A Review of a Tertiary Referral Centre's CT Coronary Angiography Programme

Aims To investigate the implication of outpatient CT coronary angiogram (CTCA) waiting times on patient outcomes and service provision. Methods All outpatient CTCAs requested for stable chest pain during 2017 in our catchment area were included. Rate of major adverse cardiovascular events (MACE), presentations with chest pain to the emergency department (ED), cardiology outpatient attendance, time interval in alteration of Coronary artery disease (CAD) prognostic treatment, rate of angiography and percutaneous coronary intervention (PCI) were noted. Results 172 CTCAs were included. 11 (6.4%) presented to ED with chest pain. 38 (22.1%) attended outpatients prior to scan completion. 17 (9.9%) required alteration of prognostic treatment, taking on average 10.4 (+/-4.5) months to occur. 21 (12.2%) underwent coronary angiography and 7 (4.1%) had PCI, which took on average 9.9 (+/-6.6) months. One non-fatal MI requiring CABG was noted. Conclusion The low rate of MACE and revascularisation likely represents appropriately low risk patient selection for CTCA. Presentation to clinic prior to scan completion highlights a need for better administration support.

Diagnostic accuracy of SUVmax in predicting malignancy of supraclavicular lymph nodes from primary oesophageal cancer

PURPOSE

To determine the diagnostic accuracy and optimum cut-off value of SUVmax on PET to predict malignancy of supraclavicular lymph nodes (SCLNs) in patients with oesophageal carcinoma.

MATERIAL AND METHODS

All diagnosed cases of oesophageal cancer were retrospectively reviewed (2010-2016). Patients that had a confirmed diagnosis of oesophageal cancer with avid SCLNs on staging PET were included in the study. 33 SCLNs that subsequently underwent ultrasound guided biopsy for staging were analysed. The maximum uptake values (SUVmax) of the SCLNs and primary tumours were measured. A receiver operating characteristic (ROC) analysis was performed to determine the optimum cut off of SUVmax in predicting malignancy.

RESULTS

24/33 PET-detected SCLNs were malignant. ROC analysis identified the best nodal SUVmax cut-off to be 3.0. The diagnostic accuracy of PET was 76.0 % (sensitivity = 78.9 %, specificity = 66.6 %). For SCLNs with SUVmax > 3.0, PET showed a positive predictor value of 88.2 %; for SCLNs < 3.0, PET showed a negative predictor value of 50 %. The median SUVmax of pathologically negative and positive nodes were 2.8 (range 1.8-6.0) and 5.3 (range 1.9-13.4). The median primary tumour SUVmax was 13.8 (range 3.7-30.0). The SUVmax of metastatic lymph nodes were significant higher than those of benign lesions (p < 0.05).

CONCLUSION

Our study revealed an accuracy rate of 76 % for PET detected SCLNs in patients with oesophageal carcinoma. For SCLNs with SUVmax > 3.0, PET had a high PPV (88 %), which can minimize the need for further diagnostic tests.

Utilising magnetic resonance imaging as the gold-standard in management of suspected scaphoid fractures in the emergency department setting

Scaphoid fractures are the most common carpal bone fracture. Up to 40% of scaphoid fractures can be missed at initial presentation and investigation. Follow-up plain film radiograph has overall poor sensitivity and reliability. MRI has been shown to have an almost 100% sensitivity and specificity and so is the gold standard in scaphoid fracture diagnosis. Additionally, early specialist involvement is recommended. We proposed that following a designated pathway, there would be no significant increase in MRI requests. Following implementation of a pathway for the management of suspected scaphoid fractures in St James's Hospital in 2012 re-auditing demonstrated that management changed to either MRI directly after initial x-ray (16/145, 11%), MRI after second x-ray (9/28, 32%) or orthopaedic follow-up (19/28, 68%). The number of MRIs requested was consistent with our predictors of demand. Thus, our new protocol maximises diagnostics, cost effectiveness and quality of patient care.

Radiology imaging delays as independent predictors of length of hospital stay for emergency medical admissions

AIM

To investigate the extent to which the time to completion for computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound could be shown to influence the length of stay and costs incurred while in hospital, while accounting for patient acuity.

MATERIALS AND METHODS

All emergency admissions, totalling 25,326 imaging investigations between 2010-2014 were evaluated. The 50(th), 75(th), and 90(th) centiles of completion times for each imaging type was entered into a multivariable truncated Poisson regression model predicting the length of hospital stay. Estimates of risk (odds or incidence rate ratios [IRRs]) of the regressors were adjusted for acute illness severity, Charlson comorbidity index, chronic disabling disease score, and sepsis status. Quantile regression analysis was used to examine the impact of imaging on total hospital costs.

RESULTS

For all imaging examinations, longer hospital lengths of stay were shown to be related to delays in imaging time. Increased delays in CT and MRI were shown to be associated with increased hospital episode costs, while ultrasound did not independently predict increased hospital costs. The magnitude of the effect of imaging delays on episode costs were equivalent to some measures of illness severity.

CONCLUSION

CT, MRI, and ultrasound are undertaken in patients with differing clinical complexity; however, even with adjustment for complexity, the time delay in a more expeditious radiological service could potentially shorten the hospital episode and reduce costs.

Post traumatic Fat Embolism in Common Femoral Vein on CT

Fat embolism syndrome usually occurs following trauma where fat globules from long bone fractures produce pulmonary, cerebral or cutaneous effects. This case illustrates the presence of macroscopic fat in the right common femoral vein secondary to a long bone fracture. This finding is rare but should be looked for on cross-sectional imaging to allow early, aggressive treatment of fat embolism syndrome.

Open-access ultrasound referrals from general practice

Direct access referral for radiological investigations from General Practice (GP) provides an indispensable diagnostic tool and avoids the inherently long waiting time that referral through a hospital based specialty would entail. Improving access to hospital based radiology services is one of Health Information and Quality Authority's key recommendations in its report on patient referrals from general practice. This study aimed to review all GP referrals for ultrasound investigations to a tertiary referral teaching hospital over a seven month period with respect to their demographics, waiting times and diagnostic outcomes. 1,090 ultrasounds originating in general practice were carried out during the study period. Positive findings were recorded in 332 (30.46%) examinations. The median waiting time from receipt of referral to the diagnostic investigation was 56 days (range 16 - 91 years). 71 (6.5%) patients had follow-up imaging investigations while recommendation for hospital based specialty referral was made in 35 cases (3.2%). Significant findings included abdominal aortic aneurysms, metastatic disease and lymphoma. Direct access to ultrasound for general practitioners allows the referring physician to make an informed decision with regard to the need for specialist referral. We believe these findings help support the case for national direct access to diagnostic ultrasound for general practitioners.

Imaging features of extrapulmonary small cell carcinoma

Small cell carcinoma accounts for approximately 20% of lung cancers; however, it rarely occurs at other sites. Extrapulmonary small cell carcinoma (EPSCC) is notoriously aggressive with a strong propensity for both regional and distant spread. The majority of the literature on these uncommon tumours is from a clinicopathological viewpoint with a relative paucity of detail regarding the radiological findings. This review will focus on the imaging features of EPSCC in its predominant sites of origin: the gastrointestinal tract, genitourinary tract, head, neck, and breast. We will also discuss the role of positron-emission tomography (PET)/computed tomography (CT) in the staging of EPSCC.

Imaging findings in recurrent extramedullary leukaemias

Acute leukaemias are relatively common malignancies. Treatment has advanced significantly in the recent past and there has been improved patient survival. This improved initial response is leading to an increasing number of cases of relapse. Extramedullary relapse occurs in a wide variety of locations with varying presentations, imaging findings and differentials. The pathophysiology and clinical course of recurrent extramedullary myeloid and lymphocytic leukaemias are reviewed in this article. The wide variety of imaging findings associated with many important sites of recurrence and the associated differential diagnosis are discussed and illustrated.

Comparison of clinical and physics scoring of PET images when image reconstruction parameters are varied

In this study the quantitative and qualitative image quality (IQ) measurements with clinical judgement of IQ in positron emission tomography (PET) were compared. The limitations of IQ metrics and the proposed criteria of acceptability for PET scanners are discussed. Phantom and patient images were reconstructed using seven different iterative reconstruction protocols. For each reconstructed set of images, IQ was scored based both on the visual analysis and on the quantitative metrics. The quantitative physics metrics did not rank the reconstruction protocols in the same order as the clinicians' scoring of perceived IQ (R(s)=-0.54). Better agreement was achieved when comparing the clinical perception of IQ to the physicist's visual assessment of IQ in the phantom images (R(s)=+0.59). The closest agreement was seen between the quantitative physics metrics and the measurement of the standard uptake values (SUVs) in small tumours (R(s)=+0.92). Given the disparity between the clinical perception of IQ and the physics metrics a cautious approach to use of IQ measurements for determining suspension levels is warranted.

Functional interaction of HTLV-1 tax protein with the POZ domain of the transcriptional repressor BCL6

The Tax protein encoded by human T-cell leukaemia virus type 1 (HTLV-1) has a pivotal role in T-cell transformation by deregulating cellular signalling pathways. Using the yeast two-hybrid system to screen a human leukocyte cDNA library, we identified BCL6 (B-cell lymphoma 6) as a cellular protein, which interacts with Tax 1. The BCL6 gene encodes a sequence-specific transcriptional repressor that contains a conserved N-terminal poxvirus and zinc finger (POZ) repressor domain and a C-terminal Kruppel-like zinc finger DNA binding domain. Using both in vivo and in vitro methods, we demonstrate that the POZ domain of BCL6 is sufficient for its interaction with Tax 1. Using functional assays, we demonstrate that Tax 1 enhanced the repressive activity of BCL6 and increased the levels of apoptosis induced by BCL6 in osteosarcoma cells indicating that both proteins cooperate in vivo to cause a physiological affect. Furthermore, BCL6 recruited Tax 1 into punctate nuclear structures, which suggests that Tax 1 colocalizes with BCL6 in repressor complexes in vivo. BCL6 expression significantly downregulated both basal and Tax-induced nuclear factor-kappaB and long terminal repeat activation. This suggests that the expression of BCL6 in HTLV infected cells may contribute to the silencing of viral gene expression and to the long clinical latency associated with HTLV infection.

Relapsing granulomatous angiitis of the central nervous system in a patient while in remission from Hodgkin lymphoma

We present a patient with granulomatous angiitis of the central nervous system (GANS) and Hodgkin lymphoma. His GANS resolved with treatment for the lymphoma, but then reactivated six months later in the absence of activate lymphoma. He made a full neurological recovery after treatment with reducing oral prednisolone over one year. This case indicates that prolonged use of steroids may be necessary to treat GANS in this setting and that it can run a course independent of the Hodgkin lymphoma.

Rheumatologists' judgements about the efficacy of anti-TNF therapy in two neighbouring regions

OBJECTIVES

The requirement in Northern Ireland to prescribe biological agents according to National Institute for Clinical Excellence/British Society for Rheumatology (NICE/BSR) guidelines and within a fixed budget has created a waiting list for treatment that has no parallel in the Republic of Ireland. The study investigated the bearing this situation may have had on consultants' judgements in the respective areas.

METHODS

Seventy-eight case vignettes created from the data on real patients with RA treated with biologicals in the north and south of Ireland were appraised by nine southern and eight northern consultants, who judged the clinical benefit and significance of the patients' condition after a trial of therapy. Quantitative (clinical judgement analysis) and qualitative (focus groups) techniques were used.

RESULTS

Northern consultants perceived a slightly greater degree of clinical benefit after a trial of therapy than southern consultants. Judgement models of northern and southern consultants were broadly comparable. The latter tended to be more uniform in their judgements than the southern group. Focus group discussions with consultants largely validated the findings of the quantitative analysis but revealed how clinical judgement analysis might be misled by gaming strategies.

CONCLUSIONS

Despite the absence of overt rationing in the south of Ireland, as far as the judgement of therapeutic benefit from biologicals was concerned, the clinical judgement policies of practitioners were very similar to those in the north. The adoption of NICE/BSR guidelines in the north may have improved the uniformity of clinical practice in Northern Ireland.

Prevalence of persistent primary reflexes and motor problems in children with reading difficulties

It has been shown that some children with reading difficulties have underlying developmental delay and that this may be related to the persistence of primary reflexes. This study investigated the prevalence of persistent primary reflexes in the ordinary primary school population and how this related to other cognitive and social factors. Three groups of 41 children were drawn from a representative, cross-sectional sample of 409 children (aged 9-10 years) attending 11 ordinary primary schools in N. Ireland. The three groups represented the bottom, middle and top 10% respectively of readers from the total sample population. The relative persistence (on a scale of 0 to 4) of the Asymmetrical Tonic Neck Reflex (ATNR) and the prevalence of motor difficulties were assessed for these 3 groups. The rôle of 5 predictor variables (verbal IQ, social deprivation, sex, month of birth and religious affiliation) in determining the reading level of the total sample was also investigated. It was found that the lowest reading group had a significantly higher mean level of ATNR (1.56 [95% CI 1.22-1.90]) compared with the middle reading group (0.56 [0.22-0.90]) and the top reading group (0.59 [0.25-0.92]). 17% of children in the lowest reading group had extremely high levels of the ATNR while 24% showed no presence of ATNR. This contrasted with 0% and 66%, respectively for both middle and top reading groups. It was also found that there was a significant difference between the lowest reading group and the top reading group on a standardised test of motor ability. Furthermore, there was evidence that ATNR persistence but not motor ability was associated with the sex of the child with boys, in particular, at risk. There was no evidence that ATNR persistence or motor ability was significantly associated with social deprivation. It was also found that there were no significant differences between dyslexic and non-dyslexic children with reading difficulties in motor (including balance) performance. This study highlights the high levels of primary reflex persistence in children with reading difficulties and it provides further evidence of the association between reading difficulties and movement difficulties in young children. However, while the implications for intervention are discussed, it is stressed that the persistence of primary reflexes cannot be used as a causal model for reading difficulties, including dyslexia.

Statins and neuroprotection

The beneficial effect of beta-hydroxy-beta-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) in primary prevention of coronary artery disease in those with hypercholesterolaemia and in secondary prevention in those with established coronary vascular disease are now well known. A growing body of evidence suggests that statins also possess important additional clinical benefits, such as stroke risk reduction. In this article we review the evidence that statins may be neuroprotective, especially in the brain parenchyma during stroke. We also review the observational data that statins may prevent the onset of dementia.

High rate of human T lymphotropic virus type IIa infection in HIV type 1-infected intravenous drug abusers in Ireland

Serological and molecular analyses of a cohort of HIV-1-infected intravenous drug abusers (IVDAs) (n = 103) in Dublin, Ireland have demonstrated that 15 of 103 (14.6%) were infected with HTLV-II, which is the highest infection rate yet recorded for any European country. Restriction fragment length polymorphism (RFLP) analysis of the env region of the provirus demonstrated that the infection involved only the HTLV-IIa subtype; the HTLV-IIb subtype was not detected. Phylogenetic analysis of the nucleotide sequences of the long terminal repeat (LTR) confirmed infection with the HTLV-IIa subtype, and demonstrated that the viruses clustered closely with HTLV-IIa isolates from North American IVDAs. Previous observations that IVDAs in southern Europe, specifically Spain and Italy, appear to be infected predominantly with the HTLV-IIb subtype, along with the present report and evidence that IVDAs in Sweden are infected with the HTLV-IIa subtype, suggest different origins of HTLV-II infection in Europe.

Analysis of partial 16S rRNA nucleotide sequences of Chlamydia pecorum and C. psittaci

Partial 16S nucleotide sequences of Chlamydia psittaci isolates S26/3 (abortion), P94/1 (pigeon) and Chlamydia pecorum isolates W73 (enteric) and E58 (encephalomyelitis) were determined. Analysis of these data indicates very high levels of interspecies sequence conservation, with C. psittaci being more closely related to C. pecorum than to C. pneumoniae or C. trachomatis. Restriction enzyme analysis of nucleotide sequences indicated that BslI can be used to clearly distinguish C. psittaci and C. pecorum isolates. Psittacine and non-psittacine (pigeon) avian isolates of C. psittaci were distinguished using MaeI.

Differentiation of Chlamydia psittaci and C. pecorum strains by species-specific PCR

Sequence analyses 5' ends of the 60-kDa cysteine-rich outer membrane protein genes (Omp2) of Chlamydia psittaci and Chlamydia pecorum strains indicate that these species have approximately 70% nucleotide identity. On the basis of this sequence information, PCR primers were designed to allow the specific amplification of DNA extracted from C. psittaci S26/3 (abortion strain), P94/1 (pigeon strain), and C. pecorum W73 (fecal strain) in one reaction tube. By using nested reactions (with primers PCR-D1 and PCR-D2 followed by the specific primers and PCR-D2), 0.6, 0.2, and 8 inclusion-forming units of S26/3, P94/1 (both diluted in tissue culture-negative placental material), and W73 (diluted in culture-negative fecal material) per ml, respectively, were detected. The differentiation of C. psittaci and C. pecorum strains of ovine and bovine origins was carried out, and the results were in agreement with those obtained from AluI restriction enzyme analysis of DNA amplified from corresponding strains by PCR. This approach allows the simultaneous detection and typing of C. psittaci and C. pecorum strains and the identification of samples containing both species.

Concurrent evolution of regions of the envelope and polymerase genes of human immunodeficiency virus type 1 during zidovudine (AZT) therapy

Nucleotide sequences of regions of the envelope (env) and polymerase (pol) genes of human immunodeficiency virus type 1 (HIV-1) proviral DNA were obtained from sequential blood and autopsy samples from an AIDS patient who had been treated with zidovudine for 9 months. Phylogenetic analyses showed that a reduction in genetic heterogeneity of the env regions of viruses present in the proviral blood population occurred during therapy, and this coincided with an increased pol gene heterogeneity. Differences were observed in different organs obtained post mortem for both the env and pol coding regions. The cardiac blood proviral population consisted mainly of variants which possessed sequences containing mutations at position 215 of the pol gene, associated with drug resistance. By contrast, the brain population consisted entirely of zidovudine sensitive genotypes, and this organ also harboured variants with genetically distinct env sequences. The lymph tissues obtained after death held more diverse proviral env and pol populations, containing both zidovudine sensitive and resistant genotypes.

Sequence analysis of reverse transcriptase genes of zidovudine (AZT)-resistant and -sensitive human immunodeficiency virus type 1 strains

Sequential isolates of human immunodeficiency virus type 1 (HIV-1) were obtained from patients with AIDS on short and long term treatment with zidovudine (3'-azido-3'-deoxythymidine; AZT). The isolates were tested for resistance to zidovudine by monitoring the inhibition of syncytium formation, HIV-1-specific immunofluorescence and p24 production in C8166 cells. The reverse transcriptase (RT) genes of zidovudine-sensitive (< 1 microM) and -resistant (10 to 15 microM) strains were amplified using the polymerase chain reaction and the products were sequenced directly. The predicted amino acid sequences of the RTs of zidovudine-sensitive and -resistant isolates showed 95 to 97% identity to the corresponding sequence of HIV-1SF2 which was used as a reference. Amino acid changes at positions 41, 67, 70, 215 and 219 which are known to be associated with zidovudine resistance were present in some, but not all isolates exhibiting zidovudine resistance in vitro. This indicates that mutations in the RT of HIV-1, other than those already identified, may be involved in conferring resistance to zidovudine.

Of mice and men--data capture in the clinical environment

We have considered the problem of data capture in the critical care area. Review of previous work on the use of alternative input devices for speed and accuracy of data entry yields conflicting information but suggests that requirements depend on input task, data type and skill of the user. We have performed comparative studies of the QWERTY keybord, cursor control keys, mouse and graphics tablet for data entry in two intensive therapy unit (ITU) environments. The graphics tablet proved overall the best of the devices studied. We report the potential applications of this type of input device.