A cadaveric study of arteriovenous trigone of heart: the triangle of Brocq and Mouchet.

Left coronary artery divides into anterior interventricular branch and circumflex branch. As both the arteries run in their corresponding grooves, an arteriovenous trigone is formed between conus arteriosus and left auricle called triangle of Brocq and Mouchet. The triangle base is formed by great cardiac vein. This study aims to describe the frequency of triangle and its type and relationship between various boundaries and content of triangle and to supplement the existing knowledge of clinicians. This observational and descriptive study was conducted on 40 formalin fixed cadaveric hearts in department of anatomy, Kalpana chawla government medical college. The triangle was found in 92.5% of specimen with most common type being closed (51.3%) which is followed by inferiorly open in 35.1%, superiorly open in 8.1% and completely open in 5.4% hearts. Most frequent content of triangle was median artery followed by diagonal branches of anterior interventricular and circumflex branches. The mean area of the triangle was 246.3 mm2. Relationship of vein with two arterial branches was either superficial or deep. The knowledge of different patterns of existence will be required for angiographic procedures. Further the triangle is a potential epicardial access route to left fibrous ring. Thus detailed knowledge of variations will help cardiologist to achieve better outcome in interventional procedures with minimal complications.

Cancer Rehabilitation Providers and Oncology Patient Expectations for Functional Outcomes after Inpatient Rehabilitation.

BACKGROUND: Cancer rehabilitation is a valued resource for patients and oncologists. Cancer rehabilitation providers are seeing increasing numbers of referrals for inpatient rehabilitation as the number of cancer survivors grows. However, cancer rehabilitation providers, oncologists, therapists, patients, and caregivers may not always clearly communicate the goals of care, which can lead to different expectations for inpatient rehabilitation. OBJECTIVE: To determine the difference in expectations of function after an acute inpatient rehabilitation stay between cancer patients and cancer rehabilitation providers and how they align with achieved goals after treatment. DESIGN: Prospective survey study. SETTING: Quaternary academic medical center inpatient rehabilitation unit. PARTICIPANTS: Out of 194 eligible patients, 132 were enrolled and completed admission surveys, and 110 completed the discharge survey. Twelve cancer rehabilitation providers completed the surveys. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Barthel Index. RESULTS: Patients estimated their expected functional status as a median (interquartile range) score of 19 points (18, 20) using the Barthel Index, compared to cancer rehabilitation providers, who estimated a median score of 17 points (15, 19) (P < .001). Actual functional status upon discharge was a median score of 16 points (13, 18) using the Barthel Index, which was three points lower than expected by patients (P < .001). CONCLUSIONS: Oncology patients and cancer rehabilitation providers significantly overestimate functional goals for acute inpatient rehabilitation. This overestimation was clinically significant for oncology patients and statistically but not clinically significant for cancer rehabilitation providers. Increased communication may allow for a more realistic expectation of functional status upon discharge.

Cancer Patients' Perception of Usefulness of Wearable Exercise Trackers.

OBJECTIVE: To determine the feasibility and perception of usefulness of wearable trackers in inpatient and outpatient cancer rehabilitation patients. DESIGN: Prospective study. SETTING: Acute inpatient rehabilitation and outpatient clinic at a tertiary cancer center. PARTICIPANTS: Adult cancer patients (N = 100). INTERVENTIONS: Participants were provided with wearable trackers for the duration of the study. MAIN OUTCOME MEASURES: Survey regarding feasibility (as defined as equal or more than two-thirds of participants reporting use of the wearable tracker) and usefulness of the wearable tracker and Edmonton Symptom Assessment Scale (ESAS-FS) in both inpatient and outpatient populations. Activity minutes, number of steps, heart rate, and sleep data were collected from the wearable tracker. RESULTS: Patients reported the use of a wearable tracker is feasible, with 48/50 (96%) outpatients and 47/50 (94%) inpatients reported wearing the wearable tracker daily and 37/49 (76%) outpatients and 29/50 (58%) inpatients reported that they would continue to wear the wearable tracker after this study. The majority of cancer patients (41/49 [84%] of outpatient and 33/50 [66%] of inpatient patients) reported that the wearable tracker was useful and 41/49 (84%) outpatients and 27/50 (54%) inpatients perceived the wearable tracker as helping to increase physical activity. CONCLUSIONS: The use of wearable trackers in cancer patients is feasible and patients perceive wearable trackers as useful in both the inpatient and outpatient rehabilitation setting. Physical activity in these patients was better in the outpatient population, as expected because of less medical acuity.

An Exploratory Study on Physical Function in Stem Cell Transplant Patients Undergoing Corticosteroid Treatment for Acute Graft-Versus-Host-Disease.

ABSTRACT: Acute graft-versus-host disease after allogeneic hematopoietic stem cell transplantation is treated with corticosteroids, placing patients at risk for steroid myopathy. In this single-arm cohort study, 23 patients who were started on high-dose corticosteroids for acute graft-versus-host disease underwent a series of functional tests (baseline and days 14, 28, and 56): 6-min walk test, hip flexor and knee extensor strength via dynamometry, five times sit-to-stand, Brooke scale for myopathy, modified Adult Myopathy Assessment Tool, and manual muscle testing. Participants were prescribed home exercises including walking and resistance exercises, with low adherence. Fifteen (63%) participants were male and median (range) age was 60 (36-70) yrs. Median (range) corticosteroid duration and cumulative equivalent methylprednisolone dose were 66 (22-165) days and 3625 (1020-11720) mg, respectively. At day 14, there was a significant decline in five times sit-to-stand (P = 0.0132), knee extensor (P = 0.0182), and manual muscle testing (P = 0.0466). Functional tests negatively associated with cumulative corticosteroid dose included 6-min walk test distance (P = 0.0103), hip flexor strength (P = 0.0262), knee extensor strength (P = 0.0369), and manual muscle testing strength (P = 0.0319). Five times sit-to-stand was positively associated with corticosteroid dose (P = 0.0003). In conclusion, stem cell transplant patients receiving high-dose corticosteroids for acute graft-versus-host disease are at risk for weakness detected as early as day 14. Increasing adherence to exercise may mitigate these changes.

Introducing psychology services to advanced cancer patients: A randomized double-blind trial.

CONTEXT: Psychology services utilization in cancer patients remains low due to barriers such as patient/caregiver acceptance of counseling. OBJECTIVE: We aimed to determine if the manner of introducing psychology services impacted patients' acceptance of services and to identify factors associated with acceptance and barriers to psychology utilization. METHODS: In this double-blind randomized cross-over trial, cancer patients with no prior psychology services observed two video vignettes: (a) physician introducing counselor and psychology services to the patient (PI) and (b) counselor introducing psychology services alone (CI). A counterbalanced design was used to control for order effects. After viewing both videos, patients completed a survey regarding preference, attitudes, and barriers for psychology services. Patients and investigators were blinded to the purpose of the study and content and order of videos, respectively. We hypothesized that patients would prefer physician introduction of counselor. RESULTS: One hundred patients participated: 40 (40%) expressed no difference, 34 (34%) preferred PI, and 26 (26%) preferred CI (P > .2). Younger patients (less than 40 years) either preferred PI (86%) or had no preference (14%, P = .01). Most reported awareness of available psychology services (N = 63), and half (N = 50) were offered psychology services by their physician. Only 40 (40%) and 43 (43%) patients felt psychology services would be helpful for them and their family/caregivers, respectively. Patients who perceived psychology as helpful for self or family had higher anxiety (P = .01 and P = .006, respectively). CONCLUSIONS: No significant difference was found in patient preference of introducing psychology services except in patients less than 40 years old who preferred PI.

Identifying Barriers to Building a Diverse Physician Workforce: A National Survey of the ACR Membership.

PURPOSE: The aim of this study was to identify potential barriers to building a diverse workforce in radiology and radiation oncology by conducting a national survey of physicians in these fields and studying their reported career experiences. METHODS: An electronic survey of ACR members (February 27, 2018, to April 26, 2018) was conducted in which physicians' attitudes about their work environment, relationships, and culture were queried. The aim was to determine if responses differed by gender or race/ethnicity. In total, 900 invitations were issued; women were oversampled with the goal of equal representation. Descriptive summaries (proportions of yes or no responses) were calculated per item, per subgroup of interest. Logistic regression analysis was used to identify significant associations between gender- and item-specific responses; it was not used in the race/ethnicity analysis because of the small sizes of many subgroups. RESULTS: The response rate was 51.2% (461 of 900). In total, 51.0% of respondents identified as women (235 of 461); the 9.5% (44 of 461) who identified as black or African American, Hispanic, or American Indian or Alaska Native were considered underrepresented minorities. Respondents' mean age was 40.2 ± 10.4 years. Subgroups varied most in their reporting of unfair or disrespectful treatment. Women were significantly more likely than men to report such treatment attributable to gender (50.6% versus 5.4%; odds ratio, 18.00; 95% confidence interval, 9.29-34.86; P < .001), and 27.9% of underrepresented minorities compared with 2.6% of white non-Hispanic respondents reported such treatment attributable to race/ethnicity. CONCLUSIONS: Women and underrepresented minorities disproportionately experience unfair or disrespectful treatment in the workplace. Addressing this problem is likely to be critically important for improving workforce diversity.

2018 ACR Commission on Human Resources Workforce Survey.

PURPOSE: The ACR Commission on Human Resources conducts an annual workforce survey to determine the makeup of the radiology workforce and to identify potential plans for hiring new staff in an attempt to better understand our profession. METHODS: The Practice of Radiology Environment Database group leaders were asked to complete an electronic survey regarding the makeup of their present workforce by subspecialty as well as the numbers and types of subspecialists hired in 2017 and the numbers and types of subspecialists expected to be hired in 2018 and 2019. They were also asked about midlevel practitioner employment. RESULTS: Twenty-three percent of practice leaders (367) represente 10,179 radiologists, 30% of all practicing radiologists in the United States, responded to the survey. The number of radiology groups represented in this survey decreased from 1,811 in the 2017 survey to 1,588 groups in the 2018 survey. The current makeup of radiology workforce remains similar to 2016 and 2017. The workforce distribution by practice type and radiologists' ages has been relatively stable since 2012. Practice leaders report they plan to hire between 1,393 to 1,808 radiologists in 2018 (similar to 2017 reported hires between 1,434 to 1,861) with the greatest number of hires to be in breast imaging, neuroradiology, and interventional radiology. The study represented 549 midlevel practitioners and 693 medical physicists. CONCLUSION: The 2018 ACR workforce survey continues to show a positive picture and outlook for those seeking jobs as practicing radiologists in 2018.

The 2017 ACR Commission on Human Resources Workforce Survey.

PURPOSE: The ACR Commission on Human Resources conducts an annual workforce survey to determine the makeup of the radiology workforce and to identify potential plans for hiring new staff in an attempt to understand our profession better. METHODS: The Practice of Radiology Environment Database group leaders were asked to complete an electronic survey regarding the makeup of their present workforce by subspecialty, as well as the numbers and types of subspecialists hired in 2016 and the numbers and types of subspecialists expected to be hired in 2017 and 2020. They were also asked about midlevel practitioners. RESULTS: Twenty-six percent of practice leaders (477) representing 11,056 radiologists, 33% of all practicing radiologists in the United States, responded to the survey. The workforce distribution by practice type and radiologists' ages has been relatively stable since 2012. Six percent of the practicing workforce is over the age of 65 years. Sixteen percent of radiologists work part-time, and 21.5% of radiologists are female. The survey results indicate that 1,569 to 2,037 radiologists were hired in 2016. In 2017, 1,826 to 2,370 new job opportunities are anticipated, a 14.1% increase compared with 2016. For 2017, the subspecialists most recruited will be neuroradiologists, general interventionalists, after-hours radiologists, and body imagers. Approximately 2,156 midlevel practitioners are presently working and supervised by radiologists. CONCLUSIONS: The 2017 ACR workforce study shows an optimistic picture and outlook for those seeking jobs as practicing radiologists in 2017. For practice leaders, the market will be much more competitive than it has been in past years.

Patient-Reported Usefulness of Acute Cancer Rehabilitation.

BACKGROUND: Cancer survivors often have unmet needs, and cancer rehabilitation is becoming an integral part of the continuum of care. Understanding the needs and satisfaction of patients undergoing cancer rehabilitation is important for the development of effective programs. OBJECTIVE: To determine the overall perception of acute inpatient cancer rehabilitation usefulness. DESIGN: Prospective study. SETTING: Acute inpatient cancer rehabilitation unit at a National Cancer Institute (NCI) Comprehensive Cancer Center. PARTICIPANTS: Patients admitted to the acute inpatient cancer rehabilitation unit from September 2014 to July 2015 were approached, and 200 patients enrolled with completed surveys. METHODS: Patients meeting study criteria were asked to complete a survey about their perception of the rehabilitation received; their attitudes and beliefs on their condition, treatment, functional independence; and their attitudes and beliefs on obtaining health information and psychosocial issues. MAIN OUTCOME MEASURES: Functional Independence Measure (FIM) scores, FIM efficiency, and results from an anonymous survey with a 22-item Likert-type scale at the end of patients' rehabilitation stay were analyzed. RESULTS: Of 327 patients admitted, 239 patients (73%) were approached, and 200 patients (84%) were enrolled with completed surveys. Patients agreed or strongly agreed that rehabilitation helped with improving physical function (n = 193, 97%), regaining physical independence (n = 181, 91%), and preparing to deal with self-care tasks (n = 183, 94%). Patients agreed that rehabilitation improved hope (n = 187, 94%), mood (n = 176, 84%), anxiety (n = 180, 90%), and spirituality (n = 182, 94%). FIM score improvements (from admission to discharge) and FIM efficiency (change in FIM score / length of stay) were significant in all functional domains. Overall, respondents believed that their rehabilitation stay was extremely good (n = 128, 64%) or very good (n = 60, 30%). CONCLUSIONS: Patients perceived their rehabilitation stay as beneficial in multiple respects. Significant improvements in FIM measurements were also found. LEVEL OF EVIDENCE: IV.

The 2016 ACR Commission on Human Resources Workforce Survey.

PURPOSE: The ACR Commission on Human Resources conducts an annual electronic survey to better understand the present workforce scenario for radiologists. METHODS: The Practice of Radiology Environment Database was used to identify group leads, who were asked to complete an electronic survey developed by the Commission on Human Resources. The survey asked group leads to report the number of radiologists they currently employ or supervise, the number hired in 2015, and the numbers they plan to hire in 2016 and 2019. Leaders were asked to report the subspecialty area used as the main reason for hiring each physician, as well the ages and genders of their current workforce. RESULTS: Thirty-two percent of group leaders, corresponding to 13,074 radiologists or 39% of all practicing radiologists, responded to this survey. The percentage of practicing radiologists who are male is 78.6%, compared with 21.4% who are female. Six percent of radiologists are older than 65 years, and 22% are between the ages of 56 and 65 years. Nineteen percent of radiologists older than 65 years retired in 2015. Fifteen percent of all radiologists work part-time. Among the part-time radiologists, 9% are male and 30% are female. General radiologists now make up only 13.3% of the radiologist workforce. In 2015, 45% of new hires moved from existing jobs; 55% were first-time hires. In 2016, it is projected that between 1,713 and 2,223 new jobs will be available, a 16.2% increase from hiring in 2015. CONCLUSIONS: Job opportunities for radiologists have continued to increase since 2013.

The 2015 ACR Commission on Human Resources Workforce Survey.

PURPOSE: The ACR Commission on Human Resources continues to conduct its annual electronic survey to better understand the present workforce scenario for radiologists. METHODS: The Practice of Radiology Environment Database was used to identify group leads, who were asked to complete an electronic survey developed by the Commission on Human Resources. The survey asked group leaders to report the number of radiologists they currently employ or supervise, the number hired in 2014, and the numbers they plan to hire in 2015 and 2018. The leaders were asked to report the subspecialty area used as the main reason for hiring each physician, as well as the ages and genders of their current workforce. RESULTS: Thirty-two percent of group leaders responded to the survey, corresponding to 12,079 radiologists or 39% of all practicing radiologists. Twenty-one percent of the workforce is female and 79% is male. Ten percent of radiologists older than 65 years are women, while 32% younger than 35 are women. Twelve percent of radiologists work part-time, corresponding to a breakdown of 10% of men and 24% of women working part-time. The current workforce is 13% general radiologists and 87% subspecialists. In 2015, a projected 1,131 to 1,484 jobs will be available for radiologists. CONCLUSIONS: Job opportunities for radiologists seem to be increasing compared with 2013 and are relatively similar to 2014. Radiologists continue to subspecialize in greater numbers, but only 39% of radiologists practice more than 50% of the time in their subspecialties.

Gender and the radiology workforce: results of the 2014 ACR workforce survey.

PURPOSE: As part of the 2014 ACR Human Resources Commission Workforce Survey, an assessment of the gender of the U.S. radiologist workforce was undertaken. Radiologist gender in relation to type of practice, work location, leadership roles, and full- versus part-time employment have not previously been assessed by this survey. METHODS: The survey was completed by group leaders in radiology identified through the Practice of Radiology Environment Database. RESULTS: The response rate to the survey was 22%, representing 35% of all practicing radiologists. The survey found that 78% of the radiology workforce is male, and 22% female. Among the men, 58% work in private practice, and 18% in the academic/university environment; among women, percentages were 43% and 31%, respectively. Of all physician leads, 85% are men, 15% women. Of the full-time radiologists, 15% of men are practice leaders compared with 11% of women. CONCLUSIONS: Fewer women than men are in private practice. More women than men practice in academic/university environments. Among part-time radiologists, there are more men than women, but significantly more women work part time than men. Women are in the minority among practice leaders.

Bedside clinical signs associated with impending death in patients with advanced cancer: preliminary findings of a prospective, longitudinal cohort study.

BACKGROUND: Five highly specific physical signs associated with death within 3 days among cancer patients were recently reported that may aid in the diagnosis of impending death. In this study, the frequency and onset of another 52 bedside physical signs and their diagnostic performance for impending death were examined. METHODS: Three hundred fifty-seven consecutive patients with advanced cancer who had been admitted to acute palliative care units at 2 tertiary care cancer centers were enrolled. Fifty-two physical signs were systematically documented every 12 hours from admission to death or discharge. The frequency and median time of onset of each sign from death backwards were examined, and the likelihood ratios (LRs) associated with death within 3 days were calculated. RESULTS: Two hundred three of the 357 patients (57%) died at the end of the admission. Eight physical signs that were highly diagnostic of impending death were identified. These signs occurred in 5% to 78% of the patients within the last 3 days of life, had a late onset, and had a high specificity (>95%) and a high positive LR for death within 3 days. They included nonreactive pupils (positive LR, 16.7; 95% confidence interval [CI], 14.9-18.6), a decreased response to verbal stimuli (positive LR, 8.3; 95% CI, 7.7-9), a decreased response to visual stimuli (positive LR, 6.7; 95% CI, 6.3-7.1), an inability to close eyelids (positive LR, 13.6; 95% CI, 11.7-15.5), drooping of the nasolabial fold (positive LR, 8.3; 95% CI, 7.7-8.9), hyperextension of the neck (positive LR, 7.3; 95% CI, 6.7-8), grunting of vocal cords (positive LR, 11.8; 95% CI, 10.3-13.4), and upper gastrointestinal bleeding (positive LR, 10.3; 95% CI, 9.5-11.1). CONCLUSIONS: Eight highly specific physical signs associated with death within 3 days among cancer patients were identified. These signs may inform the diagnosis of impending death.

The 2014 ACR Commission on Human Resources workforce survey.

BACKGROUND: The ACR Commission on Human Resources conducts an annual electronic survey during the first quarter of the year to better understand the present workforce scenario for radiologists and allied health professionals. METHODS: The Practice of Radiology Environment Database is used to identify group leaders who are asked to complete an electronic survey developed by the Commission on Human Resources. The survey asked 1,936 group leaders or their designates to report the number of radiologists currently employed or supervised, the number hired in 2013, and the number they plan to hire in 2014 and 2017. The leaders were asked to report the subspecialty area that was used as the main reason for hiring each physician. RESULTS: The 22% response rate corresponds to 35% of all practicing radiologists in the United States. The 2014 survey demonstrated that 78% of the workforce is male and 22% is female and that 87% of the workforce works full time. Fifty-three percent of the current workforce is in private practice and 47% in varying forms of employment. The current workforce consists of 18% general radiologists and 82% subspecialists. In 2013, 1,069 radiologists were hired. In 2014, 1,114 job opportunities are projected, and 1,131 estimated jobs are forecast for 2017. CONCLUSIONS: Job opportunities for radiologists in 2014 remain similar to those in 2013 and close to the numbers of residents completing training programs in diagnostic radiology. Job opportunities remain available but may not necessarily be in the subspecialty, geographic area, or type of practice an individual most desires.

Phase angle for prognostication of survival in patients with advanced cancer: preliminary findings.

BACKGROUND: Accurate survival prediction is essential for decision-making in cancer therapies and care planning. Objective physiologic measures may improve the accuracy of prognostication. In this prospective study, the authors determined the association of phase angle, handgrip strength, and maximal inspiratory pressure with overall survival in patients with advanced cancer. METHODS: Hospitalized patients with advanced cancer who were seen by palliative care specialists for consultation were enrolled. Information regarding phase angle, handgrip strength, maximal inspiratory pressure, and known prognostic factors including the Palliative Prognostic Score, Palliative Prognostic Index, serum albumin, and body composition was collected. Univariate and multivariate survival analysis were performed, and the correlation between phase angle and other prognostic variables was examined. RESULTS: A total of 222 patients were enrolled. The average age of the patients was 55 years (range, 22 years-79 years); 59% of the patients were female, with a mean Karnofsky performance status of 55 and a median overall survival of 106 days (95% confidence interval [95% CI], 71 days-128 days). The median survival for patients with phase angle 2 to 2.9°, 3 to 3.9°, 4 to 4.9°, 5 to 5.9° and ≥ 6° was 35 days, 54 days, 112 days, 134 days, and 220 days, respectively (P = .001). On multivariate analysis, phase angle (hazards ratio [HR], 0.86-per degree increase; 95% CI, 0.74-0.99 increase [P = .04]), Palliative Prognostic Score (HR, 1.07; 95% CI, 1.02-1.13 [P = .008]), serum albumin (HR, 0.67; 95% CI, 0.50-0.91 [P = .009]), and fat-free mass (HR, 0.98; 95% CI, 0.96-0.99 [P = .02]) were found to be significantly associated with survival. Phase angle was found to be only weakly (γ < 0.4) associated with other prognostic variables. CONCLUSIONS: Phase angle was found to be a novel predictor of poor survival, independent of established prognostic factors, in the advanced cancer setting. This objective and noninvasive tool may be useful for bedside prognostication.

Clinical signs of impending death in cancer patients.

BACKGROUND: The physical signs of impending death have not been well characterized in cancer patients. A better understanding of these signs may improve the ability of clinicians to diagnose impending death. We examined the frequency and onset of 10 bedside physical signs and their diagnostic performance for impending death. METHODS: We systematically documented 10 physical signs every 12 hours from admission to death or discharge in 357 consecutive patients with advanced cancer admitted to two acute palliative care units. We examined the frequency and median onset of each sign from death backward and calculated their likelihood ratios (LRs) associated with death within 3 days. RESULTS: In total, 203 of 357 patients (52 of 151 in the U.S., 151 of 206 in Brazil) died. Decreased level of consciousness, Palliative Performance Scale ≤20%, and dysphagia of liquids appeared at high frequency and >3 days before death and had low specificity (<90%) and positive LR (<5) for impending death. In contrast, apnea periods, Cheyne-Stokes breathing, death rattle, peripheral cyanosis, pulselessness of radial artery, respiration with mandibular movement, and decreased urine output occurred mostly in the last 3 days of life and at lower frequency. Five of these signs had high specificity (>95%) and positive LRs for death within 3 days, including pulselessness of radial artery (positive LR: 15.6; 95% confidence interval [CI]: 13.7-17.4), respiration with mandibular movement (positive LR: 10; 95% CI: 9.1-10.9), decreased urine output (positive LR: 15.2; 95% CI: 13.4-17.1), Cheyne-Stokes breathing (positive LR: 12.4; 95% CI: 10.8-13.9), and death rattle (positive LR: 9; 95% CI: 8.1-9.8). CONCLUSION: We identified highly specific physical signs associated with death within 3 days among cancer patients.