What explains regional variation in privately provided out-of-area residential placement costs for people with intellectual disability in Ireland?

BACKGROUND: Expenditure on residential placements for people with intellectual disability (ID) in Ireland is considerable and expected to increase. Despite this, there is limited evidence on the factors driving variation in privately provided 'out-of-area' residential placement costs, including across Community Health Organisations (CHOs)/regions. This is important to help inform the delivery of services at best value. METHODS: We analyse unit cost data from 2019 for a sample of 278 high-cost publicly funded privately provided out-of-area residential placements for people with ID in Ireland. We undertake univariate analysis of the relationship between costs and a wide range of variables using t-tests and one-way analysis of variance. We employ multivariable regression analysis to examine how raw differentials in unit costs across regions can be accounted for by individual-level characteristics. RESULTS: We estimate average unit costs of €264 170 per annum in our sample. The univariate analysis shows considerable variation in costs across a range of personal, disability, psychiatry/psychological, forensic issues, behaviour and supports and plans related variables. We also find wide variation in average unit costs across CHOs/regions (F = 4.58, P < 0.001), ranging from €213 380 to €331 880. The multivariable analysis shows that regional differences remain even after accounting for a wide range of individual characteristics that influence costs. CONCLUSIONS: Our analysis shows that while the majority of differences in costs across regions can be explained, there is potential for cost savings in the provision of high-cost publicly funded out-of-area residential placements in Ireland. Overall this can help to develop and implement a more sustainable disability residential funding model in a context of rising demand for services. It also has potential implications for the approach to procurement of services.

High resolution whole brain diffusion imaging at 7T for the Human Connectome Project.

Mapping structural connectivity in healthy adults for the Human Connectome Project (HCP) benefits from high quality, high resolution, multiband (MB)-accelerated whole brain diffusion MRI (dMRI). Acquiring such data at ultrahigh fields (7T and above) can improve intrinsic signal-to-noise ratio (SNR), but suffers from shorter T2 and T2(⁎) relaxation times, increased B1(+) inhomogeneity (resulting in signal loss in cerebellar and temporal lobe regions), and increased power deposition (i.e. specific absorption rate (SAR)), thereby limiting our ability to reduce the repetition time (TR). Here, we present recent developments and optimizations in 7T image acquisitions for the HCP that allow us to efficiently obtain high quality, high resolution whole brain in-vivo dMRI data at 7T. These data show spatial details typically seen only in ex-vivo studies and complement already very high quality 3T HCP data in the same subjects. The advances are the result of intensive pilot studies aimed at mitigating the limitations of dMRI at 7T. The data quality and methods described here are representative of the datasets that will be made freely available to the community in 2015.

Evaluation of highly accelerated simultaneous multi-slice EPI for fMRI.

Echo planar imaging (EPI) is the MRI technique that is most widely used for blood oxygen level-dependent (BOLD) functional MRI (fMRI). Recent advances in EPI speed have been made possible with simultaneous multi-slice (SMS) methods which combine acceleration factors M from multiband (MB) radiofrequency pulses and S from simultaneous image refocusing (SIR) to acquire a total of N=S×M images in one echo train, providing up to N times speed-up in total acquisition time over conventional EPI. We evaluated accelerations as high as N=48 using different combinations of S and M which allow for whole brain imaging in as little as 100ms at 3T with a 32 channel head coil. The various combinations of acceleration parameters were evaluated by tSNR as well as BOLD contrast-to-noise ratio (CNR) and information content from checkerboard and movie clips in fMRI experiments. We found that at low acceleration factors (N≤6), setting S=1 and varying M alone yielded the best results in all evaluation metrics, while at acceleration N=8 the results were mixed using both S=1 and S=2 sequences. At higher acceleration factors (N>8), using S=2 yielded maximal BOLD CNR and information content as measured by classification of movie clip frames. Importantly, we found significantly greater BOLD information content using relatively fast TRs in the range of 300ms-600ms compared to a TR of 2s, suggesting that faster TRs capture more information per unit time in task based fMRI.

Effects of image reconstruction on fiber orientation mapping from multichannel diffusion MRI: reducing the noise floor using SENSE.

PURPOSE: To examine the effects of the reconstruction algorithm of magnitude images from multichannel diffusion MRI on fiber orientation estimation. THEORY AND METHODS: It is well established that the method used to combine signals from different coil elements in multichannel MRI can have an impact on the properties of the reconstructed magnitude image. Using a root-sum-of-squares approach results in a magnitude signal that follows an effective noncentral-χ distribution. As a result, the noise floor, the minimum measurable in the absence of any true signal, is elevated. This is particularly relevant for diffusion-weighted MRI, where the signal attenuation is of interest. RESULTS: In this study, we illustrate problems that such image reconstruction characteristics may cause in the estimation of fiber orientations, both for model-based and model-free approaches, when modern 32-channel coils are used. We further propose an alternative image reconstruction method that is based on sensitivity encoding (SENSE) and preserves the Rician nature of the single-channel, magnitude MR signal. We show that for the same k-space data, root-sum-of-squares can cause excessive overfitting and reduced precision in orientation estimation compared with the SENSE-based approach. CONCLUSION: These results highlight the importance of choosing the appropriate image reconstruction method for tractography studies that use multichannel receiver coils for diffusion MRI acquisition.

The Human Connectome Project: a data acquisition perspective.

The Human Connectome Project (HCP) is an ambitious 5-year effort to characterize brain connectivity and function and their variability in healthy adults. This review summarizes the data acquisition plans being implemented by a consortium of HCP investigators who will study a population of 1200 subjects (twins and their non-twin siblings) using multiple imaging modalities along with extensive behavioral and genetic data. The imaging modalities will include diffusion imaging (dMRI), resting-state fMRI (R-fMRI), task-evoked fMRI (T-fMRI), T1- and T2-weighted MRI for structural and myelin mapping, plus combined magnetoencephalography and electroencephalography (MEG/EEG). Given the importance of obtaining the best possible data quality, we discuss the efforts underway during the first two years of the grant (Phase I) to refine and optimize many aspects of HCP data acquisition, including a new 7T scanner, a customized 3T scanner, and improved MR pulse sequences.

Detunable transverse electromagnetic (TEM) volume coil for high-field NMR.

Most high-field MRI systems do not have the actively detuned body coils that are integral to clinical systems operating at 1.5T and lower field strengths. Therefore, many clinical applications requiring homogeneous volume excitation in combination with local surface coil reception are not easily implemented at high fields. To solve this problem for neuroimaging applications, actively detunable transverse electromagnetic (TEM) head coils were developed to be used with receive-only surface coils for signal-to-noise ratio (SNR) gains and improved spatial coverage from homogeneously excited regions. These SNR and field of view (FOV) gains were achieved by application of a detunable TEM volume coil to human brain imaging at 4T.

Investigation of the initial dip in fMRI at 7 Tesla.

In agreement with optical imaging studies, previous fMRI studies have reported an initial decrease (i.e. the initial dip) in the BOLD response, which is believed to arise from an increase in oxygen consumption and to be mostly microvascular. To date, experimental studies of the initial dip in humans have been performed at fields up to 4 T, with relatively low spatial resolution. Because the sensitivity to microvascular contribution is increased at high magnetic fields, the present study investigated the initial dip at 7 T. In addition, to reduce the partial volume effect, the study is conducted at a high spatial resolution. The initial dip was detected in all subjects studied and was found to reside mostly in the gray matter. The relative amplitude of the early response was found to be 0.6, higher than that at 4 T (0.3) and 1.5 T (0.11). In addition, based on the assumption that the initial dip is a result of increased oxygen utilization, the fractional change in oxygen utilization was estimated to be 40% of that of the fractional change in cerebral blood flow. These results are in agreement with the notion that the initial dip arises from an increase in oxygen consumption.

New strategy for reconstructing partial-Fourier imaging data in functional MRI.

Most partial Fourier (PF) approaches use a low-resolution phase estimate in the reconstruction to account for non-zero phases of the image. These methods may fail when there are large phase errors, a situation commonly encountered in T(*)(2)-weighted functional MRI (fMRI). To mitigate this problem, a method was developed based on the inversion of a matrix formulated according to a phase map derived from iterative reconstruction. To make this method computationally practical for fMRI, a strategy was introduced such that the matrix inversion is performed only once for each slice in the time series, assuming that the phase map remains constant in the time series. To ensure the temporal phase invariance, physiological noise correction and global phase correction were applied to the data before the reconstruction. This method was demonstrated to be robust and efficient for fMRI. Magn Reson Med 46:1045-1048, 2001.

Nonadditive two-way ANOVA for event-related fMRI data analysis.

A significant recent development in functional magnetic resonance imaging (fMRI) is the introduction of event-related fMRI, also known as time-resolved fMRI. Because the exact shape of the MR response in an event-related fMRI experiment is often not known, traditional methods developed for block design experiments, such as t test and correlation analysis, are not well-suited for extracting activated pixels from the event-related data. In this work, a statistical technique based on nonadditive two-way analysis of variance is developed for use in event-related studies. Theoretical and experimental work were carried out for establishing a statistical threshold to determine pixel activation. Experimental studies were performed to demonstrate the utility of this approach.

Imaging brain function in humans at 7 Tesla.

This article describes experimental studies performed to demonstrate the feasibility of BOLD fMRI using echo-planar imaging (EPI) at 7 T and to characterize the BOLD response in humans at this ultrahigh magnetic field. Visual stimulation studies were performed in normal subjects using high-resolution multishot EPI sequences. Changes in R(*)(2) arising from visual stimulation were experimentally determined using fMRI measurements obtained at multiple echo times. The results obtained at 7 T were compared to those at 4 T. Experimental data indicate that fMRI can be reliably performed at 7 T and that at this field strength both the sensitivity and spatial specificity of the BOLD response are increased. This study suggests that ultrahigh field MR systems are advantageous for functional mapping in humans. Magn Reson Med 45:588-594, 2001.

Detection of the early decrease in fMRI signal in the motor area.

The initial decrease in BOLD signal at stimulus onset (i.e., the initial dip) has generated a great deal of interest because of its potential for providing more spatially specific mapping. Despite a number of experimental fMRI studies demonstrating its existence in the visual cortex, the initial dip has not been reported in other areas. The present work examined the initial dip in the motor area. Using a visually-guided finger-tapping paradigm, the dip was detected in both motor and visual areas simultaneously. The dip in the motor area was found to exhibit characteristics similar to those revealed by visual stimulation studies. The motor dip peaked approximately 2 sec after stimulus onset and reached an amplitude that was roughly 0.3 times of the positive amplitude. Furthermore, the dip in the motor area was more localized and less sensitive to large vessels, indicating an improvement in spatial specificity despite the relatively low spatial resolution used in this study. These data indicate that the initial dip is a general phenomenon that can be employed for more spatially specific functional mapping, although its full utility in humans remains to be further demonstrated. Magn Reson Med 45:184-190, 2001.

Neural correlates of visual form and visual spatial processing.

Cortico-cortical projections for visual processing that originate from the striate cortex are organized into two streams. The dorsal stream projects to the parietal region and the ventral stream to the inferior temporal region. One hypothesis is that the dorsal stream processes visual spatial information, and the ventral stream processes visual object information. Although recognition of human faces or common objects has been shown preferentially to activate the ventral stream, the issue of when such processing starts to engage the ventral or the dorsal stream is not clear. The question explored in this study is whether processing of visual form per se without evoking the brain mechanisms that are associated with recognition of human faces or common objects is sufficient to activate the ventral stream more significantly relative to the condition when only visual spatial processing is involved. Functional magnetic resonance images were acquired while subjects performed a delayed comparison task in which either visual spatial or visual form information was processed. Cortical areas that were preferentially activated in visual spatial or visual form processing showed not only ventral-dorsal segregation, but also hemispheric laterality. The results extended previous findings by showing that preferential activation in the ventral pathway is not contingent upon such powerful stimuli as faces and common objects. Processing of simple visual form information is cause enough for such activation to be observed. A strong left hemisphere dominance in visual form recognition was also revealed. The observed laterality may be a reflection that the left hemisphere is more important in symbolic and/or semantic coding of visual form information.

Detection of the early negative response in fMRI at 1.5 Tesla.

Recent experimental studies have revealed an initial decrease in magnetic resonance (MR) signal that is consistent with optical imaging results. This initial response, thought to arise from a transient increase in deoxyhemoglobin concentration, is probably more localized to the site of neuronal activation. However, with MR imaging, this early response has only been demonstrated at high fields. In this paper, the observation of the initial response at 1.5 T is reported. Compared with results obtained at 4 T, the present study reveals that the initial response grows more rapidly with the field strength than the late positive response, suggesting a more microvascular origin of the initial response.

Further evaluation of the initial negative response in functional magnetic resonance imaging.

The initial negative response (i.e., the dip) in the functional MR signal at stimulus onset has aroused much interest. Such a response is consistent with optical imaging data and can be potentially mapped to generate spatially more specific maps. However, there are still controversies regarding the exact origin of the initial response. In particular, experimental reports of its echo-time dependence have been inconsistent. Furthermore, several investigators have suggested the possibility of an apparent dip that may arise artifactually when the interstimulus interval (ISI) is not sufficiently long. The present study investigates the echo-time dependence of the initial response and the effect of the ISI on the initial response. Experimental results obtained at TEs of 21, 30, and 45 msec demonstrate that the initial dip has a TE dependence that is in agreement with a T2* contrast, and thereby consistent with a blood oxygenation level-dependent origin. At an ISI of 90 sec, a statistically significant initial negative response was detected and shown to be indistinguishable from that observed at an ISI of 45 sec, which was used in our previous studies, indicating that the initial negative response observed at 4 T is not a consequence of short ISI.

[In situ protection of the liver with Bretschneider HTK solution]. / In-situ-Protektion der Leber mit der HTK-Lösung nach Bretschneider.

Liver resections are usually performed under occlusion of the hepatoduodenal ligament (Pringle manoeuvre) in order to limit operative blood loss. The maximal ischemic tolerance, although individually different, is generally accepted to be 60 min. Resections of centrally located tumors require precise preparation, sometimes combined with vascular reconstructions. In such cases a prolonged ischemic time is inevitable. A save prolongation of the ischemic tolerance could be useful for extensive liver resections. In an experimental study in pigs ischemic tolerance of the liver was studied under hypothermic protection with the HTK solution of Bretschneider during 2 and 3 h. Deterioration of liver function was compared with a warm ischemia during 2 h. Results showed significantly less serum transaminase activities and better hepatic blood flow (ICG test) after an ischemia under protection with the HTK solution compared to a warm ischemia during 2 h. A prolonged ischemia during 3 h under protection with the HTK solution was well tolerated. First clinical applications of hypothermic hepatic protection during resection were successful.