Impact of the COVID-19 pandemic on radiology physician work RVUs at a large subspecialized radiology practice

PURPOSE

As the COVID-19 pandemic continues, efforts by radiology departments to protect patients and healthcare workers and mitigate disease spread have reduced imaging volumes. This study aims to quantify the pandemic's impact on physician productivity across radiology practice areas as measured by physician work Relative Value Units (wRVUs).

MATERIALS AND METHODS

All signed diagnostic and procedural radiology reports were curated from January 1st to July 1st of 2019 and 2020. Physician work RVUs were assigned to each study type based on the Medicare Physician Fee Schedule. Utilizing divisional assignments, radiologist schedules were mapped to each report to generate a sum of wRVUs credited to that division for each week. Differential impact on divisions were calculated relative to a matched timeframe in 2019 and a same length pre-pandemic time period in 2020.

RESULTS

All practice areas saw a substantial decrease in wRVUs from the 2020 pre- to intra-pandemic time period with a mean decrease of 51.5% (range 15.4%-76.9%). The largest declines were in Breast imaging, Musculoskeletal, and Neuroradiology, which had decreases of 76.9%, 75.3%, and 67.5%, respectively. The modalities with the greatest percentage decrease were mammography, MRI, and non-PET nuclear medicine.

CONCLUSION

All radiology practice areas and modalities experienced a substantial decrease in wRVUs. The greatest decline was in Breast imaging, Neuroradiology, and Musculoskeletal radiology. Understanding the differential impact of the pandemic on practice areas will help radiology departments prepare for the potential depth and duration of the pandemic by better understanding staffing needs and the financial effects.

Operational Radiology Recovery in Academic Radiology Departments After the COVID-19 Pandemic: Moving Toward Normalcy

This article presents a current snapshot in time, describing how radiology departments around the country are planning recovery from the baseline of the coronavirus disease 2019 pandemic, with a focus on different domains of recovery such as managing appointment availability, patient safety and workflow changes, and operational data and analytics. An e-mail survey was sent through the Society of Chairs of Academic Radiology Departments list server to 114 academic radiology departments. On the basis of data reported by the 38 survey respondents, best practices and shared experience are described for three key areas: (1) planning for recovery, (2) creating a new normal, and (3) measuring and forecasting. Radiology practices should be aware of the common approaches and preparations academic radiology departments have taken to reopening imaging in the post-coronavirus disease 2019 world. This should all be done when maintaining a safe and patient-centric environment and preparing to minimize the impact of future outbreaks or pandemics.

Benefits of EMDR therapy on the memory in the treatment of PTSD

According to some studies, 80% of subjects suffering from post-traumatic stress disorder (PTSD) present twice the risk of developing an insanity as they age because of the high level of stress that has been induced. Indeed, the triggered trauma has a deleterious effect on the establishment of the stress’ axis (the hypothalamic pituitary adrenal axis) which is then not able to regulate itself. As a consequence, the hippocampal neurons will be attacked by an excess of cortisol. Memory's dysfunction is central in the symptomatology of PTSD, particularly in respect to encoding and recall. The hippocampus is able to transfer information to the prefrontal cortex. Actually, subjects with PTSD present less activity in the prefrontal cortex triggered by a decrease of encoding and recall capacities. EMDR therapy (eye movement desensitization and recruitment) allow for a fast relief of symptoms by a bilateral alternate stimulation (SBA). Indeed, saccadic eye movements stem affect related to the traumatic event and process the associated cognitions. During the desensitization phase in EMDR, we noticed an increase in activity of the brain's prefrontal, ventromedial, amygdala and thalamic regions. Indeed, the recall of traumatic memories goes through implicit emotional valence regions and associative areas for which the experience is already deeply integrated. After comparing cerebral activity before and after the therapy, researches on EMDR shows that a reduction of stress’ symptoms has some sensitive link to PTSD (in prevention to dementia).

Disclosure of interest

The authors have not supplied their declaration of competing interest.

L’information du sujet schizophrène en pratique clinique : données actuelles

Social isolation has got to be one of the greatest losses in schizophrenia. For many authors, people with schizophrenia can have no friends, no spouse, and sometimes no family. Two thirds of patients with schizophrenia return to their parents' house after discharge from a hospital for the first psychosi episode. Family members generally receive very little education as to what they can expect. They may not know the importance of medication compliance. Family members are the primary victims of violence from psychotic individuals, usually their own son or daughter, and most families cannot believe their own son or daughter would be capable of such a thing. Although families are usually the main care givers at the beginning of schizophrenia they often find their experience very frustrating for a number of reasons, and relationships suffer. Family education and support have been shown to improve outcomes considerably and family education is the second strongest factor in relapse prevention. Without education and good relapse prevention families often burst out. Most of the homeless mentally ill in downtown city cores have lost their family relationships. It is not a reflection on their families so much as the lack of adequate treatment and support. The families tried and tried and lost their ill relative. A patient writes: "My father lives just outside of Monaco. My mother developed Alzheimer's a couple of years ago or so and with a series of mild strokes died recently. I haven't seen either of them very much in the last fifteen years. I have a sister, Nicole, who also lives in Paris. I lost those relationships to some degree over the years. I am rebuilding them now. Enter the professional friend, the case manager, usually in cases where the individual is quite disabled by schizophrenia and/or at considerable risk of relapse, and usually when the individual has lost their family relationships to some degree. I had a case manager for several years and always looked forward to her visits. Case managers help negotiate compliance to medication, housing, meaningful activity, substance abuse, poverty, isolation, and everything else living in the community can throw at you. Without a spouse you tend to spend a lot of time alone. One of the main reasons Marie-Claude and I moved in with each other was that neither of us was enjoying living alone. It was very romantic at first but now we are just friends who see less and less of each other. I suspect schizophrenia interferes with the quality and depth of relationships you have with other people. Amongst the people I know, schizophrenia has meant a pretty solitary life of poverty. I have a lot of acquaintances, and colleagues, but few close friends when not at work. Over the last ten years of living with schizophrenia on medication it is celibacy that has hurt the most. It saps the life out of you, your self confidence, your self esteem. In some Scandinavian countries and Holland disabled people are allowed monthly visits by state approved sex workers. To me that is only common sense. To live without sex is unnatural and can only cause emotional suffering. We don't recognize the importance of quality sexual experience in keeping people healthy and happy in France. That doesn't mean it isn't I have a pretty high profile in my community through the meaningful activity I do. From having a half dozen names and faces to remember, I now have what seems like hundreds. I have a lot of trouble remembering people's names and faces. I am still meeting new people but I'm rarely invited to socialize with any after work. They have families, full time jobs, kids, cars, cottages, etc. My life at home is pretty solitary. It's a nuisance to travel across the city to visit people. There are few people that I share a similar background with. Since people with schizophrenia tend to have trouble learning new things, and change very little as a result, we tend to have trouble making new friends. People with schizophrenia can come alive talking about things in the past before they became ill. It's as if their life grinded to halt when they became sick. I'm stuck in the mid seventies, and that's the music I like. Everybody I know with schizophrenia is quite isolated socially and I don't really know why. That is especially true for the older people in my age group. Younger people seem to be doing much better. Many still live with their parents. Most older people live alone. There is also the odd person who recovers well, returns to a career, and marries someone without schizophrenia. In cases where marriage predates the onset of schizophrenia, the outcome is often divorce although women are more likely to stick with their husbands with schizophrenia than vice versa, especially if there are already children. I hope the next generation who appears to be less disabled survives better than people of my age with schizophrenia. The goal of community integration is one that requires: more effective treatments and/or more financial support and/or a compassionate non-discriminating community. The combination of early diagnosis and atypical medications will change the face of schizophrenia. I'm not expecting more financial support from the government, but many more people with schizophrenia will start working again instead. Their social networks will develop but social networks are probably the hardest hit in schizophrenia. It's better that you never lose your friends in the first place". This testimony shows how the information of the schizophrenic patient is necessary, and underlines the importance of the relationships between the patient and his family. Our article insists on this theme, rarely developed in the literature.

[About the use of seclusion in psychiatry: the patients' point of view]

In this study of psychiatric inpatients' perceptions of the seclusion-room experience, 67 admitted inpatients were interviewed during 6 Months within 3 days of the experience, and 24 hours after. A 35-items semistructured interview schedule was used to obtain information on six research questions. Subjects' perception of the reasons for their seclusions varied greatly from perceptions of staff members. Findings implied that for some patients seclusion may have been unnecessary, but for others it was beneficial. Subjects who reported out-of-control impulses or pathological intensity of relationships prior to seclusion and who showed positive change in mood, behavior, or thinking toward staff and/or other patients during or after seclusion seem to have benefited from the experience. Seclusion is a common practice in most psychiatric inpatient settings. The reported incidence of seclusion varies from 4% to 66% of admissions to psychia-tric facilities. But seclusion is controversial. Opponents of seclusion have based their arguments on a concern for the rights of mental patients and a dedication to treat patients in the least restrictive environment. Proponents of seclusion have based their arguments on the theoretical benefits of isolation and the reduction of external stimuli. However, little information about the psychiatric patients experience before, during and after seclusion is currently available. The purpose of this exploratory descriptive study is to gather information on psychiatric patients' perceptions of their seclusion-room experiences, their experiences immediately before and after seclusion, and how they thought these experiences affected them or others. Subjects and staff described the reasons for seclusion differently. For example, subjects described situations leading up to seclusion, but staff described aggressive behavior justifying seclusion. Yet, almost all reasons provided by both groups involved subjects' out-of-control impulses or problems in relationships. The physical, behavioral, and emotional responses of patients to seclusion have been the subject of both observation and more formal investigation. In a study of 263 seclusion episodes, Gerlock and Solomons (1983) noted that 83% of the patients evidenced disturbed behavior at the initiation of seclusion and only 23% did so on release. In a study of the use of the quiet room on a children's unit, Joshi et al. (1988) observed that 92% of the patients who were agitated when placed in the quiet room were calm on release and that 79% were able to rejoin group activities. As for nonempirical investigations, Gair et al. (1965) observed no ill effects (such as fear, withdrawal, or disorganization) and an improvement in inner controls as a result of the use of seclusion on a children's unit. Way and Banks (1990) cautioned against the side effects of humiliation, disorientation, and medical complications of restraint and seclusion in the elderly. As previously noted, many re-presentatives of the psychiatric consumer/survivor movement have characterized seclusion as an extraordinarily traumatic intervention. It is therefore important to examine empirical studies of the emotional effects of this intervention on patients. Perhaps the best-known study is that of Wadeson and Carpenter (1976), which involved 62 mostly unmedicated patients on an NIMH research unit with a seclusion rate of 66%. Patients were asked to draw their experiences and feelings connected with their illness and treatment in three art sessions (2 weeks after admission, 2 weeks before discharge, and 1 Year later). Thirty-three percent of the patients drew the seclusion experience. Their art work and their discussions of it revealed negative feelings (fear, estrangement, hostility, retaliation, guilt, paranoia, bitterness) as well as sadomasochistic conflicts and comforting hallucinations (possibly as a response to sensory deprivation). Several other studies have investigated patients' emotional responses to seclusion. Binder and Mac Coy (1983) conducted semistructured interviews with 24 patients who had been secluded. Thirteen of the 24 patients had no idea or a false idea as to why they had been secluded, 22 were unaware that staff checked on them every 15 minutes, and 13 felt that there was nothing good about the experience. Ne-vertheless, half of the 24 patients felt that the intervention had been necessary and about half felt that it would not adversely affect their attitudes toward treatment. Plutchik et al. (1978) investigated the perceptions of seclusion of patients who had or had not been secluded. Patients who had not been secluded felt safer when they saw others being secluded. Patients who had been secluded felt angry when others were secluded and bored and angry while in seclusion, but the majority felt that seclusion helped calm them down. Patients accurately perceived the precipitants of seclusion. Plutchik et al. also looked at staff perceptions. They found that although most staff felt that seclusion was beneficial to patients, professional staff had the most "regrets" about it. Patients accurately estimated and staff significantly underestimated the average duration of seclusion. Joshi et al. (1988) noted that 14% of children who had been secluded on their unit were angry and 17% were sad while they were in seclusion. Sheridan et al. (1990) observed a 2:1 ratio of negative-to-positive attitudes toward seclusion among patients interviewed at a VA hospital. They also noted that patients' attitudes toward initial seclusion had no effect on subsequent seclusion rates. Thus, although it appears to be reasonably well-established that seclusion "works", i.e., it provides an effective means for preventing injury and reducing agitation, it is at least equally well-established that this procedure can have serious deleterious physical and (more often) psychological effects on patients.

Robot-aided neurorehabilitation: from evidence-based to science-based rehabilitation

There is no "magic bullet" in rehabilitation. In the absence of direct neural transplants, neurological rehabilitation is an arduous process. We have pioneered the clinical application of robotics in stroke rehabilitation and have shown evidence of the positive impact of targeted exercise on stroke recovery. In this article, we will review results obtained in the initial clinical trials with 96 stroke patients at the Burke Rehabilitation Hospital. We will provide evidence that robot-aided training enhances recovery, that this enhanced recovery is sustained in the long term, and that this recovery is not due to a general physiological improvement--in fact, it appears to be limb and muscle group specific. An evidence-based approach must now segue into a more scientific approach to stroke rehabilitation. Given the length of the required protocols and patients' variability and limited census, the practical limitations of the evidence-based approach are self-evident and extend trials for years. Each patient and lesion is unique in stroke rehabilitation, so there is no reason to believe that a "one-size-fits-all" optimal treatment exists. To optimize therapy for individual patients, we need science-based models. In this article, we will summarize the scientific tools and models that we are investigating and present some of the results to date.

[About the use of restraints in psychiatry: the patient's point of view]

Previous research about the use of restraints has mainly sought generalizations regarding who is likely to be restrained, the frequency of the use of restraints, and the behavior that precipitates the application of restraining devices. Therefore, there has been a paucity of research that attempts to understand the impact of restraint on the restrained person. The purpose of this study is to understand the meaning of the experience of being restrained for 43 psychiatric patients who had been restrained in leather restraints. Participants were interviewed in unstructured interviews. The taped interviews were transcribed and analyzed by means of a modification of an interpretive process, grounded in phenomenology. In this article, the theme of power is reported and discussed.

[Characteristics of patients hospitalized in a specialized hospital center after after attempted suicide]

Authors have counted, during a period of one year, the totality of patients having been admitted to the Centre Hospitalier Spécialisé de la Savoie (Chambéry) following a volunteer medicinal intoxication; 227 patients have been thus included, this type of acting out concerning third more women than men. The higher impact is found in young adults (20-40 years). Professional inactivity appears as a favoring factor, while the way of life (bachelor or in couple) does not seem to have consequence on the frequency of occurrence of the suicidal attempts. Relapses are numerous, and happen in most cases during the year. Concerning used medicines, they have been generally prescribed by a practitioner or a psychiatrist. The prominent fact is the presence of a very short period between the prescription, the deliverance of the medicine and the acting out. Plurimedicinal intoxications are increasingly frequent, with often concurrent absorption of alcohol. The diminution of the use of barbiturics in ambulatory medicine to the profit of other molecules, and especially the benzodiazepines, has reduced the frequency of their use in volunteers medicinal intoxications. Benzodiazepines are the most employed medicines in this type of acting out. This epidemiological and toxicological study confirms that used substances during volunteer medicinal intoxication are a reflection of the general medicinal consumption.

[Restraint and seclusion in psychiatry: review and prospects]

In this article, the authors reviewed the literature published since 1965 concerning restraint and seclusion. They synthesized the contents of the articles reviewed using the categories of indications and contraindications; rates of seclusion and restraint as well as demographic, clinical, and environmental factors that affect these rates; effects on patients and staff; implementation; and training. The literature on restraint and seclusion supports the following: 1) Seclusion and restraint are basically efficacious in preventing injury and reducing agitation; 2) It is nearly impossible to operate a program for severely symptomatic individuals without some form of seclusion or physical or mechanical restraint; 3) Demographic and clinical factors have limited influence on rates of restraint and seclusion; 4) Training in prediction and prevention of violence, in self-defense, and in implementation of restraint and/or seclusion is valuable in reducing rates and untoward effects; 5) Studies comparing well-defined training programs have potential usefulness.

[Apropos of using patient isolation in psychiatry: point of view of nurses]

Seclusion continues to be used in the care of acutely disturbed psychiatric patients despite often emotionally charged debate about its appropriateness within mental health services. Powerful legal and moral arguments about the use of seclusion emphasize an urgent need to critically examine its role in the care of mentally ill people. This paper examines the use of seclusion on psychiatric departments in the management of acutely disturbed patients: 36 psychiatric nurses working in 6 departments in a specialized hospital (the CHS de la Savoie, in Chambery) were interviewed in relation to their perceptions of the role of seclusion. Data were analysed using grounded theory methodology revealing the core conceptual category "controlling" and two sub-categories "watching out for" and "watching over". Seclusion was found to be used as an adjunctive treatment in the care of individuals considered to be "out of control". Clinicians expressed comfort with the use of seclusion, citing a strict protocol that provided parameters for its use. While expert therapeutic interventions were described by clinicians, they are contextualized within a framework of power and control--a framework that stands in stark contrast to contemporary philosophies of nursing care, providing impetus for a reconsideration of the use of constraining practices in the care of mentally ill people.

[Apropos of sleep quality in students: prospective study]

This study about the pupils' sleep in the academy of Aix-Marseille has been realized after the observations of second cycle's teachers; they have noted a somnolence by an important number of pupils during lessons, consequence of a supposed sleep lack able to have repercussions on the scholastic success. Hearing teachers and pupils' suggestions, the authors have established a questionnaire with 20 items; this study is concerning 1,300 pupils, 15 to 20 years old, in classic, technical and agricultural high schools, both in public and private establishments. The most salient characteristic is the differences between the sleep of the scholastic period and the sleep of week end or holiday. In the future, a better knowledge of pupils' sleeping habits could be the starting point of information and prevention campaign.

[About ethics in psychiatry and psychiatrists facing ethics]

The plug in account of the suffering, notably psychological, in a consultation, puts the problem of the relationship between suffering and ethics. However, the originality of the ethical step is justly not to be confined to the social norm conformism, but being specific to the individual dimension. The psychiatric pathology offers in this area of particularities interesting. The neurotic, as the obsessed, suffering inwardly pathological manifestations that he judges absurd, replies to the medical moral in asking a care. The psychotic, which projects his suffering on the other, does not feel sick, requests no therapeutic assistance. As such he contests the medical order in an immoral position by definition, and the patient represents from then on a social and medical scandal. In front of a such clinical diversity, we can easily underline that approaching the theme of ethics in psychiatry isn't a well-off exercise, and necessitates a precise locating registered in the history of the patient.

[Between compliance and freedom: the patient's statement]

According to the patient, obtaining a good compliance is related to a good relationship with his practitioner; this relationship is directly connected to being a good listener for the patient, and not only for their symptoms. If the individual motivation is very important at the beginning, it will be itself greatly influenced by the relationship between the practitioner and the patient. It is one of the rare factors with a positive correlation with compliance, that's what almost all of the researches on medical psychology have observed. Once the problem is sumed up, it's the turn to speak for the patient, who explains how he considers compliance.

[The use of therapeutic isolation and confinement in psychiatry. A prospective study]

Despite recent developments in psychopharmacology and a better understanding of agitation patterns in psychiatric patients, the use of seclusion and restraint procedures remains a matter of daily practice. Little or no time is spent on its teaching in a formal way. There is almost no literature on these issues, and it has grown only since legal procedures initiated by patients, which forced practitioners to spend some time analysing these methods. Facing this problem, we realized a prospective study at the CHS de la Savoie, in Chambéry, so as to clarify the current modes of these procedures. This study was led among 460 secluded patients, during one year. 11 data were studied, such as the duration of the seclusion, the reason and the medical history, the desire of the patient to be liberated ... The review or awareness of certain variables may give clinicians a better perspective on the use of procedures which, unfortunately, continue to be the cause of deaths in psychiatric practice.

[Social trajectory and schizophrenia]

On the occasion of the Clozapine symposium we have had cause to reflect on the social life-histories of schizophrenic patients. After an analysis of a cohort of 40 patients aged over 65 years, whose medical records had been kept up since the start of their disease, we have set up a methodology which enables us to study the social life-histories of these patients. Our aim is ultimately to compare the course of the disease with the treatments received by these patients and the therapeutic structures they have been offered. For this purpose, we shall study three criteria of social exposure: 1) Autonomy, 2) Integration into the family, 3) Integration through work. The aim of the present paper is to record our initial analytical findings in these three years.