Accelerated implementation of remote reporting during the COVID-19 pandemic.

AIM: To assess, via a survey of UK radiological departments, if the COVID-19 pandemic led to a change in radiological reporting undertaken in a home environment with appropriate IT support. MATERIALS AND METHODS: All imaging departments in the UK were contacted and asked about the provision of home reporting and IT support before and after the first wave of the pandemic. RESULTS: One hundred and thirty-seven of the 217 departments contacted replied, producing a response rate of 61%. There was a 147% increase in the provision of remote access viewing and reporting platforms during the pandemic. Although 578 consultants had access to a viewing platform pre-pandemic, this had increased to 1,431 during the course of the first wave. CONCLUSION: This survey represents work undertaken by UK NHS Trusts in co-ordinating and providing increased home-reporting facilities to UK radiologists during the first wave of this global pandemic. The impact of these facilities has been shown to allow more than just the provision of reporting of both elective and emergency imaging and provides additional flexibility in how UK radiologists can help support and provide services. This is a good start, but there are potential problems that now need to be overcome.

A national UK audit for diagnostic accuracy of preoperative CT chest in emergency and elective surgery during COVID-19 pandemic.

AIM: To report on a snap audit of all departments in the UK as to the value of preoperative thoracic imaging, preferably computed tomography (CT), of patients undergoing any surgery to assess for changes consistent with COVID-19 preoperatively. MATERIALS AND METHODS: All Imaging departments in the UK were contacted and asked to record the number of preoperative CT examinations performed in patients being considered for both emergency and elective surgical intervention over a 5-day period in May 2020. RESULTS: Forty-seven percent of departments replied with data provided on >820 patients. Nineteen percent of additional preoperative CT was in patients undergoing elective intervention and 81% in patients presenting with surgical abdominal pain. There was a high rate of false positives in patients who tested negative for COVID-19, producing a sensitivity for thoracic CT of 68.4%. CONCLUSION: This UK-wide audit demonstrates that a large number of additional thoracic imaging examinations over a 5-day period were performed with a low sensitivity for the identification of COVID-19 in this preoperative group of patients. Given these findings, it is difficult to justify this additional examination in this group of patients.

Evaluating the role of fluorodeoxyglucose positron emission tomography-computed tomography in multi-disciplinary team recommendations for oesophago-gastric cancer.

BACKGROUND: National guidelines recommend that fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) is performed in all patients being considered for radical treatment of oesophageal or oesophago-gastric cancer without computerised tomography scan (CTS) evidence of metastasis. Guidance also mandates that all patients with cancer have treatment decisions made within the context of a multi-disciplinary team (MDT) meeting. Little is known, however, about the influence of PET-CT on decision making within MDTs. The aim of this study was to assess the role of PET-CT in oesophago-gastric cancer on MDT decision making. METHODS: A retrospective analysis of a prospectively held database of all patients with biopsy-proven oesophageal or oesophago-gastric cancer discussed by a specialist MDT was interrogated. Patients selected for radical treatment without CTS evidence of M1 disease were identified. The influence of PET-CT on MDT decision making was examined by establishing whether the PET-CT confirmed CTS findings of M0 disease (and did not change the patient staging pathway) or whether the PET-CT changed the pathway by showing unsuspected M1 disease, refuting CTS suspicious metastases, or identifying another lesion (needing further investigation). RESULTS: In 102 MDT meetings, 418 patients were discussed, of whom 240 were initially considered for radical treatment and 238 undergoing PET-CT. The PET-CT confirmed CTS findings for 147 (61.8%) and changed MDT recommendations in 91 patients (38.2%) by (i) identifying M1 disease (n=43), (ii) refuting CTS suspicions of M1 disease (n=25), and (iii) identifying new lesions required for investigations (n=23). CONCLUSION: The addition of PET-CT to standard staging for oesophageal cancer led to changes in MDT recommendations in 93 (38.2%) patients, improving patient selection for radical treatment. The validity of the proposed methods for evaluating PET-CT on MDT decision making requires more work in other centres and teams.

MRI appearance of the pancreas in patients with cystic fibrosis: a comparison of pancreas volume in diabetic and non-diabetic patients.

We investigated differences in the volume of the pancreas in cystic fibrosis (CF) patients with and without diabetes using MRI to study the natural history of CF-related diabetes (CFRD). We investigated 29 pancreas-insufficient adult CF patients, 13 with CFRD and 16 without diabetes. Patients with CFRD were receiving insulin therapy at the time of study. None of the non-diabetic CF patients had evidence of impaired glucose tolerance. Pancreas volume was estimated by MRI scans using T1 weighted fat-suppression sequences and assessed by an examiner who was unaware of the patients' diabetes status. Pancreas volume of CF patients was measured and subsequently compared with that of non-CF age-matched Type 1 diabetes (T1DM) patients and healthy controls previously investigated. The two CF groups were matched for age and gender. There were no differences in spirometry values, body mass index or pancreatic exocrine function. The pancreas was visible by MRI in only 3 of 13 (23.1%) patients with CFRD and in 5 of 16 (31.3%) patients without diabetes (p-value = 0.7). In total, the pancreas was not detected by MRI as an anatomical entity in 21 of 29 (72.4%) CF patients, irrespective of their diabetes status. When comparing the four study groups, the pancreas was significantly smaller in CF patients than in T1DM patients and healthy controls.

The size of the spleen by magnetic resonance imaging in patients with cystic fibrosis; with and without diabetes--a novel observational study.

BACKGROUND: Magnetic resonance imaging (MRI) has been shown to be a useful tool to evaluate the volume of the pancreas. There is currently no information about the size of the spleen in cystic fibrosis (CF) patients. PATIENTS AND METHODS: We investigated 51 adult volunteers: 28 pancreatic insufficient CF patients [13 with CF-related diabetes (CFRD) and 15 non-diabetic] and 23 male non-CF patients [12 with type 1 diabetes mellitus (T1DM) and 11 healthy control subjects]. Patients with known liver cirrhosis or portal hypertension were excluded. The size of the spleen was measured in all subjects by an investigator unaware of patients' clinical status. For comparison of spleen size in the four study groups only male CF patients were included. For CF patients, spleen size was compared with forced expiratory volume in 1 s (FEV(1)), body mass index (BMI), total number of days of intravenous (IV) antibiotic treatment for pulmonary exacerbations in year previous to study, levels of circulating white blood cells, glycosylated haemoglobin A1c (HbA1c), and exocrine function of the pancreas, as assessed by daily requirement of oral lipase. RESULTS: Amongst the four study groups, spleen size was greatest in the male non-diabetic CF patients (P = 0.01). For CF patients, spleen size was greater in male compared to female patients (P = 0.012). For patients with CFRD, there was an inverse correlation between the spleen size and HbA1c (r = -0.59, P = 0.04) and the daily intake of supplementary lipase (r = -0.63, P = 0.02). The size of the spleen in patients with CFRD, but not in CF patients without CFRD, inversely correlated with the days of IV antibiotic treatment received in the year previous to the study (r = -0.67, P = 0.012). There was no correlation between spleen size and BMI, FEV1 and white blood cell counts in any group. CONCLUSION: On MRI, the spleen size was greatest in male non-diabetic CF patients in comparison with other groups. The size of the spleen in CFRD patients was smaller when diabetes was poorly controlled, when exocrine pancreatic function was greatly impaired and in those with greater need for IV antibiotics in the year prior to the study.

Magnetic resonance imaging: a reliable method for measuring pancreatic volume in Type 1 diabetes.

AIM: To validate magnetic resonance imaging (MRI) for monitoring pancreatic atrophy in Type 1 diabetes. METHODS: Twelve male patients with Type 1 diabetes of duration >or= 10 years (median age 28, range 19-32 years) and 12 healthy controls (median age 30, range 22-36 years) were invited for two abdominal MRI scans, 14 days apart. Four sequences were used: standard T1-weighted; standard T2-weighted; volumetric interpolated breath-hold examination (VIBE); and T1-weighted breath hold with fat suppression (T1BHFS). The pancreas was identified on coded images by one observer and volumes estimated by interpolation. RESULTS: Eleven patients and all controls were scanned twice. Visualization of the pancreas was best with VIBE and T1BHFS, allowing volume estimation from 47 and 46 scans, respectively. The pancreatic volume of patients estimated from these sequences were half those of controls (52.4 ml, +/- 17.1 ml, mean +/- sd) vs. (101 ml, +/- 19.5 ml, P < 0.001) and estimates showed little bias between visits; mean difference 1.1 ml (95% CI; -3.1 to 5.3 ml, P = 0.61) using VIBE and -2.6 ml (-5.8 to 0.6 ml, P = 0.03) using T1BHFS. Both sequences gave similar precision; the standard deviation of the differences in volume estimates between visits was 9.7 ml for VIBE and 7.3 ml for T1BHFS, although mean volumes estimated from T1BHFS were 4.9 ml lower (-8.2 to -1.7 ml, P = 0.005). CONCLUSIONS: Pancreatic volume can be measured reliably using MRI and shows a 48% reduction in long-standing Type 1 diabetes as compared with age-matched normal subjects. MRI should prove useful in determining the natural history of pancreatic atrophy in diabetes.

Life-threatening hematuria requiring transcatheter embolization following radiofrequency ablation of renal cell carcinoma.

Radiofrequency ablation is increasingly being acknowledged as a valid treatment for renal cell carcinoma in patients in whom definitive curative resection is deemed either undesirable or unsafe. A number of published series have shown the technique to have encouraging results and relatively low complication rates. In this article, we report a case of delayed life-threatening hematuria requiring transcatheter embolization of a bleeding intrarenal artery in a patient who had undergone imaging-guided radiofrequency ablation of a 3 cm renal cell carcinoma. To our knowledge, such a complication has not been reported previously.

Pulmonary staging in colorectal cancer--is computerised tomography the answer?

INTRODUCTION: Pulmonary staging in colorectal cancer (CRC) has traditionally been carried out by means of plain chest radiograph (CXR), although computerised tomography (CT) imaging of the chest is increasingly being performed for this purpose. The aim of this study was to assess the value of pre-operative thoracic CT for pulmonary staging in CRC. PATIENTS AND METHODS: Data were collected prospectively on all patients referred into hospital over a 20-month study period for double contrast barium enema evaluation of symptoms suggestive of an underlying CRC. Patients with a CRC went on to have a staging intravenous, contrast-enhanced CT of the chest, abdomen and pelvis prior to an out-patient appointment with a colorectal surgeon. The CXRs of those patients in whom a radiological abnormality was seen on thoracic CT were reviewed blindly by an independent consultant radiologist. RESULTS: A total of 403 barium enemas were performed, of which 38 demonstrated a CRC (9%). In those patients diagnosed with CRC, nine (24%) had an abnormality on thoracic CT. Four patients with positive thoracic CTs had chemotherapy and or radiotherapy with no surgery. One patient underwent colectomy, and 2 patients who had primary lung tumours as opposed to metastases also underwent colectomies. One patient received palliative care only. In addition, one of the patients underwent multiple, non-diagnostic thoracic investigations prior to a diagnosis of sarcoidosis being made and then proceeding to surgery. An independent consultant radiologist reviewed seven out of the nine CXRs of patients with an abnormality on thoracic CT without knowledge of the clinical diagnosis, and reported three of the CXRs to be normal. CONCLUSIONS: Thoracic CT appears to improve the accuracy of pulmonary staging in CRC allowing a more appropriate level of intervention. However, CT is likely to identify more benign radiological abnormalities than CXR alone, and investigations should not occur to the detriment of treating the primary tumour.

Fast-track barium enema: meeting the two-week wait rule for patients with suspected colorectal cancer.

OBJECTIVES: To meet the introduction of the two-week wait (TWW) rule for patients with suspected colorectal cancer, a fast-track barium enema (FTBE) service was set up. This study was conducted to evaluate the success of this approach in preparation for meeting the forthcoming targets on waiting times to treatment from referral and diagnosis. METHODS: All patients were offered a double-contrast barium enema within two-weeks, except those with a palpable rectal mass. FTBE were double-reported by specialist gastrointestinal radiologists. Patients with a suspected malignancy were booked for an urgent staging CT and outpatient appointment, whilst the remaining patients were referred back to their general practitioner with a report. Prospective data were collected and two 16-month periods analysed. RESULTS: Three hundred and nine patients had a FTBE over the first 16-month period and 277 (89.6%) were seen within two-weeks. Mean times from initial referral to staging CT and first outpatient appointment were 30.7 and 36.0 days, respectively. Cancer was confirmed histologically in 32 (10.4%) patients. Of 267 patients without a malignancy, 46 (17.2%) were referred back to the colorectal outpatient or endoscopy service within 6-months. The number of referrals increased with time from a mean of 19.3 per month in the first period to 27.8 in the second, but the percentage with a suspected malignancy remained similar at 13.6% and 10.1%, respectively. CONCLUSION: FTBE diagnosed malignancy accurately and facilitated rapid staging. The TWW target was met in almost 90% of patients, whilst the impact on the colorectal outpatient and endoscopy service was minimized.

The role of preoperative TIPSS to facilitate curative gastric surgery.

The use of TIPSS to facilitate radical curative upper gastrointestinal surgery has not been reported. We describe a case in which curative gastric resection was performed for carcinoma of the stomach after a preoperative TIPSS and embolization of a large gastric varix in a patient with portal hypertension.

Comparison of ultrasound and manometric sphincter length and incontinence scores.

PURPOSE: Fecal incontinence can be assessed by a wide variety of means that vary in their clinical relevance. This study assesses the correlation between two methods of recording sphincter length and incontinence scores. METHODS: A retrospective review of results from 1999 to 2001 of 137 patients with fecal incontinence was undertaken on patients who had both ultrasound and manometric assessment. Incontinence scores, ultrasonic sphincter length, and manometrically derived sphincter length were recorded. The data were analyzed using the Spearman rank correlation coefficient (r(s)) for nonparametric data. RESULTS: There was negative correlation between incontinence scores and manometric sphincter length (r(s) = -0.27; P = 0.002) but not with ultrasonic length (r(s) = -0.08; P = 0.38). There was correlation between manometric and ultrasonic lengths (r(s) = 0.21; P = 0.02). In males, all three correlated but none of the values were significant (n = 12). Internal and external sphincter defects had no effect on correlation coefficients. CONCLUSION: Given that all measurements include a degree of subjectivity, manometry more closely correlates with the fecal incontinence scores than ultrasound measurements. There seems to be little benefit in measuring the sphincter length with ultrasound. Manometric sphincter length measurement seems to have a role in assessing patients with fecal incontinence.

Chest radiograph interpretation by medical students.

AIM: To assess the ability of final year medical students to interpret conventional chest radiographs. MATERIALS AND METHODS: Ten conventional chest radiographs were selected from a teaching hospital radiology department library that were good radiological examples of common conditions. All were conditions that a medical student should be expected to recognize by the end of their training. One normal radiograph was included. The radiographs were shown to 52 final year medical students who were asked to describe their findings. RESULTS: The median score achieved was 12.5 out of 20 (range 6-18). There was no difference between the median scores of male and female students (12.5 and 12.3, respectively, p=0.82) but male students were more likely to be certain of their answers than female students (median certainty scores 23.0 and 14.0, respectively). The overall degree of certainty was low. On no radiograph were more than 25% of students definite about their answer. Students had received little formal radiology teaching (2-42 h, median 21) and few expressed an interest in radiology as a career. Only two (3.8%) students thought they were good at interpreting chest radiographs, 17 (32.7%) thought they were bad or awful. CONCLUSION: Medical students reaching the end of their training do not perform well at interpreting simple chest radiographs. They lack confidence and have received little formal radiological tuition. Perhaps as a result, few are interested in radiology as a career, which is a matter for concern in view of the current shortage of radiologists in the UK.

Low molecular weight heparin and the risk of haemorrhage following percutaneous biopsy, despite a normal standard clotting screen.

There has been an increase of the use of low molecular weight heparin in the treatment of thrombotic events. This case report describes a complication of a pelvic mass biopsy performed whilst the patient was being treated with low molecular weight heparin (LMWH). Despite an uncomplicated biopsy procedure and confirmation of normal clotting screen, INR (International normalised ratio), APTR (Activated partial thromboplastin ratio) and platelet levels, the biopsy was complicated by severe haemorrhage.