Impact of decompressive craniectomy on brain perfusion scintigraphy as an ancillary test for brain death diagnosis.

OBJECTIVES: Decompressive craniectomy is occasionally performed for patients with impending brain death, which is intended to relieve critically elevated intracranial pressure to keep effective intracranial perfusion. It has been in debate if this surgery later affects the result of brain perfusion scintigraphy performed as an ancillary test in the course of brain death diagnosis because rigid closed skull is deemed essential to elevate intracranial pressure to the point of total absence of intracranial radiotracer uptake on scintigraphy. The purpose of this study is to elucidate the impact of decompressive craniectomy on the result of brain perfusion scintigraphy in patients with suspected brain death. METHODS: This retrospective cross-sectional study included consecutive 151 brain perfusion scintigraphy performed in 138 patients with suspected brain death from various causes (male 82 patients, female 56 patients; range 0-74 years; mean age 36.6 years). All exams were indicated due to inconclusive clinical diagnosis of brain death. The scintigraphy protocol consists of immediate flow phase and delayed parenchymal phase planar imaging. Additional SPECT imaging was performed in 15 studies in 14 patients. The results, positive or negative brain flow, were compared between patients with and without decompressive craniectomy using Chi-squared test. As there were patients with repeat studies, analysis was performed for both initial and final exam results. Same dataset was used for initial and final exams in patients with only one exam. RESULTS: Out of 138 patients, 15 patients underwent decompressive craniectomy (11%) and 123 patients were managed medically (89%). On the initial exam, negative brain flow was demonstrated in 11 of 15 patients with craniectomy (73.3%) and 106 of 123 patients without craniectomy (86.2%). On the final exam, negative brain flow was demonstrated 12 of 15 patients with craniectomy (80%) and 111 of 123 patients without craniectomy (90.2%). There were no statistically significant differences between the two groups on both initial and final exams (p = 0.19 and 0.23, respectively). CONCLUSION: In patients with suspected brain death, history of decompressive craniectomy does not affect the result of brain perfusion scintigraphy.

Multiple open wrist fractures and dislocation of the distal radioulnar joint from a dog bite injury.

Dogs are commonly kept as household pets, but sometimes pet dogs bite people. We report the case of a 69-year-old man who was bitten by his pet pit bull terrier. The dog bite resulted in multiple open wrist fractures and dislocation of the distal radioulnar joint, requiring surgical debridement, open reduction and internal fixation, and bone grafting. CT of the fractures showed that the dog's maxillary canine teeth had been deeply embedded in the hamate and second metacarpal bones, requiring that the dog's mouth be opened and the teeth disengaged in order to remove the injured limb from the dog.

Emotional Wellness of Current Musculoskeletal Radiology Fellows.

RATIONALE AND OBJECTIVES: Burnout is a psychological syndrome composed of emotional exhaustion, depersonalization, and sense of lack of personal accomplishment, as a result of prolonged occupational stress. The purpose of our study was to determine the prevalence of burnout among current musculoskeletal radiology fellows and to explore causes of emotional stress. MATERIALS AND METHODS: A 24-item survey was constructed on SurveyMonkey using the Maslach Burnout Inventory. We identified 82 musculoskeletal radiology fellowship programs. We recruited subjects indirectly through the program director or equivalent. RESULTS: Fifty-eight respondents (48 male, 10 female) identified themselves as current musculoskeletal radiology fellows and completed the survey. Comparison of the weighted subscale means in our data to the Maslach normative subscale thresholds for medical occupations indicates that musculoskeletal radiology fellows report relatively high levels of burnout with regard to lack of personal accomplishment and depersonalization, whereas emotional exhaustion levels in our sample are within the average range reported by Maslach. Although male musculoskeletal radiology fellows experience relatively high levels in two of the three dimensions of burnout (depersonalization and personal accomplishment), female musculoskeletal radiology fellows experience relatively high burnout across all three dimensions. Job market-related stress and the effort required providing care for dependents significantly affect personal accomplishment. Conversely, imbalances in the work-life relationship and feelings of powerlessness are significantly associated with depersonalization and emotional exhaustion. CONCLUSIONS: Musculoskeletal radiology fellows report relatively high levels of burnout. Because the consequences of burnout can be severe, early identification and appropriate intervention should be a priority.

Individual, interpersonal, and organisational factors of healthcare conflict: A scoping review.

Unresolved conflicts among healthcare professionals can lead to difficult patient care consequences. This scoping review examines the current healthcare literature that reported sources and consequences of conflict associated with individual, interpersonal, and organisational factors. We identified 99 articles published between 2001 and 2015 from PubMed, Cumulative Index to Nursing and Allied Health Literature, and Excerpta Medical Database. Most reviewed studies relied on healthcare professionals' perceptions and beliefs associated with conflict sources and consequences, with few studies reporting behavioural or organisational change outcomes. Individual conflict sources included personal traits, such as self-focus, self-esteem, or worldview, as well as individuals' conflict management styles. These conflicts posed threats to one's physical, mental, and emotional health and to one's ability to perform at work. Interpersonal dynamics were hampered by colleagues' uncivil behaviours, such as low degree of support, to more destructive behaviours including bullying or humiliation. Perceptions of disrespectful working environment and weakened team collaboration were the main interpersonal conflict consequences. Organisational conflict sources included ambiguity in professional roles, scope of practice, reporting structure, or workflows, negatively affecting healthcare professionals' job satisfactions and intent to stay. Future inquiries into healthcare conflict research may target the following: shifting from research involving single professions to multiple professions; dissemination of studies via journals that promote interprofessional research; inquiries into the roles of unconscious or implicit bias, or psychological capital (i.e., resilience) in healthcare conflict; and diversification of data sources to include hospital or clinic data with implications for conflict sources.

Prevalence of burnout among musculoskeletal radiologists.

OBJECTIVE: Burnout is a job-related psychological syndrome with three aspects: emotional exhaustion, depersonalization, and perceived lack of personal accomplishment. Burnout is associated with deleterious effects on both workers and their work. When burnout affects physicians, their well-being, longevity, and care of patients are at risk. Recent studies concerning physician burnout treat specialists such as radiologists as one group. We studied burnout in musculoskeletal (MSK) subspecialist radiologists. MATERIALS AND METHODS: An institutional review board exemption was obtained. Society of Skeletal Radiology members received invitations to an anonymous survey that included questions from the Maslach Burnout Inventory ™ (MBI) measuring all three aspects of burnout. The response rate was 36.4% (433/1190). RESULTS: The prevalence of emotional exhaustion was 61.7% (255/413), of depersonalization 53.3% (219/411), and of perceived lack of personal accomplishment 39.6% (161/407). Only 19.5% (79/405) of MSK radiologists reported no burnout, while 80.5% (326/405) reported burnout along one or more dimensions. For all three dimensions, the prevalence was higher and the mean severity was worse for private practice compared with academic practice. The prevalence of burnout was affected more by practice setting than by gender. Burnout prevalence and severity also varied systematically with years since completion of training. CONCLUSION: Among MSK radiologists, we found a much higher prevalence and greater severity of burnout than has been previously reported for radiologists and other physicians. There were differences in prevalence and severity of burnout among practice settings, genders, and longevity cohorts.

The Development of a Validated Checklist for Ultrasound-Guided Thyroid Nodule Fine-Needle Aspiration Biopsies: Preliminary Results.

Ultrasound-guided fine-needle aspiration (USgFNA) is the procedure of choice for biopsy of thyroid nodules (TNs) that are suspicious for malignancy. Poor technique in performing this procedure can result in nondiagnostic specimens, increased patient anxiety, repeated aspirations, and unnecessary surgery. Validated checklists are a central component of teaching and assessing procedural skills. The results of the first step of the validation of a TN USgFNA checklist are described. A comprehensive review of articles published on TN fine-needle aspiration did not yield a validated checklist. A modified Delphi technique, involving a panel of 8 interdisciplinary experts, was used to develop a TN USgFNA checklist. The internal consistency coefficient using Cronbach α was 0.74. Development of the 23-item TN USgFNA checklist for teaching and assessing TN USgFNA is the first step in the validation process. Further validation can be achieved via implementation and study of the checklist in clinical settings.

Major regulatory changes and the impact on diagnostic imaging in the United States 2005 to 2012∗: ∗effective May 15, 2013.

Federal regulation of diagnostic imaging in the United States has increased dramatically in recent years. The primary statutes aimed at curbing escalating costs and reorienting the national priorities of health care have a direct effect on the specialty of diagnostic imaging. This paper surveys the major regulations and current issues that pose challenges to the practice of diagnostic imaging in the United States, from the Deficit Reduction Act of 2005 through the American Taxpayer Relief Act of 2012.

Using the Internet for image transfer in a regional trauma network: effect on CT repeat rate, cost, and radiation exposure.

PURPOSE: The aims of this study were to evaluate an Internet-based and compact disc-based image transfer system and to compare this system with others in the literature, specifically regarding effects on repeat imaging rate, cost, and radiation dose to patients transferred to a level I regional trauma center. METHODS: Five hundred consecutive trauma patients transferred to a level I trauma center between June 1 and July 15, 2009, were included in the study. Images were transferred from an outside facility to the trauma center using the Internet and compact discs and uploaded to the trauma center's PACS. Radiographic studies and CT scans at the trauma center were classified as outside studies, completion studies, or repeat studies. Repeat rate, costs, and radiation doses of transferred and repeated CT scans were calculated. RESULTS: Four hundred ninety-one patients met the inclusion criteria. The patients' average age was 40.5 years, and 70% were men. The average Injury Severity Score was 14.7. Three hundred eighty-three patients had 852 CT studies and 380 nonextremity radiographs imported into the trauma center's PACS. At the trauma center, 494 completion CT scans and 2,924 radiographic studies were performed on these patients. Sixty-nine repeat CT scans were performed on 55 patients, equalling a 17% repeat rate. The total value of imported CT studies was $244,373.69. Repeat imaging totaled $20,495.95, or $84.65 per patient with transferred CT studies. CONCLUSIONS: Using a combination of the Internet and compact discs to transfer images during inter-hospital transfer is associated with much lower repeat rates than those in the literature, suggesting that regional PACS networks may be useful for reducing cost and radiation exposure associated with trauma.

Last Call: decreasing drunk driving among 21-34-year-old bar patrons.

Any effort to decrease the toll of drunk driving must include efforts directed at people who drink in bars, particularly young adults who use motor vehicles after drinking. We designed a multifaceted social marketing campaign, Last Call, to increase the use of designated drivers and safe rides homes among 21-34-year olds. There were three components to the intervention: (1) use of taxi stands to promote taxi use; (2) point-of-sale information to patrons at partner bars and (3) a mass media campaign to support the designated driver/safe ride home message. Among the heaviest drinkers, the programme significantly increased the use of designated drivers and increased the use of taxis by 63%.

Ethical considerations in CMS's coverage with evidence development.

This paper reviews the CMS coverage with evidence development policy, its manner of implementation, and key ethical issues raised by the policy. The author describes ethical considerations and issues associated with the process of coverage with evidence development for generating evidence for novel or emerging technologies.

Detection of ventricular shunt malfunction in the ED: relative utility of radiography, CT, and nuclear imaging.

The study objective was to determine the relative diagnostic utility of the radiographic shunt series (SS), head computed tomography (CT), and nuclear imaging performed in our Emergency Department (ED) for evaluating ventricular shunt malfunction. We retrospectively reviewed medical records, head CT (if performed), and nuclear imaging (if performed) for all ED patients with suspected shunt malfunction from 2002 to 2007 who underwent plain film shunt evaluation (296 cases/186 individuals) to determine if surgical shunt revision was performed. Logistic regression analysis was applied. Four percent (12/296) of radiographic SS were abnormal. Only 0.3% (1/296) underwent surgical revision in the absence of an abnormal head CT or nuclear imaging. Eighteen percent (51/282) of head CT exams were positive and 19% (24/128) of nuclear imaging exams were positive for shunt malfunction. Twenty-three percent (67/296) underwent surgical shunt revisions. Statistical analysis demonstrated that SS evaluation was not significantly associated with surgical shunt revision (OR 0.92; 95% CI, 0.7-1.2; p=0.47). Head CT demonstrated a significant association with surgical revision (OR 1.4; 95% CI, 1.2-1.5; p<0.001), as did nuclear imaging (OR 1.4; 95% CI, 1.2-1.6; p<0.001). Patients with suspected ventricular shunt malfunction frequently require surgical revision. Abnormal radiographic SS was not associated with progression to surgical shunt revision, whereas abnormal head CT and abnormal nuclear imaging were significantly associated with surgical revision. We conclude that radiographic SS in the ED is of low diagnostic utility and that patients with suspected shunt malfunction should instead initially undergo CT and/or nuclear imaging.

A dedicated general competencies curriculum for radiology residents development and implementation.

RATIONALE AND OBJECTIVES: The Accreditation Council on Graduate Medical Education (ACGME) through its Outcome Project requires training programs in all medical specialties to integrate six general competencies into residency training: patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice. In response, a required, or dedicated general competencies rotation for diagnostic radiology residents was instituted. MATERIALS AND METHODS: We describe the development and implementation of this rotation. The rotation augments the core curriculum, with primary emphasis placed on resident-initiated quality improvement (QI) and quality assurance (QA) projects. RESULTS: Between academic years 2003 and 2009 diagnostic radiology residents completed 38 QI/QA projects and performed clinical float coverage for the department. Residents met requirements of the systems-based practice and practice-based learning competency domains. In this process, residents improved their medical knowledge, interpersonal communication skills, professionalism, and provided patient care. CONCLUSIONS: A dedicated general competencies rotation can be successfully implemented, and complement the requirements of the core curriculum. In combination with coverage for clinical services, the rotation makes a substantive contribution to resident education to further the goal of improved patient care.

Radiation exposure from pediatric head CT: a bi-institutional study.

BACKGROUND: Medical radiation from CT should be kept as low as reasonably achievable (ALARA), particularly in young patients. OBJECTIVE: To examine radiation dose from head CT in children in a trauma center (TC) and a regional children's hospital (RCH). MATERIALS AND METHODS: A random sample of 240 children (0-3, 4-9, 10-14 years of age) from the TC were compared with a similar cohort from the RCH. All children had undergone at least one head CT scan without contrast enhancement; data from PACS and Department of Radiology Information System were used to estimate normalized effective dose (ED). Lifetime attributable risk of cancer incidence was estimated using the Biologic Effects of Ionizing Radiation (BEIR) VII report. RESULTS: The mean normalized ED was significantly higher in the youngest children at the TC (2.74 mSv in those aged 0-3 years vs. 2.23 mSv in those aged 10-14 years; P<0.001) and at the RCH (2.44 mSv in those aged 0-3 years vs. 1.71 mSv in those aged 10-14 years; P<0.001). Each decreasing year of age was independently associated with a 0.06 mSv higher mean normalized ED (P<0.001). After adjusting for the age difference between the institutions, the mean normalized ED was 0.44 mSv lower at the RCH than at the TC across all ages (95% CI 0.31-0.58, P<0.001). A higher lifetime attributable risk of cancer was associated with younger age. CONCLUSION: The radiation dose from head CT in children as defined by the normalized ED was highest in the youngest children and varied significantly between institutions in this bi-institutional study.

Personal bankruptcy after traumatic brain or spinal cord injury: the role of medical debt.

OBJECTIVE: To estimate the prevalence of medical debt among traumatic brain injury (TBI) and spinal cord injury (SCI) patients who discharged their debts through bankruptcy. DESIGN: A cross-sectional comparison of bankruptcy filings of injured versus randomly selected bankruptcy petitioners. SETTING: Patients hospitalized with SCI or TBI (1996-2002) and personal bankruptcy petitioners (2001-2004) in western Washington State. PARTICIPANTS: Subjects (N=186) who filed for bankruptcy, comprised of 93 patients with previous SCI or TBI and 93 randomly selected bankruptcy petitioners. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Medical and nonmedical debt, assets, income, expenses, and employment recorded in the bankruptcy petition. RESULTS: Five percent of randomly selected petitioners and 26% of petitioners with TBI or SCI had substantial medical debt (debt that accounted for more than 20% of all unsecured debts). SCI and TBI petitioners had fewer assets and were more likely to be receiving government income assistance at the time of bankruptcy than controls. SCI and TBI patients with a higher blood alcohol content at injury were more likely to have substantial medical debts (odds ratio=2.70; 95% confidence interval, 1.04-7.00). CONCLUSIONS: Medical debt plays an important role in some bankruptcies after TBI or SCI. We discuss policy options for reducing financial distress after serious injury.

The disruptive professional case scenarios.

This article examines certain critical aspects relating to the clinical competency of professionalism. A discussion is presented which is centered on an analysis of two fictional scenarios explored from the standpoint of a current and a former program director, an associate dean, a department chair, and a lawyer. These cases are followed by a series of questions and a legal discussion which can then be used for either individual study or group discussion.

Methodology and application of clinical trials in radiology: self-assessment module.

The educational objectives of this self-assessment module are for the participant to understand the differences between cohort and case-control studies in radiology, to understand the advantages of randomized controlled trials over observational studies, to understand the basic principles underlying the use of imaging examinations for screening asymptomatic populations for particular diseases, and to understand the biases associated with the use of survival statistics in the evaluation of screening.

Dedicated core clerkship in radiology for medical students development, implementation, evaluation, and comparison with distributed clerkship.

RATIONALE AND OBJECTIVES: The authors performed this study to develop, implement, and evaluate a dedicated core clerkship in radiology for the required clinical clerkship year of medical school, and to compare it with the distributed core clerkship that it replaced. MATERIALS AND METHODS: A dedicated 5-day clerkship was added to the clinical core year of medical school. The course offered a variety of learning experiences, including lectures, clinical observation, case discussions, and a team project. Learner achievement was measured by posttest and compared with a control group. Student satisfaction was determined by structured and unstructured surveys. Faculty comment was elicited by survey, and administrative staff perspective was established through interviews. The evaluation of the dedicated clerkship was compared with the distributed clerkship along the dimensions of learner achievement, student satisfaction, faculty comment, and administrative staff perspective. RESULTS: The dedicated clerkship was developed and implemented successfully. Compared with the distributed clerkship, there was no significant difference in learner achievement or student satisfaction for the dedicated clerkship, but the dedicated clerkship was easier to conduct for faculty and administrative staff. CONCLUSION: The dedicated clerkship was advantageous for faculty and administrative staff, whereas maintaining a comparable level of learner achievement and student satisfaction as the distributed clerkship.