Use of Radiological Facilities by General Practitioners

The 11,360 direct referrals to diagnostic radiological facilities by general practitioners in the Aberdeen area during 1973 were studied. These represented about 12% of the adult radiology performed in the main x-ray departments of the city, and barium meal examinations amounted to half of all such outpatient contrast examinations. Chest x-ray and barium meal examinations were the most frequently used procedures.Some abnormality was detected at 34% of all examinations, and the barium meal examinations requested by general practitioners showed a similar percentage of abnormal findings to those requested by Aberdeen hospital doctors.The average referral rate for all practices was 24·6 per 1,000 practice population per year. Singlehanded general practitioners referred fewer patients for diagnostic radiology than those working in group practices, and rural practitioners referred fewer than urban general practitioners. This trend was emphasized at a distance greater than 15 miles from the city.     

What is Diagnostic Radiology's Place in Medicine?

The question that the title of this lecture poses must depend considerably on the attitude of physicians and surgeons. I have indicated the very low position diagnostic radiology holds in this country relative to our peers in medicine elsewhere.If its improvement is considered to be warranted, we must:(1) Interest medical students at the beginning of their career.(2) Bear in mind that radiologists are likely to be able to teach some anatomy but the reciprocal seldom applies.(3) Obtain chairs in radiology, which are desperately needed.(4) Obtain the acceptance by the medical establishment of the proper place of radiology in clinical medicine.(5) See to the reduction in numbers of unnecessary x-ray examinations.(6) Press for the improvement and enlargement of radiological departments with proper provision for expansion.     

Reliability of ultrasonography in identification of reflux nephropathy in children.

OBJECTIVE--To assess the ability of ultrasonography to identify reflux nephropathy in children after urinary tract infection. DESIGN--Ten experienced radiologists performed a total of 240 ultrasonographic examinations of kidneys in a one day study. The examiners were unaware of the results of previous radiological and clinical examinations and of the proportions of normal and abnormal kidneys. Urography was used as method of reference, supported by static renal scintigraphy (dimercaptosuccinic acid labelled with technetium-99m) in half of the cases. SETTING--Outpatient radiology department. SUBJECTS--25 children aged 2-16 years (20 kidneys with and 30 kidneys without renal scarring). MAIN OUTCOME MEASURES--Renal scarring. Overall size and length of kidneys. Sensitivity and specificity including receiver operator characteristics and variation between observers. RESULTS--With renal scarring as the diagnostic criterion and including cases classified as abnormal, probably abnormal, and uncertain the sensitivity of ultrasonography was 54% (specificity 80%). Addition of reduced renal size as a diagnostic criterion increased the sensitivity to 64% (specificity 79%). There were, however, wide variations between observers, with sensitivity ranging between 40% and 90% (specificity 94% to 65%). CONCLUSIONS--Because of its low sensitivity and specificity and poor agreement between observers, ultrasonography cannot be generally recommended for the detection of reflux nephropathy after urinary tract infection in children.     

Diagnosis of gastric cancer.

A prospective comparison was made of the accuracy of different diagnostic methods for gastric cancer. The basis of the study was a consecutive series of 113 patients thought to have gastric pathology; cancer was the final diagnosis in 32. Endoscopy and radiology were the most accurate investigations, whereas biopsy, cytology, and clinical examination gave disappointing results. A wide range of clinical features and laboratory investigations were studied in all patients in an attempt to identify criteria suggestive of malignancy. Multifactorial computer analysis of these investigations failed to improve upon the radiological diagnosis. A systemic approach designed to make optimal use of limited endoscopic and histopathological resources in the diagnosis of gastric lesions is presented.     

Urethrographic examinations: Patient and staff exposures and associated radiobiological risks

Medical exposure of the general population due to radiological investigations is the foremost source of all artificial ionising radiation. Here, we focus on a particular diagnostic radiological procedure, as only limited data are published with regard to radiation measurements during urethrograpic imaging. Specifically, this work seeks to estimate patient and occupational effective doses during urethrographic procedures at three radiology hospitals. Both staff and patient X-ray exposure levels were calculated in terms of entrance surface air kerma (ESAK), obtained by means of lithium fluoride thermoluminescent dosimeters (TLD-100(LiF:Mg:Cu.P)) for 243 urethrographic examinations. Patient radiation effective doses per procedure were estimated using conversion factors obtained from the use of Public Health England computer software. In units of mGy, the median and range of ESAK per examination were found to be 10.8 (3.6–26.2), 7.0 (0.2–32.3), and 24.3 (9.0–32.0) in Hospitals A, B, and C, respectively. The overall mean and range of staff doses (in µGy) were found to be 310 (4.0–1750) per procedure. With the exception of hospital C, the present evaluations of radiation dose have been found to be similar to those of previously published research. The wide range of patient and staff doses illustrate the need for radiation dose optimisation.     

Radiology services for remote communities: cost minimisation study of telemedicine.

OBJECTIVES--To determine the social costs of providing a rural population with radiology services under three different systems: the existing system (a small x ray unit at the remote site and all other examinations at the nearest radiology department (the host site)); a teleradiology system (most examinations at the remote site and more advanced examinations at the host site); and all examinations at the host site. DESIGN--Cost minimisation study. SETTING--Primary health care in a remote community in Norway. SUBJECTS--A randomly selected sample (n = 597) of all patients (n = 1793) having radiological examinations in 1993. MAIN OUTCOME MEASURES--Annual direct medical costs, direct non-medical (travel) costs, and indirect costs (lost production) of the three options. RESULTS--After exclusion of costs common to the three systems the direct medical, direct non-medical, and indirect costs of the three options were, respectively, 9000 pounds, 51,000 pounds, and 31,500 pounds (total 91,500 pounds) for the existing system; 108,000 pounds, 2,000 pounds, and 13,500 pounds (total 123,500 pounds) for the teleradiology option; and 0 pounds, 75,000 pounds, and 42,000 pounds (117,000 pounds in total) for the "all at host" option. Sensitivity analyses indicated that the existing system is the least costly option except when lost leisure is valued as highly as lost production. CONCLUSION--The teleradiology option did not seem to be cost saving in the study community. Such systems, however, may be justified on the grounds of equity of access and quality of care.     

Discontinuation of cervical spine immobilisation in unconscious patients with trauma in intensive care units--telephone survey of practice in south and west region.

OBJECTIVE: To study how the cervical spine is assessed before discontinuation of cervical spine immobilisation in unconscious trauma patients in intensive care units. DESIGN: Telephone interview of consultants responsible for adult intensive care units. SETTING: All 25 intensive care units in the South and West region that admit victims of major trauma. MAIN OUTCOME MEASURES: The clinical and radiological basis on which the decision is made to stop cervical spine immobilisation in unconscious patients with trauma. RESULTS: In 19 units cervical spine immobilisation was stopped in unconscious patients on the basis of radiology alone, and six units combined radiology with clinical examination after the patient had regained consciousness. Sixteen units relied on a normal lateral radiological view of the cervical spine alone, five required a normal lateral and anteroposterior view, and four required a normal lateral, anteroposterior, and open mouth peg view. CONCLUSIONS: There are inconsistencies in the clinical and radiological approach to assessing the cervical spine in unconscious patients with trauma before the removal of immobilisation precautions. There is an overreliance on the lateral cervical spine view alone, which has been shown to be insensitive in this setting.     

A GPU Simulation Tool for Training and Optimisation in 2D Digital X-Ray Imaging

Conventional radiology is performed by means of digital detectors, with various types of technology and different performance in terms of efficiency and image quality. Following the arrival of a new digital detector in a radiology department, all the staff involved should adapt the procedure parameters to the properties of the detector, in order to achieve an optimal result in terms of correct diagnostic information and minimum radiation risks for the patient. The aim of this study was to develop and validate a software capable of simulating a digital X-ray imaging system, using graphics processing unit computing. All radiological image components were implemented in this application: an X-ray tube with primary beam, a virtual patient, noise, scatter radiation, a grid and a digital detector. Three different digital detectors (two digital radiography and a computed radiography systems) were implemented. In order to validate the software, we carried out a quantitative comparison of geometrical and anthropomorphic phantom simulated images with those acquired. In terms of average pixel values, the maximum differences were below 15%, while the noise values were in agreement with a maximum difference of 20%. The relative trends of contrast to noise ratio versus beam energy and intensity were well simulated. Total calculation times were below 3 seconds for clinical images with pixel size of actual dimensions less than 0.2 mm. The application proved to be efficient and realistic. Short calculation times and the accuracy of the results obtained make this software a useful tool for training operators and dose optimisation studies.     

Predicted cancer risks induced by computed tomography examinations during childhood,by a quantitative risk assessment approach

The potential adverse effects associated with exposure to ionizing radiation from computed tomography (CT) in pediatrics must be characterized in relation to their expected clinical benefits. Additional epidemiological data are, however, still awaited for providing a lifelong overview of potential cancer risks. This paper gives predictions of potential lifetime risks of cancer incidence that would be induced by CT examinations during childhood in French routine practices in pediatrics. Organ doses were estimated from standard radiological protocols in 15 hospitals. Excess risks of leukemia, brain/central nervous system, breast and thyroid cancers were predicted from dose–response models estimated in the Japanese atomic bomb survivors’ dataset and studies of medical exposures. Uncertainty in predictions was quantified using Monte Carlo simulations. This approach predicts that 100,000 skull/brain scans in 5-year-old children would result in eight (90 % uncertainty interval (UI) 1–55) brain/CNS cancers and four (90 % UI 1–14) cases of leukemia and that 100,000 chest scans would lead to 31 (90 % UI 9–101) thyroid cancers, 55 (90 % UI 20–158) breast cancers, and one (90 % UI <0.1–4) leukemia case (all in excess of risks without exposure). Compared to background risks, radiation-induced risks would be low for individuals throughout life, but relative risks would be highest in the first decades of life. Heterogeneity in the radiological protocols across the hospitals implies that 5–10 % of CT examinations would be related to risks 1.4–3.6 times higher than those for the median doses. Overall excess relative risks in exposed populations would be 1–10 % depending on the site of cancer and the duration of follow-up. The results emphasize the potential risks of cancer specifically from standard CT examinations in pediatrics and underline the necessity of optimization of radiological protocols.     

Radiology and endoscopy in acute upper gastrointestinal bleeding.

Of 112 patients admitted with acute upper gastrointestinal bleeding, the presumed bleeding site was detected in 61-5% of cases by radiology and in 57% of cases on endoscopy. Thirty-one patients who had barium-meal examination were operated on and the surgical and radiological findings agreed in 26 (84%). Twenty-three patients who had endoscopy were operated on and the surgical and endoscopic findings agreed in 15 (65%). In 10 cases radiology detected a lesion not identified on endoscopy and in nine endoscopy detected a lesion not seen at radiology. We suggest that when there are two potential sources of bleeding radiology as well as endoscopy can detect the actively bleeding lesion. The supplementary nature of radiology and endoscopy is emphasised and we conclude that both methods should be used if there is any doubt at the initial radiological or endoscopic examination about the source of the bleeding.     

Dental cone beam CT: An updated review

Cone beam computed tomography (CBCT) is a diverse 3D x-ray imaging technique that has gained significant popularity in dental radiology in the last two decades. CBCT overcomes the limitations of traditional two-dimensional dental imaging and enables accurate depiction of multiplanar details of maxillofacial bony structures and surrounding soft tissues. In this review article, we provide an updated status on dental CBCT imaging and summarise the technical features of currently used CBCT scanner models, extending to recent developments in scanner technology, clinical aspects, and regulatory perspectives on dose optimisation, dosimetry, and diagnostic reference levels. We also consider the outlook of potential techniques along with issues that should be resolved in providing clinically more effective CBCT examinations that are optimised for the benefit of the patient.     

Reappraisal of clinical features of diverticular disease of the colon

In patients with diverticular disease of the colon factors which indicate a worse prognosis include widespread abdominal pain, nausea and vomiting, disturbed bowel habit, a palpable abdominal mass, abdominal distension, and any of the inflammatory complications. While radiology is of prime importance in the initial diagnosis, it is often impossible to differentiate between diverticulosis and diverticulitis. A more accurate distinction can be made by assessing all the available clinical, radiological, and pathological data, but again there are limitations and inaccuracies. The use of the term “diverticular disease” is preferable.     

Rural radiology: training

About half of the population of many countries live in rural areas and in these countries about half of the rural hospitals do not have X-ray services. Among the reasons for such a deficiency are the high cost and sophistication of radiological equipment, requiring fully trained technicians, and the high standard required for a radiologist's training, none of which a rural hospital can afford. Simplified equipment makes it possible for locally recruited auxiliary personnel to obtain radiographs of consistently acceptable quality after a short training period. The training of physicians in radiographic interpretation could also be abbreviated if it were directed at a limited range of basic X-ray examinations that provide essential diagnostic information in most clinical conditions. The activities of the World Health Organization in these areas is discussed.     

Influence of the Royal College of Radiologists' guidelines on hospital practice: a multicentre study. Royal College of Radiologists Working Party.

OBJECTIVE--To measure the effect on hospital radiology referral practice of introducing a strategy for change involving guidelines of good practice, monitoring, and peer review. DESIGN--Prospective data collection over a continuous 21-24 month period at each centre some time between January 1987 and December 1990. SETTING--Five district general hospitals and one district health authority. SUBJECTS--314,663 inpatient discharges, deaths, and day cases and 1,706,781 outpatient attendances under the care of 722 consultants from 25 clinical specialties. MAIN OUTCOME MEASURES--Number of referrals for x ray examination per 100 inpatient discharges, deaths, and day cases and per 100 new outpatient attenders. RESULTS--Most doctors were prepared to accept standards of clinical practice set by peers and also the monitoring and review of their practice with respect to these standards by local colleagues. 18% of firms were identified before guidelines were instituted as having persistently high referral rates. Appreciable, and often dramatic reductions in referral rates for individual x ray examinations were recorded by a substantial number of firms in every centre and in every specialty after guidelines were instituted. The major part of this reduction was achieved by some of the firms whose initial practice did not meet "high referral" criteria. Important variations in compliance with agreed standards of good practice were observed. CONCLUSIONS--The study offers strong experimental evidence to support a recent suggestion that at least a fifth of radiological examinations carried out in NHS hospitals are clinically unhelpful. The problem of how to assure compliance with agreed standards of practice needs to be resolved. Until this happens medical audit alone is unlikely to translate good practice into common practice.     

Aspectos actuales de las enfermedades invasivas por hongos filamentosos

Invasive fungal infections have become a major cause of morbimortality in intensive care patients, persons suffering from cancer or immune deficiencies, and other diseases with impaired immunity. Candida albicans remains the most frequent fungal pathogen, but advances in the diagnosis, prevention and treatment of invasive candidiasis are leading to important etiological changes. Among the emerging invasive mycoses, are those caused by filamentous fungi, such as Aspergillus, Lomentospora/Scedosporium, Fusarium or the Mucorales. Invasive aspergillosis is difficult to diagnose, and although there are diagnostic tools available, their use is not widespread, and their effectiveness vary depending on the group of patients. Clinical suspicion in high-risk patients, radiological diagnosis and the use of biomarkers, such as 1,3-β-D-glucan and galactomannan, can be of great help. However, diagnostic resources are limited in other mycoses, but radiology, pathological studies and the microbiological diagnosis can be useful. The high mortality of these mycoses requires early empirical antifungal treatment in many cases. Voriconazole is the first choice for treatment of the majority of aspergillosis, scedosporiasis, fusariosis and other hyalohyphomycoses. The treatment of mucormycoses, Lomentospora prolificans infections or mycoses by dematiaceous fungi are more complicated. Amphotericin B is active against many mucoralean fungi, but the combination of two or more antifungal agents could be a therapeutic alternative in many amphotericin B-refractory mycoses. Current clinical challenges include improving the diagnosis and the treatment of these mycoses, along with improving the adequate prevention in patients at high risk of suffering from them.     

Le point sur les niveaux de référence diagnostiques en médecine nucléaire en 2011

Seven years after the publication of the first diagnostic reference levels (DRL) order, the analysis of the data allows the French Institute for radiation protection and nuclear safety (IRSN) to assess and evaluate the increase of the nuclear medicine departments involvement and of the level administered activities to the patients during the most common examinations performed in France. IRSN analyses show a good agreement between the distribution of transmitted examinations and the frequency of examinations performed in France, taking into account 95% of the number of examinations and 95% of the dose delivered to patients by nuclear medicine. These analyses highlight the necessary consistency between DRL regulation, the French society of nuclear medicine (SFMN) recommendations and national practice. The IRSN recommendations established from data analyses have leaded the authorities to publish a new DRL order in January 2012. This first update of the regulation takes into account actual clinical practice in nuclear medicine and introduces fundamental points as pediatric DRL. In the future, periodical updates will be implemented in order to take into account procedures and devices evolutions.     

Chronic inflammatory bowel disease in childhood.

The diagnosis of Crohn''s disease in childhood has been facilitated by the use of fibreoptic endoscopy with biopsies, complemented by double-contrast radiology. Clinical suspicion leads initially to several relevant blood tests. These are followed by endoscopy and multiple colonic biopsies or barium follow-through studies depending on whether large-bowel or small-bowel disease is suspected. The present approach to diagnosis is based on corroborative investigative techniques-endoscopy, radiology, and histology, The availability of paediatric colonoscopes of small diameter should make it possible for paediatricians to perform limited examinations, but when more extensive endoscopy is indicated the child should be referred to special centres.     

Nouvelle stratégie dans le diagnostic,la prévention et le suivi de l’ostéonécrose drépanocytaire en Côte d’Ivoire à partir de la scintigraphie osseuse

Osteonecrosis is the most frequent complications of sickle-cell disease (SCD) whose prevalence in Côte d’Ivoire is 21%. The main of this study was to compare scintigraphy, clinical and radiological observations to assess earlier diagnosis in SCD osteonecrosis. It was a prospective study about 45 SCD patients who presented coxopathy and had radio-labelled diphosphonates bone scintigraphy. The results revealed 49% of lesions whose 48% appeared wiyh homogeneous hyperfixation, 11% homogeneous hypofixation, 5% of hypofixation contourned by hyperfixation. Eighty-one percent of lesions concerned femoral head, 6% femoral condyle and 3% humoral head. Fifty percent of osteonecrosis was not visible in radiology and corresponded to the earlier stade. These invisible radiology aspects were observed in 100% hips without lameness, and in 43% permanent lameness. Scintigraphy (sensitive in 100%) isolated 38% more than conventional radiography. In main to improve SCD osteonecrosis prognostic in Côte d’Ivoire, this preliminary study outline that scintigraphy is fundamental in management.     

Serum tumor markers may precede instrumental response to chemotherapy in patients with metastatic cancer

PURPOSE: Although serum tumor markers (STMs) are widely used in clinical practice, their predictive role for the response to anticancer treatment is still controversial. The correlation of CEA, CA 15.3, CA 19.9, CA 125 (only with peritoneal involvement) and NSE levels with imaging response and clinical benefit was investigated in 60 non-selected patients with metastatic epithelial cancers treated by single-agent docetaxel chemotherapy. METHODS: STM measurement was performed at baseline and subsequently every three to four weeks. We applied the WHO criteria to evaluate both STM and instrumental responses. Concordance analysis was performed by the Cohen Kw index, and the significance of the results was established using the Fleiss, Cohen & Everitt test. Qualitative interpretation of data was obtained with the Landis & Koch scale. Correlations of STM response with clinical benefit (PS or pain improvement) were evaluated by the chi-square test. RESULTS: The primary tumors included breast cancers (38 patients), gastrointestinal non-colorectal cancers (12 patients), and lung cancers (10 patients). An overall significant good degree of agreement was observed between STM and instrumental response (p < 0.0005). The degree of agreement for each marker was as follows: excellent for CEA (p < 0.0005) and CA 125 (p = 0.006), good for CA 15.3 (p < 0.0005) and CA 19.9 (p = 0.011). Restricted analysis for the correlation of each marker with primary tumor origin showed good prediction of radiological response for CA 15.3 and CEA in breast cancer patients (p<0.0005 for both), for CEA and CA 19.9 in gastrointestinal cancer patients (p = 0.01 and 0.04, respectively), and for CEA+NSE in lung cancer patients (p = 0.01). Conversely, STM response did not correlate significantly with the clinical benefit for the patients, both in terms of PS and pain improvement (p = 0.24 and p=0.42, respectively). CONCLUSION: This study showed STMs to be good predictors of tumor response. Although STMs cannot replace diagnostic imaging, in metastatic cancer they might be useful to optimize the timing of radiological re-evaluation in the palliative setting.