Interactive visualization tool to understand and monitor health disparities in diabetes care and outcomes.

Objective: Type 2 diabetes (T2DM) poses a significant public health challenge, with pronounced disparities in control and outcomes. Social determinants of health (SDoH) significantly contribute to these disparities, affecting healthcare access, neighborhood environments, and social context. We discuss the design, development, and use of an innovative web-based application integrating real-world data (electronic health record and geospatial files), to enhance comprehension of the impact of SDoH on T2 DM health disparities. Methods: We identified a patient cohort with diabetes from the institutional Diabetes Registry (N = 67,699) within the Duke University Health System. Patient-level information (demographics, comorbidities, service utilization, laboratory results, and medications) was extracted to Tableau. Neighborhood-level socioeconomic status was assessed via the Area Deprivation Index (ADI), and geospatial files incorporated additional data related to points of interest (i.e., parks/green space). Interactive Tableau dashboards were developed to understand risk and contextual factors affecting diabetes management at the individual, group, neighborhood, and population levels. Results: The Tableau-powered digital health tool offers dynamic visualizations, identifying T2DM-related disparities. The dashboard allows for the exploration of contextual factors affecting diabetes management (e.g., food insecurity, built environment) and possesses capabilities to generate targeted patient lists for personalized diabetes care planning. Conclusion: As part of a broader health equity initiative, this application meets the needs of a diverse range of users. The interactive dashboard, incorporating clinical, sociodemographic, and environmental factors, enhances understanding at various levels and facilitates targeted interventions to address disparities in diabetes care and outcomes. Ultimately, this transformative approach aims to manage SDoH and improve patient care.

Decoding EEG for optimizing naturalistic memory.

BACKGROUND: Spectral features of human electroencephalographic (EEG) recordings during learning predict subsequent recall variability. NEW METHOD: Capitalizing on these fluctuating neural features, we develop a non-invasive closed-loop (NICL) system for real-time optimization of human learning. Participants play a virtual navigation-and-memory game; recording multi-session data across days allowed us to build participant-specific classification models of recall success. In subsequent closed-loop sessions, our platform manipulated the timing of memory encoding, selectively presenting items during periods of predicted good or poor memory function based on EEG features decoded in real time. RESULTS: The induced memory effect (the difference between recall rates when presenting items during predicted good vs. poor learning periods) increased with the accuracy of neural decoding. COMPARISON WITH EXISTING METHODS: This study demonstrates greater-than-chance memory decoding from EEG recordings in a naturalistic virtual navigation task with greater real-world validity than basic word-list recall paradigms. Here we modulate memory by timing stimulus presentation based on noninvasive scalp EEG recordings, whereas prior closed-loop studies for memory improvement involved intracranial recordings and direct electrical stimulation. Other noninvasive studies have investigated the use of neurofeedback or remedial study for memory improvement. CONCLUSIONS: These findings present a proof-of-concept for using non-invasive closed-loop technology to optimize human learning and memory through principled stimulus timing, but only in those participants for whom classifiers reliably predict out-of-sample memory function.

Human Hippocampal Ripples Signal Encoding of Episodic Memories.

Direct human brain recordings have confirmed the presence of high-frequency oscillatory events, termed ripples, during awake behavior. While many prior studies have focused on medial temporal lobe (MTL) ripples during memory retrieval, here we investigate ripples during memory encoding. Specifically, we ask whether ripples during encoding predict whether and how memories are subsequently recalled. Detecting ripples from MTL electrodes implanted in 116 neurosurgical participants (n = 61 male) performing a verbal episodic memory task, we find that encoding ripples do not distinguish recalled from not recalled items in any MTL region, even as high-frequency activity during encoding predicts recall in these same regions. Instead, hippocampal ripples increase during encoding of items that subsequently lead to recall of temporally and semantically associated items during retrieval, a phenomenon known as clustering. This subsequent clustering effect arises specifically when hippocampal ripples co-occur during encoding and retrieval, suggesting that ripples mediate both encoding and reinstatement of episodic memories.

Improving Hypertension Control in the Black Patient Population: A Quality Improvement Study of Workflow Redesign Using the Electronic Health Record to Integrate Self-Monitoring, Education, and Reporting.

BACKGROUND: Nearly half of American adults have hypertension (HTN), and non-Hispanic Black patients are diagnosed at a higher rate than others. LOCAL PROBLEM: Our local clinic population reflected disproportionate rates of uncontrolled HTN among Black patients. METHODS: A quality improvement pre-/postintervention design was used to evaluate an educational intervention to reduce blood pressure (BP) and improve self-monitoring of BP in Black patients using the Chronic Care Model. INTERVENTIONS: A team-based approach was used to redesign clinic workflows and patient education, prescribe self-paced videos from an electronic health record (EHR) patient portal, and provide home BP cuffs. RESULTS: Black participants (n = 79) improved viewing of prescribed videos (7.9% to 68.5%), knowledge scores (67.9 to 75.2), and mean systolic BP (-20.3 mm Hg; P > .001). CONCLUSIONS: This team-based approach enhanced patient engagement, self-monitoring skills, EHR-reported BP, and overall BP control for a cohort of Black patients with uncontrolled BP.

ACR Appropriateness Criteria® Pretreatment Detection, Surveillance, and Staging of Prostate Cancer: 2022 Update.

Prostate cancer is second leading cause of death from malignancy after lung cancer in American men. The primary goal during pretreatment evaluation of prostate cancer is disease detection, localization, establishing disease extent (both local and distant), and evaluating aggressiveness, which are the driving factors of patient outcomes such as recurrence and survival. Prostate cancer is typically diagnosed after the recognizing elevated serum prostate-specific antigen level or abnormal digital rectal examination. Tissue diagnosis is obtained by transrectal ultrasound-guided biopsy or MRI-targeted biopsy, commonly with multiparametric MRI without or with intravenous contrast, which has recently been established as standard of care for detecting, localizing, and assessing local extent of prostate cancer. Although bone scintigraphy and CT are still typically used to detect bone and nodal metastases in patients with intermediate- or high-risk prostate cancer, novel advanced imaging modalities including prostatespecific membrane antigen PET/CT and whole-body MRI are being more frequently utilized for this purpose with improved detection rates. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Identifying causal subsequent memory effects.

Over 40 y of accumulated research has detailed associations between neuroimaging signals measured during a memory encoding task and later memory performance, across a variety of brain regions, measurement tools, statistical approaches, and behavioral tasks. But the interpretation of these subsequent memory effects (SMEs) remains unclear: if the identified signals reflect cognitive and neural mechanisms of memory encoding, then the underlying neural activity must be causally related to future memory. However, almost all previous SME analyses do not control for potential confounders of this causal interpretation, such as serial position and item effects. We collect a large fMRI dataset and use an experimental design and analysis approach that allows us to statistically adjust for nearly all known exogenous confounding variables. We find that, using standard approaches without adjustment, we replicate several univariate and multivariate subsequent memory effects and are able to predict memory performance across people. However, we are unable to identify any signal that reliably predicts subsequent memory after adjusting for confounding variables, bringing into doubt the causal status of these effects. We apply the same approach to subjects' judgments of learning collected following an encoding period and show that these behavioral measures of mnemonic status do predict memory after adjustments, suggesting that it is possible to measure signals near the time of encoding that reflect causal mechanisms but that existing neuroimaging measures, at least in our data, may not have the precision and specificity to do so.

The interagency care team: A new model to integrate social and medical care for older adults in primary care.

To integrate management of social drivers of health with complex clinical needs of older adults, we connected patients aged 60 and above from primary care practices with a nurse practitioner (NP) led Interagency Care Team (ICT) of geriatrics providers and community partners via electronic consult. The NP conducted a geriatric assessment via telephone, then the team met to determine recommendations. Thirteen primary care practices referred 123 patients (median age = 76) who had high rates of emergency department use and hospitalization (28.9% and 17.4% respectively). Issues commonly identified included medication management (84%), personal safety (72%), disease management (69%), food insecurity (63%), and cognitive decline (53%). Referring providers expressed heightened awareness of older adults' social needs and high satisfaction with the program. The ICT is a scalable model of care that connects older adults with complex care needs to geriatrics expertise and community services through partnerships with primary care providers.

Telehealth for the Longitudinal Management of Chronic Conditions: Systematic Review.

BACKGROUND: Extensive literature support telehealth as a supplement or adjunct to in-person care for the management of chronic conditions such as congestive heart failure (CHF) and type 2 diabetes mellitus (T2DM). Evidence is needed to support the use of telehealth as an equivalent and equitable replacement for in-person care and to assess potential adverse effects. OBJECTIVE: We conducted a systematic review to address the following question: among adults, what is the effect of synchronous telehealth (real-time response among individuals via phone or phone and video) compared with in-person care (or compared with phone, if synchronous video care) for chronic management of CHF, chronic obstructive pulmonary disease, and T2DM on key disease-specific clinical outcomes and health care use? METHODS: We followed systematic review methodologies and searched two databases (MEDLINE and Embase). We included randomized or quasi-experimental studies that evaluated the effect of synchronously delivered telehealth for relevant chronic conditions that occurred over ≥2 encounters and in which some or all in-person care was supplanted by care delivered via phone or video. We assessed the bias using the Cochrane Effective Practice and Organization of Care risk of bias (ROB) tool and the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation. We described the findings narratively and did not conduct meta-analysis owing to the small number of studies and the conceptual heterogeneity of the identified interventions. RESULTS: We identified 8662 studies, and 129 (1.49%) were reviewed at the full-text stage. In total, 3.9% (5/129) of the articles were retained for data extraction, all of which (5/5, 100%) were randomized controlled trials. The CHF study (1/5, 20%) was found to have high ROB and randomized patients (n=210) to receive quarterly automated asynchronous web-based review and follow-up of telemetry data versus synchronous personal follow-up (in-person vs phone-based) for 1 year. A 3-way comparison across study arms found no significant differences in clinical outcomes. Overall, 80% (4/5) of the studies (n=466) evaluated synchronous care for patients with T2DM (ROB was judged to be low for 2, 50% of studies and high for 2, 50% of studies). In total, 20% (1/5) of the studies were adequately powered to assess the difference in glycosylated hemoglobin level between groups; however, no significant difference was found. Intervention design varied greatly from remote monitoring of blood glucose combined with video versus in-person visits to an endocrinology clinic to a brief, 3-week remote intervention to stabilize uncontrolled diabetes. No articles were identified for chronic obstructive pulmonary disease. CONCLUSIONS: This review found few studies with a variety of designs and interventions that used telehealth as a replacement for in-person care. Future research should consider including observational studies and studies on additional highly prevalent chronic diseases.

Impact of a clinical pharmacist on provider prescribing patterns in a primary care clinic.

BACKGROUND: Sodium-glucose transporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) agonists have demonstrated beneficial outcomes in patients with type 2 diabetes at high cardiovascular risk. Unfortunately, these agents are still underutilized in primary care practice. A clinical pharmacist was embedded at a primary care clinic to provide diabetes and hypertension management under a collaborative practice agreement with a supervising physician. OBJECTIVES: This study will evaluate whether the presence of an embedded pharmacist in a primary care clinic affects prescribing patterns of novel, evidence-based diabetes therapies. METHODS: We abstracted information on SGLT2 inhibitor and GLP-1 agonist prescribing patterns from 3 primary care clinics across 2 time periods as a single-center, retrospective cohort study. We used a difference-in-difference analysis to compare prescription rates and assess the impact of embedding the pharmacist into clinical practice. Prescriptions written by the pharmacist were excluded. RESULTS: Across all 3 clinics, 1309 and 1489 patients were included in the pre-intervention and postintervention periods, respectively. The percentage of patients prescribed either an SGLT2 inhibitor or GLP-1 agonist, similar between both groups at baseline, rose to 11.6% in the nonintervention clinics and 15.0% in the intervention clinic. There was a statistically significant increase in SGLT2 inhibitor and GLP-1 agonist prescribing in the intervention clinic compared with nonintervention clinics (P = 0.034). This change in prescribing patterns appeared even greater when excluding prescribers who were not present during both pre-intervention and postintervention periods (P = 0.009). CONCLUSION: The presence of a pharmacist is associated with increased SGLT2 inhibitor and GLP-1 agonist prescribing within a clinic, even in patients not seen directly by the pharmacist. These results suggest that an on-site clinical pharmacist providing care for patients with diabetes may indirectly influence the prescribing behavior of co-located primary care providers, increasing the adoption of novel noninsulin diabetic medications.

ACR Appropriateness Criteria® Post-Treatment Surveillance of Bladder Cancer: 2021 Update.

Urothelial cancer is the second most common cancer, and cause of cancer death, related to the genitourinary tract. The goals of surveillance imaging after the treatment of urothelial cancer of the urinary bladder are to detect new or previously undetected urothelial tumors, to identify metastatic disease, and to evaluate for complications of therapy. For surveillance, patients can be stratified into one of three groups: 1) nonmuscle invasive bladder cancer with no symptoms or additional risk factors; 2) nonmuscle invasive bladder cancer with symptoms or additional risk factors; and 3) muscle invasive bladder cancer. This document is a review of the current literature for urothelial cancer and resulting recommendations for surveillance imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Intolerance of uncertainty modulates brain-to-brain synchrony during politically polarized perception.

Political partisans see the world through an ideologically biased lens. What drives political polarization? Although it has been posited that polarization arises because of an inability to tolerate uncertainty and a need to hold predictable beliefs about the world, evidence for this hypothesis remains elusive. We examined the relationship between uncertainty tolerance and political polarization using a combination of brain-to-brain synchrony and intersubject representational similarity analysis, which measured committed liberals' and conservatives' (n = 44) subjective interpretation of naturalistic political video material. Shared ideology between participants increased neural synchrony throughout the brain during a polarizing political debate filled with provocative language but not during a neutrally worded news clip on polarized topics or a nonpolitical documentary. During the political debate, neural synchrony in mentalizing and valuation networks was modulated by one's aversion to uncertainty: Uncertainty-intolerant individuals experienced greater brain-to-brain synchrony with politically like-minded peers and lower synchrony with political opponents-an effect observed for liberals and conservatives alike. Moreover, the greater the neural synchrony between committed partisans, the more likely that two individuals formed similar, polarized attitudes about the debate. These results suggest that uncertainty attitudes gate the shared neural processing of political narratives, thereby fueling polarized attitude formation about hot-button issues.

Reducing Imaging Utilization in Primary Care Through Implementation of a Peer Comparison Dashboard.

BACKGROUND: High clinical variation has been linked to decreased quality of care, increased costs, and decreased patient satisfaction. We present the implementation and analysis of a peer comparison intervention to reduce clinical variation within a large primary care network. OBJECTIVE: Evaluate existing variation in radiology ordering within a primary care network and determine whether peer comparison feedback reduces variation or changes practice patterns. DESIGN: Radiology ordering data was analyzed to evaluate baseline variation in imaging rates. A utilization dashboard was shared monthly with providers for a year, and imaging rates pre- and post-intervention were retrospectively analyzed. PARTICIPANTS: Providers within the primary care network spanning 1,358,644 outpatient encounters and 159 providers over a 3-year period. INTERVENTIONS: The inclusion of radiology utilization data as part of a provider's monthly quality and productivity dashboards. This information allows providers to compare their practice patterns with those of their colleagues. MAIN MEASURES: We measured provider imaging rates, stratified by modality, as well as order variation over time. KEY RESULTS: We observed significant variation in imaging rates among providers in the network, with the top decile ordering an average of 4.2 times more than the lowest decile in the two years prior to intervention. Provider experience and training were not significantly associated with imaging utilization. In the first year after sharing utilization data with providers, we saw a 17.3% decrease in median imaging rate (p < 0.001) and a 21.4% reduction in provider variation between top and bottom deciles. Median ordering rate for more costly cross-sectional imaging, including CT, MRI, and nuclear medicine studies, decreased by 30.4% (p < 0.001), 20.2% (p = 0.008), and 41.8% (p = 0.002), respectively. CONCLUSIONS: Peer comparison feedback can shape provider imaging behavior even in the absence of targets or financial incentives. Peer comparison is a low-touch, low-cost intervention for influencing provider ordering and may have applicability in other clinical areas.

Causal Information-Seeking Strategies Change Across Childhood and Adolescence.

Intervening on causal systems can illuminate their underlying structures. Past work has shown that, relative to adults, young children often make intervention decisions that appear to confirm a single hypothesis rather than those that optimally discriminate alternative hypotheses. Here, we investigated how the ability to make informative causal interventions changes across development. Ninety participants between the ages of 7 and 25 completed 40 different puzzles in which they had to intervene on various causal systems to determine their underlying structures. Each puzzle comprised a three- or four-node computer chip with hidden wires. On each trial, participants viewed two possible arrangements of the chip's hidden wires and had to select a single node to activate. After observing the outcome of their intervention, participants selected a wire configuration and rated their confidence in their selection. We characterized participant choices with a Bayesian measurement model that indexed the extent to which participants selected nodes that would best disambiguate the two possible causal structures versus those that had high causal centrality in one of the two causal hypotheses but did not necessarily discriminate between them. Our model estimates revealed that the use of a discriminatory strategy increased through early adolescence. Further, developmental improvements in intervention strategy were related to changes in the ability to accurately judge the strength of evidence that interventions revealed, as indexed by participants' confidence in their selections. Our results suggest that improvements in causal information-seeking extend into adolescence and may be driven by metacognitive sensitivity to the efficacy of previous interventions in discriminating competing ideas.

Characterization and normal measurements of the left ventricular outflow tract by ECG-gated cardiac CT: implications for disorders of the outflow tract and aortic valve.

RATIONALE AND OBJECTIVES: Studies suggest that electrocardiographically gated coronary computed tomographic angiography provides a clear definition of the left ventricular outflow tract (LVOT), and normal LVOT morphology may not be round, as assumed when the continuity equation is applied during echocardiography. The aims of this study were to demonstrate the morphology of the LVOT on coronary computed tomographic angiography and to establish normal values for LVOT measurements. MATERIALS AND METHODS: Two independent readers retrospectively measured anterior-posterior (AP) and transverse diameters of the LVOT and performed LVOT planimetry on coronary computed tomographic angiographic studies of 106 consecutive patients with normal aortic valves. RESULTS: Excellent interobserver agreement was observed for all measurements (r = 0.78-0.94). The LVOT was ovoid, with a larger transverse diameter than AP diameter during diastole and systole (P < .001). However, the ratio of AP diameter to transverse diameter was closer to 1.0 during systole (P < .001). Mean indexed LVOT area was minimally larger in systole than in diastole (P = .01-.04) and was larger in men than in women during diastole (P ≤ .001) and systole (P ≤ .01). Mean LVOT area indexed to body surface area was 2.3 ± 0.5 cm(2)/m(2) in women and 2.6 ± 0.7 cm(2)/m(2) in men. LVOT area demonstrated significant correlation with aortic root diameter. CONCLUSIONS: The normal LVOT is ovoid in shape. LVOT is more circular during systole, but the AP diameter remains smaller than the transverse diameter throughout the cardiac cycle. The oval shape of the LVOT has important implications when LVOT area is calculated from LVOT diameters. Normal LVOT area values established in this study should facilitate diagnosis of the fixed component of LVOT obstruction.

Interventions for individuals with low health literacy: a systematic review.

The U.S. Department of Health and Human Services recently called for action on health literacy. An important first step is defining the current state of the literature about interventions designed to mitigate the effects of low health literacy. We performed an updated systematic review examining the effects of interventions that authors reported were specifically designed to mitigate the effects of low health literacy. We searched MEDLINE®, The Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Educational Resources Information Center (ERIC), and the Cochrane Library databases (2003 forward for health literacy; 1966 forward for numeracy). Two reviewers independently reviewed titles, abstracts, and full-text articles for inclusion and included studies that examined outcomes by health literacy level and met other pre-specified criteria. One reviewer abstracted article information into evidence tables; a second checked accuracy. Two reviewers independently rated study quality using predefined criteria. Among 38 included studies, we found multiple discrete design features that improved comprehension in one or a few studies (e.g., presenting essential information by itself or first, presenting information so that the higher number is better, adding icon arrays to numerical information, adding video to verbal narratives). In a few studies, we also found consistent, direct, fair or good-quality evidence that intensive self-management interventions reduced emergency department visits and hospitalizations; and intensive self- and disease-management interventions reduced disease severity. Evidence for the effects of interventions on other outcomes was either limited or mixed. Multiple interventions show promise for mitigating the effects of low health literacy and could be considered for use in clinical practice.

Low health literacy and health outcomes: an updated systematic review.

BACKGROUND: Approximately 80 million Americans have limited health literacy, which puts them at greater risk for poorer access to care and poorer health outcomes. PURPOSE: To update a 2004 systematic review and determine whether low health literacy is related to poorer use of health care, outcomes, costs, and disparities in health outcomes among persons of all ages. DATA SOURCES: English-language articles identified through MEDLINE, CINAHL, PsycINFO, ERIC, and Cochrane Library databases and hand-searching (search dates for articles on health literacy, 2003 to 22 February 2011; for articles on numeracy, 1966 to 22 February 2011). STUDY SELECTION: Two reviewers independently selected studies that compared outcomes by differences in directly measured health literacy or numeracy levels. DATA EXTRACTION: One reviewer abstracted article information into evidence tables; a second reviewer checked information for accuracy. Two reviewers independently rated study quality by using predefined criteria, and the investigative team jointly graded the overall strength of evidence. DATA SYNTHESIS: 96 relevant good- or fair-quality studies in 111 articles were identified: 98 articles on health literacy, 22 on numeracy, and 9 on both. Low health literacy was consistently associated with more hospitalizations; greater use of emergency care; lower receipt of mammography screening and influenza vaccine; poorer ability to demonstrate taking medications appropriately; poorer ability to interpret labels and health messages; and, among elderly persons, poorer overall health status and higher mortality rates. Poor health literacy partially explains racial disparities in some outcomes. Reviewers could not reach firm conclusions about the relationship between numeracy and health outcomes because of few studies or inconsistent results among studies. LIMITATIONS: Searches were limited to articles published in English. No Medical Subject Heading terms exist for identifying relevant studies. No evidence concerning oral health literacy (speaking and listening skills) and outcomes was found. CONCLUSION: Low health literacy is associated with poorer health outcomes and poorer use of health care services. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Diagnosis of coronary stenosis with CT angiography comparison of automated computer diagnosis with expert readings.

RATIONALE AND OBJECTIVES: To compare computer-generated interpretation of coronary computed tomography angiography (cCTA) by commercially available COR Analyzer software with expert human interpretation. MATERIALS AND METHODS: This retrospective Health Insurance Portability and Accountability Act­compliant study was approved by the institutional review board. Among 225 consecutive cCTA examinations, 207 were of adequate quality for automated evaluation. COR Analyzer interpretation was compared to human expert interpretation for detection of stenosis defined as ≥50% vessel diameter reduction in the left main, left anterior descending (LAD), circumflex (LCX), right coronary artery (RCA), or a branch vessel (diagonal, ramus, obtuse marginal, or posterior descending artery). RESULTS: Among 207 cases evaluated by COR Analyzer, human expert interpretation identified 48 patients with stenosis. COR Analyzer identified 44/48 patients (sensitivity 92%) with a specificity of 70%, a negative predictive value of 97% and a positive predictive value of 48%. COR Analyzer agreed with the expert interpretation in 75% of patients. With respect to individual segments, COR Analyzer detected 9/10 left main lesions, 33/34 LAD lesions, 14/15 LCX lesions, 27/31 RCA lesions, and 8/11 branch lesions. False-positive interpretations were localized to the left main (n = 16), LAD (n = 26), LCX (n = 21), RCA (n = 21), and branch vessels (n = 23), and were related predominantly to calcified vessels, blurred vessels, misidentification of vessels and myocardial bridges. CONCLUSIONS: Automated computer interpretation of cCTA with COR Analyzer provides high negative predictive value for the diagnosis of coronary disease in major coronary arteries as well as first-order arterial branches. False-positive automated interpretations are related to anatomic and image quality considerations.

Health literacy interventions and outcomes: an updated systematic review.

OBJECTIVES: To update a 2004 systematic review of health care service use and health outcomes related to differences in health literacy level and interventions designed to improve these outcomes for individuals with low health literacy. Disparities in health outcomes and effectiveness of interventions among different sociodemographic groups were also examined. DATA SOURCES: We searched MEDLINE®, the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, PsychINFO, and the Educational Resources Information Center. For health literacy, we searched using a variety of terms, limited to English and studies published from 2003 to May 25, 2010. For numeracy, we searched from 1966 to May 25, 2010. REVIEW METHODS: We used standard Evidence-based Practice Center methods of dual review of abstracts, full-text articles, abstractions, quality ratings, and strength of evidence grading. We resolved disagreements by consensus. We evaluated whether newer literature was available for answering key questions, so we broadened our definition of health literacy to include numeracy and oral (spoken) health literacy. We excluded intervention studies that did not measure health literacy directly and updated our approach to evaluate individual study risk of bias and to grade strength of evidence. RESULTS: We included good- and fair-quality studies: 81 studies addressing health outcomes (reported in 95 articles including 86 measuring health literacy and 16 measuring numeracy, of which 7 measure both) and 42 studies (reported in 45 articles) addressing interventions. Differences in health literacy level were consistently associated with increased hospitalizations, greater emergency care use, lower use of mammography, lower receipt of influenza vaccine, poorer ability to demonstrate taking medications appropriately, poorer ability to interpret labels and health messages, and, among seniors, poorer overall health status and higher mortality. Health literacy level potentially mediates disparities between blacks and whites. The strength of evidence of numeracy studies was insufficient to low, limiting conclusions about the influence of numeracy on health care service use or health outcomes. Two studies suggested numeracy may mediate the effect of disparities on health outcomes. We found no evidence concerning oral health literacy and outcomes. Among intervention studies (27 randomized controlled trials [RCTs], 2 cluster RCTs, and 13 quasi-experimental designs), the strength of evidence for specific design features was low or insufficient. However, several specific features seemed to improve comprehension in one or a few studies. The strength of evidence was moderate for the effect of mixed interventions on health care service use; the effect of intensive self-management inventions on behavior; and the effect of disease-management interventions on disease prevalence/severity. The effects of other mixed interventions on other health outcomes, including knowledge, self-efficacy, adherence, and quality of life, and costs were mixed; thus, the strength of evidence was insufficient. CONCLUSIONS: The field of health literacy has advanced since the 2004 report. Future research priorities include justifying appropriate cutoffs for health literacy levels prior to conducting studies; developing tools that measure additional related skills, particularly oral (spoken) health literacy; and examining mediators and moderators of the effect of health literacy. Priorities in advancing the design features of interventions include testing novel approaches to increase motivation, techniques for delivering information orally or numerically, "work around" interventions such as patient advocates; determining the effective components of already-tested interventions; determining the cost-effectiveness of programs; and determining the effect of policy and practice interventions.

Is coronary stent assessment improved with spectral analysis of dual energy CT?

RATIONALE AND OBJECTIVES: The aims of this study were to distinguish stents from iodinated contrast on the basis of spectral characteristics on dual-energy computed tomographic (DECT) imaging and to determine whether DECT imaging might provide a more accurate measurement of true stent lumen. MATERIALS AND METHODS: Three stainless steel stents and one cobalt chromium stent were scanned using a multidetector, single-source DECT scanner. Stents 2.5, 3.5, and 4.0 mm in diameter were filled with iodinated contrast, submerged in water, and scanned. Spectral analysis was performed to assess the separation of stents from iodinated contrast. Two independent reviewers measured stent lumen diameter and strut thickness on low-energy (L(0)), high-energy (L(1)), and combined-energy (L(c)) images. Dual-energy full-width half-maximum edge detection analysis was used to provide an independent assessment of stent luminal diameter and strut thickness. RESULTS: Two-dimensional graphical plots of computed tomographic attenuation for the L(0) and L(1) images did not demonstrate a sharp separation between the absorption characteristics of stents and iodinated contrast material. Stent lumens were underestimated by approximately 50% on L(c) images. Observer measurements on L(1) images demonstrated a 24% decrease in strut thickness and a 25% increase in stent luminal diameter compared to L(0) images (P < .0001). Full-width half-maximum measurements did not demonstrate significant changes in stent luminal diameters or strut thicknesses between L(0) and L(1) images. CONCLUSIONS: Spectral analysis did not clearly distinguish stents from iodinated contrast with the DECT system used in this study. The larger stent lumens visualized by the high-energy components of the x-ray spectrum were not related to improved computed tomographic delineation of stent thickness.