Anticipated schedule of the number of retained Sitz markers on serial daily abdominal radiographs in a 20 Sitz marker exam. Day number is in the left column and retained Sitz marker number is in the right column.
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\\n"}]',published:!0,mainMedia:{caption:"Highly Cited",originalUrl:"/media/original/117"}},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
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Since 2008, she has been a Professor at the Federal University of Campina Grande (UFCG).",coeditorTwoBiosketch:"Dr. Marco Antônio Alves Schetino studied biological sciences at the Federal University of Viçosa (UFV), Brazil, he received a master´s degree in Genetics, Conservation, and Evolutionary Biology from the National Institute of Amazonian Research (INPA), Brazil, and a Ph.D. in Genetics from the Federal University of Minas Gerais (UFMG), Brazil. He is a researcher with experience in Genetics (with emphasis on Animal Genetics, Evolution, and major health areas) and philosophy of science areas.",coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"212393",title:"Prof.",name:"Rafael",middleName:"Trindade",surname:"Trindade Maia",slug:"rafael-trindade-maia",fullName:"Rafael Trindade Maia",profilePictureURL:"https://mts.intechopen.com/storage/users/212393/images/system/212393.jpg",biography:"Dr. Rafael Trindade Maia studied biological sciences at the Federal Rural University of Pernambuco, Brazil (2005). He received a master´s degree in Genetics, Conservation, and Evolutionary Biology from the National Institute of Amazonian Research, Brazil, in 2008, and a Ph.D. in Animal Biology from the Federal University of Pernambuco, Brazil, in 2013. He is currently an adjunct professor at the Center for the Sustainable Development for Semiarid (CDSA) at Federal University of Campina Grande (UFCG), Brazil. He has experience with population genetics, bioinformatics, molecular docking, and modeling and molecular dynamics of proteins. He works in science and biology education. Dr. Maia also leads the research groups Computational and Theoretical Biology (CTB) and Education in Sciences and Biology (ESB).",institutionString:"Federal University of Campina Grande",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"4",totalChapterViews:"0",totalEditedBooks:"3",institution:{name:"Federal University of Campina Grande",institutionURL:null,country:{name:"Brazil"}}}],coeditorOne:{id:"265397",title:"Dr.",name:"Magnólia De Araújo",middleName:null,surname:"Campos",slug:"magnolia-de-araujo-campos",fullName:"Magnólia De Araújo Campos",profilePictureURL:"https://mts.intechopen.com/storage/users/265397/images/system/265397.png",biography:"Magnólia A. Campos is a biologist, has a Masters in Agronomy / Plant Breeding from the Federal University of Pelotas and a PhD in Biological Sciences / Molecular Biology from the University of Brasília (2002). She had a total five years of experience in genomic sciences as a postdoctoral researcher at the Federal University of Lavras / Agronomic Institute (IAC). Since 2008, she has been a Professor at the Federal University of Campina Grande (UFCG). She has experience in the area of plant biotechnology, working mainly on the following topics: genomics, bioinformatics, tissue culture and plant cells, genetic transformation of plants, study of gene expression during plant-microbe interactions and expression of heterologous proteins in bacteria.",institutionString:"Federal University of Campina Grande",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Federal University of Campina Grande",institutionURL:null,country:{name:"Brazil"}}},coeditorTwo:{id:"468502",title:"Dr.",name:"Marco Antônio",middleName:null,surname:"Alves Schetino",slug:"marco-antonio-alves-schetino",fullName:"Marco Antônio Alves Schetino",profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:"Dr. Marco Antônio Alves Schetino studied biological sciences at the Federal University of Viçosa (UFV), Brazil (2005), received a master´s degree in Genetics, Conservation, and Evolutionary Biology from the National Institute of Amazonian Research (INPA), Brazil, in 2008, and a Ph.D. in Genetics from the Federal University of Minas Gerais (UFMG), Brazil, in 2017. He is currently a Postdoc at the Federal University of Vales do Jequitinhonha e do Mucuri (UFVJM), Brazil. He has experience with Phylogenetic systematics, phylogeography, population genetics, evolution and conservation. Former professor at UNI-BH of the Biological Sciences and Ecology Course. Former substitute professor of the Bachelor of Science and Technology, BCT, at UFVJM.",institutionString:"Federal University of Vales do Jequitinhonha",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:null},coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"6",title:"Biochemistry, Genetics and Molecular Biology",slug:"biochemistry-genetics-and-molecular-biology"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"347259",firstName:"Karmen",lastName:"Daleta",middleName:null,title:"Ms.",imageUrl:"//cdnintech.com/web/frontend/www/assets/author.svg",email:"karmen@intechopen.com",biography:null}},relatedBooks:[{type:"book",id:"6694",title:"New Trends in Ion Exchange Studies",subtitle:null,isOpenForSubmission:!1,hash:"3de8c8b090fd8faa7c11ec5b387c486a",slug:"new-trends-in-ion-exchange-studies",bookSignature:"Selcan Karakuş",coverURL:"https://cdn.intechopen.com/books/images_new/6694.jpg",editedByType:"Edited by",editors:[{id:"206110",title:"Dr.",name:"Selcan",surname:"Karakuş",slug:"selcan-karakus",fullName:"Selcan Karakuş"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1591",title:"Infrared Spectroscopy",subtitle:"Materials Science, Engineering and Technology",isOpenForSubmission:!1,hash:"99b4b7b71a8caeb693ed762b40b017f4",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/1591.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophile",surname:"Theophanides",slug:"theophile-theophanides",fullName:"Theophile Theophanides"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3161",title:"Frontiers in Guided Wave Optics and Optoelectronics",subtitle:null,isOpenForSubmission:!1,hash:"deb44e9c99f82bbce1083abea743146c",slug:"frontiers-in-guided-wave-optics-and-optoelectronics",bookSignature:"Bishnu Pal",coverURL:"https://cdn.intechopen.com/books/images_new/3161.jpg",editedByType:"Edited by",editors:[{id:"4782",title:"Prof.",name:"Bishnu",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"371",title:"Abiotic Stress in Plants",subtitle:"Mechanisms and Adaptations",isOpenForSubmission:!1,hash:"588466f487e307619849d72389178a74",slug:"abiotic-stress-in-plants-mechanisms-and-adaptations",bookSignature:"Arun Shanker and B. 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Imaging evaluation of constipation has evolved from radiography and contrast enemas to advanced cross-sectional and functional imaging. A dilemma that physicians of medical and surgical specialties encounter when confronted with a patient with constipation is the decision of if or when radiology is indicated. The clinical presentation of the patient and what information is desired will ultimately govern if imaging is warranted and then what is the most appropriate exam to order. If the patient presents in the acute setting with a potential surgical emergency, fast and widely available imaging exams, such as radiography or computed tomography (CT), are the most appropriate exams to order. If the patient has a chronic issue or data regarding colorectal function is desired, a colorectal transit time exam with Sitz markers or defecography with fluoroscopy or magnetic resonance (MR) imaging are the exams of choice. With a diverse range of anatomic and functional imaging tests available, radiology has developed into an invaluable mechanism in the assessment of patients with constipation.
\nRadiography, also known as plain film or X-ray, is a widely available, inexpensive, and easily obtained imaging test to assess for constipation. While the reported diagnostic sensitivity of radiography for the detection of constipation is 84%, the reported specificity is 72% [1]. Despite its relatively low sensitivity and specificity, radiographs serve as a basis for triage for further imaging work-up and assist in the therapeutic decision-making process. Inherent pitfalls in radiography of patients whom are constipated are other causes of colonic dilation, particularly adynamic ileus and colonic pseudo-obstruction [1].
\nRadiography is commonly used to image pediatric patients with constipation, particularly in the acute setting. However there is a unified consensus throughout the medical community to reduce non-essential and unnecessary radiation exposure to the pediatric population [2]. The latest consensus guidelines from the North American and European Societies of Pediatric Gastroenterology, Hepatology, and Nutrition advocate that constipation should be diagnosed clinically in pediatric patients because there is no reliable system to diagnose constipation and, instead, this modality may lead to misdiagnosis of more acute pathology [2]. Expert consensus also advocates that radiography has no role in imaging of children with functional constipation, which is best diagnosed with careful clinical assessment and physical examination [2].
\nAnteroposterior (AP) images of the abdomen and pelvis in the supine position are performed to visualize and qualify the burden of feces, visualize the size of the colon, and assess for colonic obstruction. Erect and lateral decubitus images of the abdomen and pelvis to may be added if there is concern for complications of constipation such as free air from a perforation [1].
\nThe key radiographic findings of constipation are the presence of large fecal burden throughout the colon, luminal fecalomas, and a relative paucity or absence of luminal gas [3]. Feces appear as soft tissue opacities with internal mottled air (Figures 1 and 2) [3].
\nAP radiograph of the abdomen and pelvis in a patient with constipation displays diffuse dilation of the colon (arrow) with an abrupt transition in luminal caliber by a large soft tissue opacity, which contains internal mottled air, indicative of feces (arrowhead).
AP radiograph of the abdomen and pelvis of patient with constipation shows a dilated colon with a transition in caliber due to a soft tissue opacity, which contains internal mottled air, characteristic of feces (arrow).
Radiography is helpful to assess for the presence of complications associated with constipation. Non-dependent images of the abdomen in the upright or left lateral decubitus positions may also be used for assessment of free air [1]. Bowel ischemia and infarction may be manifested on radiographs as pneumatosis, or air within the bowel wall, and/or portal venous gas, which projects over the silhouette of the liver [1]. Pneumoperitoneum from bowel perforation can be detected on radiography by air external to the bowel wall, air along the peritoneal ligaments, and air in the right upper abdominal quadrant [1]. If a surgical emergency is suspected on radiography, emergent surgical consultation is recommended. However, if surgery is not imminently planned or other treatment options are being considered, assessment of the severity and cause of the constipation with cross-sectional imaging becomes a priority. CT is the preferred imaging modality because of its superior sensitivity and specificity and it can potentially modify treatment.
\nTwo entities that mimic mechanical causes of constipation are adynamic paralytic ileus and acute colonic pseudo-obstruction. Adynamic paralytic ileus is commonly due to medications, metabolic abnormalities, and recent surgery. Acute colonic pseudo-obstruction, also known as Ogilvie’s Syndrome, is due to altered autonomic innervation of the colon and may also be caused by medications and metabolic disturbances [1].
\nAssessment of the small bowel and colon in pediatric patients may be challenging because the appearances, fold pattern, and location of the small bowel and colon overlap more so than in adult patients. There is also no established system to diagnose constipation in pediatric patients. Therefore radiography may be misleading in the assessment of pediatric patients it may result in missed diagnoses; this modality should be used in children in a limited fashion.
\nA radiographic test that is used to estimate transit time of the colon is a Sitz marker exam [4]. In patients with constipation, this study may help discriminate between delayed colonic transit and defecation disorders.
\nPatients are instructed to discontinue laxatives or any pro-motility medications. Otherwise no preparation is needed. The most common technique used is the ingestion of 20 or 24 Sitz markers in a single dose with a meal. Sitz markers are small, plastic rings that contain radio-opaque material so they may be visible on radiographs (Figure 3) [4]. Then serial anteroposterior radiographic images of the abdomen and pelvis are obtained to monitor the clearance of the Sitz markers from the colon (Figure 4). A normal colonic transit time ranges between 24 and 56 h. Most patients will clear all of the Sitz markers in 4–5 days [4].
\nMagnified AP radiograph of the pelvis shows Sitz markers.
AP radiograph of the abdomen and pelvis in this patient on day 3 of a Sitz marker exam, 18 of 20 Sitz markers are present and indicate that colonic transit will be delayed at 5 days.
A normal colonic transit time, which is between 24 and 56 hours, corresponds to retention of less than 20% of the original Sitz markers at 5 days [4]. In a Sitz marker exam that used 20 Sitz markers, the anticipated schedule of the number of retained Sitz markers on serial daily abdominal radiographs is as follows (Table 1).
\nDay | \nSitz markers | \n
---|---|
1 | \n≤16 | \n
2 | \n≤8 | \n
3 | \n≤4 | \n
4 | \n≤2 | \n
5 | \n≤1 | \n
Anticipated schedule of the number of retained Sitz markers on serial daily abdominal radiographs in a 20 Sitz marker exam. Day number is in the left column and retained Sitz marker number is in the right column.
Fluoroscopy employs the administration of contrast with real-time, moving radiographs to image both anatomy and function. Two fluoroscopic imaging techniques used to evaluate patients with constipation are contrast enema and evacuation proctography exams.
\nContrast enema may be valuable in the initial imaging assessment of patients with constipation because of it allows delineation of mechanical causes of constipation by displaying the luminal size of the colon and rectum, site(s) of transition in luminal caliber, and the length of involvement [5]. This exam is unique because it may be both diagnostic and therapeutic: the instillation of contrast material into the colon and rectum may relieve fecal impaction [5].
\nPrior to the exam, patients undergo a bowel cleanse preparation with an oral laxative, such as magnesium citrate or polyethylene glycol. Contrast enema exams are performed with fluoroscopy and may be performed with either single contrast: barium or water-soluble contrast only or double contrast: barium or water-soluble contrast with the insufflation of air or carbon dioxide.
\nPre-procedural radiographic anteroposterior images of the abdomen and pelvis and a left lateral radiographic view of pelvis are obtained. The patient then lies in the left lateral decubitus position on the fluoroscopy table. A digital rectal exam in performed. Then a thin, small-gauge, flexible catheter is placed into the rectum. This catheter is typically paired with a small, balloon that is inflated to ensure that the catheter does not back out of the rectum. If double contrast is performed, air or carbon dioxide is gently insufflated by hand pump to patient tolerance. The contrast is then instilled into the rectum and colon by gravity. During contrast administration, fluoroscopic-guided spot radiographic left and right lateral and left and right posterior oblique images of the rectum, rectosigmoid junction, sigmoid colon, descending colon and splenic flexure are obtained. Then an anteroposterior view of the transverse colon and a left posterior oblique view of hepatic flexure are obtained. Finally anteroposterior and posterior oblique images of the ascending colon, cecum, ileocecal valve, and the terminal ileum, are obtained. At the end of the exam, the contrast is emptied out of the colon by gravity and a post evacuation anteroposterior radiographic view of the abdomen and pelvis is obtained.
\nContrast enema exams can depict filling defects in the colon and rectum from feces and fecalomas from constipation or an obstructive mass, such as malignancy (Figure 5) [5].
\nContrast enema image of the sigmoid colon in a patient with constipation and irregular bowel movements shows an abrupt transition (arrow) with obstruction of passage of contrast. The patient was referred for a colonoscopy and then surgery for resection of an adenocarcinoma.
Colonic and rectal luminal size and the presence, degree, and length of strictures are all displayed and can be assessed on contrast enemas [5, 6]. Strictures, which are due to fibrosis from repeated inflammation or de-vascularization, may be caused by diverticulitis (Figure 6), ischemia, prior radiation or surgery (Figure 7), and inflammatory bowel disease (Figure 8) [5, 6].
\nA patient with abnormal and irregular bowel movements and constipation following an episode of acute diverticulitis underwent a contrast enema. Adjacent to multiple diverticula (arrowhead) in the descending colon, there is focal, short-segment, low-grade stricture (arrow) from prior diverticulitis.
Contrast enema image of a patient with constipation and decreased bowel movements; she has a history of cervical cancer that was treated with radiation therapy. There is a short-segment, high-grade stricture (arrow) in the sigmoid colon due to prior radiation therapy.
A patient with ulcerative colitis underwent a contrast enema. AP image after evacuation of contrast shows contrast outlining diffuse colonic wall thickening (arrows) and dilatation with smooth tapering in the sigmoid colon (asterisk).
Contrast enema is a dynamic imaging modality in the assessment of pediatric patients with constipation [7]. Contrast enemas are invaluable in both the diagnosis and extent of involvement for Hirschsprung’s disease, an entity that results in constipation due aganglionosis, or absence of the ganglion cells, in the distal colon and rectum [7]. The denervated distal colon or rectum is small in luminal size with proximal dilation [7]. Early filling views of the sigmoid colon and rectum allow for detection of an abnormal sigmoid colon to rectum size ratio and fasciculation or saw-tooth irregularity of the denervated segment [7].
\nWhile contrast enema can reliably display these causes of constipation, computed tomography (CT) may characterize these entities with greater spatial and temporal resolution, in a shorter time, with improved patient comfort, and that is more available, particularly in the emergent setting [8]. CT also permits visualization of extra-colorectal structures [8]. Therefore these causes of constipation are discussed in further depth in the CT section of this chapter.
\nDefecography is a fluoroscopic exam that provides valuable data for patients with constipation that is caused by both anatomic and functional disorders, which range from pelvic floor dysfunction to spastic pelvic floor syndrome. This exam is typically performed in adult and adolescent patients whom may follow instructions for the dynamic portion of the exam.
\nPre-procedural bowel preparation consists of a bowel cleanse preparation with an oral laxative, such as magnesium citrate or polyethylene glycol. Barium may be administered in the vagina (5 mL barium instillation) and small bowel (500 mL barium oral ingestion) to simultaneously assess these structures in relation to the colon and rectum.
\nThe patient is placed on the fluoroscopy table in left lateral decubitus position. 120–240 mL of barium paste is introduced into the rectum with a large-bore, soft catheter. Then spot lateral radiographic images of the patient at rest in the left lateral decubitus position with knees flexed to recreate the seated position. The patient is then positioned in a special defecography chair. Continuous and spot right lateral images of the seated patient are obtained at rest at rest, during strain (Valsalva maneuver), and then during defecation. A post-evacuation image during strain is obtained to assess for retained barium paste.
\nDefecography is a highly sensitive modality for the detection and classification of rectocele and rectal prolapse [9, 10]. A rectocele is the abnormal bulging or protrusion of the rectal wall due to a fascial or ligamentous defect [10]. A rectocele may cause inhibit defecation due to weakening of the vector force during strain [9, 10]. Feces may become entrapped in rectoceles that in turn results in incomplete evacuation [9, 10]. The presence of an anterior rectocele (Figure 9) is indicative of a defect in the rectovaginal fascia whereas the presence of a posterior rectocele indicates a defect in the anococcygeal ligament [9, 10]. Rectal prolapse may cause constipation by infolding of the rectum that is caused by repetitive straining and fascial disruption [9, 10].
\nEvacuation image from a fluoroscopic defecography in a patient with difficult evacuation and constipation shows a mucosal, intra-rectal prolapse (arrow) and an anterior rectocele (arrowhead), which incompletely empties.
Rectoceles are measured and classified on the basis of distance of the anterior or posterior rectal wall from the anal canal axis [9, 11, 12]. Rectal prolapses are classified by mucosa-only or full wall-thickness involvement and intra-rectal, internal intra-anal, or external location (Figure 9) [9, 11, 12]. While fluoroscopic defecography has been shown to be highly sensitive for rectal prolapse detection, MR defecography allows for similarly reliable and accurate classification of rectocele and rectal prolapse type due to superior tissue resolution [12].
\nAs an analogue to fluoroscopic defecography, MR defecography plays a vital role in the management of patients with constipation that is caused by both anatomic and functional disorders, which range from pelvic floor dysfunction to spastic pelvic floor syndrome [9, 11, 12]. High resolution and dynamic MR techniques provide detailed anatomic and physiologic information of the colon, rectum, and pelvic floor [9, 11, 12]. This data may then be used to discriminate patients that need surgery from those that need more conservative therapy [9, 11, 12]. For example, many patients with rectoceles from pelvic floor dysfunction will never improve without surgical repair whereas patients with functional constipation are treated with positive biologic feedback [9, 11, 12].
\nMR defecography is typically performed in adult and adolescent patients whom may tolerate confined space of the bore of the magnet and follow instructions for the dynamic portion of the exam. Challenges to MR imaging are pre-procedural preparation and scan times that are longer than radiography or CT exams. Also MR imaging exams may be limited in certain patients because of claustrophobia, as well as medical devices and orthopedic metallic hardware.
\nPrior to the exam, patients undergo a bowel cleanse preparation with an oral laxative, such as magnesium citrate or polyethylene glycol, and fast for 6 h. The patient is instructed to use one rectal enema the night before the examination and another up to 1 h before the exam. The patient lies in the right decubitus position on an absorbent, waterproof pad on the MR table and approximately 100–150 mL of warmed ultrasound gel is instilled in the rectum with a flexible tube. In female patients, 60 mL of ultrasound gel may be instilled into the vagina for to simultaneously assess the vagina and cervix in relation to the colon and rectum.
\nSimple and clear communication is important to establish with the patient during the examination to ensure direct instructions are followed that will in turn yield the best possible images. A phased-array torso coil is used to acquire sagittal, coronal, and axial T2-weighted steady-state fast spin echo (SSFSE) MR images: 24–30 cm field of view (FOV), 6 mm thickness, 512 × 256 matrix, repetition time (TR) = 5170 ms, echo time (TE) = 137 ms, from the superior border of the pubic symphysis to the lower end of the anal canal. Are then obtained of the entire pelvis. T2-weighted MR images are helpful in assessing for wall edema or masses and accentuate mucosal features against a bright background created by rectal ultrasound gel contrast. The high-resolution images provide superb soft tissue detail for hernias and muscular or fascial defects.
\nDynamic fast imaging employing steady-state acquisition is then performed. The FOV is centered at the rectum and then imaging is performed at rest, during strain (Valsalva maneuver), and then during defecation. Serial, single-section mid-sagittal SSFSE MR images (30 cm FOV, 8 mm thickness, 256 × 256 matrix, TR = 3840 ms, TE = 1670 ms) are acquired every 2 s and repeated 15–20 times and viewed as a cine loop. Gradient echo imaging may also be used for the dynamic sequences. Imaging is also performed of the patient while performing squeeze maneuver to evaluate puborectalis muscle contraction. The use of these dynamic sequences allows real-time functional imaging.
\nThe excellent tissue resolution of MR imaging provides valuable information on anatomic abnormalities of the rectum and pelvic floor. The dynamic component of MR imaging enables assessment of function and physiology. MR imaging has a high sensitivity of the presence of rectoceles (Figure 10) and rectal prolapse (Figure 10) [9, 11]. Rectoceles are measured and classified on the basis of distance of the anterior or posterior rectal wall from the anal canal axis [9, 11]. A bulge of the rectum that measures less than 2 cm is normal; over 2 cm is abnormal and diagnostic of a rectocele [9, 11, 12]. Rectoceles that protrude up to 3 cm from the normal margin are a significant cause of constipation or incomplete defecation [9, 11, 12]. A rectocele of more than 4 cm is classified as large [9, 11, 12].
\nMid-sagittal SSFSE MR image of the pelvis during evacuation in a patient with constipation shows a large anterior rectocele (arrowhead) and internal intra-rectal prolapse (arrow).
Rectal prolapse may cause constipation due to rectal wall infolding that is induced by chronic straining and fascial disruption [9, 11, 12]. Rectal prolapse can only involve the mucosa or the entire wall thickness [9, 11, 12]. Rectal prolapses may also be internal intra-rectal, internal intra-anal, or external [9, 11, 12]. Although fluoroscopy has been shown to be a highly sensitive modality for the detection of rectal prolapse relative to MR imaging, the superior resolution of MR imaging similarly provides accurate differentiation of mucosa-only prolapse from full-wall-thickness prolapse [9, 11, 12]. Thus MR imaging provides crucial anatomical and functional information for surgical planning and enables accurate discrimination between the subtypes of rectal prolapse [9, 11, 12].
\nSpastic pelvic floor syndrome, or anismus, is caused by paradoxical and involuntary contraction of the puborectalis muscle in the pelvic floor [9, 11]. It results in non-relaxation of the external anal sphincter complex and impairs normal defecation [9, 11]. This causes constipation with prolonged and incomplete defecation [9, 11]. Imaging findings include persistent puborectalis muscular contraction during the strain (Valsalva maneuver) and defecation phases, absence of pelvic floor descent, and an abnormally acute anorectal angle (Figure 11) [9, 11].
\nMid-sagittal gradient echo MR image of the pelvis during evacuation in a patient with chronic constipation show persistent puborectalis muscular contraction (arrow) without expulsion of intra-rectal gel.
CT is the most important imaging modality in the evaluation of patients with known or suspected constipation. It is readily available, performed quickly, allows assessment for potential complications, and permits visualization of extra-colonic structures. The advent of multi-detector CT scanners with improved technical protocols has resulted in faster and more available imaging, particularly in the acute setting. Multi-planar and thin section reconstruction capability may allow for identification of sites of obstruction in the colon and rectum and delineation of colorectal morphology. CT has a reported sensitivity of 96% and specificity of 93% in the identification of constipation. Additional benefits of CT are visualization of complications associated with constipation, particularly stercoral colitis, ischemia, and perforation, and other organ systems for comorbid conditions that may cause constipation [1, 3, 13, 14, 15]. CT is widely used to image adult patients however it is used judiciously in pediatric patients to avoid radiation exposure. If, however, a pediatric patient has constipation that may be secondarily caused by another acute pathology, CT can be of vital importance to diagnosis and management. Radiation dose reduction and modulation may be performed to reduced exposure to pediatric patients.
\nCT has been particularly valuable in the determination of which patients would benefit from conservative medical management or immediate surgical intervention. CT imaging is typically performed using a 64 or 128-section multi-detector row scanner. Each exam is acquired during a single breath hold and in helical mode. Typical exposure settings are 120 kVp, automated tube current modulation with minimum tube current 100–150 mAs and beam pitch, 0.8–1.375. The administration of intravenous (IV) non-ionic contrast material is advised to assess for the presence of a colonic mass, or wall ischemia or inflammation. Exposure settings are set to 100 kVp and automated tube current modulation with minimum tube current is reduced to 80–100 mAs. If IV contrast is administered (contrast-enhanced), a single-phase technique is used with the acquisition of portal venous phase images 70 s after the IV administration of nonionic contrast material that is injected at a rate of 3–5 mL/s. Positive oral contrast material may or may not be used, depending on the indication and urgency or timing of the exam. Multi-planar reconstruction imaging in the coronal and sagittal planes, which are automatically created at the CT technologist’s console, is routinely used. These images may be of great value in not only the diagnosis of constipation but also in the detection of the variety of common and uncommon causes and potential complications.
\nCT may have a substantial and significant impact on the clinical management of the patient by helping to answer major questions: is the patient constipated? Do feces impact the rectum? Are there associated complications of constipation, such as stercoral colitis, ischemia, or perforation? Is the colon obstructed? If the colon is obstructed, can the cause of the constipation be identified, as well as its exact site? CT is particularly useful in the detection of the variety of mechanical causes of constipation.
\nPrimary colonic malignancy is one of the most common mechanical causes [1]. Colonic malignancy is shown on CT as an annular, semi-annular, polypoid, or ulcerated mass that arises from the colon and extends into the lumen or through the wall (Figure 12A–C) [16].
\n(A and B) Axial and coronal images from a contrast-enhanced CT of the abdomen and pelvis of a patient with constipation and bloody bowel movements. There is an enhancing polypoid mass that arises in the cecum and extends into the lumen. (C) The patient then underwent colonoscopy and right colectomy for resection of a colonic adenocarcinoma.
Strictures are another mechanical cause of constipation. The pathophysiological mechanism for the development of a stricture is fibrosis from repeated inflammation or de-vascularization [17]. The main causes of strictures are diverticulitis, ischemia, inflammatory bowel disease, and prior medical therapy like surgery or radiation [17]. CT may display ancillary features of the primary cause of the stricture that may lead to an accurate diagnosis [17]. If the patient has colonic diverticular disease, repeated episodes of diverticulitis may cause a stricture (Figure 13) [15, 18].
\nA patient with several prior episodes of diverticulitis presented with pain and constipation. Coronal image from a contrast-enhanced CT shows a significant amount of feces and fluid in the dilated colon (asterisk) due to sigmoid colonic wall thickening and pericolonic fat stranding in the setting of diverticulosis, compatible with a diverticular stricture.
Multiple and prolonged episodes of inflammation Crohn disease and ulcerative colitis are types of inflammatory bowel disease that may cause a fixed stricture (Figure 14) [15, 19]. Surgical and treatment history may reveal that the fixed stenosis is likely due to adhesive fibrosis from a surgical anastomosis or (Figure 15A and B) [15].
\nCoronal image from a contrast-enhanced CT of a patient with Crohn disease displays a short-segment stricture in the mid-transverse colon (arrow) that results in a short-segment stricture (arrowhead) and upstream constipation.
(A and B) A patient presented with severe constipation and no bowel movements for over 1 week. Axial and coronal images from a contrast-enhanced CT show large feces that distend the cecum and ascending colon (arrow) due to a stricture at the hepatic flexure (circle). The stricture is due to post-surgical fibrosis that developed between the colon and the site of a prior cholecystectomy (circle).
CT plays an invaluable role in the detection of a significant and even fatal complication of constipation that is known as stercoral colitis. Elderly patients, especially those with chronic diseases, are at the highest risk for development of stercoral colitis [3, 13, 14, 15]. Signs and symptoms of stercoral colitis are not specific; however, the most common complaints are constipation and pain [3, 13, 14]. Serologic tests and physical examination are also not specific [3, 13, 14].
\nThe pathophysiology of stercoral colitis begins with constipation. Chronic constipation, without treatment or intervention, may lead to fecal impaction and fecaloma formation [3, 13, 14, 20]. A fecaloma is dehydrated, compacted feces. Impacted feces and fecalomas exert pressure upon the walls of the colon and rectum that in turn impairs vascular perfusion [3, 13, 14, 20]. Hypoperfusion leads to ischemia, infarction, and necrosis of the colon and rectum with consequent perforation [3, 13, 14]. The sigmoid colon is the most common site because: (1) it is the narrowest point in the colon, thereby impeding the transit of dehydrated feces and (2) the rectosigmoid vascular watershed region, known as Sudeck’s point, is susceptible to ischemia [3, 13, 14].
\nRadiography can detect fecal impaction and fecalomas in the colon and rectum however provides no sensitive or specific findings of stercoral colitis [3, 13, 14]. CT is diagnostic of stercoral colitis and its complications and can also exclude alternative causes of pain [3, 13, 14, 15]. The finding that is present in all patients with stercoral colitis is a fecaloma (Figure 16A and B) [3, 13, 14, 15]. Proximal to the fecaloma, the colon may or may not be dilated. The walls of the colon and rectum are asymmetrically thickened to greater than 0.3 cm and my have increased attenuation due to ischemic hemorrhage (Figure 17A–D) [3, 13, 14]. Extra-colorectal findings are inflammatory stranding of the fat that surrounds the colon and rectum and extra-luminal air, which is indicative of a perforation (Figure 18A–C) [3, 13]. Complications of stercoral colitis are perforation, abscess, peritonitis, sepsis, and death; mortality has been reported to approach nearly 50% [3, 13, 14, 15].
\n(A and B) Coronal and sagittal contrast-enhanced CT images of a patient with constipation show fecal impaction in a dilated colon and rectum (arrowhead) with a large, rim-calcified fecaloma (arrow) that causes stercoral colitis.
(A and B) Sagittal and axial non-contrast CT images of a patient with severe abdominal distention and constipation show a dilated colon with a large volume of feces and concentric wall thickening (arrows), indicative of stercoral colitis. (C and D) The majority of the fecaloma was removed in a piecemeal fashion with irrigation and retrieval devices. Images from the colonoscopy show friable, dusky, and erythematous mucosa (arrows), consistent with stercoral colitis and ischemia.
(A and B) Sagittal and axial contrast-enhanced CT images show fecal impaction of the cecum with asymmetric wall thickening (arrowheads) and extraluminal air (arrow) adjacent to a thinned segment of the cecal wall and throughout the peritoneum (arrow), consistent with a perforation. (C) Gross surgical specimen of the resected and perforated cecum, which is filled with feces.
The clinical presentation of a patient with constipation will help govern if imaging is warranted and what is the most appropriate exam to order. Identification of the specific etiologies and associated complications of constipation is facilitated by both anatomic and functional imaging which range from basic radiography to MR imaging. Understanding what information each imaging modality can provide is of paramount importance to order the appropriate test, make an accurate diagnosis, and guide the appropriate management.
\nThe author acknowledges Shaile Philips, M.D. for her contributions and mentorship.
\nThe author declares no conflict of interest.
The author thanks his parents for their support and guidance.
\nMedical equipment is a product that can directly affect human lives. They have been and are considerable investments and in many cases have high maintenance costs. That is why it is important to have a well-planned, managed maintenance program that can keep medical equipment in a reliable, safe, and available medical service. In addition, such a management program extends the life of the equipment and minimizes the cost of its maintenance [1].
A modern medical equipment maintenance strategy includes periodic inspection procedures to which preventive maintenance (PM) and corrective maintenance (CM) are added when necessary. Performance inspections ensure that the equipment operates correctly within the limits set by the manufacturer or according to the standards in force for that type of equipment. Safety inspections ensure that the equipment is safe to use for both patients and operators. Preventive maintenance (PM) aims to extend the life of the equipment and reduce the downtime of medical equipment [2].
In addition, there may be some hidden issues that can be easily detected during a scheduled inspection. The technical inspection procedure of medical equipment only ensures that the device is in good working order at the time of inspection and cannot eliminate the possibility of a malfunction during future use. It must be borne in mind that by their nature, electrical and mechanical components can be damaged at any time. Corrective maintenance (CM) restores the operation of a defective device and allows it to be put back into operation in optimal parameters.
Planning a maintenance program requires more effort to establish a comprehensive medical equipment management program. There are a number of critical factors to consider:
Inventory – types and models of medical equipment to be followed by technical staff and the steps by which they are specifically included in specific maintenance programs;
Methodology – identify the method by which maintenance will be provided to the medical equipment included in the program;
Resources – the financial, technical, and human resources included in the program.
In the process of planning a maintenance program, it is essential to determine the types of medical equipment they need to be included in a maintenance management program. This fact will depend on the types of medical services to be provided covered by the program, ranging from primary care clinics to hospitals as well as the range of equipment in them. The clinical engineering department of the hospital is the one that has to identify and select the medical equipment to be included in the inventory and to include it in the maintenance program [3].
A maintenance program can be implemented in several ways, the variety of methodologies available at a given time must be taken into account. For example, the healthcare provider may enter into service contracts with device manufacturers, independent service organizations, or a combination of both, in addition to the assistance that their own technical staff can provide.
As for the resources needed for maintenance, they are difficult to predict. This requires a well-maintained maintenance history, personnel requirement calculations, test equipment as well as their technical knowledge to repair defective equipment. Outside suppliers are required for the maintenance of complex equipment. Maintenance often requires access to equipment that can be difficult to obtain due to budget constraints and purchasing difficulties, especially when buying from abroad (Table 1). In order to meet such challenges, it is important to consider the financial advance, technical, and human resources required to properly carrying out the planned activities [4].
Initial cost | Operating cost | |
---|---|---|
Space, tools, test equipment, and computer resources | Utilities, operation, maintenance, and calibration | |
Recruiting and initial training | Salaries and continuing education | |
Not applicable | Service contract, spare parts, and materials |
Financial resources required for a maintenance program.
A maintenance schedule is also based on a defined number of physical resources. This category includes workspace, tools and test equipment, consumables, spare parts, and maintenance and service manuals required to perform maintenance. Various testing tools and equipment are required to perform PM and/or CM procedures, depending on the type of medical equipment. It is possible to perform many PM and CM with a basic set of electronic service instruments and test equipment (e.g. temperature meter, voltmeter, power indicator, oscilloscope, and electrical safety meter) (Table 2). However, all these involve additional costs that must be provided in the financial and technological management.
Medical device | Test equipment required |
---|---|
All electrical equipment | Electrical safety analyzer |
ICU monitors and ECG machines | Simulators/arrhythmia simulators |
Defibrillators | Defibrillator analyzer |
Electrosurgical units | Frequency electrosurgical analyzer |
Ventilators, heart-lung machine, and anesthesia machine | Pneumatic tester and pneumatic flow meter |
Noninvasive blood pressure monitors | Noninvasive blood pressure simulator |
Anesthesia machines and ventilators, | Gas flow meters |
Test equipment for some medical device category.
Fortunately, in hospitals, we see more and more technology. And this can only make us happy, proving to us that medicine is advancing, so the diagnosis is made earlier and more precisely, the treatment is more personalized and more effective. Overall, technology allows us to better care for the patient for his/her benefit, but also for the doctor, who has powerful tools to practice his/her profession. At the same time, the presence of these increasingly sophisticated medical equipment comes with the need for medical engineers in hospitals who know how to use this equipment, to identify when they are not used correctly or when they no longer work at optimal parameters.
For a patient, the staff of a hospital means doctors, nurses, and sisters, and it is normal to be like that, because only with them they interact but, a hospital in order to operate continuously, 24/7, in safe conditions, there is a whole team of technicians behind it, which makes this possible. Someone has to make sure that the medical equipment, the ventilation systems, the medical gas systems, and the electrical network are working properly, and these are the bioengineers, the clinical engineers, and the medical engineers.
Operational management involves making very diverse decisions, which can be classified into two broad categories: strategic and tactical. Strategic decisions have a longer time horizon and are less structured than tactical ones. They focus on the entire organization, drawing certain lines and directions, while tactical decisions are more focused on departments, teams, and issues. Device management takes place within a generalized business model, so clinical engineers work in collaboration with the financial and procurement departments of the institution to ensure efficient management of technical equipment, but also assistance policies are properly implemented through the efficient use of financial resources [5]. Consequently, the role of clinical engineering includes the development of equipment support strategies, the management and periodic review of these strategies, as well as the management of both fiscal resources and specialized personnel. Various problems may occur with medical devices resulting from device malfunctions, equipment operation problems, or malfunctioning devices [6, 7].
The first maintenance policies developed consisted of interventions on the devices that worked until their accidental shutdown (breakdown) due to wear and tear or due to the occurrence of malfunctions. The intervention is considered satisfactory as long as the device/system is operating at a minimum acceptable level (reactive maintenance) [8].
The development and increase in the complexity of medical equipment have led to the modernization and updating of maintenance techniques and policies. The preventive and predictive activity makes it possible to plan the shutdown, prepare the intervention team, ensure the necessary spare parts, and respectively, reduce to a minimum the parking time for repair [9]. Predictive maintenance is a qualitative leap forward in a modern maintenance system, regardless of the scope or specifics of production, as it provides all the information needed to:
early detection of defects;
their location;
fault diagnosis; and
calculation of the safe operating time of the machine.
Many healthcare providers have now implemented continuous quality improvement programs based on innovation in the way care is provided in order to improve safety, control costs, and make these services more accessible and effective for patients. Staff involved in operational management also use risk management methodologies to optimize hospital resources to provide a healthcare technology management program that focuses on ensuring that the hospital’s clinical work can be performed safely and cost-effectively.
The lack of specialized technical staff, including medical bioengineers and clinical engineers in hospitals, as well as an inefficient maintenance system are the major causes that determine incidents of all kinds. This has been highlighted more than ever, during the pandemic, when hospitals and all their medical equipment were and still are overburdened. During this time, more than ever, we have realized that the rules and standards of hospital care (including the care of medical equipment, medical gas networks, ventilation, electrical networks, etc.) need to be improved, and maintenance policies need to be optimized as quickly as possible.
Healthcare is one of the largest industries in the world, with a high degree of diversity in terms of therapeutic activities and how they are performed. There is compelling evidence that while healthcare brings enormous benefits to all people, the frequency of errors and unwanted events is increasing, directly related to the development of innovation in biomedical technologies. Understanding and ensuring the safety of medical care is an extreme challenge in health system management [10].
For departments and organizations that target medical devices, whether they are manufactured or used, one of the key goals should be patient safety and risk management. Risk management is a complex process of identifying, analyzing, and responding to potential risks, through a documented approach, which uses material, financial, and human resources to achieve objectives, aiming to reduce their exposure to losses [11]. Thus, internal control is directly associated with risk management, because, through the measures taken, a functional framework is reasonably ensured that allows that entity to achieve its objectives [12].
The risk appetite of the organization must be clearly articulated in the policy, and this can be informed through legal and financial issues. Policy should also clearly define roles and responsibilities in risk management. There must also be a periodic review process in which each risk is reviewed to ensure that control measures are effective and that the residual risk is properly classified. The policy should set out the process, methods, and tools used to manage the risks within the organization.
Risk management is a cyclical process, which takes place throughout the course of an activity and involves several stages of work as shown in Figure 1.
Risk management cycle.
The first step in the risk management process involves focusing efforts on identifying all possible sources of risk that could affect in any way the development of the project or activity analyzed. Effective risk management assumes that risk identification is an ongoing process that allows the entity to connect to the process of change and adaptation. An efficient risk management process at the level of the entity must also take into account the priorities of the institutions under coordination/subordination or under authority, which contribute to the achievement of the objectives of the respective entity [13].
The sources of risk come from both inside and outside an organization that provides healthcare services. External sources are those sources of risk that are the result of events outside the organization under analysis. The main factors that can influence the external risk environment and that need to be taken into account are as follows:
regulations and/or legislation – each healthcare provider must identify those laws and regulations under which they operate and which define the limits of action of this entity;
modifying/updating the objectives – in some situations, the treatment of some risks by the managers of the organization is influenced by the external decisions that influence the own activities;
sometimes, budget cuts can affect the achievement/limitation or stoppage of some professional activities or the number of employees.
Due to the fact that in the case of external risk no preventive measures can be taken, the only way to act is by insurance. Internal sources are the result of events within the organization. These sources of risk can be controlled. In this category, we can distinguish the risks of using technology equipment, the risks of specialized labor, or the risks associated with organizational management. These risks can be prevented by simply eliminating the sources that produce them, which is possible due to the fact that they are generated by the activity of the organization, so they come from within it.
There are two main categories in the risk analysis process:
qualitative risk analysis;
quantitative risk analysis.
The results of the qualitative risk analysis are less accurate, as they are more indicative than precise. In the qualitative analysis, the Probability Impact Matrix technique can be used, a technique that combines the two components of risk, thus presenting an overview of it [10]. This method can be applied at several levels, with varying degrees of difficulty. Most healthcare organizations use a 535 risk matrix based on Australian standards AS/4360: 2004, where the two axes correspond to the scales for consequences, sometimes called severity and probability as illustrated in Figure 2 [14].
Probability impact matrix examples.
If these results are not satisfactory, the risk management also provides the quantitative analysis which presents results in numerical form as a result of the calculations made. If the risk analyst cannot give an accurate probability of such an event occurring, he/she can instead calculate the size of the losses or depreciations generated.
In this sense, risk management has developed a series of calculation methods and techniques such as [15]:
SWOT analysis (
Concatenation principle: by concatenating the risks, a chain of risky events is identified, and these will be analyzed together.
Script technique: this technique involves describing one or more possible ways of conducting an event from a concrete situation.
Expected value analysis.
Decision-based tree analysis.
Monte Carlo simulation method.
Measures should be taken to reduce the probability (possibility) of occurrence of the risk and/or to reduce the consequences (impact) on the results (objectives), if the risk is materialized. Risk response is a reduction in risk exposure if it is a threat.
If disposal is not feasible, control measures should be put in place:
Elimination or avoidance
Replacement
Control of risks at source
Separation and isolation
Safe working procedures
Training, instruction, and supervision
Personal protection
Other considerations: social assistance facilities, first aid, and emergency procedures
Lack of control can compromise the entire risk management process.
In general, the risk management framework should not be seen as a single task but should be continually reviewed to ensure that it remains fit for purpose. There are a variety of technical standards for medical devices designed to ensure the consistency of a device’s safety throughout its life [16, 17]. These should be seen as a starting point in the risk profile and are the basis of the medical device directives: directive on implantable active medical devices (90/385/EEC), Medical Devices Directive (93/42/EEC), and directive on in vitro diagnostic medical devices (98/79/EEC). Another useful standard is BS ISO 31100 which sets a framework for incorporating risk management into any organization [18].
A very important component in the management of medical technologies is represented by the realization of a maintenance program in which to take into account the characteristics and failures of medical equipment. At the moment of including such a maintenance strategy, a distinction will have to be made between older medical devices and high-tech devices, as they cannot be effectively managed if the same maintenance strategies are used [19]. The World Health Organization has issued guidelines for the application of corrective maintenance at the hospital level. Corrective maintenance is actually a whole process from identifying the defect to repairing the device and putting it back into operation.
The first step in the corrective maintenance process is to report a fault/incident to a user. Also, a malfunction can be found when a medical technician/bioengineer from the Department of Clinical Engineering performs the periodic technical inspection. In order to make the maintenance process more efficient, the first step is the realization of the finding and then the corrective maintenance is initiated. A reduction in the failure time of the defective medical device can be achieved when the medical technician/bioengineer performs some corrective maintenance steps himself/herself and uses internal expertise or external service providers. This corrective maintenance may be accomplished at various levels:
component level: old generation equipment requires isolation of the fault by troubleshooting and repairing the level of components. In the case of new generation medical equipment, electronic devices, repairing the level of components can be time-consuming and difficult. In addition, this type of maintenance is not feasible, so the repair of the board level or even the system level is applied.
board level: in the case of modern electronic equipment, the faults of a certain circuit board are isolated, and the entire board is replaced.
device or system level: in the case of modern equipment, troubleshooting and repairing at the plate level are sometimes difficult and time-consuming. Therefore, if the cost of a repair exceeds 60% of the value of the purchase of new equipment, it is more profitable to replace the entire device or subsystem.
The type of corrective maintenance applied at the hospital level is dependent on a number of cumulative factors including the availability of financial, physical, and human resources, as well as the urgency of a particular request for repair. One strategy that can be considered is the application of repairs at the device level, in emergency situations and when more time is available, the repair can be used at the plate level or at the component level. If it is proposed to repair the component level, parts may need to be replaced.
Replacement can be done with specialized parts from the manufacturer or with spare parts recovered from malfunctioning or obsolete equipment (only after the announced risk assessment).
In the event of an unforeseen fault, environmental factors must also be considered, such as stabilizing the power supply sources by using voltage regulators, installing uninterruptible power supplies (UPS), using surge protection devices and avoiding connection. Another important environmental aspect is the interaction of medical devices with other utility systems (e.g. medical gas and vacuum systems, temperature and ventilation control systems, water supply, and information technology).
There must be a permanent collaboration with the other categories of engineers in the organization in order to optimize the capacity of the utility systems so that the medical equipment works in optimal parameters. The environment in which medical equipment is used should be controlled in terms of temperature and humidity. There are situations in which some medical equipment is designed to be used in accordance with the specific climate of a country/region. In this case, the maintenance procedures in a particular country or region are adjusted according to these local factors. Other important environmental factors are the age and condition of medical equipment or old facilities built to old standards that are not applicable.
The actions required after the repair is completed include recalibration processes and a performance and safety inspection. These activities are essential for measuring device performance. Once these activities are completed, the medical equipment will be returned for use to the patient care.
In the case of corrective maintenance, a decisive role is played by the periodic technical verification, part of the preventive maintenance process. The technical file of the medical device in which any intervention made on the medical device is recorded is a reference document in corrective maintenance that helps to make decisions. Existing data in the worksheet includes the actions performed, the parts replaced, and their cost helps to identify if or when the parts need to be replaced again and helps to explain the condition of the parts during the current inspection.
An important aspect in the corrective maintenance process is the consideration of safety aspects. In this case, procedures must be included regarding the safety of the technical staff during maintenance, the safety of the user after maintenance, and the general control of infections. In order to increase the safety of service personnel, it is necessary to train and use personal protective equipment and knowledge of techniques that will allow technical personnel to work safely in dangerous conditions.
Following maintenance, in particular following procedures which could have affected the safety features of a medical device, the technical staff must check that the device is safe to use, mechanically and electrically. Particular attention shall be paid to the electrical safety of medical devices so that they are earth-proof and leakage current is measured to ensure that they are within the applicable limits. (In the absence of electrical safety test equipment, technical personnel must rely on careful repair techniques and simple electrical tests to verify the integrity of the device). Physicians should be advised to check the settings of the device and perform basic operational checks before using the device with patients [20].
An important conclusion we can draw is that the best maintenance strategy is to apply the mixed maintenance strategy. This process is due to the fact that we are talking about a very large number of medical equipment and complex technologies. The maintenance process must be divided between the parts: internal maintenance is adopted for surgical lamps, sciatic lamps, and telemetry devices. In the case of critical devices, maintenance is covered by full-risk agreements with authorized manufacturers or service centers.
External maintenance is adopted for anesthesia machines, mechanical ventilators, electrocardiographs, patient monitors, and surgical tables [21].
Good management of medical technologies at the hospital level can minimize malfunctions in medical devices. If we refer to developing countries, here the problem is the limited financial resources. In this case, a proper management of medical technologies, based on increasing reliability and reducing failures, could lead to the provision of good health services in limited economic conditions. Assessing the effectiveness of any maintenance program is critical to optimizing the use of available resources within the hospital. The emphasis cannot be placed solely on scheduled maintenance [22].
Patients’ access to an accurate diagnosis, effective treatment, or rehabilitation process with appropriate medical devices is related to the efficient management of the maintenance of medical devices. This process can increase the efficiency and productivity of medical technology resources, which is especially important when resources are limited (Figure 3) [23].
A summary of basics for evaluating and identifying the mode of operation within the clinical engineering department of any hospital.
A possible approach to medical technology management involves the inclusion of a priority analysis step. The division into three levels of emergency (high, medium, and low) can be proposed based on the operation and implementation of subsequent actions in appropriate stages, appropriate to urgency, criticality, and seriousness. This analysis of priorities can be done both in terms of preventive maintenance, corrective maintenance, and in the case of a replacement program. In this case, the management priority can be recognized by the maintenance [24]
Another operational diagram that can be applied to evaluate the management process of medical technologies is the Ishikawa diagram or the fish bone diagram. This diagram is a verbal tool that has the relationship between an effect (a problem) and all possible causes that influence the effect (Figure 4).
Ishikawa diagram or the fish bone diagram applied to the management process of medical technologies.
The optimization of the functions of the maintenance department can be obtained by implementing a procedure that includes three important aspects: the task of the annual maintenance plan, the time available for the technical department, and the amount of equipment to be maintained. Taking into account these parameters, it is possible to estimate the personnel necessary to perform the maintenance function, responding to the most critical component of the management act – human resources [25]
Block diagram of the process required to calculate the set proposed by the KPI, starting from technological, organizational, and financial data.
A proper evaluation of the medical equipment maintenance process should include the development of a checklist for evaluating medical technology management. Implementing a list can be helpful in ensuring the profitability of health facilities and the reliability of medical equipment. In addition, she/he is involved in decision-making in support of the selection, measurement, repair, and maintenance of medical equipment, in particular for capital equipment managers and hospital medical engineers, and also for the evaluation of this process.
An example of a maintenance management evaluation checklist proposes the inclusion of 15 indicators: type of medical equipment, quality control tests, application of training processes, correct storage of medical equipment and spare parts, existence of maintenance contracts, supervision of the process of operation, the existence of the decommissioning procedure, the existence of the reintegration system in use/system and the reporting of adverse events, ensuring the supply of electricity in optimal conditions, implementation of a process of continuous development of maintenance, general administration, management, and allocation of a separate budget for medical equipment maintenance services [23].
Another approach to evaluating the management process was implemented by Herrera-Galán and included evaluating the performance of the maintenance function by implementing management audits. Assessments include equipment availability, response to a service request, monitoring and control of biomedical equipment, staff training, quality of work performed by maintenance technicians, workload of maintenance technicians, control of work performed by maintenance technicians, effectiveness of annual planning, and maintenance and performance of the department. The results of this research show that the audit technique is a valuable checklist in evaluating the performance of a hospital. And in this case, it was highlighted that the most critical component of the results of a management audit is human resources [26].
Amerion et al. managed to identify the effective factors that influence the management of medical technologies at the level of a military hospital. Following the study, 26 components with an important influence on the management process were extracted. These are user training, human resources, user engagement and experience, the foreign exchange market, regular checks, and trade name. Attention to the evaluation of these components could reduce maintenance costs and increase the lifespan of medical equipment. The process of training users that must be continuous and the quality of human resources are the two main aspects [27].
A general conclusion regarding the implementation of management strategies in the maintenance of medical equipment shows us that the necessary adequate resources underlying are human resources, material, financial, and documentation resources [28].
The maintenance of medical equipment becomes more expensive every year, and to optimize maintenance programs and reduce total cost of ownership, hospital management structures are constantly looking for solutions to extend the time of operation of equipment, in the required safety and technical performance and through the efficient use of available resources. The analysis and substantiation of capital expenditures in medical organizations must be based on quantifiable factors, with a direct impact on the full associated costs. In order to optimize operating and support costs, medical technology management structures develop medical equipment maintenance programs, based on assessments and prioritization, based on risks and costs. The development of alternative plans for medical equipment must take into account the complexity and large number of existing equipment, the skills of its own specialists and their number, the technical means of calibration and control, and the budgetary resources available.
In this regard, healthcare facilities need to implement evidence-based maintenance strategies, through the development of prioritization procedures aimed at a balanced assessment of relevant factors in the life of medical equipment, through an integrated approach to the elements of reliability-based maintenance, on risk-based conditions and maintenance.
The authors declare no conflict of interest.
Today's modern hospital is highly dependent on different types of medical equipment to help diagnose, monitor, and treat patients. Medical equipment maintenance is important to reduce costs, reduce patient dissatisfaction, treat the patient in a timely manner, and reduce mortality and risks during patient care. Good maintenance management is important to have well-planned and implemented programs through which hospitals can minimize medical device failures or other problems with the operation of medical equipment. Medical equipment plays an important role in the hospital system; therefore, the acquisition, maintenance, and replacement of medical equipment are key factors in hospitals for the implementation of the health service. Thus, in order to ensure the quality of medical devices for the provision of medical care, it is imperative to evaluate the safety of using hospital maintenance management. In order to achieve these goals, hospitals must develop checklists that identify the state of performance of medical equipment maintenance. It is essential for clinical managers and engineers not only to increase the capacity of the hospital but also to predict the risks of sudden failure. Given the lack of unique and comprehensive maintenance management checklists, the current goal is to design and develop medical equipment maintenance management checklists.
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Thermoplastic starch (TPS), by itself, exhibits poor mechanical properties such as low tensile strength and severe deformations, which limits its application in packaging or films. In addition, TPS presents high hygroscopicity. The use of reinforcing agents in the starch matrix is an effective means to overcome these drawbacks and several types of biodegradable reinforcements, such as cellulosic fibers, whiskers, and nanofibers, have been utilized to develop new and inexpensive starch biocomposites. 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In this regard, optimum conditions of air temperature and humidity are explored and compared on psychrometric charts. Thermodynamic limitations of existing AC systems are discussed from the subject point of view. Consequently, four kinds of low-cost energy-efficient AC systems, namely: (i) direct evaporative cooling (DEC), (ii) indirect evaporative cooling (IEC), (iii) Maisotsenko cycle (M-Cycle) evaporative cooling (MEC), and (iv) desiccant AC (DAC), are investigated for climatic conditions of two cities, that is, Multan (Pakistan) and Fukuoka (Japan). In addition, systems’ fundamentals and principles are explained by means of schematic diagrams and basic heat/mass transfer relationships. According to the results, performance of all systems is influenced by ambient air conditions; therefore, a particular AC system cannot provide optimum AC for all nonhuman applications. However, one or other AC system can successfully provide desired conditions of temperature and relative humidity. 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\r\n\tThe environment is subject to severe anthropic effects. Among them are those associated with pollution, resource extraction and overexploitation, loss of biodiversity, soil degradation, disorderly land occupation and planning, and many others. These anthropic effects could potentially be caused by any inadequate management of the environment. However, ecosystems have a resilience that makes them react to disturbances which mitigate the negative effects. It is critical to understand how ecosystems, natural and anthropized, including urban environments, respond to actions that have a negative influence and how they are managed. It is also important to establish when the limits marked by the resilience and the breaking point are achieved and when no return is possible. The main focus for the chapters is to cover the subjects such as understanding how the environment resilience works, the mechanisms involved, and how to manage them in order to improve our interactions with the environment and promote the use of adequate management practices such as those outlined in the United Nations’ Sustainable Development Goals.
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",coverUrl:"https://cdn.intechopen.com/series_topics/covers/38.jpg",keywords:"Human activity, Pollutants, Reduced risks, Population growth, Waste disposal, Remediation, Clean environment"},{id:"41",title:"Water Science",scope:"