Retained surgical swabs: possible causes for errors in x-ray detection and an atlas to assist recognition.

A swab or pack left in a patient may not be recognised on a radiograph. This will usually be due to poor observation, but errors may result from unfamiliarity with the pattern of the markers. In addition, some markers may be difficult to detect, though this usually applies only to swabs which are very small or to those produced by some continental manufacturers. It should also be realised that, in a very few hospitals, swabs which do not have an opaque marker may occasionally be used in theatre. All the X-ray detectable swabs provided by the major suppliers in the U.K. are demonstrated.

Penetrating injuries: how easy is it to see glass (and plastic) on radiographs?

The radiopacity of objects commonly associated with penetrating wounds and made from modern glass was assessed. It is concluded that all glass fragments should be detected because they are all radiopaque. Occasionally thin slivers of glass may be difficult to detect, but should be visualised with good radiography and careful scrutiny. Plastic from the housing of motor vehicle lamps is not radiopaque.

An assessment of the clinical effects of reporting accident and emergency radiographs.

A prospective study of the accuracy of interpretation of radiographs by casualty officers and radiologists is presented. The casualty officers readings were correct in 83% of cases, and the radiologists' in 95%. There was agreement of interpretation in 83% of the examinations. This study indicates that there are clinical and economic benefits when the radiologist's report is available before the patient leaves the hospital. Delayed reporting of films is considered to be less satisfactory but is still of value as it increases the detection of clinically significant abnormalities and also clarifies most of the 10% of studies about which the casualty officer is uncertain. Where a delayed reporting system is practised, a25% reduction in radiologist's workload would be achieved by reporting only those films considered by the casualty officer to be "normal" or "uncertain". Attempts to reduce workload still further by not reporting any films will increase the number of patients poorly managed in casualty.

Diverticular disease (adenomyomatosis) of the gallbladder: a radiological-pathological survey.

Seventy consecutive gallbladders removed at surgery were examined radiologically and pathologically. Fifteen (21%) of the operative specimens showed naked-eye changes of adenomyomatosis. The main conclusions drawn from this study are that this abnormality is present in a much higher proportion of gallbladders removed at surgery than is generally realised, and that the pathogenesis is primarily an abnormality of muscle contractions, with a strong similarity to diverticular disease of the colon. Diverticular disease of the gallbladder might well be the most appropriate name for this condition. The results of a post-operative clinical assessment of patients with diverticular disease are also presented. But this represents a small number of patients and larger, perhaps multicentre, surveys would be required in order to assess the clinical significance of this interesting abnormality.

The radiology of nasal injuries: problems of interpretation and clinical relevance.

Films of 50 normal patients and 50 dry skulls were examined to detect lines which might stimulate a nasal fracture. These were visible on the occipito-mental view but on the lateral view any line which reaches the anterior cortex must be regarded as a fracture. The results of an analysis of 100 patients with trauma to the nasal bone are also presented. It is concluded that radiography of the nasal bone is an unnecessary examination unless requested by the E.N.T. surgeon, and this will in any case occur infrequently.

Testing a policy for skull radiography (and admission) following mild head injury.

There has been, and continues to be, conflicting advice regarding skull radiography following an apparently uncomplicated head injury. Policies on admission are often ill defined. In 1983, representatives of the Royal College of Radiologists met neurosurgeons at a seminar in Harrogate organized by the DHSS and laid down clear, but little publicized, joint recommendations: "The Harrogate Criteria". The survey described here evaluated an existing liberal policy for skull radiography (and a loose policy for admissions) against these recommendations, and it was concluded that the number of patients having skull radiography (74% of head injury attenders) was excessive. Measured against the "Harrogate Criteria", requests for 36% of the adult and 47% of children's skull radiographs did not fulfil these criteria. As a corollary, it was also concluded that loose admissions policies could usefully be altered to comply more closely with the Harrogate recommendations. This would not necessarily reduce the numbers admitted, but would provide casualty officers with a framework on which to base this crucial aspect of clinical decision making, where presently there is often very little structure at all. The authors suggest that all the options have not been fully explored, and that a simple but important alteration to the Harrogate guidelines would provide an even closer link between policy on skull radiography and patient admission. Specifically, most patients who are to be admitted do not need skull radiographs.

"Diaphragm-like" strictures of the small bowel in patients treated with non-steroidal anti-inflammatory drugs.

The radiological findings are described in four patients who developed strictures of the small bowel, and who had received non-steroidal, anti-inflammatory drugs (NSAIDs) for 1.5-15 years. Clinical presentation was that of subacute small bowel obstruction. Small bowel barium studies showed multiple discrete strictures. Some strictures were indistinguishable from those of regional enteritis. Others however were narrow "diaphragm-like" septae encroaching on and markedly narrowing the ileal lumen, and shown histologically to be due to submucosal fibrosis. It is suggested that these strictures are likely to be consequent on NSAIDs administration and that radiologists and surgeons need to be aware of these "diaphragms" which can be very difficult to detect on barium examination, either small bowel follow-through or enteroclysis, and at laparotomy.

Posters for accident departments: simple method of sustaining reduction in x ray examinations.

OBJECTIVE: To assess whether a simple strategy would sustain a reduction in the number of unnecessary x ray examinations. DESIGN: Use of posters to display guidelines encouraging the more effective use of radiology in patients with head injuries, twisted ankles, neck injuries, and abdominal pain. SETTING: Accident department of a large metropolitan district general hospital. PATIENTS: 15,875 patients attending the accident department over two years. MAIN OUTCOME MEASURE: Proportion of patients having radiography. RESULTS: Referrals for skull radiography fell from 56% to 20% and those for abdominal radiography fell from 31% to 7%. Referral patterns for adults attending with twisted ankles and cervical spine injuries did not change. Reductions were sustained over two years. CONCLUSION: Carefully designed posters provide a simple method of reducing unnecessary x ray examinations.

Rationalising requests for x-ray examination of acute ankle injuries.

Radiographs of injured ankles represent about 1 in 50 of all radiological examinations. The notes and radiographs of 100 patients with ankle injuries were reviewed, and the films of a further 93 patients who had ankle fractures treated by immobilisation were also scrutinised to assess the presence of absence of soft tissue swelling over the malleoli. Any accompanying radiographs of the foot requested at the same time were also studied. In 65 of the 100 cases of ankle injury there was no soft tissue swelling, and none of the patients had a major fracture, while 92 of the 93 patients with a major fracture had soft tissue swelling at the level of the malleoli. In 32 of the 100 cases of ankle injury foot radiographs had also been requested, but only three foot injuries were found. If the simple maxim of "No swelling adjacent to a malleolus, no radiographs" were applied radiography of twisted ankles could be reduced by as much as two-thirds. Moreover, if this maxim included the rider "and no routine foot films" the total casualty radiographic work load could be reduced by 8%.

Peroperative colonoscopy in massive rectal bleeding.

Massive rectal bleeding can pose a difficult problem in management. We describe a new technique employing peroperative colonic irrigation and direct colonoscopy to identify the source of the bleeding, so avoiding blind colonic resection.

The effect on patients of non-referral for skull radiography following mild head injury.

This paper assesses the attitude of 705 patients who attended the Accident department of a large metropolitan district general hospital, with a mild head injury and who were not referred for skull radiography. A questionnaire was sent to patients 5-7 months after they had attended. Fifty-one per cent had expected an X-ray, and when this did not occur, the majority of this group (63 per cent) left the Accident department disappointed. Furthermore, the duration of symptoms in this group was prolonged. The introduction of guidelines may reduce clinically unnecessary X-ray examinations, but some of the consequences may not be fully appreciated. In this study, a significant number of patients were dissatisfied with the lack of X-ray referral. The main cause for the associated prolongation of symptoms is not clear, but a contributory factory may be that lack of referral for radiography led to anxiety concerning the thoroughness of their management.

How accurate are quotations and references in medical journals?

The accuracy of quotations and references in six medical journals published during January 1984 was assessed. The original author was misquoted in 15% of all references, and most of the errors would have misled readers. Errors in citation of references occurred in 24%, of which 8% were major errors--that is, they prevented immediate identification of the source of the reference. Inaccurate quotations and citations are displeasing for the original author, misleading for the reader, and mean that untruths become "accepted fact." Some suggestions for reducing these high levels of inaccuracy are that papers scheduled for publication with errors of citation should be returned to the author and checked completely and a permanent column specifically for misquotations could be inserted into the journal.

A survey of accident and emergency reporting: results and implications.

Surveys have shown a consistent error rate in the detection of radiographically demonstrable abnormalities by casualty officers. A high incidence of medical litigation is related to casualty departments. For these reasons, a survey of hospitals in England and Wales was carried out to determine when and whether accident and emergency radiographs are reported. The practice in 146 hospitals was analysed. It was found that two-thirds of hospitals report all radiographs within 48 h. Seven per cent of hospitals either do not report any radiographs, report only radiographs of certain areas, or delay reporting for over 1 week. It is suggested that the patients attending as many as a quarter of all hospitals as casualties are at increased risk from errors which will inevitably be recognised late, and that these errors are directly attributable to shortage of staff.