Health Equity: What the Neuroradiologist Needs to Know.

Health equity means that everyone has the opportunity to be as healthy as possible, but achieving health equity requires the removal of obstacles to health such as poverty, discrimination, unsafe environments, and lack of access to health care. The pandemic has highlighted the awareness and urgency of delivering patient-centered, high-value care. Disparities in care are antithetical to health equity and have been seen throughout medicine and radiology, including neuroradiology. Health disparities result in low value and costly care that is in conflict with evidence-based medicine, quality standards, and best practices. Although the subject of health equity is often framed as a moral or social justice issue, there are compelling economic arguments that also favor health equity. Not only can waste in health care expenditures be countered but more resources can be devoted to high-value care and other vital national economic interests, including sustainable support for our health system and health providers. There are many opportunities for neuroradiologists to engage in the advancement of health equity, while also advancing the interests of the profession and patient-centered high-value care. Although there is no universal consensus on a definition of health equity, a recent report seeking clarity on the lexicon offered the following conceptual framework: "Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care."1 This definition contrasts with that of health disparities that contribute to inequitable care as a result of demographic differences among populations such as those attributable to race, sex, access, residence, socioeconomic status, insurance status, age, religion, and disability.2,3 In effect, the greater the health disparities and negative social determinants of health, the greater the health inequities will be.

Headache and Neuroimaging: Why We Continue to Do It.

The appropriate imaging of patients with headache presents a number of important and vexing challenges for clinicians. Despite a number of guidelines and studies demonstrating a lack of cost-effectiveness, clinicians continue to image patients with chronic nonfocal headaches, and the trend toward imaging is increasing. The reasons are complex and include the fear of missing a clinically significant lesion and litigation, habitual and standard of care practices, lack of tort reform, regulatory penalties and potential impact on one's professional reputation, patient pressures, and financial motivation. Regulatory and legislative reforms are needed to encourage best practices without fear of professional sanctions when following the guidelines. The value of negative findings on imaging tests requires better understanding because they appear to provide some measure of societal value. Clinical decision support tools and machine intelligence may offer additional guidance and improve quality and cost-efficient management of this challenging patient population.

Phase-coherent sensing of the center-of-mass motion of trapped-ion crystals.

Trapped ions are sensitive detectors of weak forces and electric fields that excite ion motion. Here measurements of the center-of-mass motion of a trapped-ion crystal that are phase coherent with an applied weak external force are reported. These experiments are conducted far from the trap motional frequency on a two-dimensional trapped-ion crystal of approximately 100 ions, and determine the fundamental measurement imprecision of our protocol free from noise associated with the center-of-mass mode. The driven sinusoidal displacement of the crystal is detected by coupling the ion crystal motion to the internal spin degree of freedom of the ions using an oscillating spin-dependent optical dipole force. The resulting induced spin precession is proportional to the displacement amplitude of the crystal, and is measured with near-projection-noise-limited resolution. A 49 pm displacement is detected with a signal-to-noise ratio of 1 in a single experimental determination, which is an order-of-magnitude improvement over prior phase-incoherent experiments. This displacement amplitude is 40 times smaller than the zero-point fluctuations. With our repetition rate, an 8.4   pm / Hz displacement sensitivity is achieved, which implies 12   ( yN/ion ) / Hz and 77   ( µ V/m ) / Hz sensitivities to forces and electric fields, respectively. This displacement sensitivity, when applied on-resonance with the center-of-mass mode, indicates the possibility of weak force and electric field detection below 10-3 yN/ion and 1 nV/m, respectively.

Health professionals and students encounter multi-level barriers to implementing high-value osteoarthritis care: a multi-national study.

OBJECTIVE: Consistent evidence-practice gaps in osteoarthritis (OA) care are observed in primary care settings globally. Building workforce capacity to deliver high-value care requires a contemporary understanding of barriers to care delivery. We aimed to explore barriers to OA care delivery among clinicians and students. DESIGN: A cross-sectional, multinational study sampling clinicians (physiotherapists, primary care nurses, general practitioners (GPs), GP registrars; total possible denominator: n = 119,735) and final-year physiotherapy and medical students (denominator: n = 2,215) across Australia, New Zealand and Canada. Respondents answered a survey, aligned to contemporary implementation science domains, which measured barriers to OA care using categorical and free-text responses. RESULTS: 1886 clinicians and 1611 students responded. Items within the domains 'health system' and 'patient-related factors' represented the most applicable barriers experienced by clinicians (25-42% and 20-36%, respectively), whereas for students, 'knowledge and skills' and 'patient-related factors' (16-24% and 19-28%, respectively) were the most applicable domains. Meta-synthesis of qualitative data highlighted skills gaps in specific components of OA care (tailoring exercise, nutritional/overweight management and supporting positive behaviour change); assessment, measurement and monitoring; tailoring care; managing case complexity; and translating knowledge to practice (especially among students). Other barriers included general infrastructure limitations (particularly related to community facilities); patient-related factors (e.g., beliefs and compliance); workforce-related factors such as inconsistent care and a general knowledge gap in high-value care; and system and service-level factors relating to financing and time pressures, respectively. CONCLUSIONS: Clinicians and students encounter barriers to delivery of high-value OA care in clinical practice/training (micro-level); within service environments (meso-level); and within the health system (macro-level).

The ASNR-ACR-RSNA Common Data Elements Project: What Will It Do for the House of Neuroradiology?

The American Society of Neuroradiology has teamed up with the American College of Radiology and the Radiological Society of North America to create a catalog of neuroradiology common data elements that addresses specific clinical use cases. Fundamentally, a common data element is a question, concept, measurement, or feature with a set of controlled responses. This could be a measurement, subjective assessment, or ordinal value. Common data elements can be both machine- and human-generated. Rather than redesigning neuroradiology reporting, the goal is to establish the minimum number of "essential" concepts that should be in a report to address a clinical question. As medicine shifts toward value-based service compensation methodologies, there will be an even greater need to benchmark quality care and allow peer-to-peer comparisons in all specialties. Many government programs are now focusing on these measures, the most recent being the Merit-Based Incentive Payment System and the Medicare Access Children's Health Insurance Program Reauthorization Act of 2015. Standardized or structured reporting is advocated as one method of assessing radiology report quality, and common data elements are a means for expressing these concepts. Incorporating common data elements into clinical practice fosters a number of very useful downstream processes including establishing benchmarks for quality-assurance programs, ensuring more accurate billing, improving communication to providers and patients, participating in public health initiatives, creating comparative effectiveness research, and providing classifiers for machine learning. Generalized adoption of the recommended common data elements in clinical practice will provide the means to collect and compare imaging report data from multiple institutions locally, regionally, and even nationally, to establish quality benchmarks.

A Call to Improve the Visibility and Access of the American College of Radiology Practice Parameters in Neuroradiology: A Powerful Value Stream Enhancer for Both Neuroradiologists and Patients.

Clinical practice guidelines and clinical practice parameters are among the tools that clinicians and radiologists use to inform decision making in the diagnosis and treatment of patients. Radiologists have been urged to objectively establish their value and measurable contributions to patient care. Radiology's contribution to the health care value stream can be established in the development of sound clinical practice guidelines. Neuroradiologists have been quite active in developing clinical guidelines, particularly in collaboration with the American College of Radiology, but there is a need to increase the visibility and accessibility of such documents. Increasing access and visibility can contribute to improved patient outcomes and an improved overall quality of care.

Verification of a Many-Ion Simulator of the Dicke Model Through Slow Quenches across a Phase Transition.

We use a self-assembled two-dimensional Coulomb crystal of ∼70 ions in the presence of an external transverse field to engineer a simulator of the Dicke Hamiltonian, an iconic model in quantum optics which features a quantum phase transition between a superradiant (ferromagnetic) and a normal (paramagnetic) phase. We experimentally implement slow quenches across the quantum critical point and benchmark the dynamics and the performance of the simulator through extensive theory-experiment comparisons which show excellent agreement. The implementation of the Dicke model in fully controllable trapped ion arrays can open a path for the generation of highly entangled states useful for enhanced metrology and the observation of scrambling and quantum chaos in a many-body system.

RelA regulates virulence and intracellular survival of Francisella novicida.

Analysis of the genome of Francisella tularensis has revealed few regulatory systems, and how the organism adapts to conditions in different niches is poorly understood. The stringent response is a global stress response mediated by (p)ppGpp. The enzyme RelA has been shown to be involved in generation of this signal molecule in a range of bacterial species. We investigated the effect of inactivation of the relA gene in Francisella by generating a mutant in Francisella novicida. Under amino acid starvation conditions, the relA mutant was defective for (p)ppGpp production. Characterization showed the mutant to grow similarly to the wild-type, except that it entered stationary phase later than wild-type cultures, resulting in higher cell yields. The relA mutant showed increased biofilm formation, which may be linked to the delay in entering stationary phase, which in turn would result in higher cell numbers present in the biofilm and reduced resistance to in vitro stress. The mutant was attenuated in the J774A macrophage cell line and was shown to be attenuated in the mouse model of tularaemia, but was able to induce a protective immune response. Therefore, (p)ppGpp appears to be an important intracellular signal, integral to the pathogenesis of F. novicida.

[A view Down Under. Self-management initiatives and patient education in Australia]. / Ein Blick Down Under. Selbstmanagementinitiativen und Patientenschulungen in Australien.

The growing burden of chronic disease and the current nature of healthcare systems which are structurally ill-equipped to cater to the complex needs of patients with chronic conditions has led to governments and healthcare providers seeking alternative ways to improve patients own capacity to actively self-manage their chronic condition. In Australia, there has been a focus on patient education and self-management programs within the healthcare system to achieve this. These programs aim to empower patients through providing information and teaching skills and techniques to improve self-care and doctor-patient interaction with the ultimate goal of improving quality of life. Patient education and self-management programs have been supported through several national government initiatives and implemented within the healthcare setting. This paper describes the current position of patient education and self-management within the Australian healthcare system. It further describes a new collaboration project between an Australian and a German research team which aims at translating an assessment questionnaire used in Australia for the evaluation of self-management programs, the "Health Education Impact Questionnaire" ("heiQ"); this instrument is expected to be of significant use in the German rehabilitative system.

Improving the quality of health care for chronic conditions.

Chronic conditions are increasingly the primary concern of health care systems throughout the world. In response to this challenge, the World Health Organization has joined with the MacColl Institute for Healthcare Innovation to adapt the Chronic Care Model (CCM) from a global perspective. The resultant effort is the Innovative Care for Chronic Conditions (ICCC) framework which expands community and policy aspects of improving health care for chronic conditions and includes components at the micro (patient and family), meso (health care organisation and community), and macro (policy) levels. The framework provides a flexible but comprehensive base on which to build or redesign health systems in accordance with local resources and demands.

Inhibition of mannose-binding lectin reduces postischemic myocardial reperfusion injury.

BACKGROUND: Complement consists of a complex cascade of proteins involved in innate and adaptive immunity. The cascade can be activated through 3 distinct mechanisms, designated the classical, alternative, and lectin pathways. Although complement is widely accepted as participating in the pathophysiology of ischemia-reperfusion injury, the specific role of the lectin pathway has not been addressed. METHODS AND RESULTS: Monoclonal antibodies (mAbs; P7E4 and 14C3.74, IgG1kappa isotypes) were raised against rat mannose-binding lectin (rMBL). Both mAbs recognized rMBL-A by Western analysis or surface plasmon resonance. P7E4, but not 14C3.74, exhibited a concentration-dependent inhibition of the lectin pathway, with maximal effect at 10 microg/mL. In vivo, rats were subjected to 30 minutes of left coronary artery occlusion and 4 hours of reperfusion. Complement C3 deposition was greatly attenuated in hearts pretreated with P7E4 compared with 14C3.74-treated hearts. Pretreatment with P7E4 (1 mg/kg) significantly reduced myocardial creatine kinase loss (48%), infarct size (39%), and neutrophil infiltration (47%) compared with 14C3.74-treated animals. In addition, P7E4 pretreatment significantly attenuated the expression of proinflammatory genes (intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and interleukin-6) after ischemia-reperfusion. CONCLUSIONS: The lectin complement pathway is activated after myocardial ischemia-reperfusion and leads to tissue injury. Blockade of the lectin pathway with inhibitory mAbs protects the heart from ischemia-reperfusion by reducing neutrophil infiltration and attenuating proinflammatory gene expression.

Recombinant human complement C5a receptor antagonist reduces infarct size after surgical revascularization.

OBJECTIVES: This study tested the hypothesis that a recombinant human C5a antagonist, CGS 32359, attenuates neutrophil activation and reduces infarct size in a porcine model of surgical revascularization. METHODS: CGS 32359 (0.16-16 micromol/L) dose-dependently inhibited superoxide production by human C5a-activated porcine neutrophils (18 +/- 3.7 vs 1.6 +/- 0.5 nmol/5 min/5 x 10(6) neutrophils; P <.05) and reduced neutrophil adherence to coronary endothelium from 194 +/- 9 to 43 +/- 6 neutrophils/mm(2) (P <.05). The left anterior descending coronary artery was occluded for 50 minutes, after which saline solution (n = 8), mannitol-buffer vehicle (n = 9, 102 mg/kg bolus, 102 mg. kg(-1). h(-1)), or CGS 32359 (CGS, n = 7, 60 mg/kg bolus, 60 mg. kg(-1). h(-1)) was infused. After ischemia, 1-hour arrest was achieved by means of multidose hypothermic (4 degrees C) blood cardioplegia, followed by 2.5 hours of off-bypass reperfusion. The ligature on the left anterior descending artery was released before the second infusion of cardioplegic solution. RESULTS: Area at risk was similar in all groups (saline solution, 27% +/- 2%; mannitol-buffer vehicle, 26% +/- 2%; CGS, 26% +/- 2% left ventricular mass). Infarct size (area necrosis/area at risk) was significantly reduced by CGS (18% +/- 6%, P <.05) versus saline solution (52% +/- 3%) and mannitol-buffer vehicle (60% +/- 4%). Postischemic systolic shortening (sonomicrometry) in the area at risk was significantly improved with CGS (0.8% +/- 0.9%) compared with saline solution (-3.7% +/- 1.1%) and mannitol-buffer vehicle (-6.4% +/- 1.0%). Myeloperoxidase activity from accumulated neutrophils was less in the ischemic zone of CGS (0.014 +/- 0.002 U/100 mg tissue; P <.05) than mannitol-buffer vehicle (0.133 +/- 0.012 U/100 mg tissue). CONCLUSIONS: We conclude that the recombinant human C5a receptor antagonist CGS 32359 inhibits surgical ischemia-reperfusion injury after coronary occlusion.

Genetic technology and testing: perceptions of allied health professional education departmental chairs.

This study elicited a preliminary report that reflected the perspectives and interest of health professional academicians in regard to the need for and appropriateness of genetic technology and testing information in their curricula. Of the original attainable sample of 135 departmental chairs of allied health professional education programs nationwide, 88 responded to a mailed questionnaire, for a response rate of 65%. Of the 88, 11 (13%) saw no need for such information to be provided for allied health students at the undergraduate or graduate level or for currently practicing allied health professionals (AHPs). Consequently, the elicited results were based on the responses of the other respondents who perceived a need for genetic technology and testing information to be made available to both AHP students (86% undergraduate and 92% graduate) and currently practicing AHPs (91%). In regard to preferences for required and/or recommended student exposures to and participation in genetic technology information and coursework, their responses varied.

Economic and outcomes assessment of magnetic resonance imaging in the evaluation of headache.

We sought to evaluate the economic impact and diagnostic utility of magnetic resonance imaging (MRI) in the management of patients with headache and nonfocal physical examinations. Computerized medical records were retrospectively reviewed of 1,233 patients presenting for MRI of headache at our institution over a 3-year period (1992-1995). Patients with focal findings at physical examination, prior brain surgery, head trauma, or immunocompromise were excluded. A model was developed to assess the cost associated with the MR test results, and actual average institutional costs of performing an examination applied. Correlative statistical analysis of referring specialties and positive tests was also performed. Three hundred twenty-eight patients who met the above criteria were retained in the sample. One hundred sixty-three patients (50%) had negative MR test results. Of the 50% of patients with positive studies, only 5 (1.5%) had clinically significant MR results. The average cost of an MR examination was 517 dollars (1998 dollars). The cost per clinically significant managed case detected was 34,535 dollars. No statistically significant difference was found among referring specialties and clinically significant MR results. Our results indicate that MRI of nonfocal headache yields a low percentage of positive clinically significant results and has limited cost-effectiveness. Referring specialty had no significant bearing on these outcomes, regardless of specialist experience.

Intrusive thoughts and avoidance in breast cancer: Individual differences and association with psychological distress.

Abstract Eighty-five women with newly diagnosed breast cancer were classified on the basis of high and low levels of cancer-related intrusive thoughts and avoidance at diagnosis, and their psychological adjustment was studied prospectively at 3 and 6 months post diagnosis. Patients who initially reported high levels of both intrusive thoughts and avoidance and those who reported high levels of intrusive thoughts but low avoidance experienced the highest levels of anxiety and depression symptoms, and continued intrusive thoughts and avoidance. Patients who were high in avoidance but low in intrusive thoughts also experienced adjustment problems, including increased intrusive thoughts, when compared with patients who were low in both types of symptoms. The findings highlight the value of considering subgroup differences in patterns of intrusion and avoidance as predictors of subsequent psychological adjustment to breast cancer.

Broad-spectrum cardioprotection with adenosine.

Ischemia-reperfusion results in contractile dysfunction, necrosis, and vascular injury. This postischemic injury is mediated in part by superoxide radical production, neutrophils, dysfunction to ionic pumps, and edema formation. Adenosine is an autacoid released tonically by myocytes, endothelium, and neutrophils; the release of adenosine from the myocyte compartment into the interstitium is increased during ischemia. The major effects of adenosine are mediated by specific receptors identified as A1, A2a, A2b, and A3. Each receptor subtype contributes to physiological responses that influence ischemia-reperfusion injury. Adenosine has potent cardioprotective properties exerted during three major windows of opportunity: pretreatment, ischemia, and reperfusion. The cardioprotective effects exerted during pretreatment and ischemia may involve metabolic changes and hyperpolarization via K(ATP)-channel activation, mediated through A1 receptor mechanisms. The cardioprotective mechanisms exerted during reperfusion involve inhibition of neutrophils directly (superoxide anion generation, expression of adhesion molecules), and by inhibiting activation of the endothelium through A2 receptor-mediated mechanisms, thereby preventing neutrophil-endothelial cell interactions, which initiate the inflammatory-like component of reperfusion injury. Activation of the newly identified A3 receptor has been shown to be cardioprotective partially by inhibition of neutrophil adherence to endothelium and by neutrophil-independent mechanisms. These mechanisms of cardioprotection have been suggested to play major roles in the reduction of infarction and apoptosis after myocardial ischemia, cardioplegic arrest, and subsequent reperfusion. Adenosine has been used as an adjunct to both crystalloid and blood cardioplegia, but its potential as a cardioprotective agent has not been fully explored.

A(3) adenosine receptor activation attenuates neutrophil function and neutrophil-mediated reperfusion injury.

This study tested the hypothesis that A(3) adenosine receptors inhibit neutrophil (PMN) function and PMN-mediated reperfusion injury. 2-Chloro-N(6)-(3-iodobenzyl)adenosine-5'-N-methyluronamide (Cl-IB-MECA), an A(3) agonist, did not attenuate superoxide production or myeloperoxidase release from stimulated PMNs. However, Cl-IB-MECA reduced platelet-activating factor-stimulated PMN adherence to coronary endothelium at low concentrations: 52 +/- 27, 45 +/- 10, and 87 +/- 23 PMNs/mm(2) at 0.1, 1.0, and 10 nM vs. 422 +/- 64 PMNs/mm(2) with platelet-activating factor alone. This inhibition was not blocked by A(1) (5 microM KW-3902) or A(2a) (5 microM KF-21326) antagonists: 44 +/- 3 and 43 +/- 2 PMNs/mm(2), respectively. Endothelial pretreatment with 1 nM Cl-IB-MECA reduced PMN adherence, which was reversed by the A(3) antagonist MRS-1220 (100 nM). PMN-mediated reperfusion injury was initiated in isolated rabbit hearts by infusion of 28 x 10(6) PMNs/min for 10 min early in reperfusion. PMNs caused a significant decrease in recovery of left ventricular developed pressure and positive and negative time derivatives of pressure (23 +/- 3, 25 +/- 3, and 23 +/- 3% of baseline, respectively) vs. buffer-perfused hearts (43 +/- 7, 44 +/- 7, and 45 +/- 6%, respectively). Cl-IB-MECA (10 nM) given at reperfusion attenuated the PMN-mediated loss of contractile recovery (40 +/- 3, 46 +/- 5, and 42 +/- 4% of baseline). Cl-IB-MECA reduced myeloperoxidase release activity (5.3 +/- 0.6 absorbance units/min) and CD18-positive cells (54 +/- 9 cells/slide) compared with the untreated PMN group (17.9 +/- 1.7 absorbance units/min and 183 +/- 68 cells/slide). We conclude that Cl-IB-MECA attenuates reperfusion injury by decreasing PMN-endothelial cell interactions. These results suggest that the A(3) adenosine receptor may be a novel therapeutic target for treatment of myocardial ischemia and reperfusion.

Effects of noradrenergic and serotonergic antidepressants on chronic low back pain intensity.

To understand the relative efficacy of noradrenergic and serotonergic antidepressants as analgesics in chronic back pain without depression, we conducted a randomized, double-blind, placebo-control head-to-head comparison of maprotiline (a norepinephrine reuptake blocker) and paroxetine (a serotonin reuptake blocker) in 103 patients with chronic low back pain. Of these 74 completed the trial; of the 29 who did not complete, 19 were withdrawn because of adverse effects. The intervention consisted of an 8-week course of maprotiline (up to 150 mg daily) or paroxetine (up to 30 mg daily) or an active placebo, diphenhydramine hydrochloride (up to 37.5 mg daily). Patients were excluded for current major depression. Reduction in pain intensity (Descriptor Differential Scale scores) was significantly greater for study completers randomized to maprotiline compared to placebo (P=0.023), and to paroxetine (P=0.013), with a reduction of pain by 45% compared to 27% on placebo and 26% on paroxetine. These results suggest that at standard dosages noradrenergic agents may provide more effective analgesia in back pain than do selective serotonergic reuptake inhibitors.

Psychological adjustment in breast cancer: processes of emotional distress.

The process of psychological adjustment to breast cancer was examined at diagnosis and at 3- and 6-month follow-ups in a sample of 80 women with Stage I-Stage IV breast cancer. At diagnosis, symptoms of anxiety/depression were predicted by low dispositional optimism, and this path was partially mediated by use of emotion-focused disengagement coping. Younger age also was predictive of anxiety/depression symptoms at time of diagnosis, and this relationship was fully mediated by magnitude of intrusive thoughts. At 3 months, changes in anxiety/depression symptoms were predicted only by intrusive thoughts. At 6 months, low dispositional optimism reemerged as a significant predictor of changes in anxiety/depression and again was partially mediated by the use of emotion-focused disengagement coping. Independent effects for problem-focused engagement and disengagement and emotion-focused engagement coping were also found at 6 months. Implications of these data for psychosocial interventions with breast cancer patients are highlighted.