Minimising the impact of errors in the interpretation of CT images for surveillance and evaluation of therapy in cancer

Radiological error is inevitable and usually multifactorial. Error can be secondary to radiologist-specific causes, including cognitive and perceptive errors or ambiguity of report, or system-related causes, including inadequate, misleading, or incorrect clinical information, poor imaging technique, excessive workload, and poor working conditions. In this paper, we discuss a systematic approach to reduce errors in oncological radiology reporting, thus reducing risk to the patient. Rather than attempt to discuss all types of error, we concentrate on the most important and commonly occurring errors that we have encountered over 20 years of practice, based on weekly discrepancy reviews of our practice and independent reviews of clinical and research imaging from other institutions. This review focuses on computed tomography (CT) reporting for staging, surveillance, and response assessment of cancer patients, but the messages apply to all imaging methods.

Reproductive performance in ewes fed varying levels of cut lucerne pasture around conception

Elevated intakes of protein and energy may increase embryo mortality, but it is not clear whether fresh lucerne (Medicago sativa) pasture poses a risk. A two-year pen study using oestrous synchronised and artificially inseminated Merino ewes (n=175 in 2013 and 215 in 2014) evaluated whether feeding freshly cut lucerne pasture (mean crude protein 19.7%, metabolisable energy 9.4MJ/kg DM) at maintenance or ad libitum during different periods around insemination altered reproductive performance in comparison with ewes fed a Control diet (mean crude protein 7.8%, metabolisable energy 9.0MJ/kg DM) of pelleted faba bean hulls and oat grain hulls at maintenance. The proportion of pregnant ewes carrying multiple fetuses was reduced (P=0.026) when ewes were fed lucerne ad libitum between days 0 and 17 after insemination compared with the Control diet (0.18 and 0.34, respectively), but not when ewes were fed lucerne ad libitum between days 0 and 7 after insemination (0.22). Reproductive performance, including the proportion of ewes pregnant and the proportion with multiple fetuses, was not different (P>0.05) when ewes were fed lucerne at maintenance between days 0 and 7 compared with the Control diet. While reproductive performance was similar when ewes were fed lucerne at maintenance between 0 and 17 days after artificial insemination compared with pellets at maintenance, fetal numbers per pregnant ewe were reduced by feeding lucerne ad libitum after insemination.

Utilization of a Preemptive, Multimodal Analgesic Regimen in Adult Ambulatory Septoplasty Patients: A Quality Improvement Project

This paper describes a quality improvement project designed to decrease postoperative pain, decrease post-operative nausea and vomiting (PONV), decrease time in the recovery room, and increase patient satisfaction in adult ambulatory septoplasty patients using a multimodal, preemptive analgesic regimen. The project was conducted in a community hospital setting with nine operating rooms, and a twenty one bed recovery room. Project participants included certified registered nurse anesthetists, anesthesiologists, operating room nurses, recovery room nurses, and otolaryngology surgeons. Following a period of departmental education, adult patients scheduled for outpatient septoplasty surgery received a preoperative regimen of medications that included gabapentin, celecoxib, and acetaminophen. Using a pre-post test design, (intervention group n = 17, non-intervention group n = 17) data was collected from patient and analyzed using SPSS version 18.0. The change in practice resulted in a significant decrease in pain scores in the recovery room and on discharge from the recovery room. In addition, patients who received the preemptive regimen also required significantly fewer opioid medications and were ready to be discharged from the recovery room in less time.

Adult post-mortem imaging in traumatic and cardiorespiratory death and its relation to clinical radiological imaging

The use of post-mortem imaging is expanding throughout the world with increasing use of advanced imaging techniques, such as contrast-enhanced CT and MRI. The questions asked of post-mortem imaging are complex and can be very different, for example for natural sudden death investigation will focus on the cause, whereas for trauma the cause of death is often clear, but injury patterns may be very revealing in investigating the background to the incident. Post-mortem imaging is different to clinical imaging regarding both the appearance of pathology and the information required, but there is much to learn from many years of clinical research in the use of these techniques. Furthermore, it is possible that post-mortem imaging research could be used not only for investigating the cause of death but also as a model to conduct clinically relevant research. This article reviews challenges to the development of post-mortem imaging for trauma, identification and cardiorespiratory death, and how they may be influenced by current clinical thinking and practice.

A new variable for SRS plan quality evaluation based on normal tissue sparing: the effect of prescription isodose levels

OBJECTIVE

A new dosimetric variable, dose-dropping speed (DDS), was proposed and used to evaluate normal tissue sparing among stereotactic radiosurgery (SRS) plans with different prescription isodose lines.

METHODS

40 plans were generated for 8 intracranial SRS cases, prescribing to isodose levels (IDLs) ranging from 50% to 90% in 10% increments. Whilst maintaining similar coverage and conformity, plans at different IDLs were evaluated in terms of normal tissue sparing using the proposed DDS. The DDS was defined as the greater decay coefficient in a double exponential decay fit of the dose drop-off outside the planning target volume (PTV), which models the steep portion of the drop-off. Provided that the prescription dose covers the whole PTV, a greater DDS indicates better normal tissue sparing.

RESULTS

Among all plans, the DDS was found to be the lowest for the prescription at 90% IDL and the highest for the prescription at 60% or 70%. The beam profile slope change in the penumbra and its field size dependence were explored and given as the physical basis of the findings.

CONCLUSION

A variable was proposed for SRS plan quality evaluation. Using this measure, prescriptions at 60% and 70% IDLs were found to provide best normal tissue sparing.

ADVANCES IN KNOWLEDGE

A new variable was proposed based on which normal tissue sparing was quantitatively evaluated, comparing different prescription IDLs in SRS.

Post-mortem computed tomography ventilation; simulating breath holding

Whilst the literature continues to report on advances in the use of post-mortem computed tomography (PMCT), particularly in relation to post-mortem angiography, there are few papers published that address the diagnostic problems related to post-mortem changes in the lungs and ventilation. We present a development of previous methods to achieve ventilated PMCT (VPMCT). We successfully introduced a supraglottic airway in 17/18 cases without causing overt damage, despite rigor mortis. Using a clinical portable ventilator, we delivered continuous positive airway pressure to mimic clinical breath-hold inspiratory scans. This caused significant lung expansion and a reduction in lung density and visible normal post-mortem changes. All thoracic pathology identified at autopsy, including pneumonia, was diagnosed on VPMCT in this small series. This technique provides a rapid form of VPMCT, which can be used in both permanent and temporary mortuaries, allowing for the post-mortem radiological comparison of pre-ventilation and post-ventilation images mimicking expiratory and inspiratory phases. We believe that it will enhance the diagnostic ability of PMCT in relation to lung pathology.

The multifaceted effects of omega-3 polyunsaturated Fatty acids on the hallmarks of cancer

Omega-3 polyunsaturated fatty acids, in particular eicosapentaenoic acid, and docosahexaenoic acid have been shown to have multiple beneficial antitumour actions that affect the essential alterations that dictate malignant growth. In this review we explore the putative mechanisms of action of omega-3 polyunsaturated fatty acid in cancer protection in relation to self-sufficiency in growth signals, insensitivity to growth-inhibitory signals, apoptosis, limitless replicative potential, sustained angiogenesis, and tissue invasion, and how these will hopefully translate from bench to bedside.