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M P Rosen

Publications and source records attributed to M P Rosen.

At least 19 recordsLinked to original sources
PubMed2006

Methylenetetrahydrofolate reductase C677T and A1298C variants do not affect ongoing pregnancy rates following IVF.

BACKGROUND: There is concern that IVF could compromise normal imprinting and methylation of DNA. Methylenetetrahydrofolate reductase (MTHFR) regulates the flow of folic acid-derived, one-carbon moieties for methylation and is critical to early embryonic development. Therefore, we hypothesized that common polymorphisms in MTHFR could associate with IVF outcome. METHODS: MTHFR C677T and A1298C polymorphism genotyping was performed on 374 subjects for this study, representing 197 couples undergoing IVF in a university setting from July 2005 to January 2006. Analysis of variance (ANOVA), chi-square and/or multivariate analyses were used to assess whether these polymorphisms are associated with embryo quality or with ongoing pregnancy or spontaneous abortion rates. RESULTS: Allele frequencies for C677T ( p=0.67, q=0.33) and A1298C ( p=0.71, q=0.29) were in Hardy-Weinberg equilibrium. The C677T and A1298C variants, either alone or in combination, did not associate with embryo quality or short-term pregnancy outcome. CONCLUSIONS: The common polymorphisms in MTHFR are not associated with embryo quality, as defined by cell number or fragmentation score, or with short-term pregnancy outcomes. Therefore, in our population in which women receive adequate folic acid, MTHFR genotypes are not informative in explaining IVF failure. Further studies, however, examining birth outcomes and the other enzymes in the folic acid pathway are warranted.

Adult↗
PubMed2001

Newer diagnostic modalities for pulmonary embolism. Pulmonary angiography using CT and MR imaging compared with conventional angiography.

CTPA is a highly sensitive and excellent primary method for evaluating patients with symptoms of PE. Ongoing studies will demonstrate the good clinical outcome of patients with negative CTPA results. The ability to visualize the lung parenchyma in addition to the pulmonary vasculature, and the smaller number of nondiagnostic scans, make CT more cost effective than V/Q scans, and CT therefore should be used as a first-line evaluation. MR imaging is a continually developing modality with more imaging options that could make it an invaluable or adjunctive test in the near future.

Algorithms↗
PubMed2001

Classifying complications of interventional procedures: a survey of practicing radiologists.

PURPOSE: To determine the variability of radiologists' classification of complications from interventional procedures. MATERIALS AND METHODS: Fifteen test cases were selected from a database of morbidity and mortality cases that occurred in our department during the past 2 years. Ten cases were selected randomly, and five were chosen because of classification difficulties within our department. A survey with the case descriptions was presented to 145 SCVIR members via the World Wide Web and 48 were distributed to participants at a statewide angiography club meeting. Participants were asked to complete a short assessment of the their clinical background and to classify each case as "no complication," "minor complication," or "major complication." RESULTS: Thirty-eight percent (74 of 193) of the surveys were completed. Seventy percent (52 of 74) of the respondents were affiliated with an academic program, 12% (nine of 74) were affiliated with private practice groups, and 18% (13 of 74) claimed both academic and private affiliation. The consensus rate in classifying the complications for the randomly selected cases varied from 50% to 95%, with a median of 69%, and the consensus rate in classifying the selected cases varied from 46% to 95%, with a median of 85%. The lowest consensus rates occurred when (i) a significant procedural event was followed by a normal outcome, (ii) when a procedure was aborted, and (iii) when a significant event occurred but did not prolong hospital stay. CONCLUSION: Current criteria for reporting complications are associated with moderate rates of disagreement among interventional radiologists.

Adult↗
PubMed2001

Cost-effectiveness of percutaneous radiofrequency ablation for malignant hepatic neoplasms.

PURPOSE: Percutaneous radiofrequency (RF) ablation is a promising technique for the treatment of hepatic malignancies. However, its cost-effectiveness has not been established. The purpose of this study is to determine the cost-effectiveness of RF ablation compared to palliative care in the treatment of hepatocellular cancer and colorectal liver metastases. This study also seeks to evaluate the effects of transition from traditional to newly implemented prospective outpatient reimbursement mechanisms on RF ablation cost-effectiveness. MATERIALS AND METHODS: The marginal direct costs of a percutaneous RF ablation treatment strategy were compared to palliative care over a range of survival benefits with use of a cost-effectiveness model built from the perspective of the payer. Variables used in the model, including complication rates and procedure efficacy, were obtained from the literature and the authors' experience with 46 consecutive patients. RESULTS: The cost-effectiveness of a standardized percutaneous RF ablation treatment strategy compared to palliative care was $20,424, $11,407, $5,034, and $3,492, respectively, per life-year (LY) gained when marginal median survival conferred by RF ablation is 6 months, 1 year, 3 years, and 5 years. The RF ablation treatment strategy would be required to generate 6.14, 2.26, and 1.10 months of marginal median survival benefit to achieve strict ($20,000/LY gained), moderate ($50,000/LY gained), and generous ($100,000/LY gained) cost-effectiveness thresholds. Cost-effectiveness was sensitive to the number of lifetime treatments, hours of observation time, frequency of follow-up evaluations, cost of abdominal computed tomography, and decision to perform RF ablation as an inpatient or outpatient. CONCLUSION: Percutaneous RF ablation is a cost-effective treatment strategy compared to palliative care and has likely already achieved the survival benefit required to meet even a strict cost-effectiveness criterion. Dependence on reimbursement mechanism highlights the importance of concordance between policy and RF ablation technology. The results of this study allow flexible application of cost-effectiveness data despite current uncertainties in treatment and survival data and heterogeneity in treatment populations.

Catheter Ablation↗
PubMed2001

Remote sonographic interpretation using a laser printer network: system performance and diagnostic accuracy in actual clinical practice.

OBJECTIVE: The purpose of our study was to evaluate the technical and clinical performance of remote sonographic interpretation using a laser printer network connecting a community-based imaging center and an academic medical center. SUBJECTS AND METHODS: During a 3-month period, 161 consecutive sonographic examinations were performed at a community-based imaging center and all 161 patients were enrolled in the study. Seventy-one (44%) of 161 examinations were interpreted on-site at the community-based imaging center, and 90 (56%) of 161 were transmitted over a T-1 line to an academic medical center where the static images were interpreted remotely. For the purposes of this study, the examination time was defined as the interval from the time the technologist started to scan the patient to the time the patient was dismissed from the radiology department. Examination times were recorded for each patient. Follow-up was available for 92 (57%) of 161 studies. Sensitivity and specificity for studies interpreted at the community-based imaging center and at the academic medical center were calculated. RESULTS: The mean examination time for pelvic sonographic examinations interpreted at the academic medical center (43 min) was significantly longer than for scans interpreted at the community-based imaging center (31 min) (p < 0.01). However, no significant difference was noted in the examination time for abdominal sonography. For all examinations interpreted on-site at the community-based imaging center for which follow-up was available, the sensitivity and specificity were 95% and 100%, respectively. For all examinations interpreted remotely at the academic medical center for which follow-up was available, the sensitivity and specificity were 93% and 90%, respectively. No significant difference was seen in the sensitivity (p = 1.00) or specificity (p = 0.24) of studies interpreted on-site versus remotely. CONCLUSION: Static sonographic images can be interpreted remotely without loss of sensitivity, but with decreased specificity. However, more time must be allotted for performing pelvic sonography when these examinations are to be interpreted remotely.

Abdomen↗
PubMed2001

Patient expectations and costs of immediate reporting of screening mammography: talk isn't cheap.

OBJECTIVE: Our purpose was to determine whether patients prefer immediate or delayed results of screening mammography and to determine the cost of immediate reporting at our institution. MATERIALS AND METHODS: A survey was anonymously and randomly distributed to 129 women who were 35-70 years old during a visit to their primary care physician, asking the women's preference for receiving mammography results by one of two systems: by letter with a return visit for any additional tests; or by speaking at once with the radiologist, with the option of additional tests being performed during the same visit. Patients' willingness to pay for the latter service was also determined. A cost identification model was constructed using commercially available software. We considered the impact on radiologists' and technologists' time and the need for additional equipment and space, and we analyzed the effect on the cost of immediate reporting. RESULTS: One hundred twenty (93%) surveys were completed. Eighty women (67%) preferred immediate reporting, and 62 (78%) of these 80 patients would wait 30-60 min. The additional cost of immediate reporting is $28.22 per patient. Only 11% of patients were willing to pay this additional cost. When new equipment and space were not required, the cost would increase by $4.38. This cost was most influenced by the time required to give patients normal results. CONCLUSION: Most surveyed patients preferred speaking with a radiologist immediately but were unwilling to pay additional fees. Radiologists, hospital administrators, and health care planners must be aware of the costs of immediate reporting and must factor these costs into any change in hospital or national policy.

Adult↗
PubMed2000

Indications for pelvic sonography-Do patients and doctors agree?

PURPOSE: Often, it seems that the patient history provided by the referring clinician on the sonography requisition form differs from that given by the patient during the sonographic examination. Because such a discrepancy in the history may delay the scan and disrupt the daily work flow while the referring clinician is contacted for clarification, we sought to document the incidence and cause of such discrepancies at our institution. METHODS: During a 3-month period, all outpatients who were referred for a pelvic sonographic examination were asked to indicate their understanding of why the examination had been requested. The health care providers' reasons for requesting sonography were recorded using a computer order entry system. Each pair of responses (health care provider and patient) were classified as either concordant or discordant. Patient and physician characteristics were fit into a logistic regression model with concordance of history as the outcome variable. RESULTS: One hundred fifty-six (90%) of the 173 patients enrolled in our study indicated that their health care provider had discussed with them the reason for ordering the sonographic examination. The histories provided by the patient and health care provider were concordant in 134 (77%) of 173 cases. The histories provided by the patient and health care provider were more likely to be concordant if the patient's insurance was a managed care plan or if the patient had a college or graduate level education, had been cared for by the same health care provider for more than 2 years, or had been seen by a female health care provider. Concordance of history was not associated with a higher incidence of abnormal sonographic findings. CONCLUSIONS: It appears that health care providers, despite increased demands on their time, adequately discuss with their patients the reasons for ordering a pelvic sonographic examination. However, our study suggests that health care providers may need to spend additional time with patients whose education is limited and that male physicians may need to pay particular attention to their communication with female patients.

Adult↗
PubMed2000

Physicians' attitudes toward misdiagnosis of pulmonary embolism: a utility analysis.

RATIONALE AND OBJECTIVES: The purpose of this study was to measure physicians' utilities for outcomes after ventilation-perfusion lung scanning and to explore physicians' attitudes toward misdiagnosis and the treatment of patients suspected of having pulmonary embolism (PE) in a quantitative manner by using a utility analysis. MATERIALS AND METHODS: Before ordering lung scanning for suspected PE, physicians rated five possible outcomes on a scale of 0-100 by using a computer order-entry system. These responses were rescaled and transformed to a utility measure by using the Torrance transformation. RESULTS: The mean utility for the potential outcomes after 341 lung scans were (a) no PE and no treatment (true-negative, 93 +/- 22 [mean +/- standard deviation]), (b) PE with appropriate treatment (true-positive, 84 +/- 24), (c) no PE but patient received treatment (false-positive, 54 +/- 32), (d) PE but patient did not receive treatment (false-negative, 14 +/- 23), and (e) death during pulmonary angiography (2 +/- 11). After lung scanning for acute PE, physicians placed greatest value on excluding the diagnosis (true-negative). Providing unnecessary treatment (false-positive) was valued in the midrange of utilities. The value of missing PE (false-negative) was rated almost equal to that of dying during pulmonary angiography. CONCLUSION: Physicians consider providing treatment for PE without objective confirmation of an embolus to be preferable to missing a case of PE.

Adult↗
PubMed2000

Does a physician's ability to accurately assess the likelihood of pulmonary embolism increase with training?

PURPOSE: Pulmonary embolism (PE), an elusive diagnosis, is detected by a diagnostic work-up that is often guided by the physician's level of clinical suspicion. The ability to accurately assess PE risk on solely clinical grounds may increase with the physician's level of training. This study documented the ability of house staff practicing in an academic teaching hospital to accurately assess the clinical likelihood of PE in patients. METHOD: During a seven-month period, all 245 patients with suspected acute PE who had had lung scans ordered via a computerized order-entry system were enrolled in the study. When ordering the lung scans, all physicians (interns, residents, and attending physicians) were required to also enter their levels of clinical suspicion on a scale of 0 to 100. The physicians' levels of clinical suspicion were correlated with the final determinations of PE, and receiver operating characteristic (ROC) curves were calculated for patients' and physicians' subgroups. RESULTS: Attending physicians were most able to diagnose PE; residents were moderately able to make the diagnosis, and interns were least able to diagnose PE. The area under the ROC curve for a correct identification of patients with PE was greatest for attending physicians (0.839), intermediate for residents (0.601), and least for interns (0.594). CONCLUSION: The ability to correctly assess a patient's likelihood of PE increases with a physician's level of training, suggesting that more senior physicians should be involved in the diagnostic work-up of patients with suspected acute PE. More instruction may help medical students, interns, and residents navigate clinical scenarios in which the diagnosis is uncertain or in which sequential tests must be performed to reach the correct diagnosis.

Acute Disease↗
PubMed2000

Cost-effectiveness of hepatic arterial chemoembolization for colorectal liver metastases refractory to systemic chemotherapy.

PURPOSE: To calculate the cost-effectiveness of hepatic arterial chemoembolization (HACE) for the treatment of colorectal liver metastases (CLM) over a range of survival benefits and to determine the survival benefit that HACE must confer to meet three thresholds of cost-effectiveness. MATERIALS AND METHODS: A spreadsheet model was used to estimate the marginal direct cost of HACE compared with palliative care from a payer's perspective. Medicare reimbursement amounts represented costs, while probabilities of reembolization and complications were obtained from records of patients who underwent HACE. Marginal cost-effectiveness was calculated from marginal direct cost by varying the survival benefit of HACE compared with palliative care from 0 to 24 months. Break-even analyses were conducted to determine the survival benefit at which the cost-effectiveness of HACE would decrease below three threshold values derived from a literature review. RESULTS: The marginal cost-effectiveness of HACE compared with palliative care, given survival benefits of 3, 6, and 12 months, was $82,385, $41,193, and $21,045 per life-year (LY) gained, respectively. Cost-effectiveness thresholds of $20,000 (strict), $50,000 (moderate), and $100,000 (generous) per LY gained required survival benefits of 12.63, 4.94, and 2.47 months, respectively, more than the expected baseline. CONCLUSION: The cost-effectiveness of HACE for the treatment of CLM varies considerably according to the anticipated survival benefit. Results of future randomized controlled trials must demonstrate a survival benefit of nearly 5 months for HACE to meet the moderate cost-effectiveness standard of $50,000 per LY gained.

Antibiotics, Antineoplastic↗
PubMed2000

Right lower quadrant pain and suspected appendicitis: nonfocused appendiceal CT--review of 100 cases.

PURPOSE: To determine the value of standard, nonfocused computed tomography (CT) in examining patients with right lower quadrant (RLQ) pain and suspected appendicitis. MATERIALS AND METHODS: The CT scans and medical records of 100 consecutive patients who presented to the emergency department with RLQ pain and were clinically suspected of having appendicitis were retrospectively reviewed. Helical CT of both the abdomen and pelvis was performed at 7-mm increments after oral and intravenous contrast material administration. CT scans were evaluated for the presence of appendiceal or other disease. Results were correlated with surgical and pathologic findings in 34 patients or with 3-month clinical follow-up in 66 patients. RESULTS: CT depicted abnormalities in 66 patients (66%). In 59 (59%) patients, the abnormality was located in the pelvis; 23 (39%) of these patients had appendicitis. Seven (7%) patients had abnormalities outside of the pelvis, a region not typically scanned during focused appendiceal imaging. Four of these seven patients required surgery. Thus, if only pelvic focused RLQ CT had been performed, overall sensitivity would have decreased from 99% to 88% (P <.05) and sensitivity for cases necessitating surgery would have decreased from 96% to 82% (P <.05). CONCLUSION: Both abdominal and pelvic CT examinations are necessary to increase sensitivity and identify the many possible causes of RLQ pain in patients with clinically suspected appendicitis.

Abdominal Pain↗
PubMed2000

Impact of abdominal CT on the management of patients presenting to the emergency department with acute abdominal pain.

OBJECTIVE: The purpose of this study is to document the impact of CT performed in the emergency department of patients presenting with nontraumatic acute abdominal pain. SUBJECTS AND METHODS: Fifty-seven patients were enrolled in this prospective study. Using a computer order entry system, emergency department physicians were required to report their most likely diagnosis, level of certainty, and management plan for their patients before ordering abdominal CT. After CT was performed, each physician was required to provide again his or her diagnosis, level of diagnostic certainty, and treatment plan. The outcome of each patient was evaluated by either surgery, other imaging studies, or clinical follow-up. RESULTS: After the abdominal CT, physicians' mean level of certainty in their diagnoses increased by 1.5 points (on a five-point scale; p < 0.0001). Patient management was changed in 33 (60.0%) of 55 patients. Planned treatment before CT was admission in 42 patients. Actual admissions after CT totaled 32 patients (excluding the two patients in whom preimaging information was not recorded). Thus, the net effect of abdominal CT scanning was to avert 10 (23.8%) of 42 hospital admissions. CONCLUSION: CT performed in the emergency department increases the physician's level of certainty, reduces hospital admission rates by 23.8%, and leads to more timely surgical intervention.

Abdominal Pain↗
PubMed1999

Diagnostic accuracy with US: remote radiologists' versus on-site radiologists' interpretations.

PURPOSE: To compare the diagnostic accuracy of radiologists interpreting static ultrasonographic (US) images electronically transmitted to an academic medical center (remote radiologists) with that of radiologists performing "hands-on" US at a community-based outpatient site (on-site radiologists). MATERIALS AND METHODS: During 8 months, 80 patients underwent pelvic US at a community-based outpatient site. Images were electronically transmitted to a remote medical center as they were acquired at the community site and were printed on a laser printer identical to the one used at the outpatient site. The reference standard for correct diagnosis was based on histopathologic findings (n = 13), additional imaging results (n = 34), or review by a second independent observer (n = 33). Both an on-site and a remote radiologist interpreted the images, and their interpretations were rated as agree, both correct; agree, both incorrect; or disagree. Cases of disagreement were rated as major or minor. RESULTS: On-site and remote radiologists agreed in 69 of 80 patients (86%), and both radiologists were correct in all of these cases. There were 10 minor discrepancies and one major discrepancy. The diagnostic accuracies of the one-site and remote radiologists were 92% and 94%, respectively. CONCLUSION: High levels of diagnostic accuracy can be achieved by radiologists interpreting static US images. Strict protocols and excellent communication between the radiologist and sonographer are necessary to avoid diagnostic errors.

Academic Medical Centers↗