Audit of radiology communication systems for critical, urgent, and unexpected significant findings.

AIM: To determine the compliance of UK radiology departments and trusts/healthcare organisations with National Patient Safety Agency and Royal College of Radiologist's published guidance on the communication of critical, urgent, and unexpected significant radiological findings. MATERIALS AND METHODS: A questionnaire was sent to all UK radiology department audit leads asking for details of their current departmental policy regarding the issuing of alerts; use of automated electronic alert systems; methods of notification of clinicians of critical, urgent, and unexpected significant radiological findings; monitoring of results receipt; and examples of the more common types of serious pathologies for which alerts were issued. RESULTS: One hundred and fifty-four of 229 departments (67%) responded. Eighty-eight percent indicated that they had a policy in place for the communication of critical, urgent, and unexpected significant radiological findings. Only 34% had an automated electronic alert system in place and only 17% had a facility for service-wide electronic tracking of radiology reports. In only 11 departments with an electronic acknowledgement system was someone regularly monitoring the read rate. CONCLUSION: There is wide variation in practice across the UK with regard to the communication and monitoring of reports with many departments/trusts not fully compliant with published UK guidance. Despite the widespread use of electronic systems, only a minority of departments/trusts have and use electronic tracking to ensure reports have been read and acted upon.

Staging cancer of the uterus: a national audit of MRI accuracy.

AIM: To report the results of a nationwide audit of the accuracy of magnetic resonance imaging (MRI) staging in uterine body cancer when staging myometrial invasion, cervical extension, and lymph node spread. MATERIALS AND METHODS: All UK radiology departments were invited to participate using a web-based tool for submitting anonymized data for a 12 month period. MRI staging was compared with histopathological staging using target accuracies of 85, 86, and 70% respectively. RESULTS: Of the departments performing MRI staging of endometrial cancer, 37/87 departments contributed. Targets for MRI staging were achieved for two of the three standards nationally with diagnostic accuracy for depth of myometrial invasion, 82%; for cervical extension, 90%; and for pelvic nodal involvement, 94%; the latter two being well above the targets. However, only 13/37 (35%) of individual centres met the target for assessing depth of myometrial invasion, 31/36 (86%) for cervical extension and 31/34 (91%) for pelvic nodal involvement. Statistical analysis demonstrated no significant difference for the use of intravenous contrast medium, but did show some evidence of increasing accuracy in assessment of depth of myometrial invasion with increasing caseload. CONCLUSION: Overall performance in the UK was good, with only the target for assessment of depth of myometrial invasion not being met. Inter-departmental variation was seen. One factor that may improve performance in assessment of myometrial invasion is a higher caseload. No other clear factor to improve performance were identified.

Is film-reading performance related to the number of films read? The Scottish experience.

AIM: To determine whether a drop-off in reading performance occurred with high-volume caseloads in Scotland. MATERIALS AND METHODS: The reading performance figures for all eligible film readers over a 36 month period were reviewed to determine the number of films read as first and second reader, the recall rates, the cancers detected, and the cancers missed by each reader. RESULTS: During the 3 year period, screen-reading volumes varied from 7009 to 53,598. There were six low-volume readers, 16 medium-volume readers, and 15 high-volume readers (>25,000 cases in the 3 year period). No statistically significant differences were found in the first read specificity or the recall rate between the three groups. CONCLUSION: The present results do not support the suggestion that reading performance drops off with a three year case volume of greater than 25,000 reads.

A somatic cell genetic method for identification of untargeted mutations in the glucocorticoid receptor that cause hormone binding deficiencies.

Mouse T lymphoma cell line W7MG1, which is killed by physiological concentrations of glucocorticoid agonists, was used as a convenient genetic system for isolating sublines containing mutant glucocorticoid receptors (GR) with hormone-binding deficiencies. Partially hormone-resistant cell clones were derived from chemically mutagenized cell populations by selecting for growth in moderate concentrations of dexamethasone (Dex) and then screening for failure to grow in high Dex concentrations. Such clones are likely to have mutant GR. In GR cDNA clones from the partially resistant cell sublines, three different functionally significant mutations in the hormone-binding domain were identified: Leu-569 changed to Phe (L569F), Leu-670 to Phe (L670F), and Met-672 to Ile (M672I). Dose-response analyses with Dex and affinity labeling studies with dexamethasone 21-mesylate in transiently transfected cells indicated that all three mutant GR species had hormone-binding deficiencies. However, at saturating Dex concentrations the mutant and wild type GR activated a hormone-inducible reporter gene to the same extent; thus, these three mutations did not affect the ability of GR to activate transcription of the reporter gene after hormone was bound. In dose-response curves conducted with several glucocorticoid agonists, mutations L670F and M672I caused no change in ligand-binding specificities, while mutation L569F caused a modest change in specificity. Quantitative hormone-binding studies conducted with mutant GR synthesized in cell-free reactions showed that mutant GR species L569F and M672I had reduced Dex-binding affinities both at 0 C and at 22 C in the presence of molybdate. In contrast, for the L670F mutant, which exhibited the severest deficiency in vivo, the hormone-binding deficiency in the cell-free system was evident only at 26-37 C and primarily in the absence of molybdate. We propose that the L670F GR is an activation-labile type of mutant, which binds hormone normally in the presence of heat shock protein 90 but loses hormone rapidly after dissociation from heat shock protein 90. These three mutations define two new subregions of the GR polypeptide that are important for hormone binding.

Computed tomography of the chest in T1NoMo non-small cell bronchial carcinoma.

There has been controversy within the recent literature as to the value of computed tomography (CT) of the chest in patients with T1NoMo non-small cell bronchial carcinoma, as staged by plain radiography and bronchoscopy. This paper reports on 63 such patients, nine (14.2%) of whom were shown correctly by CT of the chest to have metastatic spread which rendered them inoperable. Of these nine, four had stage N3 mediastinal disease; the other five had metastatic disease, either pulmonary or bony. Patients with lesions less than 2 cm in diameter were also looked at separately: 4/20 had inoperable disease on CT of the chest. In both groups the detection rate of inoperability by CT of the chest justifies its use pre-operatively in all T1NoMo non-small cell bronchial carcinomas, in terms of clinical morbidity, mortality and cost.

The diagnostic acceptability of low-bandwidth transmission for tele-ultrasound.

Ultrasound recordings were made of 100 consecutive patients attending for obstetric examination in Peterhead and 100 patients attending for non-obstetric examination in Aberdeen. Two identical video-conferencing machines were used to transmit and receive the original ultrasound images at data rates of 384 kbit/s and 128 kbit/s, thus producing a total of three tapes for each case. Four experienced observers, who were blinded to the transmission bandwidth, each viewed 300 examinations and decided whether the images were acceptable or not for diagnosis. Almost 100% of the obstetric ultrasound images on the original recordings were considered diagnostically acceptable, compared with 93% of the 384 kbit/s transmissions and 44% of the 128 kbit/s transmissions. Similarly, 99% of the non-obstetric ultrasound images were considered acceptable, compared with 87% of the 384 kbit/s transmissions and 21% of the 128 kbit/s transmissions. For the obstetric ultrasound images the intra-observer diagnostic agreement was 93% (kappa = 0.89) between the original and the 384 kbit/s transmissions, and 78% (kappa = 0.63) between the original and the 128 kbit/s transmissions. For the non-obstetric ultrasound images the respective intra-observer diagnostic agreements were 77% (kappa = 0.62) and 78% (kappa = 0.63). The quality of dynamic ultrasound images transmitted at 384 kbit/s was diagnostically acceptable, but was unsatisfactory at 128 kbit/s.

Evolving community health information networks.

A community health information network (CHIN) provides technology-based information services to help maintain optimal health for all the residents of a community. Defining features of a CHIN are that its services are available to all stakeholders and that competitors collaborate to share information. The initial impetus for a CHIN is usually to facilitate paying for health care or to share clinical records. Complex legal, organizational, funding, and control issues confront CHIN initiators, and reliable models do not exist today. During development, issues of program focus and technology selection arise, followed by concerns about information privacy and the CHIN's role in quality of care. Once basic capabilities are implemented, a mature CHIN can offer extensive cost-recovering health-related services to providers, related agencies, and consumers. Developments are underway that eventually will allow a CHIN to support a fully integrated longitudinal health record. A national network of mature CHINs would offer health care professionals further collaborative possibilities that could change the shape of future health care.

Induced synthesis of oestrogens by glia in the songbird brain.

Studies on birds have long provided landmarks and touchstones in the fields of neuroendocrinology, immunology and neuroplasticity. The passerine brain is an excellent model for studying the actions of hormones, including steroids, on a diversity of behavioural endpoints. Oestrogens, for example, have profound effects on avian neuroanatomy and neurophysiology throughout life and, importantly, are synthesised at high levels within neurones of the songbird brain. More recently, aromatisation in another set of neural cells has been identified. Specifically, aromatase expression is induced in astrocytes and radial glia following disruption of the neuropil by multiple forms of perturbation. The avian brain, therefore, can be provided with high levels of oestrogens constitutively or via induction, by aromatisation in neurones and glia, respectively. In this review, we begin with the initial discovery of aromatisation by non-neuronal cells and discuss the mechanisms underlying the induction of aromatase expression in glial cells. We then focus on the emerging interactions between the neuroendocrine and neuroimmune systems with respect to brain injury. Next, we briefly review the extensive literature on the influence of glial aromatisation on neuroplasticity, and end with some recent data on sex differences in the induction of glial aromatase in the zebra finch. Throughout this review, we consider the unanswered questions and future studies that may emerge from these findings.

The effect of voice recognition software on comparative error rates in radiology reports.

This study sought to confirm whether reports generated in a department of radiology contain more errors if generated using voice recognition (VR) software than if traditional dictation-transcription (DT) is used. All radiology reports generated over a 1-week period in a British teaching hospital were assessed. The presence of errors and their impact on the report were assessed. Data collected included the type of report, site of dictation, the experience of the operator, and whether English was the first language of the operator. 1887 reports were reviewed. 1160 (61.5%) were dictated using VR and 727 reports (38.5%) were generated by DT. 71 errors (3.8% of all reports) were identified. 56 errors were made using VR (4.8% of VR reports), whereas 15 errors were identified in DT reports (2.1% of transcribed reports). The difference in report errors between these two dictation methods was statistically significant (p = 0.002). Of the 71 reports containing errors, 37 (52.1%) had errors that affecting understanding. Other factors were also identified that significantly increased the likelihood of errors in a VR-generated report, such as working in a busy inpatient environment (p<0.001) and having a language other than English as a first language (p = 0.034). Operator grade was not significantly associated with increased errors. In conclusion, using VR significantly increases the number of reports containing errors. Errors using VR are significantly more likely to occur in noisy areas with a high workload and are more likely to be made by radiologists for whom English is not their first language.

Antenatal renal pelvic dilatation; the long-term outlook.

AIM: The purpose of this study was twofold: first to provide data for more accurate counselling of parents with regard to prognosis, and second, to ensure that by following a policy of selective micturating cystourethography (MCUG), significant pathology is not missed, in particular vesicoureteric reflux (VUR). (MCUG is only undertaken if the renal pelvic diameter (RPD) is >/= 10 mm or if there is calyceal or ureteric dilatation.) MATERIAL AND METHODS: Data were collected prospectively over a 6-year period. Pre and postnatal imaging findings were collected for all infants in whom a RPD of >/= 5 mm was identified at any gestational age. The imaging records of all patients were reviewed in 2005 for evidence of pathology detected after re-presentation with symptoms. The age range at review varied from 2-8 years. RESULTS: Complete data were available in 527 infants. The risk of significant pathology was related to the degree of antenatal renal pelvic dilatation varying from 6% for a RPD of 5 mm at 20 weeks gestation to 38% at 10 mm. At 28-33 weeks gestation the risk varied from 5% at 5mm to 15% at 10 mm. Subsequent imaging record review revealed only one patient with grade II VUR in the study population not picked up by our selective MCUG policy. CONCLUSION: The present study provides prognostic information that can be given to parents both antenatally and postnatally, and reassurance that a selective MCUG policy is appropriate.

CHINs in the context of an evolving health care system.

Community Health Information Network (CHIN) developments have slowed, due to the chaotic change in the health care system and stakeholders' attendant short-sighted focus. CHINs are a long-term investment that is necessary for the health care system's evolution to maturity. Several arenas of essential CHIN activity are given that would be characteristic of a mature, goal-directed health care system Lack of enterprise-wide computer-based patient record systems is a major barrier. Even in the short term, however, trends and incentives exist that are likely to push stakeholders toward CHIN development. Some of these trends include changes in organizational structure and political pressures. Practical incentives include the need for stakeholder cooperation to achieve healthy communities, the prospects for telemedicine, and the demand for greater quality assurance.

Urinary lipid bodies in polycystic kidney disease.

Urinary doubly refractile lipid bodies (oval fat bodies) are observed most frequently in patients with heavy proteinuria resulting from glomerular disease. We observed doubly refractile lipid bodies (DRLB) in the urine sediment of 60% of 35 patients with autosomal dominant polycystic kidney disease (ADPKD). All patients had clinical courses typical of ADPKD, and none exhibited the features of a second, unrelated renal disease. DRLB in the urine were correlated with a urine dipstick protein reading exceeding trace. Age, sex, BP, and serum creatinine concentration were not associated with the presence of DRLB in the urine. Examination of cyst fluid obtained from kidneys of six ADPKD patients revealed DRLB in 80% of cyst fluid samples that contained degraded blood (so-called chocolate cysts). The DRLB in cyst fluid were morphologically indistinguishable from those observed in urine, and DRLB from both sources were stained with oil red O. We conclude that urinary DRLB are a clinical feature of ADPKD.

Filtration by rat glomeruli after expansion of extracellular fluid volume.

We studied the filtration characteristics of glomeruli isolated from the superficial and deep renal cortex of Munich-Wistar rats (180 to 300 gm) to determine whether the ultrafiltration coefficient (Kf) or hydraulic conductivity (Lp) of the glomerular capillary is altered during expansion of extracellular fluid volume with isotonic protein-free (SAL) or hyperoncotic (ALB) solutions. SAL rats were given an initial infusion of 1% dextrose in lactated Ringer's solution (0.1 ml/gm body weight) followed by a maintenance infusion for 18 to 20 hours. ALB rats were given hyperoncotic bovine serum albumin (0.01 gm/gm body weight) intravenously 2 hours before sacrifice. At sacrifice, urine flow rate and fractional excretion of sodium were increased and plasma renin activity decreased in both SAL and ALB rats. Expansion of intravascular volume was evidenced by a decrease in the hematocrit of ALB but not of SAL rats; plasma protein concentration was increased in ALB and unchanged in SAL rats. Kf and Lp were estimated during in vitro filtration. Because SAL rats were significantly larger than ALB rats, results were compared with those in separate size-matched controls. Kf of superficial glomeruli of large control and SAL rats did not differ (3.7 +/- 0.4 and 3.5 +/- 0.4 nl/min/mm Hg, respectively). Lp, of the same glomeruli, calculated as the quotient of Kf and estimated filtering area (LpD), were also comparable (1.9 +/- 0.2 and 1.8 +/- 0.2 microliter/min/mm Hg/cm2). Kf of superficial glomeruli of ALB rats was significantly greater than Kf of size-matched control rats (3.7 +/- 0.3 vs. 2.9 +/- 0.1 nl/min/mm Hg, P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Intraperitoneal fluid collections following liver transplantation in a paediatric population.

Reduced-size liver transplant techniques are now widely used in paediatric liver transplantation programmes. An argument against their use is the potential for an increased incidence of post-operative fluid collections arising from the cut surface of the liver. The distribution and management of fluid collections after 70 paediatric liver transplants (18 whole and 52 reduced), performed over a 3 year period is reported. Fluid collections occurred in seven of the whole liver transplant (WLT) group and in 23 of the reduced-size liver transplant (RLT) group. The incidence of fluid collections in the two groups was therefore similar (39% and 44%). Intervention was required in 20 collections: in the RLT group, seven of these were due to biliary anastomosis leaks or bowel perforation, the incidence of the remaining collections requiring intervention was similar in the two groups. In conclusion the overall incidence of fluid collections was not increased by the use of reduced-size liver transplants, and the increased rate of intervention in the RLT group was not related to the cut surface.

Temporomandibular joint MRI: a 2-D gradient-echo technique.

Magnetic resonance imaging (MRI) of the temporomandibular joint (TMJ) has been most commonly performed using spin-echo sequences. Gradient-echo sequences have previously been investigated in the context of 3-D and 'dynamic' (pseudo-kinematic) imaging. We have used gradient-echo to improve image quality in static studies with rapid acquisition, high spatial resolution (512 x 512 matrix) and excellent contrast resolution. Using pragmatic methods and a non-randomized study group we have demonstrated a definite advantage to image quality, and thus diagnostic confidence, from the use of a gradient-echo high spatial resolution sequence incorporating split acquisition open mouth views.

Incident round cancers: what lessons can we learn?

At the time of implementation of the National Health Service Breast Screening Programme a range of targets were set, and have since been updated. This study looks at a subset of cancers detected by screening - the incident round cancers - which are not currently identified and addressed by the targets. In our first incident round we screened 24838 women and detected 112 breast cancers in 111 women. On the basis of a two-stage retrospective evaluation of the prevalent round mammograms in these 111 women, we classified the prevalent mammograms as false negative 21 (19%), minimal signs 32 (28%) and new tumours 59 (53%). Analysis of the radiographic features revealed a disproportionate number with parenchymal deformity (21%) and asymmetry (17%) among the missed tumours when compared to all tumours detected by our screening programme (12% and < 1%, respectively). Identification and quantification of these incidence detected missed cancers could be incorporated into the Quality Assurance Data Set, and used as another performance indicator. Reviewing the mammograms proved a valuable teaching exercise and has allowed us to develop a test set of challenging mammograms.

The financial abuse of mentally incompetent older adults: a canadian study.

ABSTRACT This article reports the results of a pilot study on the financial abuse of mentally incompetent seniors. The objectives of the study were to: (1) establish the incidence of suspected financial abuse among the clientele of the Office of Public Trustee, Province of Manitoba, (2) identify the characteristics of mentally incompetent older adults most at risk, and (3) identify indicators of financial abuse. Approximately 20% of the cases opened in a one year period were under suspicion of abuse. Findings were consistent with those of other research projects on elder abuse, in general, showing an over-representation of women over the age of eighty as victims of financial abuse. Unpaid personal care home bills when money should have been available was the most common indicator. In addition to providing a list of indicators of financial abuse that are of potential use to professionals, devising prevention programs, practical implications for service providers are presented.

A comparison of Fleet Phospho-soda with Picolax in the preparation of the colon for double contrast barium enema.

This study was performed to compare the patient acceptability and the efficacy of two different agents for bowel preparation prior to double contrast barium enema. One-hundred and ninety-four outpatients were randomized to have either two sachets of Picolax or two bottles of Fleet Phospho-soda and restricted to clear fluids on the day prior to their examination. Patients answered a short questionnaire before their enema. The decubitus films were assessed for faecal residue and bowel coating by three observers blinded to the type of preparation used. There was no significant difference in faecal residue nor in the bowel coating between the preparations. However patients found Picolax significantly easier to take, being better tasting and provoking less nausea and vomiting than Fleet Phospho-soda.

Dietary protein and glomerular response to subtotal nephrectomy in the rat.

Renal tubules and glomeruli undergo hypertrophy after partial renal ablation. Glomerular and vascular scarring and progressive renal insufficiency may later occur. In the present studies, we have documented the filtration characteristics of glomeruli isolated from rats that had undergone subtotal nephrectomy and been fed a normal protein (NP) diet (24 gm protein per 100 gm chow) or a protein-restricted (PR) diet (6 gm protein per 100 gm chow) and compared these glomeruli to those of sham-operated (SHAM) rats maintained on a normal diet. Body weight of SHAM rats increased by 30% during the 28 weeks of the study. Weight of NP rats did not change significantly, and weight of PR rats decreased by about 25%. Seven weeks after surgery, the glomeruli of NP rats were significantly larger and the ultrafiltration coefficients (Kf) were higher than those of SHAM rats; glomeruli of PR rats were of normal size but also had increased Kf. Twenty-eight weeks after surgery, the glomeruli of rats in each group were larger than at 7 weeks. Kf was no longer elevated in NP rats. Glomerular capillary hydraulic conductivity (Lp) was equal in all groups at 8 days but was increased at 7 weeks and decreased 28 weeks after surgery in NP rats. We hypothesize that glomerular hypertrophy occurs in response to renal ablation and that subsequent changes in the capillary wall lead to diminished Lp. Protein restriction in this model prevents both glomerular hypertrophy and a decrease in Lp.