Managing errors in radiology: a working model.

AIM: To develop a practical mechanism for reviewing reporting discrepancies as addressed in the Royal College of Radiologists publication "To err is human. The case for review of reporting discrepancies". MATERIALS AND METHODS: A regular meeting was developed, and has evolved, within the department to review discrepancies. Standard forms were devised for submission of cases as well as recording and classification of discrepancies. This has resulted in availability of figures that can be audited annually. RESULTS: Eighty-one cases involving error were reviewed over a 12-month period. Seven further cases flagged as discrepancies were not identified on peer review. Twenty-four reports were amended subsequent to the meeting. Nineteen additional cases were brought to the meeting as illustrative of teaching points or for discussion. CONCLUSION: We have evolved a successful process of reviewing reporting errors, which enjoys the confidence and support of all clinical radiologists, and is perceived as a method of improving patient care through an increasing awareness of lapses in performance.

A low-dose radioisotope procedure for assessment of subcutaneous drug delivery systems used for slow intrathecal infusion of antispasmodic agents.

STUDY DESIGN: Retrospective single centre study. OBJECTIVES: To evaluate a low-dose radioisotope imaging procedure for assessment of implanted intrathecal drug delivery and to compare the radiation dose and diagnostic value of these studies with other reported studies using higher administered radiation dose. SETTING: National Spinal Injuries Centre, Stoke Mandeville Hospital, UK. METHOD: A total of 11 spinally injured patients with subcutaneous drug delivery systems and uncontrolled spasm were investigated for catheter failure using a low-dose radioisotope procedure with an administered dose of radioactivity of 40 MBq Technetium-99m. RESULTS: Loss of catheter patency was demonstrated in six patients, enabling identification of the site of blockage. Catheter patency and subsequent perfusion of CSF (ie normal result) was demonstrated in five patients. Radiation effective dose was estimated at 1.3 mSv per patient study, with a low associated risk of deleterious effect of one in 13,000. CONCLUSION: Radioisotope investigation using a reduced administered dose of 40 MBq Technetium-99m DTPA, formulated according to a strict radiopharmaceutical protocol, provides a safe test for assessment of intrathecal drug delivery systems.

A clinical magnetic resonance imaging study of the traumatised spinal cord more than 20 years following injury.

One hundred and fifty three patients who had sustained a spinal cord injury more than 20 years previously were assessed neurologically and by MRI scanning of their spinal cords. The spinal cord pathologies shown were, in order of prevalence, extended atrophy, malacia, syrinx, cyst, disruption and tethering. There was no relationship between the prevalence of any type of pathology and the degree of spinal canal compromise or angulation of the spine adjacent to the level of injury. Neurological changes after initial neurological stabilisation were seen only in patients with extended atrophy, malacia or a syrinx, not in those with only a cyst or cord disruption. Tethering is always associated with other lesion(s). Longer syrinxes were more likely to have associated neurological changes than shorter ones. The most common neurological change was pain.

A comparison of the chest radiograph and computerised tomography in assessing lung changes in acute spinal injuries--an assessment of their prevalence and the accuracy of the chest X-ray compared with CT in their assessment.

Lung function in patients following an acute spinal injury is frequently much more compromised than may be expected from the level of injury and the chest radiograph appearance. Experimental evidence in anaesthetised patients and subsequently our own experience with patients with acute spinal injuries suggested that in paralysed patients lung changes were frequent and that in many spinal patients large pleural effusions and lung consolidation could be present without the usual associated chest radiograph changes being recognised. This study was performed to assess the prevalence of chest pathology and the sensitivity of the chest radiograph in portraying it. Sixty patients (50 males, 10 females, 31 cervical, 29 thoracic or thoracolumbar; 15 incomplete, 45 complete; ages 17-66, mode 22 years) with spinal injuries from a variety of causes were assessed with a supine chest radiograph and three computerised tomography axial cuts at standardised locations through the thorax. The chest radiograph agreed with the computerised tomography in only 12 patients (six normal, six abnormal). The chest radiograph suggested that there were 19 normals but computerised tomography only showed 12. In a total of 35 patients, the chest radiograph significantly underestimated the degree of change and in 13 the chest radiograph suggested greater pathology than was shown on computerised tomography. Thirteen of the 20 patients with cervical lesions but no chest trauma had lung changes.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiological percutaneous gastrostomy placement for enteral feeding.

Many patients who are unable to swallow have normal intestinal absorption and therefore do not need expensive and potentially problematic parenteral nutrition. Long term nasogastric tubes are unpleasant and interfere with communications, thus a gastrostomy is often felt to be appropriate. Traditionally this has been inserted at laparotomy but recently, other less invasive techniques of insertion such as endoscopy have been used for placement. We describe three patients where a percutaneous gastrostomy was placed by a radiological technique that we feel deserves wider recognition. It is quicker, cheaper and more versatile than the endoscopic method and avoids the unpleasant necessity for intubation by other than a fine-bore nasogastric tube.

[Radiology of late damage after spinal cord injuries]. / Radiologie von Spätschäden nach Rückenmarkverletzungen.

Most patients who have suffered spinal cord injuries now expect a normal life span, so the late complications of these injuries are becoming increasingly frequent. Regular surveillance of the state of the urinary tract and the treatment of impending, even if clinically silent, complications is a well-established aspect of follow-up. With an increasing ability to diagnose and treat the neurological complications, surveillance of the state of the spinal cord has now assumed great importance. Magnetic resonance imaging (MRI), or computerized tomography (CT) with myelography if MRI is contra-indicated is the method of choice and can demonstrate the pathology with great clarity. In most patients, midline sagittal T1W images are sufficient for screening purposes and for monitoring the success of treatment. Operative, imaging and postmortem studies have shown that the two main changes that occur are: (a) atrophic and (b) cystic-the microcystic and myxoid gel changes of myelomalacia, focal cysts and the larger, more expansive, syringomyelia. As yet, there is no standardization of terminology to describe the various pathological and radiological states. This is critical as only one condition, syringomyelia, is currently amenable to definitive surgery and without conformity, comparisons of incidence in different populations and assessment of the results of surgery are impossible. The published small studies of predominantly symptomatic patients at varying stages of chronicity give differing incidences of changes. Preliminary results of a surveillance MRI study of the spinal cord changes in 153 patients who had had a spinal cord injury over 20 years previously are presented. Atrophy was present in 62%, myelomalacia in 54%, syringomyelia in 22%, focal cysts in 9% and disruption in 7%.

The incidence of acute arthritis in stroke patients, and its impact on rehabilitation.

To investigate the occurrence of acute arthritis after stroke, we prospectively studied 111 patients presenting with their first stroke and no history of previous arthritis. Clinical, biochemical and serological assessment was complemented by brain CT scan; appropriate X-rays were taken of any inflamed joints and synovial fluid was collected and analysed. Those with aseptic arthritis were randomly chosen to receive either intra-articular steroids or non-steroidal anti-inflammatory drugs (NSAIDs). Patients with significant renal impairment were excluded. Acute arthritis was observed within 8.34 (median) days, on the paretic side in 19 patients (10 crystal, 4 inflammatory osteoarthritis, 1 septic, 4 unexplained) and on the non-paretic side in 4 patients (1 inflammatory osteoarthritis, 1 septic, 2 unexplained). One patient had pseudogout affecting both sides. Thiazide therapy prior to the stroke was associated with gout in 3 patients. Hospital patients with arthritis had a longer median length of stay than those without (41 vs. 21 days: p = 0.01). Patients receiving intra-articular steroids recovered more rapidly than those treated with NSAIDs (p < 0.05). This prospective study demonstrates the occurrence of acute arthritis in paretic limbs after stroke. Physicians should be aware of this complication, and that administration of intra-articular steroids in aseptic cases speeds rehabilitation and recovery.

Ultrasound in the early diagnosis of heterotopic ossification in patients with spinal injuries.

Heterotopic ossification (HO) is a potentially disabling complication of spinal injuries and other chronic disorders. It is of unknown aetiology and currently there is no easy or convenient diagnostic method that will allow very early confirmation of the inflammatory changes that precede osteoid and, later, true bone formation. Clinical experience, however, indicates that early treatment with radiotherapy, antiinflammatory agents or diphosphonates is needed to control the progression. This study was undertaken to assess the role of ultrasound (US) in the very early diagnosis of HO in patients with spinal injuries. US was found to be very sensitive in detecting focal soft tissue abnormalities around joints and in the muscles of these patients. If combined with a Doppler study to exclude deep venous thrombosis (DVT), and infection or tumour could be excluded clinically, US was extremely accurate in predicting the presence or absence of early HO changes within hours of the clinical manifestation. In 2 patients it successfully predicted HO in the opposite leg before clinical signs were evident. This study also provided supportive evidence of the theory of microtrauma in the aetiology of HO. As ultrasound is portable, safe, cheap, reproducible and accurate, it is the method of choice in the early diagnosis of HO. It allows early treatment to prevent the formation of osteoid and subsequent bone formation.

Magnetic resonance imaging of the knee: initial experience in a district general hospital.

We present the results of a prospective study comparing the accuracy of magnetic resonance imaging with arthroscopy in the assessment of knee complaints. Using a low field strength magnet, MRI was able to achieve a high diagnostic accuracy within the setting of a district general hospital.

Antibodies to cardiolipin in stroke: association with mortality and functional recovery in patients without systemic lupus erythematosus.

Antibodies to cardiolipin were measured in 100 consecutive patients with first ever stroke, on admission and at three and six months after the acute event. One hundred healthy, age- and sex-matched, British elderly individuals were also screened for antibodies to cardiolipin as a control group. Elevated levels of anticardiolipin antibody (i.e. 5 SD above the laboratory control mean) were present in none of the control group, but in 21 per cent of the patients with stroke. Thirteen of these 21 patients (62 per cent) died within three months, compared to 17 (21.5 per cent) of the seventy-nine patients without elevated levels of anticardiolipin antibodies (p less than 0.001). Six of the eight survivors with persistently elevated anticardiolipin antibodies had significant residual disability following stroke (Barthel score 0-9) compared to 11 of the 62 without (p less than 0.001). Two patients with initially raised anticardiolipin antibodies who became independent at six months showed a progressive decline in the level of these antibodies to normal. The presence of high levels of anticardiolipin antibody did not correlate with other recognized prognostic indices of stroke, except for incontinence. No correlation was noted between levels of antibody to cardiolipin, antinuclear factor, antibody to double-stranded DNA and C-reactive protein, either in the stroke patients or in the elderly control population. Hypertension was significantly more common in the patients with high anticardiolipin antibodies than in the rest of the patients in the stroke population (p = 0.33). There was no correlation between levels of anticardiolipin antibody and age. Anticardiolipin antibody may be considered as an independent prognostic marker for both mortality and clinical outcome after acute stroke.

Urography prior to prostatectomy.

As part of the pre-operative assessment for prostatectomy, the routine intravenous urogram continues to be requested by many practitioners. One hundred and ten patients being considered for prostatectomy underwent, prospectively, intravenous urography and trans-abdominal ultrasound. This paper specifically examines the respective contribution to management of these investigations. In 34% of patients, management was influenced in some way. This could have been achieved by ultrasound and plain abdominal radiograph alone. Additional intravenous urography would not have affected the clinical management of any patient.