European guidelines on radiographic image quality in chiropractic practice - proposal of a cross-sectional graded classification reporting principle.

BACKGROUND: The Commission of the European Communities (CEC) has published: European Guidelines on Quality Criteria for Diagnostic Radiographic Images. These guidelines are considered a gold standard, recommended for use in quality assurance protocols. The objectives of this study: 1) Propose a graded classification format for Danish chiropractic clinics according to the CEC-quality criteria for diagnostic radiographic images of the lumbar spine. 2) Propose a reporting principle for quality of radiographic images. 3) Document variation in radiation exposure among clinics. METHODS: This is a cross-sectional study of image quality based on random sampling from 148 chiropractic clinics. Clinics were included if using: 1) Digital radiography and 2) The chiropractic picture and archiving system (KirPACS) at the Nordic Institute of Chiropractic and Clinical Biomechanics (NIKKB) in Denmark. A sample of 296 lumbar spine series were randomly collected from KirPACS (January 2018). Two independent observers reviewed 50 lumbar spine series twice with a 4-week interval, testing intra- and inter-observer reproducibility. The same observers then reviewed the remaining 246 radiographic studies. All studies were evaluated using the CEC Quality Criteria. Patient radiation dose values were retrieved from KirPACS (First quarter of 2020). RESULTS: A reporting and classification principle of diagnostic image quality was used in 148 chiropractic clinics. Compliance with the 22 CEC Quality Criteria had proportions ranging from 0.72-0.96 for 18 criteria, while 4 criteria specifying detail and definition ranged between 0.20-0.66. The proposed rating system (A to E) revealed: 18 A clinics, 28 B clinics, 32 C clinics, 25 D clinics and 45 E clinics (A = highest quality; E = lowest quality). The patient radiation reference dose in Denmark is 7 mGy for the AP/PA lumbar spine. Very few clinics exceed the reference dose value, approximately 50% of clinics were below 5 mGy. CONCLUSION: A reporting principle is proposed for a graded classification format based on the CEC-quality criteria for diagnostic radiographic images of the lumbar spine. The Quality Criteria are for the most part met satisfactorily in 148 Danish chiropractic clinics, but important image details are compromised, in most cases, because of low patient radiation doses. The results of a patient radiation dose survey enabled documentation of variation in radiation exposure among chiropractic clinics.

European guidelines on quality criteria for diagnostic radiographic images of the lumbar spine - an intra- and inter-observer reproducibility study.

Background: The Commission of the European Communities has published guidelines to be used as a gold standard for quality assessment of diagnostic radiographic images. Image quality and radiation dose must be monitored and optimally balanced for diagnostic purposes on patients. The objective of the current study was to assess intra- and inter-observer reproducibility in less experienced observers using the proposed European Guidelines on Quality Criteria for Diagnostic Radiographic Images in a quality assessment of lumbar spine radiographs in primary chiropractic practice in Denmark. Methods: Two observers initially evaluated lumbar spine radiographs randomly selected from fifty chiropractic clinics, all connected to the national PACS server (KirPACS) in Denmark. All evaluations were performed twice by both observers using a four-week interval and for compliance with the European Quality Criteria for Diagnostic Radiographic Images. Inter- and intra-observer reproducibility was calculated using kappa statistics. In the interpretation of the kappa coefficient, the standards for strength of agreement reported by Landis and Koch were followed. Results: The strength of the inter-observer agreement of general image quality at baseline ranged from moderate agreement (k = 0.47) to substantial agreement (k = 0.68). After four weeks, the inter-observer agreement still ranged from moderate agreement (k = 0.59) to substantial agreement (k = 0.71), but with increased agreement for both kappa coefficients. In relation to intra-observer agreement of general image quality, the strength for observer A ranged from moderate (k = 0.58) to substantial (k = 0.72) and the strength for observer B overall was substantial (k = 0.63-0.75). Conclusion: The European Guidelines on Quality Criteria for Diagnostic Radiographic Images are considered a gold-standard and used in a method for quality assurance within the Danish chiropractic profession. The inter-rater and intra-rater agreements in this study, using the CEC-criteria, were found mostly acceptable. With appropriate attention to clear understanding of the individual criteria and sufficient training, this method is found to be reliable, even using less experienced observers, to carry out Diagnostic Radiographic Image Quality-assurance in primary care settings.

Local Anesthetic Wound Infiltration after Osteosynthesis of Extracapsular Hip Fracture Does Not Reduce Pain or Opioid Requirements: A Randomized, Placebo-Controlled, Double-Blind Clinical Trial in 49 Patients.

Background and purpose: Local infiltration analgesia (LIA) supports early mobilization after hip and knee arthroplasty. Inspired by this, we studied the effectiveness of wound infiltration with the long acting local anesthetic ropivacaine in an effort to decrease the need for postoperative opioids after osteosynthesis of extracapsular hip fracture. Methods: Forty-nine patients undergoing osteosynthesis with a sliding hip screw were randomized into two groups in a double-blind study (ClinicalTrials.gov:NCT01119209). The patients received intraoperative infiltration followed by 6 postoperative injections through a wound catheter in eight-hour intervals. 23 patients received ropivacaine and 26 received saline. The intervention period was 2 days, and the observation period was 5 days. In both groups, there were no restrictions on the total daily dose of opioids. Pain was assessed at specific postoperative time points, and the daily opioid usage was registered. Results: Intraoperative infiltration with 200 mg ropivacaine and postoperative repeated infiltration with 100 mg ropivacaine did not result in statistically significant difference between the groups regarding postoperative opioid consumption or pain. Interpretation: Ropivacaine as single component in postoperative treatment of pain after hip fracture is not effective. In our setup, wound infiltration with ropivacaine is not statistically significantly better than placebo.

Local anaesthetic wound infiltration after internal fixation of femoral neck fractures: a randomized, double-blind clinical trial in 33 patients.

Pain control may assist early mobilisation after internal fixation of femoral neck fractures. Systemic opioids have significant side effects in elderly patients. We present an evaluation of the effect of local anaesthetic infiltration in such cases , the objective being to decrease the need for postoperative opioids and to improve pain control for patients after surgery. 33 patients undergoing internal fixation with 2 parallel hook pins were randomized into 2 groups in a double blind study (ClinicalTrials.gov: NCT00529425). 33 patients received intraoperative infiltration followed by 6 postoperative injections through an intraarticular catheter in eight-hour intervals. 19 patients received ropivacaine and 14 received saline. The intervention period was 48 hours and the observation period was 5 days. In both groups there were no restrictions on the total daily dose of rescue analgesics. Pain was assessed at specific postoperative time-points and the daily consumption of opioid drugs needed for analgesia was registered. There was no significantly reduced consumption of standardized opioid rescue analgesics or pain in the study group receiving ropivacaine injections. Apart from a reduction in nausea in the study group on the second postoperative day, there were no significant differences in the occurrence of side effects between the groups. On day 2 the placebo group had less pain than the study group. Local anaesthetic infiltration after fixation of femoral neck fractures does not reduce opioid consumption or pain'.