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Over the last 2 decades, the proliferation of magnetic resonance imaging (MRI) availability and continuous improvements in acquisition speeds have led to significantly increased MRI utilization across the health care system, and MRI studies are increasingly ordered in the emergent setting. Depending on the clinical presentation, MRI can yield vital diagnostic information not detectable with other imaging modalities. The aim of this text is to report on the up-to-date indications for MRI of the spine in the ED, and review the various MRI appearances of commonly encountered acute spine pathology, including traumatic injuries, acute non traumatic myelopathy, infection, neoplasia, degenerative disc disease, and postoperative complications. Imaging review will focus on the aspects of the disease process that are not readily resolved with other modalities.

Acute intracranial infections of the central nervous system and skull base are uncommon but time sensitive diagnoses that may present to the emergency department. As symptoms are frequently nonspecific or lack typical features of an infectious process, a high index of suspicion is required to confidently make the diagnosis, and imaging may not only serve as the first clue to an intracranial infection, but is often necessary to completely characterize the disease process and exclude any confounding conditions. Although computed tomography is typically the initial imaging modality for many of these patients, magnetic resonance imaging offers greater sensitivity and specificity in diagnosing intracranial infections, characterizing the full extent of infection, and identifying potential complications. The aim of this article is to serve as a review of the typical and most important imaging manifestations of these infections that can be encountered in the emergent setting.

Adjuvant endocrine therapy (AET) for breast cancer reduces mortality, but one-third to one-half of patients discontinue it early or are nonadherent.We developed a pilot single-site study of patients with evidence of early nonadherence to AET to assess the feasibility of a novel, clinical pharmacist-led intervention targeting symptom and medication management.Patients with prescription fill records showing nonadherence were enrolled in a single-arm feasibility study. Automated reminders were sent by e-mail or text with a link to symptom monitoring assessments weekly for 1 month and monthly until 6 months. Clinical oncology pharmacists used guideline-based symptom management and other medication management tools to support adherence and ameliorate symptoms reported on the assessments. Patient-reported outcome assessments included physical, mental, and social health domains and self-efficacy to manage symptoms and medications. Feasibility outcomes included completion of symptom reports and pharmacist recommendations.Of 19 participants who were nonadherent who enrolled and completed initial assessments, 18 completed all final study procedures, with 14 completing all assessments and no patient missing more than 3 assessments. All 18 participants reported at least one of 3 symptom types, and the majority reported attempting pharmacist recommendations. Patient-reported measures of physical, mental, and social health and self-efficacy improved, and 44% of the patients became adherent.An intervention using pharmacists in an oncology practice to systematically monitor and manage symptoms shows promise to reduce symptoms, enhance support and self-efficacy, and improve adherence to AET.

BACKGROUND Patient-centered care is respectful of and responsive to individual patient preferences, needs, and values. To provide patient-centered care, clinicians need to know and incorporate patients’ context into their communication and care with patients. Patient contextual data (PCD) encompass social determinants of health and patients’ needs, values, goals, and preferences relevant to their care. PCD can be challenging to collect as a routine component of the time-limited primary care visit. OBJECTIVE This study aims to determine if patient-provider communication and patient activation are different for patient users and patient nonusers of an electronic health record (EHR)–integrated PCD tool and assess if the impact of using PCD on patient-provider communication and patient activation differs for Black and White patients. METHODS We describe a randomized controlled trial of a prospective cohort of non-Hispanic White and Black patients who receive primary care services at a midwestern academic health care system in the United States. We will evaluate whether providing PCD through a consumer informatics tool enhances patient-provider communication, as measured by the Communication Assessment Tool, and we will evaluate patient activation, as measured by the Patient Activation Measure for PCD tool users and nonusers. Furthermore, owing to racial disparities in care and communication, we seek to determine if the adoption and use of the tool might narrow the differences between patient groups. RESULTS The trial was funded in November 2017 and received local ethics review approval in February 2019. The study began recruitment in April 2019 and enrollment concluded in October 2019 with 301 participants. The analysis was completed in May 2020, and trial results are expected to be published in winter 2020. CONCLUSIONS Recently, there has been increased attention to the role of health information technology tools to enable patients to collaborate with providers through the sharing of PCD. The adoption of such tools may overcome the barriers of current EHRs by directly engaging patients to submit their contextual data. Effectively, these tools would support the EHR in providing a more holistic understanding of the patient. Research further supports that individuals who have robust digital engagement using consumer informatics tools have higher participation in treatment follow-up and self-care across populations. Therefore, it is critical to investigate interventions that elicit and share patients’ social risks and care preferences with the health care team as a mechanism to improve individualized care and reduce the gap in health outcomes. CLINICALTRIAL ClinicalTrials.gov NCT03766841; https://clinicaltrials.gov/ct2/show/NCT03766841 INTERNATIONAL REGISTERED REPORT RR1-10.2196/20309

Blunt cerebrovascular injury involves injury to the carotid and/or vertebral arteries sustained via generalized multitrauma or directed blunt craniocervical trauma. Stroke remains the most consequential outcome. Timely diagnosis and initiation of treatment before the development of neurologic complications has a well-established role in decreasing morbidity and mortality. This article presents evidence and controversies surrounding the optimization of diagnostic imaging for suspected blunt cerebrovascular injury. Discussion centers on the increasing reliance on multidetector computed tomography angiography for screening, considering relevant clinical criteria for determining screening. Imaging protocols, imaging findings, injury grading, pearls, and pitfalls are discussed.

During surgical procedures, patients can have potentially life-threatening hypotension that requires immediate treatment with ephedrine sulfate, which requires compounding at the patient’s bedside. This study was conducted to validate and compare Nexus Pharmaceutical’s EMERPHED®, a pre-diluted ephedrine sulfate injection, with commercially used concentrated ephedrine sulfate in a simulated clinical setting. Twenty-four compounding simulations were performed in the clinical setting to simultaneously formulate EMERPHED® and concentrated ephedrine with a standardized dose of 10mg. The time to prepare the formulations, syringe volume, and the remaining contents of each vial were measured to determine compounding efficacy. Wastage reduction was theoretically discussed based on the waste disposal, and beyond use date. Inter-day variations were evaluated on different parameters. The time taken to formulate EMERPHED® was significantly faster (104.10±21.78 vs 70.63±12.45 seconds) than concentrated ephedrine (P≤0.05). The mean value for EMERPHED® was higher for the syringe accuracy, although it was not statistically significant (P=0.20) compared to concentrated ephedrine. Whereas for the remaining vial volume accuracy, EMERPHED® performed better (97.70±1.55% Vs 78.85±10.81%) than concentrated ephedrine (P≤0.05). Participants improved in the time to formulate both products between the first and second day. There was no significant difference in the percent mean accuracy of syringe dosing and remaining vial volume between days. There was no detected difference in waste reduction. EMERPHED® showed significantly greater compounding efficacy and ease of use compared to commercially available concentrated ephedrine in the clinical simulations. The results indicate that EMERPHED® could be a potential replacement option to institutions using concentrated ephedrine.

Blunt cerebrovascular injury involves injury to the carotid and/or vertebral arteries sustained via generalized multitrauma or directed blunt craniocervical trauma. Stroke remains the most consequential outcome. Timely diagnosis and initiation of treatment before the development of neurologic complications has a well-established role in decreasing morbidity and mortality. This article presents evidence and controversies surrounding the optimization of diagnostic imaging for suspected blunt cerebrovascular injury. Discussion centers on the increasing reliance on multidetector computed tomography angiography for screening, considering relevant clinical criteria for determining screening. Imaging protocols, imaging findings, injury grading, pearls, and pitfalls are discussed.

Discriminating among benign chondroid tumors, low-grade chondrosarcomas, and grade 2/3 chondrosarcomas is frequently difficult with standard imaging modalities. We systematically reviewed the literature to determine the performance of PET-CT in making this distinction. A systematic review was performed identifying 811 PubMed- and Embase-indexed articles containing combinations of “chondrosarcoma,” “enchondroma,” “chondroid,” “cartilage” and “PET/CT,” “PET,” “positron.” Eight articles including 166 lesions were included. Age, gender, tumor size, histologic grade, and SUVmax values were extracted for individual lesions when possible and otherwise recorded as aggregated data. Comparisons in SUVmax among benign, low-grade, and intermediate-/high-grade chondroid neoplasms were made. Individual SUVs were available for 101 lesions; 65 additional lesions were reported as aggregated data. There were 101 malignant and 65 benign tumors. Benign tumors were seen more frequently in females (p = 0.04, Fischer’s exact test), but malignancy was not associated with age or lesion size. SUVmax was lower for benign (1.6 ± 0.7) than malignant tumors (4.4 ± 2.5) (p

We studied health utilities in patients with type 1 diabetes to understand potential differences in health utilities as function of age, type of respondent (self report vs. proxy report), and method of assessment (direct vs. indirect).We elicited self-reported health utilities for adults (n=213) and children (n=238) with type 1 diabetes, and by parent proxy report (n=223) for overall quality of life [Health Utilities Index (HUI) Mark 3 and experienced time-trade-off (TTO) questions] and hypothetical complication states (TTO questions).Mean health utilities for overall quality of life (QOL) ranged from 0.81 to 0.91. Children had significantly higher overall QOL compared with adults (0.89 vs. 0.85, P0.01) by HUI, but had no significant difference in QOL by TTO. There were no significant differences in QOL between child self report and parent proxy report. Utilities were higher for HUI versus TTO for parent proxy report (P0.01) but not for adult or child self report. Utilities for hypothetical complication states were lower than for current QOL. Values were lower for stroke (0.34 to 0.53), end stage renal disease (0.47 to 0.55), and blindness (0.52 to 0.69) than for amputation (0.73 to 0.82) and angina (0.74 to 0.80). Complication utilities for parent proxy report were higher compared with adult self report for most hypothetical complication states.Individuals with type 1 diabetes with few complications report a relatively high QOL; however, future end stage complications are rated as having a significant impact on QOL. Differences in utilities by age, self report versus proxy report, and method raise important questions about whose utilities should be used in economic analyses.

Multiple chronic comorbidities (MCCs) are an issue of growing significance in diabetes because they are highly prevalent and can increase disease burden and costs. We examined MCC patterns among patients with type 2 diabetes mellitus and identified specific comorbidity clusters associated with poor patient outcomes.We conducted a cross-sectional analysis of 161,174 patients with diabetes using electronic health record data supplied by US providers in the 2008 to 2012 Humedica data sets. We examined prevalence of MCC clusters in younger and older patients. For each of the 15 most common MCC clusters, we reported predicted probabilities for diabetes face-to-face visits, reaching glycated hemoglobin8%; emergency department (ED) visits; and 30-day hospital readmissions, based on logistic regression results.The leading MCC combination was the presence of hypertension-hyperlipidemia-obesity and no other diagnosed comorbidities (19% of the sample). The most notable difference, by age, was a higher prevalence of obesity in the younger cohort. MCC clusters were more diverse among the older population: the top 10 MCC clusters accounted for 66% of older patients, compared with 78% of younger patients. Patients with certain comorbidity profiles, such as those with obesity only, were less likely to have diabetes-related face-to-face visits and to meet A1C treatment goals, and more likely to have ED visits and 30-day readmissions.Patients with diabetes have substantial comorbidities, but the patterns vary considerably across patients and by age. Diabetes care remained suboptimal among many types of MCC patients, and patient outcomes varied by MCC profile. Specific management strategies should be developed for common MCC clusters, such as hypertension-hyperlipidemia-obesity.

Value-based insurance design (V-BID) has emerged as an approach to improve health outcomes and contain healthcare costs by encouraging use of high-value care. We estimated the impact of a V-BID for osteoporosis treatments using comparative effectiveness evidence and real-world data from a California health insurance plan to estimate the benefits of the design's implementation.This study consisted of 4 steps. First, we reviewed randomized clinical trials including osteoporosis treatments-alendronate, ibandronate, risedronate, raloxifene, and teriparatide-reported in a recent Agency for Health Research Quality systematic review. Second, we performed a network meta-analysis to synthesize data from the clinical trials and estimate the comparative effectiveness of included treatments. Third, we implemented a V-BID by removing co-payments for the most effective treatments. Fourth, using a Monte Carlo simulation, we estimated the impact of the V-BID in terms of fracture reduction and cost-savings.Thirty-two randomized controlled trials were included in the network meta-analysis. We estimated that alendronate, risedronate, and teriparatide have the highest probability of being most effective across each fracture type-vertebral, hip, and nonvertebral/ nonhip. After eliminating co-payments, (ie, reducing them to zero), for these treatments, we estimated the health plan would experience a 7% (n = 287) decrease in fractures and an 8% ($6.8 million) decrease in costs.Our study illustrates the benefits of comparative effectiveness evidence in V-BID development. We show that where clinical trials are lacking, network meta-analysis can provide valuable insights into the potential clinical and economic benefits of V-BID.