Improving practice in radiology: a quality-improvement project examining CT colonography patient dose and scanning technique.

AIM: To audit scanning technique and patient doses for computed tomography (CT) colonography (CTC) examinations in a large UK region and to identify opportunities for quality improvement. MATERIALS AND METHODS: Scanning technique and patient dose data were gathered for both contrast-enhanced and unenhanced CTC examinations from 33 imaging protocols across 27 scanners. Measurements of patient weight and effective diameter were also obtained. Imaging protocols were compared to identify technique differences between similar scanners. Scanner average doses were calculated and combined to generate regional diagnostic reference limits (DRLs) for both examinations. RESULTS: The regional DRLs for contrast-enhanced examinations were volume CT dose index (CTDIvol) of 11 and 5 mGy for the two scan phases (contrast-enhanced and either delayed phase or non-contrast enhanced respectively), and dose-length product (DLP) of 740 mGy·cm. For unenhanced examinations, these were 5 mGy and 450 mGy·cm. These are notably lower than the national DRLs of 11 mGy and 950 mGy·cm. Substantial differences in scan technique and doses on similar scanners were identified as areas for quality-improvement action. CONCLUSION: A regional CTC dose audit has demonstrated compliance with national DRLs but marked variation in practice between sites for the dose delivered to patients, notably when scanners of the same type were compared for the same indication. This study demonstrates that the national DRL is too high for current scanner technology and should be revised.

Tumour growth rate of carcinoma of the colon and rectum: retrospective cohort study.

BACKGROUND: The growth pattern of colorectal cancer is seldom investigated. This cohort study aimed to explore tumour growth rate in colorectal cancers managed non-surgically or deemed not resectable, and to determine its implication for prognosis. METHODS: Consecutive patients with colonic or rectal adenocarcinoma were identified through the colorectal multidisciplinary team database at Leeds Teaching Hospitals NHS Trust over a 2-year interval. Patients who received no treatment (surgery, stenting, colonic defunctioning procedures, chemotherapy, radiotherapy) and who underwent CT twice more than 5 weeks apart were included. Multidetector CT/three-dimensional image analysis was performed independently by three experienced radiologists. RESULTS: Of 804 patients reviewed, 43 colorectal cancers were included in the final analysis. Median age at first CT was 80 (73-85) years and the median interval between scans was 150 (i.q.r. 72-471) days. An increase in T category was demonstrated in 31 of 43 tumours, with a median doubling time of 211 (112-404) days. The median percentage increase in tumour volume was 34·1 (13·3-53·9) per cent per 62 days. The all-cause 3-year mortality rate was 81 per cent (35 of 43) with a median survival time of 1·1 (0·4-2·2) years after the initial diagnostic scan. In those obstructed, the relative risk of death from subsequent perforation was 1·26 (95 per cent c.i. 1·07 to 1·49; P = 0·005). CONCLUSION: This study documented a median doubling time of 211 days, with a concerning suggestion of tumour progression, which has implications for the current management standard.

ANTECEDENTES: El patrón de crecimiento del CRC (colorectal cancer, CRC) ha sido poco investigado. El objetivo de este estudio de cohortes fue explorar la tasa de crecimiento tumoral en los pacientes con CRC no tratados quirúrgicamente o con tumores irresecables para determinar su valor pronóstico. MÉTODOS: Los pacientes consecutivos con adenocarcinoma de colon o recto se identificaron a partir de la base de datos del equipo multidisciplinario colorrectal del "Leeds Teaching Hospitals NHS Trust" durante un período de 2 años. Se incluyeron los pacientes que no recibieron tratamiento (cirugía, colocación de endoprótesis, procedimientos de desfuncionalización del colon, quimioterapia, radioterapia), en los que se obtuvieron tomografías computarizadas con > 5 semanas de diferencia. El análisis de imágenes TC/3D multidetector fue realizado de forma independiente por tres radiólogos expertos. RESULTADOS: De los 804 pacientes revisados, 43 CRCs se incluyeron en el análisis final con una mediana de 150 días (rango intercuartílico, interquartile range, IQR: 72-471) entre los escáners. La mediana de edad en el primer escáner era de 80 años (IQR: 73-85). En 31 (72%) casos, se demostró un aumento del estadio TNM del tumor, con un tiempo medio de duplicación del tamaño tumoral de 211 días (IQR: 112-404). La mediana de aumento porcentual del volumen del tumor era de un 34% cada 62 días (IQR: 13,3-53,9). La mortalidad por cualquier causa a los 3 años fue del 81% (35/43), con una mediana de supervivencia de 1,1 años (IQR: 0,4-2,2) desde el escáner inicial diagnóstico. El riesgo relativo de mortalidad como resultado de la obstrucción intestinal y perforación subsiguiente era de 1,26 (i.c. del 95% 1,07-1,49, P < 0,01). CONCLUSIÓN: Este estudio documentó una mediana de tiempo de duplicación del tamaño del tumor de 211 días, así como datos preocupantes de la progresión del tumor que podrían tener repercusión en el tratamiento estándar actual.

Acceptability of a new practice development for radiographers focussed on reducing 'never events' related to nasogastric feeding tubes in adult patients.

INTRODUCTION: Ascertain if a new practice development designed to reduce 'never events' from feeding through misplaced nasogastric tubes (NGT) in a large teaching hospital Trust was acceptable to a large radiography workforce. METHODS: Despite National Patient Safety Agency guidance advising on safe practice for confirming position of NGTs a number of 'never events' still occur nationally due to misinterpretation of the check X-ray. A new practice development for radiographers included providing an immediate comment and removal of misplaced NGTs at the time of the check X-ray examination. Success of the new system was partly assessed using qualitative and quantitative measures of radiographer opinion of the training and different aspects of the system. RESULTS: There was a significant improvement in radiographers' level of confidence in image interpretation after training (58/98 positive responses before, 89/98 positive after training) and after five months of experience at undertaking the role (96/98 positive) (p < 0.01). There was increased confidence in NGT removal post training and with five months of experience (16/95 positive before training, 67/96 positive after and 81/95 positive with five months of experience). 97/98 (99%) of radiographers agreed the new system benefits patients, 93/98 (95%) believed it a positive step for the radiography profession. CONCLUSION: Evaluation of this new practice development has shown it was embraced by radiographers and is a workable and potentially cost-effective solution in addressing real time image interpretation issues that were evident from previous 'never events'. Large scale implementation of this system across the NHS Radiography workforce should be considered.

Radiographer workforce role expansion to improve patient safety related to nasogastric tube placement for feeding in adults.

AIM: To determine whether the active involvement of radiographers in nasogastric tube (NGT) management at a large multisite healthcare institution can contribute to risk reduction regarding feeding through misplaced NGTs. MATERIALS AND METHODS: Despite national guidance in the National Health Service advising on safe practice to confirm NGT position, a number of "never events" (feeding through misplaced NGT) continue to occur due to misinterpretation of the check radiograph. Practice change was introduced, including all plain film radiographers providing contemporaneous comments on NGT position on the check radiograph. The success of the system was assessed to determine the accuracy of radiographer comments against the reference standard of the radiologist report to see whether the system has helped reduce the number of "never events". RESULTS: During the first 27 months post-implementation, 4,675 check NGT radiography examinations were analysed. Two hundred and twenty-seven examinations were excluded due to absent or incomplete radiographer comments. The accuracy of the radiographer comments was 98.5% (95% confidence interval [CI]: 97.7-99.5%), sensitivity 97.4% (95% CI: 96.3-98.3%), specificity 98.9% (95% CI: 98.5-99.2%), positive predictive value 96.8% (95% CI: 95.6-97.7%), and negative predictive value 99.1% (95% CI: 98.8-99.4%). CONCLUSION: After focused training, radiographer comments are a safe, sustainable, and workable solution offering an effective solution for image misinterpretation issues relating to NGT "never events". This should be considered for wider implementation in healthcare.

Tc99m-hepatobiliary iminodiacetic acid (HIDA) scintigraphy in clinical practice.

There have been evolutionary changes in the management of pathological conditions of the hepatobiliary system over recent years, particularly with an increasing emphasis on modern hepatobiliary surgical techniques. Concurrent advances have occurred in imaging technology and availability, leading to a greater use of ultrasound, multidetector computed tomography (CT), and magnetic resonance imaging (MRI) in the primary evaluation of hepatobiliary disease. Radionuclide imaging using technetium(99m) (Tc(99m)) hepatobiliary iminodiacetic acid (HIDA) derivatives is an established technique that complements morphological imaging, providing valuable functional information in both pre- and postoperative evaluation of patients with suspected or known hepatobiliary disease. This review discusses the current clinical indications for Tc(99m) HIDA scintigraphy using clinical cases to demonstrate how this technique continues to play a valuable diagnostic role in the assessment of the functional integrity of the hepatobiliary system.

Characterization of Chlamydiaceae species using PCR and high resolution melt curve analysis of the 16S rRNA gene.

AIM: To design a rapid diagnostic test to differentiate species belonging to the family Chlamydiaceae. METHODS AND RESULTS: Five oligonucleotide sets each targeting various conserved regions of the genome of six species (Chlamydia muridarum, C. suis, C. trachomatis, Chlamydophila felis, Cp. pneumoniae and Cp. psittaci) belonging to the family Chlamydiaceae were tested for their suitability for polymerase chain reaction (PCR) and high resolution melt (HRM) curve analysis to differentiate Chlamydiaceae species. Three of the oligonucleotide sets were able to detect all six reference species used in this study, but only one set (16SG) could clearly differentiate between them by HRM curve analysis. The PCR-HRM curve analysis confidence percentages correlated strongly with the nucleotide sequence identities. Clinical specimens from a number of animal species suspected of chlamydiosis were tested with the newly developed 16SG PCR-HRM curve analysis and sequenced to confirm the infecting species. It was demonstrated that PCR-HRM using the 16SG oligonucleotide set could relate the infecting Chlamydiaceae species to the most similar (based on 16S rRNA gene nucleotide sequence) reference species tested. Although Cp. pecorum was not included initially as a reference species in this assay, inclusion of a field isolate of Cp. pecorum as a reference allowed two koala specimens to be correctly identified. CONCLUSION: PCR-HRM analysis using the oligonucleotide set 16SG is a robust, simple and rapid technique for differentiation of at least the Chlamydiaceae species used in this study. SIGNIFICANCE AND IMPACT OF THE STUDY: This technique allowed for the rapid detection and identification of the six Chlamydiaceae reference species and may be useful for identification of uncharacterized Chlamydiaceae species or for use in animal species where occurrence of the disease has not been fully investigated.

Prognostic significance of BRCA1 expression in sporadic breast carcinomas.

BRCA1 is a tumour suppresser gene frequently mutated in familial breast cancer and thought to influence the progression of sporadic breast cancer. Decreased BRCA1 mRNA and protein expression has been identified in breast cancer cell lines and sporadic breast tumours. Here the prognostic significance of reduced BRCA1 protein expression is investigated in primary operable breast cancer. Immunohistochemical analysis was used to determine the level of BRCA1 protein expression in 100 breast cancers. BRCA1 expression was compared with known prognostic factors and survival to investigate its prognostic significance. BRCA1 nuclear expression was reduced by varying amounts in breast carcinomas. A progressive loss of BRCA1 expression correlated well with higher histological grade (p = 0.002) and an excess of medullary/atypical medullary/grade 3 ductal carcinomas (p = 0.0001). When adjusted for grade, patients with loss of BRCA1 expression had a significantly longer disease-free survival time. Loss of BRCA1 expression associated with high-grade breast tumours suggests that BRCA1 may play an important role in the pathogenesis of sporadic breast cancer.