[Diagnostic Test Requests in the Family Medicine Consultation: An Ethical Perspective Concerning Requests for Maxillofacial Computerized Tomography Scan Prior to Dental Implants]. / A Transcrição de Exames na Consulta de Medicina Geral e Familiar: Perspetiva Ética Sobre o Caso do Pedido de Tomografia Computorizada Maxilofacial para Realização de Implantes Dentários.

In the Portuguese National Health Service, little attention has been paid to oral health care. The almost nonexistence of a dentistry network raises concern about accessibility to services, and justifies the need to call on a predominantly private provision of services. The coexistence between the public and private settings is not always easy, especially when services need to interact and actively collaborate in order to find answers to the patient's problems. Dental implant procedures and the need to perform a previous maxillofacial computerized tomography to study the bone bed where osseointegrated dental implants are placed are a common situation. The current governmental regulation, blinded to the clinical context, may limit the accessibility to the tests. Based on this scenario, we discuss the possible options from an ethical point of view, framing the patient's and the physician's perspective and the relation between both. We conclude that the medical decision can't be disregarded from the clinical evaluation, in the intimacy of the medical consultation. This is an ethical duty that overrules the administrative and bureaucratic constraints. A good management of this apparent dichotomy may enhance better health and greater empowerment for the patient.

A saúde oral tem sido pouco cuidada no contexto do Serviço Nacional de Saúde em Portugal. A quase inexistência de uma rede de medicina dentária levanta problemas de acessibilidade que condicionam a necessidade de complementar os serviços públicos com uma oferta predominantemente privada. Mas esta coexistência não é sempre fácil, sobretudo quando há necessidade dos serviços se cruzarem e colaborarem ativamente na resolução dos problemas do doente. Uma situação comum é a colocação de implantes dentários e a necessidade de realizar uma tomografia computorizada maxilofacial prévia para estudo de leito para colocação de implantes dentários osteointegrados, onde a aplicação de regulação governamental desenquadrada do contexto clínico pode condicionar a acessibilidade aos tratamentos. Com base neste cenário, discutem-se as opções do ponto de vista ético, na perspetiva do doente, do médico e da relação entre ambos. Conclui-se que a decisão médica não pode ser desenquadrada de uma avaliação clínica que apenas o ambiente de intimidade da consulta médica pode proporcionar. É um imperativo ético que se sobrepõe aos constrangimentos administrativos e burocráticos e que se bem gerido é potenciador de uma melhor saúde e de maior capacitação da pessoa.

Shared decision-making: is it time to obtain informed consent before radiologic examinations utilizing ionizing radiation? Legal and ethical implications.

Concerns about the possibility of developing cancer due to diagnostic imaging examinations utilizing ionizing radiation exposure are increasing. Research studies of survivors of atomic bomb explosions, nuclear reactor accidents, and other unanticipated exposures to similar radiation have led to varying conclusions regarding the stochastic effects of radiation exposure. That high doses of ionizing radiation cause cancer in humans is generally accepted, but the question of whether diagnostic levels of radiation cause cancer continues to be hotly debated. It cannot be denied that overexposure to ionizing radiation beyond a certain threshold, which has not been exactly determined, does generate cancer. This causes a dilemma: what should patients be informed about the possibility that a CT or similar examination might cause cancer later in life? At present, there is no consensus in the radiology community as to whether informed consent must be obtained from a patient before the patient undergoes a CT or similar examination. The author analyzes whether there is a legal duty mandating radiologists to obtain such informed consent but also, irrespective of the law, whether there an ethical duty that compels radiologists to inform patients of potential adverse effects of ionizing radiation. Over the past decade, there has been a noticeable shift from a benevolent, paternalistic approach to medical care to an autonomy-based, shared-decision-making approach, whereby patient and physician work as partners in determining what is medically best for the patient. Radiologists should discuss the benefits and hazards of imaging with their patients.

Patient attitudes regarding consent for emergency department computed tomographies.

INTRODUCTION: Little is known about patient attitudes towards informed consent for computed tomography (CT) in the emergency department (ED). We set out to determine ED patient attitudes about providing informed consent for CTs. METHODS: In this cross-sectional questionnaire-based survey study, we evaluated a convenience sample of patients' attitudes about providing informed consent for having a CT at 2 institutional sites. Historically, at our institutional network, patients received a CT at approximately 25% of their ED visits. The survey consisted of 17 "yes/no" or multiple-choice questions. The primary outcome question was "which type of informed consent do you feel is appropriate for a CT in the Emergency Department?" RESULTS: We analyzed 300 survey responses, which represented a 90% return rate of surveys distributed. Seventy-seven percent thought they should give their consent prior to receiving a CT, and 95% were either comfortable or very comfortable with their physician making the decision regarding whether they needed a CT. Forty percent of the patients felt that a general consent was appropriate before receiving a CT in the ED, while 34% thought a verbal consent was appropriate and 15% percent thought a written consent was appropriate. Seventy-two percent of the ED patients didn't expect to receive a CT during their ED visit and 30% of the ED patients had previously provided consent prior to receiving a CT. CONCLUSION: Most patients feel comfortable letting the doctor make the decision regarding the need for a CT. Most ED patients feel informed consent should occur before receiving a CT but only a minority feel the consent should be written and specific to the test.

Barriers to computed tomography radiation risk communication in the emergency department: a qualitative analysis of patient and physician perspectives.

OBJECTIVES: This qualitative study aimed to characterize the barriers to informed discussions between patients and emergency physicians (EPs) about radiation risk from computed tomography (CT) and to identify future interventions to improve patient understanding of CT radiation risk. METHODS: This study used a focus group approach to collect concepts about radiation risk exposure from a national sample of EPs and a local sample of emergency department (ED) patients. A directed content analysis used an a priori medical ethics framework to explore themes from the focus groups while a subsequent normative ethics analysis compared these results with existing perceptions about discussing CT radiation risk. RESULTS: Focus groups (three each for a total of 19 EPs and 27 patients) identified concepts consistent with core medical ethics principles: patients emphasized autonomy and nonmaleficence more than physicians, while physicians emphasized beneficence. Subjects' knowledge of radiation dose and risk were equivalent to previously published reports. When asked about whether they should talk about radiation with patients, 74% of EPs reported that radiation exposure should be discussed, but the study EPs self-reported doing so with only an average of 24% of patients. Patients reported wanting to hear about radiation from their physicians the next time they need CT scans and thought that a written handout would work better than any other method. When presented with options for how to discuss risk with patients, EPs reported needing easy access to risk information and preferred discussion over other communications approaches, but had mixed support of distributing patient handouts. CONCLUSIONS: The normative view that radiation from diagnostic CT should be discussed in the ED is shared by patients and physicians, but is challenged by the lack of a structured method to communicate CT radiation risk to ED patients. Our analysis identifies promising interest among physicians and patients to use information guides and electronic order prompts as potential informational tools to overcome this barrier.

Obscuring surface anatomy in volumetric imaging data.

The identifying or sensitive anatomical features in MR and CT images used in research raise patient privacy concerns when such data are shared. In order to protect human subject privacy, we developed a method of anatomical surface modification and investigated the effects of such modification on image statistics and common neuroimaging processing tools. Common approaches to obscuring facial features typically remove large portions of the voxels. The approach described here focuses on blurring the anatomical surface instead, to avoid impinging on areas of interest and hard edges that can confuse processing tools. The algorithm proceeds by extracting a thin boundary layer containing surface anatomy from a region of interest. This layer is then "stretched" and "flattened" to fit into a thin "box" volume. After smoothing along a plane roughly parallel to anatomy surface, this volume is transformed back onto the boundary layer of the original data. The above method, named normalized anterior filtering, was coded in MATLAB and applied on a number of high resolution MR and CT scans. To test its effect on automated tools, we compared the output of selected common skull stripping and MR gain field correction methods used on unmodified and obscured data. With this paper, we hope to improve the understanding of the effect of surface deformation approaches on the quality of de-identified data and to provide a useful de-identification tool for MR and CT acquisitions.

Consent of the recently bereaved to post-mortem targeted angiography research: 207 adult cases.

AIMS: To present our experience of prospective telephone consenting for post-mortem CT angiography (PMCT-A) research using HM coroners' cases. METHODS: Local ethics committee, research and development office, and local HM coroners gave their permission for the families of the deceased, in cases where a 'routine' coroner's autopsy had been authorised, to be approached for their consent to PMCT-A research before the autopsy examination. A forensic pathologist or trial consenter telephoned the next of kin, discussed the nature of the study and obtained verbal informed consent for post-mortem imaging, angiography, case-dependent histological and toxicology sampling and for the use of the images for teaching and training. Thematic analyses of the reasons for giving or refusing consent are provided. RESULTS: Of the 207 cases approached, seven relatives refused to enter their next of kin into the study (96.6% consent rate). CONCLUSIONS: This study shows that prospective consenting for HM coroners' cases to be used for autopsy research is feasible in adults, and can be done ethically, and in the limited time available, by obtaining the consent of the next of kin by telephone before autopsy.

Do we really need to thank the Beatles for the financing of the development of the computed tomography scanner?

It is commonly believed that the revenues from the selling of the Beatles' records by Electric and Musical Industries (EMI) allowed the company to develop the computed tomography (CT) scanner. Some went to define this as the Beatles' gift to medicine. However, significant controversies and discrepancies arise from analysis of this statement, making its correctness doubtful. The details of financing required for the CT development and the part of EMI in financial input have never been publicly announced. This work analyzes the financial contributions to the CT development and investigates if the revenues received from the sales of the Beatles' records were used for the creation of the CT scanner. Timeline of the development of the EMI CT scanner and the financial inputs of EMI and British Department of Health and Social Security (DHSS) were assessed. Without salary expenses to Godfrey Hounsfield and his team, the development of the CT scanner cost EMI approximately £100,000. The British DHSS's expenses were £606,000. Hence, the financial contribution of DHSS into the development of the CT scanner was significantly bigger than that of EMI. Accordingly, British tax payers and officials of British DHSS are to be thanked for the CT scanner. The Beatles' input into the world's culture is valuable and does not require decoration by nonexistent connection to the development of CT. A positive aspect to this misconception is that it keeps in public memory the name of the company that developed the CT scanner.

Osteometría-escapulometría glenohumeral en las inestabilidades anteriores recidivantes de hombro. Estudio etiopatogénico de uno de los estabilizadores estáticos mediante tomografía computarizada / Glenohumeral osteometry-scapulometry in anterior shoulder instabilities. Study of one of the static stabilizers through computer tomography

Se realizó un estudio escapulométrico de 98 hombros,mediante TAC: 36 con luxación anterior recidivante(LRH), 37 hombros estables contralaterales de esospacientes (HEC) y 25 hombros normales (HN). Se evaluaronseis parámetros: índice glenohumeral horizontal,índice glenohumeral vertical, inclinación glenoidea,ángulo de anteversión de la escápula, ángulo glenoideoy retroversión humeral.Encontramos diferencias estadísticamente significativasentre los grupos LRH y HEC en relación al índiceglenohumeral horizontal. Ambos grupos (LRH y HEC)mostraban diferencias significativas en comparacióncon el grupo de hombros normales (HN) en relación alíndice glenohumeral horizontal, inclinación glenoidea yángulo de anteversión de la escápula. La desproporcióncefalo-glenoidea y la inclinación anterior glenoidea sonlos factores anatómicos desestabilizantes.Nuestros resultados confirman que, aunque la etiologíade la inestabilidad anterior de hombro es multifactorial,existe una predisposición congénita anatómicaque la favorece y, en menor grado, también en el hombroestable contralateral, confirmando la existencia deuna sutil displasia congénita. Además se revelan comoparámetros relevantes en el estudio de la inestabilidadanterior: el índice glenohumeral horizontal, inclinaciónglenoidea y ángulo de anteversión de la escápula, siendodiscutido el papel de la retroversión humeral(AU)

We have carried out a scapulometric study, usingCT-scan, of 98 shoulders: 36 with recurrent anteriorshoulder dislocation (RAD), 37 stable contralateralshoulders (CSS) and 25 normal shoulders (NS). Sixparameters were evaluated: Horizontal and Verticalglenohumeral index, glenoid tilt, anteversion angle ofthe scapula, glenoid angle and humeral retroversion.We found statistically significant differences betweenthe RAD and CSS groups in the horizontal glenohumeralindex. Both the RAD and CSS groups showed significantdifferences in comparison with the NS group in the horizontalglenohumeral index, glenoid tilt and anteversionangle of the scapula. An imbalance of the head-glenoidsize and the anterior glenoid tilt are the anatomicalfactors which favour instability. The determination ofthese three parameters has great value when assessingpatients with anterior shoulder instability.Our results confirm that although the aetiology ofanterior glenohumeral instability is multifactorial, thereis an anatomical congenital predisposition which favoursinstability and this predisposition affects (to a lesser extent)the stable contralateral side, confirming the roleof subtle congenital dysplasic theory. In addition the followingwere revealed as relevant parameters in the studyof anterior instability: the horizontal glenohumeral index,glenoid tilt and angle of anteversion of the scapula; whilethe value of the humeral retroversion is under discussion(AU)

Arco aórtico derecho, divertículo de Kommerell y arteria subclavia izquierda aberrante / Right aortic arch, Kommerell’s diverticulum and aberrant left subclavian artery

La arteria subclavia derecha aberrante o «arterialusoria» es la variante anatómica más común del desarrolloembrionario de la aorta y sus ramas, llegando aestar presente en un 0,5-2% de la población; con menosfrecuencia se puede encontrar una arteria subclaviaizquierda aberrante asociada al arco aórtico derecho.Estas variantes anatómicas deben incluirse en el diagnósticodiferencial del ensanchamiento mediastínicosuperior visible en la radiografía de tórax. Se presentael caso clínico de un paciente que presentaba arcoaórtico derecho y arteria subclavia izquierda aberrantecon dilatación en su origen (divertículo de Kommerell)como causa de ensanchamiento mediastínico superiorde etiología incierta detectado de manera incidental enuna radiografía de tórax realizada en un paciente consintomatología respiratoria (AU)

The right aberrant subclavian artery or «arterialusoria» is the most common anatomical variant of theembryonic development of the aorta and its branches,with a presence in 0.5-2% of the population. Less frequently,a right aortic arch with aberrant left subclavianartery may be present. These anatomical variationsshould be included in the differential diagnosisof superior mediastinal widening seen on chest radiographs.In this report, we present a right aortic archwith left aberrant subclavian artery dilated at its origin(Kommerell’s diverticulum) as a cause of superiormediastinal widening detected incidentally on a chestradiograph (AU)

Recognition of noncardiac findings on cardiac computed tomography examination.

Multislice computed tomography (CT) is rapidly emerging as a novel technique for the evaluation of coronary artery disease. It is anticipated that with increasing acceptance of this imaging technique, CT for calcium scores and CT angiography will be performed in ever greater numbers. Thus, it is all but inevitable that clinicians will stumble upon incidental findings given the sheer number of vital organs and blood vessels that are imaged in the field of view. This article reviews the literature on incidental findings on cardiac CT with a focus on pulmonary nodules, ethical aspects of following up such findings, and cost implications.

Radiation exposure and diagnostic imaging.

PURPOSE: The purpose of this article is to increase clinician awareness of current radiation exposures of diagnostic testing, discuss current practice patterns, and suggest strategies to address issues at the systems level, institution level, and the healthcare provider level. DATA SOURCES: Evidence-based literature including interdisciplinary peer-reviewed articles in the biological and health-related fields. CONCLUSIONS: Radiation exposure related to diagnostic testing is often higher than anticipated for both the clinician and the patient. Strategies to address radiation exposure need to be implemented at many different levels in the system. Best practice initiatives are surfacing and will require a team approach for success. IMPLICATIONS FOR PRACTICE: Nurse practitioners need to be aware of the benefits and risks of diagnostic testing involving radiation exposure. Patients should also be informed of potential risks and benefits. Alternative imaging should be considered and repetitive testing should be monitored closely.

Report of a consultation on justification of patient exposures in medical imaging.

Radiation protection in medicine is underpinned by the concepts of justification and optimisation. Over the last 20 y much successful work has been devoted to developing and consolidating approaches to optimisation. A substantial knowledge base and a set of practical approaches have now been created to give effect to it. With respect to justification, less effort has been applied and the efforts applied have not yet been as successful. Authoritative sources suggest that a substantial fraction of radiological examinations may be unnecessary. In addition, a mainstream general medical journal has identified that few of those responsible for prescribing or performing examinations were familiar with the units used to specify the amount of radiation (and risk) received. This report sets out the conclusions of a consultation held in Vienna, by the International Atomic Energy Agency, dealing with the nature of justification and how to give effect to it in practice.