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Midtlien JP, Iyer AM, Jones BS, Kittel C, Hirsch JA, Fargen KM. Conflicts of interest and neurointerventional surgery. J Neurointerv Surg 2024; 16:537-540. [PMID: 37491382 DOI: 10.1136/jnis-2023-020646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2023] [Indexed: 07/27/2023]
Affiliation(s)
- Jackson P Midtlien
- Neurological Surgery and Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Ankitha M Iyer
- Neurological Surgery and Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Brie S Jones
- Neurological Surgery and Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Carol Kittel
- Biostatistics, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Kyle M Fargen
- Neurological Surgery and Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Mazurek MH, Abruzzo AR, King AH, Koranteng E, Rigney G, Lie W, Razak S, Gupta R, Mehan WA, Lev MH, Hirsch JA, Buch KA, Succi MD. Implementation of a Survey Spine Magnetic Resonance Imaging Protocol for Cord Compression in the Emergency Department: Experience at a Level-1 Trauma Center. AJNR Am J Neuroradiol 2024:ajnr.A8326. [PMID: 38702066 DOI: 10.3174/ajnr.a8326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 04/22/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND AND PURPOSE Imaging stewardship in the emergency department (ED) is vital in ensuring patients receive optimized care. While suspected cord compression (CC) is a frequent indication for total spine MRI in the ED, the incidence of CC is low. Recently, our level-I trauma center introduced a survey spine MRI protocol to evaluate for suspected CC while reducing exam time to avoid imaging overutilization. This study aims to evaluate the time savings, frequency of ordering patterns of the survey, and the symptoms and outcomes of patients undergoing the survey. MATERIALS AND METHODS This retrospective study examined patients who received a survey spine MRI in the ED at our institution between 2018 and 2022. All exams were performed on a 1.5T GE scanner using our institutional CC survey protocol, which includes sagittal T2 and STIR sequences through the cervical, thoracic, and lumbar spine. Exams were read by a blinded, board-certified neuroradiologist. RESULTS A total of 2,002 patients received a survey spine MRI protocol during the study period. Of these patients, 845 (42.2%, mean age 57 ± 19 years, 45% female) received survey spine MRI exams for the suspicion of CC, and 120 patients (14.2% positivity rate) had radiographic CC. The survey spine MRI averaged 5 minutes and 50 seconds (79% faster than routine MRI). On multivariate analysis, trauma, back pain, lower extremity weakness, urinary or bowel incontinence, numbness, ataxia, and hyperreflexia were each independently associated with CC. Of the 120 patients with CC, 71 underwent emergent surgery, 20 underwent non-emergent surgery, and 29 were managed medically. CONCLUSIONS The survey spine protocol was positive for CC in 14% of patients in our cohort and acquired at a 79% faster rate compared to routine total spine. Understanding the positivity rate of CC, the clinical symptoms that are most associated with CC, and the subsequent care management for patients presenting with suspected cord compression who received the survey spine MRI may better inform the broad adoption and subsequent utilization of survey imaging protocols in emergency settings to increase throughput, improve allocation of resources, and provide efficient care for patients with suspected CC.ABBREVIATIONS: CC, cord compression; ED, emergency department; MRI, magnetic resonance imaging; T2; T2-weighted imaging sequence; STIR, short TI inversion recovery.
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Affiliation(s)
- Mercy H Mazurek
- From the Harvard Medical School, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Department of Radiology, Massachusetts General Hospital, Boston, MA (R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.)
| | - Annie R Abruzzo
- From the Harvard Medical School, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Department of Radiology, Massachusetts General Hospital, Boston, MA (R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.)
| | - Alexander H King
- From the Harvard Medical School, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Department of Radiology, Massachusetts General Hospital, Boston, MA (R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.)
| | - Erica Koranteng
- From the Harvard Medical School, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Department of Radiology, Massachusetts General Hospital, Boston, MA (R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.)
| | - Grant Rigney
- From the Harvard Medical School, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Department of Radiology, Massachusetts General Hospital, Boston, MA (R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.)
| | - Winston Lie
- From the Harvard Medical School, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Department of Radiology, Massachusetts General Hospital, Boston, MA (R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.)
| | - Shahaan Razak
- From the Harvard Medical School, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Department of Radiology, Massachusetts General Hospital, Boston, MA (R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.)
| | - Rajiv Gupta
- From the Harvard Medical School, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Department of Radiology, Massachusetts General Hospital, Boston, MA (R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.)
| | - William A Mehan
- From the Harvard Medical School, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Department of Radiology, Massachusetts General Hospital, Boston, MA (R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.)
| | - Michael H Lev
- From the Harvard Medical School, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Department of Radiology, Massachusetts General Hospital, Boston, MA (R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.)
| | - Joshua A Hirsch
- From the Harvard Medical School, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Department of Radiology, Massachusetts General Hospital, Boston, MA (R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.)
| | - Karen A Buch
- From the Harvard Medical School, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Department of Radiology, Massachusetts General Hospital, Boston, MA (R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.)
| | - Marc D Succi
- From the Harvard Medical School, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA (M.H.M., A.R.A.,A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Department of Radiology, Massachusetts General Hospital, Boston, MA (R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.)
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Ahmed RA, Hirsch JA, Leslie-Mazwi TM, Patel AB, Regenhardt RW. Penultimate proof for posterior occlusions: a commentary on "Focused update to guidelines for endovascular therapy for emergent large vessel occlusion: basilar artery occlusion patients". J Neurointerv Surg 2024:jnis-2024-021870. [PMID: 38729744 DOI: 10.1136/jnis-2024-021870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 05/12/2024]
Affiliation(s)
- Rashid A Ahmed
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Brook AD, Clerk-Lamalice O, De Leacy RA, Brook AL, Hirsch JA. Armed kyphoplasty-the future? J Neurointerv Surg 2024; 16:435. [PMID: 38448228 DOI: 10.1136/jnis-2024-021575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 03/08/2024]
Affiliation(s)
- Andrew D Brook
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Olivier Clerk-Lamalice
- Interventional Spine Service, Beam Interventional & Diagnostic Imaging, Calgary, Alberta, Canada
| | - Reade A De Leacy
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Allan L Brook
- Interventional Neuroradiology, Montefiore Medical center, Bronx, New York, USA
| | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
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Hirsch JA, Sahr DM, Brook AL, Chandra RV, Manfre L, Marcia S, Milburn J, Muto M. Basivertebral nerve ablation meets neurointervention-déjà vu? J Neurointerv Surg 2024:jnis-2024-021484. [PMID: 38653523 DOI: 10.1136/jnis-2024-021484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2024] [Indexed: 04/25/2024]
Affiliation(s)
- Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Diane M Sahr
- Perceive Medical LLC, Minneapolits, Minnesota, USA
| | - Allan L Brook
- Director of Interventional Neuroradiology, Montefiore Medical Center, Bronx, New York, USA
| | - Ronil V Chandra
- Interventional Neuroradiology, Monash Medical Center and Monash University, Clayton, Victoria, Australia
| | - Luigi Manfre
- ESNR Secretary of State, Department Head Minimally Invasive Spine, IOM Mediterranean Oncology Institute, Viagrande-Cantania, Sicily, Italy
| | - Stefano Marcia
- Departmento dei servizi, Radiologia Area Ospedaliera ASL Cagliari, SS Trinita Hospital, Cagliari, Sardinia, Italy
| | - James Milburn
- Department of Radiology, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Mario Muto
- Chairman Diagnostic and Interventional Radiology, Cardarelli Hospital, Naples, Italy
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Hirsch JA, Buch K, Keysor K, Mehan WA, Milburn JM. No Surprises Act: Legal Challenges and Implications for Radiology. J Am Coll Radiol 2024; 21:651-655. [PMID: 37922971 DOI: 10.1016/j.jacr.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/28/2023] [Accepted: 10/13/2023] [Indexed: 11/07/2023]
Abstract
When the word "surprise" is used as a noun, it generally describes an unexpected event. When "surprise" is used in conjunction with "billing", it conjures up images with which even the most hardened backroom medical administrator can empathize. One's first reaction is likely patient based, that a person received medical services from a health care provider or facility that are larger than anticipated in-network charges. As a result, the bill for services incorporates that, no-doubt unpleasant, surprise. The whole truth is understandably more complex. Radiology groups contract with insurance companies who for their own reasons, might have historically preferred progressively narrower networks. Nonetheless, these contracts allow providers the opportunity to negotiate reasonable payments for services rendered. Events have changed the historic dynamic between providers and insurance companies.
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Affiliation(s)
- Joshua A Hirsch
- Vice Chair of Procedural Services, Director of Interventional Neuroradiology, Chief of Interventional Spine, and Associate Department Quality Chair, Department of Radiology, Division of NeuroInterventional Radiology, Massachusetts General Hospital, Boston, Massachusetts; and Councilor SNIS, Chair of Future Trends Committee, and Chair of Academic Committee, ACR, Reston, Virginia.
| | - Karen Buch
- Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital, Boston, Massachusetts; and Member, ACR, Reston, Virginia
| | - Kathryn Keysor
- Senior Director, Economics & Health Policy Division and Staff, Payer Relations Committee and Network, ACR, Reston, Virginia
| | - William A Mehan
- Associate Chair, Radiology Finance and Associate Chair, Off-Campus Imaging, Massachusetts General Hospital, Boston, Massachusetts; and Member, ACR, Reston, Virginia
| | - James M Milburn
- Vice Chair of Radiology, Diagnostic Radiology Program Director, and Director of Neurointerventional Services, Department of Radiology, Ochsner Medical Center, New Orleans, Louisiana; and Chair, Neuroradiology Section of the Economics Committee and Alternate Councilor for Louisiana; and FACR Chair for Louisiana, ACR, Reston, Virginia
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Christensen EW, Waid MD, Hirsch JA, Parikh JR, Raja AS, Rathmell JP, Rula EY. Financial Viability of the No Surprises Act Independent Dispute Resolution Process: Radiology and Other Hospital-Based Specialties. AJR Am J Roentgenol 2024; 222:e2330687. [PMID: 38230900 DOI: 10.2214/ajr.23.30687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
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.
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Affiliation(s)
- Eric W Christensen
- Harvey L. Neiman Health Policy Institute, 1892 Preston White Dr, Reston, VA 20191
- Health Services Management, University of Minnesota, St. Paul, MN
| | - Mikki D Waid
- Harvey L. Neiman Health Policy Institute, 1892 Preston White Dr, Reston, VA 20191
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Jay R Parikh
- Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - James P Rathmell
- Department of Anesthesiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Elizabeth Y Rula
- Harvey L. Neiman Health Policy Institute, 1892 Preston White Dr, Reston, VA 20191
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Rigney GH, King AH, Chung J, Ghoshal S, Jain A, Shi Z, Razak S, Hirsch JA, Lev MH, Buch K, Succi MD. Trends in non-focal neurological chief complaints and CT angiography utilization among adults in the emergency department. Intern Emerg Med 2024:10.1007/s11739-024-03569-9. [PMID: 38512433 DOI: 10.1007/s11739-024-03569-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 02/22/2024] [Indexed: 03/23/2024]
Abstract
Prudent imaging use is essential for cost reduction and efficient patient triage. Recent efforts have focused on head and neck CTA in patients with emergent concerns for non-focal neurological complaints, but have failed to demonstrate whether increases in utilization have resulted in better care. The objective of this study was to examine trends in head and neck CTA ordering and determine whether a correlation exists between imaging utilization and positivity rates. This is a single-center retrospective observational study at a quaternary referral center. This study includes patients presenting with headache and/or dizziness to the emergency department between January 2017 and December 2021. Patients who received a head and neck CTA were compared to those who did not. The main outcomes included annual head and neck CTA utilization and positivity rates, defined as the percent of scans with attributable acute pathologies. Among 24,892 emergency department visits, 2264 (9.1%) underwent head and neck CTA imaging. The percentage of patients who received a scan over the study period increased from 7.89% (422/5351) in 2017 to 13.24% (662/5001) in 2021, representing a 67.4% increase from baseline (OR, 1.14; 95% CI 1.11-1.18; P < .001). The positivity rate, or the percentage of scans ordered that revealed attributable acute pathology, dropped from 16.8% (71/422) in 2017 to 10.4% (69/662) in 2021 (OR, 0.86; 95% CI 0.79-0.94; P = .001), a 38% reduction in positive examinations. Throughout the study period, there was a 67.4% increase in head and neck CTA ordering with a concomitant 38.1% decrease in positivity rate.
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Affiliation(s)
- Grant H Rigney
- Harvard Medical School, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Alexander H King
- Harvard Medical School, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Janice Chung
- Harvard Medical School, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Soham Ghoshal
- Harvard Medical School, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Aditya Jain
- Harvard Medical School, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Zhuo Shi
- Harvard Medical School, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Shahaan Razak
- Harvard Medical School, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Joshua A Hirsch
- Harvard Medical School, Boston, USA
- Department of Radiology, Massachusetts General Hospital, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Michael H Lev
- Harvard Medical School, Boston, USA
- Department of Radiology, Massachusetts General Hospital, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Karen Buch
- Harvard Medical School, Boston, USA
- Department of Radiology, Massachusetts General Hospital, Boston, USA
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA
| | - Marc D Succi
- Harvard Medical School, Boston, USA.
- Department of Radiology, Massachusetts General Hospital, Boston, USA.
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, USA.
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Levitt MR, Hirsch JA, Chen M. Middle meningeal artery embolization for chronic subdural hematoma: an effective treatment with a bright future. J Neurointerv Surg 2024; 16:329-330. [PMID: 38365442 DOI: 10.1136/jnis-2024-021602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 02/18/2024]
Affiliation(s)
- Michael R Levitt
- Departments of Neurological Surgery, Radiology, Neurology, Mechanical Engineering, and Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington, USA
| | - Joshua A Hirsch
- Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Chen
- Neurology, Neurosurgery and Radiology, Rush University Medical Center, Chicago, Illinois, USA
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10
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Fogel G, Musie J, Phillips TR, Shonnard M, Youssef S, Hirsch JA, Beall DP. Assessment and management of patients developing low energy vertebral compression fractures following basivertebral nerve ablation. Pain Med 2024; 25:249-251. [PMID: 37756701 DOI: 10.1093/pm/pnad132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/14/2023] [Accepted: 09/21/2023] [Indexed: 09/29/2023]
Affiliation(s)
- Guy Fogel
- Christus Santa Rosa Spine Clinic, San Antonio, TX 78229, United States
| | - Jacob Musie
- University of Texas at San Antonio, San Antonio, TX 78249, United States
| | | | - Matthew Shonnard
- Baylor Scott & White PM&R Department, Baylor Institute for Rehabilitation, Dallas, TX 75246, United States
| | - Salma Youssef
- University College Dublin School of Medicine, University College Dublin, Belfield, Dublin 4D04 V1W8, Ireland
| | - Joshua A Hirsch
- Massachusetts General Hospital, Harvard Medical School Department of Interventional Neuroradiology, Boston, MA 02114, United States
| | - Douglas P Beall
- Comprehensive Specialty Care, Edmond, OK 73034, United States
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11
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Ospel JM, Kunz WG, Rinkel LA, Sanelli PC, Hirsch JA. What should neurointerventionalists know about cost-effectiveness research, and why should they care? J Neurointerv Surg 2024; 16:221-224. [PMID: 37468268 DOI: 10.1136/jnis-2023-020753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2023] [Indexed: 07/21/2023]
Affiliation(s)
- Johanna M Ospel
- Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Wolfgang G Kunz
- Department of Radiology, Ludwig Maximilians University Munich, Munich, Germany
| | - Leon A Rinkel
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Neurology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Pina C Sanelli
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
- Institute for Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
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12
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Manchikanti L, Knezevic E, Knezevic NN, Sanapati MR, Kaye AD, Abdi S, Soin A, Hirsch JA. Effectiveness of Facet Joint Nerve Blocks in Managing Chronic Axial Spinal Pain of Facet Joint Origin: A Systematic Review and Meta-Analysis. Pain Physician 2024; 27:E169-E206. [PMID: 38324785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
BACKGROUND Chronic axial spinal pain is one of the major causes of disability. Literature shows that spending on low back and neck pain and musculoskeletal disorders continues to escalate, not only with disability, but also with increasing costs, accounting for the highest amount of various disease categories. Based on the current literature utilizing controlled diagnostic blocks, facet joints, nerve root dura, and sacroiliac joints have been shown as potential sources of spinal pain. Therapeutic facet joint interventional modalities of axial spinal pain include radiofrequency neurotomy, therapeutic facet joint nerve blocks, and therapeutic intraarticular injections. OBJECTIVE The objective of this systematic review and meta-analysis is to evaluate the effectiveness of facet joint nerve blocks as a therapeutic modality in managing chronic axial spinal pain of facet joint origin. STUDY DESIGN A systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. METHODS The available literature on facet joint nerve blocks in axial spinal pain was reviewed. The quality assessment criteria utilized were the Cochrane review criteria to assess risk of bias, the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) for randomized therapeutic trials, and the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR) for nonrandomized studies. The evidence was graded according to Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) assessment criteria. The level of evidence was based on best evidence synthesis with modified grading of qualitative evidence from Level I to Level V. A comprehensive literature search of multiple databases from 1966 to July 2023, including manual searches of the bibliography of known review articles was performed. Quality assessment of the included studies and best evidence synthesis were incorporated into qualitative and quantitative evidence synthesis. OUTCOME MEASURES The primary outcome measure was the proportion of patients with significant relief and functional improvement of greater than 50% of at least 3 months. Duration of relief was categorized as short-term (less than 6 months) and long-term (greater than 6 months). RESULTS This assessment identified 8 high-quality and one moderate quality RCTs and 8 high quality and 4 moderate quality non-randomized studies with application of spinal facet joint nerve blocks as therapeutic modalities. However, based on the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) assessment, only 3 of the 21 studies showed high levels of evidence and clinical applicability, with 11 studies showing moderate levels of GRADE evidence and clinical applicability. LIMITATIONS Despite the availability of multiple studies, the paucity of literature is considered as the major drawback. Based on Grading of Recommendations, Assessment Development, and Evaluations (GRADE) assessment, only 3 of the 21 studies showed high levels of evidence and clinical applicability. CONCLUSION Based on the present systematic review and meta-analysis with 9 RCTs and 12 non-randomized studies, the evidence is Level II with moderate to strong recommendation for therapeutic facet joint nerve blocks in managing spinal facet joint pain.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA
| | - Emilija Knezevic
- University of Illinois at Urbana-Champaign, College of Liberal Arts and Sciences, Champaign, IL
| | - Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center and College of Medicine, University of Illinois, Chicago, IL
| | | | - Alan D Kaye
- Louisiana State University School of Medicine, Shreveport, LA
| | - Salahadin Abdi
- Department of Pain Medicine, Division of Anesthesiology, Critical Care, Medicine, and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Amol Soin
- Wright State University Boonshoft School of Medicine, Fairborn, OH; Ohio Pain Clinic, Dayton, OH
| | - Joshua A Hirsch
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
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13
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Mbonde A, Young MJ, Dmytriw AA, Moyer QJ, Hirsch JA, Leslie-Mazwi TM, Rost NS, Patel AB, Regenhardt RW. Informed consent practices for acute stroke therapy: principles, challenges and emerging opportunities. J Neurol 2024; 271:188-197. [PMID: 37815578 DOI: 10.1007/s00415-023-12028-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/24/2023] [Accepted: 09/25/2023] [Indexed: 10/11/2023]
Abstract
IMPORTANCE Informed consent (IC) plays a crucial yet underexplored role in acute stroke treatment, particularly in the context of intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT). This narrative review examines data on current IC practices in acute ischemic stroke management, specifically for patients treated with IVT or EVT, with the aim of identifying areas for improvement and strategies to enhance the IC process. OBSERVATIONS IC practices for IVT vary significantly among hospitals and physicians with the frequency of always requiring consent ranging from 21 to 37%. Factors influencing IC for IVT include patient decision-making capacity, standard of care, time sensitive nature of treatments, legal and moral obligations, risk of complications, physician age and speciality, treatment delays, and hospital size. Consent requirements tend to be stricter for patients presenting within the 3-4.5-h window. The content and style of information shared as part of the IC process revealed discrepancies in the disclosure of stroke diagnosis, IVT mechanism, benefits, and risks. Research on IC practices for EVT is scarce, highlighting a concerning gap in the available evidence base. CONCLUSIONS AND RELEVANCE This review underscores the significant variability and knowledge gaps in IC for EVT and IVT. Challenges related to decision-making capacity assessment and the absence of standardised guidance substantially contributes to these gaps. Future initiatives should focus on simplifying information delivery to patients, developing formal tools for assessing capacity, standardising ethical frameworks to guide physicians when patients lack capacity and harmonizing IC standards across sites. The ultimate goal is to enhance IC practices and uphold patient autonomy, while ensuring timely treatment initiation.
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Affiliation(s)
- Amir Mbonde
- Harvard Medical School, Boston, MA, USA.
- Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA.
| | | | - Adam A Dmytriw
- Harvard Medical School, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Quentin J Moyer
- Harvard Medical School, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | | | | | | | - Robert W Regenhardt
- Harvard Medical School, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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14
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Fargen KM, Kittel C, Curry BP, Hile CW, Wolfe SQ, Brown P, Mokin M, Rai AT, Chen M, Starke RM, Albuquerque FC, Ansari SA, Kan P, Spiotta AM, Dabus G, Leslie-Mazwi TM, Hirsch JA. Mechanical thrombectomy decision making and prognostication: Stroke treatment Assessments prior to Thrombectomy In Neurointervention (SATIN) study. J Neurointerv Surg 2023; 15:e381-e387. [PMID: 36609542 DOI: 10.1136/jnis-2022-019741] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 12/28/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Mechanical thrombectomy (MT) is the standard-of-care treatment for stroke patients with emergent large vessel occlusions. Despite this, little is known about physician decision making regarding MT and prognostic accuracy. METHODS A prospective multicenter cohort study of patients undergoing MT was performed at 11 comprehensive stroke centers. The attending neurointerventionalist completed a preprocedure survey prior to arterial access and identified key decision factors and the most likely radiographic and clinical outcome at 90 days. Post hoc review was subsequently performed to document hospital course and outcome. RESULTS 299 patients were enrolled. Good clinical outcome (modified Rankin Scale (mRS) score of 0-2) was obtained in 38% of patients. The most frequently identified factors influencing the decision to proceed with thrombectomy were site of occlusion (81%), National Institutes of Health Stroke Scale score (74%), and perfusion imaging mismatch (43%). Premorbid mRS score determination in the hyperacute setting accurately matched retrospectively collected data from the hospital admission in only 140 patients (46.8%). Physicians correctly predicted the patient's 90 day mRS tertile (0-2, 3-4, or 5-6) and final modified Thrombolysis in Ischemic Cerebral Infarction score preprocedure in only 44.2% and 44.3% of patients, respectively. Clinicians tended to overestimate the influence of occlusion site and perfusion imaging on outcomes, while underestimating the importance of pre-morbid mRS. CONCLUSIONS This is the first prospective study to evaluate neurointerventionalists' ability to accurately predict clinical outcome after MT. Overall, neurointerventionalists performed poorly in prognosticating patient 90 day outcomes, raising ethical questions regarding whether MT should be withheld in patients with emergent large vessel occlusions thought to have a poor prognosis.
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Affiliation(s)
- Kyle M Fargen
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Carol Kittel
- Division of Public Health Sciences, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Brian P Curry
- Neurological Surgery, Walter Reed Army Medical Center, Bethesda, Maryland, USA
| | - Connor W Hile
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Stacey Q Wolfe
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Patrick Brown
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Maxim Mokin
- Neurosurgery, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Ansaar T Rai
- Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
| | - Michael Chen
- Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Robert M Starke
- Department of Neurosurgery and Radiology, University of Miami School of Medicine, Miami, Florida, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Sameer A Ansari
- Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Peter Kan
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Guilherme Dabus
- Interventional Neuroradiology and Neuroendovascular Surgery, Miami Neuroscience Institute and Miami Cardiac and Vascular Institute-Baptist Hospital, Miami, Florida, USA
| | | | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
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15
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Fiorella D, Jovin TG, Arthur AS, Nogueira R, Siddiqui AH, Hirsch JA, Albuquerque FC. Triage of Emergent Large Vessel Occlusion (ELVO) patients directly to Comprehensive Stroke Centers (CSCs) is good practice and benefits patients in Urban and Suburban population Centers - New insights from the TRIAGE-STROKE and RACECAT studies. J Neurointerv Surg 2023; 16:1-3. [PMID: 38114326 DOI: 10.1136/jnis-2023-021341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Affiliation(s)
- David Fiorella
- Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA
- SUNY SB, Stony Brook, New York, USA
| | - Tudor G Jovin
- Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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16
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Ahmed RA, Dmytriw AA, Regenhardt RW, Leslie-Mazwi TM, Hirsch JA. Posterior circulation cerebral infarction: A review of clinical, imaging features, management, and outcomes. Eur J Radiol Open 2023; 11:100523. [PMID: 37745629 PMCID: PMC10511775 DOI: 10.1016/j.ejro.2023.100523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 09/11/2023] [Indexed: 09/26/2023] Open
Abstract
Objective This narrative review discusses posterior circulation cerebral infarcts (PCCI) and provides an update given recent randomized trials in the management of basilar artery occlusion (BAO). We examine clinical characteristics, imaging protocols, management updates, and outcomes of PCCI. Methods The following databases were searched: MEDLINE, Scopus, Google Scholar, and Web of Science for articles on PCCI. We included randomized trials and observational studies in humans. We also reviewed relevant references from the literature identified. Results PCCI and BAO is associated with high morbidity and mortality. Early assessment and accurate diagnosis of PCCI remains a clinical challenge. Neuroimaging advances have improved early detection, but barriers remain due to costs and availability. Recent randomized trials provide new insights for BAO patients and support the efficacy of endovascular thrombectomy. Discussion PCCI requires specific diagnostic and management that is distinct from anterior circulation stroke. While further studies are needed in varied populations and in the subset of BAO patients presenting with milder deficits, growing randomized data support the treatment of BAO patients with endovascular thrombectomy.
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Affiliation(s)
- Rashid A. Ahmed
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA
| | - Adam A. Dmytriw
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, USA
| | - Robert W. Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, USA
| | - Thabele M. Leslie-Mazwi
- Department of Neurology, Neurosciences Institute, University of Washington, Seattle, WA, USA
| | - Joshua A. Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, USA
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17
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Manchikanti L, Kaye AM, Knezevic NN, Giordano J, Applewhite MK, Bautista A, Soin A, Blank SK, Sanapati MR, Karri J, Christo PJ, Abd-Elsayed A, Kaye AD, Calodney A, Navani A, Gharibo CG, Harned M, Gupta M, Broachwala M, Sehgal N, Kaufman A, Wargo B, Solanki DR, Hsu ES, Limerick G, Dennis A, Swicegood JR, Slavin K, Snook L, Pasupuleti R, Kosanovic R, Justiz R, Barkin R, Atluri S, Shah S, Pampati V, Helm Ii S, Grami V, Myckowiak V, Galan V, Singh V, Manocha V, Hirsch JA. Comprehensive, Evidence-Based, Consensus Guidelines for Prescription of Opioids for Chronic Non-Cancer Pain from the American Society of Interventional Pain Physicians (ASIPP). Pain Physician 2023; 26:S7-S126. [PMID: 38117465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
BACKGROUND Opioid prescribing in the United States is decreasing, however, the opioid epidemic is continuing at an uncontrollable rate. Available data show a significant number of opioid deaths, primarily associated with illicit fentanyl use. It is interesting to also note that the data show no clear correlation between opioid prescribing (either number of prescriptions or morphine milligram equivalent [MME] per capita), opioid hospitalizations, and deaths. Furthermore, the data suggest that the 2016 guidelines from the Centers for Disease Control and Prevention (CDC) have resulted in notable problems including increased hospitalizations and mental health disorders due to the lack of appropriate opioid prescribing as well as inaptly rapid tapering or weaning processes. Consequently, when examined in light of other policies and complications caused by COVID-19, a fourth wave of the opioid epidemic has been emerging. OBJECTIVES In light of this, we herein seek to provide guidance for the prescription of opioids for the management of chronic non-cancer pain. These clinical practice guidelines are based upon a systematic review of both clinical and epidemiological evidence and have been developed by a panel of multidisciplinary experts assessing the quality of the evidence and the strength of recommendations and offer a clear explanation of logical relationships between various care options and health outcomes. METHODS The methods utilized included the development of objectives and key questions for the various facets of opioid prescribing practice. Also utilized were employment of trustworthy standards, and appropriate disclosures of conflicts of interest(s). The literature pertaining to opioid use, abuse, effectiveness, and adverse consequences was reviewed. The recommendations were developed after the appropriate review of text and questions by a panel of multidisciplinary subject matter experts, who tabulated comments, incorporated changes, and developed focal responses to questions posed. The multidisciplinary panel finalized 20 guideline recommendations for prescription of opioids for chronic non-cancer pain. Summary of the results showed over 90% agreement for the final 20 recommendations with strong consensus. The consensus guidelines included 4 sections specific to opioid therapy with 1) ten recommendations particular to initial steps of opioid therapy; 2) five recommendations for assessment of effectiveness of opioid therapy; 3) three recommendations regarding monitoring adherence and side effects; and 4) two general, final phase recommendations. LIMITATIONS There is a continued paucity of literature of long-term opioid therapy addressing chronic non-cancer pain. Further, significant biases exist in the preparation of guidelines, which has led to highly variable rules and regulations across various states. CONCLUSION These guidelines were developed based upon a comprehensive review of the literature, consensus among expert panelists, and in alignment with patient preferences, and shared decision-making so as to improve the long-term pain relief and function in patients with chronic non-cancer pain. Consequently, it was concluded - and herein recommended - that chronic opioid therapy should be provided in low doses with appropriate adherence monitoring and understanding of adverse events only to those patients with a proven medical necessity, and who exhibit stable improvement in both pain relief and activities of daily function, either independently or in conjunction with other modalities of treatments.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA
| | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA
| | - Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center and College of Medicine, University of Illinois, Chicago, IL
| | - James Giordano
- Department of Defense Medical Ethics Center, Uniformed Services University of Health Sciences, Bethesda, MD; Departments of Neurology and Biochemistry and Pellegrino Center for Clinical Bioethics, Georgetown University Medical Center, Washington DC
| | - Megan K Applewhite
- Department of Surgery and MacClean Center of Bioethics, University of Chicago, Chicago, IL; Department of Defense Medical Ethics Center, Uniformed Services University of Health Sciences, Bethesda, MD
| | - Alexander Bautista
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA
| | - Amol Soin
- Wright State University Boonshoft School of Medicine, Fairborn, OH; Ohio Pain Clinic, Dayton, OH
| | | | | | - Jay Karri
- Department of Anesthesiology and Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Paul J Christo
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alaa Abd-Elsayed
- UW Health Pain Services and University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Alan D Kaye
- Louisiana State University School of Medicine, Shreveport, LA
| | - Aaron Calodney
- Precision Spine Care, Tyler, TX and Department of Anesthesiology, Louisiana State University, Shreveport, LA, USA
| | - Annu Navani
- Le Reve Regenerative Wellness, Campbell, CA; Stanford University School of Medicine, Stanford, CA; Boomerang Health Care, Walnut Creek, CA, USA
| | - Christopher G Gharibo
- Peri-Operative Care & Pain Medicine and Orthopedics at NYU Grossman School of Medicine, New York, NY, USA
| | - Michael Harned
- Department of Anesthesiology, Perioperative, Critical Care and Pain Medicine, University of Kentucky, Lexington, KY, USA
| | - Mayank Gupta
- Kansas Pain Management and Neuroscience Research Center, LLC, Overland Park, KS; Department of Clinical Education, Kansas City University of Medicine and Biosciences, Kansas City, MO, USA
| | | | - Nalini Sehgal
- Department of Orthopedics and Rehabilitation, UW Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Andrew Kaufman
- Departments of Pain Management and Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Bradley Wargo
- Baptist University, Memphis, TN; Shoals Interventional Pain Management, Muscle Shoals, AL, USA
| | - Daneshvari R Solanki
- University of Texas Medical Branch, Galveston, TX; HD Research, First Surgical Hospital, Bellaire, TX, USA
| | - Eric S Hsu
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, CA, USA
| | - Gerard Limerick
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allen Dennis
- Advanced Pain Care and Round Rock Surgery Center, Round Rock, TX, USA
| | | | - Konstantin Slavin
- Department of Neurosurgery, University of Illinois at Chicago, and Neurology Section, Jesse Brown Veterans Administration Medical Center, Chicago, IL, USA
| | - Lee Snook
- Metropolitan Pain Management Consultants, Inc., Sacramento, CA
| | | | - Radomir Kosanovic
- Interventional Pain Management, Baptist Health South Florida, Miami, FL, USA
| | - Rafael Justiz
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | | | - Shalini Shah
- Department of Anesthesiology & Perioperative Care, University of California Irvine Health, Orange, CA, USA
| | | | - Standiford Helm Ii
- Division of Pain Medicine, Department of Anesthesiology and Peri-Operative Care, University of California, Irvine, UCI Health Center for Pain and Wellness, Gottschalk Medical Plaza, Irvine, CA, USA
| | - Vahid Grami
- Department of Anesthesiology and Pain Medicine, Geisinger Commonwealth School of Medicine, Danville, PA, USA
| | - Vicki Myckowiak
- Partner with The Health Law Partners, Farmington Hills, MI, USA
| | - Vincent Galan
- Georgia Pain Care & Affiliated Surgery Center; Center for Pain and Spine, Stockbridge, GA, USA
| | - Vijay Singh
- Spine Pain Diagnostics Associates, Niagara, WI
| | - Vivek Manocha
- Department of Surgery, Wright State University School of Medicine, Dayton, OH; Beacon Orthopedics & Sports Medicine, Cincinnati, OH, USA
| | - Joshua A Hirsch
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
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18
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Ahmed RA, Dmytriw AA, Patel AB, Stapleton CJ, Vranic JE, Rabinov JD, Leslie-Mazwi TM, Rost NS, Hirsch JA, Regenhardt RW. Basilar artery occlusion: A review of clinicoradiologic features, treatment selection, and endovascular techniques. Interv Neuroradiol 2023; 29:748-758. [PMID: 35695210 PMCID: PMC10680956 DOI: 10.1177/15910199221106049] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/17/2022] [Accepted: 05/15/2022] [Indexed: 12/20/2022] Open
Abstract
Basilar artery occlusion (BAO) is an infrequent but often fatal subtype of stroke. Predicting outcomes and selecting patients for endovascular therapy (EVT) remains challenging. Advances in neuroimaging and the development of prognostic scoring systems have augmented clinical decision-making over time. Recent randomized trials, BEST (Basilar Artery Occlusion Endovascular Intervention vs. Standard Medical Treatment), BASICS (Basilar Artery International Cooperation Study), BAOCHE (Basilar Artery Occlusion CHinese Endovascular Trial) and ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion), compared EVT and medical management for patients with BAO. These trials yielded mixed results. The former two suggested unclear benefit while the latter two supported a benefit of EVT. While all had limitations, most providers agree caution should be exercised when excluding patients from EVT who may stand to benefit. Further studies are therefore needed to determine the effectiveness, safety, selection criteria, and optimal technical approach for EVT among patients with BAO. Hyperacute-phase advanced imaging can offer several benefits to aid decision making. It is reasonable to exclude patients with low National Institutes of Health Stroke Scale (NIHSS), large imaging-proven cores, and evidence of perforator occlusion by branch atheromatous disease. Herein, we review the clinical presentation, imaging work-up, treatments, and clinical outcomes for BAO, while highlighting knowledge gaps in treatment selection and technique.
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Affiliation(s)
- Rashid A Ahmed
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam A Dmytriw
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher J Stapleton
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Justin E Vranic
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - James D Rabinov
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thabele M Leslie-Mazwi
- Department of Neurology, Neurosciences Institute, University of Washington, Seattle, WA, USA
| | - Natalia S Rost
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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19
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Grossberg JA, Heller RE, Niknejad KG, Milburn JM, Hirsch JA. No Surprises Act - what neurointerventionalists need to know. J Neurointerv Surg 2023:jnis-2023-021147. [PMID: 38041672 DOI: 10.1136/jnis-2023-021147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 12/03/2023]
Affiliation(s)
| | | | - Kathy G Niknejad
- Urology and Chief Medical Offer, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - James M Milburn
- Radiology, Ochsner Medical System, New Orleans, Louisiana, USA
| | - Joshua A Hirsch
- Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
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20
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Grewal SS, Hirsch JA, Cancelliere NM, Ghozy S, Pereira VM, Dmytriw AA. Efficacy and safety of percutaneous cement discoplasty in the management of degenerative spinal diseases: A systematic review and meta-analysis. Neuroradiol J 2023:19714009231212368. [PMID: 37920948 DOI: 10.1177/19714009231212368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Percutaneous cement discoplasty (PCD) is a minimally invasive procedure. We aim to explore the efficacy and indication(s) of PCD in patients with degenerative disc disease (DDD). METHODS The search was conducted across Ovid MEDLINE, Ovid Embase, and PubMed. Data on study design, patient demographics, pre- and post-procedure Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) scores, and complications were extracted. Inclusion criteria focused on adult patients with degenerative spinal diseases treated with cement discoplasty. The overall effect size was evaluated using a forest plot, and heterogeneity was assessed using the I2 statistic and chi-squared test. RESULTS The search strategy yielded six studies, which included 336 patients (73.8% female, 26.2% male) with a mean average age of 74.6 years. VAS scores were reported in all studies, showing a significant difference between pre- and post-PCD pain scores (Weighted Mean Difference [WMD]: -3.45; 95% CI: -3.83, -3.08; I2 = 15%; P < .001). ODI scores were reported in 83% of studies, with a significant difference between pre- and post-PCD scores (WMD: -22.22; 95% CI: -25.54, -18.89; I2 = 61%; p < .001). Complications reported included infections, thrombophlebitis, vertebral fractures, disc extrusion, and the need for further operations. CONCLUSIONS The analysis showed clinically significant improvements in pain and functional disability based on VAS and ODI scores. However, due to methodological limitations and a high risk of bias, the validity and generalizability of the findings are uncertain. Despite these issues, the results provide preliminary insights into PCD's potential efficacy and can guide future research to address current limitations.
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Affiliation(s)
- Sahibjot Singh Grewal
- Neurovascular Centre, Departments of Medical Imaging & Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Joshua A Hirsch
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicole M Cancelliere
- Neurovascular Centre, Departments of Medical Imaging & Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Nuffield Department of Primary Care Health Sciences and Department for Continuing Education (EBHC program), Oxford University, Oxford, UK
| | - Vitor Mendes Pereira
- Neurovascular Centre, Departments of Medical Imaging & Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Adam A Dmytriw
- Neurovascular Centre, Departments of Medical Imaging & Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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21
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Ospel JM, Dmytriw AA, Regenhardt RW, Patel AB, Hirsch JA, Kurz M, Goyal M, Ganesh A. Recent developments in pre-hospital and in-hospital triage for endovascular stroke treatment. J Neurointerv Surg 2023; 15:1065-1071. [PMID: 36241225 DOI: 10.1136/jnis-2021-018547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 10/05/2022] [Indexed: 11/04/2022]
Abstract
Triage describes the assignment of resources based on where they can be best used, are most needed, or are most likely to achieve success. Triage is of particular importance in time-critical conditions such as acute ischemic stroke. In this setting, one of the goals of triage is to minimize the delay to endovascular thrombectomy (EVT), without delaying intravenous thrombolysis or other time-critical treatments including patients who cannot benefit from EVT. EVT triage is highly context-specific, and depends on availability of financial resources, staff resources, local infrastructure, and geography. Furthermore, the EVT triage landscape is constantly changing, as EVT indications evolve and new neuroimaging methods, EVT technologies, and adjunctive medical treatments are developed and refined. This review provides an overview of recent developments in EVT triage at both the pre-hospital and in-hospital stages. We discuss pre-hospital large vessel occlusion detection tools, transport paradigms, in-hospital workflows, acute stroke neuroimaging protocols, and angiography suite workflows. The most important factor in EVT triage, however, is teamwork. Irrespective of any new technology, EVT triage will only reach optimal performance if all team members, including paramedics, nurses, technologists, emergency physicians, neurologists, radiologists, neurosurgeons, and anesthesiologists, are involved and engaged. Thus, building sustainable relationships through continuous efforts and hands-on training forms an integral part in ensuring rapid and efficient EVT triage.
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Affiliation(s)
- Johanna M Ospel
- Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Neurointerventional Program, Departments of Medical Imaging & Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ontario, Canada
| | | | - Aman B Patel
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Martin Kurz
- Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Mayank Goyal
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Aravind Ganesh
- Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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22
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Manchikanti L, Sanapati MR, Pampati V, Hirsch JA. Compliance and Documentation for Evaluation and Management Services in Interventional Pain Management Practice. Pain Physician 2023; 26:503-525. [PMID: 37976475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Evaluation of new and established patients is an integral part of interventional pain management. Over the last 3 decades, there has been significant confusion over the proper documentation for evaluation and management (E/M) services in general and for interventional pain management in particular. Interventional pain physicians have learned how to evaluate patients presenting with pain on the basis of their specialty training. Although modern training programs are introducing residents and fellows to the intricacies of E/M services and federal regulations, this has not always been the case. Multiple textbooks about pain management, physiatry, and neurology, and numerous journal articles have described the evaluation of pain patients, but they have not been specific to chronic pain patients and may not meet the regulatory perspective.A multitude of these issues led to the development of guidelines in 1995 and 1997, which were highly complicated and difficult to follow. These also led to significant criticism from clinicians. Consequently, further guidance was developed to be effective January 2021.The crucial concept in the present system of coding for E/M services is medical decision making, which includes 3 elements since 2021: 1.The number and complexity of problems addressed. 2. Amount or complexity of data to be reviewed and analyzed. 3. Risk of complications and/or morbidity or mortality of patient management. In order to select a level of E/M service, 2 of the 3 elements of medical decision making (MDM) must be met or exceeded. This is in contrast to prior guidelines wherein for new patients, all 3 elements with history, physical examination and MDM , and for established patients have been met. For ease of appreciation, an algorithmic approach created by the American Medical Association (AMA), and Centers for Medicare and Medicaid Services (CMS) approved a new MDM table outlining all of the appropriate criteria.This review systematically describes the changes and provides an algorithmic approach for application in interventional pain management practices.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA
| | | | | | - Joshua A Hirsch
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
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23
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Hirsch JA, Milburn JM, Woo H, Chen M, Chen MM, Mocco J. 61624/26 and You! J Neurointerv Surg 2023; 15:1059-1060. [PMID: 37734931 DOI: 10.1136/jnis-2023-021005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James M Milburn
- Radiology, Ochsner Medical System, New Orleans, Louisiana, USA
| | - Henry Woo
- Neurosurgery, Stony Brook University, Stony Brook, New York, USA
| | - Michael Chen
- Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Melissa M Chen
- Neuroradiology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - J Mocco
- The Mount Sinai Health System, New York, New York, USA
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24
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Manchikanti L, Pasupuleti R, Pampati V, Sanapati MR, Hirsch JA. Assessment of Radiation Exposure with Mandatory Two Fluoroscopic Views for Epidural Procedures. Pain Physician 2023; 26:557-567. [PMID: 37976484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
BACKGROUND Various regulations and practice patterns develop on the basis of Local Coverage Determination (LCD), which are variably perceived as guidelines and/or mandated polices/ regulations. LCDs developed in 2021 and effective since December 2021 mandated a minimum of 2 views for final needle placement with contrast injection which includes both anteroposterior (AP) and lateral or oblique view. Radiation safety has been a major concern for pain physicians and multiple tools have been developed to reduce radiation dose, along with improvement in technologies to limit radiation exposure while performing fluoroscopically guided interventional procedures, with implementation of principles of As Low As Reasonably Achievable (ALARA). The mandated 2 views of epidural injections have caused concern among some physicians, because of the potential of increased exposure to ionizing radiation, despite application of various principles to minimize radiation exposure. Others, including policymakers are of the opinion that it reduces potential abuse and improves safety. OBJECTIVE To assess variations in the performance of epidural procedures prior to the implementation of the new LCD compared with after the implementation of the new LCD by comparing time and dosage for all types of epidural procedures. STUDY DESIGN A retrospective, case controlled, comparative evaluation of radiation exposure during epidural procedures in interventional pain management. SETTING An interventional pain management practice and a specialty referral center in a private practice setting in the United States. METHODS The study was performed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria. The main outcome measure was radiation exposure time measured in seconds and dose measured in mGy-kG2 (milligray to kilogray squared per procedure). RESULTS Changes in exposure and dose varied by procedural type and location. Exposure time in seconds increased overall by 21%, whereas radiation dose mGy-kG increased 133%. Fluoroscopy time increased most for lumbar interlaminar epidural injections of 43%, followed by 29% for cervical interlaminar epidural injections, 20% for caudal epidural injections, and 14% for lumbar transforaminal epidural injections. In contrast, highest increases were observed in the radiation dose mGy of 191% for caudal epidural injections, followed by 173% for lumbar interlaminar epidural injections, 113% for lumbar transforaminal epidural injections, and the lowest being cervical interlaminar epidural injections of 94%. This study also shows lesser increases for cervical interlaminar epidural injections because an oblique view is utilized rather than a lateral view resulting in a radiation dosage increase of 94% compared to overall increase of 133%, whereas the duration of time of 29% was higher than the overall combined duration of all procedures which only increased by 21%. LIMITATIONS A retrospective evaluation utilizing the experience of a single physician. CONCLUSION The results of this study showed significant increases in radiation exposure time and dosage; however, increase of dosage was overall 21% median Interquartile Range (IQR) compared to 133% of radiation dose median IQR. In addition, the results also showed variations for procedure, overall showing highest increases for lumbar interlaminar epidural injections for time (43%) and caudal epidural injections for dosage (191%).
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA
| | | | | | | | - Joshua A Hirsch
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
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25
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Jedi F, Krysiak R, Hirsch JA, Ventura F, De Vivo E, Manfrè L. Chronic sacroiliac joint dysfunction and CT-guided percutaneous fixation: a 6-year experience. Neuroradiology 2023; 65:1527-1534. [PMID: 37289228 DOI: 10.1007/s00234-023-03171-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 05/21/2023] [Indexed: 06/09/2023]
Abstract
PURPOSE Reporting the clinical outcomes, patient satisfaction, and complications following an imaging-guided percutaneous screw fixation in the treatment of sacroiliac joint dysfunction and evaluating the safety and effectiveness of this method. METHODS We performed a retrospective study on a prospectively gathered cohort of patients with physiotherapy-resistant pain due to sacroiliac joint incompetence that underwent percutaneous screw fixation, between 2016 and 2022 in our center. A minimum of two screws were used in all patients to obtain fixation of the sacroiliac joint, using percutaneous screw insertion under CT guidance, coupled with a C-arm fluoroscopy unit. RESULTS The mean visual analog scale significantly improved at 6 months of follow-up (p < 0.05). One hundred percent of the patients reported significant improvement in pain scores at the final follow-up. None of our patients experienced intraoperative or postoperative complications. CONCLUSION The use of percutaneous sacroiliac screws provides a safe and effective technique for the treatment of sacroiliac joint dysfunction in patients with chronic resistant pain.
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Affiliation(s)
- F Jedi
- Minimal Invasive Spine Therapy Department, Mediterranean Institute of Oncology (IOM), Viagrande, Catania, Italy.
| | - R Krysiak
- Department of Pediatric Radiology, Medical University of Warsaw, Warsaw, Poland
| | - J A Hirsch
- Department of Radiology, Division of Neurointerventional Imaging, Massachusetts General Hospital, Boston, USA
| | - F Ventura
- Minimal Invasive Spine Therapy Department, Mediterranean Institute of Oncology (IOM), Viagrande, Catania, Italy
| | - E De Vivo
- Minimal Invasive Spine Therapy Department, Mediterranean Institute of Oncology (IOM), Viagrande, Catania, Italy
| | - L Manfrè
- Minimal Invasive Spine Therapy Department, Mediterranean Institute of Oncology (IOM), Viagrande, Catania, Italy
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26
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D'Anna G, Shah L, Kranz PG, Hirsch JA, Khan M, Johnson M, Feydy A, Nathan J, Manfre L, Nguyen DT, Sze G, Goethem JV, Vanhoenacker FM. Results of an International Survey on Spinal Imaging by the ASNR/ASSR/ESNR/ESSR "Nomenclature 3.0" Working Group. Semin Musculoskelet Radiol 2023; 27:561-565. [PMID: 37816364 DOI: 10.1055/s-0043-1768247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
Our goal was to determine if "Nomenclature 2.0," the classification of lumbar disk pathology consensus, should be updated. We conducted a social media and e-mail-based survey on preferences regarding the use of classification on magnetic resonance spine reporting. Members of the European Society of Neuroradiology, European Society of Musculoskeletal Radiology, American Society of Neuroradiology, and American Society of Spine Radiology received a 15-question online survey between February and March 2022. A total of 600 responses were received from 63 countries. The largest number of responses came from Italy and the United States. We found that 71.28% of respondents used Nomenclature 2.0, Classification of Lumbar Disk Pathology. But classification on stenosis is used less often: 53.94% and 60% of respondents do not use any classification of spinal canal stenosis and foraminal stenosis, respectively. When queried about which part of Nomenclature needs improving, most respondents asked for a Structured Reporting Template (SRT), even though 58.85% of respondents do not currently use any template and 54% routinely use a clinical information questionnaire. These results highlight the importance of an updated Nomenclature 3.0 version that integrates the classifications of lumbar disk disease and spinal canal and foraminal stenosis. Further attention should also be directed toward developing a robust endorsed SRT.
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Affiliation(s)
- Gennaro D'Anna
- Neuroimaging Unit, ASST Ovest Milanese, Legnano, Milan, Italy
| | - Lubdha Shah
- Department of Radiology, University of Utah, Salt Lake City, Utah
| | - Peter G Kranz
- Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Joshua A Hirsch
- Department of Neurointerventional Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - M Khan
- Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Michele Johnson
- Departments of Radiology and Biomedical Imaging and Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | | | - J Nathan
- Department of Neuroradiology, Emory School of Medicine, Atlanta, Georgia
| | - L Manfre
- Minimal Invasive Spine Department of Neurosurgery, Istituto Oncologico del Mediterraneo IOM, Viagrande, Italy
| | - Dan T Nguyen
- Neuroradiology and Pain Solutions of Oklahoma, Oklahoma City, Oklahoma
| | - Gordan Sze
- Department of Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Johan Van Goethem
- Department of Radiology, University Hospital Antwerp, Antwerp, Belgium
- Department of Medical and Molecular Imaging, General Hospital VITAZ, Sint-Niklaas, Belgium
| | - Filip M Vanhoenacker
- Department of Radiology General Hospital Sint-Maarten Mechelen, Antwerp University Hospital, Edegem, Belgium
- Antwerp/Ghent University Faculty of Medicine and Health Sciences, Faculty of Medicine KU Leuven, Leuven, Belgium
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27
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Christensen EW, Nicola GN, Rula EY, Nicola LP, Hemingway J, Hirsch JA. Budget Neutrality and Medicare Physician Fee Schedule Reimbursement Trends for Radiologists, 2005 to 2021. J Am Coll Radiol 2023; 20:947-953. [PMID: 37656075 DOI: 10.1016/j.jacr.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/16/2023] [Accepted: 07/08/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE The Medicare program, by law, must remain budget neutral. Increases in volume or relative value units (RVUs) for individual services necessitate declines in either the conversion factor or assigned RVUs for other services for budget neutrality. This study aimed to assess the contribution of budget neutrality on reimbursement trends per Medicare fee-for-service beneficiary for services provided by radiologists. METHODS The study used aggregated 100% of Medicare Part B claims from 2005 to 2021. We computed the percentage change in reimbursement per beneficiary, actual and inflation adjusted, to radiologists. These trends were then adjusted by separately holding constant RVUs per beneficiary and the conversion factor to demonstrate the impact of budget neutrality. RESULTS Unadjusted reimbursement to radiologists per beneficiary increased 4.2% between 2005 and 2021, but when adjusted for inflation, it declined 24.9%. Over this period, the conversion factor declined 7.9%. Without this decline, the reimbursement per beneficiary would have been 9 percentage points higher in 2021 compared with actual. RVUs per beneficiary performed by radiologists increased 13.1%. Keeping RVUs per beneficiary at 2005 levels, reimbursement per beneficiary would have been 12.1 percentage points lower than observed in 2021. CONCLUSIONS Given budget neutrality, a substantial decline has occurred in inflation-adjusted reimbursement to radiologists per Medicare beneficiary. Decreases due to both inflation and the decline in conversion factor are only partially offset by increased RVUs per beneficiary, meaning more services per patient with less overall pay, an equation likely to heighten access challenges for Medicare beneficiaries and shortages of radiologists.
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Affiliation(s)
- Eric W Christensen
- Director, Economic and Health Services Research, Harvey L. Neiman Health Policy Institute, Reston, Virginia; Adjunct Professor, Health Services Management, University of Minnesota, St Paul, Minnesota.
| | - Gregory N Nicola
- Partner, Hackensack Radiology Group, PA, River Edge, New Jersey; ACR Board of Chancellors; Chair, ACR Commission on Economics
| | - Elizabeth Y Rula
- Executive Director, Harvey L. Neiman Health Policy Institute, Reston, Virginia
| | - Lauren P Nicola
- Chief Executive Officer, Triad Radiology Associates, Winston Salem, North Carolina; ACR Board of Chancellors; Chair, ACR Commission on Ultrasound
| | - Jennifer Hemingway
- Senior Research Associate, Harvey L. Neiman Health Policy Institute, Reston, Virginia
| | - Joshua A Hirsch
- Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts; ACR, Commission on Economics; Chair, ACR Future Trends Committee-Economics
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28
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Manchikanti L, Knezevic E, Knezevic NN, Pasupuleti R, Sanapati MR, Janapala RN, Kaye AD, Hirsch JA. Medial Branch Blocks and the Effectiveness of Radiofrequency Neurotomy in Managing Chronic Thoracic Pain: A Systematic Review and Meta-Analysis. Pain Physician 2023; 26:413-435. [PMID: 37774177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
BACKGROUND Extensive research into potential sources of thoracic pain with or without referred pain into the chest wall has demonstrated that thoracic facet joints can be a potential source of pain confirmed by precise, diagnostic blocks.The objective of this systematic review and meta-analysis is to evaluate the effectiveness of medial branch blocks and radiofrequency neurotomy as a therapeutic thoracic facet joint intervention. METHODS Systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies of medial branch blocks and the radiofrequency neurotomy in managing thoracic pain utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was performed. A comprehensive literature search of multiple databases of RCTs and observational studies of medial branch blocks and radiofrequency neurotomy in managing chronic thoracic pain were identified from 1996 to December 2022 with inclusion of manual searches of the bibliography of known review articles and multiple databases. Methodologic quality and risk of bias assessment was also conducted. Evidence was synthesized utilizing principles of quality assessment and best evidence synthesis, with conventional and single meta-analysis. The primary outcome measure of success was 3 months of pain reduction for medial branch blocks and 6 months for radiofrequency thermoneurolysis for a single treatment. Short-term success was defined as up to 6 months and long-term was more than 6 months. RESULTS This literature search yielded 11 studies meeting the inclusion criteria, of which 3 were RCTs and 8 were observational studies. Of the 3 RCTs, 2 of them assessed medial branch blocks and one trial assessed radiofrequency for thoracic pain. The evidence for managing thoracic pain with qualitative analysis and single-arm meta-analysis and GRADE system of appraisal, with the inclusion of 2 RCTs and 3 observational studies for medial branch blocks was Level II. For radiofrequency neurotomy, with the inclusion of one RCT of 20 patients in the treatment group and 5 observational studies, the evidence was Level III in managing thoracic pain. LIMITATIONS There was a paucity of literature with RCTs and real-world pragmatic controlled trials. Even observational studies had small sample sizes providing inadequate clinically applicable results. In addition, there was heterogeneity of the available studies in terms of their inclusion and exclusion criteria, defining their endpoints and the effectiveness of the procedures. CONCLUSION This systematic review and meta-analysis show Level II evidence of medial branch blocks and Level III evidence for radiofrequency neurotomy on a long-term basis in managing chronic thoracic pain. KEY WORDS Chronic spinal pain, thoracic facet or zygapophysial joint pain, facet joint nerve blocks, medial branch blocks, controlled comparative local anesthetic blocks, diagnostic accuracy, radiofrequency neurotomy.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA
| | - Emilija Knezevic
- University of Illinois at Urbana-Champaign, College of Liberal Arts and Sciences, Champaign, IL
| | - Nebojsa Nick Knezevic
- Advocate Illinois Masonic Medical Center and College of Medicine, University of Illinois, Chicago, IL
| | | | | | | | - Alan D Kaye
- LSU Health Sciences Center, Shreveport, Ochsner Shreveport Hospital and Interventional Pain Clinic Feist-Wieller Cancer Center, Shreveport, LA
| | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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29
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Riegger M, Le H, van Kuijk SMJ, Guyenes G, Candrian C, Cianfoni A, Hirsch JA, Koetsier E. Intradiscal Glucocorticoid Injection in Discogenic Back Pain and Influence on Modic Changes: A Systematic Review and Meta-analysis of RCTs. Pain Physician 2023; 26:E449-E465. [PMID: 37774181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
BACKGROUND The benefit of intradiscal glucocorticoid injection (IGI) for discogenic low back pain (LBP) remains controversial. OBJECTIVES The objective of this study was to systematically assess and meta-analyze the efficacy of IGI compared with these control groups. STUDY DESIGN Systematic review and meta-analysis. METHODS A comprehensive literature search was performed screening PubMed and Embase through May 2022. Only randomized controlled trials (RCTs) comparing IGI to control groups in adult patients with discogenic lumbar back pain were included. A random effects model was used to pool mean differences of pain intensity (visual analaog scale [VAS] 0-100), and physical function assessed with the Oswestry Disability Index (ODI). Subgroup analyses were stratified by Modic magnetic resonance imaging findings. RESULTS Seven studies met inclusion criteria with a total of 626 patients. The short-term (< 3 months) follow-up showed a significant pooled mean difference in both pain intensity (-20.1; 95% CI, -25.5 to -14.7) and physical function (-9.9; 95% CI, -16.1 to -3.6). In the intermediate -term follow-up (3 to < 6 months), only physical function remained significantly better in the glucocorticoid group (-13.1; 95% CI, -22.3 to -3.9). There was no clinically meaningful or significant difference in pain scores and physical function at the long-term (>= 6 months) follow-up. A subgroup analysis did not demonstrate an effect of Modic (type I) changes on the efficacy of IGI. LIMITATIONS A limited number of studies was available and consequently publication bias could not be evaluated using a funnel plot. Statistical heterogeneity was detected among the included studies. CONCLUSION We conclude that IGI reduces discogenic LBP intensity and improves physical function effectively at short-term follow-up, and continues to improve physical function at intermediate-term. However, 6 months posttreatment, outcomes are similar in comparison to the control groups. The type of Modic change does not appear to be related with the response to IGI. KEY WORDS Low back pain, lumbar back pain, intradiscal glucocorticoid injection, modic changes, meta-analysis.
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Affiliation(s)
- Martin Riegger
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Huyen Le
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Sander M J van Kuijk
- Pain Management Center, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland; Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Gabor Guyenes
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
| | - Christian Candrian
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Alessandro Cianfoni
- Diagnostic and Interventional Neuroradiology, Neurocenter of Southern Switzerland EOC; Department of Neuroradiology, Inselspital University Hospital Bern, Switzerland
| | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Eva Koetsier
- Pain Management Center, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
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Manchikanti L, Pampati V, Knezevic NN, Kaye AD, Abdi S, Sanapati MR, Abd-Elsayed A, Kosanovic R, Soin A, Beall DP, Shah S, Hirsch JA. The Influence of COVID-19 on Utilization of Epidural Procedures in Managing Chronic Spinal Pain in the Medicare Population. Spine (Phila Pa 1976) 2023; 48:950-961. [PMID: 36728775 DOI: 10.1097/brs.0000000000004574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 09/19/2022] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN A retrospective cohort study of utilization patterns and variables of epidural injections in the fee-for-service (FFS) Medicare population. OBJECTIVES To update the utilization of epidural injections in managing chronic pain in the FFS Medicare population, from 2000 to 2020, and assess the impact of COVID-19. SUMMARY OF BACKGROUND DATA The analysis of the utilization of interventional techniques also showed an annual decrease of 2.5% per 100,000 FFS Medicare enrollees from 2009 to 2018, contrasting to an annual increase of 7.3% from 2000 to 2009. The impact of the COVID-19 pandemic has not been assessed. METHODS This analysis was performed by utilizing master data from the Centers for Medicare and Medicaid Services, physician/supplier procedure summary from 2000 to 2020. The analysis was performed by the assessment of utilization patterns using guidance from Strengthening the Reporting of Observational Studies in Epidemiology. RESULTS Epidural procedures declined at a rate of 19% per 100,000 Medicare enrollees in the FFS Medicare population in the United States from 2019 to 2020, with an annual decline of 3% from 2010 to 2019. From 2000 to 2010, there was an annual increase of 8.3%. This analysis showed a decline in all categories of epidural procedures from 2019 to 2020. The major impact of COVID-19, with closures taking effect from April 1, 2020, through December 31, 2020, will be steeper and rather dramatic compared with April 1 to December 31, 2019. However, monthly data from the Centers for Medicare and Medicaid Services is not available as of now. Overall declines from 2010 to 2019 showed a decrease for cervical and thoracic transforaminal injections with an annual decrease of 5.6%, followed by lumbar interlaminar and caudal epidural injections of 4.9%, followed by 1.8% for lumbar/sacral transforaminal epidurals, and 0.9% for cervical and thoracic interlaminar epidurals. CONCLUSION Declining utilization of epidural injections in all categories was exacerbated to a decrease of 19% from 2019 to 2020, related, in part, to the COVID-19 pandemic. This followed declining patterns of epidural procedures of 3% overall annually from 2010 to 2019.
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Affiliation(s)
| | | | - Nebojsa Nick Knezevic
- Advocate Illinois Masonic Medical Center and College of Medicine, University of Illinois, Chicago, IL
| | - Alan D Kaye
- LSU Health Sciences Center, Shreveport, Ochsner Shreveport Hospital and Interventional Pain Clinic Feist-Wieller Cancer Center, Shreveport, LA
| | - Salahadin Abdi
- University of Texas, MD Anderson Cancer Center, Houston, TX
| | | | - Alaa Abd-Elsayed
- UW Health Pain Services and University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Amol Soin
- Ohio Pain Clinic, Centerville, OH, Wright State University, Dayton, OH
| | | | | | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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31
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Manchikanti L, Knezevic NN, Knezevic E, Pasupuleti R, Kaye AD, Sanapati MR, Hirsch JA. Efficacy of Percutaneous Adhesiolysis in Managing Low Back and Lower Extremity Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Pain Ther 2023:10.1007/s40122-023-00508-y. [PMID: 37227685 DOI: 10.1007/s40122-023-00508-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/27/2023] [Indexed: 05/26/2023] Open
Abstract
INTRODUCTION Chronic refractory low back and lower extremity pain recalcitrant to conservative management and epidural injections secondary to postsurgery syndrome, spinal stenosis, and disc herniation are sometimes managed with percutaneous adhesiolysis. Consequently, this systematic review and meta-analysis was undertaken to assess the efficacy of percutaneous adhesiolysis in managing low back and lower extremity pain. METHODS A systematic review and meta-analysis of randomized controlled trials (RCTs) utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was performed. A comprehensive literature search of multiple databases from 1966 to July 2022, including manual searches of the bibliography of known review articles was performed. Quality assessment of the included trials, meta-analysis, and best evidence synthesis was performed. The primary outcome measure was a significant reduction in pain (short term up to 6 months and long term more than 6 months). RESULTS The search identified 26 publications, with 9 trials meeting the inclusion criteria. The results of dual-arm and single-arm analyses showed significant improvement in pain and function at 12 months. Opioid consumption was also significantly reduced at 6 months with dual-arm analysis, whereas single-arm analysis showed a significant decrease from baseline to treatment at the 3-, 6-, and 12-month analyses. At 1 year follow-up, seven of seven trials were positive for improvements in pain relief, function, and diminution of opioid use. DISCUSSION Based on the present systematic review of nine RCTs, the evidence level is I to II, with moderate to strong recommendation for percutaneous adhesiolysis in managing low back and lower extremity pain. The limitations of the evidence include paucity of literature, lack of placebo-controlled trials, and the majority of the trials studying post lumbar surgery syndrome. CONCLUSION The evidence is level I to II or strong to moderate based on five high-quality and two moderate-quality RCTs, with 1 year follow-up that percutaneous adhesiolysis is efficacious in the treatment of chronic refractory low back and lower extremity pain.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, 67 Lakeview Drive, Paducah, KY, 42001, USA.
- Pain Management Centers of America, Evansville, IN, USA.
| | - Nebojsa Nick Knezevic
- Advocate Illinois Masonic Medical Center and College of Medicine, University of Illinois, Chicago, IL, USA
| | - Emilija Knezevic
- College of Liberal Arts and Sciences, University of Illinois at Urbana-Champaign, Champaign, IL, USA
| | | | - Alan D Kaye
- LSU Health Sciences Center, Shreveport, Ochsner Shreveport Hospital and Interventional Pain Clinic Feist-Wieller Cancer Center, Shreveport, LA, USA
| | - Mahendra R Sanapati
- Pain Management Centers of America, 67 Lakeview Drive, Paducah, KY, 42001, USA
- Pain Management Centers of America, Evansville, IN, USA
| | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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32
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Milburn JM, Fiorella D, Hirsch JA. Betwixt and between: an idiomatic understanding of anesthesia in stroke intervention. J Neurointerv Surg 2023; 15:411-412. [PMID: 37055071 DOI: 10.1136/jnis-2023-020364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2023] [Indexed: 04/15/2023]
Affiliation(s)
- James M Milburn
- Radiology, Ochsner Medical System, New Orleans, Louisiana, USA
| | - David Fiorella
- Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA
- SUNY SB, New York, New York, USA
| | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
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Manchikanti L, Kaye AD, Latchaw RE, Sanapati MR, Pampati V, Gharibo CG, Albers SL, Hirsch JA. Impact of the COVID-19 Pandemic on Utilization Patterns of Facet Joint Interventions in Managing Spinal Pain in a Medicare Population. Pain Ther 2023; 12:505-527. [PMID: 36723804 PMCID: PMC9890434 DOI: 10.1007/s40122-023-00476-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/10/2023] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION The COVID-19 pandemic resulted in major disruptions in all aspects of human life including a decline of medical services utilized during 2020. An analysis of the impact of COVID-19 pandemic showed an 18.7% reduction in utilization patterns of interventional techniques in managing chronic pain in the Medicare population from 2019 to 2020. However, specific changes in utilization patterns of facet joint interventions have not been studied. Thus, we sought to assess the utilization patterns including an update of facet joint interventions from 2018 to 2020, with analysis of the impact of COVID-19 pandemic in managing chronic spinal pain utilizing facet joint interventions in the fee-for-service Medicare population of the United States. METHODS The present investigation was designed to assess utilization patterns and variables of facet joint interventions, in managing chronic spinal pain from 2010 to 2020 in the fee-for-service (FFS) Medicare population in the United States (US), and how the COVID-19 pandemic impacted these utilization patterns. Data for the analysis were obtained from the master database from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2020. RESULTS Results of this analysis showed significant impact of COVID-19 with overall decrease of 18.5% of all facet joint interventions per 100,000 Medicare population compared to 20.2 and 20.5% decrease for lumbar and cervical facet joint injections, 15 and 13.1% decrease per 100,000 Medicare population of lumbosacral and cervicothoracic facet joint neurolysis procedures. The results are significant in that comparative analysis from 2000 to 2010 and 2010 to 2019 showing an annual increase of 14.4 vs. 2.2%, illustrating a decelerating pattern. There were also significant growth patterns noted with decreases in facet joint injections and nerve blocks compared to facet joint neurolytic procedures. CONCLUSIONS This analysis shows a significant effect of COVID-19 producing an overall decrease in utilization of facet joint interventions relative to pre-COVID data. Further, the analysis demonstrates continued deceleration of utilization patterns of facet joint interventions compared to the periods of 2000-2010 and 2010-2019.
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Affiliation(s)
- Laxmaiah Manchikanti
- grid.419960.30000 0004 0649 0485Pain Management Centers of America, 67 Lakeview Drive, Paducah, KY 42001 USA
- grid.266623.50000 0001 2113 1622University of Louisville, Louisville, KY USA
- grid.411417.60000 0004 0443 6864Department of Anesthesiology, School of Medicine, LSU Health Sciences Center, Shreveport, LA USA
| | - Alan D. Kaye
- grid.411417.60000 0004 0443 6864Louisiana State University Health Sciences Center, Shreveport, LA USA
| | - Richard E. Latchaw
- grid.416958.70000 0004 0413 7653Department of Radiology, University of California at Davis Health System, Sacramento, CA USA
| | - Mahendra R. Sanapati
- grid.419960.30000 0004 0649 0485Pain Management Centers of America, Evansville, IN USA
| | - Vidyasagar Pampati
- grid.419960.30000 0004 0649 0485Pain Management Centers of America, 67 Lakeview Drive, Paducah, KY 42001 USA
| | - Christopher G. Gharibo
- grid.137628.90000 0004 1936 8753NYU Langone Health and NYU School of Medicine, New York, NY USA
- grid.137628.90000 0004 1936 8753NYU Grossman School of Medicine, New York, NY USA
| | | | - Joshua A. Hirsch
- grid.38142.3c000000041936754XMassachusetts General Hospital and Harvard Medical School, Boston, MA USA
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Jayaraman K, Santavicca S, Hughes DR, Hirsch JA, Duszak R, Chatterjee AR. Recent trends in high-volume Medicare stroke thrombectomy provider characteristics. J Neurointerv Surg 2023; 15:399-401. [PMID: 35210330 DOI: 10.1136/neurintsurg-2021-018611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 02/03/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Intracranial mechanical thrombectomy (MT) is increasingly indicated for use in acute ischemic stroke patients. We analyzed recent trends in the characteristics and geographic distributions of physicians providing this service with frequency to Medicare beneficiaries. METHODS We linked public data sources to elucidate and visualize trends in high-volume MT providers between 2016 and 2019. RESULTS High-volume MT providers increased by 184% between 2016 and 2019. The number of neurosurgeons, neurologists, and radiologists in this physician population increased by 251%, 205%, and 139%, respectively. Male practitioners accounted for 96% of providers in the most recent year of analysis. International medical graduates accounted for roughly one-third of these physicians across all 4 years of analysis. As of 2019, the three states with the most high-volume MT providers were Florida, California, and Texas, accounting for 7%, 7%, and 6% of providers, respectively. CONCLUSIONS High-volume providers of MT services for Medicare beneficiaries represent a dynamic and rapidly expanding subset of physicians with diverse specialty backgrounds.
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Affiliation(s)
- Keshav Jayaraman
- Mallinckrodt Institute of Radiology, Department of Neurosurgery and Department of Neurology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Stefan Santavicca
- Radiology and Imaging Sciences, Emory University, Atlanta, Georgia, USA
| | - Danny R Hughes
- Radiology and Imaging Sciences, Emory University, Atlanta, Georgia, USA.,School of Economics, Georgia Institute of Technology, Atlanta, Georgia, USA
| | | | - Richard Duszak
- Radiology and Imaging Sciences, Emory University, Atlanta, Georgia, USA
| | - Arindam R Chatterjee
- Mallinckrodt Institute of Radiology, Department of Neurosurgery and Department of Neurology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
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Affiliation(s)
- Kyle M Fargen
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Ferdinand Hui
- Neuroscience Institute, Division of Neurointerventional Surgery, Queen's Medical Center, Honolulu, Hawaii, USA
| | - Joshua A Hirsch
- Interventional Neuroradiology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Chen M, Leslie-Mazwi TM, Hirsch JA, Albuquerque FC. Large core stroke thrombectomy: paradigm shift or futile exercise? J Neurointerv Surg 2023; 15:413-414. [PMID: 36810356 DOI: 10.1136/jnis-2023-020219] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 02/23/2023]
Affiliation(s)
- Michael Chen
- Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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37
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Cheng D, Ghoshal S, Zattra O, Flash M, Lang M, Liu R, Lev MH, Hirsch JA, Saini S, Gee MS, Succi MD. Trends in oncological imaging during the COVID-19 pandemic through the vaccination era. Cancer Med 2023; 12:9902-9911. [PMID: 36775966 PMCID: PMC10166903 DOI: 10.1002/cam4.5678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/22/2023] [Accepted: 01/31/2023] [Indexed: 02/14/2023] Open
Abstract
BACKGROUND This study examines the impact that the COVID-19 pandemic has had on computed tomography (CT)-based oncologic imaging utilization. METHODS We retrospectively analyzed cancer-related CT scans during four time periods: pre-COVID (1/5/20-3/14/20), COVID peak (3/15/20-5/2/20), post-COVID peak (5/3/20-12/19/20), and vaccination period (12/20/20-10/30/21). We analyzed CTs by imaging indication, setting, and hospital type. Using percentage decrease computation and Student's t-test, we calculated the change in mean number of weekly cancer-related CTs for all periods compared to the baseline pre-COVID period. This study was performed at a single academic medical center and three affiliated hospitals. RESULTS During the COVID peak, mean CTs decreased (-43.0%, p < 0.001), with CTs for (1) cancer screening, (2) initial workup, (3) cancer follow-up, and (4) scheduled surveillance of previously treated cancer dropping by 81.8%, 56.3%, 31.7%, and 45.8%, respectively (p < 0.001). During the post-COVID peak period, cancer screenings and initial workup CTs did not return to prepandemic imaging volumes (-11.4%, p = 0.028; -20.9%, p = 0.024). The ED saw increases in weekly CTs compared to prepandemic levels (+31.9%, p = 0.008), driven by increases in cancer follow-up CTs (+56.3%, p < 0.001). In the vaccination period, cancer screening CTs did not recover to baseline (-13.5%, p = 0.002) and initial cancer workup CTs doubled (+100.0%, p < 0.001). The ED experienced increased cancer-related CTs (+75.9%, p < 0.001), driven by cancer follow-up CTs (+143.2%, p < 0.001) and initial workups (+46.9%, p = 0.007). CONCLUSIONS AND RELEVANCE The pandemic continues to impact cancer care. We observed significant declines in cancer screening CTs through the end of 2021. Concurrently, we observed a 2× increase in initial cancer workup CTs and a 2.4× increase in cancer follow-up CTs in the ED during the vaccination period, suggesting a boom of new cancers and more cancer examinations associated with emergency level acute care.
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Affiliation(s)
- Debby Cheng
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Soham Ghoshal
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ottavia Zattra
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Moses Flash
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Min Lang
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Raymond Liu
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael H Lev
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua A Hirsch
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sanjay Saini
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael S Gee
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marc D Succi
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts, USA
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Chan A, Flash MJ, Guo T, Zattra O, Boms O, Succi MD, Hirsch JA. Trends in Academic Productivity Among Radiologists During the COVID-19 Pandemic. J Am Coll Radiol 2023; 20:276-281. [PMID: 36496090 PMCID: PMC9729584 DOI: 10.1016/j.jacr.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/21/2022] [Accepted: 10/03/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE There is a scarcity of literature examining changes in radiologist research productivity during the COVID-19 pandemic. The current study aimed to investigate changes in academic productivity as measured by publication volume before and during the COVID-19 pandemic. METHODS This single-center, retrospective cohort study included the publication data of 216 researchers consisting of associate professors, assistant professors, and professors of radiology. Wilcoxon's signed-rank test was used to identify changes in publication volume between the 1-year-long defined prepandemic period (publications between May 1, 2019, and April 30, 2020) and COVID-19 pandemic period (May 1, 2020, to April 30, 2021). RESULTS There was a significantly increased mean annual volume of publications in the pandemic period (5.98, SD = 7.28) compared with the prepandemic period (4.98, SD = 5.53) (z = -2.819, P = .005). Subset analysis demonstrated a similar (17.4%) increase in publication volume for male researchers when comparing the mean annual prepandemic publications (5.10, SD = 5.79) compared with the pandemic period (5.99, SD = 7.60) (z = -2.369, P = .018). No statistically significant changes were found in similar analyses with the female subset. DISCUSSION Significant increases in radiologist publication volume were found during the COVID-19 pandemic compared with the year before. Changes may reflect an overall increase in academic productivity in response to clinical and imaging volume ramp down.
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Affiliation(s)
- Alex Chan
- Medically Engineered Solutions in Healthcare Incubator, Innovations in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts; Faculty of Medicine, McMaster University, Hamilton, Ontario, Canada; and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Moses J.E. Flash
- Medically Engineered Solutions in Healthcare Incubator, Innovations in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Teddy Guo
- Medically Engineered Solutions in Healthcare Incubator, Innovations in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts; Faculty of Medicine, McMaster University, Hamilton, Ontario, Canada; and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ottavia Zattra
- Medically Engineered Solutions in Healthcare Incubator, Innovations in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Okechi Boms
- Medically Engineered Solutions in Healthcare Incubator, Innovations in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Marc D. Succi
- Medically Engineered Solutions in Healthcare Incubator, Innovations in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Associate Chair, Innovation and Commercialization, Mass General Brigham Enterprise Radiology; and Member, ACR Economics Committee,Corresponding authors and reprints: Marc D. Succi, MD, Massachusetts General Hospital, Department of Radiology, 55 Fruit Street, Boston, MA 02114
| | - Joshua A. Hirsch
- Medically Engineered Solutions in Healthcare Incubator, Innovations in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Vice Chair Procedural Services, Director Interventional Neuroradiology, Chief Interventional Spine, Associate Department Quality Chair at Massachusetts General Hospital; Councilor to the ACR for Society of NeuroInterventional Surgery; Chair, Future Trends and Academic Committees ACR; Deputy Editor; JNIS; and Senior Affiliate Research Fellow, Neiman Health Policy Institute Joint Grant Program,Joshua A. Hirsch, MD, Massachusetts General Hospital, Department of Radiology, 55 Fruit Street, Boston, MA 02114
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Di Caterino F, Koetsier E, Hirsch JA, Isalberti M, San Millan D, Marchi F, La Barbera L, Pileggi M, Cianfoni A. Middle column Stent-screw Assisted Internal Fixation (SAIF): a modified minimally-invasive approach to rescue vertebral middle column re-fractures. J Neurointerv Surg 2023; 15:jnis-2022-019752. [PMID: 36593116 DOI: 10.1136/jnis-2022-019752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 12/26/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND There is limited literature regarding the re-fracture of a previously augmented vertebral compression fracture (VCF). These re-fractures may present as an asymptomatic remodeling of the vertebral body around the cement cast while in other cases they involve the middle column, at the transition zone between the cement-augmented and non-augmented vertebral body. In the latter, a posterior wall retropulsion is possible and, if left untreated, might progress to vertebral body splitting, central canal stenosis, and kyphotic deformity. There is no consensus regarding the best treatment for these re-fractures. There are cases in which a repeated augmentation relieves the pain, but this is considered an undertreatment in cases with middle column involvement, posterior wall retropulsion, and kyphosis. METHODS We report four cases of re-fracture with middle column collapse of a previously augmented VCF, treated with the stent-screw assisted internal fixation (SAIF) technique. A modified more postero-medial deployment of the anterior metallic implants was applied, to target the middle column fracture. This modified SAIF allowed the reduction and stabilization of the middle column collapse as well as the partial correction of the posterior wall retropulsion and kyphosis. RESULTS Complete relief of back pain with stable clinical and radiographic findings at follow-up was obtained in all cases. CONCLUSIONS In selected cases, the middle column SAIF technique is safe and effective for the treatment of the re-fracture with middle column collapse of a previously cement-augmented VCF. This technique requires precision in trocar placement and could represent a useful addition to the technical armamentarium for VCF treatment.
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Affiliation(s)
- Fortunato Di Caterino
- Department of Interventional Neuroradiology, University Hospital Centre Besancon, Besancon, France
| | - Eva Koetsier
- Pain Management Center, Neurocenter of Southern Switzerland EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera italiana Facoltà di scienze biomediche, Lugano, Switzerland
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Maurizio Isalberti
- Department of Neuroradiology, Neurocenter of Southern Switzerland EOC, Lugano, Switzerland
| | - Diego San Millan
- Neuroradiology Unit, Service of Diagnostic and Interventional Radiology, Sion Hospital Valais Romand Hospital Center, Sion, Switzerland
| | - Francesco Marchi
- Neurosurgery Department, Neurocenter of the Southern Switzerland EOC, Lugano, Switzerland
| | - Luigi La Barbera
- Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milano, Italy
- IRCCS Istituto Ortopedico Galeazzi, Milano, Italy
| | - Marco Pileggi
- Department of Neuroradiology, Neurocenter of Southern Switzerland EOC, Lugano, Switzerland
| | - Alessandro Cianfoni
- Department of Neuroradiology, Neurocenter of Southern Switzerland EOC, Lugano, Switzerland
- Department of Neuroradiology, Inselspital University Hospital Bern, Bern, Switzerland
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Nguyen TH, Heller RE, Keysor K, Milburn JM, Rula EY, Spangler R, Hirsch JA. The No Surprises Act: What Neuroradiologists Should Know. AJNR Am J Neuroradiol 2023; 44:7-10. [PMID: 36549854 PMCID: PMC9835917 DOI: 10.3174/ajnr.a7739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/10/2022] [Indexed: 12/24/2022]
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Singh N, Menon BK, Dmytriw AA, Regenhardt RW, Hirsch JA, Ganesh A. Replacing Alteplase with Tenecteplase: Is the Time Ripe? J Stroke 2023; 25:72-80. [PMID: 36746381 PMCID: PMC9911848 DOI: 10.5853/jos.2022.02880] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/15/2022] [Indexed: 02/04/2023] Open
Abstract
Thrombolysis for acute ischemic stroke has predominantly been with alteplase for over a quarter of a century. In recent years, with trials showing evidence of higher rates of successful reperfusion, similar safety profile and efficacy of tenecteplase (TNK) as compared to alteplase, TNK has now emerged as another potential choice for thrombolysis in acute ischemic stroke. In this review, we will focus on these recent advances, aiming: (1) to provide a brief overview of thrombolysis in stroke; (2) to provide comparisons between alteplase and TNK for clinical, imaging, and safety outcomes; (3) to focus on key subgroups of interest to understand if there is an advantage of using TNK over alteplase or vice-versa, to review available evidence on role of TNK in intra-arterial thrombolysis, as bridging therapy and in mobile stroke units; and (4) to summarize what to expect in the near future from recently completed trials and propose areas for future research on this evolving topic. We present compelling data from several trials regarding the safety and efficacy of TNK in acute ischemic stroke along with completed yet unpublished trials that will help provide insight into these unanswered questions.
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Affiliation(s)
- Nishita Singh
- Calgary Stroke Program, Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, and the Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada,Department of Internal Medicine-Neurology Division, Health Sciences Center, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Bijoy K. Menon
- Calgary Stroke Program, Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, and the Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Adam A. Dmytriw
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA,Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert W. Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joshua A. Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aravind Ganesh
- Calgary Stroke Program, Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, and the Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada,Correspondence: Aravind Ganesh Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, HMRB 103, Heritage Medical Research Building, 3280 Hospital Dr. NW, Calgary, Alberta T2N 4Z6, Canada Tel: +1-403-220-3747 E-mail:
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Kraft AW, Regenhardt RW, Awad A, Rosenthal JA, Dmytriw AA, Vranic JE, Bonkhoff AK, Bretzner M, Hirsch JA, Rabinov JD, Stapleton CJ, Schwamm LH, Singhal AB, Rost NS, Leslie-Mazwi TM, Patel AB. Spoke-administered thrombolysis improves large vessel occlusion early recanalization: the real-world experience of a large academic hub-and-spoke telestroke network. Stroke Vasc Interv Neurol 2023; 3:e000427. [PMID: 36816048 PMCID: PMC9936963 DOI: 10.1161/svin.122.000427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 08/11/2022] [Indexed: 11/16/2022]
Abstract
Introduction Intravenous thrombolysis (IVT) prior to mechanical thrombectomy (MT) for large vessel occlusion (LVO) stroke is increasingly controversial. Recent trials support MT without IVT for patients presenting directly to MT-capable "hub" centers. However, bypassing IVT has not been evaluated for patients presenting to IVT-capable "spoke" hospitals that require hub transfer for MT. A perceived lack of efficacy of IVT to result in LVO early recanalization (ER) is often cited to support bypassing IVT, but ER data for IVT in patients that require interhospital transfer is limited. Here we examined LVO ER rates after spoke-administered IVT in our hub-and-spoke stroke network. Methods Patients presenting to 25 spokes before hub transfer for MT consideration from 2018-2020 were retrospectively identified from a prospectively maintained database. Inclusion criteria were pre-transfer CTA-defined LVO, ASPECTS ≥6, and post-transfer repeat vessel imaging. Results Of 167 patients, median age was 69 and 51% were female. 76 received spoke IVT (+spokeIVT) and 91 did not (-spokeIVT). Alteplase was the only IVT used in this study. Comorbidities and NIHSS were similar between groups. ER frequency was increased 7.2-fold in +spokeIVT patients [12/76 (15.8%) vs. 2/91 (2.2%), P<0.001]. Spoke-administered IVT was independently associated with ER (aOR=11.5, 95% CI=2.2,99.6, p<0.05) after adjusting for timing of last known well, interhospital transfer, and repeat vessel imaging. Interval NIHSS was improved in patients with ER (median -2 (IQR -6.3, -0.8) vs. 0 (-2.5, 1), p<0.05). Conclusion Within our network, +spokeIVT patients had a 7.2-fold increased ER relative likelihood. This real-world analysis supports IVT use in eligible patients with LVO at spoke hospitals before hub transfer for MT.
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Affiliation(s)
- Andrew W. Kraft
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Robert W. Regenhardt
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Amine Awad
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Joseph A. Rosenthal
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Adam A. Dmytriw
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Justin E. Vranic
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Anna K. Bonkhoff
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Martin Bretzner
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Joshua A. Hirsch
- Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - James D. Rabinov
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | | | - Lee H. Schwamm
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Aneesh B. Singhal
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Natalia S. Rost
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | | | - Aman B. Patel
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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Manchikanti L, Knezevic NN, Knezevic E, Abdi S, Sanapati MR, Soin A, Wargo BW, Navani A, Atluri S, Gharibo CG, Simopoulos TT, Kosanovic R, Abd-Elsayed A, Kaye AD, Hirsch JA. A Systematic Review and Meta-analysis of the Effectiveness of Radiofrequency Neurotomy in Managing Chronic Neck Pain. Pain Ther 2022; 12:1-48. [PMID: 36465720 PMCID: PMC9686245 DOI: 10.1007/s40122-022-00455-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/28/2022] [Indexed: 11/25/2022] Open
Abstract
Background Extensive research into potential sources of neck pain and referred pain into the upper extremities and head has shown that the cervical facet joints can be a potential pain source confirmed by precision, diagnostic blocks. Study Design Systematic review and meta-analysis utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, quality assessment of the included studies, conventional and single-arm meta-analysis, and best evidence synthesis. Objective The objective of this systematic review and meta-analysis is to evaluate the effectiveness of radiofrequency neurotomy as a therapeutic cervical facet joint intervention in managing chronic neck pain. Methods Available literature was included. Methodologic quality assessment of studies was performed from 1996 to September 2021. The level of evidence of effectiveness was determined. Results Based on the qualitative and quantitative analysis with single-arm meta-analysis and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system of appraisal, with inclusion of one randomized controlled trial (RCT) of 12 patients in the treatment group and eight positive observational studies with inclusion of 589 patients showing positive outcomes with moderate to high clinical applicability, the evidence is level II in managing neck pain with cervical radiofrequency neurotomy. The evidence for managing cervicogenic headache was level III to IV with qualitative analysis and single-arm meta-analysis and GRADE system of appraisal, with the inclusion of 15 patients in the treatment group in a positive RCT and 134 patients in observational studies. An overwhelming majority of the studies produced multiple lesions. Limitations There was a paucity of literature and heterogeneity among the available studies. Conclusion This systematic review and meta-analysis shows level II evidence with radiofrequency neurotomy on a long-term basis in managing chronic neck pain with level III to IV evidence in managing cervicogenic headaches. Supplementary Information The online version contains supplementary material available at 10.1007/s40122-022-00455-0.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, 67 Lakeview Drive, Paducah, KY 42001 USA
- Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY USA
- Department of Anesthesiology, School of Medicine, LSU Health Sciences Center, Shreveport, LA USA
| | - Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL USA
- College of Medicine, University of Illinois, Chicago, IL USA
| | - Emilija Knezevic
- College of Liberal Arts and Sciences, University of Illinois at Urbana-Champaign, Champaign, IL USA
| | - Salahadin Abdi
- Department of Pain Medicine, University of Texas, MD Anderson Cancer Center, Houston, TX USA
| | | | - Amol Soin
- Ohio Pain Clinic and Wright State University, Dayton, OH USA
| | - Bradley W. Wargo
- Interventional Pain Management, Mays & Schnapp Neurospine & Pain, Memphis, TN USA
| | - Annu Navani
- Comprehensive Spine & Sports Center and Le Reve Regenerative Wellness, Campbell, CA USA
| | | | | | - Thomas T. Simopoulos
- Department of Anesthesiology, Critical Care and Pain Medicine, Arnold Warfield Pain Management Center, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA USA
| | | | - Alaa Abd-Elsayed
- UW Health Pain Services and UW Pain Clinic, Chronic Pain Medicine, Department of Anesthesiology, and University of Wisconsin School of Medicine and Public Health,, Madison, WI USA
| | - Alan D. Kaye
- Anesthesiology and Pharmacology, Toxicology, and Neurosciences, LSUHSC, Shreveport, LA USA
| | - Joshua A. Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA USA
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Regenhardt RW, Rosenthal JA, Dmytriw AA, Vranic JE, Bonkhoff AK, Bretzner M, Hirsch JA, Rabinov JD, Stapleton CJ, Patel AB, Singhal AB, Rost NS, Leslie-Mazwi TM, Etherton MR. Direct to angio-suite large vessel occlusion transfers achieve faster arrival-to-puncture times and improved outcomes. Stroke Vasc Interv Neurol 2022; 2:e000327. [PMID: 36571077 PMCID: PMC9787192 DOI: 10.1161/svin.121.000327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 05/16/2022] [Indexed: 12/30/2022]
Abstract
Introduction For patients with large vessel occlusion (LVO) stroke, time to treatment with endovascular thrombectomy (EVT) is crucial to prevent infarction and improve outcomes. We sought to evaluate the hub arrival-to-puncture times and outcomes for transferred patients accepted directly to the angio-suite (LVO2OR) versus those accepted through the emergency department (ED) in a hub-and-spoke telestroke network. Methods Consecutive patients transferred for EVT with spoke CTA-confirmed LVO, spoke ASPECTS >6, and LKW-to-hub arrival <6 hours were identified. Our LVO2OR protocol began implementation in January 2017. The LVO2OR cohort includes patients who underwent EVT from July 2017 to October 2020; the ED cohort includes those from January 2011 to December 2016. Hub arrival-to-puncture time and 90-day modified Rankin Scale (mRS) were prospectively recorded. Results The LVO2OR cohort was comprised of 91 patients and the ED cohort 90. LVO2OR patients had more atrial fibrillation (AF, 51% vs 32%, p=0.02) and more M2 occlusions (27% vs 10%, p=0.01). LVO2OR patients had faster median hub arrival-to-puncture time (11 vs 92 minutes, p<0.001), faster median telestroke consult-to-puncture time (2.4 vs 3.6 hours, p<0.001), greater TICI 2b-3 reperfusion (92% vs 69%, p<0.001), and greater 90-day mRS <2 (35% vs 21%, p=0.04). In a multivariable model, LVO2OR significantly increased the odds of 90-day mRS <2 (aOR 2.77, 95%CI 1.07,7.20; p=0.04) even when controlling for age, baseline mRS, AF, NIHSS, M2 location, and TICI 2b-3. Conclusion In a hub-and-spoke telestroke network, accepting transferred patients directly to the angio-suite was associated with dramatically reduced hub arrival-to-puncture time and may lead to improved 90-day outcomes. Direct-to-angio-suite protocols should continue to be evaluated in other regions and telestroke models.
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Affiliation(s)
- Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
| | - Joseph A Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
| | - Adam A Dmytriw
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School
| | - Justin E Vranic
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School
| | - Anna K Bonkhoff
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
| | - Martin Bretzner
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School
| | - James D Rabinov
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School
| | | | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
| | - Natalia S Rost
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
| | - Thabele M Leslie-Mazwi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
| | - Mark R Etherton
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
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Christensen EW, Liu CM, Duszak R, Hirsch JA, Swan TL, Rula EY. Association of State Share of Nonphysician Practitioners With Diagnostic Imaging Ordering Among Emergency Department Visits for Medicare Beneficiaries. JAMA Netw Open 2022; 5:e2241297. [PMID: 36355374 PMCID: PMC9650604 DOI: 10.1001/jamanetworkopen.2022.41297] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
IMPORTANCE The use of nonphysician practitioners (NPPs) in the emergency department (ED) continues to expand, yet little is known about associations between NPPs and ED imaging use. OBJECTIVE To investigate whether the state share of ED visits for which an NPP was the clinician of record is associated with imaging studies ordered, given that state NPP share is associated with state-level NPP scopes of practice. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study compared diagnostic imaging ordering patterns associated with ED visits based on 2005-2020 Medicare claims for a nationally representative 5% sample of fee-for-service beneficiaries. For all 50 states and the District of Columbia, the state NPP share of ED visits by year was used to represent state-specific practice patterns for NPPs and physicians and how those patterns have evolved over time. The analysis controlled for patient demographic characteristics, Charlson Comorbidity Index scores, ED visit severity, year, and principal diagnosis. EXPOSURES The share of ED visits in each state in each year (state share) for which an NPP was the evaluation and management clinician. MAIN OUTCOMES AND MEASURES The main outcomes were the number and modality of imaging studies associated with ED visits. Analyses were by logistic regression and generalized linear model with γ-distribution and log-link function. RESULTS Among 16 922 274 ED visits, 60.0% involved women, and patients' mean (SD) age was 70.3 (16.1) years. The share of all ED visits with an NPP as the clinician increased from 6.1% in 2005 to 16.6% in 2020. Compared with no NPPs, the presence of NPPs in the ED was associated with 5.3% (95% CI, 5.1%-5.5%) more imaging studies per ED visit, including a 3.4% (95% CI, 3.2%-3.5%) greater likelihood of any imaging order per ED visit and 2.2% (95% CI, 2.0%-2.3%) more imaging studies ordered per visit involving imaging. CONCLUSIONS AND RELEVANCE In this study, use of NPPs in the ED was associated with higher imaging use compared with the use of only physicians in the ED. Although expanded use of NPPs in the ED may improve patient access, the costs and radiation exposure associated with more imaging warrants additional study.
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Affiliation(s)
- Eric W. Christensen
- Harvey L. Neiman Health Policy Institute, Reston, Virginia
- Health Services Management, University of Minnesota, St Paul
| | - Chi-Mei Liu
- Harvey L. Neiman Health Policy Institute, Reston, Virginia
| | - Richard Duszak
- Department of Radiology, University of Mississippi Medical Center, Jackson
| | - Joshua A. Hirsch
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Hirsch JA, Zini C, Anselmetti GC, Ardura F, Beall D, Bellini M, Brook A, Cianfoni A, Clerk-Lamalice O, Georgy B, Maestretti G, Manfré L, Muto M, Ortiz O, Saba L, Kelekis A, Filippiadis DK, Marcia S, Masala S. Vertebral Augmentation: Is It Time to Get Past the Pain? A Consensus Statement from the Sardinia Spine and Stroke Congress. Medicina (B Aires) 2022; 58:medicina58101431. [PMID: 36295591 PMCID: PMC9609022 DOI: 10.3390/medicina58101431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 09/21/2022] [Accepted: 09/29/2022] [Indexed: 11/16/2022] Open
Abstract
Vertebral augmentation has been used to treat painful vertebral compression fractures and metastatic lesions in millions of patients around the world. An international group of subject matter experts have considered the evidence, including but not limited to mortality. These considerations led them to ask whether it is appropriate to allow the subjective measure of pain to so dominate the clinical decision of whether to proceed with augmentation. The discussions that ensued are related below.
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Affiliation(s)
- Joshua A. Hirsch
- Department of Radiology Massachusetts General Hospital, Harvard Medical School Boston, Boston, MA 02114, USA
| | - Chiara Zini
- UOC Radiologia Firenze 1, USL Toscana Centro, 50100 Firenze, Italy
| | | | - Francisco Ardura
- Spine Unit, Orthopedics and Traumatology Department, University Clinical Hospital of Valladolid, 47005 Valladolid, Spain
| | - Douglas Beall
- Comprehensive Specialty Care, Oklahoma City, OK 7301, USA
| | - Matteo Bellini
- UOC Neuroimmagini, Neuroradiologia Clinica e Funzionale Dipartimento di Scienze Neurologiche e Motorie Azienda Ospedaliera Universitaria Senese, 53100 Siena, Italy
| | - Allan Brook
- Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467-2490, USA
| | - Alessandro Cianfoni
- Department of Interventional and Diagnostic Neuroradiology, Neurocenter of Southern Switzerland, EOC, 6900 Lugano, Switzerland
| | - Olivier Clerk-Lamalice
- Beam Interventional & Diagnostic Imaging, Department of Interventional Pain Management, Calgary, AB 2500, Canada
| | - Bassem Georgy
- Department of Radiology, University of California, San Diego, CA 92025, USA
| | - Gianluca Maestretti
- Department of Orthopaedic Sugery and Traumatology, HFR Hôpital Cantonal, Unibversity of Fribourg, CH-1708 Fribourg, Switzerland
| | - Luigi Manfré
- Minimal Invasive Spine Department of Neurosurgery, Istituto Oncologico del Mediterraneo IOM, 95029 Viagrande, Italy
| | - Mario Muto
- UOC Neuroradiologia AO Cardarelli Naples Italy, 80131 Napoli, Italy
| | - Orlando Ortiz
- Department of Radiology, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY 11501, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.) di Cagliari, 09100 Cagliari, Italy
| | - Alexis Kelekis
- 2nd Department of Radiology, University General Hospital “ATTIKON” Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Dimitrios K. Filippiadis
- 2nd Department of Radiology, University General Hospital “ATTIKON” Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
- Correspondence:
| | - Stefano Marcia
- UOC Radiologia SS, Trinità Hospital, 09121 Cagliari, Italy
| | - Salvatore Masala
- Diagnostica per Immagini e Radiologia Interventistica, Università di Roma Tor Vergata, 00148 Roma, Italy
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Manchikanti L, Knezevic E, Latchaw RE, Knezevic NN, Abdi S, Sanapati MR, Staats PS, Gharibo CG, Simopoulos TT, Shah S, Abd-Elsayed A, Navani A, Kaye AD, Albers SL, Hirsch JA. Comparative Systematic Review and Meta-Analysis of Cochrane Review of Epidural Injections for Lumbar Radiculopathy or Sciatica. Pain Physician 2022; 25:E889-E916. [PMID: 36288577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Epidural injections are among the most commonly performed procedures for managing low back and lower extremity pain. Pinto et al and Chou et al previously performed systematic reviews and meta-analyses, which, along with a recent update from Oliveira et al showing the lack of effectiveness of epidural steroid injections in managing lumbar disc herniation, spinal stenosis, and radiculopathy. In contrast to these papers, multiple other systematic reviews and meta-analyses have supported the effectiveness and use of epidural injections utilizing fluoroscopically guided techniques. A major flaw in the review can be related to attributing active-controlled trials to placebo-controlled trials. The assumption that local anesthetics do not provide sustained benefit, despite extensive evidence that local anesthetics provide long-term relief, similar to a combination of local anesthetic with steroids is flawed. STUDY DESIGN The Cochrane Review of randomized controlled trials (RCTs) of epidural injections in managing chronic low back and lower extremity pain with sciatica or lumbar radiculopathy were reanalyzed using systematic methodology and meta-analysis. OBJECTIVES To re-evaluate Cochrane data on RCTs of epidural injections in managing chronic low back and lower extremity pain with sciatica or lumbar radiculopathy utilizing qualitative and quantitative techniques with dual-arm and single-arm analysis. METHODS In this systematic review, we have used the same RCTs from the Cochrane Review of a minimum of 20% change in pain scale or significant pain relief of >= 50%. The outcome measures were pain relief and functional status improvement. Significant improvement was defined as 50% or greater pain relief and functional status improvement. Our review was performed utilizing the Cochrane Review methodologic quality assessment and the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB). Evidence was summarized utilizing the principles of best evidence synthesis and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. Clinical relevance of the pragmatic nature of each study was assessed. RESULTS In evaluating the RCTs in the Cochrane Review, 10 trials were performed with fluoroscopic guidance. Utilizing conventional dual-arm and single-arm meta-analysis, the evidence is vastly different from the interpretation of the data within the Cochrane Review. The overall combined evidence is Level I, or strong evidence, at one and 3 months, and Level II, or moderate evidence, at 6 and 12 months. LIMITATIONS The limitation of this study is that only data contained in the Cochrane Review were analyzed. CONCLUSION A comparative systematic review and meta-analysis of the Cochrane Review of randomized controlled trials (RCTs) of epidural injections in managing chronic low back and lower extremity pain with sciatica or lumbar radiculopathy yielded different results. This review, based on the evidence derived from placebo-controlled trials and active-controlled trials showed Level I, or strong evidence, at one and 3 months and Level II at 6 and 12 months. This review once again emphasizes the importance of the allocation of studies to placebo-control and active-control groups, utilizing standards of practice with inclusion of only the studies performed under fluoroscopic guidance.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA
| | - Emilija Knezevic
- University of Illinois at Urbana-Champaign, College of Liberal Arts and Sciences, Champaign, IL
| | - Richard E Latchaw
- Neuroradiology Section, Dept. of Radiology, University of California at Davis Health System, Sacramento, CA
| | - Nebojsa Nick Knezevic
- Vice Chair for Research and Education, Department of Anesthesiology and Pain Management, Advocate Illinois Masonic Medical Center, Clinical Associate Professor of Anesthesiology and Surgery at University of Illinois, Chicago, IL
| | - Salahadin Abdi
- Department of Pain Medicine, Helen Buchanan & Stanley Joseph Seeger Endowed Research Professor, University of Texas, MD Anderson Cancer Center, Houston, TX
| | | | - Peter S Staats
- National Spine and Pain Centers, Rockville, MD, CoFounder and Chief Medical Officer, electroCore, and Former Contributor, Best Practices Pain Management Inter-agency Task Force, US Department of Health and Human Services, Washington, DC, USA
| | - Christopher G Gharibo
- NYU Langone Health, Professor of Anesthesiology, Peri-Operative Care & Pain Medicine, and Professor of Orthopedics, NYU Grossman School of Medicine, New York, NY, USA
| | - Thomas T Simopoulos
- Arnold Warfield Pain Management Center, Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, and Associate Professor, Harvard Medical School, Boston, MA, USA
| | - Shalini Shah
- University of California, Irvine, Department of Anesthesiology, Orange, CA
| | - Alaa Abd-Elsayed
- UW Health Pain Services and University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Annu Navani
- Comprehensive Pain Management Center, Campbell, CA
| | - Alan D Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, LSU Health Sciences Center, Shreveport, Ochsner Shreveport Hospital and Pain Clinic Feist-Wieller Cancer Center, Shreveport, LA, USA
| | | | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Kim HW, Regenhardt RW, D'Amato SA, Nahhas MI, Dmytriw AA, Hirsch JA, Silverman SB, Martinez-Gutierrez JC. Asymptomatic carotid artery stenosis: a summary of current state of evidence for revascularization and emerging high-risk features. J Neurointerv Surg 2022:jnis-2022-018732. [DOI: 10.1136/jnis-2022-018732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/23/2022] [Indexed: 11/03/2022]
Abstract
Carotid artery stenosis is a leading cause of ischemic stroke. While management of symptomatic carotid stenosis is well established, the optimal approach in asymptomatic carotid artery stenosis (aCAS) remains controversial. The rapid evolution of medical therapies within the time frame of existing landmark aCAS surgical revascularization trials has rendered their findings outdated. In this review, we sought to summarize the controversies in the management of aCAS by providing the most up-to-date medical and surgical evidence. Subsequently, we compile the evidence surrounding high-risk clinical and imaging features that might identify higher-risk lesions. With this, we aim to provide a practical framework for a precision medicine approach to the management of aCAS.
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Affiliation(s)
- Amit Mahajan
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut, USA
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Regenhardt RW, Awad A, Kraft AW, Rosenthal JA, Dmytriw AA, Vranic JE, Bonkhoff AK, Bretzner M, Etherton MR, Hirsch JA, Rabinov JD, Singhal AB, Rost NS, Stapleton CJ, Leslie-Mazwi TM, Patel AB. Characterizing reasons for stroke thrombectomy ineligibility among potential candidates transferred in a hub-and-spoke network. Stroke Vasc Interv Neurol 2022; 2:e000282. [PMID: 36187724 PMCID: PMC9524427 DOI: 10.1161/svin.121.000282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Background Access to endovascular thrombectomy (EVT) is relatively limited. Hub-and-spoke networks seek to transfer appropriate large vessel occlusion (LVO) candidates to EVT-capable hubs. However, some patients are ineligible upon hub arrival, and factors that drive transfer inefficiencies are not well described. We sought to quantify EVT transfer efficiency and identify reasons for EVT ineligibility. Methods Consecutive EVT candidates presenting to 25 spokes from 2018-2020 with pre-transfer CTA-defined LVO and ASPECTS ≥6 were identified from a prospectively maintained database. Outcomes of interest included hub EVT, reasons for EVT ineligibility, and 90-day modified Rankin Scale (mRS) ≤2. Results Among 258 patients, the median age was 70 years (IQR 60-81); 50% were female. 56% were ineligible for EVT after hub arrival. Cited reasons were large established infarct (49%), mild symptoms (33%), recanalization (6%), distal occlusion (5%), sub-occlusive lesion (3%), and goals of care (3%). Late window patients [last known well (LKW) >6 hours] were more likely to be ineligible (67% vs 43%, P<0.0001). EVT ineligible patients were older (73 vs 68 years, p=0.04), had lower NIHSS (10 vs 16, p<0.0001), longer LKW-hub arrival time (8.4 vs 4.6 hours, p<0.0001), longer spoke Telestroke consult-hub arrival time (2.8 vs 2.2 hours, p<0.0001), and received less intravenous thrombolysis (32% vs 45%, p=0.04) compared to eligible patients. EVT ineligibility independently reduced the odds of 90-day mRS≤2 (aOR=0.26, 95%CI=0.12,0.56; p=0.001) when controlling for age, NIHSS, and LKW-hub arrival time. Conclusions Among patients transferred for EVT, there are multiple reasons for ineligibility upon hub arrival, with most excluded for infarct growth and mild symptoms. Understanding factors that drive transfer inefficiencies is important to improve EVT access and outcomes.
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Affiliation(s)
- Robert W Regenhardt
- Neurosurgery, Massachusetts General Hospital
- Neurology, Massachusetts General Hospital
| | - Amine Awad
- Neurology, Massachusetts General Hospital
| | | | | | - Adam A Dmytriw
- Neurosurgery, Massachusetts General Hospital
- Radiology, Massachusetts General Hospital
| | - Justin E Vranic
- Neurosurgery, Massachusetts General Hospital
- Radiology, Massachusetts General Hospital
| | | | | | | | | | - James D Rabinov
- Neurosurgery, Massachusetts General Hospital
- Radiology, Massachusetts General Hospital
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