Stayin' alive: The introduction of municipal in-patient acute care units was associated with reduced mortality and fewer hospital readmissions.

BACKGROUND: Integrated care is seen as integral in combating the current and projected resource scarcity in the healthcare systems of developed economies. Previous research finds positive effects from implementing intermediate care but there is a lack of research on how this shift towards care integration has affected traditional quality indicators within healthcare, indicators such as mortality rates and hospital readmissions. We seek to contribute to the discourse by studying how the introduction of intermediate care in the form of municipal acute units (MAUs) in Norway has affected age adjusted mortality rates and hospital readmissions. DATA AND METHODS: In this retrospective cohort study we utilize yearly population-based registry data from 2010 to 2016, analysed with fixed-effects regressions. Data on the implementation, characteristics and localization of the MAUs were gathered by telephone during the implementation period. Data on mortality rates and hospital readmissions were collected from Statistics Norway and the Norwegian patient registry. RESULTS: Our analyses finds that the introduction of MAU was associated with a statistically significant reduction in both aggregated mortality rates and hospital readmission rates. In depth analyses finds that our results are contingent upon the age of the patients treated at the MAUs and the clinical characteristics of the medical units themselves. CONCLUSION: Our findings indicate that the shift towards intermediate care through the introduction of MAUs has increased performance within the public healthcare sector in Norway. Our findings indicate that the introduction of MAU have had a positive public health impact by lowering the mortality and readmission rates for the oldest population cohort in Norway. Our findings suggests that countries with comparatively similar healthcare systems as Norway could achieve similar benefits from implementing intermediate care in the form of somatic medical institutions in the local communities.

(I can't get no) satisfaction: A comparative study of healthcare recommodification in Europe, 2010-18.

European health reforms during the last decades have strengthened patient rights and introduced choice, competition and financial incentives in a sector that has typically been state-directed and centrally controlled. The marketisation of health care has also drawn out profit and introduced private provision. The main argument behind this trend is that market competition will improve service quality and deliver health services more efficiently. Such reforms often fall under the umbrella of New Public Management (NPM), and there is a lack of empirical research on their effects. The purpose of this paper is to investigate the association between healthcare marketisation and health system outcomes across European nations. In order to measure a country's degree of healthcare marketisation we employed indicators of healthcare decommodification. The concept refers to the extent to which an individual's access to healthcare is dependent upon their market position and the extent to which a country's provision of health is independent from the market. These indicators are three measures that assess the financing, provision and coverage of the private sector, and thus reflects the varied role of the market in a health care system: private health care expenditure as amount of GDP, private hospital beds as amount of total hospital bed stock, and public healthcare coverage. As indicator of health system outcome, we employed a measure that has not previously been investigated in the context of healthcare marketisation: satisfaction with health care system. We used multilevel analyses on five waves (2009-2017) of the biannual European Social Survey (ESS), with our final models including more than 120,000 individuals from 21 countries. Our methodological approach allowed us to study both cross-sectional and longitudinal relationships. The strongest substantial associations were between coverage and satisfaction, with high public healthcare coverage being associated with higher satisfaction.

Pseudo-T2 mapping for normalization of T2-weighted prostate MRI.

OBJECTIVE: Signal intensity normalization is necessary to reduce heterogeneity in T2-weighted (T2W) magnetic resonance imaging (MRI) for quantitative analysis of multicenter data. AutoRef is an automated dual-reference tissue normalization method that normalizes transversal prostate T2W MRI by creating a pseudo-T2 map. The aim of this study was to evaluate the accuracy of pseudo-T2s and multicenter standardization performance for AutoRef with three pairs of reference tissues: fat/muscle (AutoRefF), femoral head/muscle (AutoRefFH) and pelvic bone/muscle (AutoRefPB). MATERIALS AND METHODS: T2s measured by multi-echo spin echo (MESE) were compared to AutoRef pseudo-T2s in the whole prostate (WP) and zones (PZ and TZ/CZ/AFS) for seven asymptomatic volunteers with a paired Wilcoxon signed-rank test. AutoRef normalization was assessed on T2W images from a multicenter evaluation set of 1186 prostate cancer patients. Performance was measured by inter-patient histogram intersections of voxel intensities in the WP before and after normalization in a selected subset of 80 cases. RESULTS: AutoRefFH pseudo-T2s best approached MESE T2s in the volunteer study, with no significant difference shown (WP: p = 0.30, TZ/CZ/AFS: p = 0.22, PZ: p = 0.69). All three AutoRef versions increased inter-patient histogram intersections in the multicenter dataset, with median histogram intersections of 0.505 (original data), 0.738 (AutoRefFH), 0.739 (AutoRefF) and 0.726 (AutoRefPB). DISCUSSION: All AutoRef versions reduced variation in the multicenter data. AutoRefFH pseudo-T2s were closest to experimentally measured T2s.

Let's stick together: The role of self-interest and ideological beliefs for supporting a 'solidaristic' health policy in Norway.

Previous studies of health system legitimacy have almost exclusively paid attention to patterns of service satisfaction and preference for state involvement. These two dimensions are related to substantial and procedural justice; i.e. the value of a certain policy and the way it is implemented. This study contributes to the research field by focusing on a third dimension that have been little studied so far: the willingness of citizens to contribute on a solidaristic basis. This dimension was captured through three health policy preferences: public healthcare spending willingness, opposition to co-payments and opposition to private health insurance. Building on the literature on welfare state legitimacy, the empirical model distinguished between two sets of predictors to explain individual differences: self-interest and ideological belief. Old age, poor health and poor economy is positively associated with opposition to co-payments for "self-inflicted" diseases, while low education and poor health is positively related to support for more public spending. Increasing age is furthermore positively associated with opposing co-payments and easier uptake of insurance. Liberal-conservative voters are less willing to spend more on healthcare but more willing to increase the use of co-payments and insurance.

'Professional-supportive' versus 'economic-operational' management: the relationship between leadership style and hospital physicians' organisational climate.

BACKGROUND: Health systems across the world have implemented reforms that call for a reconsideration of the role of management in hospitals, which is increasingly seen as important for performance. These reorganisation efforts of the hospitals have challenged and supplemented traditional profession-based management with more complex systems of management inspired by the business sector. Whereas there is emerging evidence on how medical professionals in their role as leaders and managers adapt to the new institutional logics of the health care sector with increasing demands for efficiency and budgetary discipline, no previous studies have investigated whether leaders' emphasis on clinical or financial priorities is related to how hospital physicians' view their working situation. The purpose of this study was therefore to examine the relationship between leadership style and hospital physicians' organisational climate. METHODS: We utilised data from a survey among 3000 Norwegian hospital physicians from 2016. The analysis used three additive indexes as dependent variables to reflect various aspects of the organisational climate: social climate, innovation climate and engagement at the workplace. The variables reflecting leadership style were based on an item in the survey asking the respondents to rate the leadership qualities of their proximate leaders (department chair) on 11 specific dimensions. We used factor analysis to identify two types of leadership styles: a traditional profession-based leadership style that emphasises the promotion of professional standards and quality in patient treatment, and a leadership style that reflects the emerging management philosophy with focus on economic administration and budgetary control. Controlling for demographic background, leader role, foreign medical exam and specialty, the empirical model was estimated via multivariate regression. RESULTS: The results documented a clear relationship between leadership style and organisational climate: a 'professional-supportive' leadership style is associated with better social climate, innovation climate and engagement at the workplace, while an 'economic-operational' leadership style is associated with a poorer social climate. CONCLUSIONS: The cross-sectional study design makes it impossible to draw inferences about direction of causality and causal pathways. However, the positive relationship between professional-supportive leadership and organisational climate is a matter, which should be seriously considered regardless of direction of causality.

Financial incentives and patient selection: Hospital physicians' views on cream skimming and economic management focus in Norway.

This paper uses survey data to analyse physician views on the risk of cream skimming under a system with activity based financing (ABF) for hospital services. We used data from two nation-wide physician surveys. A survey undertaken in 2006 captures views following a large NPM-inspired structural reform in 2002. In contrast, a survey undertaken in 2016 captures views after a period of a higher degree of institutional and financial stability. We find that the majority of physicians believed that the 2002 reform both provided incentives for and led to more cream skimming. In 2016, however there is less consensus among physicians about the extent of cream skimming. Looking at different types of physicians we find some indications that physicians in leading positions are less likely to view cream skimming as a problem. However, there is concern that hospital management in general puts too much emphasis on economic issues.

Is a Decentralised Health Policy Associated With Better Self-rated Health and Health Services Evaluation? A Comparative Study of European Countries.

BACKGROUND: While decentralisation has come to be a major policy strategy in many healthcare systems, there is still insufficient evidence about its impact. Most studies have been of developing countries, and they have provided mixed results. This study is the first to test the relevance of political decentralisation across European countries, thus meeting the demand for more studies of decentralisation in developed countries, and building on an indicator of decentralisation reflecting the allocation of authority for both health policy tasks and health policy areas. METHODS: As indicators of health system outcome, we employed 2 measures that have not previously been investigated in the context of decentralisation: self-rated health and satisfaction with healthcare system. Using multilevel modelling and controlling for individual-level demographic and socioeconomic variables, the paper utilised the 2014 (7th) and 2016 (8th) round of the European Social Survey (ESS), including more than 70 000 individuals from 20 countries. RESULTS: The results suggest that decentralisation has a positive and significant association with health system satisfaction, but not with self-rated health. Of the different operationalisations, decentralised healthcare provision had the strongest association with health system satisfaction. CONCLUSIONs: Our study fails to provide clear support for decentralised health systems. There is a need for more research on the impact of such reforms in order to provide policy-makers with knowledge of desirable governance, organisational designs, management and incentives in healthcare.

Should I stay or should I go? The role of leadership and organisational context for hospital physicians' intention to leave their current job.

BACKGROUND: Physician turnover is a concern in many health care systems globally. A better understanding of physicians' reasons for leaving their job may inform organisational policies to retain key personnel. The aim of this study was to investigate hospital physicians' intention to leave their current job, and to investigate if such intentions are associated with how physicians assess their leaders and the organisational context. METHODS: Data was derived from a survey of 971 physicians working in public hospitals in Norway in 2016. The data was analysed using descriptive statistics and multivariate analysis. RESULTS: We found that 21.0% of all hospital physicians expressed an intention to leave their current job for another job. An additional 20.3% of physicians had not made up their mind whether to stay or leave. Physicians' perceptions of their leaders and the organisational context influence their intention to leave their hospital. Respondents who perceived their leaders as professional-supportive had a significantly lower probability of reporting an intention to leave their job. The analysis suggests that organisational context, such as department mergers, weigh in on physicians' considerations about leaving their current job. Social climate and commitment are important reasons why physician stay. CONCLUSIONS: A professional-supportive leadership style may have a positive influence on retention of physicians in public hospitals. Further research should investigate how retention of physicians is associated with performance related to organisational and leadership style.

Being Healthy, Being Sick, Being Responsible: Attitudes towards Responsibility for Health in a Public Healthcare System.

Lifestyle-induced diseases are becoming a burden on healthcare, actualizing the discussion on health responsibilities. Using data from the National Association for Heart and Lung Diseases (LHL)'s 2015 Health Survey (N = 2689), this study examined the public's attitudes towards personal and social health responsibility in a Norwegian population. The questionnaires covered self-reported health and lifestyle, attitudes towards personal responsibility and the authorities' responsibility for promoting health, resource-prioritisation and socio-demographic characteristics. Block-wise multiple linear regression assessed the association between attitudes towards health responsibilities and individual lifestyle, political orientation and health condition. We found a moderate support for social responsibility across political views. Respondents reporting unhealthier eating habits, smokers and physically inactive were less supportive of health promotion policies (including information, health incentives, prevention and regulations). The idea that individuals are responsible for taking care of their health was widely accepted as an abstract ideal. Yet, only a third of the respondents agreed with introducing higher co-payments for treatment of 'self-inflicted' conditions and levels of support were patterned by health-related behaviour and left-right political orientation. Our study suggests that a significant support for social responsibility does not exclude a strong support for personal health responsibility. However, conditional access to healthcare based on personal lifestyle is still controversial.

Accuracy of breast cancer lesion classification using intravoxel incoherent motion diffusion-weighted imaging is improved by the inclusion of global or local prior knowledge with bayesian methods.

BACKGROUND: Diffusion-weighted MRI (DWI) has potential to noninvasively characterize breast cancer lesions; models such as intravoxel incoherent motion (IVIM) provide pseudodiffusion parameters that reflect tissue perfusion, but are dependent on the details of acquisition and analysis strategy. PURPOSE: To examine the effect of fitting algorithms, including conventional least-squares (LSQ) and segmented (SEG) methods as well as Bayesian methods with global shrinkage (BSP) and local spatial (FBM) priors, on the power of IVIM parameters to differentiate benign and malignant breast lesions. STUDY TYPE: Prospective patient study. SUBJECTS: 61 patients with confirmed breast lesions. FIELD STRENGTH/SEQUENCE: DWI (bipolar SE-EPI, 13 b values) was included in a clinical MR protocol including T2 -weighted and dynamic contrast-enhanced MRI on a 3T scanner. ASSESSMENT: The IVIM model was fitted voxelwise in lesion regions of interest (ROIs), and derived parameters were compared across methods within benign and malignant subgroups (correlation, coefficients of variation). Area under receiver operator characteristic curves (ROC AUCs) were calculated to determine discriminatory power of parameter combinations from all fitting methods. STATISTICAL TESTS: Kruskal-Wallis, Mann-Whitney, Pearson correlation. RESULTS: All methods provided useful IVIM parameters; D was well-correlated across all methods (r > 0.8), with a wider range for f and D* (0.3-0.7). Fitting methods gave detectable differences in parameters, but all showed increased f and decreased D in malign lesions. D was the most discriminatory single parameter, with LSQ performing least well (AUC 0.83). In general, ROC AUCs were maximized by the inclusion of pseudodiffusion parameters, and by the use of Bayesian methods incorporating prior information (maximum AUC of 0.92 for BSP). DATA CONCLUSION: DWI performs well at classifying breast lesions, but careful consideration of analysis procedure can improve performance. D is the most discriminatory single parameter, but including pseudodiffusion parameters (f and D*) increases ROC AUC. Bayesian methods outperformed conventional least-squares and segmented fitting methods for breast lesion classification. LEVEL OF EVIDENCE: 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:1478-1488.

Is having private health insurance associated with less support for public healthcare? Evidence from the Norwegian NHS.

The purpose of this study was to investigate whether increased uptake of private health insurance (PHI) in a traditionally NHS type system is likely to affect support for the public healthcare system. Using the Norwegian healthcare system as our case, and building on a survey among 7500 citizens, with 2688 respondents, we employed multivariate analysis to uncover whether the preferences for public health services are associated with having PHI, controlling for key predictors such as socio-economic background, self-rated health and perceived health service quality, as well as age and gender. The basis for our analysis was the following two propositions related to the role of public healthcare, which the respondents were asked to score on a 5-point Likert scale (1 = "totally disagree", 5 = "totally agree"): 1) "the responsibility of providing health services should mainly be public", and 2) "the activity of private commercial actors should be limited". The regression analyses showed that the willingness to increase the role of commercial private actors is positively associated with having a PHI. However, we found no relationship between holding a PHI and support for public provision of health services when other factors were controlled for.

Primary care physicians' views on osteoporosis management: a qualitative study.

Osteoporosis is an under-diagnosed condition; only around 14% of patients in Sweden receive bone-specific treatment after a fragility fracture. This qualitative interview study found that primary care physicians perceive osteoporosis as a silent disease that is overshadowed by other conditions and is complicated to manage. PURPOSE: To explore primary care physicians' views on managing osteoporosis. METHODS: A total of 17 primary care physicians in Stockholm participated in four focus group interviews. Interview transcripts were analysed with thematic analysis. RESULTS: One main theme was found: Osteoporosis-a silent disease overshadowed by other conditions. The main theme contained five sub-themes. Physicians perceived osteoporosis as a low-priority issue. They described uncertainty about managing it and insufficient awareness of the condition in primary healthcare (PHC). Physicians had differing opinions about who is responsible for managing osteoporosis. They reported that the health care system regulated their work such that they gave low priority to the condition. They were uncertain about the value of the Fracture Risk Assessment Tool (FRAX). The physicians thought that financial incentives, education, and increased collaboration with other relevant health care professionals and with patients were needed to increase the priority of osteoporosis in PHC. CONCLUSION: Physicians perceived osteoporosis as a silent disease that is complicated to manage. They gave low priority to osteoporosis and thought their patients shared this view. The physicians saw other issues and medical conditions as more important than osteoporosis. They wanted better collaboration at their PHC centres and with hospitals. They also wanted district nurses to be more involved in managing osteoporosis and especially in assessing fracture risk.

Relationship between kurtosis and bi-exponential characterization of high b-value diffusion-weighted imaging: application to prostate cancer.

BACKGROUND: High b-value diffusion-weighted imaging has application in the detection of cancerous tissue across multiple body sites. Diffusional kurtosis and bi-exponential modeling are two popular model-based techniques, whose performance in relation to each other has yet to be fully explored. PURPOSE: To determine the relationship between excess kurtosis and signal fractions derived from bi-exponential modeling in the detection of suspicious prostate lesions. MATERIAL AND METHODS: This retrospective study analyzed patients with normal prostate tissue (n = 12) or suspicious lesions (n = 13, one lesion per patient), as determined by a radiologist whose clinical care included a high b-value diffusion series. The observed signal intensity was modeled using a bi-exponential decay, from which the signal fraction of the slow-moving component was derived ( SFs). In addition, the excess kurtosis was calculated using the signal fractions and ADCs of the two exponentials ( KCOMP). As a comparison, the kurtosis was also calculated using the cumulant expansion for the diffusion signal ( KCE). RESULTS: Both K and KCE were found to increase with SFs within the range of SFs commonly found within the prostate. Voxel-wise receiver operating characteristic performance of SFs, KCE, and KCOMP in discriminating between suspicious lesions and normal prostate tissue was 0.86 (95% confidence interval [CI] = 0.85 - 0.87), 0.69 (95% CI = 0.68-0.70), and 0.86 (95% CI = 0.86-0.87), respectively. CONCLUSION: In a two-component diffusion environment, KCOMP is a scaled value of SFs and is thus able to discriminate suspicious lesions with equal precision . KCE provides a computationally inexpensive approximation of kurtosis but does not provide the same discriminatory abilities as SFs and KCOMP.

Public evaluation of health services across 21 European countries: The role of culture.

AIMS: This work examined the role of cultural values in understanding people's satisfaction with health services across Europe. METHODS: We used multilevel linear regression analysis on the seventh round of the European Social Survey from 2014, including c. 40,000 respondents from 21 countries. Preliminary intraclass correlation analyses led us to believe that some explanations of variance in the dependent variable were to be found at the country level. In search of country level explanations, we attempted to account for the role of national culture in influencing citizens' attitudes towards health systems. This was done by using Hofstede's dimensions of power distance, individualism, masculinity and uncertainty avoidance, giving each country in the survey a mean aggregated score. RESULTS: In our first model with individual level variables, being female, having low or medium education, experiencing financial strain, and reporting poor health and unmet medical needs were negatively associated with individual satisfaction with national healthcare systems, with the latter variable showing the strongest effect. After including Hofstede's cultural dimensions in our multilevel model, we found that the power distance index variable had a negative effect on the dependent variable, significant at the 0.1 level. CONCLUSIONS: Citizens are likely to evaluate their national health system more negatively in national cultures associated with autocracy and hierarchy.

Stimulated echo diffusion tensor imaging (STEAM-DTI) with varying diffusion times as a probe of breast tissue.

PURPOSE: To explore the application of diffusion tensor imaging (DTI) for breast tissue and breast pathologies using a stimulated-echo acquisition mode (STEAM) with variable diffusion times. MATERIALS AND METHODS: In this Health Insurance Portability and Accountability Act-compliant study, approved by the local institutional review board, eight patients and six healthy volunteers underwent an MRI examination at 3 Tesla including STEAM-DTI with several diffusion times ranging from 68.5 to 902.5 ms. A DTI model was fitted to the data for each diffusion time, and parametric maps of mean diffusivity, fractional anisotropy, axial diffusivity, and radial diffusivity were computed for healthy fibroglandular tissue (FGT) and lesions. The median value of radial diffusivity for FGT was fitted to a linear decay to obtain an estimation of the surface-to-volume ratio, from which the radial diameter was calculated. RESULTS: For healthy FGT, radial diffusivity presented a linear decay with the square root of the diffusion time resulting in a range of estimated radial diameters from 202 to 496 µm, while axial diffusivity presented a nearly time-independent diffusion. Residual fat signal was reduced at longer diffusion times due to the shorter T1 of fat. Residual fat signal to the overall signal in the healthy volunteers' FGT was found to range from 2.39% to 2.55% (shortest mixing time), and from 0.40% to 0.51% (longest mixing time) for the b500 images. CONCLUSION: The use of variable diffusion times may provide an in vivo noninvasive tool to probe diffusion lengths in breast tissue and breast pathology, and might aid by improving fat suppression at longer diffusion times. LEVEL OF EVIDENCE: 2 J. Magn. Reson. Imaging 2017;45:84-93.

Effect of Task-Correlated Physiological Fluctuations and Motion in 2D and 3D Echo-Planar Imaging in a Higher Cognitive Level fMRI Paradigm.

PURPOSE: To compare 2D and 3D echo-planar imaging (EPI) in a higher cognitive level fMRI paradigm. In particular, to study the link between the presence of task-correlated physiological fluctuations and motion and the fMRI contrast estimates from either 2D EPI or 3D EPI datasets, with and without adding nuisance regressors to the model. A signal model in the presence of partly task-correlated fluctuations is derived, and predictions for contrast estimates with and without nuisance regressors are made. MATERIALS AND METHODS: Thirty-one healthy volunteers were scanned using 2D EPI and 3D EPI during a virtual environmental learning paradigm. In a subgroup of 7 subjects, heart rate and respiration were logged, and the correlation with the paradigm was evaluated. FMRI analysis was performed using models with and without nuisance regressors. Differences in the mean contrast estimates were investigated by analysis-of-variance using Subject, Sequence, Day, and Run as factors. The distributions of group level contrast estimates were compared. RESULTS: Partially task-correlated fluctuations in respiration, heart rate and motion were observed. Statistically significant differences were found in the mean contrast estimates between the 2D EPI and 3D EPI when using a model without nuisance regressors. The inclusion of nuisance regressors for cardiorespiratory effects and motion reduced the difference to a statistically non-significant level. Furthermore, the contrast estimate values shifted more when including nuisance regressors for 3D EPI compared to 2D EPI. CONCLUSION: The results are consistent with 3D EPI having a higher sensitivity to fluctuations compared to 2D EPI. In the presence partially task-correlated physiological fluctuations or motion, proper correction is necessary to get expectation correct contrast estimates when using 3D EPI. As such task-correlated physiological fluctuations or motion is difficult to avoid in paradigms exploring higher cognitive functions, 2D EPI seems to be the preferred choice for higher cognitive level fMRI paradigms.

A Simplified Approach to Measure the Effect of the Microvasculature in Diffusion-weighted MR Imaging Applied to Breast Tumors: Preliminary Results.

Purpose To evaluate the relative change of the apparent diffusion coefficient (ADC) at low- and medium-b-value regimens as a surrogate marker of microcirculation, to study its correlation with dynamic contrast agent-enhanced (DCE) magnetic resonance (MR) imaging-derived parameters, and to assess its potential for differentiation between malignant and benign breast tumors. Materials and Methods Ethics approval and informed consent were obtained. From May 2013 to June 2015, 61 patients diagnosed with either malignant or benign breast tumors were prospectively recruited. All patients were scanned with a 3-T MR imager, including diffusion-weighted imaging (DWI) and DCE MR imaging. Parametric analysis of DWI and DCE MR imaging was performed, including a proposed marker, relative enhanced diffusivity (RED). Spearman correlation was calculated between DCE MR imaging and DWI parameters, and the potential of the different DWI-derived parameters for differentiation between malignant and benign breast tumors was analyzed by dividing the sample into equally sized training and test sets. Optimal cut-off values were determined with receiver operating characteristic curve analysis in the training set, which were then used to evaluate the independent test set. Results RED had a Spearman rank correlation of 0.61 with the initial area under the curve calculated from DCE MR imaging. Furthermore, RED differentiated cancers from benign tumors with an overall accuracy of 90% (27 of 30) on the test set with 88.2% (15 of 17) sensitivity and 92.3% (12 of 13) specificity. Conclusion This study presents promising results introducing a simplified approach to assess results from a DWI protocol sensitive to the intravoxel incoherent motion effect by using only three b values. This approach could potentially aid in the differentiation, characterization, and monitoring of breast pathologies. © RSNA, 2016 Online supplemental material is available for this article.

Diffusion weighted imaging for the differentiation of breast tumors: From apparent diffusion coefficient to high order diffusion tensor imaging.

BACKGROUND: To compare "standard" diffusion weighted imaging, and diffusion tensor imaging (DTI) of 2(nd) and 4(th) -order for the differentiation of malignant and benign breast lesions. METHODS: Seventy-one patients were imaged at 3 Tesla with a 16-channel breast coil. A diffusion weighted MRI sequence including b = 0 and b = 700 in 30 directions was obtained for all patients. The image data were fitted to three different diffusion models: isotropic model - apparent diffusion coefficient (ADC), 2(nd) -order tensor model (the standard model used for DTI) and a 4(th) -order tensor model, with increased degrees of freedom to describe anisotropy. The ability of the fitted parameters in the different models to differentiate between malignant and benign tumors was analyzed. RESULTS: Seventy-two breast lesions were analyzed, out of which 38 corresponded to malignant and 34 to benign tumors. ADC (using any model) presented the highest discriminative ability of malignant from benign tumors with a receiver operating characteristic area under the curve (AUC) of 0.968, and sensitivity and specificity of 94.1% and 94.7% respectively for a 1.33 × 10(-3) mm(2) /s cutoff. Anisotropy measurements presented high statistical significance between malignant and benign tumors (P < 0.001), but with lower discriminative ability of malignant from benign tumors than ADC (AUC of 0.896 and 0.897 for fractional anisotropy and generalized anisotropy respectively). Statistical significant difference was found between generalized anisotropy and fractional anisotropy for cancers (P < 0.001) but not for benign lesions (P = 0.87). CONCLUSION: While anisotropy parameters have the potential to provide additional value for breast applications as demonstrated in this study, ADC exhibited the highest differentiation power between malignant and benign breast tumors.

Benzodiazepine use in COPD: empirical evidence from Norway.

BACKGROUND: The common comorbidities associated with COPD include, among others, anxiety, depression, and insomnia, for which the typical treatment involves the use of benzodiazepines (BZD). However, these medicines should be used with extra caution among COPD patients, since treatment with traditional BZD may compromise respiratory function. AIMS: This study investigated the use of BZD among persons suffering from COPD by analyzing three relevant indicators: 1) the sum of defined daily doses (DDD); 2) the number of prescribers involved; and 3) the number of different types of BZD used. DATA AND METHODS: The study builds on a linkage of national prescription data and patient-administrative data, which includes all Norwegian drug prescriptions to persons hospitalized with a COPD diagnosis during 2009, amounting to a total of 5,380 observations. Regression techniques were used to identify the patients and the clinical characteristics associated with BZD use. RESULTS: Of the 5,380 COPD patients treated in hospital during 2009, 3,707 (69%) were dispensed BZD during the following 12 months. Moreover, they were dispensed on average 197.08 DDD, had 1.22 prescribers, and used 0.98 types of BZD during the year. Women are more likely to use BZD for all levels of BZD use. Overnight planned care not only increases the risk of BZD use (DDD), but also the number of prescribers and the types of BZD in use. CONCLUSION: In light of the high levels of BZD prescription found in this study, especially among women, it is recommended that general practitioners, hospital specialists, and others treating COPD patients should aim to acquire a complete picture of their patients' BZD medication before more is prescribed in order to keep the use to a minimum.