Patients' attitudes towards cost feedback to doctors to prevent unnecessary testing: a qualitative focus group study.

OBJECTIVES: There is a need to improve efficiency in healthcare delivery without compromising quality of care. One approach is the development and evaluation of behavioural strategies to reduce unnecessary use of common tests. However, there is an absence of evidence on patient attitudes to the use of such approaches in the delivery of care. Our objective was to explore patient acceptability of a nudge-type intervention that aimed to modify blood test requests by hospital doctors. STUDY DESIGN: Single-centre qualitative study. METHODS: The financial costs of common blood tests were presented to hospital doctors on results reports for 1 year at a hospital. Focus group discussions were conducted with recent inpatients at the hospital using a semi-structured question schedule. Discussions were transcribed and analysed using qualitative content analysis to identify and prioritise common themes explaining attitudes to the intervention approach. RESULTS: Three focus groups involving 17 participants were conducted. Patients were generally apprehensive about the provision of blood test cost feedback to doctors. Attitudes were organised around themes representing beliefs about blood tests, the impact on doctors and their autonomy, and beliefs about unnecessary testing. Patients thought that blood tests were important, powerful and inexpensive, and cost information could place doctors under additional pressure. CONCLUSION: The findings identify predominantly positive beliefs about testing and negative attitudes to the use of financial costs in the decision-making of hospital doctors. Public discussion and education about the possible overuse of common tests may allow more resources to be allocated to evidence-based healthcare, by reducing the perception that such strategies to improve healthcare efficiency negatively impact on quality of care.

Case report: Rapidly progressive metastatic pulmonary calcification: evolution of changes on CT.

Metastatic pulmonary calcification occurs in association with several disease processes and has a highly variable prognosis. In certain patients, it may prove fatal, and therefore prompt recognition of radiological signs is helpful for optimising patient management. We describe the progressive changes seen on CT in a 59-year-old man who had undergone renal transplant and subsequently developed metastatic pulmonary calcification. The merits of the different imaging techniques available and possible treatment options are reviewed.

Patient satisfaction and efficacy of vacuum-assisted excision biopsy of fibroadenomas.

AIM: To establish the efficacy, complications, and patient satisfaction for vacuum-assisted biopsy (VAB) excision of fibroadenomas. MATERIALS AND METHODS: All patients referred for VAB of benign lesions from 11 December 2002 to 30 November 2006 were identified prospectively, and the following data were recorded: age, histology, lesion size, and completeness of excision. A questionnaire was sent at least a year after the procedure to assess pain, complications, residual palpable lesions, and cosmetic result. RESULTS: One hundred and thirty-four patients were referred for VAB, 81 had fibroadenomas. Fifty-nine percent replied to the questionnaire. Fifty-four percent of patients reported no pain during the procedure, 8% rated their pain at > or =3/10. Thirty-two percent had no pain the week after the procedure, 55% had pain > or =3/10. Seventy-nine percent had no palpable mass at the site of the original lesion. Ninety-four percent would recommend the procedure to others and would prefer further VAB to surgery. Bruising was common, one patient required aspiration of a haematoma. Six percent developed infections, all resolved with antibiotic therapy. Eighty-five percent of patients were completely satisfied with the cosmetic result. Interval ultrasound was performed in 36 patients. A palpable mass was present in 11%, a non-palpable mass in 19%, and no mass in 70%. CONCLUSION: VAB excision is well-tolerated, safe, and popular with a high initial success rate for fibroadenomas. Bruising and pain are common the week after the procedure.

Radiological features of Meckel's diverticulum and its complications.

Meckel's diverticulum is the most common congenital abnormality of the small bowel. The majority of patients with this anomaly will remain asymptomatic; however, several complications may occur, including obstruction, intussusception, perforation, diverticulitis, and gastrointestinal haemorrhage. These complications may produce a variety of different clinical features and radiological appearances. The purpose of this article is to review the potential imaging manifestations of Meckel's diverticulum and its complications and discuss the advantages and disadvantages of the imaging techniques available.

Problem-based learning and radiology.

The Royal College of Radiologists recently published documents setting out guidelines to improve the teaching of radiology to medical students. These included recommendations that clinicians who teach radiology should be aware of newer educational techniques, such as problem-based learning, and should be involved in the development of curricula and assessment in medical schools. This review aims to introduce the educational theories behind problem-based learning and describe how a problem-based learning tutorial is run. The relevance of problem-based learning to radiology and the potential advantages and disadvantages are discussed.

Fluoroscopic insertion of post-pyloric feeding tubes: success rates and complications.

AIM: To examine the success and complication rates of radiological placement of post-pyloric feeding tubes, including those inserted with the assistance of a guide-wire. MATERIALS AND METHODS: Two hundred referrals (156 patients), between the dates of 5 April 2002 and 10 September 2004, were identified retrospectively from computerized records. Subsequently, the radiology reports and patients' notes were reviewed to evaluate the indications for post-pyloric feeding, success of placement, use of a guide-wire, and any complications. RESULTS: A post-pyloric tube was placed in the distal duodenum/jejunum in 183 (91.5%) patients and in the proximal duodenum or distal stomach in six (3%). A tube could not be inserted in 11 (5.5%) patients, and 51 (25.5%) of the insertions required the use of a guide-wire. Immediate complications were recorded in seven patients (3.5%): vomiting (n=5); hypotension and apnoea requiring naloxone (n=1) and hypoxia requiring endotracheal intubation (n=1). CONCLUSION: Radiological placement of post-pyloric feeding tubes has a success rate comparable with endoscopically placed tubes, and it rarely involves significant technique-related complications.

Haloalcohols deplete glutathione when incubated with fortified liver fractions.

1. This study has examined the ability of dichloropropanols, haloalcohols and their putative metabolites to deplete glutathione when incubated with liver fractions obtained from untreated and differentially induced rats. 2. 1,3-Dichloropropan-2-ol and 2,3-dichloropropan-1-ol (0-1000 microM) both depleted glutathione in a dose-dependent manner when incubated with cofactors (NADPH generating system) and liver microsomes from the untreated rat. 3. The extent of GSH depletion was significantly enhanced when liver microsomes from the isoniazid- or isosafrole-treated rat were used. 4. Epichlorohydrin produced a moderate, dose-dependent depletion of GSH. By contrast, 1,3-dichloroacetone (identified by TLC as a metabolite of 1,3-dichloropropanol) was a potent depletor of glutathione. 5. N-acetylcysteine was less efficient than glutathione as a nucleophile trap for epichlorohydrin, 1,3-dichloroacetone or reactive metabolites derived from 1,3-dichloropropan-2-ol. 6. 1,3-Dibromopropan-2-ol and 1,4-dibromobutan-2-ol were potent depletors of GSH but 1-bromopropan-2-ol produced less GSH depletion. Both dibromoalcohols depleted GSH when incubated with dialysed cytosol derived from the livers of untreated rats. 7. The GSH depletion mediated by 1,3-dichloropropan-2-ol, 1,3-dibromopropan-2-ol, 1,4-dibromobutan-2-ol and 1-bromopropan-2-ol was inhibited by inclusion of pyridine (1 mM) or cofactor omission. 1,3-Difluoropropanol did not deplete GSH under any of the conditions examined.

The familial syndrome of proliferative vasculopathy and hydranencephaly-hydrocephaly: immunocytochemical and ultrastructural evidence for endothelial proliferation.

This is the fourth report of Fowler-type hydranencephaly, or proliferative vasculopathy and hydranencephaly-hydrocephaly (PVHH), and is both the first case in Europe and the first case reported in an Asian family. A 17-week fetus showed severe arthrogryposis, pterygia and muscular hypoplasia. Massive cystic dilatation of the cerebral ventricles with thin disorganized pallium was associated with calcifications and characteristic glomeruloid vasculopathy throughout the CNS. Hydranencephaly in a previous pregnancy was demonstrated ultrasonographically at 13 weeks gestation. The glomeruloid vasculopathy, unique to this disorder, has ill-defined vascular channels, prominent reticulin network and inclusion-bearing cells which our immunocytological and ultrastructural studies suggest are endothelial cells. Aetiopathogenesis remains uncertain; previous hypothesis include congenital infection or primary neuro-ectodermal failure. Our present clinical and morphological findings suggest a primary role for the glomeruloid vasculopathy at the time of vascular invasion of the cerebral mantle during the first trimester. Previous and present case data support autosomal recessive inheritance, in contradistinction to sporadic, encephaloclastic, hydranencephaly from which PVHH can be readily differentiated by microscopic examination.