Early diagnosis of cardiomyopathies by cardiac magnetic resonance. Overview of the main criteria.

Cardiomyopathies (CMPs) are diseases of the heart muscle. They include a variety of myocardial disorders that manifest with various structural and functional phenotypes and are frequently genetic. Myocardial disease caused by known cardiovascular causes (such as hypertension, ischemic heart disease, or valvular disease) should be distinguished from CMPs for classification and management purposes. Identification of various CMP phenotypes relies primarily upon echocardiographic evaluation. In selected cases, cardiac magnetic resonance imaging (CMR) or computed tomography may be useful to identify and localize fatty infiltration, inflammation, scar/fibrosis, focal hypertrophy, and better visualize the left ventricular apex and right ventricle.  CMR imaging has emerged as a comprehensive tool for the diagnosis and follow-up of patients with CMPs. The accuracy and reproducibility in evaluating cardiac structures, the unique ability of non-invasive tissue characterization and the lack of ionizing radiation, make CMR very attractive as a potential "all-in-one technique". Indeed, it provides valuable data to confirm or establish the diagnosis, screen subclinical cases, identify aetiology, establish the prognosis. Additionally, it provides information for setting a risk stratification (based on evaluation of proved independent prognostic factors as ejection fraction, end-systolic-volume, myocardial fibrosis) and follow-up. Last, it helps to monitor the response to the therapy. In this review, the pivotal role of CMR in the comprehensive evaluation of patients with CMP is discussed, highlighting the key features guiding differential diagnosis and the assessment of prognosis.

Percutaneous closure of a paravalvular prosthetic mitral leak complicated by need for acute hemodialysis.

A case of a severe paravalvular mechanical mitral prosthesis leak (PVL) in a high-risk surgical patient, complicated with acute heart failure at presentation is described. Considering the high surgical risk and the specific echocardiographic features that would prevent the interventional cardiologist to have a direct access to the PVL with a traditional vascular plug or duct occluder, a percutaneous PVL closure with an Amplatzer-Amulet (Abbott, Abbott Park, Illinois, United States) LAA device (28 mm) was chosen for the contiguity of the PVL to the left atrial appendage (LAA). A new-onset hemolysis post-PVL closure and severe renal failure requiring hemodialysis occurred after the procedure, treated with surgical device removal and leak suture. To the best of our knowledge, this is the first case that describes the attempt to close a PVL, contiguous to the LAA, using the Amulet device. The attempt to close a PVL with these features with an Amplatzer-Amulet device, although promising, does not appear completely safe to reach the goal, as in our case. In our opinion, the most important reasons are that specific technical recommendations and broad experiences are lacking. Indeed, specific outcomes of this kind of approach are, to date, still unknown.

How Radiologists Are Paid: An Economic History, Part I: The Fight for Independent Billing.

In the first article in a four-part work, the authors review the economic history of how radiologists are paid, from the fight for independent billing in the 1960s to the impact of advanced imaging technologies on radiologists' incomes in the 1980s to the "bubble years" of the 1990s and to the end of the bubble in the first decade of the 21 century. The authors begin in this first part with the connections among a radiologist from Arkansas, a congressman, and the passage of Medicare, the program that gave radiologists the right to bill independently and gave the federal government a big role in health care spending.

How Radiologists Are Paid: An Economic History, Part IV: End of the Bubble.

During the first decade of the 21st century, the imaging bubble began to burst. The combination of digitized images, the DICOM standard, and affordable PACS sharply increased radiologists' productivity but also allowed an imaging study to be read from anywhere, creating the field of teleradiology and increased competition for radiologists. Increasing numbers of insurers contracted with radiology benefits managers to help control radiology utilization, and the Deficit Reduction Act of 2005 mandated spending cuts across the government. Consolidation of multiple Current Procedural Terminology codes and the reassessment of calculations used to estimate the utilization of a CT or an MRI scanner exerted additional downward pressure on radiology reimbursements. All of these factors, combined with more radiologists completing residency and the delayed retirement of older radiologists after the 2008 financial crisis, brought the imaging bubble to an end.

How Radiologists Are Paid: An Economic History, Part II: Advanced Imaging and Radiologists' Incomes.

The advent of the CT scanner in the early 1970s removed much, if not all, of the morbidity and discomfort previously associated with diagnostic imaging studies. Throughout the 1970s and 1980s, advances in CT technology allowed radiologists to scan "better and faster." The professional fee for reading a CT study was higher than for reading a radiograph, an uncontroversial policy. But estimating the technical fee for using CT (and later MR) raised problems that would persist for at least 30 years. Consistently generous technical fees created potential incentives to create and fill advanced imaging capacity and contributed to the emerging problem of health care inflation.

How Radiologists Are Paid: An Economic History, Part III: The Bubble Years.

With the collapse of the Clinton health care reforms, advanced imaging entered an economic bubble. Between 1995 and 2006, the number of CT and MRI studies almost tripled, from 21 million to 62 million and from 9.1 to 26.6 million, respectively. The increase reflected increases in both the number of scanners and the number of scans generated per CT or MRI scanner. Without restrictions, the profits generated by CT and MR ownership inevitably spread from hospitals first to imaging centers and later to individual physicians' offices and led to potential for conflict of interest and self-referral. During this time, the increase in radiologists' efficiency was fueled by the conversion from "film" to digitized images and PACS. In conjunction with increased volume and efficiency, radiologists' compensation increased throughout the 1990s.

Self-stigma, insight, and family burden among Israeli mothers of people with serious mental illness: Ethno-national considerations.

The current cross-sectional study investigated and compared the associations between insight, self-stigma, and family burden among Jewish and Arab mothers of an adult son or daughter with serious mental illness (SMI) in Israel. A total of 162 Israeli mothers of a person with SMI participated in the study; 95 were Jewish (58.6%), and 67 were Arab (41.4%). Insight, self-stigma, and family burden scales were administered. Jewish mothers reported higher levels of insight into their son's or daughter's illness and reported greater family burden compared to Arab mothers. No significant differences in self-stigma scores were found between Jewish and Arab mothers. The pattern of associations between insight, self-stigma, and burden differed between Jewish and Arab mothers. Self-stigma was found to mediate the relationship between insight and burden among Jewish mothers but not among Arab mothers. Ethno-national affiliation should be taken into consideration regarding how family members conceptualize and experience mental illness, as this might affect care.

Measuring the internalized stigma of parents of persons with a serious mental illness: the factor structure of the parents' internalized stigma of mental illness scale.

Research has revealed that approximately one third of persons with a serious mental illness (SMI) experience elevated internalized stigma, which is associated with a large number of negative outcomes. Family members of persons with SMI are also often subject to stigma, but the degree to which these experiences are internalized and lead to self-stigma has rarely been studied. The present study investigated the factor structure of a modification of the Internalized Stigma of Mental Illness (ISMI) scale by Ritsher, Otilingam, and Grajales (Psychiatry Res 121:31-49, 2003). A central assumption of this investigation was that the factor structure of the Parents' Internalized Stigma of Mental Illness (PISMI) scale would be similar to the factor structure of the ISMI scale. A total of 194 parents of persons with SMI completed the PISMI scale. The results revealed that the PISMI scale has high internal consistency and that it is made up of three distinctive factors: discrimination experience, social withdrawal and alienation, and stereotype endorsement. These factors are similar, but not identical, to the factors that underlie the ISMI scale. This study's findings also indicate that parents' prominent reaction to self-stigma is stereotype endorsement.

The sharp slowdown in growth of medical imaging: an early analysis suggests combination of policies was the cause.

The growth in the use of advanced imaging for Medicare beneficiaries decelerated in 2006 and 2007, ending a decade of growth that had exceeded 6 percent annually. The slowdown raises three questions. Did the slowdown in growth of imaging under Medicare persist and extend to the non-Medicare insured? What factors caused the slowdown? Was the slowdown good or bad for patients? Using claims file data and interviews with health care professionals, we found that the growth of imaging use among both Medicare beneficiaries and the non-Medicare insured slowed to 1-3 percent per year through 2009. One by-product of this deceleration in imaging growth was a weaker market for radiologists, who until recently could demand top salaries. The expansion of prior authorization, increased cost sharing, and other policies appear to have contributed to the slowdown. A meaningful fraction of the reduction in use involved imaging studies previously identified as having unproven medical value. What has occurred in the imaging field suggests incentive-based cost control measures can be a useful complement to comparative effectiveness research when a procedure's ultimate clinical benefit is uncertain.

A narrative evaluation of a psychoeducation and a therapeutic alliance intervention for parents of persons with a severe mental illness.

Most attempts to study the impact of psychosocial interventions on parents of persons with severe mental illness (SMI) are quantitative. The purpose of the present study was to investigate the subjective experience of parents of persons with SMI who participated in either a psychoeducational intervention which emphasized providing information on the illness and support, or a therapeutic alliance focused intervention (TAFI) which emphasized the alliance between the group members and group leaders. Ninety-three parents, who participated in either one of these two interventions, were interviewed using the Narrative Evaluation of Intervention Interview. Results show that participants found both interventions to be beneficial with no statistical differences in the level of perceived change. Themes describing change in relating to illness were significantly more frequently mentioned by participants in the TAFI group, whereas significantly more participants in the family psychoeducation interventions reported that implementation and information provided contributed to positive change. Also participants in the TAFI reported significantly more often that group regulation contributed to change. As both interventions were perceived as contributing, the findings support the relationship orientation to psychosocial interventions, which stresses the quality of the social support and interpersonal interaction as the source of positive outcomes of intervention.

The effect of imaging capacity on the imaging workup of patients with stroke: a preliminary case for a cross-country comparison.

PURPOSE: Medical imaging is a large and growing component of health care expenditures. To better understand some of the determinants of imaging ordering behavior, the authors analyzed the effect of differential capacity on the imaging workup of patients with acute nonhemorrhagic stroke. METHODS: All patients at a US teaching hospital and a two-campus Canadian teaching hospital between 2001 and 2005 discharged with diagnoses of acute nonhemorrhagic stroke were identified. Billing data were linked with clinical information systems to identify all imaging studies performed, comorbidities, and patient disposition. RESULTS: Nine hundred eighteen patients at the US hospital and 1,759 patients at the Canadian hospital were included. Patients were similar in age and distribution of comorbid illnesses. The rate of MRI scans at the US hospital was more than twice that at either of the Canadian hospitals (95.75 scans per 100 patients vs 41.39 scans per 100 patients). The length of stay was significantly shorter and the inpatient mortality rate significantly lower at the US hospital compared with the Canadian hospital. A multivariate regression analysis demonstrated that only patient age and site (US vs Canada) were significant predictors of MRI use, controlling for patient gender, comorbidities, and use of anticoagulants. CONCLUSIONS: Scanning utilization varied at hospitals with differential access to scanning technologies. There was less frequent use of MRI scanning at hospitals with limited access to this modality. Patient and health system factors are important considerations when interpreting the mechanisms for this variation, its importance, and the potential relationship of imaging use with patient outcomes.

Family psychoeducation and therapeutic alliance focused interventions for parents of a daughter or son with a severe mental illness.

This study compared the effectiveness of a family psychoeducational intervention (FPEI) and a therapeutic alliance focused intervention (TAFI) for parents of daughters and sons with severe mental illness (SMI). A process-outcome model was used to compare the effectiveness of the two interventions and to evaluate how they achieved their outcomes. Extent of effectiveness was assessed in terms of the family burden (FB) of the parents and the quality of life (QoL) and psychiatric symptoms of the daughters and sons. This study did not uncover a difference in effectiveness between the two interventions. However, at post-treatment, the participants in both interventions reported statistically significant less FB and attributed more QoL and less psychiatric symptoms to their daughters and sons than at pre-treatment. In addition, these pre- and post-treatment differences were mediated by specific mediating variables. These results are discussed in terms of the great psychotherapy debate (Wampold, 2001) as to the relative effectiveness of technique oriented interventions as compared to context oriented interventions.

The relationship between consumer insight and provider-consumer agreement regarding consumer's quality of life.

This study examined the relationship between insight and mental health consumers and providers agreement regarding consumers rated quality of life (QoL). Seventy mental health consumers and their 23 care providers filled-out parallel questionnaires designed to measure consumer QoL. Consumers' insight was also assessed. For most QoL domains, agreement between consumers and providers was higher for persons with high insight. For the Psychological well being dimension a negative correlation was uncovered for persons with low insight indicating disagreement between consumer and provider. These findings are discussed within the context of the literature on insight and agreement between consumer and provider as related to the therapeutic alliance.

Ultrasound-guided evaluation of the local anesthetic spread parameters required for a rapid surgical popliteal sciatic nerve block.

BACKGROUND: The ideal spread of local anesthetic (LA) solution around the sciatic nerve during a popliteal block remains unclear. We tested the hypothesis that a circumferential spread of LA and/or intraneural injection could lead to rapid surgical block. METHODS: Patients (n = 100) scheduled for foot or ankle surgery underwent popliteal sciatic nerve block using nerve stimulation according to Borgeat's technique and injection of ropivacaine (0.5 mL/kg). Sensory and motor blockades were assessed on the tibial nerve (TN) and common peroneal nerve (CPN) at 5, 15, and 30 mins after completion of the block and in the recovery room. A successful block was defined as a complete sensory block in TN and CPN. Changes in cross-sectional and longitudinal surfaces and diameters and the characteristics of LA spread around the nerve were noted using ultrasound. A suspected intraneural injection was defined as a 15% increase in the surface area or anteroposterior diameter of the nerve. Patients were followed up on days 1 and 7 after surgery. RESULTS: Successful block was noted in 57% of patients at 30 mins and in 88% of patients in the recovery room. A circumferential spread of LA occurred in 47% of patients and 53% had noncircumferential spread. Complete sensory block was significantly higher in the group that had a circumferential spread (73% vs 43%, P = 0.035) only at 30 mins. In the postoperative care unit, there was no difference among the groups. Separated circumferential spreads around TN and CPN were noted in 12% of patients. All of these patients had a complete sensory and motor blockade at 15 mins. Concerning intraneural injection, only the change in the anteroposterior diameter on a 6-cm length of nerve was associated with a higher success and faster onset block at 5 (P = 0.008), 15 (P = 0.02), and 30 (P = 0.05) mins. There were no clinically detectable nerve injuries at follow-up. CONCLUSION: For popliteal sciatic nerve block, circumferential spread of LA, and separation of the nerve into its 2 components are associated with rapid surgical block.

Computers and the supply of radiology services: anatomy of a disruptive technology.

Over the next decade, computers will augment the supply of radiology services at a time when reimbursement rules are likely to tighten. Increased supply and slower growing demand will result in a radiology market that is more competitive, with less income growth, than the market of the past 15 years.

Why the changing American economy calls for twenty-first century learning: answers to educators' questions.

While struggling with the current pressures of educational reform, some educators will ask whether their efforts make economic sense. Questioning the future makeup of the nation's workforce, many wonder how the educational system should be tempered to better prepare today's youth. This chapter answers educators' and parents' questions around the effect of fluctuations in the American economy on the future of education. The authors offer reassurance that good jobs will always be available, but warn that those jobs will require a new level of skills: expert thinking and complex communication. Schools need to go beyond their current curriculum and prepare students to use reading, math, and communication skills to build a deeper and more thoughtful understanding of subject matter. To explain the implications of the nation's changing economy on jobs, technology, and therefore education, the authors address a range of vital questions. Citing occupational distribution data, the chapter explores the supply and range of jobs in the future, as well as why changes in the U.S. job distribution have taken place. As much of the explanation for the shift in job distribution over the past several decades is due to the computerization of the workforce, the authors discuss how computers will affect the future composition of the workforce. The chapter also addresses the consequences of educational improvement on earnings distribution. The authors conclude that beyond workforce preparedness, students need to learn how to be contributing members of a democracy.