. An above ground detector positioned right outside the IR-40 reactor building could meet IAEA verification goals for reactor plutonium inventories. While detectors with the needed spectral sensitivity have been demonstrated below ground, additional research and development is needed to demonstrate an above-ground detector with this same level of sensitivity. In addition to monitoring the reactor during operation, observing antineutrino emissions from long-lived fission products could also allow monitoring the reactor when it is shut down, provided very low detector backgrounds can be achieved. Antineutrino monitoring could also be used to distinguish different levels of fuel enrichment. Most importantly, these capabilities would not require a complete reactor operational history and could provide a means to reestablish continuity of knowledge in safeguards conclusions should this become necessary.

Share of Diagnostic Imaging Interpretation: Radiology and Other Specialties.

PURPOSE: The aim of this study was to examine radiology's and other specialties' market shares for diagnostic imaging interpretation for Medicare fee-for-service claims by modality, body region, and place of service. METHODS: In this cross-sectional study of Physician/Supplier Procedure Summary data for 2022, the authors examined the proportion of diagnostic imaging interpretation by specialty. All claims for CT, MR, nuclear medicine (NM), ultrasound, and radiography and fluoroscopy (XR) were included. Claims were aggregated into 52 specialty groups using Medicare specialty codes. The market share for each specialty group was computed by modality, body region, and place of service. RESULTS: For Medicare fee-for-service beneficiaries, there were 122,851,716 imaging studies, of which 88,559,272 (72.1%) were interpreted by radiologists. This percentage varied by modality: 97.3% for CT, 91.0% for MR, 76.6% for XR, 50.9% for NM, and 33.9% for ultrasound. Radiologists interpreted a lower percentage of cardiac (67.6% for CT, 42.2% for MR, 11.8% for NM, and 0.4% for ultrasound) than noncardiac studies (97.6% for CT, 91.4% for MR, 95.6% for NM, and 53.0% for ultrasound). Among noncardiac studies, radiologists interpreted nearly all in the outpatient hospital, inpatient, and emergency department (99.5% for CT, 99.4% for MR, 98.9% for NM, 79.3% for ultrasound, and 97.9% for XR) compared with the office setting (84.4% for CT, 78.7% for MR, 85.4% for NM, 29.2% for ultrasound, and 43.1% for XR). CONCLUSIONS: Radiologists perform the dominant share of CT and MR interpretation and more so for noncardiac imaging and imaging performed in outpatient hospital, inpatient, and emergency department places of service.

Decomposition of medical imaging spending growth between 2010 and 2021 in the US employer-insured population.

Medical imaging, identified as a potential driver of unsustainable US health care spending growth, was subject to policies to reduce prices and use in low-value settings. Meanwhile, the Affordable Care Act increased access to preventive services-many involving imaging-for employer-sponsored insurance (ESI) beneficiaries. We used a large insurance claims database to examine imaging spending trends in the ESI population between 2010 and 2021-a period of considerable policy and benefits changes. Nominal spending on imaging increased 35.9% between 2010 and 2021, but as a share of total health care spending fell from 10.5% to 8.9%. The 22.5% growth of nominal imaging prices was below inflation, 24.3%, as measured by the Consumer Price Index. Other key contributors to imaging spending growth were increased use (7.4 percentage points [pp]), shifts toward advanced modalities (4.0 pp), and demographic changes (3.5 pp). Shifts in care settings and provider network participation resulted in 2.5-pp and 0.3-pp imaging spending decreases, respectively. In sum, imaging spending decreased as a share of all health care spending and relative to inflation, as intended by concurrent cost-containment policies.