An NHS Trust comparison of reporting radiographers and consultant radiologists ability to identify cancer on chest radiographs with confirmation through a Fast track CT thorax referral system.

INTRODUCTION: The National Institute for Health and Care Excellence (NICE) recommends that GPs initially refer patients with suspected lung cancer for a chest X-ray (CXR). The Radiology department has a 'fast track system' to identify those patients who may have lung cancer on CXR and are referred for a CT thorax with contrast to help determine a cancer diagnosis. This fast track system was put in place to ensure the NICE guidelines and NHS England's standards on a faster cancer diagnosis are being met. This audit studied the ability of radiologists and reporting radiographers to identify lung cancer on CXRs and the accuracy of the fast-track system. METHODS: 846 cases with lung alerts were analysed and 545 CXRs were audited. The CXRs were split into images reported by radiologists (168) and those reported by reporting radiographers (377). CT thorax results were collected through PACS and Cerner computer systems to identify if the 'fast track' system had yielded a "positive", "negative", or "other findings" result for lung cancer. RESULTS: 32.8% (179) of CXRs flagged for lung cancer were positive, 40.6% (221) were negative, and 26.6% (145) had other findings. Chi square statistical test showed no significant difference (p = 0.14) between the two reporting groups in their ability to identify lung cancer on CXRs. 27% (38) of CXRs flagged by radiologists and 35% (125) by reporting radiographers were positive for lung cancer. CONCLUSION: This clinical audit indicates, reporting radiographers and radiologists are not statistically significantly different regarding their ability to identify lung cancer on CXRs, when supported by the fast track system. The fast-track system had a 59.4 % accuracy rate, detected by the number of imaging of reports that identified a serious pathology. This concludes that the system is performing well, yet could still be improved. IMPLICATIONS FOR PRACTICE: This audit provides further evidence for the value of developing and deploying reporting radiographers for projection radiography reporting.

Diagnostic radiography students' attitudes towards gender inclusive pregnancy status checks.

INTRODUCTION: Radiographers are responsible for protecting foetuses against ionising radiation and must screen all individuals for pregnancy prior to a pelvic X-ray examination following new guidance from the Society of Radiographers. This includes male, female, transgender, non-binary and intersex patients. Student diagnostic radiographers learn to undertake this screening so this project was designed to understand their attitudes towards doing so. METHOD: A qualitative study was conducted with third-year students on the BSc Diagnostic Radiography programme at a University in the North West of England. Following ethical approval, focus groups were conducted using open-ended questions to gain insight into how comfortably students conduct Inclusive Pregnancy Status (IPS) checks at seven National Health Service (NHS) Trust clinical placement sites. Students were also asked about their attitudes towards IPS checks. These data were analysed using Clarke and Braun's thematic analysis model. RESULTS: The analysis of seven focus groups with nineteen participants yielded four themes: education, standardisation, fear of reaction, and placement involvement. Barriers to conducting IPS checks include a lack of staff encouragement as guidance is enforced at the employers' discretion, and a lack of awareness around transgender, non-binary and intersex (TNBI) inclusivity. Students showed a willingness to conduct IPS checks despite this. CONCLUSION: Age and experience range of participants were limiting factors in this study. Students who had the opportunity to practice and were encouraged to conduct IPS checks on placement felt confident in doing so. IMPLICATIONS FOR PRACTICE: More training and awareness should be provided surrounding LGBTQ + issues in healthcare. IPS checks should be standardised across placement sites to ensure equal learning opportunities.

AdHealth: a feasibility study to measure digital food marketing to adolescents through Facebook.

OBJECTIVE: To test the feasibility of a browser extension to estimate the exposure of adolescents to (un)healthy food and beverage advertisements on Facebook and the persuasive techniques used to market these foods and beverages. DESIGN: A Chrome browser extension (AdHealth) was developed to automatically collect advertisements seen by participants on their personal Facebook accounts. Information was extracted and sent to a web server by parsing the Document Object Model tree representation of Facebook web pages. Key information retrieved included the advertisement type seen and duration of each ad sighting. The WHO-Europe Nutrient Profile Model was used to classify the healthiness of products advertised as permitted (healthy) or not permitted (unhealthy) to be advertised to children. SETTING: Auckland, New Zealand. PARTICIPANTS: Thirty-four Facebook users aged 16-18 years. RESULTS: The browser extension retrieved 4973 advertisements from thirty-four participants, of which 204 (4 %) were food-related, accounting for 1·1 % of the exposure duration. Of those food advertisements, 98 % were classified as not permitted, and 33·7 and 31·9 %, respectively, of those featured promotional characters or premium offers. The mean rate of exposure to not permitted food was 4·8 (sd = 2·5) advertisements per hour spent on Facebook. CONCLUSIONS: Using a Chrome extension to monitor exposure to unhealthy food and beverage advertisements showed that the vast majority of advertisements were for unhealthy products, despite numerous challenges to implementation. Further efforts are needed to develop tools for use across other social media platforms and mobile devices, and policies to protect young people from digital food advertising.

Please be upstanding - A narrative review of evidence comparing upright to supine lumbar spine MRI.

OBJECTIVES: The objective of the review was to examine the evidence comparing upright to supine MRI of the lumbar spine. KEY FINDINGS: A literature search identified 14 articles comparing data where subjects had been scanned in both supine and upright positions on the same scanner. Lumbar spine anatomy is dynamic and therefore subject to morphological changes when transitioning from the supine to the upright position. There is strong evidence to suggest structural changes in spinal morphology due to radiographic positioning, and that upright positioning is better for evaluating spondylolisthesis. CONCLUSION: It has been demonstrated that the scanning position is important in the outcome of the MRI examination of the lumbar spine. With this in mind, it would be beneficial for guidance to be written and adopted to improve the consistency and quality of scanning. IMPLICATIONS FOR PRACTICE: As upright MRI occupies a niche in the scanning sector, many professionals are unaware of its capabilities. This article aims to increase awareness of the use of upright MRI in evaluating the lumbar spine.

Enhanced TLR2 responses in multiple sclerosis.

The roles of the microbiome and innate immunity in the pathogenesis of multiple sclerosis (MS) remain unclear. We have previously documented abnormally low levels of a microbiome-derived Toll-like receptor (TLR)2-stimulating bacterial lipid in the blood of MS patients and postulated that this is indicative of a deficiency in the innate immune regulating function of the microbiome in MS. We postulated further that the resulting enhanced TLR2 responsiveness plays a critical role in the pathogenesis of MS. As proof-of-concept, we reported that decreasing systemic TLR2 responsiveness by administering very low-dose TLR2 ligands attenuated significantly the mouse model of MS, experimental autoimmune encephalomyelitis. Studies of Toll-like receptor responses in patients with MS have been conflicting. Importantly, most of these investigations have focused on the response to TLR4 ligation and few have characterized TLR2 responses in MS. In the present study, our goal was to characterize TLR2 responses of MS patients using multiple approaches. Studying a total of 26 MS patients and 32 healthy controls, we now document for the first time that a large fraction of MS patients (50%) demonstrate enhanced responsiveness to TLR2 stimulation. Interestingly, the enhanced TLR2 responders include a significant fraction of those with progressive forms of MS, a subset of patients considered unresponsive to adaptive immune system-targeting therapies. Our results suggest the presence of a pathologically relevant TLR2 related innate immune abnormality in patients with both relapsing-remitting and progressive MS. These findings may have significant implications for understanding the role of innate immunity in the pathogenesis of MS.

Australian training for contemporary airway management of obstructive sleep apnoea in ENT surgery: current status and future recommendations.

BACKGROUND: The identification and treatment of adult obstructive sleep apnoea and other sleep-related breathing issues demands nuanced clinical judgement to determine if surgery is appropriate and which surgery should be performed. No study to date has evaluated the sleep medicine curriculum from the perspective of the Australian ENT surgical trainee, or addressed potential strategies for improving levels of surgical skill and knowledge in this field. METHODS: A cross-sectional survey was used to assess knowledge of sleep surgery in trainees enlisted with the Australian Society of Otolaryngology Head and Neck Surgery. After a cadaver dissection workshop on the latest reconstructive surgical techniques in adult OSA, a second survey was used to assess changes in the likelihood of applying techniques. RESULTS: Overall, trainee confidence, knowledge and exposure to sleep-disordered breathing cases averaged below 50 per cent. The cadaver dissection workshop achieved consistent improvements in all areas assessed. CONCLUSION: Low confidence and lack of exposure to sleep surgery cases for ENT trainees supports a broadening of the Australian Society of Otolaryngology Head and Neck Surgery curriculum. This paper outlines possible ways to improve this situation.

Beyond uvulopalatopharyngoplasty for obstructive sleep apnoea: single surgeon case series of contemporary airway reconstruction.

OBJECTIVE: Adult patients with obstructive sleep apnoea can be a therapeutic surgical challenge if other treatments fail or are rejected. We report the outcomes of a series of 17 patients for whom standard device-based treatments failed or could not be used. These patients were considered unsuitable for a lesser operation and therefore underwent multilevel upper airway reconstruction. METHOD: Data from 17 consecutive patients were collected prospectively. This included pre- and post-surgery findings for clinical assessments, body mass index, sleep questionnaires, and laboratory polysomnograms. Patients underwent a combination of modified uvulopalatopharyngoplasty, transpalatal advancement and various tongue reduction procedures. RESULTS: Analyses revealed statistically and clinically significant reductions in: mean apnoea-hypopnoea index scores (from 36.3 pre-operatively to 14.5 post-operatively, p < 0.001), mean Epworth sleepiness scale scores (from 11.3 to 5.3, p < 0.001) and mean snoring severity scores (from 6.9 to 1.3, p < 0.001). Body mass index remained unchanged. CONCLUSION: Multilevel upper airway reconstructive surgery was associated with large reductions in both objective and patient-centred subjective measures of obstructive sleep apnoea severity.

Coblation-assisted Lewis and MacKay operation (CobLAMO): new technique for tongue reduction in sleep apnoea surgery.

BACKGROUND: Obstructive sleep apnoea is a common condition that is unfortunately associated with a high rate of patient non-compliance regarding device use. Newer surgical interventions have focused on procedures at the palate level, using variants of palatoplasty and transpalatal advancement. However, the extent of tongue reduction surgery required remains controversial. The authors propose an in-between variant that combines midline glossectomy resection (with minimal mucosal sacrifice) and lateral coblation tongue channelling. METHOD: Four patients underwent a coblation-assisted Lewis and MacKay operation, which is a new technique for tongue reduction. This involved a midline glossectomy combined with lateral coblation channelling of the tongue, alone or as part of major airway reconstruction. Demographic, polysomnographic and quality of life questionnaire data were collected prospectively and analysed. RESULTS AND CONCLUSION: No significant complications were noted in the four patients. (Results of the post-surgical outcomes are presented in another paper.) The coblation-assisted Lewis and MacKay operation reduced the potential complications of aggressive tongue surgery. The contours of the tongue were maintained, but significant reduction was still achieved.

Legislative solutions to unhealthy eating and obesity in Australia.

This paper discusses legislative interventions that have potential to address factors in the food environment that contribute to unhealthy eating patterns and increasing obesity rates in the Australian population, and political barriers to the implementation of these interventions. The paper devotes particular attention to legislative interventions to require disclosure of nutrition information about food and beverage products, which would help to inform consumer choices, and are, therefore, difficult to object to on personal responsibility or 'nanny state' grounds. It is suggested that these interventions seem to be gaining political acceptance in Australia, and may provide a starting point for incremental progress.

Leucocytoclastic and renal vasculitis in a patient with autoimmune pancreatitis: new associations.

Autoimmune pancreatitis (AIP) is an uncommon condition which comprises diffuse or discrete pancreatic enlargement and irregular pancreatic duct strictures of autoimmune origin leading to pain or obstructive jaundice associated with extra-pancreatic manifestations. It is characterized by an elevated IgG, especially IgG4, level. We illustrate the first described case of a patient with AIP in association with leucocytoclastic and renal vasculitis.

Brachiopod punctae: a complexity in shell biomineralisation.

Perforations ("punctae") are one of the most characteristic morphological shell features in calcite brachiopods. The significance of punctae is that they represent discontinuities in shell biomineralisation and thus add a level of complexity that must be accounted for in any model of brachiopod shell formation. A significant hindrance to understanding punctae growth and formation is the absence of sufficient information on volume, size and density. Here, we use synchrotron-radiation X-ray tomographic microscopy (SRXTM) to obtain three-dimensional information about punctae of five species of calcite brachiopods. X-ray tomography shows that punctae morphology is species-specific and reveals previously unknown levels of complexity for each species. This information is combined with previous data on morphology to discuss the function and growth of punctae. Overall the present study demonstrates the need to increase our understanding of discontinuities and the role of cell biology in the context of biomineralisation.

Diagnosis of solid pancreatic masses by endoscopic ultrasound-guided fine-needle aspiration.

BACKGROUND: Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) is increasingly being used in the staging algorithm for pancreatic carcinoma. This allows for a tissue diagnosis, which was previously difficult to obtain. The aim of this study is to assess the utility of EUS-FNA in establishing the diagnosis of solid pancreatic mass lesions in an Australian population. METHODS: A retrospective review of the EUS databases of St Vincent's Hospital Melbourne and Western Hospital, Melbourne from November 2002 to May 2006 was undertaken. The focus was on patients with a solid pancreatic mass who underwent EUS-FNA. Surgical pathology or long-term follow up was used to identify false-positive or false-negative results. RESULTS: EUS was undertaken to investigate a solid pancreatic or distal common bile duct mass lesion in 155 patients. Seventy-two of these underwent EUS-guided FNA. Mean age was 68 years. A positive tissue diagnosis of malignancy could be made in 55 (76%). Nine (13%) had benign histology, with 8 (11%) having inadequate tissue obtained from FNA. A later tissue diagnosis of carcinoma was made in eight of those with either benign or inadequate histology, although in all cases there were EUS features diagnostic of malignancy, with FNA limited by technical difficulties. The overall utility of EUS-FNA showed a sensitivity of 87%, specificity 100%, positive predictive value 100%, negative predictive value 52% and overall accuracy 89%. CONCLUSION: EUS-FNA gives a high return for histological diagnosis of solid pancreatic mass lesions and should be part of the standard management algorithm for pancreatic carcinoma.

Habitat use and dispersal of post-smolt sea trout Salmo trutta in a Scottish sea loch system.

Post-smolt anadromous brown trout Salmo trutta, sea trout, from two Scottish west coast rivers, the Balgy and Shieldaig, flowing into adjacent sea lochs were tracked simultaneously using arrays of moored acoustic receivers to determine dispersal patterns and loss rates. Fish tended to stay close to their natal rivers for the first 14 day after entering the sea, during which time about half the fish were lost to the study. Although initially the overall pattern of dispersal was similar for individual fish from both rivers, towards the end of the study the groups had converged into one of the loch basins. There were also pronounced individual differences in habitat use with all those fish detected for >42 days exhibiting different patterns of habitat use. Loss rates were similar between the two rivers despite differences in the range of air-breathing predators to which the fish were initially exposed. These findings suggest that any management of predators or other mortality agents should be targeted towards mouths of rivers during and immediately following smolt emigration.

Over-summering behaviour of Atlantic salmon Salmo salar returning to rivers in the Cromarty Firth, north-east Scotland.

In 2005, a high percentage (50%) of Atlantic salmon Salmo salar fitted with acoustic transmitters, which entered rivers in the Cromarty Firth area of north-east Scotland, dropped back to the estuary and ascended adjacent rivers after 33-80 days of freshwater residence. Fish residing in non-natal rivers generate mixed stock fisheries, and movements of fish between rivers could increase the risk of disease transmission between catchments.

Deciphering the distribution of organic components in brachiopod shells by confocal laser scanning microscopy.

Characterization of the nature and distribution of organic components is crucial to understand shell formation in marine invertebrates. Although several techniques can provide detailed information at high spatial resolution, few of them are non-destructive and informative in a larger structural context. We explore the use of confocal laser scanning microscopy (CLSM) to obtain a better understanding of the distribution of organic components in calcitic shells of brachiopods focusing on perforations (punctae) across the shell. Resulting intensities and patterns of fluorescence correspond well with the distribution of polysaccharides and proteins as reported in previous histological and biochemical studies. Confocal laser microscopy is, therefore, a useful tool to be combined with other techniques to improve our knowledge of biomineral structures in marine invertebrates.

The link between maltreatment and juvenile firesetting: correlates and underlying mechanisms.

OBJECTIVE: Despite the widely held belief that abuse is a risk factor for childhood firesetting, the role of maltreatment in firesetting is largely unexplored. This study reports on a sample of children and adolescents referred to a brief assessment and intervention program for juvenile firesetters. Firesetting histories of maltreated youth were compared to a group of firesetting youth with no maltreatment history. METHODS: Participants included 205 children and youth aged 4-17 years and their caregivers. Assessments were completed with a standardized protocol. Forty-eight percent of the sample had a history of maltreatment as reported by caregivers; 26% of the sample had experienced more than one type of maltreatment. RESULTS: When compared to the non-maltreated group, children with histories of maltreatment demonstrated more frequent fire involvement, more versatility regarding ignition sources and targets, and a greater likelihood of an immediate family stressor as a motive for firesetting (all p<.05). Maltreated children were more likely to become involved with fire out of anger (p=.001), and there was also a trend towards higher rates of recidivism (p=.07). Children's externalizing behavior partially mediated the influence of maltreatment on specific fire-related outcomes of children (OR=1.10; 95% CI=1.04-1.17; p=.001). CONCLUSIONS: Within a juvenile firesetting population, the presence of maltreatment is a risk factor for a more severe course of firesetting. The findings also suggest that the link between maltreatment and firesetting is operating partially through heightened emotional and behavioral difficulties. PRACTICE IMPLICATIONS: This study demonstrates that maltreatment is a risk factor that contributes to a more severe course of juvenile fire involvement, and that the link between maltreatment and firesetting operates largely through heightened behavioral and emotional difficulties. These findings highlight the need for mental health clinicians to (a) be aware that these two serious clinical issues frequently co-occur, (b) screen for fire-related behaviors and maltreatment during general assessments, and (c) consider maltreatment status when thinking about the risk of firesetting.

Development and validation of an improved HPLC method for the control of potentially counterfeit isometamidium products.

Isometamidium, a mixture of related substances of which 8-(3-m-amidinophenyl-2-triazeno)-3-amino-5-ethyl-6-phenylphenanthridinium chloride hydrochloride (M&B4180A) is the principal active component, is the only chemical agent available for prophylaxis of veterinary trypanosomiasis. A method for the simultaneous quantitation of the major constituents M&B4180A, 3-(3-m-amidinophenyl-2-triazeno)-8-amino-5-ethyl-6-phenylphenanthridinium chloride hydrochloride (M&B38897), 7-(m-amidinophenyldiazo)-3,8-diamino-5-ethyl-6-phenylphenanthridinium chloride hydrochloride (M&B4250) and 3,8-di(3-m-amidinophenyltriazeno)-5-ethyl-6-phenylphenanthridinium chloride dihydrochloride (M&B4596) is described. The related substances are resolved on a Gemini C18 column (150 mm x 4.6 mm, 5 microm) using a mobile phase composed of a mixture of acetonitrile and 50 mM ammonium formate buffer pH 2.8 (25:75 v/v) at a flow rate of 1 ml/min with UV detection at 320 nm. The method is compatible with electrospray ionisation mass spectrometry and provides a tool for the control of substandard and counterfeit commercial preparations of isometamidium.

The impact of a short course of study on the performance of radiographers when highlighting fractures on trauma radiographs: "The Red Dot System".

This study was set up to determine the effect of a short course of study on radiographers' ability to identify fractures in a trauma context (Red Dot system). The performance of 133 radiographers attending Red Dot courses delivered from April 1999 to September 2003 was evaluated prospectively using a selected sample of radiographs. Assessment of fracture identification occurred before, immediately after and 6 months after the course. The same film set was used and consisted of 30 axial and appendicular cases, 18 with fractures and 12 normal or normal variants. Following a test for normality of the data, a Wilcoxon Signed-Rank Test was selected and paired tests were done between each assessment for sensitivity and specificity. There were significant differences in sensitivity between all three assessments (p