Picture archiving and communication systems lead to sustained improvements in reporting times and productivity: results of a 5-year audit

AIM

To evaluate the impact of picture archiving and communications systems (PACS) on reporting times and productivity in a large teaching hospital.

MATERIALS AND METHODS

Reporting time, defined as the time taken from patient registration to report availability, and productivity, defined as the number of reports issued per whole time equivalent (WTE) radiologist per month, were studied for 2 years pre- and 3 years post-PACS installation. Mean reporting time was calculated for plain radiographs and specialist radiology techniques [computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, and nuclear medicine]. Productivity, total department workload, and unreported film rates were also assessed. Pre- and post-PACS findings were compared.

RESULTS

Between 2002-2006 the number of radiological patient episodes increased by 30% from 11,531/month to 15,057/month. This was accompanied by a smaller increase in WTE reporting radiologists, from 32 to 37 (15%). Mean reporting times have improved substantially post-PACS, plain radiograph reporting time decreased by 26% (from 6.8 to 5 days; p=0.002) and specialty modalities by 24% (4.1 to 3.1 days; p<0.001). Radiologist productivity has increased by 18% (337 films to 407 films/WTE radiologist/month). Unreported films have decreased from 5 to 4% for plain radiographs and are steady for specialty modalities (< 1%). In most areas improvements have been sustained over a 3-year period.

CONCLUSION

Since the introduction of PACS, reporting times have decreased by 25% and the productivity improved by 18%. Sustained improvements are felt to reflect the efficiencies and cultural change that accompanied the introduction of PACS and digital dictation.

Focal renal infarction: an unusual cause of haematuria in a patient with sickle cell trait

A 29-year-old woman with sickle cell trait developed persistent haematuria. Intravenous urography, ultrasound, cystoscopy and selective renal angiography revealed focal renal infarction, but in the absence of papillary necrosis. There are no prior reports of focal renal infarction as a cause of haematuria in patients with sickle cell trait.

Postgraduate medical education homogenizes follow-up strategies after primary therapy for rectal cancer patients

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Background: The pedagogical literature suggests that continuing medical education (CME) is valuable, but objective evidence of its value has proved difficult to obtain. We investigated how self-reported surgeon age affects self-reported surveillance strategies utilized by expert surgeons following their own patients with rectal carcinoma after curative-intent treatment. We reasoned that, if there were no significant differences in strategies among surgeons of various ages, the homogenization would be ascribable to CME. Methods: We surveyed the 1,795 members of the American Society of Colon and Rectal Surgeons (ASCRS) using a questionnaire based on 4 succinct vignettes describing idealized patients treated with curative intent for TNM stages I-III rectal carcinoma. The surgeons were asked how often they use 14 specific surveillance modalities (office visit, 3 blood tests, 2 endoscopic procedures, 8 imaging studies) during years 1–5 after surgery. The motivation underlying their surveillance practices was analyzed using a menu of 12 possible factors and a Likert scale of 1 (lowest effect on motivation) to 10 (highest effect). We assessed the effect of surgeon age on follow-up intensity, controlling for TNM stage and year post- treatment, using repeated-measures ANOVA. One-way ANOVA was used to analyze the effect of surgeon age on motivation. Results: Of the 566 responses, 347 were considered evaluable. There were no significant differences among age strata (30–39, 40–49, 50–59, and = 60) in surveillance practices for any of the 4 vignettes. Only one motivating factor differed significantly among age strata: psychosocial support for the patient; surgeons = 60 were motivated more strongly (Likert score 6.9; p < .05) by this factor than younger surgeons (Likert score 5.8). Conclusions: CME contributes to homogenization of this important aspect of clinical management among ASCRS surgeons.

No significant financial relationships to disclose.

Diagnosis of angiomyolipoma using computed tomography—region of interest ≤−10HU or 4 adjacent pixels ≤−10HU are recommended as the diagnostic thresholds

AIM

To study and compare the diagnostic accuracy of region of interest (ROI) density measurement and pixel mapping [computed tomography (CT) density of individual pixels] for the diagnosis of renal angiomyolipoma (AML) using CT.

MATERIALS AND METHODS

A study group of histologically proven AMLs was compared with a control group of histologically proven renal cell cancers, normal renal parenchyma, and simple renal cysts. The mean tissue density (ROI circle) and a pixel density map were recorded. The diagnostic accuracy of various thresholds of ROI and pixel mapping values were compared using receiver operating characteristic curves.

RESULTS

Twenty-two AMLs, 16 renal cell carcinomas (RCCs), 30 simple cysts, and 30 sites of renal parenchyma were evaluated. The mean (+/-1 SD) density of the AMLs was significantly lower [-15.2(20.8) units] than the three control groups [+36.0(8.1) units, +5.4(3.4) units and +22.2(46.5) units for RCC, renal cyst and parenchyma respectively; p < 0.001 (analysis of variance)]. The sensitivities and specificities of the ROI diagnostic thresholds of < or =0 units, < or =-10 units and < or =-20 units were 77 and 97%, 73 and 100% and 50 and 100%, respectively. Using pixel mapping [diagnostic thresholds of either a line of 4 pixels < or =-10 units or a square of 4 pixels < or =-10 units] the sensitivity improves to 86% with a specificity of 97%.

CONCLUSION

Although a ROI threshold value of < or =-10 units has a very high specificity (100% in the present study) the sensitivity is modest at only 73%. Pixel mapping is more sensitive for recognizing small clusters of fat. In practice, both methods can be recommended for the analysis of suspected AMLs. ROI density measurement is convenient when analysing large areas of suspected fat and < or =-10 units should be used as the diagnostic threshold. When faced with small lucent areas or indeterminate values after ROI analysis, pixel mapping is recommended using a line of 4 pixels < or =-10 units or a square of 4 pixels < or =-10 units as the discriminating thresholds.

Current status of transrectal ultrasound-guided prostate biopsy in the diagnosis of prostate cancer

In contemporary practice, most prostate cancers are either invisible on ultrasound or indistinguishable from concurrent benign prostatic hyperplasia. Diagnosis therefore rests on prostate biopsy. Biopsies are not simply directed at ultrasonically visible lesions, as these would miss many cancers; rather the whole gland is sampled. The sampling itself is systematic, using patterns based on prostate zonal anatomy and the geographical distribution and frequency of cancer. This review explains the evolution of the prostate biopsy technique, from the classical sextant biopsy method to the more recent extended biopsy protocols (8, 10, 12, >12 and saturation biopsy protocols). Extended protocols are increasingly being used to improve diagnostic accuracy, especially in those patients who require repeat biopsy. This trend has been facilitated by the ongoing improvement in safety and acceptability of the procedure, particularly with the use of antibiotic prophylaxis and local anaesthesia. The technical details of these extended protocols are discussed, as are the current data regarding procedure-related morbidity and how this may be minimized.

Tuberose sclerosis complex: analysis of growth rates aids differentiation of renal cell carcinoma from atypical or minimal-fat-containing angiomyolipoma

AIM

To study the radiological characteristics of renal masses in individuals with tuberous sclerosis complex (TSC) using serial CT, and to examine how renal cell carcinoma (RCC) may be differentiated from indeterminate cysts or masses.

METHODS

This was a retrospective study of 12 cases of TSC in which dedicated renal CT followed after US had demonstrated cystic or sonographically unusual renal masses. The CT density of all masses was measured and the masses categorized as simple cysts, complex cysts, angiomyolipomas or indeterminate solid masses. Subjects were maintained on regular follow-up with repeat CT or MRI and interval renal US. Indeterminate masses that showed rapid growth were considered suspicious for renal cell carcinoma and biopsy or nephrectomy followed.

RESULTS

Comparative data were available for a median of 4 years. In each case the renal masses were multiple and bilateral; mean mass diameter was 3.6 cm. Among a total of 206 masses, 18 were simple cysts and 3 were complex cysts. Of the complex cysts, 1 proved to be an angiomyolipoma on histology and the other 2 showed no growth. Of the solid masses, 133 were typical angiomyolipomas (AMLs) and 52 were indeterminate. On follow-up, only 3 indeterminate masses showed rapid growth (>0.5 cm/year), of which only 1 proved to be an RCC on biopsy. The other 2 were minimal-fat AMLs, and the remainder of the masses showed no or slow growth.

CONCLUSION

Many renal masses associated with TSC are radiologically indeterminate. A growth threshold of >0.5 cm/year identified the only RCC in this study (0.5% of all masses). Yearly radiological follow-up of indeterminate renal masses is recommended for individuals with TSC.

Delivering cognitive therapy to people with psychosis in a community mental health setting: an effectiveness study

OBJECTIVE

Cognitive therapy (CT) has been shown to be an efficacious treatment for persistent psychotic symptoms. However, there is some debate regarding whether this is transportable to real life clinical settings. This study aimed to evaluate the effectiveness of CT for psychosis in a community mental health team (CMHT) setting.

METHOD

Patients referred for CT for psychosis were naturalistically allocated (determined by the availability of a therapist) to CT or waiting-list (WL)/treatment-as-usual (TAU). Outcome assessments were performed at WL, pre-CT, post-CT and 1-year follow-up. Data from 59 patients were analysed.

RESULTS

Random effects regression analyses showed there was a significant improvement, attributable to CT, on most outcome measures, and that many of the symptomatic improvements were maintained at follow-up. Wilcoxon signed ranks tests indicated that there was a significant reduction in psychiatric hospital use following CT.

CONCLUSION

These results confirm that CT is an effective treatment for psychosis that is generalizable to a community setting.

Major complications after percutaneous nephrostomy-lessons from a department audit

AIM

To audit the performance of our percutaneous nephrostomy service by comparing the major complication rate with the standards recommended by the Society of Cardiovascular and Interventional Radiology and the American College of Radiology: major haemorrhage in <4%, and septic shock in <4%. Secondary aims were to identify common sources of errors for quality improvement measures.

METHODS

Major complications sustained between January 1997-December 2002 were identified. All cases had been carried out by the interventional radiology service of a large teaching hospital with the assistance of a nurse and radiographer, under fluoroscopic and ultrasound guidance using a Seldinger technique. Existing department protocols specified pre-procedure antibiotics for suspected infected cases and normal coagulation studies. From records and review of case notes pertinent clinical/procedural details and eventual outcome were assessed. The following were particularly noted: adherence to protocols, clinical status at time of procedure, delay in referral, complication sustained, signs of infection or coagulopathy, timing of procedure (in versus out of hours), level of operator and technical faults.

RESULTS

Ten of 318 (3.1%) cases sustained a major complication: five had sepsis alone, two haemorrhage (one with sepsis as well) and three patients had a major pelvic injury (one with sepsis as well). Thus the major sepsis and haemorrhage rates were 2.2 and 0.6%, and were within the recommended threshold limits but proportionately more complications occurred out of hours: six of 105 (5.7%) versus four of 312 (1.8%; p=0.087). Sepsis was the most serious complication and may have contributed to the death of two patients. On individual case analysis, failed instrumentation with delay to definitive renal drainage was a common factor with sepsis; but the following were contributory factors in one or more cases: omitted antibiotics (in three of 10; two became septic), technical factors in four cases [medial renal puncture (n=1), damage due to fascial dilator (n=1) or peelaway sheath (n=2)] and delay in diagnosis/therapy (of 1-8 days, in six of 10 cases of whom four out of six became septic). One pelvic injury required surgical correction (contributory factor-faulty use of peelaway sheath). Patients with haemorrhage settled with prolonged tube drainage alone.

CONCLUSION

An adequately staffed percutaneous nephrostomy service can perform within published clinical standards. Best practice factors identified were: attention to agreed protocols and algorithms, pre-procedure antibiotics, careful renal puncture and care with use of dilators/peelaway sheaths, but the paramount finding was that sepsis was the most serious complication, contributing to death (two of 10 in this study) or a significant increase in the level of care required. The risk is greatest after failed instrumentation (retrograde ureteral stent or percutaneous nephrostomy insertion) and particularly if there is a further delay before establishment of renal drainage. A close working relationship between interventional radiologists and urologists is crucial.