System-based strategies for mitigating burnout in radiology.

BACKGROUND: Burnout is a chronic problem prevalent in radiology, with a significant burden on individuals and healthcare systems. DISCUSSION: A substantial portion of the literature on managing burnout has focused on individual-based remedies. We posit that burnout is a systemic problem and present an overview of some system-based strategies that could be employed to mitigate burnout in radiology. These include managing workload, optimizing work shifts, maximizing autonomy, limiting work-life conflicts, creating opportunities for professional fulfillment, utilizing user-friendly electronic medical records (EMR), deploying efficient picture archiving and communication systems (PACS), building system redundancy, leadership transparency, and fostering a healthy work environment.  CONCLUSION: System-based strategies can help mitigate burnout.

Design of overnight radiology shifts - primum non nocere.

Overnight radiology (ONR) is necessary for providing timely patient care but poses unique professional and personal challenges to the radiologists. Maintaining a sustainable, long-term overnight radiology program hinges on the retention of radiologists who grasp the institutional workflow and can adeptly navigate inherent disruptions while consistently delivering high-quality patient care. Design of radiology shifts can significantly impact the performance and well-being of radiologists, with downstream implications for patient care and risk management. We provide a narrative review of literature to make recommendations for optimally designing ONR shifts, with a focus on professional and personal challenges pertinent to overnight radiologists and system-based risk mitigation strategies.

Lower-extremity endovascular interventions for Medicare beneficiaries: comparative effectiveness as a function of provider specialty.

PURPOSE: Lower-extremity endovascular interventions are increasingly being performed by vascular surgeons (VSs) and interventional cardiologists (ICs) in addition to interventional radiologists (IRs). Regardless of specialty, well trained, experienced, and dedicated operators are expected to offer the best outcomes. To examine specialty-specific trends, outcomes of percutaneous lower-extremity revascularizations in Medicare beneficiaries were compared according to physician specialty types providing the service. MATERIALS AND METHODS: Medicare Standard Analytical Files that contain longitudinal data of all services (physician, inpatient, outpatient) provided to a 5% sample of Medicare beneficiaries were studied. All claims for percutaneous angioplasty, atherectomy, and stent implantation of lower-extremity arteries during the years 2005­2007 were extracted, and the following outcomes were assessed: mortality, transfusion, intensive care unit (ICU) use, length of stay, and subsequent revascularization or amputation. Outcomes were compared by using regression models adjusted for age, sex, race, emergency department admission, and comorbid conditions. RESULTS: Most outcomes were significantly worse if the service was provided by vascular surgeons compared with other vascular specialists. The in-hospital mortality rate for procedures performed by VSs was 19% higher than for those performed by others, but this difference was not significant (P =.351). Adjusted average 1-year procedure costs were significantly lower for IRs ($17,640) than for VSs ($19,012) or ICs ($19,096). CONCLUSIONS: Medicare data show that endovascular lower-extremity revascularization by vascular surgeons results in more transfusion and ICU use, longer hospital stay, more repeat revascularization procedures or amputations, and higher costs compared with procedures performed by interventional radiologists.

Patients' perspective about risks and benefits of treatment for peripheral arterial disease.

PURPOSE: To report the results of a standard gamble-type survey conducted to explore patients' heuristics in regard to therapy for peripheral arterial disease (PAD). MATERIALS AND METHODS: Patients presenting to a vascular and interventional radiology practice because of suspected PAD were asked to indicate their threshold for risk of amputation during a curative procedure for intermittent claudication (IC) and for risk of death from a curative medication for critical limb ischemia (CLI). Possible relationships of risk threshold with age, gender, ankle-brachial index (ABI), and functional claudication distance were assessed with univariate statistics followed by multivariable generalized linear mixed models of risk acceptance at various risk levels. RESULTS: Study participants were 20 patients (40% women), with median age of 64 years, functional claudication distance of 1 block, and ABI of 0.72. In the IC scenario, up to 1% risk of above-knee amputation was found to be the median risk acceptable to patients for undergoing a curative procedure. In the CLI scenario, the median risk acceptance for mortality from a curative medication was up to 1%. The multivariable model for the IC scenario revealed significantly greater acceptance of risk at a given level among older patients and women. No significant predictor was delineated by the multivariable model for the CLI scenario. CONCLUSIONS: Overall, patients have a low threshold for complications of PAD therapy, consistent with endovascular but not with open surgical strategies. However, considerable variation in preferences underlines the value of individualized treatment strategies.

Prevalence of abnormal ankle-brachial index among individuals with low or intermediate Framingham Risk Scores.

PURPOSE: To determine the prevalence of an abnormal ankle-brachial index (ABI) among subjects not considered to be at high risk for cardiovascular disease (CVD) based on the Framingham Risk Score (FRS). MATERIALS AND METHODS: Data from the Population-Based Examinations to Determine Ankle-brachiaL index (PEDAL) Study (2007-2009), a cross-sectional study at 23 U.S. sites, in conjunction with Legs for Life, a national ABI screening program, were analyzed. This study includes data from 822 participants (average age 64.3 years ± 11.6, 69.7% women, 89.7% non-Hispanic white) without known CVD or diabetes, who were screened for peripheral artery disease (PAD) with an ABI and for whom all FRS variables were available. Participants' 10-year coronary heart disease (CHD) risk was estimated from the FRS, and three risk categories were defined: low (< 10%), intermediate (10%-19%), and high (≥ 20%). ABI < 0.90 or > 1.4 in either leg was considered abnormal. RESULTS: The prevalence of abnormal ABI was 14.2% (95%confidence interval [CI] 11.9%-16.8%). According to the FRS, 463 (56.3%) participants were at low risk, 212 (25.8%) were at intermediate risk, and 147 (17.9%) were at high risk. Among participants with a low FRS (n = 463; without CVD or diabetes or both) and an intermediate FRS (n = 212; without CVD or diabetes or both), 12.3% and 12.2% had an abnormal ABI. CONCLUSIONS: The prevalence of abnormal ABI, a CHD equivalent, is high among individuals not identified as high risk by conventional Framingham-based risk assessment.

Persistent trigeminal artery communicating with a fetal posterior communicating artery: A case report.

A persistent trigeminal artery (PTA) is the most common carotid-vertebrobasilar anastomosis. PTA variants terminating on cerebellar arteries instead of the basilar artery have been reported previously. We present the first case of a PTA communicating with a fetal posterior communicating artery identified on a magnetic resonance angiogram. An understanding of these anatomical variants is important to clarify pathological processes that can help guide neurosurgical and endovascular procedures.

Clinical Presentation, Imaging, and Management of Acute Cholecystitis.

Acute cholecystitis (AC) is a life-threatening emergency that commonly occurs as a complication of gallstones. Severe right upper quadrant pain, abdominal guarding, fever, and a positive Murphy's sign with an elevated white blood cell count are the classical clinical manifestations of AC. Although ultrasonography is typically the initial diagnostic examination in patients with suspected AC, computed tomography and magnetic resonance imaging are commonly performed to identify complications; cholescintigraphy is recommended in patients with equivocal findings on the other imaging modalities, as this technique has the highest diagnostic accuracy in the diagnosis of AC. Imaging studies are also helpful in the timely detection of complications associated with AC. Although laparoscopic cholecystectomy is considered the gold-standard treatment for AC, percutaneous gallbladder drainage with or without cholecystostomy tube placement is a safe, effective management technique for surgically high-risk patients with multiple medical conditions. This treatment can be used as either a bridging therapy, with elective cholecystectomy performed at a later time after improvement of the patient's condition, or as definitive treatment in surgically unfit patients. Radiologists play a pivotal role in the initial diagnosis and management of patients with AC.

Visceral blood flow modulation: potential therapy for morbid obesity.

We present this preliminary investigation into the safety and feasibility of endovascular therapy for morbid obesity in a swine model. A flow-limiting, balloon-expandable covered stent was placed in the superior mesenteric artery of three Yorkshire swine after femoral arterial cutdown. The pigs were monitored for between 15 and 51 days after the procedure and then killed, with weights obtained at 2-week increments. In the two pigs in which the stent was flow limiting, a reduced rate of weight gain (0.42 and 0.53 kg/day) was observed relative to the third pig (0.69 kg/day), associated with temporary food aversion and signs of mesenteric ischemia in one pig.

Has the significance of incidental findings on unenhanced computed tomography for urolithiasis been overestimated? A retrospective review of over 800 patients.

OBJECTIVES: To evaluate the detection of clinically unsuspected pathologies using 64-slice multidetector computed tomography (CT) of the abdomen in patients with flank pain. The presence of significant incidental findings (those warranting immediate management) was also correlated with that of urolithiasis, to assess potential changes of management. PATIENTS AND METHODS: The study included 899 patients undergoing CT in a 6-month period between June and December 2008. Patients who were referred from outside, with no medical record in the hospital where the study was conducted, and those who were lost to follow-up, were excluded. All of the CT examinations were reported after a radiology resident and a consultant radiologist with >4 years of experience evaluated the CT. Genitourinary and extra-genitourinary findings were assessed and divided into clinically significant or not. RESULTS: The overall incidence of additional and incidental findings was 14%. Besides urolithiasis and obstruction there were 34 (28%) genitourinary findings and 87 (72%) extra-genitourinary findings; most of the former were insignificant. Of the extra-genitourinary findings, significant diagnoses were documented in 34 cases. CONCLUSIONS: Abdominal multidetector CT detects more incidental findings which are clinically significant.

Prevalence of low ankle-brachial index, elevated plasma fibrinogen and CRP across Framingham risk categories: data from the National Health and Nutrition Examination Survey (NHANES) 1999-2004.

OBJECTIVE: 60-80% of heart attacks or coronary-related deaths occur in individuals identified as non-high-risk per the conventional risk assessment algorithms. Abnormal ankle-brachial index (ABI), plasma fibrinogen and plasma C-reactive protein (CRP) have been shown to be associated with a higher risk of cardiovascular disease (CVD). However, comparable data have not been reported for prevalence of abnormal ABI, fibrinogen and CRP in non-high-risk population. METHODS: We analyzed data from the 1999-2004 National Health and Nutrition Examination Survey (NHANES), a nationally representative cross-sectional survey of the U.S. population, for 6292 men and women, aged 40 and older, without known CVD or diabetes, with available data on standard CVD risk factors, ABI, fibrinogen and CRP. The main objective was to identify proportions of individuals with abnormal ABI (ABI<0.9 in either leg), elevated fibrinogen (≥ 400 mg/dl), and elevated CRP (>3mg/l), with otherwise low or intermediate (<20%) 10-year Framingham risk score. RESULTS: Overall prevalence of abnormal ABI, fibrinogen, and CRP was 3.6% (95% CI 3.2-4.1%), 27.4% (95% CI 23.9-31.0%) and 38.3% (95% CI 36.5-40.0%) respectively. Among those with ABI data, 91.4% were at <20% FRS, and of these only 2.7% (95% CI 2.3-3.1%, p < 0.0001) had an abnormal ABI. Among those with fibrinogen data, 90.8% were at <20% FRS, and of these 23.6% (95% CI 20.4-26.8%, p < 0.001) had elevated plasma fibrinogen. Among those with CRP data, 91.1% were at <20% FRS, and of these 34.3% (95% CI 32.7-36.0%, p = 0.0012) had an elevated CRP. Overall, 45.0% (95% CI 42.2-47.8%; p < 0.0001) had abnormal ABI, fibrinogen or CRP but low-intermediate risk. CONCLUSION: Abnormal ABI, elevate fibrinogen and CRP are highly prevalent among individuals otherwise at low-intermediate risk. If any or all of them are shown to improve predictive ability of FRS for primary prevention, it would have a significant public health impact.

Performance of current guidelines for coronary heart disease prevention: optimal use of the Framingham-based risk assessment.

BACKGROUND: There is a strong positive association between Framingham Risk Scores (FRS) in a population and incidence of hard coronary heart disease (hCHD) events. Under current Adult Treatment Panel III guidelines, individuals with FRS that indicate ≥20% 10-year risk of hCHD are recommended to receive intensive medical risk factor modification. We sought to assess the performance of FRS as a predictive tool when used as in current guidelines. METHODS: A retrospective analysis of two prospective cohort studies, the Atherosclerosis Risk in Communities (ARIC) study, and Cardiovascular Health Study (CHS), including 11,436 and 2569 participants, respectively, without known cardiovascular disease or diabetes at baseline, with available FRS variables were analyzed. The FRS was computed according to standard algorithm. The main outcome was hCHD event defined as MI or coronary death. Using Receiver Operating Characteristics (ROC) curves, sensitivity, specificity, accuracy and other test performance characteristics were determined at various 10-year risk thresholds. ROC curves were plotted. RESULTS: During 10-year follow-up, 822 hCHD events occurred. FRS was significantly associated with hCHD with an AUC of 0.77 and 0.68 for ARIC and CHS, respectively (p-values <0.0001). However, at standard "high risk" cut-off (≥20%), the sensitivity of FRS was only 13% and 25%, respectively and Youden's Index was only 0.10 and 0.15. Lowering the 10-year risk threshold to >5% improved prediction sensitivity to 75% and 83%, with specificity of 66% and 40%, respectively. CONCLUSION: When used dichotomously as in current guidelines, sensitivity of the conventional 20% 10-year risk threshold for subsequent hCHD events is quite low. Since the 20% 10-year risk threshold for intensive medical risk factor therapy is on the steep part of the ROC curve, lowering the threshold results in substantial increases in sensitivity with much smaller losses in specificity, even to a threshold as low as 5%.

Mesenteric panniculitis with pedal edema in a 33-year-old Pakistani man: a case report and literature review.

INTRODUCTION: Mesenteric panniculitis is a rare pathology of unknown etiology characterized by inflammation and fibrosis in the mesentery. Its protean clinical and radiological manifestations make it a diagnostic challenge. There is no established treatment available for its management. The clinical outcome is inconsistent, with the prognosis ranging from complete resolution without any treatment to rapid progression culminating in death. CASE PRESENTATION: A 33-year-old Pakistani man presented with vague abdominal pain, an ill-defined epigastric mass and bilateral pedal edema. A detailed review of his history and laboratory investigations did not point to any diagnosis. The patient underwent an exploratory laparotomy based on the finding of mesenteric soft-tissue density on computed tomography. The laparotomy did not prove to be of any diagnostic or therapeutic value. Upon review of the pre-operative computed tomographic scan at our institution, a diagnosis of mesenteric panniculitis was made. An acceptable resolution of abdominal pain and pedal edema was attained after a 4-week trial of immunosuppressive therapy. This is the first reported case of mesenteric panniculitis with pedal edema as part of its presentation. CONCLUSION: An increased awareness may lead to the development of a less invasive diagnostic approach and optimal treatment for this rarely recognized condition.