RPS 1409a - Interventional practice, dose management and education

Purpose:

Numerous disposable devices are consumed daily in interventional radiology (IR) suites globally. Trainees receive no formal training or assessment on the cost and identification of these devices. Educating specialists on disiposable devices has shown to reduce costs in other disciplines. This study aims to assess radiology trainees’ ability to identify and estimate the costs of common disposable interventional radiological devices and identify deficiencies in postgraduate radiology teaching in terms of healthcare economics.

Methods and materials:

The postgraduate radiology training body of a European country was consulted to obtain numbers of all current radiology trainees. Trainees were invited to partake in a questionnaire via email. An anonymous online survey consisting of 26 multiple-choice questions (MCQs) was administered. Respondents were asked to provide their year of training and subspecialty of interest. Respondents were asked to identify 13 devices, using in vivo and ex vivo images. The devices were a PICC line, Angioseal closure device, tunnelled dialysis catheter, Port-A-Cath, pigtail drainage catheter, guidewire, biopsy needle, micropuncture kit, angioplasty balloon, IVC filter, covered metal vascular stent, gastrostomy tube, and an EVAR graft. They were asked to estimate the cost of each device. Trainees were deemed correct if they responded within 25% of true cost.

Results:

The questionnaire was delivered to 82 radiology trainees; the response rate was 60% (49/82). No trainee accurately estimated the cost for all 13 devices assessed. The cost of devices was underestimated by trainees 48.9% of the time and overestimated 32.3% of the time.

Conclusion:

Radiology trainees are deficient in cost awareness of a number of common IR devices used. A health economics module in postgraduate radiology training may improve the efficiency of healthcare expenditure within radiology departments.

Limitations:

n/a

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

Due to the hands-free nature of smart glasses, they have the potential to be useful in interventional environments where sterility has to be ensured and where the clinician has both hands occupied with surgical tasks. A visual grading analysis (VGA) study was performed to compare the perceived image quality of fluoroscopy images using smart glasses and a conventional monitor.

Methods and materials:

10 observers (3rd-year student radiographers) evaluated 4 anonymised fluoroscopic images for 4 criteria (representation of soft tissue structures, bone, contrast filled structures, and clear definition of a guidewire). Each criterion was rated on a scale of 1-5, with a higher number representing a more positive response.

The evaluation was completed with a pair of prototype Epson BT-35E smart glasses (Epson, Japan) in a controlled environment (dimmed ambient lighting with no adjustments made to the brightness, contrast, or magnification settings). The same images were also displayed on an Iiyama ProLite B2206WS monitor (Iiyama, Japan) within the same controlled environment. The area under the visual grading characteristic (AUC_VGC) was used as the figure of merit (FOM). The image evaluation would be considered statistically different if the 95% confidence interval (CI) of the AUC_VGC did not include 0.5.

Results:

The AUC_VGC and 95% CI was 0.519 (0.425, 0.618), p=0.610, for the comparison of the image evaluation with smart glasses and a conventional monitor. This means that no significant difference was detected for the evaluation of image quality in this pilot data.

Conclusion:

There were promising early results for the image quality provided by smart glasses in comparison to a conventional monitor. A larger-scale study, also considering dynamic imaging, is now required.

Limitations:

n/a

Ethics committee approval

Application HST1819-279 approved University of Salford.

Funding:

CoRIPS Student Research Award.

Purpose:

Computed tomography (CT)-guided interventions are taught across the world mostly using a traditional mentored approach on real patients. However, it is well established that simulation is a valuable training tool in medicine. This project assessed the feasibility and acceptance of replicating a CT-guided intervention using a bespoke software application within an augmented reality head-mounted display (ARHMD): the Microsoft HoloLens.

Methods and materials:

A bespoke application was written to simulate the process of performing a CT-guided procedure using augmented reality. Virtual patients were generated using CT datasets obtained from the cancer imaging archive. A mesh of a virtual patient was projected into the field of view of the operator and a virtual CT slice simulating the needle position generated on voice command. In order to provide tactile feedback, a mock biopsy phantom was made using agar jelly. ChArUco markers were used to track both the needle and phantom using RGB cameras built into the ARHMD.

The application was trialled by senior international radiologists and radiology registrars-in-training with a structured feedback questionnaire evaluating face validity and technical aspects.

Results:

Good feedback was received from participants regarding realism, usability, and the accuracy of the application.

Conclusion:

The study showed it is possible to replicate a CT-guided procedure with augmented reality and that this could be used as a training tool.

Limitations:

There is no comparison made to traditional CT training techniques, although a further study will address this. A limited CT dataset was used to simulate patient subjects and this could be increased with further study.

Ethics committee approval

The CT datasets from the cancer imaging archive have ethical approval for re-use. No other ethical approval was required.

Funding:

No funding was received for this work.

Purpose:

To evaluate the accuracy of the algorithm for calculating the skin dose distribution in interventional radiology procedures, provided by the radiation dose index monitoring software NEXO[DOSE]^® (Bracco Injeneering SA, Lausanne).

Methods and materials:

To obtain the skin dose distribution, the software uses exposure parameters taken from the radiation dose structured report (primary/secondary angles, source-to-isocenter distance, kV, Kerma-Area Product (KAP), air-Kerma at interventional reference point, and additional filters), angiographic system information (table attenuation and KAP correction factor), and other factors, such as the backscatter factor and ratio of mass-energy absorption coefficients. The software had been previously validated on a geometrical phantom. GafChromic^® XR-RV3 films were positioned under the patient’s back to evaluate the software accuracy in clinical conditions. The interventional procedures (18 cases including prostatic artery embolisation, uterine fibroid embolisation, transjugular intrahepatic portosystemic shunt, and transarterial chemoembolisation) were performed with two Philips Integris Allura FD20 and a Siemens Artis Zeego.

Results:

The peak skin dose (PSD) values were in a range from 0.2 Gy to 10 Gy. The differences between estimated and measured PSD were lower than 25%, except in one case where a discrepancy of 65% was probably due to an uncorrected geometric evaluation or to the film positioning. The mean deviation is 0.7%±20.6%.

Conclusion:

We observed a good correlation (r=0.980, p<0.0001) between film measurements and software estimates. This study suggests that NEXO[DOSE]^® software can be considered as a valuable dose calculation tool to optimise existing practices and monitor the follow-up required for patients who have received high doses, without using radiochromic films which are expensive and time-consuming.

Limitations:

The analysis of a limited number of cases due to incorrect film positioning.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

Early in 2018, the new eye lens dose limit of 20 mSv per year for occupational exposure to ionising radiation was implemented in the European Union. Dutch guidelines state that monitoring is compulsory above an expected eye lens dose of 15 mSv/year. In this study, we assess whether the eye lens dose of interventionalists in the Máxima Medical Centre, the Netherlands, would exceed 15 mSv/year and whether the measured eye lens dose measurements can be individually related to regular personal dosimeter measurements.

Methods and materials:

The eye lens dose, Hp( 3), of interventional radiologists (n=2), cardiologists (n=2), and vascular surgeons (n=3) was measured during six months, using thermoluminescence dosimeters (Mirion dosimetry services) on the forehead. Simultaneously, the surface dose, Hp (0.07), and whole-body dose, Hp (10), were measured using regular dosimeters outside the lead skirt at chest level. The dosimeters were simultaneously refreshed every four weeks. The observed dose data was extrapolated to one year to check compliance with the year limit.

Results:

A clear relation was observed between the two dosimeters: Hp(3)≈0,25 Hp(0,07). The extrapolated year dose for the eye lens did not exceed 15 mSv for any of the interventionalists (average 3 to 10 studies/month).

Conclusion:

The eye lens dose can be monitored indirectly through regular dosimeter at chest level. Additionally, all interventionalists remain below the dose limit and compulsory monitoring limit for the eye lens dose. We cannot generalise our findings to other hospitals because of too many variables involved, such as procedure type, the orientation of the tube, and the position of the interventionalist. Nevertheless, a limited monitoring period can give substantial information on the yearly eye lens dose.

Limitations:

Findings are not generalisable to other hospitals due to many variables.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

Telemedicine has been utilised in primary care to increase access for patients. As the patient acceptance of this practice has grown, specialists have also begun to utilise telehealth visits. We tested the feasibility of starting an IR TeleHealth practice and studied the impact with a focus on days from IR referral to consult and from IR referral to biopsy.

Methods and materials:

Telehealth visits were performed either by a physician or advanced practice provider at a single academic medical centre. The total patient encounters were analysed from 2017-2019. Visit types were categorised by standard documentation criteria. Time saved by the patient and physician not having to travel between locations was studied. Days from IR referral to consult and days from IR referral to biopsy were studied.

Results:

In our experience, there were 325 telehealth encounters. Patients saved a total of $10,524 in travel costs and 279 hours of travel time. A total of 521 hours of travel time was saved by physicians and a total of $76,000 was saved by the practice. Days from IR referral to a clinic consult decreased from 2.7 days to 0.33 days and days from IR referral to biopsy decreased from 17.2 days to 12.2 days.

Conclusion:

Leveraging telehealth can increase access to care for patients and allow for more efficient use of physician resources. In addition, telehealth could decrease the time from the referral to the initial office consult and could decrease both the time to the clinic consultation and the IR procedure since many of these patients could potentially be seen on the same day as the referral.

Limitations:

The equipment cost and regulations/compliance issues.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

Interventional radiology (IR) is an evolving sub-speciality, although its representation in the undergraduate curriculum is not. This has prompted the cardiovascular and interventional radiology society of Europe (CIRSE) to introduce an undergraduate curriculum. With a shortage of 500 IR consultants, we aim to assess IR representation in the undergraduate curriculum across the United Kingdom.

Methods and materials:

An 18-question questionnaire, influenced by the CIRSE undergraduate curriculum, was circulated across 18 hospitals in the United Kingdom. Recently graduated doctors were targeted to assess their understanding of IR given that they would have theoretically been exposed to the entire undergraduate curriculum and only have limited postgraduate experience.

Results:

280 replies were received. One-third of the cohort demonstrated poor exposure to general radiology, although this figure soared to 76% for IR. Only 13% of the respondents experienced a dedicated IR section in their undergraduate curriculum. Only two students were aware of international/national IR undergraduate curricula. More than 80% of respondents did not consider a career in radiology for various reasons, with 30% citing a lack of exposure. 40% of junior doctors were not aware of radiation exposure in IR. Similarly, less than half of the cohort correctly identified both the training route for IR and the imaging modalities used. Nonetheless, 80% of the respondents thought coronary stenting was being performed by IRs. Finally, the majority of the cohort welcomed radiology attachments and IR lectures as preferred teaching methods, the inclusion of IR undergraduate curriculum, and a two-week postgraduate exposure.

Conclusion:

Despite current efforts, radiology, especially IR, is still falling behind in undergraduate curriculum representation. This study confirms that improved IR undergraduate exposure is a key factor in tackling national shortages of IRs.

Limitations:

National, not international, study.

Ethics committee approval

n/a

Funding:

No funding was received for this work.