Interventional Radiology Patients Research Articles

Risk factors and comorbidities associated with cardiac arrests and medical emergencies in interventional radiology patients

PurposeTo investigate the incidence, predictors, and outcomes of medical emergencies in patients undergoing IR procedures at a tertiary care center.Materials and methodsSeven-year retrospective review of all medical emergencies in patients undergoing IR procedures at King Abdulaziz Medical City, Riyadh, Saudi Arabia. Medical emergencies included Cardiopulmonary arrest (CPA), or emergencies that required activation of the critical care response team (CCRT). Variables included demographics, procedure details and outcome data including complications and 30-day mortality. Multivariate logistic regression analysis was conducted to identify independent predictors of CPA and 30-day mortality.ResultsNinety-four patients (50% male) were included with a median age of 60.5 years. Recent or current ICU admission was recorded in 39 patients (43.8%). Comorbidities included diabetes (50%), hypertension (59.6%), coronary artery disease (25.5%), heart failure (21.5%), ESRD (28.7%), active infection 28 (31%), with ASA3 in 64 patients (68%) and ASA4 in 23 (24.5%).The incidence of CPA and CCRT activation was 0.045% and 0.049%, respectively, among 100,000 patients who underwent IR procedures during the study period. Half the events were with venous procedures, followed by non-vascular (33%) and arterial procedures (10.6%). 30-day mortality was 30.5%. Independent predictors of CPA included pulmonary disease (aOR 16.79, 95% CI 2.334–195.3, p = 0.0097), emergency procedures (aOR 11.63, 95% CI 2.517–72.46, p = 0.0035), general anesthesia (aOR 19.41, 95% CI 1.854–491.8, p = 0.0254), and sedation (aOR 13.04, 95% CI 2.081–118.8, p = 0.0108). Predictors of 30-day mortality were CPA (aOR 9.830, 95% CI 2.439–66.66, p = 0.0045) and hypotension as a complication (aOR 16.81, 95% CI 3.766–122.3, p = 0.0009).ConclusionOur findings highlight the complexity of patients undergoing IR procedures and the importance of identifying high-risk patients to prevent adverse events in the IR setting.

Virtual reality for interventional radiology patients: a preliminary study.

The aim of this prospective study was to evaluate the tolerance and feasibility of using virtual reality headsets with patients during interventional radiology procedures. In this single-center prospective study, the use of a virtual reality headset in addition to the usual analgesic and anxiolytic treatment was proposed to all patients presenting in the interventional radiology department from December 2020 to June 2022. Exclusion criteria were as follows: (1) patients with whom it was not possible to communicate (2) epileptic patients, (3) non-verbal patients, and (4) pregnant women. The main objective was to evaluate the safety of the procedure by screening complications during and after the procedure. The second objective was to evaluate feasibility, as defined by the number of patients using the helmet until the end of the procedure. Effectiveness (patient's self-evaluation of pain and anxiety), comfort, satisfaction, emotions felt, sense of security, and feeling of immersion were also evaluated. Caregivers completed a feedback questionnaire. Virtual reality headsets were offered to 100 patients, 9 of whom declined. Procedures were achieved in 93.5% of cases: 6/91 patients removed the headset before the end of the procedure. There were minor adverse events in 2/85 (2.3%) procedures (discomfort and nausea) and no major adverse events. 93.9% of patients found an overall benefit, and 90.2% would recommend virtual reality to another patient. 94.4% of caregivers were satisfied with the virtual reality equipment. The mean pain level was 2.5 ± 2.7 before the procedure, 3.3 ± 2.5 during the procedure, and 1.6 ± 2.7 after the procedure. Mean anxiety scores were 4.6 ± 2.9 before the procedure, 3.1 ± 2.7 during the procedure, and 1.1 ± 1.9 after the procedure. The use of virtual reality technology as a complement to traditional therapy for procedures under local anesthesia is feasible and safe in interventional radiology and can be beneficial for pain and anxiety management.

A model for estimating peak skin dose in CT.

In interventional radiology patient care can be improved by accurately assessing peak skin dose (PSD) from procedures, as it is the main predictor for tissue-reactions such as erythema. Historically, high skin dose procedures performed in radiology departments were almost exclusively planar fluoroscopy. However, with the increase in use of technologies involving repeated or adjacent computed tomography (CT) such as CT fluoroscopy and multi-modality rooms, the peak skin dose delivered by CT needs to be considered. In this paper, a model to estimate the PSD delivered to a patient undergoing CT has been developed to assist in determining the overall PSD. This model relates the PSD to the device-reported CT Dose Index (CTDIvol) by accounting for a variety of CT technique and patient factors. It includes a novel method for estimating dose contributions as a function of patient or phantom size, scanner geometry, and physical measurement of lateral and depth-based beam profiles. Physical measurements of PSD using radiochromic film on several phantoms have been used to determine needed model parameters. The resulting fitted model was found to agree with measured data to a standard deviation of 5.1% for the data used to fit the model, and 6.8% for measurements that were not used for fitting the model. Two methods for adapting the model for specific scanners are provided, one based on local PSD measurements with radiochromic film and another using CTDIvol measurements. The model, when suitably adapted, can accurately assess individual patients' CT PSD. This information can be integrated with radiation exposure data from other modalities, such as planar fluoroscopy, to predict the overall risk of tissue reactions, allowing for more tailored patient care.

Evaluation of an Artificial Intelligence Chatbot for Delivery of IR Patient Education Material: A Comparison with Societal Website Content

PurposeTo assess the accuracy, completeness, and readability of patient educational material produced by a machine learning model and compare the output to that provided by a societal website. Materials and MethodsContent from the Society of Interventional Radiology Patient Center website was retrieved, categorized, and organized into discrete questions. These questions were entered into the ChatGPT platform, and the output was analyzed for word and sentence counts, readability using multiple validated scales, factual correctness, and suitability for patient education using the Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) instrument. ResultsA total of 21,154 words were analyzed, including 7,917 words from the website and 13,377 words representing the total output of the ChatGPT platform across 22 text passages. Compared to the societal website, output from the ChatGPT platform was longer and more difficult to read on 4 of 5 readability scales. The ChatGPT output was incorrect for 12 (11.5%) of 104 questions. When reviewed using the PEMAT-P tool, the ChatGPT content scored lower than the website material. Content from both the website and ChatGPT were significantly above the recommended fifth or sixth grade level for patient education, with a mean Flesch-Kincaid grade level of 11.1 (±1.3) for the website and 11.9 (±1.6) for the ChatGPT content. ConclusionsThe ChatGPT platform may produce incomplete or inaccurate patient educational content, and providers should be familiar with the limitations of the system in its current form. Opportunities may exist to fine-tune existing large language models, which could be optimized for the delivery of patient educational content.

Optimisasi dengan Audit Dosis Radiasi pada Pemeriksaan Thorak Proyeksi AP Pasien Dewasa

Optimization is one of the radiation protection efforts by giving radiation doses to patients as low as possible without reducing the quality of clinical images or what is often referred to as ALARA (As Low as Reasonably Achievable). A Diagnostic Reference Level (DRL) is an investigative indicator to optimize radiation protection for diagnostic and interventional radiology patients. The typical radiation dose value in AP thoracic examination patients at Gading Pluit Hospital is higher than the Indonesian DRL (I-DRL) value, so it is necessary to optimize the dose. Optimization of radiation dose aims to protect patients by evaluating exposure factors without compromising the quality of clinical images. AP chest image acquisition was performed using clinical exposure factors and their variations on the general radiographic X-Ray Listem REX 525-R. Evaluation of dose and image quality was carried out by a reading doctor/radiologist using a blind test. Optimizing results show that a lower exposure factor can reduce the radiation dose in AP thoracic examination of adult patients without affecting image quality. Exposure factor 80 kVp; 150 mA; 3.75 mAs is recommended to replace the exposure factor used before optimization, namely 80 kVp; 200 mA; 7 mAs. Keywords: optimization, DRL, radiation protection.

EP06.01-008 COVID-Protected Pathways for Image Guided Lunc Cancer Intervention During the COVID-19 Pandemic: A Cohort Study

EP06.01-008 COVID-Protected Pathways for Image Guided Lunc Cancer Intervention During the COVID-19 Pandemic: A Cohort Study

VIP Patients in Interventional Radiology: Do Some Patients Deserve "Better" Care?

“Very important people” (VIPs) are frequently encountered in healthcare. These “well-known” patients (celebrities, benefactors, CEOs, administrators) or “well-connected” patients (family members, colleagues, healthcare providers) are often referred to as “influential” or even “intimidating” because of their status.[1] [2] [3] [4] [5] [6] [7] The “VIP” designation may be context and clinician-dependent and can extend further to include anyone for whom we have special interest. As such, VIPs are those who have been deemed important by the healthcare institution in which they are seeking care, and whose status may influence their providers.[1] [8] When this influence causes undue deviation in clinicians' trained judgment and in standards of care, the outcome is not always superior for the VIP or for the system; this is termed the “VIP syndrome.”[5] [9] [10]

Images From the Past

Nursing in interventional radiology is diverse and multifaceted. This area of specialty nursing has not yet been acknowledged as such or embraced in Canada. Professional development for interventional radiology nurses is lacking with even fewer educational opportunities for non-radiology nurses who care for interventional radiology patients throughout the hospital to develop needed interventional radiology knowledge and related skills. This qualitative descriptive study explored the experiences non-radiology nurses have caring for interventional radiology patients. Interviews with ten non-radiology nurses in a Canadian hospital provided rich data for analysis. Thematic analysis revealed that these nurses did not receive formal IR education in their nursing curriculum, acquired their knowledge through self-teaching, lacked knowledge about imaging modalities and IR procedures, were impeded to build trusting nurse-patient relationships, and felt ineffective communication disrupted the continuity of care they provided. Addressing professional development needs related to creating interventional radiology education, increasing awareness of the specialty of interventional radiology nursing, and enhancing clinical collaboration is a key recommendation.

Mixed Reality Visualization of Radiation Dose for Health Professionals and Patients in Interventional Radiology

For interventional radiology, dose management has persisted as a crucially important issue to reduce radiation exposure to patients and medical staff. This study designed a real-time dose visualization system for interventional radiology designed with mixed reality technology and Monte Carlo simulation. An earlier report described a Monte-Carlo-based estimation system, which simulates a patient’s skin dose and air dose distributions, adopted for our system. We also developed a system of acquiring fluoroscopic conditions to input them into the Monte Carlo system. Then we combined the Monte Carlo system with a wearable device for three-dimensional holographic visualization. The estimated doses were transferred sequentially to the device. The patient’s dose distribution was then projected on the patient body. The visualization system also has a mechanism to detect one’s position in a room to estimate the user’s exposure dose to detect and display the exposure level. Qualitative tests were conducted to evaluate the workload and usability of our mixed reality system. An end-to-end system test was performed using a human phantom. The acquisition system accurately recognized conditions that were necessary for real-time dose estimation. The dose hologram represents the patient dose. The user dose was changed correctly, depending on conditions and positions. The perceived overall workload score (33.50) was lower than the scores reported in the literature for medical tasks (50.60) for computer activities (54.00). Mixed reality dose visualization is expected to improve exposure dose management for patients and health professionals by exhibiting the invisible radiation exposure in real space.

Professional Development Needs of Non-Radiology Nurses: An Exploration of Nurses’ Experiences Caring for Interventional Radiology Patients

Nursing in interventional radiology is diverse and multifaceted. This area of specialty nursing has not yet been acknowledged as such or embraced in Canada. Professional development for interventional radiology nurses is lacking with even fewer educational opportunities for non-radiology nurses who care for interventional radiology patients throughout the hospital to develop needed interventional radiology knowledge and related skills. This qualitative descriptive study explored the experiences non-radiology nurses have caring for interventional radiology patients. Interviews with ten non-radiology nurses in a Canadian hospital provided rich data for analysis. Thematic analysis revealed that these nurses did not receive formal IR education in their nursing curriculum, acquired their knowledge through self-teaching, lacked knowledge about imaging modalities and IR procedures, were impeded to build trusting nurse-patient relationships, and felt ineffective communication disrupted the continuity of care they provided. Addressing professional development needs related to creating interventional radiology education, increasing awareness of the specialty of interventional radiology nursing, and enhancing clinical collaboration is a key recommendation.

Telemedicine visits reduce time to biopsy, travel time and costs for interventional radiology patients.

2082 Background: Telemedicine has been utilized to increase access to care for patients in primary care practices and more recently, specialty practices. The purpose of the study was to test the hypothesis that adding a telemedicine clinic practice could decrease the time to biopsy, travel time and cost for interventional radiology (IR) clinic patients. Methods: Telemedicine visits were performed by a physician or advanced practice provider (PA or NP) at a single institution, academic medical center to patients at 3 MSK regional locations in NY and NJ. Total patient encounters and data from November 2017 to October 2019 were analyzed. Primary outcome measures were wait time from the IR referral to biopsy procedure visits, patient travel time and travel cost, stratified by in-person vs telemedicine visit. Round-trip travel distance and costs for patients were calculated by determining the offset travel. Cost (economic) benefit was the sum of: Federal cost per mile for travel, toll and parking costs, and doctor visit lost wages. Results: There were 172 MSK Regional site telemedicine visits. There was a significant reduction in time from referral to biopsy for telemedicine visits compared to in-person visits (12 vs 17 days, p < 0.0001). Additionally, there was a significant reduction in travel time for telemedicine visits vs travel time to Manhattan for an in-person visit (p < 0.0001). Telemedicine visit patients had to travel 367 less hours than an in-person visit and saved a total of 11,222 in miles that they did not have to travel. Telemedicine patients accrued $14,652 in economic benefits due to reduced travel costs and lost wages from work. Conclusions: Telemedicine significantly reduced the time to biopsy, travel time and cost for Interventional Radiology patients compared to in-person visits. Telemedicine for IR patients increases access to care for patients and allow for more efficient use of physician time and resources.

Observations of tissue reactions following neuroradiology interventional procedures

A study has been undertaken over a period of eight years of tissue reactions in interventional radiology patients receiving cumulative air kerma values to their scalp above 3 Gy. Patients receiving doses to the scalp above this trigger level have been followed up to determine when effects occur and to provide reassurance if they do. The study has shown that hair thinning and hair loss are the more likely effects and may occur in 50% of patients at dose above 4.5 Gy.

3:27 PM Abstract No. 330 Descriptive analysis of patients with left ventricular assist devices undergoing image-guided procedures

Left ventricular assist devices (LVAD) are mechanical therapies for end-stage heart failure that require anticoagulation and are associated with high rates of complications including third spacing, bleeding, and thromboembolic events. Minimally invasive image-guided procedures can be invaluable in managing LVAD patients who are not typically considered surgical candidates. This study describes our institution’s procedural experience with LVAD patients in interventional radiology (IR). We reviewed a retrospective database of LVAD procedures performed in an academic medical center from 2010-2018. Demographics, preprocedural labs, complications, and outcomes data were collected from electronic health records. Descriptive statistics were calculated on both a patient- and encounter-level as many patients in the dataset underwent multiple image-guided procedures. Categorical variables are presented as frequencies with percentages. 67 LVAD patients underwent 109 image-guided procedures during the study period. Based on SIR guidelines, 65 (59.6%) procedures were category 2 bleeding risk and 44 (40.4%) were category 1. The most common procedures performed were chest tube placement (n = 43, 39.4%), thoracentesis (n = 12, 11%), and embolization (n = 12, 11%). Patients were therapeutically anticoagulated (preprocedural aPTT>70 and/or INR>2) for 67 (61.5%) procedures. Intraprocedural blood loss of >50 mL occurred in 2 (1.8%) cases. Postprocedural bleeding occurred in 15 (13.8%) cases, and 38 (34.9%) cases received transfusions within 30 days. Of 12 (11.0%) total complications, 3 patients had major complications requiring further intervention or contributed to clinical deterioration. Eight (11.9%) patients died within 30 days of a procedure; causes of death were determined to be unrelated to the procedure itself or were multifactorial in etiology. While performing image-guided minimally invasive procedures on the LVAD patient population is not without risk, they are sometimes necessary and can be performed if benefits are deemed to outweigh risks.

Toward Data-Driven Learning Healthcare Systems in Interventional Radiology: Implementation to Evaluate Venous Stent Patency.

We developed a code and data-driven system (learning healthcare system) for gleaning actionable clinical insight from interventional radiology (IR) data. To this end, we constructed a workflow for the collection, processing and analysis of electronic health record (EHR), imaging, and cancer registry data for a cohort of interventional radiology patients seen in the IR Clinic at our institution over a more than 20-year period. As part of this pipeline, we created a database in REDCap (VITAL) to store raw data, as collected by a team of clinical investigators and the Data Coordinating Center at our university. We developed a single, universal pre-processing codebank for our VITAL data in R; in addition, we also wrote widely extendable and easily modifiable analysis code in R that presents results from summary statistics, statistical tests, visualizations, Kaplan-Meier analyses, and Cox proportional hazard modeling, among other analysis techniques. We present our findings for a test case of supra versus infra-inguinal ligament stenting. The developed pre-processing and analysis pipelines were memory and speed-efficient, with both pipelines running in less than 2min. Three different supra-inguinal ligament veins had a statistically significant improvement in vein diameters post-stenting versus pre-stenting, while no infra-inguinal ligament veins had a statistically significant improvement (due either to an insufficient sample size or a non-significant p value). However, infra-inguinal ligament stenting was not associated with worse restenosis or patency outcomes in either a univariate (summary-statistics and Kaplan-Meier based) or multivariate (Cox proportional hazard model based) analysis.

3:00 PM Abstract No. 141 Interventional radiology patient throughput: application of lean sigma methodology and real-time delay dashboard to improve operations and patient experience

Implementation of large scale EMRs are problematic for optimization of patient experience. A large interventional radiology center performing up to 1000 procedures every month developed a customized, unique, unit-specific patient delay dashboard with real-time feedback to mitigate patient delays. Due to various inefficiencies and limitations, 28% of outpatients are delayed more than 60 minutes past their scheduled procedure start time. The purpose of this project is to achieve a 50% short-term reduction in patient delays greater than 60 minutes and a long-term 50% decrease in delays overall. Additional areas of focus include patient experience e-survey scores, procedure room downtime, reduced PACU capacity, denied insurance days, and financial cost. A multidisciplinary team utilized Lean Sigma methodology for this quality improvement project. A computer application was developed to calculate delays using daily EMR data extracts sent via sftp to our data base. The app supplies a real-time color-coded patient delay dashboard which is prominently displayed on flat screens throughout the department, and alerts staff to individual patient delays in real time with green, yellow, orange, and red lights. A bundled set of interventions targeted preprocedure care coordination and scheduling, outpatient prerounding, reduction of the PT/INR requirement, and the development of an IR bedside service. Patient delays were reduced by 27% in the > 60 minute category (p>0.05) from a baseline 5-month period in January 2016 to a corresponding period in May 2017. Top box scores for timeliness improved 21% on patient e-surveys (n = 802). An anticipated reduction in hospital insurance denied days, due to improved throughput, facilitated funding to open an additional procedure suite and add the bedside services team. Interventions resulted in significant improvement in patient delays, patient experience scores, and denied days. The invention, design, and implementation of a real-time unit-specific dashboard supplied by a data dump from the EMR was invaluable in helping to promote team awareness and transparency regarding delays and throughput.

Radiation Protection for Patients in Interventional Radiology

Radiation Protection for Patients in Interventional Radiology

Implementation of a single sign-on system between practice, research and learning systems.

Multiple specialized electronic medical systems are utilized in the health enterprise. Each of these systems has their own user management, authentication and authorization process, which makes it a complex web for navigation and use without a coherent process workflow. Users often have to remember multiple passwords, login/logout between systems that disrupt their clinical workflow. Challenges exist in managing permissions for various cadres of health care providers. This case report describes our experience of implementing a single sign-on system, used between an electronic medical records system and a learning management system at a large academic institution with an informatics department responsible for student education and a medical school affiliated with a hospital system caring for patients and conducting research. At our institution, we use OpenMRS for research registry tracking of interventional radiology patients as well as to provide access to medical records to students studying health informatics. To provide authentication across different users of the system with different permissions, we developed a Central Authentication Service (CAS) module for OpenMRS, released under the Mozilla Public License and deployed it for single sign-on across the academic enterprise. The module has been in implementation since August 2015 to present, and we assessed usability of the registry and education system before and after implementation of the CAS module. 54 students and 3 researchers were interviewed. The module authenticates users with appropriate privileges in the medical records system, providing secure access with minimal disruption to their workflow. No passwords requests were sent and users reported ease of use, with streamlined workflow. The project demonstrates that enterprise-wide single sign-on systems should be used in healthcare to reduce complexity like "password hell", improve usability and user navigation. We plan to extend this to work with other systems used in the health care enterprise.

Complications in Percutaneous Dialysis Interventions: How to Avoid Them, and How to Treat Them When They do Occur

Because of the increasing prevalence of end-stage renal disease, more percutaneous interventions are being performed. They serve an important role, allowing for restoration of access function, which is achieved with high level of technical success. However, complications are inevitable during any types of procedure, and percutaneous dialysis interventions are no exception. To provide safe and effective care these patients need, anyone performing endovascular dialysis interventions needs to understand the possible complications, how they can be avoided, and how they can be addressed if they are to occur. Topics in this article include complications seen while intervening on the thrombosed access, complications of angioplasty, potentially devastating complications of central venous interventions, and complications of dialysis catheter placement. Further, patients with end-stage renal disease are generally sicker than the average patient, usually afflicted by multiple comorbidities and are therefore more complicated from a medical perspective. This places them at higher risk for acute cardiopulmonary decompensation or arrest than any other interventional radiology patient subset. As result, we also briefly review general medical complications in this population.

Collaboration Experience Between Association for Radiologic and Imaging Nursing and Nursing Unit in Medical Imaging Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia

Nursing in interventional radiology is diverse and multifaceted. This area of specialty nursing has not yet been acknowledged as such or embraced in Canada. Professional development for interventional radiology nurses is lacking with even fewer educational opportunities for non-radiology nurses who care for interventional radiology patients throughout the hospital to develop needed interventional radiology knowledge and related skills. This qualitative descriptive study explored the experiences non-radiology nurses have caring for interventional radiology patients. Interviews with ten non-radiology nurses in a Canadian hospital provided rich data for analysis. Thematic analysis revealed that these nurses did not receive formal IR education in their nursing curriculum, acquired their knowledge through self-teaching, lacked knowledge about imaging modalities and IR procedures, were impeded to build trusting nurse-patient relationships, and felt ineffective communication disrupted the continuity of care they provided. Addressing professional development needs related to creating interventional radiology education, increasing awareness of the specialty of interventional radiology nursing, and enhancing clinical collaboration is a key recommendation.

Implementation of a Standard Interventional Radiology Signout as a Communication Quality Improvement Initiative

Purpose As the complexity and volume of cases performed in Interventional Radiology (IR) continues to grow, the need for improved communication between covering physicians, residents, and ancillary staff is critical to improve patient outcomes and minimize errors. The IR section underwent a quality improvement initiative implementing a standardized sign-out system consisting of an electronic tool and a formalized daily sign-out session. Education regarding appropriate sign-out was targeted to residents-in-training to address the growing complexity and volume within the department. The purpose of this project is to improve intra-department communication regarding the care and management of interventional radiology patients. Material and Methods A standardized electronic was created to assist with post procedural patient management. This was accessible to all interventional radiology attendings and radiology residents through a Health Insurance Portability and Accountability Act-compliant electronic database. A daily sign out session between IR staff and the on call resident was started. Baseline survey data (5-point Likert scale) was collected from the radiology residents regarding the initial informal sign-out system. The same survey was readministered 4 weeks after implementation. Results Data analysis was focused on resident responses, as they are most heavily involved in the signout process. This initial survey demonstrated that all radiology residents (n = 14) strongly agreed or agreed that an electronic accessible log of active IR cases would enable them to better answer questions, handle concerns about these cases on call, and improve patient safety. All residents strongly agreed or agreed that a digital, computer accessible log of active IR cases would allow for improved signout and communication regarding these patients. After 1 month of implementation of the new signout system, survey data demonstrated a positive trend in resident comfort handling phone calls and questions regarding IR cases while on call. In addition, the follow-up data demonstrated resident agreement that the new system allows for improved signout and communication and creates a stronger emphasis on patient safety. Conclusions There is critical need for continuous coverage and effective handoff in IR. Implementing a standardized signout helps IR physicians improve patient care and minimize hand off errors. This process also increases resident comfort in handing questions about IR patients and allows the residents to more effectively communicate with referring physicians about these patients. Based on our initial survey data, follow-up actions will include implementation of additional resident education to explain how to use the case database. A longer-term follow-up survey is needed to evaluate long-term results, as it will take many months for all of the residents to rotate through IR department and fully become acclimated to the new system.