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Adjunct diagnostic strategies in improving diagnostic yields in image-guided biopsies of musculoskeletal neoplasms-A cost-effectiveness analysis

Ramkumar, Dipak B; Kelly, Sean P; Ramkumar, Niveditta; Gyftopoulos, Soterios; Raskin, Kevin A; Lozano-Calderon, Santiago A; Chang, Connie Y
BACKGROUND:Routine use of adjunct intraprocedural fresh frozen biopsy (FFP) or point-of-care (POC) cytology at the time of image-guided biopsy can improve diagnostic tissue yields for musculoskeletal neoplasms, but these are associated with increased costs. OBJECTIVE:This study aimed to ascertain the most cost-effective adjunctive test for image-guided biopsies of musculoskeletal neoplasms. METHODS:This expected value cost-effectiveness microsimulation compared the payoffs of cost (2020 United States dollars) and effectiveness (quality-adjusted life, in days) on each of the competing strategies. A literature review and institutional data were used to ascertain probabilities, diagnostic yields, utility values, and direct medical costs associated with each strategy. Payer and societal perspectives are presented. One- and two-way sensitivity analyses evaluated model uncertainties. RESULTS:The total cost and effectiveness for each of the strategies were $1248.98, $1414.09, $1980.53, and 80.31, 79.74, 79.69 days for the use of FFP, permanent pathology only, and POC cytology, respectively. The use of FFP dominated the competing strategies. Sensitivity analyses revealed FFP as the most cost-effective across all clinically plausible values. CONCLUSIONS:Adjunct FFP is most cost-effective in improving the diagnostic yield of image-guided biopsies for musculoskeletal neoplasms. These findings are robust to sensitivity analyses using clinically plausible probabilities.
PMID: 34416016
ISSN: 1096-9098
CID: 5006412

Ultrasound-MRI Correlation for Healing of Rotator Cuff Repairs Using Power Doppler, Sonographic Shear Wave Elastography and MR Signal Characteristics: A Pilot Study

Nocera, Nicole L; Burke, Christopher J; Gyftopoulos, Soterios; Adler, Ronald S
OBJECTIVE:To determine whether the healing response in rotator cuff repairs can be quantitatively characterized using a multimodality imaging approach with MR signal intensity, power Doppler and shear wave elastography (SWE). MATERIALS AND METHODS/METHODS:Patients scheduled for rotator cuff repair were prospectively enrolled between September 2013 and June 2016. A 12 patient cohort with unilateral, full-thickness, supraspinatus tendon tears underwent MRI and ultrasound both preoperatively and postoperatively (at 3 and 6 months post-surgery). The MR signal intensity ratio of tendon-to-deltoid muscle (TMR), vascularity score by power Doppler (PD) and shear wave velocity (SWV) were measured. Repaired and asymptomatic control shoulders were compared over time and between modalities. RESULTS:TMR and vascularity of the tendon repair initially increased and then decreased postoperatively. Although not achieving statistical significance, postoperative SWV initially decreased and later increased, which negatively correlated with the TMR at 3 months (r = -0.73, p = 0.005). PD demonstrated a statistically significant change in tendon vascularity over time compared to the contralateral control (p = 0.009 at 3 months; p = 0.036 at 6 months). No significant correlation occurred between TMR and SWE at 6 months, or with PD at any time point. CONCLUSION/CONCLUSIONS:Despite a small patient cohort, this prospective pilot study suggests a temporal relationship of MRI and ultrasound parameters that parallels the expected phases of healing in the repaired rotator cuff.
PMID: 33258512
ISSN: 1550-9613
CID: 4694042

Does image-guided biopsy of discitis-osteomyelitis provide meaningful information to impact clinical management?

Lim, Elisha; Walter, William; Gyftopoulos, Soterios; Samim, Mohammad
OBJECTIVE:The aims of this study are to assess the diagnostic yield of image-guided biopsy for discitis-osteomyelitis (DO), identify factors associated with biopsy yield (laboratory, pre-defined MRI findings, and biopsy technique), and impact of biopsy on management of patients appropriately selected according to the Infectious Disease Society of America guidelines (IDSA). MATERIALS AND METHODS/METHODS:This is a retrospective review of patients who underwent biopsy for suspected DO from 2011 to 2019. Reference standards to establish diagnosis of DO in order were histopathology/microbiology from biopsy or subsequent surgical sampling, positive blood culture or serology, and imaging/clinical follow-up. Laboratory markers, pre-biopsy antibiotics and MRI features, procedural-related variables, and impact of biopsy on management were assessed. Multivariable logistic regression was also performed. RESULTS:Out of 97 included patients, 78 were diagnosed with DO. Overall sensitivity of biopsy for detecting DO was 41.0% (32/78), including 10 patients with positive histopathology only, 14 with positive biopsy culture only, and 8 with both. Elevated ESR (p < 0.001) and epidural collection on MRI (p = 0.008) were associated with higher biopsy yield (63.6% and 68.6%, respectively) in a multivariable model. Procedural variables were not associated with yield. Biopsy results impacted the management in 19/77 (24.7%) patients, of whom 15/19 (78.9%) had treatment de-escalation and 4/19 (21.0%) had treatment escalation including starting new anti-tuberculous and anti-fungal regimens. CONCLUSION/CONCLUSIONS:Sensitivity of biopsy for detecting DO was 41.0%. When IDSA guidelines are followed, biopsy provided impactful information that changed the management in 24.7% of patients. Evaluation for elevated ESR and epidural collection can help improve yield and patient selection for biopsy.
PMID: 33230728
ISSN: 1432-2161
CID: 4680502

Assessment of myofiber microstructure changes due to atrophy and recovery with time-dependent diffusion MRI

Lemberskiy, Gregory; Feiweier, Thorsten; Gyftopoulos, Soterios; Axel, Leon; Novikov, Dmitry S; Fieremans, Els
Current clinical MRI evaluation of musculature largely focuses on nonquantitative assessments (including T1-, T2- and PD-weighted images), which may vary greatly between imaging systems and readers. This work aims to determine the efficacy of a quantitative approach to study the microstructure of muscles at the cellular level with the random permeable barrier model (RPBM) applied to time-dependent diffusion tensor imaging (DTI) for varying diffusion time. Patients (N = 15, eight males and seven females) with atrophied calf muscles due to immobilization of one leg in a nonweight-bearing cast, were enrolled after providing informed consent. Their calf muscles were imaged with stimulated echo diffusion for DTI, T1-mapping and RPBM modeling. Specifically, After cast removal, both calf muscles (atrophied and contralateral control leg) were imaged with MRI for all patients, with follow-up scans to monitor recovery of the atrophied leg for six patients after 4 and 8 weeks. We compare RPBM-derived microstructural metrics: myofiber diameter, a, and sarcolemma permeability, κ, along with macroscopic anatomical parameters (muscle cross-sectional area, fiber orientation, <θ>, and T1 relaxation). ROC analysis was used to compare parameters between control and atrophied muscle, while the Friedman test was used to evaluate the atrophied muscle longitudinally. We found that the RPBM framework enables measurement of microstructural parameters from diffusion time-dependent DTI, of which the myofiber diameter is a stronger predictor of intramuscular morphological changes than either macroscopic (anatomical) measurements or empirical diffusion parameters. This work demonstrates the potential of RPBM to assess pathological changes in musculature that seem undetectable with standard diffusion and anatomical MRI.
PMID: 34002901
ISSN: 1099-1492
CID: 4876922

Imaging-based patient-reported outcomes (PROs) database: How we do it

Gyftopoulos, Soterios; Jacobs, Adam; Samim, Mohammad
Patient-reported outcomes (PROs) provide an essential understanding of the impact a condition or treatment has on a patient, while complementing other, more traditional outcomes information like survival and time to symptom resolution. PROs have become increasingly important in medicine with the push toward patient-centered care. The creation of a PROs database within an institution or practice provides a way to collect, understand, and use this kind of patient feedback to inform quality improvement and develop the evidence base for medical decision-making and on a larger scale could potentially help determine national standards of care and treatment guidelines. This paper provides a first-hand account of our experience setting up an imaging-based PROs database at our institution and is organized into steps the reader can follow for creating a PROs database of their own. Given the limited use of PROs within both diagnostic and interventional radiology, we hope our paper stimulates a new interest among radiologists who may have never considered outcomes work in the past.
PMID: 32945932
ISSN: 1432-2161
CID: 4593502

Applying Business Strategy Principles to Radiology: Weight/Variance Principle [Editorial]

Gyftopoulos, Soterios; Ciavarra, Gina
PMID: 32741658
ISSN: 1878-4046
CID: 4553612

ACR Appropriateness Criteria® Chronic Foot Pain

Tafur, Monica; Bencardino, Jenny T; Roberts, Catherine C; Appel, Marc; Bell, Angela M; Gyftopoulos, Soterios; Metter, Darlene F; Mintz, Douglas N; Morrison, William B; Small, Kirstin M S; Subhas, Naveen; Weissman, Barbara N; Yu, Joseph S; Kransdorf, Mark J
Chronic foot pain is a frequent clinical complaint, which can significantly impact the quality of live in some individuals. These guidelines define best practices with regards to requisition of imaging studies based on specific clinical scenarios, which have been grouped into different variants. Each variant is accompanied by a brief description of the usefulness, advantages, and limitations of different imaging modalities. The present narrative is the result of an exhaustive assessment of the available literature and a thorough review process by a panel of experts on Musculoskeletal Imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
PMID: 33153552
ISSN: 1558-349x
CID: 4664342

MRI of superior capsular reconstruction graft and associated short-term clinical outcomes in patients with massive irreparable rotator cuff tears

Campbell, Abigail L; Baron, Samuel L; Pham, Hien; Gyftopoulos, Soterios; Meislin, Robert; Samim, Mohammad
OBJECTIVE:To assess MRI appearance of the dermal allograft and its correlation with clinical outcome following superior capsular reconstruction (SCR). MATERIALS AND METHODS/METHODS:This is a retrospective study of patients who underwent SCR between 2015 and 2018. Patients with postoperative MRI and clinical follow-up were included. Exclusion criteria were preoperative shoulder instability, advanced glenohumeral arthritis, and lack of postoperative MRI or clinical follow-up. Radiographs and MRIs were evaluated for graft integrity and position, acromiohumeral interval, superior subluxation distance (SSD), and glenohumeral cartilage loss. Correlation between imaging and clinical outcome measures were assessed. RESULTS:24 shoulders (23 patients) met the inclusion criteria at a mean clinical and MRI follow-up of 9.1 months. There were 12 intact grafts (50%) and 12 torn grafts (50%), most commonly at the glenoid attachment (8/12). Patients with graft tear had greater SSD (mean 10.5 ± 6.1 mm) than those without tear (mean 6.1 ± 3.8 mm) (p = 0.028). SSD > 7.9 mm had a 79% sensitivity and 91% specificity for graft tear. The intact grafts were more commonly covering the superior humeral head (91.7%) compared with the torn grafts (41.7%) (p = 0.027). There was improvement of clinical outcome measures including American Shoulder and Elbow Surgeons score (p = 0.005) and forward elevation (p = 0.021) although there was no correlation between clinical outcome and integrity of the graft. CONCLUSION/CONCLUSIONS:SCR results in significant short-term clinical improvement even in the presence of graft tear on postoperative MRIs on current study. Gap between graft and the anchors, non-superior position of the graft, and humeral head superior subluxation can be associated with tear.
PMID: 33129183
ISSN: 1873-4499
CID: 4655792

Comparison between radiography and magnetic resonance imaging for the detection of sacroiliitis in the initial diagnosis of axial spondyloarthritis: a cost-effectiveness study

Gorelik, Natalia; Tamizuddin, Farah; Rodrigues, Tatiane Cantarelli; Beltran, Luis; Malik, Fardina; Reddy, Soumya; Koo, James; Subhas, Naveen; Gyftopoulos, Soterios
OBJECTIVE:The purpose of our study was to determine the cost-effectiveness of radiography and MRI-based imaging strategies for the initial diagnosis of sacroiliitis in a hypothetical population with suspected axial spondyloarthritis. MATERIALS AND METHODS/METHODS:A decision analytic model from the health care system perspective for patients with inflammatory back pain suggestive of axial spondyloarthritis was used to evaluate the incremental cost-effectiveness of 3 imaging strategies for the sacroiliac joints over a 3-year horizon: radiography, MRI, and radiography followed by MRI. Comprehensive literature search and expert opinion provided input data on cost, probability, and utility estimates. The primary effectiveness outcome was quality-adjusted life-years (QALYs), with a willingness-to-pay threshold set to $100,000/QALY gained (2018 American dollars). RESULTS:Radiography was the least costly strategy ($46,220). Radiography followed by MRI was the most effective strategy over a 3-year course (2.64 QALYs). Radiography was the most cost-effective strategy. MRI-based and radiography followed by MRI-based strategies were not found to be cost-effective imaging options for this patient population. Radiography remained the most cost-effective strategy over all willingness-to-pay thresholds up to $100,000. CONCLUSION/CONCLUSIONS:Radiography is the most cost-effective imaging strategy for the initial diagnosis of sacroiliitis in patients with inflammatory back pain suspicious for axial spondyloarthritis.
PMID: 32382977
ISSN: 1432-2161
CID: 4430602

Analysis of Different Levels of Structured Reporting in Knee Magnetic Resonance Imaging: Commentary [Editorial]

Burke, Christopher J; Gyftopoulos, Soterios
PMID: 32336648
ISSN: 1878-4046
CID: 4411772