Variation in pelvic radiography practice: Why can we not standardise image acquisition techniques?

INTRODUCTION: Pelvic radiographs remain an essential investigation in orthopaedic practice. Although it is recognised that acquisition techniques can affect image appearances and measurement accuracy, it remains unclear what variation in practice exists and what impact this could have on decision making. METHOD: This was a cross sectional survey of UK radiology departments utilising an electronic tool. An introductory letter and link was distributed. Responses were received from 69 unique hospital sites within the specified timeframe, a response rate of 37.9%. RESULTS: There was no consistent technique for the positioning of patients for pelvic radiographs. The distance varied between 90 and 115 cm and 10 different centering points were described. In relation to leg position, the feet are usually internally rotated (65 of 69 [94.2%]). Only 1 teaching hospital (1 of 69 [1.4%]) uses a weight-bearing position as standard. Orthopaedic calibration devices were not in routine use, with only 21 using on pelvic x-rays (30.4%). Further, the type of device and application criteria were inconsistent. CONCLUSIONS: To our knowledge this is the first study to directly compare radiographic positioning across hospital sites. Our data demonstrated marked variation in technique for pelvis radiographs with associated implications for clinical decision making. Research is required to determine the standard technique and quality outcome measures to provide confidence in diagnostic interpretation particularly for serial radiographs.

Pulse pressure is not an independent predictor of outcome in type 2 diabetes patients with chronic kidney disease and anemia--the Trial to Reduce Cardiovascular Events with Aranesp Therapy (TREAT).

Pulse pressure (PP) remains an elusive cardiovascular risk factor with inconsistent findings. We clarified the prognostic value in patients with type 2 diabetes, chronic kidney disease (CKD) and anemia in the Trial to Reduce cardiovascular Events with Aranesp (darbepoetin alfa) Therapy. In 4038 type 2 diabetes patients, darbepoetin alfa treatment did not affect the primary outcome. Risk related to PP at randomization was evaluated in a multivariable model including age, gender, kidney function, cardiovascular disease (CVD) and other conventional risk factors. End points were myocardial infarction (MI), stroke, end stage renal disease (ESRD) and the composite of cardiovascular death, MI or hospitalization for myocardial ischemia, heart failure or stroke (CVD composite). Median (interquartile range) age, gender, eGFR and PP was 68 (60-75) years, 57.3% women, 33 (27-42) ml min(-1) per 1.73 m2 and 60 (50-74) mm Hg. During 29.1 months (median) follow-up, the number of events for composite CVD, MI, stroke and ESRD was 1010, 253, 154 and 668. In unadjusted analyses, higher quartiles of PP were associated with higher rates per 100 years of follow-up of all end points (P⩽0.04), except stroke (P=0.52). Adjusted hazard ratios (95% confidence interval) per one quartile increase in PP were 1.06 (0.99-1.26) for MI, 0.96 (0.83-1.11) for stroke, 1.01 (0.94-1.09) for ESRD and 1.01 (0.96-1.07) for CVD composite. Results were similar in continuous analyses of PP (per 10 mm Hg). In patients with type 2 diabetes, CKD and anemia, PP did not independently predict cardiovascular events or ESRD. This may reflect confounding by aggressive antihypertensive treatment, or PP may be too rough a risk marker in these high-risk patients.

Preferences for quality of life or survival expressed by patients with heart failure.

BACKGROUND: As many patients with heart failure develop symptoms limiting daily life, newer therapies may be found to improve functional status without concomitant survival benefit. As some of these therapies may actually increase mortality, it is increasingly relevant to assess patients' preferences for survival vs improvement in symptoms. METHODS: We enrolled 99 patients with advanced heart failure (ejection fraction 24 +/- 10, duration 6 +/- 5 years). Each patient completed time trade-off and standard gamble instruments, Minnesota Living with Heart Failure questionnaires and visual analog scales for dyspnea and overall health. Jugular venous pressure was assessed in all patients and peak oxygen consumption was measured during bicycle exercise in 60 patients. RESULTS: Strong polarity of preference toward either survival or quality of life was expressed by 60% of patients. There was good correlation between time trade-off and standard gamble utility scores (r = 0.64), and between preference and functional class (r = 0.60). Higher jugular venous pressure and lower peak oxygen consumption were associated with poorer utility scores (p <.05). Higher dyspnea scores and worse Living with Heart Failure scores were also associated with preference to trade time or take risks for better health. CONCLUSIONS: These findings suggest that heart failure patients express meaningful preferences about quality vs length of life. High jugular venous pressure, low peak oxygen consumption and poor Living with Heart Failure scores were related to low utility scores. These cannot be assumed, however, to predict the intensity of individual preference to trade nothing or virtually everything for better health.

Growth stimulation by catecholamines in plant tissue/organ cultures.

Addition of catecholamines at micromolar concentrations caused a dramatic stimulation of growth of tobacco (Nicotiana tabacum) thin cell layers (TCLs) and Acmella oppositifolia "hairy" root cultures. A threefold increase in the rate of ethylene evolution was observed in the catecholamine-treated explants. Aminooxyacetic acid and silver thiosulfate, inhibitors of ethylene biosynthesis and action, respectively, reduced the growth-promoting effect of dopamine. However, these compounds alone could also inhibit the growth of the TCL explants. When ethylene in the culture vessel was depleted by trapping with mercuric perchlorate, dopamine-stimulated growth was still obtained, suggesting that ethylene does not mediate the dopamine effect. Dopamine potentiated the growth of TCLs grown in Murashige and Skoog medium supplemented with indoleacetic acid (IAA) and kinetin. When IAA was replaced by 2,4-dichlorophenoxyacetic acid, dopamine addition showed no growth-promoting effect. Instead, 2,4-dichlorophenoxyacetic acid stimulated the growth of TCL explants to the same extent as that obtained with IAA plus dopamine. Because synthetic auxins do not appear to be substrates for IAA oxidizing enzymes, we hypothesized that catecholamines exert their effect by preventing IAA oxidation. Consistent with this explanation, dopamine (25 micromolar) inhibited IAA oxidase activity by 60 to 100% in crude enzyme extracts from tobacco roots and etiolated corn coleoptiles, but had no effect on peroxidase activity in the same extracts. Furthermore, addition of dopamine to TCL cultures resulted in a fourfold reduction in the oxidative degradation of [1-(14)C]IAA fed to the explants. Because the growth enhancement by catecholamines is observed in both IAA-requiring and IAA-independent cultures, we suggest that these aromatic amines may have a role in the regulation of IAA levels in vivo.