Chart-stimulated Recall as a Learning Tool for Improving Radiology Residents' Reports.

RATIONALE AND OBJECTIVES: Workplace-based assessments gauge the highest tier of clinical competence. Chart-stimulated recall (CSR) is a workplace-based assessment method that complements chart audit with an interview based on the residents' notes. It allows evaluation of the residents' knowledge and heuristics while providing opportunities for feedback and self-reflection. We evaluated the utility of CSR for improving the radiology residents' reporting skills. MATERIALS AND METHODS: Residents in each year of training were randomly assigned to an intervention group (n = 12) or a control group (n = 13). Five pre-intervention and five post-intervention reports of each resident were independently evaluated by three blinded reviewers using a modified Bristol Radiology Report Assessment Tool. The study intervention comprised a CSR interview tailored to each individual resident's learning needs based on the pre-intervention assessment. The CSR process focused on the clinical relevance of the radiology reports. Student's t test (P < .05) was used to compare pre- and post-intervention scores of each group. RESULTS: A total of 125 pre-intervention and 125 post-intervention reports were evaluated (total 750 assessments). The Cronbach's alpha for the study tool was 0.865. A significant improvement was seen in the cumulative 19-item score (66% versus 73%, P < .001) and the global rating score (59% versus 72%, P < .001) of the intervention group after the CSR. The reports of the control group did not demonstrate any significant improvement. CONCLUSION: CSR is a feasible workplace-based assessment method for improving reporting skills of the radiology residents.

Understanding Preprocedure Patient Flow in IR.

PURPOSE: To quantify preprocedural patient flow in interventional radiology (IR) and to identify potential contributors to preprocedural delays. MATERIALS AND METHODS: An administrative dataset was used to compute time intervals required for various preprocedural patient-flow processes. These time intervals were compared across on-time/delayed cases and inpatient/outpatient cases by Mann-Whitney U test. Spearman ρ was used to assess any correlation of the rank of a procedure on a given day and the procedure duration to the preprocedure time. A linear-regression model of preprocedure time was used to further explore potential contributing factors. Any identified reason(s) for delay were collated. P < .05 was considered statistically significant. RESULTS: Of the total 1,091 cases, 65.8% (n = 718) were delayed. Significantly more outpatient cases started late compared with inpatient cases (81.4% vs 45.0%; P < .001, χ(2) test). The multivariate linear regression model showed outpatient status, length of delay in arrival, and longer procedure times to be significantly associated with longer preprocedure times. Late arrival of patients (65.9%), unavailability of physicians (18.4%), and unavailability of procedure room (13.0%) were the three most frequently identified reasons for delay. The delay was multifactorial in 29.6% of cases (n = 213). CONCLUSIONS: Objective measurement of preprocedural IR patient flow demonstrated considerable waste and highlighted high-yield areas of possible improvement. A data-driven approach may aid efficient delivery of IR care.

Benign pneumatosis intestinalis after bilateral lung transplantation.

This series details two cases of benign pneumatosis intestinalis (PI) in patients post-lung transplant, which were discovered incidentally on routine surveillance chest radiographs during ambulatory clinic visits. Both patients had uneventful post-transplant recovery and were asymptomatic at presentation. The patients were admitted for observation. Contrast-enhanced abdominal CT scans confirmed the plain film findings. Both cases were managed conservatively with bowel rest, intravenous hydration and serial abdominal examinations. The patients had unremarkable hospital courses and were both discharged in good condition. Our current understanding of benign PI in patients post-transplant is limited to a few case series and case reports. Greater awareness of this entity may decrease unnecessary invasive procedures and improve management of these patients.

Do general practitioners know what they are prescribing?

A cross-sectional study was conducted to explore general practitioners' (GPs) knowledge regarding the major therapeutic use and adverse effects of drug(s) they prescribe. Three drugs namely tablet Montelukast Sodium, tablet Somatriptan and inhaler Fluticasone Propionate were selected from the list of drugs approved by the Ministry of Health in Pakistan. GPs who had prescribed at least one of the three were inquired about the cost, therapeutic use and one common adverse effect. For each question, one correct option and three distracting options were given. Two hundred and ninety four responses of 131 GPs were included in the final analysis. The correct options for therapeutic use and adverse effect were identified by 61.2% (n = 180) and 40.8% (n = 120) respectively. A statistically significant (p < 0.01) deficit of knowledge regarding adverse effects was observed for those GPs who identified pharmaceutical advertisements as their primary source of information for new drugs and those who were less experienced.

Faculty and patient evaluations of radiology residents' communication and interpersonal skills.

OBJECTIVE: To assess communication and interpersonal skills (CIS) of radiology residents through faculty and standardised patients (SP). METHODS: In this day-long objective structured clinical examination (OSCE) in January 2009, 42 radiology residents took part at six stations in Karachi, each with a standardised patient and a faculty evaluator. Each encounter lasted 15 minutes followed by independent assessments of the residents by both the evaluators. RESULTS: Based on rating-scale evaluations, all cases had satisfactory internal consistency (Cronbach's alpha 0.6 to 0.9). The alpha values were comparatively diminutive against the checklist scores. Correlation among faculty was 0.6 (p<0.001) with the use of both the checklist and the rating scale. Among standardised patient, intra-class correlation was 0.6 (p<0.001) for checklists and 0.7 (p=0.001) for rating scales. Moderate to strong correlations (r=0.6 to 0.9) existed between checklist and rating scores by the same type of evaluator. Correlations among the faculty and standardised patient using the same assessment tool were unimpressive. CONCLUSION: Both checklists and rating scales can serve as satisfactory assessment tools for communication and interpersonal skills using objective structured and clinical examination with the assistance of faculty and standardised patients.

Growth of carotid artery duplex ultrasound among Medicare beneficiaries (2000-2007).

OBJECTIVE: Although intervention in asymptomatic carotid artery stenosis remains controversial, most carotid interventions are performed in asymptomatic individuals. Carotid duplex ultrasound is the diagnostic test that precedes more than 90% of carotid interventions. In terms of economic incentives, providers who perform carotid artery revascularization may experience synergy if they also provide carotid duplex ultrasound, because the diagnostic service is reimbursed and also can lead to referrals for revascularization procedures. To test the hypothesis that providers of revascularization services are incentivized to increase utilization of carotid duplex ultrasound, we compared the utilization of carotid duplex ultrasound among Medicare beneficiaries by three specialties that perform revascularization for carotid stenosis (interventional radiology, vascular surgery, and cardiology) with one that usually does not (diagnostic radiology). MATERIALS AND METHODS: We analyzed 100% of procedure-specific claims submitted to Medicare by the four specialties during 2000, 2002, 2004, 2005, 2006, and 2007. Only professional and global components of services approved by Medicare were included. Compounded annual growth rates were used to compare utilization by different specialties. RESULTS: Utilization by diagnostic radiology increased at a compound annual growth rate of 1% during 2000-2007. Interventional radiology and vascular surgery experienced higher compound annual growth rates of 3% and 6%, respectively. Utilization by cardiology increased at a rate 11 times that of diagnostic radiology, translating into an additional 960 procedures per 100,000 Medicare beneficiaries by cardiology in 2007 than in 2000. CONCLUSION: Medicare beneficiaries are increasingly being tested for carotid artery stenosis, especially by specialties that perform revascularization for carotid stenosis. The health benefits of this practice are uncertain.

Utilization of lower extremity arterial disease diagnostic and revascularization procedures in Medicare beneficiaries 2000-2007.

OBJECTIVE: The recent escalation in lower extremity revascularization procedures suggests a concomitant increase in peripheral arterial disease (PAD) screening. We hypothesized that self-referring physicians would show the greatest growth in noninvasive physiologic testing for PAD and similar trends for revascularization procedures. We compared utilization rates for self-referring specialties (vascular surgery, interventional radiology, and cardiology) with the utilization rate for a referral-based specialty (diagnostic radiology), assuming the latter to be "basal"--that is, responsive only to changes in demographics and medical knowledge. MATERIALS AND METHODS: We analyzed 100% procedure-specific claims for services provided to Medicare Part B beneficiaries during 6 years over an 8-year span (2000-2007). We extracted all Current Procedural Terminology codes for lower extremity vascular noninvasive physiologic studies, peripheral arterial stent placement, and transluminal angioplasty. Utilization volumes were adjusted per 100,000 beneficiaries. Compound annual growth rates were calculated. RESULTS: Utilization of both noninvasive physiologic and revascularization services increased steadily over the study period. Growth rates of diagnostic services provided by interventional radiologists (7%) and vascular surgeons (8%) were slightly higher than the basal rate (7%), with cardiologists (14%) at the top of the list. For revascularization procedures, vascular surgery showed the greatest growth (28%), a rate more than twice that of cardiology (13%); radiology experienced a decrease in volumes (-2%). CONCLUSION: Self-referring specialists are screening large volumes of Medicare beneficiaries for lower extremity PAD at an accelerated rate compared with testing done by those who do not self-refer. Similar trends exist for endovascular interventions.

An appraisal of Greulich-Pyle Atlas for skeletal age assessment in Pakistan.

OBJECTIVE: To assess accurate skeletal age (SA) in clinical and medico-legal decisions using the Greulich-Pyle (GP) atlas and to see its applicability across diverse populations in Karachi. METHODS: Hand-Wrist radiographs obtained at our institution from January 2005 to March 2008, for an indication of trauma, in subjects with chronological age (CA) up to 216 months, were reviewed by two radiologists blinded to CA. Subjects ever investigated for metabolic, growth or nutritional disorders were excluded. SA was assessed according to GP atlas. To establish inter-observer reliability, 100 random radiographs were dually evaluated. Both sexes were divided into four subgroups. For each subgroup, difference between skeletal and chronological age was calculated. (paired t-test, alpha < 0.05). RESULTS: Total 889 radiographs were analyzed. Inter-observer correlation coefficient was 0.992 (p < 0.001). Mean differences of up to 13 months between SA and CA were documented. The differences were statistically significant in all groups except adolescent males. CONCLUSION: Our findings suggest against the applicability of GP atlas for accurate SA assessment in Pakistani children.

A paradigm shift in imaging for renal colic - Is it time to say good bye to an old trusted friend?

OBJECTIVES: To study the changing pattern in the use of intravenous urogram (IVU) and non-contrast enhanced CT (CTKUB) for evaluation of flank pain at a single centre. METHODS: All patients who underwent either an IVU or CTKUB at a single, tertiary care center from January 2002 to December 2007 were retrospectively identified from the radiology database. Study samples were-divided into two groups: Pediatric (14 years or less) and Adult (greater than 14 years). For each group, overall trends as well as trends across referral setting and gender were explored by plotting line graphs using SPSS version 15. RESULTS: During the study period a total of 11245 uro-radiological examinations were performed using either IVU (43.7%, n=4915) or CTKUB (56.3%, n=6330). A remarkable majority of procedures (95.5%, n=10741) was performed in adult patients. Overall, the respective proportions of IVU and CTKUB were 87.9% (n=43) and 12.1% (n=61) in the pediatric group whereas 41.6% (n=4472) and 58.4% (n=6269) in adults. Majority in both groups were ambulatory patients (Pediatrics 83.7%, Adults 76.7%). During 2002-20007, the yearly proportion of CTKUB increased from 27% to 80% in adults and from 3% to 27% in children. CONCLUSIONS: There is major shift in the choice of imaging in adults from IVU to CTKUB during years 2002-2007. In pediatric patients, IVU referrals still comprise the greater proportion of uro-radiological exams.

Psychotherapy as a treatment modality for psychiatric disorders: Perceptions of general public of Karachi, Pakistan.

BACKGROUND: Psychiatric disorders affect about 450 million individuals worldwide. A number of treatment modalities such as psychotropic medications, psychotherapy and electroconvulsive therapy can be used to treat these disorders. Attitudes of general public play a pivotal role in effective utilization of mental health services. We explored the perceptions of general public of Karachi, Pakistan regarding psychotherapy. METHODS: A cross-sectional study was conducted in Karachi, Pakistan during July-August, 2008. A three-step sampling strategy and a structured questionnaire were employed to survey knowledge and perceptions of adult general public about psychotherapy. Descriptive statistics were used for baseline characteristics. Logistic regression models were used to investigate any significant associations between baseline characteristics of the participants and their perceptions. RESULTS: The study sample comprised of 985 individuals (536 males; 531 financially independent) with an average age of 36.7 years (SD 13.54 years) and 12.5 years (SD 3.09 years) of education were included. Majority (59.4%; n = 585) claimed to be aware of psychotherapy as a treatment option for psychiatric disorders but 47.5% of these (n = 278/585) failed to identify its correct definition. Concerns voiced by the participants about psychotherapy included stigma (48.7%) and breech in confidentiality (39.5%); 60.7% opined it cost effective and 86.5% favored its use as an adjuvant modality. A preference for psychotherapy as the treatment strategy for psychiatric disorders was demonstrated by 46.6% (n = 459/985). Younger, more educated, financially independent and female participants were more likely to prefer psychotherapy as were those who deemed it cost effective. CONCLUSION: Positive attitudes regarding the acceptability, clinical utility and cost-effectiveness of psychotherapy were observed in a sample representative of general public of Karachi, Pakistan. These findings highlight its potential utility for devising pragmatic mental health strategies in the face of limited resources.

Instituting an undergraduate core clerkship in radiology: initial experiences in Pakistan.

Utilization of radiology as an educational resource carries great potential. Accreditation bodies, physicians and medical students deem it important for a well rounded medical curriculum. Unfortunately this resource is yet to be developed and implemented to an optimal extent. We share the experiences from the first radiology core clerkship in Pakistan at the undergraduate level. An overview of clerkship objectives and structure is followed by discussion on lessons learnt during the initial three years of institution. Development of assessable objectives, integration of radiology with other specialties, and supervised andragogical learning tailored for undergraduate students are emphasized.

Where there is no PET/CT.

Technology assessment should touch upon four areas; utility, target population, cost and alternatives. Hybrid Positron Emission Tomography/Computed Tomography (PET/CT) is a promising modality for oncologic imaging. However, reservations about its accessibility and affordability prevail. Magnetic Resonance Imaging (MRI) is an alternative with certain key advantages that can potentially prove equivalent if not better than PET/CT. We have highlighted the value of comparative studies between PET/CT and whole body MRI. Diffusion Weighted sequences may aid in better diagnosis of malignancies on MRI. The 'Eye of Medicine' should not have a restricted vision even where there is no PET/CT.