Barriers to not informing patients about radiation in connection with radiological examinations: Radiographers' opinion

INTRODUCTION

In some instances, little knowledge regarding radiological examinations is provided to patients. The purpose was to investigate whether radiographers inform patients about radiation, and if not, the reasons for it.

METHODS

A questionnaire was sent to radiographers working in the public sector in Northern Finland. Radiographers were asked whether they had informed patients about the radiation dose and risks during the last year. If information was not provided, the reasons for it were investigated using multiple-answer type multiple-choice questions with the option for free text responses. The results were compared between a University Hospital and other departments and between different lengths of work experience. Altogether 174/272 (64%) radiographers responded to the questionnaire; 50% were from the University Hospital and 50% from other departments.

RESULTS

Altogether 103/174 (59%) respondents did not inform patients about the radiation dose and 93/174 (53%) did not inform them about the associated risks. Regarding a passive approach to dose information, respondents thought that the referrer had already informed the patient (49/103, 48%), information was not needed (51/103, 50%), or it might cause unnecessary fear (47/103, 46%). Reasons for a passive approach to risk information were similar (66/93, 71%; 33/93, 36%; 47/93, 51%, respectively). Regarding the results, there were no differences between the institutions or work experience levels. According to the open question, some radiographers expected patients to ask questions before informing them. Lack of time was rarely mentioned as a reason.

CONCLUSION

The main reasons for inadequate information were ignorance regarding responsibilities, assumption that information is not needed, and concern about causing unnecessary fear.

IMPLICATIONS FOR PRACTICE

Education, guidelines specifying responsibilities and contents for information, and easy-access digital educational material for public and professionals are needed.

Imaging and estimation of the prognostic features of primary sclerosing cholangitis by ultrasonography and MR cholangiography

Purpose: To evaluate the ability of US and MR cholangiography (MRC) to detect bile duct changes and prognostic signs of primary sclerosing cholangitis (PSC) seen at endoscopic retrograde cholangiography (ERC).

Material and Methods: In a prospective study, 9 patients with PSC underwent US, MRC, MR imaging and ERC of the bile ducts and the liver. Eight age- and sex-matched control patients were examined with MRC, MR imaging and ERC. A segmental comparison was performed to assess the ability of MRC-MR and US to reveal the accurate ductal involvement in different segments of the biliary tree and the specific criteria of poor prognostic outcome in PSC. The ability of MRC-MR to detect the presence of PSC in different patients was analysed blindly.

Results: MRC-MR depicted changes of PSC correctly in 9 patients (radiologist 1) and in 8 patients with 1 false-positive finding (radiologist 2) in the blinded analysis. In the segmental comparison, MRC missed especially bile duct dilatations. MRC was too pessimistic in the evaluation of the outcome. US detected features suggestive of PSC in 8 patients (radiologist 3). US was unable to show the predictors of poor outcome.

Conclusion: MRC and US seem to be useful in the detection of PSC. US is unable and MRC is too pessimistic to estimate the outcome of PSC.

Justification of CT examinations in young adults and children can be improved by education, guideline implementation and increased MRI capacity

OBJECTIVE

To determine whether the justification of CT examinations performed on young patients can be improved by various interventions and whether these have an effect on the total number of CTs performed.

METHODS

Specific interventions-education, guideline implementation and increased MRI capacity-were introduced at the Oulu University Hospital, Oulu, Finland, following a previous study demonstrating unjustified use of CT examination in young patients. In the present study, the justification of 177 CT examinations of the lumbar and cervical spine, head, abdomen, nasal sinuses and trauma performed on patients aged under 35 years in 2009 was analysed retrospectively by looking at requests and corresponding patient files. The indications of the examinations were compared with the referral guidelines recommended by the European Commission. Results from our previously published similar study carried out before the interventions were used as a reference.

RESULTS

The proportion of justified CT examinations increased from 71% (141/200) in 2005 to 87% (154/177) in 2009 (p<0.001), and in the lumbar spine group from 23% (7/30) to 81% (22/27) (p<0.001). In the case of most of the unjustified examinations, MRI could have been performed instead. The total number of CT examinations carried out on young patients decreased by 7% (p=0.012) and in the lumbar spine group by 79% (p<0.001).

CONCLUSION

The implemented interventions decreased the number of CT examinations performed on young patients, and the justification of the examinations improved significantly.

ADVANCES IN KNOWLEDGE

This study demonstrates that it is possible to reduce the number of various CT examinations and to improve their justification in young patients by regular education, guideline implementation and increased MRI capacity.

Diagnostic imaging of carcinomas of the gallbladder and the bile ducts

Early diagnosis and accurate staging of carcinomas of the gallbladder and the bile ducts are helpful in improving the prognosis. Ultrasonography (US), a useful initial modality when exploring the background of jaundice or non-specific gastrointestinal complaints, sensitively reveals bile duct obstruction in particular. In unclear cases, or if US suggests a resectable biliary malignancy, computed tomography (CT), magnetic resonance imaging (MRI) with magnetic resonance cholangiography (MRC) and / or traditional cholangiography often provide additional information, and imaging-guided fine-needle biopsy or an endoscopic brush sample may verify the malignant nature of the tumor. Complementary modalities are usually needed for accurate staging, and traditional cholangiography is often performed for therapeutic purposes as well. Comparative studies of MRI with MRC and multidetector CT in biliary cancers would be welcome.

Patency and complications of percutaneously inserted metallic stents in malignant biliary obstruction

PURPOSE

The aim of this study was to analyze the patency of percutaneously inserted metallic stents in malignant biliary obstruction and to evaluate all the complications associated with the stents and the reinterventions needed.

MATERIALS AND METHODS

Thirty-nine patients with 42 malignant strictures were treated percutaneously with 55 metallic self-expandable stents. Forty-eight were Wallstents and seven were Memotherm stents. Twenty-five strictures were hilar, 16 were in the common bile duct, and one was in the hepaticojejunal anastomosis. The patients were followed until death and the mean follow-up was 6.4 months.

RESULTS

Stent insertion was successful in 97% of the patients. Thirty percent had early complications (<30 days), and as many as 66% had late complications, including stent occlusions, which were seen in 10 patients. The patency rates of patients with cholangio-carcinoma were significantly lower than those of the patients with other diagnoses. There was also a tendency toward obstruction with less dilation of the stents, Y, T or tandem-style stent placement, an increasing number of stents, longer strictures, and hilar strictures. Thirty-one percent of the patients alive after the first 30 days had late reinterventions.

CONCLUSIONS

Although metallic stents offer an alternative in the palliation of malignant bile duct obstruction, there seem to be numerous early and late complications.

Radiological findings in biliary fistula and gallstone ileus

PURPOSE

Biliary fistula and gallstone ileus are rarely found. The diagnosis is difficult and may be delayed until operation. We reviewed the radiological findings in a retrospective material.

MATERIAL AND METHODS

The cases of 16 patients treated for biliary fistula were analyzed with respect to findings at imaging. Ten patients had a spontaneous fistula. Nine of them had an internal bilioduodenal fistula and one had an external fistula with stones passing through a subcutaneous abscess. Five patients also had gallstone ileus and one patient a rare gastric outlet obstruction caused by a gallstone (Bouveret's syndrome). Six patients had an iatrogenic fistula. One of them had internal bile ascites and 5 an external fistula, one of which was a biliocystic fistula resulting from attempted hepatic cyst sclerotherapy.

RESULTS

Various imaging modalities were used and there was often a delay in the diagnosis. Imaging did not show the fistula itself in any of the spontaneous cases. However, a nonvisualized or shrunken gallbladder seen at US often coexisted in these cases. CT yielded the diagnosis in one case of gallstone ileus, and a Gastrografin meal yielded it in the case of Bouveret's syndrome. Fistulography and cholangiography provided a correct diagnosis of fistula in all cases of iatrogenic biliocutaneous fistulas.

CONCLUSION

Patients with biliary fistula usually undergo examinations with nonspecific results. The imaging findings could be more specific if the possibility of this diagnosis were remembered.

Radiological findings in biliary fistula and gallstone ileus

PURPOSE

Biliary fistula and gallstone ileus are rarely found. The diagnosis is difficult and may be delayed until operation. We reviewed the radiological findings in a retrospective material.

MATERIAL AND METHODS

The cases of 16 patients treated for biliary fistula were analyzed with respect to findings at imaging. Ten patients had a spontaneous fistula. Nine of them had an internal bilioduodenal fistula and one had an external fistula with stones passing through a subcutaneous abscess. Five patients also had gallstone ileus and one patient a rare gastric outlet obstruction caused by a gallstone (Bouveret's syndrome). Six patients had an iatrogenic fistula. One of them had internal bile ascites and 5 an external fistula, one of which was a biliocystic fistula resulting from attempted hepatic cyst sclerotherapy.

RESULTS

Various imaging modalities were used and there was often a delay in the diagnosis. Imaging did not show the fistula itself in any of the spontaneous cases. However, a nonvisualized or shrunken gallbladder seen at US often coexisted in these cases. CT yielded the diagnosis in one case of gallstone ileus, and a Gastrografin meal yielded it in the case of Bouveret's syndrome. Fistulography and cholangiography provided a correct diagnosis of fistula in all cases of iatrogenic biliocutaneous fistulas.

CONCLUSION

Patients with biliary fistula usually undergo examinations with nonspecific results. The imaging findings could be more specific if the possibility of this diagnosis were remembered.

Radiological findings in cases of gallbladder carcinoma

Radiological findings in 80 cases of gallbladder carcinoma are analysed retrospectively. Seventy-nine of the patients had been examined by US (ultrasonography), 37 by CT (computed tomography), 26 by PTC (percutaneous transhepatic cholangiography), 17 by ERCP (endoscopic retrograde cholangio-pancreaticography), nine by angiography and 27 by US-guided FNB (fine needle biopsy). US showed the primary tumour in 68% and CT in 57%. In 67 cases the tumour had spread outside the gallbladder area, causing bile duct obstruction in 41. US showed the bile duct obstruction in 39 of these cases and CT in 20 out of 22 cases. US showed 73% of the cases that had spread to the liver; the sensitivity being 68% for direct invasion and 88% for peripheral liver metastases. The corresponding percentages for CT were 68, 67 and 75%, respectively. In lymph node enlargement, US showed the nodes in 70% of cases and CT in 52%. PTC showed either stenosis or total obstruction in 25 cases and failed in one case. ERCP showed a tumour in 76% and failed in 24%. Angiography failed to show the primary tumour in two instances out of nine. The results indicate that current imaging methods are insufficient for the accurate staging of gallbladder carcinoma.

Radiological findings in bile duct carcinoma

Radiological findings in 58 cases of pathologically proven bile duct carcinoma were analysed retrospectively. 11 patients had peripheral intrahepatic cholangiocarcinoma, 30 either hepatic duct or choledochal carcinoma and 17 carcinoma of the papilla of Vater. The tumour was local abdominally in 41 and spread abdominally in 17 cases. All cases but one were examined by US, 27 by CT, 19 by PTC, 28 by ERCP and 11 by angiography. US showed bile duct obstruction in all the cases in which it was present and CT in 94%. US showed the primary tumour in 63% and CT in 44%, while the figures for showing abdominal spread were 56 and 17% respectively. No tumour mass was found at US in 28% of cases or at CT in 52%. ERCP failed in 3 out of 28 cases, showed a tumour in 24 (86%) and showed ambiguous narrowing of the bile duct in one. PTC showed obstruction or narrowing of the bile duct caused by a tumour in all cases, while angiography detected all the intrahepatic cholangiocarcinomas but was abnormal in only 2 out of 6 cases of extrahepatic bile duct carcinoma.

Preoperative electroneuromyography and myelography in cervical root compression

The preoperative diagnostic accuracy of electroneuromyography and myelography was evaluated in 77 patients with cervical radiculopathy and/or myelopathy. In 57% of the patients, the affected root level could be determined with ENMG (accuracy 1-2 segments), 10% had a non-specific finding, and in 33% of the patients, ENMG was normal. If the symptoms had lasted less than three months, 67% of the patients had a localizing finding in ENMG. Among the 97 operated root levels, there were distinct findings in myelography in 79, minor root sheath deformities in 13, and the finding was negative in five. In addition, in myelography there were clearly pathological root sheath deformities at 20 and minor changes at 20 root levels which were not operated. ENMG and myelography have a complementary role in the diagnosis of cervical root compression. By combining the information of ENMG and myelography, the functional significance of the morphological root sheath deformities can be assessed.

Demonstration of cellular retinoic acid binding protein (CRABP) in chick embryo tendon cells and effects of retinoids on collagen synthesis in tendon and sterna

The binding of all-trans-retinoic acid (all-trans RA) to specific cytosol proteins and the effects of retinoids on procollagen synthesis were studied in chick-embryo tendon cells. For the receptor assay, tendon cytosols were incubated with [3H]all-trans-RA in the presence or absence of 100-fold excess of nonlabeled all-trans-RA up to 20 hr at +4 degrees and unbound retinoid was removed by charcoal-dextran treatment or by gel filtration chromatography. The results indicated that chick-embryo tendon cells contained cellular retinoic acid binding protein (CRABP). The binding of [3H]all-trans-RA could be displaced by 13-cis-retinoic acid, but not by retinol or etretinate. In contrast no CRABP could be found in cartilage cells isolated from sterna or in whole sterna. The treatment of tendon cytosol with proteases (pronase, trypsin, chymotrypsin) abolished the specific binding of [3H]all-trans-RA. Gel filtration studies on Sephadex G-100 indicated an apparent molecular weight of 14,500-15,000 daltons for the all-trans-retinoic acid binding protein. All-trans-RA markedly decreased procollagen synthesis in isolated chick-embryo tendon cells, the inhibition being concentration dependent; the decrease was about 58% of the control in the presence of 10(-5) M all-trans-RA. Similar decrease was noted with 13-cis-RA and etretinate, while retinol was less effective. In isolated cartilage cells the dose of 10(-5) M of all-trans-retinoic acid decreased drastically total protein and collagen synthesis. The mannosylation of procollagen, the conversion of procollagen to collagen and the size of procollagen chains were not significantly affected. The results of the present study indicate that CRABP is not expressed in sterna of chick-embryos, and in contrast high levels of CRABP could be found in tendons. However, retinoids modulated collagen synthesis in both tissues. Thus it is possible that retinoids can affect the metabolism of different collagen types also in clinical use.

Demonstration of cellular retinoic acid binding protein in cultured human skin fibroblasts

Previous studies have indicated that retinoids, such as all-trans-retinoic acid and 13-cis-retinoic acid, can modulate connective tissue metabolism in human skin fibroblast cultures. Such effects could be mediated through binding of these retinoids to specific cellular binding proteins. In the present study we have demonstrated cellular retinoic acid binding protein using both whole cell and cytosol binding assays with [3H]all-trans-retinoic acid or [3H]13-cis-retinoic acid as the ligand. Specific binding of [3H]all-trans-retinoic acid could be demonstrated by both techniques and the binding could be displaced by unlabelled all-trans-retinoic acid and 13-cis-retinoic acid, but not by retinol or RO-10-9359 (etretinate) in a 100-fold excess. Gel filtration chromatography of the cytosol proteins after incubation with [3H]all-trans-retinoic acid demonstrated that the specific binding protein had an apparent molecular weight of approximately 15 000 daltons. Thus, the cellular retinoic acid binding protein demonstrated in human skin fibroblasts may mediate the effects of the retinoids on connective tissue metabolism in these cells.

Modulation of procollagen gene expression by retinoids. Inhibition of collagen production by retinoic acid accompanied by reduced type I procollagen messenger ribonucleic acid levels in human skin fibroblast cultures

Recent clinical observations have suggested that retinoids, which are in frequent use in dermatology, can affect the connective tissue metabolism in skin and other tissues. In this study, we examined the effects of several retinoids on the metabolism of collagen by human skin fibroblasts in culture. Incubation of cultured fibroblasts with all-trans-retinoic acid or 13-cis-retinoic acid, in 10(-5) M or higher concentrations, markedly reduced the procollagen production, as measured by synthesis of radioactive hydroxyproline. The effect was selective in that little, if any, inhibition was noted in the incorporation of [3H]leucine into the noncollagenous proteins, when the cells were incubated with the retinoids in 10(-5) M concentration. Similar reduction in procollagen production was noted with retinol and retinal, whereas an aromatic analogue of retinoic acid ethyl ester (RO-10-9359) resulted in a slight increase in procollagen production in these cultures. The reduction in procollagen production by all-trans-retinoic acid was accompanied by a similar reduction in pro alpha 2(I) of type I procollagen specific messenger RNA (mRNA), as detected by dot blot and Northern blot hybridizations. Hybridizations with human fibronectin and beta-actin specific DNA probes indicated that the levels of the corresponding mRNAs were not affected by the retinoids, further suggesting selectivity in the inhibition of procollagen gene expression. Further control experiments indicated that all-trans-retinoic acid, under the culture conditions employed, did not affect the posttranslational hydroxylation of prolyl residues, the mannosylation of newly synthesized procollagen, the specific radioactivity of the intracellular prolyltransfer RNA pool, or DNA replication. All-trans-retinoic acid also elicited a reduction in trypsin-activatable collagenase, but not in the activity of prolyl hydroxylase or an elastaselike neutral protease in the fibroblast cultures. Incubation of three fibroblast lines established from human keloids with all-trans-retinoic acid or 13-cis-retinoic acid also resulted in a marked reduction in procollagen production. The results, therefore, suggest that further development of retinoids might provide a novel means of modulating collagen gene expression in patients with various diseases affecting the connective tissues.

Retinoid modulation of connective tissue metabolism in keloid fibroblast cultures

Recent observations have suggested that retinoids might affect the metabolism of the extracellular matrix of connective tissues. In this study, we examined the effects of tretinoin (all-trans-retinoic acid) and isotretinoin (13-cis-retinoic acid) on the production of procollagen in keloid fibroblast cultures that were characterized by enhanced procollagen synthesis in vitro. The activities of three enzymes relevant to connective tissue metabolism, prolyl hydroxylase, collagenase, and an elastaselike neutral protease were also determined. The results demonstrated that collagen production was markedly reduced in cultures treated with either one of the retinoids. The activity of prolyl hydroxylase, a key enzyme in the intracellular biosynthesis of collagen, was not affected, while the production of collagenase was markedly reduced by the retinoids. In contrast, the activity of an elastaselike neutral protease in the cell culture medium was markedly enhanced by both retinoids. The results, therefore, indicate a differential modulation of connective tissue metabolism by retinoids in keloid cell cultures.

Demonstration of elastin gene expression in human skin fibroblast cultures and reduced tropoelastin production by cells from a patient with atrophoderma

Atrophoderma is a rare dermal disorder characterized by a patchy distribution of areas apparently devoid of elastic fibers. Skin fibroblast cultures were established from the normal and affected dermis of a patient with this disorder. Human tropoelastin was identified in culture medium by use of electroblotting and anti-elastin antisera. An enzyme-linked immunosorbent assay was used to establish that significantly less elastin accumulated in the media of cultured cells from lesional fibroblasts over a 3-d period. Since elastin biosynthesis in most tissues is under pretranslational control, molecular hybridization to a nick-translated genomic elastin probe was performed; however, elastin messenger RNA levels were equivalent in both cell strains. Both strains produced less elastin than did normal skin fibroblasts. Extracellular proteolysis of elastin was evaluated as a possible mechanism. Elastase activity was increased and porcine tropoelastin was degraded four times faster, on a per-cell basis, in lesional fibroblast cultures than in cells derived from an unaffected site. The two cell strains exhibited no significant differences in collagen production or collagenase activity. These results are the first demonstration of elastin production by cultured human skin fibroblasts, and they suggest that the primary defect in atrophoderma may be a result of enhanced degradation of newly synthesized elastin precursors.

Anetoderma: biochemical and ultrastructural demonstration of an elastin defect in the skin of three patients

Three patients with localized cutaneous lesions characteristic of anetoderma were studied. Clinically, the onset of the disease was between the ages of 17 and 25, and numerous flaccid, saclike skin lesions developed over several subsequent years. Histologically, the lesions were characterized by paucity and fragmentation of the elastic fibers. Electron microscopy demonstrated that the elastic fibers, both in papillary and deep reticular dermis in the lesional skin, were fragmented and irregular in appearance. The concentration of elastin, determined by a radioimmunoassay of desmosine, an elastin-specific cross-link compound, was markedly reduced in the lesions, as compared with unaffected skin from the same patients or with normal skin from unrelated control subjects. In contrast, the concentrations of hydroxyproline, an index of collagen, or deoxyribonucleic acid (DNA), a measure of cellularity, were not changed in the lesions. Thus, the results indicate that in the three patients studied, the elastic fibers are defective and reduced in quantity. These observations suggest that the deficiency of elastin in the dermis may lead to development of the cutaneous lesions of anetoderma.