X-ray video defaecography is superior to magnetic resonance defaecography in the imaging of defaecation disorders.

AIM: The aim of this work was to study the technical success and diagnostic capability of magnetic resonance defaecography (MRD) compared with video defaecography (VD). METHOD: Sixty four women with defaecation disorders underwent both MRD and x-ray VD over 1 year. The assessment by two radiologists in consensus was retrospective and blinded. The technical success of straining and evacuation was evaluated subjectively. The presence of enterocele, intussusception, rectocele and dyssynergic defaecation was analysed according to established criteria, with VD as the standard of reference. RESULTS: It was found that 62/64 (96.9%) VD studies were technically fully diagnostic compared with 29/64 (45.3%) for MRD. The number of partially diagnostic studies was 1/64 (1.6%) for VD versus 21/64 (32.8%) for MRD, with 1/64 (1.6%) (VD) and 14/64 (21.9%) (MRD) being nondiagnostic. Thirty enteroceles were observed by VD compared with seven in MRD with moderate agreement (κ = 0.41). Altogether 53 intussusceptions were observed by VD compared with 27 by MRD with poor agreement (κ = -0.10 and κ = 0.02 in recto-rectal and recto-anal intussusception, respectively). Moderate agreement (κ = 0.47) was observed in diagnosing rectocele, with 47 cases by VD and 29 by MRD. Dyssynergic defaecation was observed in three patients by VD and in 11 patients by MRD, with slight agreement (κ = 0.14). CONCLUSION: The technical success and diagnostic capabilities of VD are better than those of MRD. VD remains the method of choice in the imaging of defaecation disorders.

The effect of interventions on appropriate use of lumbar spine radiograph and CT examinations in young adults and children: a three-year follow-up.

BACKGROUND: According to international guidelines, radiological examinations of the lumbar spine are of limited value and do not improve clinical outcome unless there are clinical red flags present suggesting serious pathology. Nevertheless, the utilization of lumbar spine imaging remains high. PURPOSE: To follow up the effects of active referral guideline implementation and education on the number and appropriateness of lumbar spine radiographs and computed tomography (CT) examinations in young patients and to evaluate whether the appropriate radiographs have more significant findings. MATERIAL AND METHODS: Referral guidelines for spine examinations and info pocket cards on radiation protection were distributed to referring practitioners. Educational lectures were provided annually. The number of lumbar spine radiographs and CT examinations on patients aged <35 years was analyzed before and three years after the interventions. Appropriateness and findings of 313 radiographs and appropriateness of 117 CT scans of the lumbar spine were assessed. RESULTS: The number of lumbar spine radiographs and CT scans decreased significantly after the interventions and the level remained unchanged during the follow-up (-33% and -72%, respectively, P < 0.001). Appropriateness improved significantly in radiographs from 2005 to 2009 (65% vs. 85%) and in CT scans already from 2005 to 2007 (23% vs. 63%). Radiographs that were in accordance with the guidelines had more significant findings compared to radiographs that were not; in young adults, this was 56% versus 21% (P < 0.001). CONCLUSION: A combination of interventions can achieve a sustained reduction in the number of lumbar spine examinations and improve appropriateness. Inappropriate lumbar spine radiographs do not seem to contain significant findings that would affect patient care.

Parents' received and expected information about their child's radiation exposure during radiographic examinations.

BACKGROUND: Despite regulations, insufficient information is provided to adult patients prior to their radiologic examinations. Information regarding paediatric patients has not been systematically studied. OBJECTIVE: To survey parents' experience and wishes for information in connection with their child's radiographic examination. MATERIALS AND METHODS: We provided a questionnaire to consenting parents of children younger than 12 years old at a university hospital. The questionnaire asked parents about the information obtained from the referrer prior to the radiograph, the chance to discuss with the referrer and their wishes regarding future information. Forty-one parents responded to the survey. Twenty-five children were referred for radiography of extremities, the others for dental, body and skull examinations. RESULTS: Altogether 34/41 (83%, 95% confidence interval [CI] 69-91%) parents said they received adequate information on the purpose of the examination, 8/35 (23%, 95% CI 12-39%) on other options and 3/41 (7%, 95% CI 3-19%) on radiation dose. Ten of 41 parents (24%, 95% CI 12-40%) said they were aware of radiation exposure. The number of previous radiology examinations was not sufficiently discussed. The communication was scored as mean 6.5 (95% CI 5.8-7.1) on a scale from 4 (poor) to 10 (excellent). Thirty-eight of 40 (95%, 95% CI 84-99%) of parents expected information on the purpose, 35/40 (88%, 95% CI 74-95%) on radiation dose and 31/40 (78%, 95% CI 63-88%) on other options. Symbols of radiation and corresponding period of natural background radiation are preferred to convey the dose. A referrer is the preferred source of information. CONCLUSION: Parents did not feel adequately informed prior to their child's radiographic examination. Parents expect more information about the purpose, dose and alternative tests.

Justification and active guideline implementation for spine radiography referrals in primary care.

Background Spinal disorders are a major public health problem. Appropriate diagnostic imaging is an essential part in the management of back complaints. Nevertheless, inappropriate imaging increases population collective dose and health costs without improving outcome. Purpose To determine the effects of active implementation of referral guidelines on the number and justification of spine radiography in primary care in one city. Material and Methods Specified guidelines for spine radiography were distributed to referring practitioners altogether three times during the study period. Educational lectures were provided before the guidelines were taken into use. The guidelines were also made available via the intranet. The number of spine radiography referrals during similar 6-month periods in the year preceding the interventions and the following 2 years was analyzed. Justification of 448 spine radiographs was assessed similarly. Results After interventions, the total number of spine radiography examinations decreased by 48% (P < 0.001) and that of cervical spine radiography by 46% ( P < 0.001), thoracic spine by 53% ( P < 0.001), and lumbar spine by 47% ( P < 0.001). The results persisted after 1-year follow-up. Before interventions, 24% of the cervical, 46% of the thoracic, and 32% of the lumbar spine radiography referrals were justified. After interventions, only justification of lumbar spine radiography improved significantly, 64% being justified ( P = 0.005). Conclusion Spine radiography in primary care can be reduced significantly by active referral guideline implementation. The proportion of inappropriate radiography was unexpectedly high. Thus, further education and studies concerning the appropriate use of spinal radiography seems to be needed.

Information about radiation dose and risks in connection with radiological examinations: what patients would like to know.

OBJECTIVES: To find out patients' wishes for the content and sources of the information concerning radiological procedures. METHODS: A questionnaire providing quantitative and qualitative data was prepared. It comprised general information, dose and risks of radiation, and source of information. Two tables demonstrating different options to indicate the dose or risks were also provided. Patients could give one or many votes. Altogether, 147 patients (18-85 years) were interviewed after different radiological examinations using these devices. RESULTS: 95% (139/147) of the patients wished for dose and risk information. Symbols (78/182 votes) and verbal scale (56/182) were preferred to reveal the dose, while verbal (83/164) and numerical scale (55/164) on the risk of fatal cancer were preferred to indicate the risks. Wishes concerning the course, options and purpose of the examination were also expressed. Prescriber (3.9 on a scale 1-5), information letter (3.8) and radiographer (3.3) were the preferred sources. Patients aged 66-85 years were reluctant to choose electronic channels. CONCLUSIONS: Apart from general information, patients wish for dose and risk information in connection with radiological examinations. The majority preferred symbols to indicate dose and verbal scales to indicate risks, and the preferred source of information was the prescriber or information letter. KEY POINTS: • 95% of patients expect information on the dose and risks of radiation. • Symbols and verbal scale are preferred to indicate the dose. • Verbal and numerical scales are preferred to indicate fatal cancer risk. • Patients expect information on course, options and purpose of examination. • Prescriber, information letter and radiographer are popular sources of the overall information.

Effect of display type and room illuminance in chest radiographs.

OBJECTIVES: To compare diagnostic accuracy in the detection of subtle chest lesions on digital chest radiographs using medical-grade displays, consumer-grade displays, and tablet devices under bright and dim ambient light. METHODS: Five experienced radiologists independently assessed 50 chest radiographs (32 with subtle pulmonary findings and 18 without apparent findings) under bright (510 lx) and dim (16 lx) ambient lighting. Computed tomography was used as the reference standard for interstitial and nodular lesions and follow-up chest radiograph for pneumothorax. Diagnostic accuracy and sensitivity were calculated for assessments carried out in all displays and compared using the McNemar test. The level of significance was set to p < 0.05. RESULTS: Significant differences in sensitivity between the assessments under bright and dim lighting were found among consumer-grade displays in interstitial opacities with, and in pneumothorax without, Digital Imaging and Communication in Medicine-Grayscale Standard Display Function (DICOM-GSDF) calibration. Compared to 6 megapixel (MP) display under bright lighting, sensitivity in pneumothorax was lower in the tablet device and the consumer-grade display. Sensitivity in interstitial opacities was lower in the DICOM-GSDF calibrated consumer-grade display. CONCLUSIONS: A consumer-grade display with or without DICOM-GSDF calibration or a tablet device is not suitable for reading digital chest radiographs in bright lighting. No significant differences were observed between five displays in dim light. KEY POINTS: • Ambient lighting affects performance of consumer-grade displays (with or without DICOM-GSDF calibration). • Bright light decreases detection of pneumothorax on non-medical displays. • Bright light decreases detection of interstitial opacities on DICOM-GSDF-calibrated, consumer-grade displays. • Dim light is sufficient to detect subtle chest lesions from all displays.

Unjustified CT examinations in young patients.

The doses of radiation from computed tomography (CT) are relatively high, yet CT is being increasingly utilized. Furthermore, the radiation-induced lifetime risk of cancer mortality is higher at younger age. The purpose of this study was to find out whether previous CT examinations done on patients aged under 35 years were justified, and if not, whether there would have been other, more justifiable imaging modalities available. Fifty CT examinations of the head and 30 CT examinations each of the lumbar spine, cervical spine, abdomen, nasal sinuses and trauma were evaluated consecutively since the beginning of the year 2005 by using electronic patient files, the referral guidelines for imaging recommended by the European Commission and certain principles of classification. Seventy-seven per cent of the CT examinations of the lumbar spine, 36% of the head, 37% of the abdomen, 20% of the nasal sinuses and 3% of the cervical spine were unjustified. Most of these unjustified examinations could have been replaced by magnetic resonance imaging. In order to reduce utilization of ionizing radiation, both the referring practitioner and the radiologist responsible for the examination should carefully consider the justification for CT examinations and the possibility of using other imaging modalities.

Methods to detect inappropriate use of MRI and CT for musculoskeletal conditions: A scoping review.

OBJECTIVE: Identify and evaluate methods suitable for detecting inappropriate use of MRI or CT in the musculoskeletal system. DESIGN: Systematic review of studies that described methods to measure inappropriate use of MRI or CT in the musculoskeletal system. We used a multi-step strategy to classify identified methods into categories. These categories were then analyzed according to the data needed and their limitations. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: English or German language studies that measured inappropriate use of MRI or CT in the musculoskeletal system. Articles were also included if they reported a general approach to the measurement of inappropriate imaging regardless of body region. Expert opinions, unsystematic reviews, commentaries, articles without abstracts, and studies on cancer were excluded. RESULTS: 47 studies met the inclusion criteria. The categorization of the studies resulted in seven individual approaches to measure inappropriate use: (1) availability of meaningful diagnostic information; (2) predictors associated with imaging use; (3) comparison with guideline recommendations; (4) assessment by experts; (5) comparison or analysis of patients' paths; (6) comparison with surgery findings; (7) geographic variation. All these approaches have specific data requirements and individual advantages and disadvantages regarding risk of bias and needed data. CONCLUSIONS: We could not find a single method of choice to detect inappropriate use of MRI or CT in the musculoskeletal system. A combination of different approaches is the preferred strategy to deal with the advantages and disadvantages of the individual methods.

Clinical imaging guidelines part 4: challenges in identifying, engaging and collaborating with stakeholders.

The effective development and use of clinical imaging guidelines requires an understanding of who the stakeholders are, what their interests in the process are, and what roles they should play. If the appropriate stakeholders are not engaged in the right roles, it is unlikely that clinical imaging guidelines will be successfully developed, relied on, and actually used. Some stakeholders are obvious: for the development of clinical imaging guidelines, both imagers and those who request examinations, such as general practitioners, internists, and medical specialists, must be involved. To gain acceptance, other relevant groups are stakeholders, including medical societies, other health care professionals, insurers, health IT experts and vendors, and patients. The role of stakeholders must be dictated by their specific interest. For some, involvement in the creation of guidelines is the right role. For others, such as regulators or insurers, reviews or invitations to comment are required, and for others, such as medical educators, it is probably sufficient to provide information and create awareness. Only through a careful consideration of who the stakeholders are and what are their interests are the successful development, acceptance, and use of clinical imaging guidelines likely to occur. Future efforts must focus on collaboration, particularly among groups that create clinical imaging guidelines and those that can support their use, and on regulatory roles and mandates.

Survey of inappropriate use of magnetic resonance imaging.

OBJECTIVE: There are concerns that not all costly advanced imaging is appropriate. However, studies about the appropriateness of magnetic resonance imaging (MRI) are sparse. The aim of this study was to review various MRI examinations done at a university hospital to determine whether there is inappropriate use. METHODS: Altogether 150 common MRIs (upper abdomen or liver, lumbar spine, knee, head and head of children performed under anaesthesia, 30 each) were reviewed consecutively. The referrals and corresponding patient files were analysed by senior radiologists and the indications of the examinations were compared to the referral criteria. RESULTS: Seven per cent of the examinations were deemed inappropriate. All the MRIs of the head done on children were indicated. One to three examinations in all other subgroups were not indicated. The most common appropriate indications were ambiguous hepatic, pancreatic or adrenal lesions, prolonged lower back pain, suspicion of meniscus rupture, brain malignancy and developmental disorder of a child, respectively. CONCLUSIONS: Although the proportion of inappropriate examinations was not high; financial issues and the growing number of patients referred for MRI are of concern. Education and regular use of up-to-date referral guidelines could help to further improve appropriateness. MAIN MESSAGES: •Seven per cent of the MRI examinations analysed were inappropriate at a university hospital. •Everyday practices of a hospital may contribute to the level of appropriateness. •A survey of indications for previous MRI examinations might be helpful in various institutions.