Comparative Analysis of Radiology Trainee Burnout Using the Maslach Burnout Inventory and Oldenburg Burnout Inventory.

BACKGROUND: Burnout is an individualized response to imbalances between job demands and resources that has predominantly been evaluated with the Maslach Burnout Inventory (MBI). There are other instruments not validated among healthcare providers that may be comparable to the MBI. Utilizing alternative measurements can allow researchers to assess wellness with a larger array of questions. OBJECTIVE: We explored differences between the MBI- Human Services Survey for Medical Personnel (MBI-HSS [MP]) and Oldenburg Burnout Inventory (OLBI) in evaluating emotional exhaustion (EE)/exhaustion and depersonalization (DP)/disengagement. METHODS: We administered the MBI-HSS (MP) and OLBI to United States (US) radiology trainees during three,1-month intervals in April 2018, October 2018, and April 2019. Student's T-tests or ANOVA was used to evaluate differences between demographic groups and burnout scores in the MBI-HSS (MP) and OBLI. Non-inferiority analysis was completed to evaluate if the OBLI was not inferior to the MBI-HSS (MP) in how its subscales measure exhaustion and disengagement. The MBI-HSS (MP) subtotals for EE and DP were compared with the OLBI scores for exhaustion and disengagement using two-tailed paired T-tests for each trainee. RESULTS: Of 2823 trainees emailed, 770 (27.3%) responded. The mean EE Maslach score was 21/54, and the mean DP Maslach score was 8/30. The average OBLI exhaustion and disengagement score was 2.38 and 2.22, respectively. Comparative analysis of completed MBI-HSS (MP) and OLBI subscales yielded no significant difference between the EE/exhaustion (t(496)=1.038; p=0.30) or DP/disengagement (t(498)=0.084; p=0.933) subscales. CONCLUSIONS: Our national study of radiology trainees demonstrated that the OLBI was not inferior in assessing exhaustion and disengagement to the EE and DP subscales of the MBI-HSS (MP).

The Path of Most Resistance: A Rare Instance of Metastatic Pancreatic Adenocarcinoma Identified Within Skeletal Muscle.

Soft tissue neoplastic metastases, specifically to the skeletal muscle, are uncommon in comparison to metastases within the abdomen, thorax, or intracranial regions. Specifically, pancreatic adenocarcinoma with skeletal muscle metastasis is a rare clinical phenomenon and is hardly reported. There is a high mortality rate after the diagnosis of metastatic pancreatic adenocarcinoma, attributed to inadequate screening and advanced staging upon incidental discovery. Rarely, metastatic lesions manifest in the skeletal muscle and are hardly documented. Some of the factors that deter skeletal muscle tumor implantation include the deficiency of skeletal muscle mediators and genetic makeup of the primary tumor. Surgical resection of pancreatic adenocarcinoma with adjuvant chemotherapy demonstrates the best prognosis; however, surgical management is usually limited to patients without known metastatic disease. Alternative treatment options such as chemotherapy and radiotherapy are used in the palliative care setting. Here, we present the case of a patient with previously diagnosed and treated pancreatic adenocarcinoma in remission, with biopsy-proven metastases isolated within the skeletal muscle.

Systematic review of three-dimensional printing for simulation training of interventional radiology trainees.

RATIONALE AND OBJECTIVES: Three-dimensional (3D) printing has been utilized as a means of producing high-quality simulation models for trainees in procedure-intensive or surgical subspecialties. However, less is known about its role for trainee education within interventional radiology (IR). Thus, the purpose of this review was to assess the state of current literature regarding the use of 3D printed simulation models in IR procedural simulation experiences. MATERIALS AND METHODS: A literature query was conducted through April 2020 for articles discussing three-dimensional printing for simulations in PubMed, Embase, CINAHL, Web of Science, and the Cochrane library databases using key terms relating to 3D printing, radiology, simulation, training, and interventional radiology. RESULTS: We identified a scarcity of published sources, 4 total articles, that appraised the use of three-dimensional printing for simulation training in IR. While trainee feedback is generally supportive of the use of three-dimensional printing within the field, current applications utilizing 3D printed models are heterogeneous, reflecting a lack of best practices standards in the realm of medical education. CONCLUSIONS: Presently available literature endorses the use of three-dimensional printing within interventional radiology as a teaching tool. Literature documenting the benefits of 3D printed models for IR simulation has the potential to expand within the field, as it offers a straightforward, sustainable, and reproducible means for hands-on training that ought to be standardized.

Predictors Between the Subcomponents of Burnout Among Radiology Trainees.

OBJECTIVE: The aim of this study was to investigate the effect of various predictors on burnout among radiology residents during their training. METHODS: In this cross-sectional analysis, we distributed the Maslach Burnout Index for Medical Personnel (MBI-HSS [MP]) to eligible United States (US) radiology residents. Covariates of interest included age, child status, debt burden, partner status, and self-identified gender. Primary outcomes include MBI-HSS (MP) subcomponent scores - emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). Mann-Whitney tests were used to compare averages between groups. RESULTS: Out of the 770 of 2823 residents (27.3%) who responded, 488 of 770 completed the MBI-HSS (MP). During the R1 year, male sex was associated with marginally higher PA scores (36.5 versus 33.5; P = .029). Having children or a partner was associated with lower EE scores (18.7 versus 26.8, P = .012; 22 versus 28.9, P = .022, respectively) and higher PA scores (37 vs 32.7, P = .024; 35 versus 31.3, P = .039, respectively) among the R3 cohort. Reporting debt < $200,000 was associated with lower EE scores among the R3 (21.2 versus 27.3, P = .028) and R4 (16.4 versus 21.9, P = .033) cohort. DISCUSSION: There are several predictors of burnout that transiently impact residents at different years of training and primarily impact EE or PA, but not DP scores. R3 residents' scores are most sensitive to these covariates.

Exploration of the Relationship Between the Subcomponents of Burnout Throughout Radiology Training.

PURPOSE: The aim of this study was to investigate the relationship between the subcomponents of burnout and year of training among radiology residents. METHODS: In this cross-sectional analysis, the Maslach Burnout Inventory Human Services Survey for Medical Personnel (MBI-HSS [MP]) was distributed to eligible United States (US) radiology residents. Primary outcomes included the MBI-HSS (MP) subcomponents: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). Multivariate analysis of variance, tests of between-subjects effects, and Tukey post hoc analysis with 95% confidence interval were conducted. RESULTS: A total of 770 of 2,823 residents (27.3%) responded, with 488 of 770 completing the MBI-HSS (MP). There was a statistically significant difference in subcomponent scores between cohorts based on year of training (P < .005) and a statistically significant effect between year of training and EE (P < .05) and DP (P < .005), but not PA. Third-year (R3) residents reported a higher frequency of EE than first-year (R1) residents and a higher frequency of DP than R1 and second-year (R2) residents. Fourth-year (R4) residents reported more DP than R1 residents. CONCLUSIONS: This analysis shows variation in burnout subcomponents during training, with the highest recorded EE and DP means and lowest recorded PA means among R3 residents. Although these findings demonstrate evidence of burnout among radiology residents, mean subcomponent scores for EE (21.3) and DP (8.4) were lower and for PA (35.1) was higher for all trainees than in previous studies assessing radiology residents, which correlates with less burnout. DP was the only subcomponent that remained statistically elevated between matriculating R1 and graduating R4 residents.

Pipe-Cleaning Plugged Portacaths: How to Unclog an Implanted Port After Development of a Fibrin Sheath.

Industry has long fought the battle to design a vascular catheter that is less thrombogenic. Indwelling catheters provide long-term central venous access, but they develop fibrin sheaths as the vascular system recognizes them as foreign bodies. Peripheral catheters and central catheters can be changed over a guidewire when they form a fibrin sheath or otherwise malfunction. However, totally implantable venous access devices such as a port cannot be easily exchanged over a wire. Therefore, when a port malfunctions, thrombolytics are usually the only option attempted before the port is explanted and a new site is prepared for access. We present a minimally invasive technique demonstrating port salvage that does not require explant.

Covered or Not, Here I Come: Stanford Type B Aortic Dissection Repair With a Covered and Uncovered Stent Hybrid Technique.

The complications resulting from aortic dissections are often devastating. Historically, when a Stanford B aortic dissection extended into the visceral abdominal aorta, only surgical management was considered to limit visceral organ malperfusion. Complications of surgical management for Stanford B aortic dissections are as high as 50%. The inherently high complication and mortality rate for any acute aortic dissection, in addition to the complication rates resulting from surgical management, have demonstrated poor outcomes. This is especially true when aortic dissections involve the visceral segment, where thoracic endovascular aortic repair (TEVAR) becomes limited or contraindicated. In the last two decades, various approaches for TEVAR have improved in both endograft design and interventional technique. The current literature demonstrates improved outcomes for patients that receive TEVAR for Stanford B aortic dissections, including those that involve the visceral segment. Despite favorable prognostic advancement in TEVAR, the proven management complexity of Stanford B aortic dissections continue to reflect the pitfalls of the endovascular devices that are currently available. We describe a covered and uncovered stent hybrid technique in patients with complicated Stanford B aortic dissections involving the visceral segment, considering these deficiencies. Hundred percent technical success was demonstrated in the short and mid-term surveillance periods.

When Technology Exceeds its Application: The First Reported Reconstruction of the Iliocaval Confluence Using an Aortic Endograft.

Severe venous dysfunction in the setting of subacute iliocaval occlusion is a high cause of morbidity and mortality in patients. Fortunately, the development of the appropriate interventional management has allowed for better patient prognosis, despite device limitations. Severe cases of venous insufficiency, anatomically challenging vasculature, and device failure remain imperative when discussing the caveats for interventional success. The current gold standard of treatment for iliocaval disease has proven to be venoplasty in conjunction with stent placement within thrombotic occlusive areas. Though intuitive for modern day interventionists, this standard is not always forthright, especially when the most prevailing interventions fail to adequately treat certain venous pathologies. In this case, interventional operators must be willing to adapt their technical proficiency and knowledge of readily available devices to successfully treat the progressive nature of venous insufficiency. The following report demonstrates an example of how an interventional operator acclimated their interventional approach to successfully treat a severe and technically challenging case of subacute iliocaval occlusion, using an aortic endograft. In this first documented deployment of an aortic endograft in an iliocaval confluence, the results show resolution of the patient's subacute iliocaval occlusive disease, as well as complete iliocaval patency and the absence of post-procedural complications.

Nail Gun Injury and Endovascular Repair of Cervical Internal Carotid Artery.

A male patient aged 49 years presented to the emergency room after sustaining a nail-gun injury to the left neck (Zone III). Computed tomography (CT) angiogram demonstrated retained nail traversing in close proximity to the left internal carotid artery. Catheter angiogram with three-dimensional (3D) reconstruction revealed partial left internal carotid injury without active extravasation and with preserved flow through the vessel. The nail was removed by gentle traction with the simultaneous deployment of stent-graft across the injured segment. Balloon angioplasty of the stent was performed secondary to endoleak and active extravasation. Complete vessel reconstruction with maintained blood flow was achieved. The patient was extubated the following day and was discharged home on hospital day five without neurological deficits. This case report demonstrates the usefulness of endovascular repair of high cervical arterial injuries with special attention to the unique nature of nail gun injuries.

You Can Do That? Performing Total Recanalization of Completely Stented Arterial-venous Grafts.

Establishing venous access in chronic dialysis patients is conducted by the insertion of polytetrafluoroethylene arterial-venous (AV) grafts. The continual access of these grafts allows for potential failure over extended periods of hemodialysis treatment, as a result of thrombosis and pseudoaneurysm formation. Patency of AV grafts requires interventional management of thrombosis and pseudoaneurysm formation, including thrombectomy and covered stent placement, respectively. In 2013, the Food and Drug Administration approved the Gore REVISE study, giving indication for covered stents within AV grafts. If covered stent placement is required to treat a thrombosed AV graft, it is still possible to perform a percutaneous thrombectomy procedure afterwards. Direct access of the AV graft by passing through both the graft material and covered stents allows for interventional radiology management to be performed without compromise of the stent or graft. This interventional method of direct access can salvage the AV graft before considering further invasive management, such as a new surgical venous access site.

Solving the Chinese Finger Trap: A Novel Method for Simultaneous Superior and Inferior Vena Cava Filter Removal.

As many as 130,000 inferior vena cava (IVC) filters are placed annually, with as few as 5,000 retrieved a year for patients who no longer require protection from deep vein thrombosis. Superior vena cava (SVC) filter placement is an even less common occurrence and is usually reserved for special cases. Furthermore, the simultaneous placement of IVC and SVC filters is most rare, whereas simultaneous IVC and SVC filter removal has not been reported in the literature. We present a case and a novel technique for successful concurrent removal of IVC and SVC filters in a patient.

Hydro-marking Your Territory: Using a Novel Percutaneous Tagging System to Assist Pulmonary Nodule Identification During Video-assisted Thoracoscopic Surgery.

The management of lung cancer is highly dependent on surgical resection. There are different surgical managements that are utilized on a patient to patient basis. Small lung nodules are particularly difficult to resect and have a higher postoperative complication rate. Video-assisted thoracoscopic surgery is the preferred method of surgery over open thoracotomy, but requires the preoperative percutaneous placement of a marker to help the surgeon identify the nodule once conducting surgical resection. There are various methods to place percutaneous markers, but have reported complications. The following case will present the novel placement of a hydrogel tagging system on a small pulmonary nodule, demonstrating superiority to other methods of percutaneous marker placement.

Pre-cryoablation Embolization of Renal Tumors: Decreasing Probes and Saving Loads.

The use of adjuvant pre-ablation embolization for renal tumors has been reported in endophytic, centrally located lesions to reduce the risk of injuring the renal collecting system during subsequent cryoablation. In this technical report, we present another utilization of adjuvant pre-ablation embolization, applied for the purpose of decreasing the number of cryoablation probes needed in the ablation intervention. This novel procedural protocol not only decreases the cost of the procedure, but also preserves more normal renal parenchyma, and decreases the risk of injuries related to probe positioning.

Complicated Complication: How Interventional Radiologists Should Manage Acute Iatrogenic Cardiac Tamponade.

Computed tomography guided biopsies are common interventional procedures that are necessary for confirmation of imaging findings. Additionally, percutaneous biopsies are necessary for the elucidation of a patient's clinical findings with disease pathology. Though interventionists perform these procedures regularly without consequence, various complications may arise depending on the tissues biopsied. Examples of such complications may include hemorrhage, hematoma formation, or perforation of surrounding vessels. In the case of mediastinal biopsies, less common but higher-risk complications may include pneumothorax, perforation of arterial vessels, and damage to the cardiac tissues resulting in decompensation. Interventionists should understand the risks of performing these procedures and should be prepared to intervene if life-threatening complications arise. As interventional cardiologists are often prepared to manage decompensating cardiac complications, interventional radiologists must likewise anticipate the same to occur when conducting procedures that may affect cardiac tissues. The following case demonstrates a technique for correcting a complicated complication arising from a mediastinal biopsy, which resulted in a pericardial effusion and patient decompensation.

Ruptured, weighted, enteral feeding-tube tip presenting as enteric foreign objects.

We present a patient who, upon radiographic examination, was found to have eight metallic-density foreign objects throughout her colon that were identified as pieces of the enteral feeding tube's weighted tip, which was no longer intact. Although this complication is rare, correct identification is important so that the defective feeding tube can be removed and replaced and so that the patient and clinician can be reassured that the metallic foreign objects present minimal risk of complications.

Defining and evaluating wrapping surfaces for MRI-derived spinal muscle paths.

Muscle paths can be approximated in biomechanical models by wrapping the path around geometric objects; however, the process for selecting and evaluating wrapping surface parameters is not well defined, especially for spinal muscles. In this study, we defined objective methods to select the shape, orientation, size and location of wrapping surfaces and evaluated the wrapping surfaces using an error metric based on the distance between the modeled muscle path and the centroid path from magnetic resonance imaging (MRI). We applied these methods and the error metric to a model of the neck musculature, where our specific goals were (1) to optimize the vertebral level at which to place a single wrapping surface per muscle; and (2) to define wrapping surface parameters in the neutral posture and evaluate them in other postures. Detailed results are provided for the sternocleidomastoid and the semispinalis capitis muscles. For the sternocleidomastoid, the level where the wrapping surface was placed did not significantly affect the error between the modeled path and the centroid path; use of wrapping surfaces defined from the neutral posture improved the representation of the muscle path compared to a straight line in all postures except contralateral rotation. For the semispinalis capitis, wrapping surfaces placed at C3 or C4 resulted in lower error compared to other levels; and the use of wrapping surfaces significantly improved the muscle path representation in all postures. These methods will be used to improve the estimates of muscle length, moment arm and moment-generating capacity in biomechanical models.

Numerical model for biological fluidized-bed reactor treatment of perchlorate contaminated groundwater.

Biological fluidized-bed reactor (BFBR) treatment with 1.3 mm granular activated carbon as support medium is being used for removal of 2.6 mg/L perchlorate from contaminated groundwater in California. The California drinking-water action level of 4 microg/L for perchlorate requires 99.9% perchlorate removal. Sufficient ethanol, the electron donor, is added to remove oxygen and nitrate as well as perchlorate, as all three serve as electron acceptors, but with biological preference for oxygen and nitrate. A numerical BFBR model based upon basic physical, chemical, and biological processes including reaction stoichiometry, biofilm kinetics, and sequential electron acceptor usage was developed and evaluated with the full-scale treatment results. A key fitting parameter was bacterial detachment rate, which impacts reaction stoichiometry. For best model fit this was found to vary between 0.062 and 0.31 d(-1), with an average of 0.22 d(-1). The model indicates that GAC particle size, reactor diameter, and perchlorate concentration affect BFBR performance. While empty-bed detention time might be decreased somewhat below 10 min by an increase in either GAC particle size or reactor diameter, the current design provides a good factor of safety in operation. With a 10 min detention time, the effluent goal of 4 microg/L should be achievable even with influent perchlorate concentration as high as 10 mg/L.