The Role of the Multiparametric MRI LiverMultiScanTM in the Quantitative Assessment of the Liver and Its Predicted Clinical Applications in Patients Undergoing Major Hepatic Resection for Colorectal Liver Metastasis.

Liver biopsy remains the gold standard for the histological assessment of the liver. With clear disadvantages and the rise in the incidences of liver disease, the role of neoadjuvant chemotherapy in colorectal liver metastasis (CRLM) and an explosion of surgical management options available, non-invasive serological and imaging markers of liver histopathology have never been more pertinent in order to assess liver health and stratify patients considered for surgical intervention. Liver MRI is a leading modality in the assessment of hepatic malignancy. Recent technological advancements in multiparametric MRI software such as the LiverMultiScanTM offers an attractive non-invasive assay of anatomy and histopathology in the pre-operative setting, especially in the context of CRLM. This narrative review examines the evidence for the LiverMultiScanTM in the assessment of hepatic fibrosis, steatosis/steatohepatitis, and potential applications for chemotherapy-associated hepatic changes. We postulate its future role and the hurdles it must surpass in order to be implemented in the pre-operative management of patients undergoing hepatic resection for colorectal liver metastasis. Such a role likely extends to other hepatic malignancies planned for resection.

COVID-19 and doctor emigration: the case of Ireland.

BACKGROUND: Since the 2008 recession, Ireland has experienced large-scale doctor emigration. This paper seeks to ascertain whether (and how) the COVID-19 pandemic might disrupt or reinforce existing patterns of doctor emigration. METHOD: This paper draws on qualitative interviews with 31 hospital doctors in Ireland, undertaken in June-July 2020. As the researchers were subject to a government mandated work-from-home order at that time, they utilised Twitter™ to contact potential respondents (snowball sampling); and conducted interviews via Zoom™ or telephone. FINDINGS: Two cohorts of doctors were identified; COVID Returners (N = 12) and COVID Would-be Emigrants (N = 19). COVID Returners are Irish-trained emigrant doctors who returned to Ireland in March 2020, just as global travel ground to a halt. They returned to be closer to home and in response to a pandemic-related recruitment call issued by the Irish government. COVID Would-be Emigrants are hospital doctors considering emigration. Some had experienced pandemic-related disruptions to their emigration plans as a result of travel restrictions and border closures. However, most of the drivers of emigration mentioned by respondents related to underlying problems in the Irish health system rather than to the pandemic, i.e. a culture of medical emigration, poor working conditions and the limited availability of posts in the Irish health system. DISCUSSION/CONCLUSION: This paper illustrates how the pandemic intensified and reinforced, rather than radically altered, the dynamics of doctor emigration from Ireland. Ireland must begin to prioritise doctor retention and return by developing a coherent policy response to the underlying drivers of doctor emigration.

Tracking the leavers: towards a better understanding of doctor migration from Ireland to Australia 2008-2018.

BACKGROUND: The recession of 2008 triggered large-scale emigration from Ireland. Australia emerged as a popular destination for Irish emigrants and for Irish-trained doctors. This paper illustrates the impact that such an external shock can have on the medical workforce and demonstrates how cross-national data sharing can assist the source country to better understand doctor emigration trends. METHOD: This study draws on Australian immigration, registration and census data to highlight doctor migration flows from Ireland to Australia, 2008-2018. FINDINGS: General population migration from Ireland to Australia increased following the 2008 recession, peaked between 2011 and 2013 before returning to pre-2008 levels by 2014, in line with the general economic recovery in Ireland. Doctor emigration from Ireland to Australia did not follow the same pattern, but rather increased in 2008 and increased year on year since 2014. In 2018, 326 Irish doctors obtained working visas for Australia. That doctor migration is out of sync with general economic conditions in Ireland and with wider migration patterns indicates that it is influenced by factors other than evolving economic conditions in Ireland, perhaps factors relating to the health system. DISCUSSION: Doctor emigration from Ireland to Australia has not decreased in line with improved economic conditions in Ireland, indicating that other factors are driving and sustaining doctor emigration. This paper considers some of these factors. Largescale doctor emigration has significant implications for the Irish health system; representing a brain drain of talent, generating a need for replacement migration and a high dependence on internationally trained doctors. This paper illustrates how source countries, such as Ireland, can use destination country data to inform an evidence-based policy response to doctor emigration.

Foreign-born aged care workers in Australia: A growing trend.

AIM: To address Australian aged care workforce challenges, a deeper understanding of the current care workforce is needed especially given estimated increases in demand. We provide a national picture of the aged care workforce in Australia focusing on country of birth. METHODS: Data from the 2006 and 2011 Australian censuses. RESULTS: The majority of care workers are Australia-born followed by those born in the United Kingdom, South-East Asia and South Asia. While the number of carers from all regions has grown, the increase from 2006 to 2011 has been highest for carers from South Asia (333% increase) and sub-Saharan Africa (145%). The state with the largest decrease in the proportion of Australian-born care workers is Western Australia where Australian-born workers dropped from 62% in 2006 to 49% in 2011. CONCLUSIONS: Understanding the migration patterns of the aged care workforce in Australia is critical to health workforce planning given increasing demand.

Risk Assessment and Comparative Effectiveness of Left Ventricular Assist Device and Medical Management in Ambulatory Heart Failure Patients: Results From the ROADMAP Study.

BACKGROUND: Data for left ventricular assist devices (LVADs) in patients with noninotrope-dependent heart failure (HF) are limited. OBJECTIVES: The goal of this study was to evaluate HeartMate II (HMII) LVAD support versus optimal medical management (OMM) in ambulatory New York Heart Association functional class IIIB/IV patients meeting indications for LVAD destination therapy but not dependent on intravenous inotropic support. METHODS: This was a prospective, multicenter (N = 41), observational study of 200 patients (97 LVAD, 103 OMM). Entry criteria included ≥1 hospitalization for HF in the last 12 months and 6-min walk distance (6MWD) <300 m. The primary composite endpoint was survival on original therapy with improvement in 6MWD ≥75 m at 12 months. RESULTS: LVAD patients were more severely ill, with more patients classified as Interagency Registry for Mechanically Assisted Circulatory Support profile 4 (65% LVAD vs. 34% OMM; p < 0.001) than 5 to 7. More LVAD patients met the primary endpoint (39% LVAD vs. 21% OMM; odds ratio: 2.4 [95% confidence interval: 1.2 to 4.8]; p = 0.012). On the basis of as-treated analysis, 12-month survival was greater for LVAD versus OMM (80 ± 4% vs. 63 ± 5%; p = 0.022) patients. Adverse events were higher in LVAD patients, at 1.89 events/patient-year (EPPY), primarily driven by bleeding (1.22 EPPY), than with OMM, at 0.83 EPPY, primarily driven by worsening HF (0.68 EPPY). Most patients (80% LVAD vs. 62% OMM; p < 0.001) required hospitalizations. Health-related quality of life (HRQol) and depression improved from baseline more significantly with LVADs than with OMM (Δ visual analog scale: 29 ± 25 vs. 10 ± 22 [p < 0.001]; Δ Patient Health Questionnaire-9: -5 ± 7 vs. -1 ± 5 [p < 0.001]). CONCLUSIONS: Survival with improved functional status was better with HMII LVAD compared with OMM. Despite experiencing more frequent adverse events, LVAD patients improved more in HRQol and depression. The results support HMII use in functionally limited, noninotrope-dependent HF patients with poor HRQoL. (Risk Assessment and Comparative Effectiveness of Left Ventricular Assist Device [LVAD] and Medical Management [ROADMAP]; NCT01452802).

Risk assessment and comparative effectiveness of left ventricular assist device and medical management in ambulatory heart failure patients: design and rationale of the ROADMAP clinical trial.

BACKGROUND: Mechanical circulatory support is now a proven therapy for the treatment of patients with advanced heart failure and cardiogenic shock. The role for this therapy in patients with less severe heart failure is unknown. OBJECTIVE: The objective of this study is to examine the impact of mechanically assisted circulation using the HeartMate II left ventricular assist device in patients who meet current US Food and Drug Administration-defined criteria for treatment but are not yet receiving intravenous inotropic therapy. METHODS: This is a prospective, nonrandomized clinical trial of 200 patients treated with either optimal medical management or a mechanical circulatory support device. CLINICAL CONTEXT: This trial will be the first prospective clinical evaluation comparing outcomes of patients with advanced ambulatory heart failure treated with either ongoing medical therapy or a left ventricular assist device. It is anticipated to provide novel insights regarding relative outcomes with each treatment and an understanding of patient and provider acceptance of the ventricular assist device therapy. This trial will also provide information regarding the risk of events in "stable" patients with advanced heart failure and guidance for the optimal timing of left ventricular assist device therapy.

The two cultures of health worker migration: a Pacific perspective.

Migration of health workers from relatively poor countries has been sustained for more than half a century. The rationale for migration has been linked to numerous factors relating to the economies and health systems of source and destination countries. The contemporary migration of health workers is also embedded in a longstanding and intensifying culture of migration, centred on the livelihoods of extended households, and a medical culture that is oriented to superior technology and advanced skills. This dual culture is particularly evident in small island states in the Pacific, but is apparent in other significant migrant source countries in the Caribbean, Sub-Saharan Africa and Asia. Family expectations of the benefits of migration indicate that regulating the migration and attrition of health workers necessitates more complex policies beyond those evident within health care systems alone.

Assessment of the accuracy and reproducibility of adrenal volume measurements using MRI and its relationship with corticosteroid phenotype: a normal volunteer pilot study.

OBJECTIVE: The significant role of corticosteroids in hypertension and cardiovascular disease highlights the importance of the adrenal gland in these disorders. The ability to correlate corticosteroid production with adrenal volume offers a novel research tool and intermediate phenotype in cardiovascular disease. The aim of this study was to develop and validate the use of magnetic resonance imaging (MRI) in adrenal volume assessment and investigate whether this associates with corticosteroid production. DESIGN/METHODS: Twenty normotensive men underwent noncontrast 1·5T MRI scanning of adrenals, measurement of blood pressure and plasma corticosteroids. Left adrenal volume was calculated twice using standard segmentation software by four independent observers with differing levels of clinical expertise and segmentation experience. To optimize this process, adrenal 'phantoms' with known fixed volumes underwent MRI scanning and analysis by two observers. RESULTS: Intra-observer coefficients of repeatability (CoRs) in phantoms ranged from 0·23 to 0·43 ml (interobserver CoR 0·48 ml). In the subject group, mean adrenal volumes were 3·99-5·82 ml with intra-observer CoRs 0·27-1·94 ml. Interobserver variability was 2·73 ml. Segmentation expertise was the main factor affecting variability, with experienced observers having the lowest CoRs; clinical knowledge was a factor when combined with segmentation experience. Mean adrenal volume correlated with plasma glucocorticoids (r = 0·523, P < 0·05) and aldosterone (r = 0·515, P < 0·05) for the most experienced observer only. CONCLUSIONS: Measurement of adrenal volume using MRI is challenging; most accurate volumes are achieved using a single observer with both segmentation experience and anatomical knowledge. The data also provide novel preliminary evidence that adrenal gland volume may be associated with plasma corticosteroid concentrations supporting further study of adrenal volume and steroid production across a range of blood pressures.

Enhanced dosimetry procedures and assessment for EBT2 radiochromic film.

PURPOSE: Quantitatively determine an optimum image analysis procedure to mitigate inhomogeneities within the EBT2 film and from scanning for accurate absolute dose measurement deposited by an external radiation therapy beam. Multichannel dosimetry procedures were conceived, described, and quantitatively tested against single and dual channel dosimetry. METHODS: A solid water(TM) block was placed on CT imaging and treatment tables in a configuration that avoids bulky compressive devices. CT markers helped register the CT to the treatment plan and the radiation dose distribution from the radiochromic film. The CT images were digitally rotated and resampled to match the spatial resolution of the scanned dosimetric distribution and treatment plan. The ECLIPSE treatment plan planes were digitally translated through digital triangulation of the treatment isocenter to the CT markers in the CT image. A 6 MV photon beam, conforming to the treatment plan, irradiated the EBT2 film sandwiched between solid water(TM) slabs. The exposed radiochromic film images were rotated and translated to the CT images using coincident markers in the CT image that are associated with "tattoos" marked on the radiochromic film. The exposed radiochromic film gray-levels from a flatbed scanner in reflection mode were converted to dose using calibration films. The test dose distribution was scanned and averaged six times to reduce temporal noise. This study generated dose distributions using the red channel alone, green channel alone, ratio of the red to blue channel, ratio of the green to blue channel, a hybrid approach combining the green to blue ratio for higher doses (>80 cGy) with the red to blue ratio (<80 cGy), multichannel averaging and optimized autonomous multichannel correction. Single channel, multichannel, and channel ratio methods for processing the exposed radiochromic film were compared to the treatment plan via gamma analysis. The ellipsoidal decision surface was defined by its axes of 3% of the maximum dose and 3 mm in the horizontal and vertical directions. RESULTS: The multichannel dosimetry procedures provided excellent agreement with calculation of the dose distribution as determined by the gamma analysis. The green channel mostly performed as well or better than the red channel. The green to blue channel ratio for doses when combined with red to blue ratio ("Hybrid") achieved a high level performance. In addition, new registration procedures were developed and tested for aiding the comparison of calculated and experimentally determined dose distributions. CONCLUSIONS: This study described, developed, and tested new processing methods for reducing inaccuracies in absolute dose determination due to inhomogeneities within the film and from scanning. This study found better performance using optimized multichannel following averaging of all color channels. Combining the channel ratios in a hybrid approach also achieved high performance. Averaging the test films reduced temporal noise that severely degraded the blue channel. This methodology avoided using cumbersome, registered correction matrices. Novel registration and digital rotation of CT images enabled quantitative testing and helped improve contact between the radiochromic film and phantom.

A new inequality? Privatisation, urban bias, migration and medical tourism.

Access to health care in developing countries, the main destinations of medical tourists, is notoriously uneven, and often becoming more so. Medical tourism, urban bias and privatisation have combined to exacerbate this trend. This is exemplified in both Thailand and India, where regional areas have been disadvantaged by the migration of health-care workers to hospitals focusing on medical tourism, neo-liberal national financial provision for medical tourism (and related tourism campaigns) and evidence of trickle-down gains is lacking. Medical tourism challenges rather than complements local health care providers, distorts national health care systems, and raises critical national economic, ethical and social questions.

A hybrid integrated services digital network-internet protocol solution for resident education.

OBJECTIVE: The purpose of this study was to explore the effectiveness of incorporating Web-based application sharing of virtual medical simulation software within a multipoint video teleconference (VTC) as a training tool in graduate medical education. MATERIALS AND METHODS: National Capital Consortium Radiation Oncology Residency Program resident and attending physicians participated in dosimetry teaching sessions held via VTC using Acrobat Connect application sharing. Residents at remote locations could take turns designing radiation treatments using standard three-dimensional planning software, whereas instructors gave immediate feedback and demonstrated proper techniques. Immediately after each dosimetry lesson, residents were asked to complete a survey that evaluated the effectiveness of the session. At the end of a 3-month trial of using Adobe Connect, residents completed a final survey that compared this teaching technology to the prior VTC-alone method. RESULTS: The mean difference from equality across all quality measures from the weekly survey was 0.8, where 0 indicated neither enhanced nor detracted from the learning experience and 1 indicated a minor enhancement in the learning experience. The mean difference from equality across all measures from the final survey comparing use of application sharing with VTC to VTC alone was 1.5, where 1 indicated slightly better and 2 indicated a somewhat better experience. CONCLUSIONS: The teaching efficacy of multipoint VTC is perceived by medical residents to be more effective when complemented by application-sharing software such as Adobe Acrobat Connect.

Development of a remote proton radiation therapy solution over internet2.

Through our existing partnership, our research program has leveraged the benefits of proton radiation therapy through the development a robust telemedicine solution for remote proton therapy planning. Our proof-of-concept system provides a cost-effective and functional videoconferencing desktop platform for both ad-hoc and scheduled communication, as well as a robust interface for data collaboration (application-sharing of a commercial radiation treatment planning package). Over a 2-year period, our evaluation of this model has highlighted the inherent benefits of this affordable remote treatment planning solution, i.e., (1) giving physicians the ability to remotely participate in refining and generating proton therapy plans via a secure and robust Internet2 VPN tunnel to the University of Pennsylvania's commercial proton treatment planning package; (2) allowing cancer-care providers sending patients to a proton treatment facility to participate in treatment planning decisions by enabling referring or accepting providers to initiate ad-hoc, point-to-point communication with their counterparts to clarify and resolve issues arising before or during patient treatment; and thus (3) allowing stewards of an otherwise highly centralized resource the ability to encourage wider participation with and referrals to sparsely located proton treatment centers by adapting telemedicine techniques that allow sharing of proton therapy planning services. We believe that our elegant and very affordable approach to remote proton treatment planning opens the door to greater worldwide referrals to the scarce resource of proton treatment units and wide-ranging scientific collaboration, both nationally and internationally.

Anatomic fit assessment for the Penn State pediatric ventricular assist device.

This investigation determined the ages and weights of children that could be supported with 12 and 25 ml Penn State pediatric ventricular assist devices (PVADs) using 6, 8, and 10 mm outlet cannulas and grafts. Future patients will be matched to devices based on cardiac output (CO) and ascending aortic diameter (AA). These were calculated for children 0-10 years with regression formulas given as clinical standards [<5 kg, CO = 0.2171(kg) + 0.0703], [>5 kg, CO = 3.06 (m2) + 0.37], [AA = -0.0427 + 14.54 (m2)1/2]. The 12 ml PVAD will be useful for patients from approximately birth to 3-8 months, weighing 2-7 kg, and having 0.5-1.4 L/min CO; the 25 ml PVAD will be for children 2-6 months to 5-9 years old, weighing 6-23 kg, and having 1.3-3.0 L/min of CO. The 6 mm outlet graft will fit children from 0 to 12 months, weighing 2-8 kg; the 8 mm graft from 0 to 47 months, weighing 4-14 kg; and the 10 mm graft for children 4 months to 8 years, weighing 8-21 kg.

Treatment charges and resource use among patients with heart failure enrolled in an MCO.

The purpose of this study was to determine patient-level annual expenditures and resource use for heart failure (HF) and change in annual expenditure after a hospital admission for HF. The study population comprised members of an IPA-model MCO (N = 899) who were 40 to 74 years old and continuously enrolled for at least six months before and after an index hospital admission with a primary diagnosis of HF. A retrospective analysis was conducted of administrative claims data between 1996 and 1998. Analysis was stratified by five-year age groups and by quintiles created by rank-ordering individuals according to their pre-index annualized expenditure and then dividing the cohort into five equal groups. During the year before the index HF event, median annualized charges were $6,026 (mean +/- SD, $17,490 +/- $32,234), and median postevent charges were $14,292 (mean, $35,780 +/- $60,881), a 98% increase in median (105% increase in mean). Age was unrelated to average annual expenditure or to increase in expenditure after the index event. One-year readmission rates ranged from 30% (95% confidence interval [CI], 35%-51%), for patients in the least costly quintile, to 63% for the most costly quintile (95% CI, 55%-71%). Although HF prevalence increases with age, patient-level treatment expenditures are comparable across age groups. Hospital admission for HF is associated with a substantial increase in treatment intensity and annual expenditure.