#overnight radiology coverage

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Improvement of Patient Care Through Teleradiology

It is estimated that the global teleradiology market size will reach USD 8.2 billion by 2024, with a CAGR of 19.1%.  Teleradiology is uniquely positioned to deliver radiological interpretation in emergencies and provide access to 2nd opinions from experts in the field. While it allows flexible temporal and specialty-based opportunities that augment image interpretation capacity the real emphasis is on value-directed care. Teleradiology has not only improved access but also improved optimal imaging care both temporally and geographically. A decade ago, the focus was on image quality, transmission speed, and image compression. Now the focus is on clinical governance, medico-legal issues, and quality assessment.

Teleradiology solutions were initially expected to allow radiologists to provide intramural emergency radiology services from home, focusing on underserved areas and augmenting subspecialty coverage. However, the number of emergency department imaging cases exploded between 1994 and 2015, leading to a significant strain on radiology departments worldwide. 

Value-directed care

The era of value-directed care is emphasizing patient primary and optimizing patient care. Many studies have shown the poorer quality of health care for patients admitted on weekends or overnight when compared to those admitted during the week. Data from Sentinel Stroke National Audit Programme showed that care quality showed different patterns and magnitudes of temporal variation. The role of diagnostic imaging in this care gap has not been studied yet.  Orthopaedic trauma units have benefitted, where an orthopaedist is at a remote location from the patient, teleradiology has been shown to improve diagnostic accuracy, planning the disposition of patients from emergency departments, and planning surgical procedures. This also improves the comfort level of consulting surgeons and limits the risk of litigation for an incorrect diagnosis. 

Teleradiology decreases the report turnaround time and improves service levels in the emergency setting. There are generalists who excel in acute care interpretation. Report quality is enhanced by a centralized reading room that is equipped with the night-day model. This increases radiologist productivity and healthcare costs are reduced. 

Expanding Access

There is a great disparity between rural and urban settings for healthcare. In a country like the US, one-fifth of its residents live in rural areas. There are more general radiologists in non-academic practices and smaller practices in certain regions of the United States. Some interpretations may benefit from subspecialist interpretations. Hence teleradiology can eliminate any interpretative gap that may exist. Older individuals with lower socioeconomic status with more health issues in rural can be served by contemporaneous around-the-clock imaging services in rural areas and providing subspeciality diagnostic interpretations at their local hospitals. 

Disaster management

Teleradiology has played a critical role in war-affected regions of Iran, Syria, and Afghanistan. Doctors without Borders, a widely recognized NGO uses teleradiology to assist with healthcare outreach. More than half of all radiographs sent to them were nondiagnostic because of poor exposure and artifacts during film development. Radiographer training and transition to computed radiography helped where possible. During the COVID-19 pandemic, intramural teleradiology allowed radiologists to work from home to avoid exposure and provide interpretations from home. Emergency department imaging volume surge was handled efficiently by virtue of teleradiology during the pandemic. 

Artificial Intelligence in Teleradiology

Artificial intelligence (AI) in teleradiology offers the potential for speed, accuracy, and quality of image interpretation. More urgent cases can be triaged and assigned to radiologists with the best-matched availability to render a high-quality interpretation. AI holds the promise of assisting with scheduling and developing a protocol, optimizing workflow, targeting image interpretations, improving intelligent communication, and optimizing business analytics and operations.  

Technology limitations

Interpretations in teleradiology should be led by relevant clinical information. Access to this information may be a challenge. Studies have shown that state-wise teleradiology networks resulted in fewer repeat CT examinations, decreased cumulative radiation exposure, decrease time in emergency departments and cost savings. Hence a need for long-term support and standard PACS and electronic medical record system that can provide information without compromising health information security. Radiologists should have the responsibility to oversee technologists and sonographers acquiring images. There should be ease of access to the clinical provider who ordered the image with the teleradiologist too. A reliable internet connection with sufficient bandwidth can ensure the efficient transfer of radiographic images and remote report generation and transmission. Both the receiving and transmitting sites should have reliable and consistent peer-review feedback that is audible, private, and secure. 

Conclusion

Teleradiology not only increases imaging efficiency but also bridges geographical and temporal discrepancies in imaging care. There may be however regulatory hurdles and technological limitations that may limit the optimal practice of teleradiology solutions Bangalore.

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Overnight Radiology Coverage - RadBlox

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Juniper Publishers-Open Access Journal of Case Studies

Emphysematous Cholecystitis Complicating a Transarterial Chemoembolization Procedure

Authored by Talal Alnabelsi

Abstract

Abdominal pain is a common complaint following transarterial chemoembolization (TACE). It is often attributed to hepatocyte damage and regarded as an expected side effect of therapy. Cholecystitis is an uncommon but documented complication of TACE procedures due to reflux of embolic material into the cystic artery. In most cases, cholecystitis can be managed expectantly without the need of any intervention. Our case is interesting as it describes an uncommon complication of TACE procedures: emphysematous cholecystitis requiring emergent open cholecystectomy. It highlights that physicians should be cognizant of the complications of advanced radiological interventions as these conditions can have a poor prognosis if remain unrecognized.

Keywords: Transarterial chemoembolization (TACE); hepatocellular carcinoma (HCC)

Introduction

Transarterial chemoembolization (TACE) is a well-established treatment for patients with hepatocellular carcinoma (HCC). Knowledge of the common and rare complications arising from this procedure is necessary for everyone who comes across this patient group. Cholecystitis is a rare complication of TACE procedures due to reflux of embolic material into the cystic artery. Our patient reported abdominal pain, a very common complaint following a TACE procedure. Before disregarding it as an expected side effect of therapy, one must remain vigilant as serious pathology may exist underneath.

Case Presentation

A 61 year old Asian male presents to the hospital for an elective TACE procedure. He has a history of hepatitis C cirrhosis and HCC status post left hepatic lobectomy a year prior to this admission. The patient underwent a successful right hepatic artery chemoembolization with a mixture of doxorubicin, ethiodol and embosphere particles. A few hours following the procedure, he developed moderate right upper quadrant pain which was managed supportively with intravenous opiates and close monitoring overnight.

Over the next 2 days his pain persisted and was accompanied by intermittent “shakes” and a low grade fever at 38 degrees. He was tachycardic to 110 beats per minute but remained normotensive. He had a tender right upper quadrant with a negative murphy’s sign, no rebound and no guarding. Laboratory markers were remarkable for a white cell count of 22.2 x 103cells/μL, alanine and aspartate transaminase peaking at 1190 U/L and 877 U/L respectively, alkaline phosphatase of 180 U/L and bilirubin of 1.1 mg/dL. The INR and hemoglobin levels remained stable. A liver ultrasound revealed changes related to the TACE procedure but also a moderately distended gallbladder with non-dependent air and wall edema. A CT scan of the abdomen and pelvis revealed an infracted gallbladder with emphysematous cholecystitis and small areas of gallbladder wall perforation (Figure 1).

The patient received appropriate resuscitative measures including antibiotic coverage for intra-abdominal pathogens. The general surgery team was consulted and given the patient’s deteriorating clinical status and impending gallbladder perforation a decision was made to proceed with an emergent open cholecystectomy. The patient had an uneventful postsurgical course and was discharged home 3 days later. The final pathology report revealed a perforated transmural acute necrotizing cholecystitis with identifiable chemoembolization material.

Discussion

TACE has become a commonly utilized treatment for HCC. It is offered for palliative purposes in inoperable tumors, to shrink tumors prior to surgery or as a bridge to liver transplant [1,2]. Major complications occur in 5% of patients and the risk of death is 1% [3]. Complications related to the procedure include access site injuries, hepatic failure, biloma or abscess formation, pulmonary embolization or cholecystitis [3].

Following a TACE procedure it is not uncommon for patients to experience abdominal pain. This can be accompanied by systemic symptoms such as fatigue and fever, a constellation referred to as postembolization syndrome. Additionally, laboratory abnormalities including leukocytosis and elevation in liver enzyme levels are expected after the procedure. The mechanism of these changes can be explained by hepatocyte damage however some authors postulate cystic artery embolization to be the cause of this pain [4,5].

Therefore on many occasions it may be difficult to discern the etiology of the pain and imaging may be necessary to rule out serious complications. Unfortunately, there are currently no guidelines or recommendations to image patients with abdominal pain following TACE. Clues to pursue further investigations may include persistence of symptoms and deterioration in the hemodynamic or clinical status of the patient. Cholecystitis is a rare but well-documented complication with a variable incidence ranging from 0.3 to 10% [6].

The gallbladder unlike the liver has a single vascular supply through the cystic artery. This makes the gallbladder susceptible to injury or infarction due to inadvertent embolization during the TACE procedure. The cystic artery arises most commonly from the right hepatic artery before dividing into anterior and posterior divisions. This implies that right hepatic artery chemoembolization, as the case in our patient, carries the highest risk of post TACE cholecystitis [6]. The pathogenesis of cholecystitis in TACE patients is related to gallbladder wall ischemia and infarction which is believed to be related to lipiodol embolization to the gallbladder wall [7].

For most cases, cholecystitis following TACE is a benign and self-limiting complication [6]. Patients usually do not require intervention and can be managed expectantly. However in cases such as ours, when there is evidence of gallbladder perforation or emphysematous cholecystitis, surgical intervention is mandatory [8].

Conclusion

We describe a case of emphysematous cholecytitis complicating a TACE procedure. Early imaging with ultrasound and computed tomography of the abdomen may be essential to assess patients with persistent abdominal pain following the procedure as serious pathology may exist underneath.

Author Contribution: TA and RM were responsible for literature review, preparation and final synthesis of the manuscript. GV was the attending physician on the case and the final reviewer of the manuscript. The authors obtained informed consent from the involved patient in the case. Emphysematous cholecystitis complicating atransarterial chemoembolization procedure.

For more Open Access Journals in Juniper Publishers please click on: https://juniperpublishers.business.site/ For more articles in Open Access Journal of Case Studies please click on: https://juniperpublishers.com/jojcs/ To know more about Open Access Journals Publishers To read more…Fulltext please click on:  https://juniperpublishers.com/jojcs/JOJCS.MS.ID.555584.php

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Mass transit systems around the world have taken unprecedented — and expensive — steps to curb the spread of the coronavirus, including New York shutting down its subways overnight and testing powerful ultraviolet lamps to disinfect seats, poles and floors.

The cleaning measures produced something commuters have not seen in a while, or possibly ever: thousands of freshly scrubbed cars that look, feel and even smell clean. But experts say those steps solve only part of the problem, and transit officials are studying more advanced methods that might someday automatically disinfect transit systems around the clock.

The Moscow Metro and a public bus company in Shanghai have experimented with germ-killing ultraviolet light. Agencies in Hungary and the Czech Republic have tried using ozone gas as a disinfectant. The public transit system in Dallas tested a “dry fogging” system, and Hong Kong used a robot that sprays a hydrogen peroxide solution, according to a survey by international engineering and professional services firm WSP.

In Chicago, rail cars are cleaned every day before starting service and are prowled at night by crews wearing backpack-style electrostatic sprayers that cover all interior surfaces with disinfectant.

All that cleaning does cut the threat of catching the virus, experts say, but the benefits are limited.

The virus transmits predominantly through droplets in the air — it’s “everywhere and could be nowhere,” said Robyn Gershon, a clinical professor of epidemiology at New York University.

Cleaning a train car at a maintenance yard overnight — or even several times during the day, as New York’s Metropolitan Transportation Authority does — might not help the transit employee or passenger stuck in close quarters with a coughing person.

Wearing a face mask “will protect us the most, having that control among ourselves,” Gershon said. “I think the rest of it is really more the illusion, and that’s not a small thing because it plays with our psyches.”

Patrick Warren, the MTA’s chief safety officer, said the authority’s aggressive cleaning and disinfecting began at a time when health officials were warning that the virus could easily be transmitted from hard surfaces — guidance that has since evolved to place more emphasis on airborne transmission.

“As goes the science, so goes what we are doing,” Warren said.

New York’s subway system normally serves more than 5 million riders a day, but ridership plunged more than 90 percent at the height of the pandemic. Combined with plummeting revenues at its toll bridges and tunnels, the MTA has projected the pandemic will cost the agency more than $10 billion through next year. The cleaning program will wind up costing hundreds of millions of dollars over what the MTA would normally spend, Chairman Pat Foye said this past spring.

Is it worth the price? A survey of 1,000 mass transit riders conducted by New York-based advocacy group Tri-State Transportation Campaign found that cleaning topped a list of actions people wanted before they would feel comfortable riding mass transit again.

“But to what extent are we now overspending, or veering too far into security theater?” Executive Director Nick Sifuentes asked recently.

Dr. David Brenner, director of the Center for Radiological Research at Columbia University Irving Medical Center, has assisted the MTA on its UV light pilot program. He called the cleaning “not an ideal solution, but it’s a solution that is available.”

“I think it does increase the public safety because instead of having a continuous buildup of the virus, you are going back to zero every day,” Brenner said. “A much better solution would be if you could continuously decontaminate the air throughout the course of the day.”

That possibility may be on the horizon. A 2018 study and another published this month, both of which Brenner contributed to, concluded that low levels of a certain type of ultraviolet light, called far-UVC light, can be circulated continuously in an enclosed space and kill some forms of human coronavirus as effectively as conventional UV light — without the harmful effects to human eyes and skin.

Far-UVC light could offer a whole new level of protection for passengers and transit employees, if it is also found to be effective against the virus that causes COVID-19. The MTA is exploring using the technology on its subways.

The MTA is already testing a different form of UV light to disinfect subway cars, but it can only be done at station yards when the cars are out of service because of the harmful effect on humans. The limited pilot program costs about $1 million. Officials have not said how much it would cost to expand to the whole system. Chicago Transit Authority officials are waiting for the results of New York’s pilot program to see if the light is an option for their transit system.

Fred Maxik, whose company, Healthe, makes far-UVC light systems that are being used in office buildings and schools, cautioned that far-UVC light is not necessarily a panacea for anxious subway riders.

“No technology we have today is going to be perfect. It’s going to have to be used in conjunction with other good behaviors,” he said. “But I think this is the best of what we’ve got.”

Warren called far-UVC “a great innovation” but added that the logistical challenges of installing it across a century-old subway system are formidable. He would not speculate on what the agency’s cleaning efforts might look like a year from now.

“That’s the equation that everyone wants the answer to, including us,” he said, explaining that the agency is weighing what methods are economical and effective. “If we can’t have a clean, disinfected system that the customers trust, we’re not going to get the customers to come back.”

More coronavirus coverage from Fortune:

Why black-owned businesses were hit the hardest by the pandemic

Pop-up retail was made for the pandemic

How the coronavirus crisis has affected female founders

The enduring history of health care inequality for black Americans

E-book reading is booming during the coronavirus pandemic

from Fortune https://ift.tt/2C7qcpy

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Sometimes the most entitled people aren’t those you expect

Cory Michael, MD | Physician | September 30, 2018

As I sat in a frozen yogurt store a couple of years back, I watched as two young men pulled up in an expensive vehicle. They were wearing athletic attire from a private faith-affiliated university in the neighborhood. Both grabbed sample cups and cup-by-cup consumed about ten dollars-worth of yogurt each before jestfully yelling “Gracias” to the Latin store employee and walking out the door without paying for anything. Then I saw the same thing happen with another group a few minutes later. While this may have been the most “entitled” I think I have ever seen anyone act, it occurred to me how commonplace this term has become in recent public discourse.

At some point in the past ten years, we began speaking publicly about government-sponsored health insurance and retirement plans as “entitlement” programs. The term is accurate. Veterans are entitled to VA benefits. They sacrificed their lives for the security of our nation. Senior citizens are entitled to Social Security when they retire. Their payments are commensurate with what they paid in over their careers. Since health insurance in the United States is employer-driven, Medicare is needed to provide a safety net for those beyond retirement age. Our values hold that children are entitled to healthcare even if their parents can’t provide it. That is where Medicaid comes in.

I can’t help to think that we started using the label “entitlement programs” in somewhat of a pejorative sense meaning that maybe the entitled people shouldn’t really be entitled to the government programs voted into place by the leaders we elected. Just like the affluent college students above, I have to say that the most “entitled” people I have met since becoming a physician have not been the poor or infirmed.

At a graduation party for my medical school at a nightclub, one of my classmates (the son of a physician) felt as though the bartender wasn’t serving him fast enough, so he reached behind the bar and helped himself to a bottle of liquor. During residency, one of my fellow residents (the daughter of a physician) parked in a handicap slot because she was late for work.

One of the attending physicians at my residency program who was compensated entirely by a private practice radiology group once complained about “entitled” patients over-utilizing the emergency room. In the meanwhile, this attending enjoyed never having to work overnight as well as the financial reward of having residents generate hundreds of thousands of dollars in revenue for her practice. You may think that the radiology practice that was sending the medical bills to the patients was paying the radiology residents who were doing much of their work for them. Nope. Just like most other medical residents in the United States, the residents were paid by the federal government through the hospital. Private radiology practices are entitled to having the government buy them call coverage overnight in exchange for offering an educational program that meets minimal standards, regardless of whether more radiologists are needed or not.

Maybe government health insurance isn’t the first “entitlement” program that needs to be modified.

Cory Michael is a radiologist.

Image credit: Shutterstock.com

Tagged as: Radiology

Source: https://bloghyped.com/sometimes-the-most-entitled-people-arent-those-you-expect/