Soft-leadership competencies for today's healthcare finance executives.

With the healthcare industry changing rapidly, organizations seek finance leaders who have skills that go beyond traditional expertise in revenue and expenses. These additional competencies fall under the heading of soft-leadership skills and include the ability to be strategy-oriented, agile, passionate, inspirational, influential, communicative, dependable, driven, integrative, and engaged. Networking, participation in a mentoring program, and continuing education provide avenues for finance leaders to develop these sorts of skills.

Clinical and endoscopic significance of bowel-wall thickening reported on abdominal computed tomographies in symptomatic patients with no history of gastrointestinal disease.

BACKGROUND: Bowel-wall thickening (BWT) is a commonly reported finding on diagnostic abdominal pelvic computed tomographies (CT) in patients with no history of gastroenterologic disease. The significance of this nonspecific finding is not clear. METHODS: Medical records from the Vancouver General Hospital were reviewed from October 27, 1999, to October 27, 2009. The initial search yielded 5696 cases, of which 76 cases met the inclusion criteria for review. Inclusion criteria were the following: age older than 18 years, symptoms without a diagnosis of gastrointestinal disease before CT, the reported finding of terminal ileal and/or colonic BWT, colonoscopy after CT, and/or microbiologic investigations. Exclusion criteria included known gastrointestinal disease before CT. The primary objective was to determine if BWT could be associated with a significant endoscopic pathology. The secondary objective was to determine whether the pattern of abnormality on the CT was associated with a specific endoscopic finding. RESULTS: A total of 76 patients met the inclusion criteria of our study. Of those, 76% had various identifiable pathologies on colonoscopy. Only 24% had normal colonoscopic findings. Inflammatory bowel disease (IBD) and infectious colitis were the most common causes of BWT. A report of "skip lesions" on the CT (5%) was always associated with IBD. "Pancolitis" reported on the CT (11%) was associated with endoscopic findings of IBD in 25% of cases, infection in 50% of cases, and normal findings in 25% of cases. The report of "stranding" (36%) on CT in the presence of BWT was associated with many non-neoplastic endoscopic pathologic processes, including infectious colitis (22%), IBD (19%), and ischemia (15%), but also was associated with normal endoscopic findings in 26% of the cases. "Lymphadenopathy" was reported in 17% of the CTs and was associated with infectious colitis (30%), IBD (38%), or neoplastic processes (15%) but also normal endoscopic findings in 15%. CONCLUSION: Symptomatic patients who are found to have nonspecific BWT on CT should undergo definitive endoscopic investigation because the majority will have significant gastroenterologic disease, and only a minority will have a normal colonoscopy.

A prospective randomized trial comparing image quality, study interpretability, and radiation dose of narrow acquisition window with widened acquisition window protocols in prospectively ECG-triggered coronary computed tomography angiography.

BACKGROUND: Prospectively triggered coronary computed tomography angiography (CTA) is commonly performed with a widened acquisition window to provide flexibility in image reconstruction. OBJECTIVE: We conducted a randomized controlled trial to determine whether the use of a narrow acquisition window in prospectively triggered coronary CTA would allow lower radiation dose while preserving image quality and interpretability. METHODS: Prospective 2-center 2- platform randomized trial that evaluated 205 consecutive patients 96 with widened acquisition (WA) and 109 narrow acquisition (NA) referred for coronary CTA in sinus rhythm and heart rate <65 beats/min. Patients scanned with WA had phases reconstructed at 5% intervals, and each phase was assigned an individual study ID. Images were reviewed with individual phase reconstructions interpreted randomly by 2 level 3 readers with a third for consensus. Images were evaluated with a 5-point Likert scale on a per-vessel basis (best score on any phase). Scores were then dichotomized into diagnostic (score 3-5) compared with nondiagnostic (score 1-2). Readers also reported obstructive coronary artery disease on a per-patient basis. Agreement for the diagnosis of obstructive disease and per-artery interpretability was performed. Signal and noise measurements were also performed. RESULTS: No difference in demographics between groups (P = NS). The signal-to-noise ratio was comparable 12.99 ± 3.4 NA and 12.53 ± 4.13 for the WA (P = 0.45). The median effective dose was 1.78 mSv for NA compared with 3.26 mSv for WA (P < 0.001). Image quality, diagnostic interpretability, interreader agreement, and downstream testing were not significantly different between the 2 groups (P= NS for all). CONCLUSIONS: Coronary CTA with NA resulted in a 47% lower radiation dose without significant difference in study interpretability or image quality or increased downstream resource use or testing.

Structural integrity of balloon-expandable stents after transcatheter aortic valve replacement: assessment by multidetector computed tomography.

OBJECTIVES: This study sought to evaluate the structural integrity of balloon-expandable stents used in transcatheter aortic valve replacement. BACKGROUND: Underexpansion, deformation, or fracture of stent frames may affect transcatheter heart valve (THV) function and durability. METHODS: Patients >1 year after transcatheter aortic valve replacement underwent multidetector computed tomography. Geometry of the stent frame was assessed for circularity; eccentricity; minimum and maximum external diameter; and expansion at the inflow, mid-stent, and outflow levels, as well as for stent fracture. THV noncircularity was defined as stent eccentricity >10% (1 - minimum diameter/maximum diameter) and THV underexpansion when expansion <90% (multidetector computed tomography derived external valve area/nominal external valve area). Echocardiography was performed after implantation and annually. RESULTS: Fifty patients underwent multidetector computed tomography at an average of 2.5 ± 0.9 years after transcatheter aortic valve replacement (35 Sapien, 8 Sapien XT, and 7 Cribier-Edwards valves [all Edwards Lifesciences, Irvine, California). The mean external diameter for the 23- and 26-mm valves was 23.3 ± 0.9 mm and 25.9 ± 0.9 mm, respectively. Circularity was present in 96% (48 of 50) and median eccentricity was 2.0% (interquartile range: 1.2% to 3.0%). Mean THV expansion was 104.1 ± 7.4%, which increased from stent inflow to outflow (100.8 ± 7.6% vs. 108.1 ± 6.9%, p < 0.001). Stent fracture was not observed. Underexpanded valves (8% [4 of 50]) and noncircular valves (4% [2 of 50]) demonstrated stable hemodynamic function on annual echocardiography. CONCLUSIONS: Balloon-expandable aortic valves have excellent rates of circularity with low eccentricity and maintain full expansion without stent fracture at an average 2.5 years after implantation.

Exploring nitrilase sequence space for enantioselective catalysis.

Nitrilases are important in the biosphere as participants in synthesis and degradation pathways for naturally occurring, as well as xenobiotically derived, nitriles. Because of their inherent enantioselectivity, nitrilases are also attractive as mild, selective catalysts for setting chiral centers in fine chemical synthesis. Unfortunately, <20 nitrilases have been reported in the scientific and patent literature, and because of stability or specificity shortcomings, their utility has been largely unrealized. In this study, 137 unique nitrilases, discovered from screening of >600 biotope-specific environmental DNA (eDNA) libraries, were characterized. Using culture-independent means, phylogenetically diverse genomes were captured from entire biotopes, and their genes were expressed heterologously in a common cloning host. Nitrilase genes were targeted in a selection-based expression assay of clonal populations numbering 10(6) to 10(10) members per eDNA library. A phylogenetic analysis of the novel sequences discovered revealed the presence of at least five major sequence clades within the nitrilase subfamily. Using three nitrile substrates targeted for their potential in chiral pharmaceutical synthesis, the enzymes were characterized for substrate specificity and stereospecificity. A number of important correlations were found between sequence clades and the selective properties of these nitrilases. These enzymes, discovered using a high-throughput, culture-independent method, provide a catalytic toolbox for enantiospecific synthesis of a variety of carboxylic acid derivatives, as well as an intriguing library for evolutionary and structural analyses.