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.

Gravity steam reprocessing in healthcare facilities for the reuse of N95 respirators.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has significantly impacted the health of millions of people around the world. The shortage of personal protective equipment, including N95 respirators, in hospital facilities has put frontline healthcare professionals at high risk for contracting this virus. AIM: To develop a reproducible and safe N95 respirator reprocessing method that satisfies all presented regulatory standards and that can be directly implemented by hospitals using existing available equipment. METHODS: A non-toxic gravity steam reprocessing method has been developed for the reuse of N95 respirators consisting of 30 min of steam treatment at 121°C followed by 30 min of heat drying. Samples of model number 1860, 1860s, 1870+, and 9105 N95 respirators were either collected from hospitals (for microbiology testing) or purchased new (for functionality testing), with all functionality tests (i.e. filter efficiency, fit evaluation, and strap integrity) performed at the Centers for Disease Control and Prevention using standard procedures established by the National Institute for Occupational Safety and Health. FINDINGS: All tested models passed the minimum filter efficiency of 95% after three cycles of gravity steam reprocessing. The 1870+ N95 respirator model is the most promising model for reprocessing based on its efficient bacterial inactivation coupled with the maintenance of all other key functional respirator properties after multiple reprocessing steps. CONCLUSIONS: The gravity steam method can effectively reprocess N95 respirators over at least three reprocessing cycles without negatively impacting the functionality requirements set out by regulators. Enabling the reuse of N95 respirators is a crucial tool for managing both the current pandemic and future healthcare crises.

Tracking camera control in endoscopic dacryocystorhinostomy surgery.

OBJECTIVES: Poor camera control during endoscopic dacryocystorhinostomy (EnDCR) surgery can cause inadequate visualisation of the anatomy and suboptimal surgical outcomes. This study investigates the feasibility of using computer vision tracking in EnDCR surgery as a potential formative feedback tool for the quality of endoscope control. DESIGN: A prospective cohort analysis was undertaken comparing junior versus senior surgeons performing routine EnDCR surgery. Computer vision tracking was applied to endoscopic video footage of the surgery: Total number of movements, camera path length in pixels and surgical time were determined for each procedure. A Mann-Whitney U-test was used to test for a significant difference between juniors and seniors (P < 0.05). SETTING: Operating theatre. PARTICIPANTS: Ten junior surgeons (<20 completed procedures) and 10 senior surgeons (>100 completed procedures). MAIN OUTCOME MEASURES: Total number of movements of the endoscope per procedure. Path length of the endoscope per procedure. RESULTS: Twenty videos, 10 from junior surgeons and 10 from senior surgeons were analysed. Feasibility of our tracking system was demonstrated. Mean camera path lengths were significantly different at 119,329px (juniors) versus 43,697px (seniors), P ≪ 0.05. The mean number of movements was significantly different at 9134 (juniors) versus 3690 (seniors), P ≪ 0.05. These quantifiable differences demonstrate construct validity for computer vision endoscope tracking as a measure of surgical experience. CONCLUSIONS: Computer vision tracking is a potentially useful structured and objective feedback tool to assist trainees in improving endoscope control. It enables juniors to examine how their pattern of endoscope control differs from that of seniors, focusing in particular on sections where they are most divergent.

Breast screening and ethnic minorities.

The concern for minority ethnic women is whether they are disadvantaged either in terms of the incidence of breast cancer or because of a lower uptake of screening. There are considerable worldwide variations in the incidence of breast cancer. The lowest rates are found in Chinese, Japanese and Arabic populations and women from the Indian subcontinent, and are 2-3 times lower than that of the UK. This may change in future generations. Although minority ethnic women are not a high risk group for the breast screening programme, in absolute terms breast cancer is a major health problem. Very few studies have measured ethnic differences in the uptake of screening, and they may be confounded by such factors as socio-economic group. When this is accounted for, uptake by Asian women may not necessarily be lower than by other women in the same area and can be higher for black than white women. One of the most important reasons for non-attendance is inaccurate screening registers, compounded for Asian women by their return, or extended visits, to the Indian subcontinent. A further organisational issue concerns poor awareness of minority ethnic naming systems, causing confusion over the receipt of invitations. Comprehension of the concept of screening may be difficult for minority ethnic women yet there has been little evaluation of strategies to promote understanding. However a randomised controlled trial of a linkworker intervention, designed to be feasible for implementation on a population basis, showed no increase in the uptake of breast screening by Asian women. This does not undermine linkworkers' role but suggests that their efforts should be used in other ways. It is essential to assess the relative importance of reasons for low uptake and evaluate measures to meet any unmet need, so that resources can be directed in the most effective way.

Can the uptake of breast screening by Asian women be increased? A randomized controlled trial of a linkworker intervention.

This study investigates the effectiveness of a linkworker intervention, giving encouragement and explanations about breast screening, on the subsequent attendance for screening by 'Asian' women. The control group received no visits. The study population comprised all women with Asian names, from a batch of general practices where high proportions of patients were Asian, who were invited for screening. It was found that 59 per cent of the intervention group could be contacted by linkworkers. No difference in attendance was found between the intervention and control groups (49 per cent and 47 per cent). Twenty-five per cent of women were permanently or temporarily not resident at the invitation address. Attendance for screening was related to length of stay in the United Kingdom. This type of intervention was not a successful strategy for promoting uptake by Asian women, and indicates that it is essential to evaluate rigorously projects with such objectives.

Pre-operative haemoglobin estimation in paediatric ENT surgery.

Estimation of haemoglobin is still undertaken routinely before ENT surgery in many centres despite evidence that it is unnecessary, traumatic and expensive. The haemoglobin was estimated of all 372 children about to undergo ENT surgery in a busy district general hospital over a one year period. No child was noted to be clinically anaemic, and no child had a haemoglobin of less than 9 g/dl. Of 18 children with a haemoglobin level of 10.5 or less, 10 had their operations postponed and eight did not. There were no complications in the latter group. We can find no published evidence that operating on children with mild anaemia is unsafe. Ceasing routine pre-operative haemoglobin estimation would safely save an estimated 9000 pounds per year in our unit.

Detection of laryngeal cancer--the case for early specialist assessment.

The first 300 patients referred from 11 participating general practices (GPs) to the Hoarse Voice Clinic, Queen Elizabeth Hospital, Birmingham, were studied prospectively to estimate the accuracy of GPs' diagnosis of laryngeal symptoms and to assess whether the provision of a direct referral immediate access service for the assessment of persistent laryngeal symptoms is an effective way of ensuring early referral and detection of laryngeal cancer. The GPs' assessment of laryngeal symptoms was inaccurate. Diagnosis after the initial clinic visit was accurate, predicting all histological cases of cancer. Laryngoscopy was possible in all patients at the first clinic visit. Disease requiring admission for direct laryngoscopy and biopsy was found in 39 patients (14%). Ten (3.3%) were found to have laryngeal cancer, of which eight were early lesions. When seen in the clinic 102 (34%) had normal voices and larynxes. A hoarse voice is a symptom requiring specialist assessment. By using the flexible fibreoptic nasendoscope all patients larynxes can be seen in clinic, an accurate diagnosis quickly made and the appropriate management instigated. It is feasible to offer this service without appointments to patients with persistent hoarseness.

A case of congenital angiofibroma.

A case of angiofibroma affecting the right maxilla of a new born baby is presented with histological evidence. We believe this to be the first congenital case of this condition to have been reported.

Milk nasendoscopy in the assessment of dysphagia.

The bedside assessment of dysphagia may be difficult, due to the inability to witness the act of swallowing directly. The milk test described in this paper gives a good assessment of swallowing, is cheap and easily portable and allows an instant decision to be made without recourse to special investigations.

Outpatient clinic referrals and their outcome.

A cohort of 392 patients referred to six outpatient clinics by general practitioners during 1987 with diagnoses of rheumatoid arthritis, osteoarthritis, peripheral vascular disease, psoriasis or eczema, were studied from the time of their first attendance until up to two years later. Six consultant clinics were studied in the three specialties: rheumatology, vascular surgery and dermatology. For each specialty a clinic in both a teaching hospital and a district general hospital were included. The cohort members were predominantly middle-aged or elderly people, with a greater proportion of women, except at the vascular surgery clinic where 65% of patients were men. The 392 patients made a total of 936 visits (median two, range one-eight) during the study period; 91 patients were still attending up to two years after the first visit. Patients referred by their general practitioner for therapy were less likely to be discharged than those referred for other reasons. The principal reason for continuing attendance as perceived by patients, general practitioners and hospital doctors was the necessity for consultant supervision, although agreement was far from complete in individual cases. Junior staff tended to see a higher proportion of patients at follow-up visits than did consultants, and were found to have lower discharge rates than consultants. Analyses of data showed that at the first visit, diagnosis, disease severity and the grade of doctor seeing the patient in the clinic was significantly associated with patient discharge at the P < 0.05 level of significance. Patients considered that their visits had produced improvement in their condition in 38% of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Hearing loss due to cranio-metaphysial dysplasia.

Craniometaphysial dysplasia is a rare cause of conductive hearing loss. It is a genetic disorder of bone due to decreased osteoclastic activity in the endosteal and periosteal regions of craniofacial and long bones. The characteristic temporal bone abnormalities are attic fixation, abnormally shaped ossicles and obliterated foramina ovale. Computerised tomography is helpful in predicting operative findings; surgery should be reserved for those with a severe hearing loss.