CTC service heterogeneity and design of a workforce calculator.

AIM: To determine the level of heterogeneity in delivery of computed tomography (CT) colonography services and develop a workforce calculator that accommodates the variation identified. MATERIALS AND METHODS: A national survey, based on the "WHO workforce indicators of staffing need", established activity standards for essential tasks in delivery of the service. From these data a workforce calculator was designed to guide the required staffing and equipment resource by service size. RESULTS: Activity standards were established as mode responses >70%. Service homogeneity was greater in areas where professional standards and guidance were available. The mean service size was 1,101. Did not attend (DNA) rates were lower where direct booking was available (p<0.0001). Service sizes were larger where radiographer reporting was embedded in reporting paradigms (p<0.024). CONCLUSION: The survey identified benefits of radiographer-led direct booking and reporting. The workforce calculator derived from the survey provides a framework to guide the resourcing of expansion while maintaining standards.

What is the impact of CT colonography interpretation by advanced practitioner radiographers on delivery of the 28 day colorectal cancer target?

INTRODUCTION: CT Colonography (CTC) is an indicated test to assess the colon and rectum for evidence of polyps and neoplasms. The advanced practitioner radiographer (APR) is increasingly involved with the entirety of the radiology pathway including procedural modification, preliminary clinical evaluation (PCE) and multi-disciplinary team (MDT) meeting notification of high risk colonic pathologies. METHODS: A retrospective audit of the Radiology Information System (RIS) was undertaken at a large secondary care centre, 12 months of data of 119 consecutive patients who had undergone CTC with summary coded reports of high risk pathology were included for analysis. Analysis of accuracy of procedural modification, PCE and impact of hypothesised earlier full radiological staging data being available for MDT discussions were measured and evaluated. RESULTS: For high risk C4b studies, just 16.67% of colonic pathology was observed during the CTC study, rising to 79% during radiographer PCE. For likely colonic neoplasm C5a studies 86% of colonic pathology was observed during the CTC study, rising to 93% during radiographer PCE. Where subsequent CT chest staging was deemed necessary following CTC by the referring team, patients had a median wait of 34 days for completion CT chest scan staging. CONCLUSION: This study supports the integration of the advanced practitioner radiographer into the entire radiological processes of a CTC, with time advantages apparent for both diagnostics, but also the decision to treat. IMPLICATIONS FOR PRACTICE: Appropriately trained radiographers are able to support CTC services to ensure delivery of an effective two-week wait diagnostic service with direct MDT liaison.

Abdominal radiograph preliminary clinical evaluation image test bank project.

INTRODUCTION: Literature documenting preliminary clinical evaluation (PCE) commonly focuses on the evaluation of musculoskeletal radiographs. Despite this, the professional body suggest that a diagnostic radiographer should be able to provide a PCE for any radiograph. METHODS: An image bank of 30 abdominal radiographs was designed comprising of 17 abnormal cases with a range of pathologies which one could expect to encounter in the emergency department (ED). Participants' were asked to select one of four taxonomies to represent their PCE for each radiograph. Participants' answers were compared to a gold standard PCE taxonomy based on the radiological report. Inferential statistics were applied to assess for any significant different in accuracy between NHS pay bands of the participants. RESULTS: On average participants selected an abdominal radiograph PCE taxonomy with a sensitivity of 75.2% and a specificity of 75.7%. Whilst band 7 radiographers selected the most accurate abdominal radiograph PCE and had the highest area under curve (AUC), no significant difference was found in the PCE categorisation of abdominal radiographs by radiographers of all pay bands. CONCLUSION: Participants' have shown good sensitivity in recognising prominent findings on abdominal radiographs. This sensitivity is however reduced when assessing less obvious radiographic appearances, illustrating areas where additional training would be beneficial. The study provides evidence towards the consideration of an expansion of current practice regarding the implementation of a scheme of abdominal radiograph PCE. Further research with a larger cohort of participants' and a lower abnormal case prevalence would be beneficial to the limited research base.

Quantitative and qualitative assessment of a coding system for reporting CT colonography.

AIM: To validate a coding system implemented to summarise computed tomography colonography (CTC) findings for the detection of suspected colorectal cancer (CRC) by assessing interobserver variability and also to evaluate any weaknesses through qualitative analysis. MATERIALS AND METHODS: All CTC investigations over a 6-month period (01/07/2016 to 31/12/2016) were analysed retrospectively. Each study was read initially by an advanced practitioner radiographer with a final report issued by a consultant gastrointestinal radiologist. Rates of interobserver agreement, using the kappa statistic, provided a quantitative assessment of levels of agreement. Areas of poor interobserver agreement were identified for further qualitative assessment. RESULTS: The present study included 1,321 CTC procedures and the mean age of patients was 68.4 years (range 28-96 years). Percentage agreement for colonic coding was 90% and for extra-colonic coding 47%. This corresponds to kappa scores of 0.69 (substantial agreement) and 0.22 (fair agreement), respectively. Reasons and examples of disagreement in the colonic coding are highlighted. CONCLUSIONS: High interobserver agreement was observed for C coding, suggesting it is a reproducible method of classifying intra-colonic CTC findings. Some of the difference in classifying extra-colonic findings is the perceived importance of incidental findings between readers, as well as differences in skill set; however, some themes recurred in areas of disagreement and recommendations for refining and improving the coding system are provided.

Comparative yield of positive brain computed tomography after implementing the NICE or SIGN head injury guidelines in two equivalent urban populations.

AIMS: To compare the yield of positive computed tomography (CT) brain examinations after the implementation of the National Institute for Clinical Excellence (NICE) or the Scottish Intercollegiate Guidance Network (SIGN) guidelines, in comparable urban populations in two teaching hospitals in England and Scotland. MATERIALS AND METHODS: Four hundred consecutive patients presenting at each location following a head injury who underwent a CT examination of the head according to the locally implemented guidelines were compared. Similar matched populations were compared for indication and yield. Yield was measured according to (1) positive CT findings of the sequelae of trauma and (2) intervention required with anaesthetic or intensive care unit (ICU) support, or neurosurgery. RESULTS: The mean ages of patients at the English and Scottish centres were 49.9 and 49.2 years, respectively. Sex distribution was 64.1% male and 66.4% male respectively. Comparative yield was 23.8 and 26.5% for positive brain scans, 3 and 2.75% for anaesthetic support, and 3.75 and 2.5% for neurosurgical intervention. Glasgow Coma Score (GCS) <13 (NICE) and GCS ≤ 12 and radiological or clinical evidence of skull fracture (SIGN) demonstrated the greatest statistical association with a positive CT examination. CONCLUSION: In a teaching hospital setting, there is no significant difference in the yield between the NICE and SIGN guidelines. Both meet the SIGN standard of >10% yield of positive scans. The choice of guideline to follow should be at the discretion of the local institution. The indications GCS <13 and clinical or radiological evidence of a skull fracture are highly predictive of intracranial pathology, and their presence should be an absolute indicator for fast-tracking the management of the patient.

Is primary care access to CT brain examinations effective?

AIM: Primary care access to CT head examinations could enable common neurological conditions to be managed within primary care. Outcome data from the first 8 years of a local service were used to identify effective referral criteria. METHODS: Primary care head CT results from 1 March 1995 to 31 October 2003 were categorized as normal, incidental or significant findings. Normal reports were cross-referenced for referral to secondary care. Case notes with incidental or significant CT findings were reviewed for secondary care attendance and outcome. RESULTS: Records of 1403/1645 CT head examinations (85%) were available for review. Of these 1403, 951 (67.8%) returned normal findings, 317 (22.6%) incidental findings and 135 (9.6%) significant findings. The commonest indication for referral was investigation of headaches (46.6%). Of the total 533 patients under 50 years of age, 13 (2.4%) yielded significant findings and all 13 showed other features in addition to headache. Of 314 cases presenting with focal neurology, 83 (26.4%) showed significant findings. 314 patients were referred from primary to secondary care. 189 had normal scans and 74 had findings described as incidental. 60% of secondary care referrals were for normal CT scans. In patients with focal neurology, 90 of 314 were referred, allowing 71% to be managed in primary care. Yield was also 0% for headaches, dizziness, visual disturbance or nausea and vomiting. CONCLUSION: Primary care access to CT brain examinations is effective for patients with focal neurology, neurological symptoms or a known malignancy, but not for patients aged less than 50 years, or with uncomplicated headaches, dizziness or diplopia.

Immediate CT pneumocolon for failed colonoscopy; comparison with routine pneumocolon.

AIM: To assess the role and reliability of 2D CT pneumocolon in the diagnosis of colonic malignancy, and compare feasibility of referral sources. MATERIALS AND METHODS: A prospective study of 50 patients with suspected large bowel malignancy. Patients underwent bowel cleansing, rectal air insufflation and contrast enhanced CT with 5 mm collimation, 3 mm reconstruction and a pitch of 1.4. Subsequent correlation was with pathology (16), colonoscopy (13), barium enema (5), ERCP (1) and clinical follow-up alone (8). RESULTS: Diagnostic images were obtained in 43/50 patients (86% feasibility). Follow-up was obtained in 35/43 patients (one patient died of an unrelated cause, and seven patients were deemed unfit for further investigation). Seventeen colonic carcinomas were diagnosed (three false-positives: one ischaemic colitis, one diverticular stricture and one faecal mass), one diverticular stricture, one fistula, one pancreatic carcinoma and one ovarian malignancy. The remaining 14 were negative. Overall sensitivity was 100% (for lesions >1.5 cm) with a specificity of 94% for structural abnormalities, but only 82% for the correct identification of malignancy. CONCLUSION: Computed tomography (CT) pneumocolon is a reliable alternative to barium enema where colonoscopy is incomplete, with the advantage of extraluminal screening, and examination of the proximal bowel. In the frail elderly or young unfit patient, it is a valuable additional diagnostic tool.

Survey of intussusception reduction in England, Scotland and Wales: how and why we could do better.

Britton, I. and Wilkinson, A. G. (2000). Clinical Radiology55, 984-985.

Ultrasound features of intussusception predicting outcome of air enema.

OBJECTIVE: To examine features identified on US which predict success or failure of air-enema reduction of intussusception. MATERIALS AND METHODS: A retrospective study of 117 consecutive episodes of intussusception, presenting for US over a 6-year period. The specific features examined were: free fluid within the peritoneum, small-bowel obstruction, colonic wall thickness, and fluid trapped between the colon and the intussusceptum. RESULTS: The overall reduction rate, irrespective of US features, over the 6-year period was 72 %. Reduction rates were significantly higher with the absence of free fluid, trapped fluid, or small-bowel obstruction (93 %). The presence of trapped fluid predicted an unfavourable outcome, with a significantly lower success rate (25 %). Colonic wall thickness did not predict outcome; in successful reductions, mean wall thickness was 7.2 mm and in failed reductions 7.6 mm. CONCLUSIONS: Where free fluid, small-bowel obstruction, and trapped fluid are absent, almost 100 % success with air-enema reduction should be achievable. Where trapped fluid is present, air enema should be performed cautiously to avoid perforation caused by overvigorous attempts at pneumatic reduction of an incarcerated intussusception.

Assessment of the role and reliability of sonographic post-prandial flow response in grading Crohn's disease activity.

PURPOSE: To investigate the value of pre and post prandial Duplex colour Doppler sonographic (DCDS) measurement of superior mesenteric artery (SMA) flow in the assessment of Crohn's disease activity, and its response to treatment. MATERIALS AND METHODS: SMA volume flow rates before and after a food challenge (200 ml of Ensure Plus) were recorded over 60 min in 11 controls, and 25 patients with proven Crohn's disease. Peak flow rates and the time interval to peak flow were recorded. Eleven patients with active disease were monitored longitudinally and their response following the introduction of systemic steroids was assessed. RESULTS: The time interval from food challenge to peak SMA flow rate was significantly lower in patients with untreated active disease (median 20 min, range 14.5-21.25) compared to inactive patients (median 33 mins, range 28.75-40.5, P = 0.0006). Longitudinal follow-up of active disease demonstrated prolongation of time to peak flow following clinical remission (P = 0.0024) CONCLUSIONS: This technique is useful in offering an immediate, noninvasive means of assessing disease activity. Further longitudinal follow up data is necessary to determine its utility in assessing response to treatment.

Do supine oblique views provide better imaging of the cervicothoracic junction than swimmer's views?

OBJECTIVE: To determine whether a swimmer's view or supine (trauma) oblique views are more likely to visualise the lower cervical spine when a lateral view fails to show the cervicothoracic junction. DESIGN: A prospective study comparing two 20 week periods. In the first phase the swimmer's view was performed as an additional view when the cervicothoracic junction was not demonstrated. In the second phase paired supine oblique views replaced the swimmer's view. RESULTS: 230 patients were included in the first phase, of whom 60 required swimmer's views. In the second phase 62 of 197 patients required supine oblique views. Radiology analysis of 53 pairs of supine oblique views showed that the vertebral bodies were adequately demonstrated at the cervicothoracic junction in only 20 patients (38%) compared with 22 in the swimmer's group (37%). The facet joints and posterior elements were, however, clearly seen in 37 (70%) of the supine oblique patients compared with 22 (37%) of the swimmer's group (p < 0.001, chi2 test). Exposure dose calculations showed a substantial reduction for a pair of supine oblique views (1.6 mGy) over a single swimmer's view (7.2 mGy). CONCLUSIONS: In injured patients for whom the standard three view series fails to demonstrate the cervicothoracic junction, swimmer's views and supine oblique views show the alignment of the vertebral bodies with equal frequency. However, supine oblique films are safer, expose patients to less radiation, and are more often successful in demonstrating the posterior elements.