Striving for Excellence: Multicentre Quality Improvement Project to Optimize CT KUB Technique in Renal Colic Patients.

OBJECTIVE: To perform audit of imaging practice in different hospitals to assess their adherence to guidelines on optimizing computerized tomography of kidneys, ureter and bladder (CT KUB) technique in order to reduce unnecessary scan length. To assess improvement in adherence to guidelines after intervention, following education of the technologists. MATERIAL AND METHODS: There were 12 participant radiology departments in eight cities of Islamic Republic of Pakistan. Findings of first audit round were presented in respective departmental meetings and technologists were educated. Second round was performed after 12 weeks. Our target was to achieve 100% compliance to standards. Comparison of adherence to guidelines before and after intervention was done. Total number of axial slices of KUB CT scan, images above upper pole of highest kidney (overscan/unnecessary slices) and percentage of unnecessary images were recorded. To calculate statistical significance of difference, Fischer exact and Chi-square tests were applied. RESULTS: Percentage of patients with appropriate CT KUB technique according to RCR guidelines was far less in first round (0-64%). It significantly improved after educating the technologists (35.57- 90.90%). CONCLUSION: By following standard practice of CT KUB scan, significant radiation dose reduction is achievable without compromising diagnostic details. ADVANCES IN KNOWLEDGE: Standardization of CT KUB examination technique can valuably contribute to reduction in unessential radiation exposure.

Diagnostic Accuracy of Magnetic Resonance Spectroscopy in Predicting the Grade of Glioma Keeping Histopathology as the Gold Standard.

Background Gliomas are the most prevalent intrinsic tumors of the central nervous system and are categorized from grade I to grade IV. Magnetic resonance imaging (MRI) provides exact diagnosis, prognosis, and assessment of tumor response to current chemotherapy/immunotherapy and radiation therapy. With histopathology serving as the gold standard, we aimed to assess the diagnostic accuracy of magnetic resonance spectroscopy (MRS) in predicting glioma grade. Methodology This cross-sectional study was conducted in the Department of Radiology, KRL Hospital, Islamabad, from December 15, 2019, to September 30, 2021. After providing written consent, 80 patients with untreated gliomas were included in this study. The voxel of interest was identified using MRI brain conventional contrast-enhanced sequences to assess the grade of the gliomas and link it to the histology report. Following this identification, tissue metabolites were calculated using MRS. Results The patients' age ranged from 13 to 80 years, with a mean age of 49.5 years. Male patients comprised 57.5% of the total study population, while female patients comprised 42.5%. Overall, 23.75% of patients had low-grade tumors, while 76.25% had high-grade tumors. Low-grade tumors had a choline (Cho)/creatine (Cr) metabolite ratio of 1.7421, whereas high-grade tumors had an average Cho/Cr metabolite ratio of 2.5575. N-acetyl aspartate (NAA)/Cr ratio was 1.6368 in low grade and 0.6734 in high-grade tumors. Sensitivity of 77% and specificity of 84.2% were noted, with 78.75% diagnostic accuracy for the Cho/Cr ratio. Conclusions Multivoxel MRS has been shown to reliably predict the grade of gliomas despite its non-invasive nature and lack of procedural challenges. When used together Cho/Cr and NAA/Cr ratios and histopathology can accurately determine tumor grade and can be used as a supplementary non-invasive technique.

Diagnostic Accuracy of Cerebroplacental Ratio in Prediction of Postnatal Outcomes in Oligohydramnios.

BACKGROUND AND AIM: The evidence on isolated oligohydramnios (IO) patients and their postnatal outcomes are inconsistent. Recent research has clarified the connection between that IO and negative outcomes in the postnatal period. Our goal was to analyze the correlation between Doppler measurements and postnatal outcomes in oligohydramnios patients, with a focus on the cerebroplacental ratio (CPR). METHODOLOGY: A cohort study was conducted in the Radiology Department of Khan Research Laboratories (KRL) Hospital from October 2021 to July 2022. One hundred women were chosen as the sample size. For this study, we used the Raosoft sample size calculator with a 95% confidence interval and a 5% margin of error. Both the middle cerebral artery and the umbilical artery were imaged using ultrasound, and the systolic-to-diastolic ratio and peak systolic velocity are recorded. Pulsatility index (PI) and resistive index (RI) were also calculated. If the amniotic fluid index (AFI) is less than 5 cm, the condition is known as oligohydramnios. The newborn's APGAR score was taken immediately after birth as well as after 5 minutes. RESULTS: We have determined that, on average, mothers are 35.45 weeks/248.15 days pregnant. When compared to the reference standard, CPR diagnostic features showed a sensitivity of 92% and a specificity of 77.27. Overall diagnostic accuracy is predicted to be 93.0%, with a 93.50% positive prognosis and a 73.91% negative prognosis. The effect size for the change in APGAR scores before and after the test was -2.38 1.03, with a 95% confidence interval of -2.58 to -2.17 and a significance level of 0.00. CONCLUSION: This study concludes that CPR is an effective screening tool and that it can be used to predict postnatal outcomes in patients with oligohydramnios. Clinical prediction rules were found to be a more effective screening tool, with a sensitivity of 92%, a specificity of 77.27%, and a diagnostic accuracy of 92.3%.

Ideal proportion of the population to be patch tested: How many should we be doing?

BACKGROUND: How many patients should we be patch testing? A previous study suggested that the minimum proportion of a population to be patch tested for allergic contact dermatitis was 1:700 annually. OBJECTIVES: To evaluate if the current minimum rate for patch testing has changed over the 20 years since the previous study in order to maximize the value. METHODS: In cooperation with the British Society for Cutaneous Allergy, a proforma for collation of retrospective data between January 2015 and December 2017 was sent to patch-test centers in the United Kingdom (UK) and the Republic of Ireland (ROI). The number of positive tests was analyzed against the proportion of population tested to see what proportion of the population would yield the greatest number of positive results. RESULTS: Responses from 11 centers showed that the minimum number needed to patch test had increased to 1:550 per head of population per year using the current criteria. CONCLUSIONS: In agreement with previous studies, we should be patch testing more people than we are. We could reduce the threshold for referral of patients we patch test to derive the most benefit from this investigation.

The Ability of Ultrasound Sonography (USG) to Detect Intrauterine Growth Restriction (IUGR) in the Third Trimester of Pregnancy With the Gold Standard of IUGR (Parameters by USG Hadlock) as a Diagnostic Criterion.

Objective To investigate the diagnostic accuracy of the placental thickness measured by ultrasound sonography test (USG) in detecting intrauterine growth restriction (IUGR) babies in the third trimester of pregnancy, keeping IUGR (by parameters using Hadlock) as the gold standard. Methods and materials This cross-sectional study was conducted at the radiology department of KRL Hospital from August 5, 2020, to October 25, 2021. Informed written consent was also obtained from each patient, and the hospital's ethical committee approved the study. Three hundred and sixty-two (N=362) pregnant women patients knowing of their last menstrual period, age group 20-35 years, BMI usual, and 24 weeks gestation were included. The patient's complete history was taken by clinical examination and then ultrasound was carried out to measure the placental thickness. At 24, 32, and 36 weeks, the thickness of the placenta was assessed. The Hadlock method was used to compute the predicted fetal weight by measuring biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL) on the GC Logiq P/6 three-dimensional machine (GE, Tampa, FL). SPSS v 23 (IBM Corp., Armonk, NY) was used to calculate the mean and standard deviation from the collected data. Results A total of 362 patients who presented in the radiology department for antenatal ultrasound in the third trimester were recruited in our study. The mean age was 27.26 ± 4.21 years (20-35 years). In our study, the mean placenta thickness at 24 gestation weeks was 24.55 ± 0.79 mm, at 32 gestation weeks was 31.84 ± 1.34 mm, and at 36 gestation weeks was 35.54 ± 2.78. Thus, ultrasound's sensitivity, specificity, positive predictive value, and negative predictive value to determine IUGR by placental thickness was 86.30%, 86.70%, 75%, and 92%, respectively. The diagnostic accuracy of ultrasound incorrectly estimating low placental thickness was 86.40%. Conclusion Between 24 and 36 weeks of pregnancy, placental thickness rises almost linearly. As a result, measuring placental thickness and other factors is critical for estimating fetal age, particularly in the late second and early third trimesters, when the exact duration of pregnancy is uncertain. Placentas that were less than 29 mm thick at 32 weeks and 31 mm thick at 36 weeks were related to higher morbidity, lower Apgar scores, and more nursery admissions.

An audit of the activities of the pediatric dermatology nurse specialist (PDNS).

In the current financial climate where resources in the National Health Service are becoming increasingly limited, it is essential that the role of the pediatric dermatology nurse specialist remains appreciated and supported. Our pediatric dermatology nurse specialist was first employed in September 2002 having had 6 years experience nursing children with a wide variety of dermatologic conditions prior to her employment. She achieved her pediatric community nursing degree in 2003 undertaking the nurse prescribing extended formulary course in 2006, her training history representative of many nurse specialists. We present the results of an audit highlighting how the employment of our pediatric dermatology nurse specialist has led to a decrease in hospital admissions as well as providing a significant positive impact on waiting lists.

A case of cutaneous symplastic leiomyoma - a rare variant of cutaneous pilar leiomyoma.

We describe the case of a cutaneous symplastic leiomyoma in a 37-year-old woman who presented with a 4-year history of a painful slow growing lesion on the left upper arm. The lesion was excised and subjected to histological examination. A poorly circumscribed lesion was seen in the dermis composed of spindle shaped cells with marked nuclear pleomorphism. No mitotic figures or necrosis were seen. The cells stained strongly positive with desmin and smooth muscle actin, and negative with S100, melan A, MNF116 a mouse monoclonal antibody to cytokeratin and CK5/6. The diagnosis was felt to be in keeping with a cutaneous symplastic leiomyoma, a rarely reported variant of the pilar leiomyoma. Histologically, it shows features similar to the symplastic variant of uterine leiomyoma with cytological atypia, nuclear pleomorphism and minimal mitotic activity. Although the long-term outlook is probably benign, the presence of cytological atypia and mitoses in any spindle cell tumor is generally a concerning feature and warrants long-term follow up.

Efalizumab in the treatment of discoid lupus erythematosus.

BACKGROUND: Discoid lupus erythematosus is a chronic inflammatory condition in which the pathogenesis and the role of cell-mediated immunity remains unclear. Currently, the most effective treatments for severe disease are thalidomide, methotrexate, and cyclosporin, although the evidence for this is limited. Efalizumab is a monoclonal antibody directed against CD11a, the alpha-subunit of the leukocyte-functioning antigen 1, with a current license for use in psoriasis. Because discoid lupus erythematosus is known to be predominantly T-cell mediated, our aim was to use efalizumab as a T-cell modulator in patients with recalcitrant disease. OBSERVATIONS: Thirteen patients received efalizumab, with treatment responses varying from good to excellent in 12 of 13 patients. There was a significant reduction in the cutaneous lupus activity and severity score (CLASS) score after therapy with efalizumab (P = .002). CONCLUSIONS: We have presented efalizumab as a novel alternative treatment for patients with difficult discoid lupus erythematosus. The response to treatment in 12 patients was very encouraging, with the mean time to response being 5.5 weeks. However, patient numbers were small, and many remain in the early stages of therapy. A prospective randomized study with a long-term follow-up is required, especially in light of recent findings to evaluate both the effectiveness and safety profile of this monoclonal antibody.

Subungual Bowen's disease treated by topical aminolevulinic acid-photodynamic therapy.

A 66-year-old man presented with an 18-month history of progressive nail dystrophy involving his left index finger. A diagnostic biopsy specimen confirmed the clinical suggestion of subungual Bowen's disease (carcinoma in situ). Various treatment options were considered, and the decision was made to treat with photodynamic therapy using topical 5-aminolevulunic acid administered as two treatments 4 weeks apart. The patient was reviewed 3 months after treatment and then regularly at 6-month intervals. Thirty months after treatment there remained no clinical evidence of recurrence of the condition with preservation of a normal nail unit. Although the successful treatment of cutaneous Bowen's disease with photodynamic therapy is well documented, this is the first report of the successful treatment of subungual Bowen's disease using topical aminolevulunic acid-photodynamic therapy.