Towards the definition of Institutional diagnostic reference levels in paediatric interventional cardiology procedures in Greece.

This study aimed to evaluate paediatric radiation doses in a dedicated cardiology hospital, with the objective of characterising patterns in dose variation. The ultimate purpose was to define Local (Institutional) Diagnostic Reference Levels (LDRLs) for different types of paediatric cardiac interventional procedures (IC), according to patient age. From a total of 710 cases performed during three consecutive years, by operators with more than 15 years of experience, the age was noted in only 477 IC procedures. The median values obtained for Fluoroscopy Time (FT), Number of Frames (N) and Kerma Area Product (PKA) by age range were 5.8 min, 1322 and 2.0 Gy.cm2 for <1 y; 6.5 min, 1403 and 3.0 Gy.cm2 for 1 to <5 y; 5.9 min, 950 and 7.0 Gy.cm2 for 5 to <10 y; 5.7 min, 940 and 14.0 Gy.cm2 for 10 to <16 y, respectively. A large range of patient dose data is observed, depending greatly on procedure type and patient age. In all age groups the range of median FT, N and PKA values was 3.1-15.8 min, 579-1779 and 1.0-20.8 Gy.cm2 respectively. Consequently, the definition of LDRLs presents challenges mainly due to the multiple clinical and technical factors affecting the outcome. On the other hand the lack of paediatric IC DRLs makes the identification of good practices more difficult. A consensus is needed on IC procedures nomenclature and grouping in order to allow a common assessment and comparison of doses.

Left main coronary artery aneurysm.

Left main coronary artery aneurysms (LMCA) are usually asymptomatic and are rarely encountered during coronary angiography. The most serious complications include coronary thrombosis, acute myocardial infarction and sudden death. Atherosclerosis is the most common cause, although several autoimmune diseases and congenital abnormalities have been associated with the presence of coronary aneurysms. The case of a symptom-free 63-year-old man with a giant LMCA and severely ectatic coronary arteries is presented.

Atherosclerosis in premenopausal women with antiphospholipid syndrome and systemic lupus erythematosus: a controlled study.

OBJECTIVE: To evaluate whether premenopausal women with antiphospholipid syndrome (APS) or systemic lupus erythematosus (SLE) have increased prevalence of atherosclerosis after adjustment has been made for known cardiovascular risk factors. METHODS: We evaluated premenopausal women with APS in comparison with age-matched groups of patients with SLE [positive or negative for anticardiolipin (aCL) antibodies] or rheumatoid arthritis (RA), and healthy subjects. Thirty-three subjects in each group were assessed for cardiovascular risk factors, including a detailed lipid profile. Ultrasonography of carotid and femoral arteries assessed the intima-media thickness (IMT) and the presence of atherosclerotic plaque. RESULTS: Atherosclerotic plaques were detected in 5, 2, 4, 1 and 1 subject in the five groups respectively. APS patients had significantly more affected vessels than RA patients and healthy controls (P=0.042 and P=0.016, respectively), but not compared with SLE patients. No consistent differences in IMT, traditional cardiovascular risk factors or lipid parameters were detected among the five groups. The odds for atherosclerosis independently increased 1.19-fold per year of increasing age [95% confidence interval (CI) 1.08-1.31; P=0.001), 1.019-fold per 1 mg/dl increase in low-density lipoprotein (LDL) (95% CI 1.003-1.036; P=0.020), 1.035-fold per additional 1 g of methylprednisolone equivalent cumulative corticosteroid dose (95% CI, 0.996-1.074; P=0.074), and 4.35-fold in the presence of APS or SLE (95% CI 0.75-25.2; P=0.10). Neither aCL nor anti-beta(2)GPI antibodies were associated with atherosclerosis. CONCLUSION: Premenopausal APS and SLE women have an increased prevalence of carotid and femoral plaque that is not accounted for by other predictors of atherosclerosis, including age, lipid parameters and cumulative steroid dose.

Clinical evaluation of manual and automatic exposure control techniques in film-based chest radiography.

Chest radiographs obtained with either automatic exposure control (AEC) technique, or manual exposure control (MEC) technique, were compared in a sample of 329 cardiological and cardiosurgery patients. Parameters evaluated, were various anatomical regions, according to their appearance in both posteroanterior (PA) and lateral radiographs. Lateral radiographs obtained with the AEC technique demonstrated better image quality than those obtained with the manual technique. There was no definite advantage of the AEC technique in PA radiographs. The AEC technique has the potential to improve the quality of lateral chest radiographs of cardiological and cardiosurgery patients. It is considered to be a useful tool in chest radiography.

Pulsatility and resistance indices in intrarenal arteries of normal adults.

In order to establish the normal range of values of Pulsatility (PI) and Resistance (RI) Indices in the intrarenal vasculature, a study of 50 healthy volunteers (23 males, 27 females), divided into five groups of 10 according to age, was performed with Duplex Doppler ultrasound. Both kidneys were examined in all individuals and, in 12, indices were also compared between upper and lower poles of both kidneys. In addition, repeat examinations were performed in nine subjects on three different days, in order to assess the reproducibility of the method. No differences were found in the mean values of both indices between males and females, upper and lower poles, right and left kidneys. A statistically significant increase (p < 0.01, unpaired t-test) was demonstrated when the oldest age group (7th decade) was compared to the youngest age group (3rd decade). The method appeared remarkably reproducible for RI (4.2-7%), with wider variation in the PI (9.5-22.7%).

Resistance and pulsatility Doppler indices: how accurately do they reflect changes in renal vascular resistance.

Doppler indices such as the resistance (RI) and pulsatility indices (PI) are generally thought to indicate the resistance of the vascular bed supplied by the artery under investigation. However, this association remains uncertain; some studies have demonstrated an excellent correlation between alterations in vascular resistance and changes in Doppler indices, while others have shown no consistent change. In order to assess the validity of these two indices in estimating alterations in renal vascular resistance, 12 female Large White pigs, 45 weeks old, were entered into a double blind study. In nine of the pigs both kidneys received a single dose of 9.8 Gy 60Co gamma-rays; the remaining three served as sham-irradiated controls. Renal haemodynamics were measured using 131I-hippuran renography and Duplex Doppler prior to and at 8, and 12 weeks after kidney (sham-)irradiation. The sham-irradiated animals exhibited no significant changes in any of the parameters. In contrast, the animals in which both kidneys were irradiated exhibited a significant decrease (p < 0.001) in renal blood flow (RBF) 8 and 12 weeks after irradiation. In addition, both PI and RI were increased following kidney irradiation; however, this increase was not significant until 12 weeks after irradiation (p < 0.01). This suggests that the reduction in RBF was not simply a reflection of an increased vascular resistance and/or that PI and RI do not truly represent alterations in vascular resistance. Further studies are required to confirm the applicability of PI and RI in the assessment of renal haemodynamics.

Ultrasonography in the acute abdomen.

In a prospective study 152 consecutive patients presenting with acute abdominal pain were assessed clinically and an ultrasonographic examination was performed immediately. Of these, 16 (11 per cent) patients would normally have had an immediate ultrasonographic scan requested; routine (within 24 h of admission) ultrasonographic examination would have been requested in a further 66 (43 per cent) patients. In 70 (46 per cent) patients an ultrasonographic examination would not have been requested. Ultrasonography altered the diagnosis in one patient from probable appendicitis to cholecystitis. Ultrasonography missed one abdominal aortic aneurysm and one empyema of the gallbladder. Ultrasonography had a sensitivity of 96 per cent, a specificity of 94 per cent, a positive predictive value of 96 per cent, a negative predictive value of 94 per cent and an accuracy of 95 per cent in diagnosing appendicitis. Exactly the same values were found for the clinical diagnosis of appendicitis. The study shows that routine immediate ultrasonographic examination of the acute abdomen is rarely helpful, with the possible exception of appendicitis. Where an urgent ultrasonographic scan is necessary on clinical grounds the expertise of a radiologist is probably required, whereas in specific areas, for example in the diagnosis of right iliac fossa pain, there may be a place for training the surgical trainee.

Flexible cystoscopy compared with ultrasound in the detection of recurrent bladder tumours.

A combination of transrectal and transabdominal ultrasound was compared with flexible cystoscopy as a means of detecting recurrent bladder tumours. The study group comprised 50 patients who had previously had rigid cystoscopy. They underwent combination ultrasound in the out-patient department 1 week before flexible cystoscopy. Combination ultrasound identified 25 patients with recurrent tumours and flexible cystoscopy identified 26. Thirty-four patients (68%) preferred ultrasound, 10 (20%) preferred flexible cystoscopy, 3 (6%) preferred general anaesthesia and rigid cystoscopy and 3 (6%) had no preference. The main objection to ultrasound was the use of the transrectal probe.

Ultrasonography compared with intravenous urography in the investigation of adults with haematuria.

OBJECTIVE: To compare ultrasonography with intravenous urography in the investigation of adults with haematuria. DESIGN: Prospective study entailing the examination of all patients with both investigations concurrently. The investigations were performed independently on routine lists by different duty radiologists. Each was aware of the details of the request form but not of the findings of the other investigation. SETTING: Radiology department of a teaching hospital. PATIENTS: 155 Consecutive adult patients (aged 18-93) referred from general practitioners and hospital outpatient clinics with a history of haematuria. FOLLOW UP: When results of both examinations proved normal no clinical or radiological follow up was sought. All abnormal findings of either investigation were correlated with results of subsequent imaging studies or operative findings. RESULTS: 81 Patients (52%) had normal findings on urography and ultrasonography. Overall, the findings of ultrasonography concurred with those of urography in 144 cases (93%). Among the discrepant findings of the two investigations ultrasonography missed two ureteric calculi; one was in a non-dilated ureter, and in the other case ultrasonography detected the secondary ureteric dilatation. Ultrasound examination alone detected four bladder tumours not visible on urography with sizes ranging from 5 to 21 mm, representing one fifth of the 20 cystoscopically proved bladder tumours detected in the series. Ultrasonography detected all the 22 neoplastic lesions discovered in the study (20 bladder, two renal). Ultrasonography clarified the nature of renal masses evident in three urograms (simple cysts). CONCLUSIONS: Ultrasonography is a safe and accurate method of investigating the urinary tract in adults with haematuria. When combined with a single plain abdominal radiograph it proved to be superior to urography as the primary imaging study in this series. Ultrasonography should certainly be preferred to urography if cystoscopy is not planned. No urothelial tumours of the upper urinary tract were found in the series, reflecting their rarity. For those patients in whom ultrasonography and plain radiography have shown no abnormality and in whom cystoscopic appearances are normal urography would be advisable to exclude urothelial tumours of the upper urinary tract.

Ultrasonography compared with intravenous urography in investigation of urinary tract infection in adults.

OBJECTIVE: To compare ultrasonography with intravenous urography for investigating adults with proved urinary tract infection. DESIGN: Prospective study of patients presenting consecutively for radiological investigation of urinary tract infection between October 1988 and December 1989. Both investigations were performed concurrently and performed independently on routine lists by different duty radiologists, each of whom knew the details on the request form but not the findings of the other investigation. SETTING: Radiology department of a teaching hospital. PATIENTS: 158 Consecutive adults (89 women, 69 men; mean age 49.7 (range 18-83)) referred from general practitioners and hospital outpatient clinics with a history of proved urinary tract infection. INTERVENTIONS: Urography and ultrasonography performed concurrently. When both examinations gave normal findings no clinical or radiological follow up was sought. All abnormal findings detected with either investigation were confirmed by subsequent imaging studies or by operative procedures. MAIN OUTCOME MEASURE: Accuracy of detection of abnormalities of urinary system by ultrasonography compared with urography. RESULTS: 113 Patients (72%) had normal urographic and ultrasonic findings. Overall, ultrasonography concurred with the findings of urography in 149 (94%) patients, and when a single abdominal radiograph was included in the procedure, in 152 (96%). Ultrasonography missed only one important diagnosis, that of mild papillary necrosis in normal sized kidneys in a diabetic patient. It detected one early bladder tumour not visible on urography and was able to clarify the nature of renal masses (simple cysts) evident on three urograms. CONCLUSION: Ultrasonography provides a safe and accurate method of imaging the urinary tract in adults with infection. Combined with a plain abdominal radiograph, it should replace urography as the initial imaging investigation in these patients. Major savings would result from adopting this policy, and the risks to patients from ionising radiation and intravenous contrast media would be appreciably reduced.

The role of abdominal and transrectal ultrasound and cytology in the detection of recurrent bladder tumours.

Transrectal and transabdominal ultrasound combined with cytology were compared with conventional cystoscopy as a mean of detecting recurrences of bladder tumours. One hundred and twenty-five patients underwent combination ultrasound in the outpatient department 1 week before cystoscopy. Combination ultrasound identified 90% of recurrent tumours and tumour identification with the results of ultrasound and cytology combined was 93%. The false positive rate was 2%. The ultrasonographer would have referred 97% of patients with recurrent tumour for cystoscopy. Combination ultrasound and cytology may be a satisfactory alternative to check cystoscopy in certain categories of bladder tumours.