Faculty Bibliography

Triple-rule-out computed tomographic angiography (TRO CTA), performed to evaluate the coronary arteries, pulmonary arteries, and thoracic aorta, has been associated with high radiation exposure. The use of sequential scanning for coronary computed tomographic angiography reduces the radiation dose. The application of sequential scanning to TRO CTA is much less well defined. We analyzed the radiation dose and image quality from TRO CTA performed at a single outpatient center, comparing the scans from a period during which helical scanning with electrocardiographically controlled tube current modulation was used for all patients (n = 35) and after adoption of a strategy incorporating sequential scanning whenever appropriate (n = 35). Sequential scanning was able to be used for 86% of the cases. The sequential-if-appropriate strategy, compared to the helical-only strategy, was associated with a 61.6% dose decrease (mean dose-length product of 439 mGy x cm vs 1,144 mGy x cm and mean effective dose of 7.5 mSv vs 19.4 mSv, respectively, p <0.0001). Similarly, a 71.5% dose reduction occurred among the 30 patients scanned with the sequential protocol compared to the 40 patients scanned with the helical protocol using either strategy (326 mGy x cm vs 1,141 mGy x cm and 5.5 mSv vs 19.4 mSv, respectively, p <0.0001). Although the image quality did not differ between the strategies, a nonstatistically significant trend was seen toward better quality in the sequential protocol than in the helical protocol. In conclusion, approaching TRO CTA with a diagnostic strategy of sequential scanning, as appropriate, can offer a marked reduction in the radiation dose while maintaining the image quality

Radiation dose from coronary computed tomographic angiography may be decreased using a sequential scanning protocol rather than a conventional helical scanning protocol. We compared radiation dose and image quality from coronary computed tomographic angiography in a single center between an initial period during which helical scanning with electrocardiographically controlled tube current modulation was used for all patients (n = 138) and after adoption of a strategy incorporating sequential scanning whenever appropriate (n = 261). Using the sequential-if-appropriate strategy, sequential scanning was employed in 86.2% of patients. Compared to the helical-only strategy, this strategy was associated with a 65.1% dose decrease (mean dose-length product [DLP] 305.2 vs 875.1 and mean effective dose 14.9 vs 5.2 mSv, respectively), with no significant change in overall image quality, step artifacts, motion artifacts, or perceived image noise. For the 225 patients undergoing sequential scanning, the DLP was 201.9 +/- 90.0 mGy x cm; for patients undergoing helical scanning under either strategy, the DLP was 890.9 +/- 293.3 mGy x cm (p <0.0001), corresponding to mean effective doses of 3.4 and 15.1 mSv, respectively, a 77.5% decrease. Image quality was significantly greater for the sequential studies, reflecting the poorer image quality in patients undergoing helical scanning in the sequential-if-appropriate strategy. In conclusion, a sequential-if-appropriate diagnostic strategy decreases dose markedly compared to a helical-only strategy, with no significant difference in image quality

Patients with frequent hospitalizations generate a disproportionate share of hospital visits and costs. Accurate determination of patients who might benefit from interventions is challenging: most patients with frequent admissions in 1 year would not continue to have them in the next. Our objective was to employ a validated regression algorithm to case-find Medicaid patients at high-risk for hospitalization in the next 12 months and identify intervention-amenable characteristics to reduce hospitalization risk. We obtained encounter data for 36,457 Medicaid patients with any visit to an urban public hospital from 2001 to 2006 and generated an algorithm-based score for hospitalization risk in the subsequent 12 months for each patient (0 = lowest, 100 = highest). To determine medical and social contributors to the current admission, we conducted in-depth interviews with high-risk hospitalized patients (scores >50) and analyzed associated Medicaid claims data. An algorithm-based risk score >50 was attained in 2,618 (7.2%) patients. The algorithm's positive predictive value was equal to 0.67. During the study period, 139 high-risk patients were admitted: 60 met inclusion criteria and 50 were interviewed. Fifty-six percent cited the Emergency Department as their usual source of care or had none. Sixty-eight percent had >1 chronic medical conditions, and 42% were admitted for conditions related to substance use. Sixty percent were homeless or precariously housed. Mean Medicaid expenditures for the interviewed patients were $39,188 and $84,040 per patient for the years immediately prior to and following study participation, respectively. Findings including high rates of substance use, homelessness, social isolation, and lack of a medical home will inform the design of interventions to improve community-based care and reduce hospitalizations and associated costs

The purpose of this study was to examine the relationship of social support and religion to mortality after elective open heart surgery in older patients. Of the 232 patients included in the study, 21 died within 6 months of surgery. Three biomedical variables were significant predictors of mortality and selected as adjustment variables for a multivariate analysis: history of previous cardiac surgery; greater impairment in presurgery basic activities of daily living; and older age. Among the social support and religion variables, two were consistent predictors of mortality in the multivariate analyses: lack of participation in social or community groups and absence of strength and comfort from religion. These results suggest that in older persons lack of participation in groups and absence of strength and comfort in religion are independently related to risk for death during the 6-month period after cardiac surgery

The diagnosis of adjustment disorder is a dilemma in older medically ill patients. The authors conducted a prospective study of older cardiac surgery patients. Semistructured interview techniques were used to distinguish emotional impairment from physical impairment to diagnose an adjustment disorder. Among 71 patients interviewed at three points in time, 50.7% had an adjustment disorder. At 6 months after surgery, 30.6% were still showing evidence of emotional functional impairment. Continued impairment was related to initial severity of depressive and anxiety symptoms. Implications and suggestions for future research are discussed

OBJECTIVE: To assess the relationship of specific patient chief physical complaints to underlying depressive symptoms in primary care practice. DESIGN: A cross-sectional study that was part of a larger prevalence study of depression in primary care. SETTING: A general medical primary care practice in a teaching medical center in rural New England. PATIENTS: 1,042 consecutive outpatients screened for depression with the Hopkins Symptom Checklist 49-item depression scale and for whom physicians filled out a form recording both specific chief complaints and two aspects of complaint presentation style, clarity and amplification. INTERVENTIONS: None. RESULTS: Complaints that discriminated between depressed and non-depressed patients (at the p = 0.05 level) were sleep disturbance (PPV 61%), fatigue (PPV 60%), multiple (3+) complaints (PPV 56%), nonspecific musculoskeletal complaints (PPV 43%), back pain (PPV 39%), shortness of breath (PPV 39%), amplified complaints (PPV 39%), and vaguely stated complaints (PPV 37%). CONCLUSIONS: Depressed patients are common in primary care practice and important to recognize. Certain specific complaints and complaint presentation styles are associated with underlying depressive symptoms

In an effort to elucidate the process of internists' recognition of depression in primary care settings, a comparison of internist and "gold standard" psychiatric assessments of patients was undertaken in a rural primary care practice over a 15-month period. Clinical characteristics and diagnoses, global assessments of psychosocial stress, and two aspects of chief-complaint presentation style, clarity and somatization, were recorded by the internists for each patient, who was independently assessed by a psychiatrist for the presence of any specific depressive disorder by structured interview. Internists correctly labeled 57% of the interview-assessed depressives as depressed; 13% of patients with "no psychiatric disorder" were assessed as depressed by internists. Clinical and demographic characteristics of the "false-negative" and "false-positive" internists' diagnoses were examined to clarify how internists think of "depression" in the primary care context.