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Equity impact of a choice reform and change in reimbursement system in primary care in Stockholm County Council. - BMC health services research
In 2008 reforms were introduced in primary care in Stockholm County Council to increase patient choice. These reforms included changes to the reimbursement system from one that was primarily based on need-weighted capitation system (75Â %) to a system largely based on fee-for-service (60Â %) and freedom of establishment of primary care clinics. The new reimbursement system created incentives for producing many visits and additional primary care clinics were established, particularly in areas that were already well served. This study analyses if and how the choice reform and change of reimbursement system has affected equity in primary care consumption by investigating whether the increase in visits reflects levels of need and to what extent the reform have affected equity in health care between areas.Cross-sectional data from the public health survey in Stockholm County 2006 (nâ€‰=â€‰34,707) and 2010 (nâ€‰=â€‰30,767) were linked to individual register data on socio-demographic characteristics and health care utilization in 2007 and 2011. Information on self-reported health status and disability pension was used as indicators of need of health care. Negative binomial regression was used to analyse the differences in GP visits between the two years.The total number of visits to GPs increased by 46Â % from 2007 to 2011 and the proportion visiting a GP increased by 17Â %. Both men and women reporting poor mental health and women with limiting longstanding illness and poor self-rated health had significantly smaller increase in number of visits than healthy women and men. Men with poor health status living in disadvantaged areas had a smaller increase than men with poor health status living in other areas of Stockholm County.The reform did not particularly benefit those with greater health care needs, and there are indications of a negative impact on equity in primary care after the introduction of the reform. There were signs of a lesser increase in total number of visits to GPs among those with poor mental health, among women with poor self-rated health and limiting longstanding illness, and among men living in disadvantaged areas.
Assessment of tumor morphology on diffusion-weighted (DWI) breast MRI: Diagnostic value of reduced field of view DWI. - Journal of magnetic resonance imaging : JMRI
To compare the diagnostic value of conventional, bilateral diffusion-weighted imaging (DWI) and high-resolution targeted DWI of known breast lesions.Twenty-one consecutive patients with known breast cancer or suspicious breast lesions were scanned with the conventional bilateral DWI technique, a high-resolution, reduced field of view (rFOV) DWI technique, and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) (3.0 T). We compared bilateral DWI and rFOV DWI quantitatively by measuring the lesions' apparent diffusion coefficient (ADC) values. For qualitative comparison, three dedicated breast radiologists scored image quality and performed lesion interpretation.In a phantom, ADC values were in good agreement with the reference values. Twenty-one patients (30 lesions: 14 invasive carcinomas, 10 benign lesions [of which 5 cysts], 3 high-risk, and 3 in situ carcinomas) were included. Cysts and high-risk lesions were excluded from the quantitative analysis. Quantitatively, both bilateral and rFOV DWI measured lower ADC values in invasive tumors than other lesions. In vivo, rFOV DWI gave lower ADC values than bilateral DWI (1.11 Ã— 10(-3) mm(2) /s vs. 1.24 Ã— 10(-3) mm(2) /s, P = 0.002). Regions of interest (ROIs) were comparable in size between the two techniques (2.90 vs. 2.13 cm(2) , P = 0.721). Qualitatively, all three radiologists scored sharpness of rFOV DWI images as significantly higher than bilateral DWI (P â‰¤ 0.002). Receiver operating characteristic (ROC) curve analysis showed a higher area under the curve (AUC) in BI-RADS classification for rFOV DWI compared to bilateral DWI (0.71 to 0.93 vs. 0.61 to 0.76, respectively).Tumor morphology can be assessed in more detail with high-resolution DWI (rFOV) than with standard bilateral DWI by providing significantly sharper images. J. MAGN. RESON. IMAGING 2015.Â© 2015 Wiley Periodicals, Inc.
A Passive Parallel Master-Slave Mechanism for Magnetic Resonance Imaging-Guided Interventions. - Journal of medical devices
A passive, parallel master-slave mechanism is presented for magnetic resonance imaging (MRI)-guided interventions in the pelvis. The mechanism allows a physician to stand outside the MRI scanner while manipulating a needle inside the bore and, unlike a powered robot, does not place actuators in proximity to the patient. The manipulator combines two parallel mechanisms based on the Delta robot architecture. The mechanism also includes a two-axis gimbal to allow for tool angulation, giving a total of five degrees of freedom so that the physician can insert and steer a needle using continuous natural arm and wrist movements, unlike simple needle guides. The need for access between the patient's legs and within the MRI scanner leads to an unusual asymmetric design in which the sliding prismatic joints form the vertices of an isosceles triangle. Kinematic analysis shows that the dexterity index of this design is improved over the desired workspace, as compared to an equilateral design. The analysis is extended to estimate the effect of friction and model the input:output force transmission. Prototypes, with final dimensions selected for transperineal prostate interventions, showed force transmission behavior as predicted by simulation, and easily withstood maximum forces required for tool insertion.
Balanced SSFP Dixon imaging with banding-artifact reduction at 3 Tesla. - Magnetic resonance in medicine
To develop a three-dimensional (3D) balanced steady-state free-precession (bSSFP) two-point Dixon method with banding-artifact suppression to offer robust high-resolution 3D bright-fluid imaging.A complex sum reconstruction that combines phase-cycled bSSFP images acquired at specific echo times for robust fat/water separation without banding was investigated and compared with a magnitude-based method. Bloch simulations using both single-peak and multiple-peak fat models were performed to predict the performance of these methods for a wide range of echo times and repetition times. The quality and degree of fat/water separation was evaluated in both simulations and using in vivo imaging.Simulations predicted that both effective banding-artifact suppression and substantial improvements in fat/water separation are possible at echo times that are different from conventional echo times, enabling improved spatial resolution. Comparisons between various echo times and repetition times in vivo validated the improved fat/water separation and effective banding-artifact removal predicted by the simulations.The proposed complex sum Dixon 3D bSSFP method is able to effectively separate fat and water at different sets of echo times, while removing banding-artifacts, providing a fast, high-resolution, T2 -like sequence without blurring. Magn Reson Med 74:706-715, 2015. Â© 2014 Wiley Periodicals, Inc.Â© 2014 Wiley Periodicals, Inc.
Autonomous real-time interventional scan plane control with a 3-D shape-sensing needle. - IEEE transactions on medical imaging
This study demonstrates real-time scan plane control dependent on three-dimensional needle bending, as measured from magnetic resonance imaging (MRI)-compatible optical strain sensors. A biopsy needle with embedded fiber Bragg grating (FBG) sensors to measure surface strains is used to estimate its full 3-D shape and control the imaging plane of an MR scanner in real-time, based on the needle's estimated profile. The needle and scanner coordinate frames are registered to each other via miniature radio-frequency (RF) tracking coils, and the scan planes autonomously track the needle as it is deflected, keeping its tip in view. A 3-D needle annotation is superimposed over MR-images presented in a 3-D environment with the scanner's frame of reference. Scan planes calculated based on the FBG sensors successfully follow the tip of the needle. Experiments using the FBG sensors and RF coils to track the needle shape and location in real-time had an average root mean square error of 4.2 mm when comparing the estimated shape to the needle profile as seen in high resolution MR images. This positional variance is less than the image artifact caused by the needle in high resolution SPGR (spoiled gradient recalled) images. Optical fiber strain sensors can estimate a needle's profile in real-time and be used for MRI scan plane control to potentially enable faster and more accurate physician response.
Rim sign in breast lesions on diffusion-weighted magnetic resonance imaging: diagnostic accuracy and clinical usefulness. - Journal of magnetic resonance imaging : JMRI
To investigate the diagnostic accuracy and clinical usefulness of the rim sign in breast lesions observed in diffusion-weighted magnetic resonance imaging (DWI).The magnetic resonance imaging (MRI) findings of 98 pathologically confirmed lesions (62 malignant and 36 benign) in 84 patients were included. Five breast radiologists were asked to independently review the breast MRI results, to grade the degree of high peripheral signal, the "rim sign," in the DWI, and to confirm the mean apparent diffusion coefficient (ADCmean ) values. We analyzed the diagnostic accuracy and compared the consensus (when â‰¥ 4 of 5 independent reviewers agreed) results of the rim sign with the ADCmean values. Additionally, we evaluated the correlation between the dynamic contrast-enhanced (DCE)-MRI morphologic appearance and DWI rim sign.According to the consensus results, the rim sign in DWI was observed on 59.7% of malignant lesions and 19.4% of benign lesions. The sensitivity, specificity, and area under the curve (AUC) value for the rim sign in DWI were 59.7%, 80.6%, and 0.701, respectively. The sensitivity, specificity, and AUC value for the ADCmean value (criteria â‰¤ 1.46 Ã— 10(-3) mm(2) /sec) were 82.3%, 63.9%, and 0.731, respectively. Based on consensus, no correlation was observed between the DCE-MRI and DWI rim signs.In DWI, a high-signal rim is a valuable morphological feature for improving specificity in DWI.Â© 2014 Wiley Periodicals, Inc.
High-resolution, three-dimensional diffusion-weighted breast imaging using DESS. - Magnetic resonance imaging
To evaluate the use of the double-echo steady-state (DESS) sequence for acquiring high-resolution breast images with diffusion and T2 weighting.Phantom scans were used to verify the T2 and diffusion weighting of the DESS sequence. Image distortion was evaluated in volunteers by comparing DESS images and conventional diffusion-weighted images (DWI) to spoiled gradient-echo images. The DESS sequence was added to a standard clinical protocol, and the resulting patient images were used to evaluate overall image quality and image contrast in lesions.The diffusion weighting of the DESS sequence can be easily modulated by changing the spoiler gradient area and flip angle. Radiologists rated DESS images as having higher resolution and less distortion than conventional DWI. Lesion-to-tissue contrast ratios are strongly correlated between DWI and DESS images (R=0.83) and between T2-weighted fast spin-echo and DESS images (R=0.80).The DESS sequence is able to acquire high-resolution 3D diffusion- and T2-weighted images in short scan times, with image quality that facilitates morphological assessment of lesions.Copyright Â© 2014 Elsevier Inc. All rights reserved.
Breast Imaging in Women Previously Irradiated for Hodgkin Lymphoma. - American journal of clinical oncology
Women treated with mantle irradiation for Hodgkin lymphoma (HL) are at an increased risk of developing breast cancer (BC). Current guidelines recommend screening breast magnetic resonance imaging (MRI) as an adjunct to mammography (M) in these patients. There are limited data, however, as to the impact of breast MRI on cancer detection rates. The aim of the current study is to evaluate the use of breast MRI in survivors of HL treated and followed at a single institution.We retrospectively reviewed 980 female patients treated with mantle irradiation for HL between 1961 and 2008. Records were reviewed to determine age at radiotherapy treatment, radiotherapy dose, breast imaging (including M and breast MRI), biopsy results if applicable, and incidence of BC.A total of 118 patients had breast imaging performed at our institution. Median age at HL diagnosis was 28 years (range, 10 to 69 y). Median radiotherapy dose was 36 Gy (range, 20 to 45 Gy). Seventy-nine patients (67%) underwent M screening only, 1 (1%) breast MRI only, and 38 (32%) both M and breast MRI. Of these 38, 19 (50%) underwent 54 screening MRI studies (range per patient=1 to 8), 13 (34%) underwent preoperative MRI for workup of BC, and 6 (16%) initiated screening MRI of the contralateral breast only after diagnosed with BC. Fifty-nine biopsies were performed: 47 were prompted by suspicious M findings only, 10 by palpable findings on physical examination (PE), and 2 by suspicious breast MRI findings. Of the 47 biopsies prompted by M, 24 revealed malignant disease, whereas 23 proved to be benign. All 10 biopsies performed by palpation were malignant. Both biopsies prompted by MRI findings were benign. With M, there were 34 true-positive findings in 32 patients, 23 false-positive findings, and 1 false-negative finding. With screening MRI, there were 2 false-positive findings, 1 false-negative finding, and no true-positive findings.The role of screening breast MRI in women previously irradiated for HL is evolving. Further education of patients and physicians is important to increase awareness of more sensitive BC screening modalities in this high-risk population. Future studies are necessary to determine the appropriate integration of screening breast MRI into the ongoing follow-up of these women.
Why are patients noncompliant with follow-up recommendations after MRI-guided core needle biopsy of suspicious breast lesions? - AJR. American journal of roentgenology
The objective of this study was to investigate patient and breast MRI characteristics associated with noncompliance with recommended follow-up after MRI-guided core needle biopsy of suspicious breast lesions.A retrospective review was performed of 576 breast lesions biopsied under MRI guidance between 2007 and 2010. Patient follow-up was obtained from the medical record and from contact with referring physicians.Of 415 women who underwent 576 MRI-guided core needle biopsies for suspicious breast lesions, 123 (29.6%) patients representing 154 of 576 (26.7%) lesions were noncompliant with recommended excision or 6-month MRI follow-up. Referring physicians provided information for 63% (97/154) of lesions in noncompliant patients, of which 49.5% (48/97) were followed by mammography instead of excision or MRI. Noncompliance with MRI follow-up was significantly associated with referral for biopsy by outside hospital physicians (odds ratio [OR], 2.40; p = 0.0001) and with referral for screening MRI (1.46; p = 0.093) and biopsy of a focus or foci lesion (1.63; p = 0.088). Among 178 lesions in patients compliant with follow-up MRI after MRI-guided core needle biopsy, 7.9% (14/178) had abnormal follow-up MRI results, half of which (3.9%, 7/178) were found on repeat biopsy to be high-risk or malignant.Institutions performing MRI-guided core biopsies should be aware that patients referred from outside institutions are more likely to be noncompliant with recommended follow-up. Strategies to improve follow-up should include educating patients on the difference between mammography and MRI follow-up.
Variable spatiotemporal resolution three-dimensional Dixon sequence for rapid dynamic contrast-enhanced breast MRI. - Journal of magnetic resonance imaging : JMRI
To investigate a new variable spatiotemporal resolution dynamic contrast-enhanced (DCE) MRI method termed DIfferential Subsampling with Cartesian Ordering (DISCO), for imaging of breast cancer.DISCO combines variable density, pseudorandom k-space segmentation and two-point Dixon fat-water separation for high spatiotemporal resolution breast DCE MRI. During the contrast wash-in phase, view sharing is used to achieve high temporal resolution. Forty patients referred for breast MRI were imaged, 26 using the proposed DISCO sequence and 14 using a conventional low-spatial-resolution dynamic sequence (VIBRANT-FLEX) on a 3 Tesla scanner. DISCO dynamic images from 14 patients were compared with VIBRANT-FLEX images from 14 other patients. The image quality assessed by radiologist image ranking in a blinded manner, and the temporal characteristics of the two sequences were compared.A spatial resolution of 1.1 Ã— 1.1 Ã— 1.2 mm(3) (160 slices, 28 cm field of view) was achieved with axial bilateral coverage in 120 s. Dynamic images with âˆ¼ 9 s effective temporal resolution were generated during the 2-min contrast wash-in phase. The image quality of DISCO dynamic images ranked significantly higher than low spatial resolution VIBRANT-FLEX images (19.5 versus 9.5, Mann-Whitney U-test P = 0.00914), with no significant differences in the maximum slope of aortic enhancement.DISCO is a promising variable-spatiotemporal-resolution imaging sequence for capturing the dynamics of rapidly enhancing tumors as well as structural features postcontrast. A near 1-mm isotropic spatial resolution was achieved with postcontrast static phase images in 120 s and dynamic phase images acquired in 9 s per phase.Â© 2013 Wiley Periodicals, Inc.
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