Development of a Competency-Based Radiology Clerkship Using Categorical and Statistical Analysis of Assessment.

PURPOSE: The purpose was to create and analyze a competency-based model of educating medical students in a radiology clerkship that can be used to guide curricular reform. METHODS: During the 2019 to 2020 academic year, 326 fourth-year medical students were enrolled in a 2-week required clerkship. An online testing platform, ExamSoft (Dallas, Texas), was used to test pre- and postinstruction knowledge on "must see" diagnoses, as outlined in the National Medical Student Curriculum in Radiology. Assessment analysis was used to compare the frequency with which the correct diagnosis was identified on the pretest to that on the posttest. At the end of the academic year, in addition to statistical analysis, categorical analysis was used to classify the degree of this change to uncover topics that students found most challenging. RESULTS: For 23 of the 27 topics (85%), there was a significant improvement in diagnostic accuracy after instruction in the test curriculum. Categorical analysis further demonstrated that the clerkship had a high impact in teaching 13 of the 27 topics (48%), had a lower impact for 6 topics (22%), and identified the remaining 8 topics (30%) as gaps in teaching and learning. CONCLUSIONS: For medical students, our instructional program significantly increased competency for most critical radiologic diagnoses. Categorical analysis adds value beyond statistical analysis and allows dynamic tailoring of teaching to address gaps in student learning.

Assertive outreach treatment versus care as usual for the treatment of high-need, high-cost alcohol related frequent attenders: study protocol for a randomised controlled trial.

BACKGROUND: Alcohol-related hospital admissions have doubled in the last ten years to > 1.2 m per year in England. High-need, high-cost (HNHC) alcohol-related frequent attenders (ARFA) are a relatively small subgroup of patients, having multiple admissions or attendances from alcohol during a short time period. This trial aims to test the effectiveness of an assertive outreach treatment (AOT) approach in improving clinical outcomes for ARFA, and reducing resource use in the acute setting. METHODS: One hundred and sixty ARFA patients will be recruited and following baseline assessment, randomly assigned to AOT plus care as usual (CAU) or CAU alone in equal numbers. Baseline assessment includes alcohol consumption and related problems, physical and mental health comorbidity and health and social care service use in the previous 6 months using standard validated tools, plus a measure of resource use. Follow-up assessments at 6 and 12 months after randomization includes the same tools as baseline plus standard measure of patient satisfaction. Outcomes for CAU + AOT and CAU at 6 and 12 months will be compared, controlling for pre-specified baseline measures. Primary outcome will be percentage of days abstinent at 12 months. Secondary outcomes include emergency department (ED) attendance, number and length of hospital admissions, alcohol consumption, alcohol-related problems, other health service use, mental and physical comorbidity 6 and 12 months post intervention. Health economic analysis will estimate the economic impact of AOT from health, social care and societal perspectives and explore cost-effectiveness in terms of quality adjusted life years and alcohol consumption at 12-month follow-up. DISCUSSION: AOT models piloted with alcohol dependent patients have demonstrated significant reductions in alcohol consumption and use of unplanned National Health Service (NHS) care, with increased engagement with alcohol treatment services, compared with patients receiving CAU. While AOT interventions are costlier per case than current standard care in the UK, the rationale for targeting HNHC ARFAs is because of their disproportionate contribution to overall alcohol burden on the NHS. No previous studies have evaluated the clinical and cost-effectiveness of AOT for HNHC ARFAs: this randomized controlled trial (RCT) targeting ARFAs across five South London NHS Trusts is the first. TRIAL REGISTRATION: International standard randomized controlled trial number (ISRCTN) registry: ISRCTN67000214, retrospectively registered 26/11/2016.

A Survey of GPs Awareness and Use of Risk Assessment Tools and Cardiovascular Disease Prevention Guidelines.

Cardiovascular disease (CVD) is the leading cause of death worldwide. This study aimed to benchmark awareness and use of CVD risk assessment (RA) tools and prevention guidelines in Irish general practice. 493 (18%) Irish general practitioners (GPs) were invited to participate in a cross-sectional study in 2011. 213 (43%) GPs responded with most being male (n = 128, 58.2%) and aged ≥ 45 years (n = 124, 56.8%). While 197 (92.5%) GPs were aware of at least one RA tool, only 69 (32.4%) GPs reported frequent use. 187 (87.8%) GPs were aware of one or more CVD prevention guidelines with 115 (54.0%) GPs reporting frequent use of at least one guideline. No age or gender difference observed. Barriers to implementation of CVD prevention guidelines were lack of remuneration, too many CVD guidelines and time constraints. Most Irish GPs were aware of RA tools and CVD prevention guidelines with half reporting frequent use of guidelines.

Comparing the decline in coronary heart disease and stroke mortality in neighbouring countries with different healthcare systems.

OBJECTIVE: To examine age and gender specific trends in coronary heart disease (CHD) and stroke mortality in two neighbouring countries, the Republic of Ireland (ROI) and Northern Ireland (NI). DESIGN: Epidemiological study of time trends in CHD and stroke mortality. SETTING/PATIENTS: The populations of the ROI and NI, 1985-2010. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Directly age standardised CHD and stroke mortality rates were calculated and analysed using joinpoint regression to identify years where the slope of the linear trend changed significantly. This was performed separately for specific age groups (25-54, 55-64, 65-74 and 75-84 years) and by gender. Annual percentage change (APC) and 95% CIs are presented. RESULTS: There was a striking similarity between the two countries, with percentage change between 1985 and 1989 and between 2006 and 2010 of 67% and 69% in CHD mortality, and 64% and 62% in stroke mortality for the ROI and NI, respectively. However, joinpoint analysis identified differences in the pace of change between the two countries. There was an accelerated pace of decline (negative APC) in mortality for both CHD and stroke in both countries from the mid-1990s (APC ROI -8% (95% CI -9.5 to 6.5) and NI -6.6% (-6.9 to -6.3)), but the accelerated decrease started later for CHD mortality in the ROI. In recent years, a levelling off in CHD mortality was observed in the 25-54 year age group in NI and in stroke mortality for men and women in the ROI. CONCLUSIONS: While differences in the pace of change in mortality were observed at different time points, similar, substantial decreases in CHD and stroke mortality were achieved between 1985 and 1989 and between 2006 and 2010 in the ROI and NI despite important differences in health service structures. There is evidence of a levelling in mortality rates in some groups in recent years.

Assessment of chronic pancreatitis: utility of diffusion-weighted MR imaging with secretin enhancement.

PURPOSE: To retrospectively measure and compare changes in pancreatic apparent diffusion coefficient (ADC) following secretin administration in patients with and those without chronic pancreatitis (CP) who underwent magnetic resonance (MR) cholangiopancreatography with diffusion-weighted (DW) imaging. MATERIALS AND METHODS: This retrospective HIPAA-compliant study was approved by the authors' institutional review board, with waiver of informed consent. Eighty-nine patients were categorized by the referring gastroenterologist as having no CP (n = 37), mild CP (n = 33), or severe CP (n = 19) on the basis of Cambridge criteria and/or clinical course. Mean age was 52.2 years (range, 21-82 years) in women and 54.3 years (range, 32-81 years) in men. Patients underwent 1.5-T MR cholangiopancreatography, including DW sequences (b = 0, 100, and 400 sec/mm(2)) performed serially for 10 minutes after secretin injection. Severity level of CP was analyzed for sex (Fisher exact test) and age (analysis of variance) differences. Pairwise comparisons of mean ADCs for each parameter (no CP vs mild CP, no CP vs severe CP, mild CP vs severe CP) were performed (Mann-Whitney test). Threshold values of non-secretin-enhanced ADC for pancreatitis discrimination were calculated with receiver operating characteristic analysis. P < .05 was considered to show a significant difference. RESULTS: Patients with severe CP were more likely to be men than were those without pancreatitis; there were no significant age differences between groups. Mean nonenhanced and maximum secretin-enhanced ADCs were higher in patients without CP than in those with mild or severe CP but did not vary between those with mild and severe CP. Percentage increase in ADC after secretin injection and time to peak ADC did not vary among groups. An ADC of less than 179 x 10(-5) mm(2)/sec was optimal for delineating normal pancreas from CP groups. CONCLUSION: In symptomatic patients, baseline pancreatic ADC obtained with DW imaging prior to secretin administration may aid in diagnosis of CP and assessment of its severity; ADC response to secretin administration may be less useful.

Planning for PACS: a comprehensive guide to nontechnical considerations.

A complete picture archiving and communication system (PACS) installation is one of the largest projects a radiology department will undertake. Although technology issues are important, they often draw focus away from many other significant issues This paper describes in detail all of these other necessary components that need to be addressed if a PACS installation is to be relatively trouble free, provides guidelines for successful PACS implementation, and details pitfalls to be avoided.

Lung tumor growth: assessment with CT--comparison of diameter and cross-sectional area with volume measurements.

PURPOSE: To compare diameter and cross-sectional area measurements with volume measurements in the assessment of lung tumor growth with serial computed tomography (CT). MATERIALS AND METHODS: Patients with lung cancer who underwent at least one pair of chest CT examinations 25 or more days apart before treatment and with a tumor size of T1 (< or =3-cm diameter) at the initial CT examination were identified. A total of 63 patients (62 men, one woman) who underwent 93 pairs of CT examinations were included. Images obtained at each examination were displayed, and the maximum diameter, cross-sectional area, and volume of the tumor were measured. For each measurement, the change between examinations was assessed to determine whether the change reached a detection threshold for growth, as determined in a prior study with simulated tumors. Results were then compared between measurement methods, with volume change serving as the reference standard, by calculating Spearman rank-order coefficients between examinations. Tumor size or section width were also evaluated with the two-tailed Fisher exact probability test to determine if they affected agreement about tumor growth between measurement methods. RESULTS: Thresholds were as follows: diameter, 2.1 mm with hand-held calipers and 0.68 mm with electronic calipers; area, 9.4%; volume, 16.5%. The median time between examinations was 92 days (range, 25-1,221 days). Median diameter increased from 19.3 mm to 23.0 mm (19.2%), median area from 207 mm(2) to 267 mm(2) (29.0%), and median volume from 1,652 mm(3) to 2,443 mm(3) (47.9%). Growth assessment with these diameter (as assessed with hand-held and electronic calipers) and area thresholds disagreed with those obtained with volume in 34 (37%), 26 (28%), and 25 (27%) of the 93 pairs of CT examinations, respectively. Of diameter assessments with the hand-held caliper threshold, 28 (30%) were false-negative; false-negative results occurred with this diameter threshold and area threshold with examination intervals as long as 1 year. CONCLUSION: Growth assessment of T1 lung tumors on serial CT scans with nonvolumetric measurements frequently disagrees with growth assessment with volumetric measurements.

Capacity and equity in cardiac rehabilitation in the eastern region: good and bad news.

AIM: To document current baseline eligibility for Phase 3 cardiac rehabilitation (CR) and the capacity to meet this need in hospitals in the Eastern Regional Health Authority. METHODS: Information on the eligible population and the capacity for CR was collected in all nine hospitals retrospectively (February-March 2001). RESULTS: Forty-seven per cent of eligible patients were invited to participate with only two-thirds attending. Completion rates were very high (89%) in attenders. Age and health board area were significant independent predictors of being invited to CR. Gender was not independent of age. Fifty-three per cent of the need for this service was met by capacity in the region's nine hospitals in 2000 rising to 59% in 2002. CONCLUSIONS: Many eligible patients are not invited to CR. Lack of capacity is a problem. Among the invited, non-participation is a factor. Inequity in age and inter-hospital variation in invitation is noted.

Agreement and reproducibility of subjective methods of measuring faculty time distribution.

RATIONALE AND OBJECTIVES: The authors performed this study to compare self-reported estimates of the time radiology members spend performing various activities between reporting methods and academic years. MATERIALS AND METHODS: For 3 consecutive academic years, the percentage of time each faculty member reported spending on clinical, teaching, research, and service and/or administrative activities was noted on each of three separate reports: a quarterly report to department administration, an annual report to university administration, and the annual review with his or her department supervisor. For each activity, the means were compared between methods and between years. RESULTS: In general, the year-to-year changes in mean percentage for each activity and method were not statistically significant (34 of 36 comparisons). Nineteen of 36 comparisons, however, showed significant differences between reporting methods for a particular activity. For example, the mean percentages obtained with the three methods from 1999 to 2000 varied from 49% to 66% (clinical), 14% to 34% (teaching), 8% to 15% (research), and 3% to 11% (service and/or administrative). CONCLUSION: Current methods used to quantify faculty time distribution yield significantly different results despite internal consistency from year to year for each method. New and clearer methods for determining faculty time distribution are needed.

Pulmonary embolism in pregnant patients: fetal radiation dose with helical CT.

PURPOSE: To calculate mean fetal radiation dose from helical chest computed tomography (CT) by using maternal-fetal geometries obtained from healthy pregnant women and to compare the calculated CT doses with the fetal doses reported with scintigraphy. MATERIALS AND METHODS: Maternal-fetal geometries were determined in 23 pregnant women with varying body mass index and fetal gestational age. Monte Carlo techniques were used to estimate the dose that would be received by each fetus from CT scanning performed with the following parameters: 120 kVp; 100 mA; scanning time, 1 second per section; collimation, 2.5 mm; pitch of 1. Craniocaudal extent of the scan was 11 cm, with the most caudal section edge being 5 mm inferior to the xiphoid process. RESULTS: For helical CT, estimated mean fetal doses in micrograys at varying gestational ages were as follows: 3.3-20.2 microGy, first trimester; 7.9-76.7 microGy, second trimester; and 51.3-130.8 microGy, third trimester. These values were all less than mean fetal doses reported with scintigraphy, with 37-74 MBq of macroaggregates of human serum albumin labeled with technetium 99m. If 200 mAs (pitch of 1.8) was used, the mean fetal doses were still less than those with scintigraphy. CONCLUSION: The average fetal radiation dose with helical CT is less than that with ventilation-perfusion lung scanning during all trimesters.

Application of risk assessment and decision analysis to the evaluation, ranking and selection of environmental remediation alternatives.

A single framework integrating risk assessment and decision analysis methods for evaluating, ranking and selecting preferred remediation alternatives at a contaminated site was developed and demonstrated. The methodology used relies on stakeholder inputs throughout the entire process and employs those inputs to combine the results of multiple risk assessments to arrive at a total impact for each remediation alternative. The total impact values allow the ranking of the alternatives, which in turn, serves as the basis for deliberations among the stakeholders in order to identify the preferred alternative. Six major risk or impact categories were considered in the evaluation of the alternatives: human health and safety, environmental protection, life cycle cost, socio-economics, cultural, archeological and historical resources, and programmatic assumptions.

The impact of blood cultures on antibiotic therapy in pneumococcal pneumonia.

INTRODUCTION: The cost-effectiveness of blood cultures in community-acquired pneumonia (CAP) has been questioned. Although penicillin-resistant Streptococcus pneumoniae is an increasing problem, penicillin therapy, where appropriate, reduces cost and may reduce antibiotic resistance. Blood cultures, however, can only reduce cost if physicians are prepared to alter therapy based on the results. We reviewed our experience to determine how often physicians changed management based on blood culture results positive for S pneumoniae. METHODS: Retrospective chart review was performed of all CAP admissions between January 1996 and December 1998 with blood culture results positive for S pneumoniae. RESULTS: Seventy-four patients out of 1,805 patients admitted with CAP during this period had pneumococcemia. Penicillin resistance was identified in 15 cases (20.3%; high grade in 4 cases) with cephalosporin resistance in 4 of these cases (1 high grade). Fifty-one patients had initial empiric therapy with a third-generation cephalosporin, and 58 patients had empiric coverage of atypical organisms; no patient received empiric penicillin therapy. Blood culture results altered management in 31 patients (41.9%), but in only 2 cases was this due to antibiotic resistance. Fifty-one patients without penicillin allergy grew penicillin-sensitive pneumococci; only 11 patients (21.6%) were changed to penicillin therapy. Thirteen of 35 patients (37.1%) who were given an additional antibiotic for atypical coverage had this antibiotic ceased. CONCLUSION: Despite evidence of penicillin-sensitive pneumococcal CAP, physicians were reluctant to narrow antibiotic therapy, potentially adding to treatment cost and reducing the impact of blood culture results on management. The impact of penicillin resistance was reduced by the usual empiric choice of a third-generation cephalosporin. While positive blood culture results can clearly be useful in the management of patients with CAP, their cost-effectiveness needs to be assessed in prospective clinical trials.

Carers of the elderly--knowledge, use of and satisfaction with day care services.

This is a descriptive study of carers of dependent elderly in inner city Dublin, outlining their awareness, use of and satisfaction with day services. A striking finding from this work, consistent with other studies, is the heavy burden of care which is shouldered by informal carers which should be acknowledged by society. The study highlights a) that levels of use of domiciliary care by carers appear to be very low, b) that there is some evidence of targeting of domiciliary services to the more dependent elderly, c) that day centres and clubs are popular and acceptable to a minority of carers, d) that many carers have no informal help, e) where informal help is available, relatives of carers play a very important role in facilitating carers to accept formal domiciliary care. Recommendations include, a) improving the level and range of provision of domiciliary care, b) alerting professionals such as general practitioners and public health nurses to their role as informant and facilitator of formal care to carers, c) formulating a plan to encourage uptake of domiciliary services by carers, d) review of care provided in day centres.

Physiological cost index of paraplegic locomotion using the ORLAU ParaWalker.

Energy expenditure is an important parameter in the assessment of gait and orthotic treatment of locomotor disabilities. Up until now oxygen uptake measurement has been the most common method used to assess this. In able bodied subjects heart rate monitoring is also increasingly used. In high thoracic level lesion paraplegics monitoring heart rate was considered to be unreliable because of suspicion of injury to the sympathetic contribution to the cardiac plexus. Bar-On & Nene found that in paraplegics below the lesion level T3 heart rate still shows linear relation to oxygen uptake. MacGregor combined the heart rate and speed of locomotion to produce a single index called physiological cost index. This study consists of monitoring heart rate and speed of 16 adult thoracic level paraplegics walking with the ORLAU ParaWalker, calculation of their physiological cost index, and establishing a range of physiological cost index of paraplegic locomotion using the ORLAU ParaWalker.

Behavioural risk factors among young adults in small areas with high mortality versus those in low-mortality areas.

A community-based cross-sectional survey of behavioural risk factors for premature mortality was carried out on a group of 354 adults aged 25-44 from previously identified high-mortality 'black-spots' in Dublin who were compared with 333 others from low-mortality areas. In the black-spot areas, 50.9% of respondents were current smokers versus 28.5% in low-mortality areas and 14.6% took 'sufficient' exercise versus 31.4% in low-mortality areas. People living in black spots were also less likely to make 'healthy' dietary choices than those in low-mortality areas. There is a higher prevalence of behavioural risk factors for premature mortality among young adults living in electoral wards/district electoral divisions (DEDs) with high standardized mortality ratios (SMRs) from all causes than among those in areas with low SMRs. A health promotion programme aimed at increasing exercise levels, reducing smoking and encouraging healthy eating should be aimed at young adults in DEDs with high SMRs.

Trauma center imaging problems: proposed solution with picture archiving communication systems.

Radiologic support for trauma center activities presents special problems that are discussed. This article proposed the use of a picture archiving communication system (PACS) as a potential solution. A sample PACS for this purpose is described to illustrate this approach.

Health promotion versus health protection? Employees' perceptions and concerns.

The "second public health revolution" targets factors in the environment, together with lifestyle, to prevent illness and untimely death. Yet the growth of the "wellness movement" has driven a wedge between public health advocates who argue for environmental solutions and those whose major focus is individual behavior. This tension is nowhere more evident than in the workplace, where the new wellness professionals are at odds with specialists in occupational health and industrial hygiene. This paper reports findings from a cross-sectional survey of a sizeable sample of workers at six New England facilities of a very large American manufacturing firm, assessing their perceptions of risk in the two domains: environmental exposures and lifestyle risks. Multiple regression analyses reveal that both job risks and life risks are associated with a variety of potentially costly and disruptive health problems, even after controlling for demographic and occupational factors. This analysis suggests that wellness programs in the workplace will be more effective if they integrate environmental protection with efforts to reduce lifestyle risk.