Structured education to improve primary-care management of headache: how long do the benefits last? A follow-up observational study.

BACKGROUND AND PURPOSE: Our earlier study showed that structured education of general practitioners (GPs) improved their practice in headache management. Here the duration of this effect was assessed. METHODS: In a follow-up observational study in southern Estonia, subjects were the same six GPs as previously, managing patients presenting with headache as the main complaint. Data reflecting their practice were collected prospectively during a 1-year period commencing 2 years after the educational intervention. The primary outcome measure was referral rate (RR) to neurological services. Comparisons were made with baseline and post-intervention data from the earlier study. RESULTS: In 366 patients consulting during the follow-up period, the RR was 19.9%, lower than at baseline (39.5%; P < 0.0001) or post-intervention (34.7%; P < 0.0001). The RR was diagnosis-dependent: the biggest decline was for migraine. Use of headache diagnostic terms showed changes generally favouring specific terminology. In particular, the proportion of patients given migraine diagnoses greatly increased whilst use of the inappropriate M79.1 (Pericranial) myalgia almost disappeared. Requests for investigations, which had fallen from 26% (of patients seen) at baseline to 4% post-intervention, resurged to 23% (mostly laboratory investigations; requests for X-rays continued to dwindle). Initiation of treatment by the GPs remained at the post-intervention level of just over 80% (up from baseline 58%). CONCLUSIONS: Improvements in GPs' practice after a structured educational programme mostly last for ≥3 years, some showing further betterment. A few measures suggest the beginnings of a decline towards baseline levels. This policy-informing evidence for continuing medical education indicates that the educational programme needs repeating every 2-3 years.

Short-term changes in magnetic resonance imaging and disease activity in response to infliximab.

OBJECTIVES: To characterise and quantify short-term changes in local inflammation using magnetic resonance imaging (MRI), and to correlate the findings with clinical disease activity in response to infliximab in patients with spondyloarthritis. METHODS: 28 consecutive patients with established spondyloarthritis under successful long-term treatment with infliximab underwent MRI immediately before and one week after re-administration of the TNF blocker. C-reactive protein and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) were assessed at both time points. The MRI protocol included coronal and sagittal turbo-short T1 inversion recovery (STIR) images as well as contrast-enhanced sagittal T1-weighted, fat-suppressed images. Images were assessed in independent sessions using the ASspiMRI-a score, the signal-difference-to-noise ratios (SDNR) and volumetry to assess oedematous and inflamed tissues. RESULTS: BASDAI values were expectedly low at study entry (3.3, SD 2.3). One week after administration of infliximab, 46% of patients reached a BASDAI 20, 39% a BASDAI 50. Kappa values for qualitative assessments and all measurements were excellent (range between 0.83 and 1.0) The ASspiMRI-a dropped most in the thoracic (3.3 points), less in the lumbar (1.21 points) and least in the cervical spine (0.38 points). The decrease of the ASspiMRI-a, the SDNR and the inflamed volumes in response to infliximab re-treatment was significant (p<0.01). The BASDAI showed a weak correlation with the ASspiMRI-a (r = 0.41). CONCLUSIONS: MRI proves to be a valid method to assess and quantify short-term effects of therapy in spondyloarthritis. Comparison between MRI and BASDAI changes show that the BASDAI may underestimate local inflammation. It suggests an explanation for the structural disease progression despite clinical remission.

Radiological diagnosis of hepatocellular carcinoma.

Treatment of hepatocellular carcinomas (HCC) is often complicated by the fact that early HCCs are mostly asymptomatic and the carcinoma is often discovered at an advanced stage. The aim of diagnostic imaging is to detect HCC at an early stage, when curative options are available. In recent years, there have been many efforts to improve early detection of small HCC. The purpose of this article is to describe the pertinent findings of HCCs in non-invasive, diagnostic imaging, including ultrasound, computed tomography, as well as modern magnetic resonance imaging techniques. Special emphasis is given to the frequently addressed difficulties of differentiation of precancerous lesions and small HCCs. A non-invasive diagnostic approach is considered with a review of the literature.

Prospective study on bright lumen magnetic resonance colonography in comparison with conventional colonoscopy.

The aim of this prospective trial was to evaluate sensitivity and specificity of bright lumen magnetic resonance colonography (MRC) in comparison with conventional colonoscopy (CC). A total of 120 consecutive patients with clinical indications for CC were prospectively examined using MRC (1.5 Tesla) which was then followed by CC. Prior to MRC, the cleansed colon was filled with a gadolinium-water solution. A 3D GRE sequence was performed with the patient in the prone and supine position, each acquired during one breathhold period. After division of the colon into five segments, interactive data analysis was carried out using three-dimensional post-processing, including a virtual intraluminal view. The results of CC served as a reference standard. In all patients MRC was performed successfully and no complications occurred. Image quality was diagnostic in 92% (574/620 colonic segments). On a per-patient basis, the results of MRC were as follows: sensitivity 84% (95% CI 71.7-92.3%), specificity 97% (95% CI 89.0-99.6%). Five flat adenomas and 6/16 small polyps (< or =5 mm) were not identified by MRC. MRC offers high sensitivity and excellent specificity rates in patients with clinical indications for CC. Improved MRC techniques are needed to detect small polyps and flat adenomas.

[Trachoma in Senegal: results of a national survey]. / Le trachome au Sénégal: résultats d'une enquête nationale.

A national survey was conducted to determine the prevalence of trachoma in Senegal between February and July 2000. The methodology consisted of a cross-sectional survey based on random sampling with two levels of stratification in five areas or area groups. A total of 12,328 children under 10 years of age and 8753 women over the age of 14 years were examined from 150 clusters (30 clusters per stratum). Excluding the Dakar stratum, the estimated prevalence of active trachoma (TF/TI) and severe trachoma (TI) in children under 10 years of age was 10.8% (IC 95%: 9.2-11.4) and 1.2% (IC 95%: 0.5-2.3) respectively. The corresponding prevalence for the areas around Dakar were 3.3% et 0.3%. Prevalence rates were highest between the ages of 2 and 3 years (17.4%). However these rates concealed major differences between strata since prevalence ranged from 3.3% in Dakar to 14.2% in Thiès-Diourbel. Excluding Dakar, the estimated prevalence of entropion/trichiasis and corneal opacity among women over the age of 14 years was 2.6% (IC 95%: 1.9-3.4) and 1.4% (IC 95%: 0.9-1.8). The prevalence of trichiasis was over 1% in every area except Tambacouna and reached 4% in Thiès-Diourbel. Trichiasis was observed in 17.1% of women over the age of 70. Based on extrapolation of these data to the whole country, it can be deduced that 272,020 children have active trachoma requiring medical treatment and that 115,000 persons over 14 years of age present trichiasis requiring surgical treatment.

Tumors of the urinary bladder: technique, current use, and perspectives of MR and CT cystography.

In comparison with other applications of virtual endoscopy, reports about virtual cystocopy are limited. In this update article, the various techniques of magnetic resonance (MR) and computed tomographic (CT) cystography are explained with their inherent advantages and disadvantages. The principal methods of postprocessing are presented, and future technical developments of MR and CT cystography are described. The present clinical applications and the possible role of MR and CT cystography in the future are discussed.

[Virtual endoscopy of the urinary tract from T(2)-weighted and gadolinium-enhanced T(1)-weighted MR urographic images]. / Virtuelle Endoskopie des Urogenitaltraktes auf der Basis T(2)-gewichteter und kontrastmittelunterstützter T(1)-gewichteter Datensätze.

PURPOSE: To determine the diagnostic performance of T(2)-weighted (T2w) and gadolinium-enhanced T(1)-weighted (T1w-Gd-enhanced) MR urographic images for virtual endoscopy of the urinary tract. MATERIALS AND METHODS: 36 patients underwent MR urography at 1.5 T. In each patient a T2w (3D-TSE, respiration-triggered) and a T1w-Gd-enhanced sequence (T1-FFE, breathhold) were acquired. Data reconstruction was performed as maximum intensity projection (MIP) and virtual endoscopy (VE). RESULTS: Combined analysis of MIP and VE delineated 32 of 36 pathologies; 86 % (19/22) of intraluminal pathologies could be depicted by VE and 15 % (3/22) by MIP (p

Magnetic resonance colonography and virtual magnetic resonance colonoscopy with the 1.0-T system: a feasibility study.

RATIONALE AND OBJECTIVES: An ex vivo study and a clinical, prospective, patient study were undertaken to evaluate the feasibility of magnetic resonance (MR) colonography with a 1.0-T system. METHODS: An ex vivo colon model was scanned. A cleaned pig colon was prepared with six simulated sessile polyps (diameters of 4-12 mm) and one simulated pedunculated polyp (diameter of 5 mm). Subsequently, five patients (aged 39-81 years; four women, one man) were examined with MR colonography, immediately followed by endoscopic colonoscopy. After preparation for colonoscopy, the colon was filled with a Gd-DTPA/water solution (1:100). A breath-hold 3D gradient-echo sequence was acquired in both the prone and supine positions and after intravenous Gd-DTPA administration. Images were analyzed interactively by using multiplanar projections, maximum-intensity projection, and a virtual endoscopic view. The MR results were compared with the findings of the fiberoptic endoscopy. RESULTS: All seven simulated lesions of the colon model could be detected by MR imaging. In one patient, an advanced colon cancer as well as an additional small polyp was depicted. In the other four patients, single polyps with a diameter of 1 to 2.5 cm and a large adenoma were visualized by MR colonography. Contrast enhancement of the polyps was noted only after subtraction. CONCLUSIONS: The 1.0-T system is feasible for MR colonography. Reduced requirements for hardware could contribute to establish the novel technique as a screening method for colorectal polyps.

[Control of percutaneous biopsy with CT fluoroscopy]. / Steuerung von perkutanen Biopsien mittels CT-Fluoroskopie.

PURPOSE: Clinical evaluation of CT fluoroscopy and comparison with conventional CT guidance for monitoring of non-pulmonary percutaneous biopsy procedures. MATERIALS AND METHODS: 20 non-pulmonary CT-guided biopsy procedures were prospectively performed either with CT fluoroscopy or with conventional CT guidance. CT fluoroscopy was performed using 120 kV and 50, 70 or 90 mA at a frame-rate of three or six images per second. Number of punctures and biopsies, procedure times, radiation doses and histologic results were analyzed separately for conventional CT guidance and for CT fluoroscopy. RESULTS: With CT fluoroscopy, yield of biopsies was improved (p = 0.005, t-test) and procedure times were shorter than for conventional CT guidance (11.4 +/- 6.0 vs. 23.6 +/- 13.8 min; p = 0.03, t-test). Analysis of procedure related radiation exposure and histologic outcome showed no significant difference between conventional and fluoroscopic CT-guided procedures (p > 0.05, t-test). CONCLUSIONS: CT fluoroscopy facilitates guidance of percutaneous biopsy procedures. Compared to conventional CT assistance, procedure times are decreased while yield of biopsies is improved.

[Mortality and morbidity conference in radiology]. / Mortalitäts- und Morbiditätskonferenz in der Radiologie.

PURPOSE: To establish a morbidity and mortality conference in a radiology department as an instrument of quality assurance. METHODS: Since April 1995 a monthly conference is held in the radiology department. Complications of invasive diagnostic procedures (angiography and biopsy) and minimal invasive interventions are presented. Cases of morbidity (major complications) and mortality (deceased patients, who were examined or treated in the radiology department before) are discussed. The identification of cases was possible due to a data base that included all such procedures prospectively. RESULTS: Twenty cases of major complications were identified and discussed during 18 morbidity and mortality conferences in 1996 and 1997. Out of the 9 patients who died in our hospital and previously had an interventional procedure in the radiology department, one case was identified as being procedure-related. An analysis of this case was performed. CONCLUSION: With a formalised structure of case detection, the morbidity and mortality conference becomes a tool of a complete analysis of complications and a meaningful instrument for the solution of problems concerning procedure-related complications.