Radionuclide radiologist directed nuclear medicine services in district general hospitals in the South Thames Region.

The equipment, staffing levels and imaging workload of all 14 radiologist directed nuclear medicine services in district general hospitals in the South Thames Region are presented. These are generally single camera departments providing a broad range of imaging procedures, including cardiac studies and white cell labelling, as well as the more usual renal, lung, thyroid and bone examinations. All departments have a high throughput, averaging 2358 examinations per year. Departmental staffing levels are variable, with some institutions having inadequate consultant radiology sessions free of other commitments as well as inadequate physics support. Potentially, these are important quality and legal issues that departments may need to address with hospital Trusts and Commissioning Agencies. Four small departments provided a service without any formally contracted radiologist sessions for nuclear medicine in the radiologists' job plans. The three medium sized departments have a closer match between sessions contracted and those actually worked, but in only one of these did the contracted sessional commitment equal the recommendation of the Nuclear Medicine Committee of the Royal College of Physicians. There is a disparity between the number of contracted consultant sessions and those actually worked in most institutions (86%), being at least two sessions in eight hospitals. Recommendations are made regarding the adequacy of some of the elements of provision in South Thames and the legal and safety implications for hospital Trust management and Commissioning Agencies.

The development of regional nuclear medicine audit in south Thames.

A programme of audit, including clinical audit, organizational audit and patient/clinician satisfaction surveys, has been implemented in nuclear medicine departments throughout the South Thames Regional Health Authority (RHA). The clinical topics which have been audited include. ventilation-perfusion lung imaging, bone imaging, liver imaging, thyroid imaging and renal static DMSA imaging. Guidelines have been set for nuclear medicine practice in each of these areas against which further audit can be performed. Organizational audits have been performed in 10 nuclear medicine departments in the South Thames RHA and a confidential report supplied to the head of each department, consisting of findings and recommendations. A programme of re-audit has also commenced. The main findings have been a lack of facilities and space. Patient satisfaction surveys have been implemented in nine departments and a high level of patient satisfaction has been demonstrated. A clinical satisfaction survey has been implemented in 13 departments. It is hoped to continue this successful programme of audit to improve nuclear medicine practice by closing audit loops.

South Thames Nuclear Medicine Survey 1996-97. South Thames Regional Nuclear Medicine Specialty Service Committee.

Data on the equipment available, staffing levels, number and type of procedures carried out in the South Thames Region during 1993-94 and 1996-97 are presented. These are compared with national data for 1993. The number of gamma cameras has increased by 5%, overall staffing by 15% and the number of procedures has increased by 31%. There has been a disproportionate increase in the technically more complex procedures, for example cardiac tomography (84%). Regional data have been collated since 1979 and techniques have been established to ensure consistency. Staffing levels, although improving, do not meet the minimum levels recommended by professional bodies. This raises questions about the quality and, possibly, the legality of the service provision.

Changes in diurnal blood pressure variation and red cell and plasma volumes in patients with renal failure who develop erythropoietin-induced hypertension.

Hypertension is the most common side-effect of treatment with recombinant human erythropoietin (EPO) for the anemia of chronic renal failure. To elucidate why this occurs in some patients we measured changes in blood volumes and diurnal blood pressure (BP) variation during treatment. Isotope labelled measurements of red cell and plasma volume (RCV and PV) were carried out along with ambulatory BP monitoring before starting EPO and after target hemoglobin (Hb) was reached. RCV did not differ between the patient group developing EPO-induced hypertension (EpHT, n = 11) and the group with no change in BP (NC, n = 13) either before or after treatment. However PV was significantly lower in the EpHT group after treatment (2.97 vs 3.92 litres; p < 0.025). Mean BPs differed little between groups because antihypertensive medications were increased as necessary for clinical safety but after achieving target Hb, day-night difference in diastolic BP was greater in the EpHT than the NC group (11.5 vs 4.6 mmHg; p < 0.025) due to a greater rise in daytime BP. There were significant correlations between high day-night diastolic BP differences after EPO in all the studied patients and low plasma volumes either pre- or post-EPO. The study group was heterogeneous but the changes were in the same direction irrespective of type of renal replacement therapy. These results suggest that EPO-induced hypertension is associated with increased daytime vasoconstriction and greater hemoconcentration due to lower plasma volume.

Identification of reversible ischaemia after acute myocardial infarction using thallium tomography with early and delayed imaging after resting injection.

We studied 30 patients 6 weeks after first myocardial infarction in order to compare early and delayed imaging after resting injection of thallium for the detection of viable myocardium. Twenty-six of the 30 patients studied had received thrombolysis. Conventional stress and redistribution thallium tomography was followed by a resting injection of thallium with imaging immediately after in all patients and 3 h later in a subgroup of 15 patients. Thallium uptake was graded semi-quantitatively in each of nine myocardial segments. Eighty-eight of the 270 segments had a fixed defect on redistribution imaging, 40 (45%) of which had improved uptake in the immediate reinjection images. Only 9 of 135 (6%) segments with fixed defects on immediate reinjection imaging showed additional uptake with delayed reinjection imaging. These data suggest that imaging early after thallium reinjection is of value in the detection of reversible ischaemia after infarction, but that delayed reinjection imaging offers little additional benefit.

Effect of labetalol on indices of myocardial necrosis in patients with suspected acute infarction.

The role of combined alpha and beta blockade as a means of limiting infarct size has been studied in a randomised controlled trial using labetalol. Only 166 of 630 (26%) consecutive patients admitted to a cardiac care unit with suspected myocardial infarction were deemed suitable for inclusion; most of the remainder had delayed admission to hospital, were over the age limit of 75, or had complications which precluded the use of labetalol. Those on active treatment received a loading dose followed by a slow intravenous infusion over six hours, and oral therapy for the subsequent five days. Doses were adjusted to maintain systolic pressure in the range 100 to 120 mmHg. The control group received only conventional therapy. Labetalol caused lowering of the blood pressure and heart rate during the phase of intravenous treatment, but little effect occurred subsequently because oral dosage was constrained by low systolic pressures. The group that received active treatment had significantly greater release of CKMB enzyme. Little difference was observed in R wave scores or ejection fraction. Only low doses of labetalol can be used for most patients with acute myocardial infarction. Labetalol cannot be recommended as routine treatment for normotensive patients admitted to hospital with suspected infarction.

Aspiration cytology of solid renal tumours.

The results of needle aspiration cytology of solid renal lesions in Brighton from 1977 have been reviewed. Thirty-one lesions were aspirated and of the 21 malignant tumours, cytology accurately diagnosed 19 (90%) when sufficient material was sent for analysis. Of the eight avascular solid renal space-occupying lesions aspirated, cytology gave a correct differentiation (benign versus malignant) in seven (87%). The results compare favourably with those of other published experience. A modification is suggested to the accepted diagnostic pathway.

Pulmonary oedema without critical increase in left atrial pressure in acute myocardial infarction.

Twelve patients with acute myocardial infarction and radiological evidence of pulmonary oedema were observed in whom the left atrial pressure, measured indirectly as pulmonary artery end-diastolic pressure, was not critically increased (range 5-12 mm Hg with reference to sternal angle). Eight of the patients had been treated with frusemide, but only six had responded: hence in at least half of the series diuresis could not account for the anomalous finding. Six patients with low cardiac output were given infusions to expand plasma volume. Appreciable increments in mean values for cardiac index (1.6 to 2.0 1/min/m2), stroke index (18 to 23 ml/beat/m2), mean arterial pressure (65 to 86 mm Hg), and pulmonary artery end-diastolic pressure (8 to 15 mm Hg) were recorded. This group, and the remaining six patients with higher cardiac output, survived to leave hospital. Delay in radiographic clearing after a fall of left atrial pressure was a possible explanation for the relatively low pulmonary artery end-diastolic pressures, especially in the patients treated successfully with diuretics. Other mechanisms, such as alterations in pulmonary vascular permeability, might also have contributed to the syndrome. Pulmonary oedema without a critical increase in the left atrial pressure is unusual in acute myocardial infarction but the therapeutic implications are important. Withdrawal;of diuretics may be indicated, and in some cases expansion of plasma volume may lead to striking clinical improvement.

The endoscopic, radiological, and surgical findings in chronic duodenal ulceration.

A prospective study of the endoscopic, radiological, and surgical features of chronic duodenal ulceration has been performed. Double contrast barium meal and upper gastrointestinal endoscopy were both performed within five days of elective surgery for chronic duodenal ulceration on 50 patients. The surgical diagnosis correlated with endoscopy in 88% and radiology in 82%, but if both techniques were employed, an accurate pre-operative diagnosis was achieved in 96% of cases. There was poorer correlation in determining the position of the ulcer within the bulb, with only 41% correlation between all three parameters and complete disagreement in 24%. Surgery correlated with endoscopy in 71% but with radiology in only 41%. The correlation between endoscopy and surgery in the diagnosis of duodenitis was only 42%, suggesting that this should be a histological diagnosis. This study suggests that endoscopy is slightly more precise than radiology in the diagnosis of chronic duodenal ulceration, but with a combination of the two techniques almost 100% accuracy can be achieved.