Text Message Reminders Reduce Outpatient Radiology No-Shows But Do Not Improve Arrival Punctuality.

PURPOSE: To assess whether text-based appointment reminders are a cost-effective strategy to decrease patient no-shows and improve arrival punctuality in the setting of outpatient radiology imaging. METHODS AND MATERIALS: From July 2016 through October 2016, all patients scheduled for MRI imaging at two outpatient locations were randomly assigned to a texting or nontexting arm based on the day. On texting days, patients scheduled for MRI received both the traditional phone call reminder as well as a text-based reminder of their MRI examination. On nontexting days, patients scheduled for MRI received only the traditional phone call reminder. All patients were evaluated based on whether they attended the MRI appointment and, if attended, whether they arrived 30 minutes before the MRI appointment as requested in the text message. Potential associations between the text reminder and examination attendance and punctuality were assessed by χ2 test with associations considered significant at P ≤ .05. RESULTS: A total of 6,989 patients were eligible for analysis, 3,086 in the texting group and 3,903 in the nontexting group. In the texting group, 67.5% (2,083/3,086) of patients were successfully texted with an appointment reminder, with the other 32.5% not having text accessibility. The percent of no-shows was significantly decreased for the texting group compared with the nontexting group (3.8% versus 5.1%, P = .02, odds ratio 0.75, 95% confidence interval 0.59 to 0.94). There was no significant difference between the percent of patients arriving the requested 30 minutes before the MRI appointment between the texting and nontexting groups (60.0% versus 58.5%, P = .25). CONCLUSION: Text message appointment reminders are an effective strategy for decreasing radiology no-shows, even in the presence of traditional phone reminders, but do not improve patient arrival punctuality.

Improving Radiology Workflow with Automated Examination Tracking and Alerts.

The modern radiology workflow is a production line where imaging examinations pass in sequence through many steps. In busy clinical environments, even a minor delay in any step can propagate through the system and significantly lengthen the examination process. This is particularly true for the tasks delegated to the human operators, who may be distracted or stressed. We have developed an application to track examinations through a critical part of the workflow, from the image-acquisition scanners to the PACS archive. Our application identifies outliers and actively alerts radiology managers about the need to resolve these problems as soon as they happen. In this study, we investigate how this real-time tracking and alerting affected the speed of examination delivery to the radiologist. We demonstrate that active alerting produced a 3-fold reduction of examination-to-PACS delays. Additionally, we discover an overall improvement in examination-to-PACS delivery, evidence that the tracking and alerts instill a culture where timely processing is essential. By providing supervisors with information about exactly where delays emerge in their workflow and alerting the correct staff to take action, applications like ours create more robust radiology workflow with predictable, timely outcomes.

Identifying contrasting influences and surface water signals for specific groundwater phosphorus vulnerability.

Two groundwater dominated catchments with contrasting land use (Grassland and Arable) and soil chemistry were investigated for influences on P transfer below the rooting zone, via the aquifer and into the rivers. The objective was to improve the understanding of hydrochemical process for best management practise and determine the importance of P transfer via groundwater pathways. Despite the catchments having similar inorganic P reserves, the iron-rich soils of the Grassland catchment favoured P mobilisation into soluble form and transfer to groundwater. Sites in that catchment had elevated dissolved reactive P concentrations in groundwater (>0.035 mg l(-1)) and the river had flow-weighted mean TRP concentrations almost three times that of the aluminium-rich Arable catchment (0.067 mg l(-1) compared to 0.023 mg l(-1)). While the average annual TRP flux was low in both catchments (although three times higher in the Grassland catchment; 0.385 kg ha(-1) compared to 0.128 kg ha(-1)), 50% and 59% of TRP was lost via groundwater, respectively, during winter periods that were closed for fertiliser application. For policy reviews, slow-flow pathways and associated time-lags between fertiliser application, mobilisation of soil P reserves and delivery to the river should be carefully considered when reviewing mitigating strategies and efficacy of mitigating measures in groundwater fed catchments. For example, while the Grassland catchment indicated a soil-P chemistry susceptibility, the Arable catchment indicated a transient point source control; both resulted in sustained or transient periods of elevated low river-flow P concentrations, respectively.

Evaluating the critical source area concept of phosphorus loss from soils to water-bodies in agricultural catchments.

Using data collected from six basins located across two hydrologically contrasting agricultural catchments, this study investigated whether transport metrics alone provide better estimates of storm phosphorus (P) loss from basins than critical source area (CSA) metrics which combine source factors as well. Concentrations and loads of P in quickflow (QF) were measured at basin outlets during four storm events and were compared with dynamic (QF magnitude) and static (extent of highly-connected, poorly-drained soils) transport metrics and a CSA metric (extent of highly-connected, poorly-drained soils with excess plant-available P). Pairwise comparisons between basins with similar CSA risks but contrasting QF magnitudes showed that QF flow-weighted mean TRP (total molybdate-reactive P) concentrations and loads were frequently (at least 11 of 14 comparisons) more than 40% higher in basins with the highest QF magnitudes. Furthermore, static transport metrics reliably discerned relative QF magnitudes between these basins. However, particulate P (PP) concentrations were often (6 of 14 comparisons) higher in basins with the lowest QF magnitudes, most likely due to soil-management activities (e.g. ploughing), in these predominantly arable basins at these times. Pairwise comparisons between basins with contrasting CSA risks and similar QF magnitudes showed that TRP and PP concentrations and loads did not reflect trends in CSA risk or QF magnitude. Static transport metrics did not discern relative QF magnitudes between these basins. In basins with contrasting transport risks, storm TRP concentrations and loads were well differentiated by dynamic or static transport metrics alone, regardless of differences in soil P. In basins with similar transport risks, dynamic transport metrics and P source information additional to soil P may be required to predict relative storm TRP concentrations and loads. Regardless of differences in transport risk, information on land use and management, may be required to predict relative differences in storm PP concentrations between these agricultural basins.

Empowering individuals as carers of their own health.

Self-care as both treatment and prevention is assuming new importance for several reasons: chronic illness, which calls for self-care is becoming a more serious global problem; illnesses that are related to unhealthy behavior are more common; medical care is becoming more participative because of increased individualism; the costs of care make it necessary for more care to be assumed by patients; and new technology expands what people can do for themselves. Self-care is relevant to the enhancement of health, the prevention of illness; the management of disease, particularly chronic illnesses; and rehabilitation to reduce disability. Barriers to self-care include mental attitudes of depression and denial, addictions, cultural factors, low intelligence and illiteracy, and family conflict. Self-care is enhanced by a sustaining relationship with a health professional, trustworthy information, patient education that is culturally sensitive, technological aids, financial and other positive incentives, and peer group support. Self-care is a growing dimension of health care that needs and deserves further research and innovation.

Seclusion and restraint: a review of recent literature.

An October 1998 Hartford Courant investigative series highlighted alleged cases of brutality and death suffered by involuntarily secluded, restrained, and/or emergently medicated patients. The resulting public and professional furor prompted a spate of new federal regulations and legislative initiatives setting national standards for reporting and clinical oversight. These events provide stimulus for this literature review. Rates, duration, and methods of seclusion and restraint still vary widely. Little evidence is available to guide clinical practice regarding relative benefits and risks of various methods to control acute adult patient aggression; even less evidence exists in child and adolescent populations. Further efficacy and effectiveness studies are needed to address this issue. Various programmatic efforts successfully reduce seclusion and restraint-at times dramatically-and can be used as examples of systematic quality improvement so "best practices" may evolve and spread throughout psychiatric inpatient settings.

Autonomic dysfunction in patients with fibromyalgia: application of power spectral analysis of heart rate variability.

OBJECTIVES: To assess the interaction between the sympathetic and parasympathetic systems in patients with fibromyalgia syndrome (FM), using power spectrum analysis (PSA) of heart rate variability (HRV). In addition, we explored the association between HRV, measures of tenderness, FM symptoms, physical function, psychological well being and quality of life. METHODS: We studied 22 women with FM and 22 age-matched healthy women. Twenty-minute electrocardiogram recordings were obtained in a supine position during complete rest. Spectral analysis of R-R intervals was done by the fast-Fourier transform algorithm. RESULTS: Heart rate was significantly higher in FM patients compared with controls (P < .006). FM patients had significantly lower HRV compared with controls (P= .001), and higher low-frequency (LF) and lower high-frequency (HF) components of PSA than controls (P < .001). Quality of life, physical function, anxiety, depression, and perceived stress were moderately to highly correlated with LF, HF (in normalized units), and LF/HF. No association was observed between HRV parameters and measures of tenderness and FM symptoms. CONCLUSIONS: The basal autonomic state of patients with FM is characterized by increased sympathetic and decreased parasympathetic tones. Autonomic dysregulation may have implications regarding the symptomatology, physical and psychological aspects of health status.

Time course of nodal enhancement with CT X-ray nanoparticle contrast agents: effect of particle size and chemical structure.

RATIONALE AND OBJECTIVES: Levels of CT enhancement in rabbit lymph nodes were followed with time after subcutaneous injection of four iodinated, insoluble nanoparticle contrast agents to provide experimental support for the hypothesis that clearance of these agents is related to the chemical structure of the agent itself. The impact of particle size was also studied. METHODS: Subcutaneous injections (2 x 0.25 mL) were made in the dorsum of rabbit paws with 15% suspensions of four nanoparticle contrast agents. Images were obtained at 4, 10, 24, 48, and 72 hours and 5, 7, and 14 days after injection. Average attenuation (in Hounsfield units [HU]), node volume, and total iodine uptake were estimated from the CT scans for each lymph node at each time point. RESULTS: All the agents provided adequate enhancement of both the popliteal and axillary lymph nodes of the rabbit (ie, > delta100 HU). Lymph node volume appears to be related to the persistence of enhancement, with long-lived agents demonstrating the greatest increase in size. The rate of clearance from the lymph nodes is related to the structure of the agent. CONCLUSIONS: Clearance of insoluble, iodinated nanoparticle contrast agents from lymph nodes can be modulated by changes in the structure of the agent itself. Using the same agent, smaller particles deliver material to the lymph nodes more quickly and clear more quickly.

Radio-frequency-induced coagulation necrosis in rabbits: immediate detection at US with a synthetic microsphere contrast agent.

PURPOSE: To determine whether a synthetic ultrasonographic (US) contrast agent can be used to differentiate coagulation necrosis from untreated tumor immediately after radio-frequency ablative therapy. MATERIALS AND METHODS: VX2 (adenocarcinoma) tumors (0.8-1.5-cm diameter) were implanted into 12 rabbits. Gray-scale and color Doppler US were performed with or without intravenous injection of a US contrast agent composed of poly-lactide-co-glycolic acid polymeric (PLGA) microspheres (2-micron diameter) filled with perfluorocarbon gas. Radio frequency was applied to each nodule for 6 minutes at 127 mA +/- 33 (mean +/- SD) (tip temperature, 92 degrees C +/- 2). Repeat US with a second dose of the contrast agent was performed immediately after ablation. In four animals, a third dose was administered 30-120 minutes after ablation. Radiologic-histopathologic correlation was performed and included in vivo staining and studies of mitochondrial function. RESULTS: Intense contrast agent enhancement was seen throughout the tumor prior to ablation. At gray-scale US, ablation produced hyperechoic foci, which were within 1 mm of the foci identified at histopathologic examination in seven of 12 animals (58%). After the administration of contrast material, foci devoid of previously visualized enhancement, which measured 7.3-15.0 mm, were identified. These were within 1 mm of the size of the foci identified at histopathologic examination in 11 of 12 animals (92%, P < .01). In two animals, enhancement depicted viable tumor, which appeared hyperechoic, on nonenhanced images. On delayed images, hyperechoic areas decreased in size, whereas the nonenhanced region remained unchanged. CONCLUSION: A PLGA microspherical US contrast agent enabled the immediate detection of coagulation necrosis as a region devoid of contrast enhancement after radio-frequency ablation in rabbit hepatic tumors. Therefore, this agent could provide real-time guidance during complex ablative procedures and may provide an efficient technique for postprocedural assessment.

Service quality in health care.

Although US health care is described as "the world's largest service industry," the quality of service--that is, the characteristics that shape the experience of care beyond technical competence--is rarely discussed in the medical literature. This article illustrates service quality principles by analyzing a routine encounter in health care from a service quality point of view. This illustration and a review of related literature from both inside and outside health care has led to the following 2 premises: First, if high-quality service had a greater presence in our practices and institutions, it would improve clinical outcomes and patient and physician satisfaction while reducing cost, and it would create competitive advantage for those who are expert in its application. Second, many other industries in the service sector have taken service quality to a high level, their techniques are readily transferable to health care, and physicians caring for patients can learn from them.

Lymph node extraction of radiopaque nanoparticulates in the rabbit as measured in vivo with CT.

RATIONALE AND OBJECTIVES: The purpose of this study was to estimate in vivo extraction of lymphographic material in the popliteal node of the rabbit. MATERIALS AND METHODS: Serial quantitative computed tomography (CT) of target tissues in four legs of two rabbits was performed after subcutaneous injection of an improved lymphographic contrast agent. Massage was used as a lymphotrophic intervention. RESULTS: At 15 minutes, the mean change in Hounsfield units measured 815 in the popliteal node, 219 in afferent lymphatic vessels, and 127 in efferent lymphatic vessels. The nodal extraction of nanoparticulates from the lymph was approximately 55%. Nodal massage allowed the amount of nanoparticulate remaining in sinusoidal lymph to be estimated. CONCLUSION: Functional CT performed with timed studies, proper radiopaque materials, and physiologic interventions can depict in vivo lymphatic physiology under minimally invasive conditions.

Surgical management of rectal and jejunal tears associated with dystocia in a cow.

The rectal and jejunal tears associated with dystocia in a cow were treated surgically. The cow developed peritonitis which was treated medically. It recovered, was successfully rebred and delivered a live calf.