Radiology reporting of incidental osteoporotic vertebral fragility fractures present on CT studies: results of UK national re-audit.

AIM: To describe a UK-wide re-audit of the 2019 Royal College of Radiologists (RCR) audit evaluating patient-related data and organisational infrastructure in the radiological reporting of vertebral fragility fractures (VFFs) on computed tomography (CT) studies and to assess the impact of a series of RCR interventions, initiated to raise VFF awareness, on reporting practice and outcomes. MATERIALS AND METHODS: Patient specific and organisational questionnaires largely replicated those utilised in 2019. The patient questionnaire involved retrospective analysis of between 50 and 100 consecutive, non-traumatic CT studies which included the thoracolumbar spine. All RCR radiology audit leads were invited to participate. Data collection commenced from 1 April 2022. RESULTS: Data were supplied by 129/194 (67%) departments. One thousand five hundred and eighty-six of 7,316 patients (21.7%) had a VFF on auditor review. Overall improvements were demonstrated in key initial/provisional reporting results; comment on spine/bone (93.2%, 14.4% improvement, p<0.0002); fracture severity assessment (34.7%, 8.5% improvement, p=0.0007); use of recommended terminology (67.8%, 7.5% improvement, p=0.0034); recommendations for further management (11.7%, 9.1% improvement, p<0.0002). CONCLUSIONS: The 2022 national re-audit confirms improvements in diagnostic performance and practice in VFF reporting. Continuing work is required to build on this improvement and to further embed best practice.

Hyperechoic kidneys in a patient with bronchiectasis.

INTRODUCTION: Hyperechoic renal cortex in a normal-sized kidney has a range of causes, some of which irreparably damage the kidney and should initiate further investigations. CASE REPORT: We present a 72-year-old woman with longstanding bronchiectasis, noticed to have worsening renal function. Renal tract ultrasonography showed hyperechoic normal-sized kidneys. Renal biopsy confirmed amyloidosis. DISCUSSION: Imaging findings in renal amyloidosis tend to be non-specific and are not always present. However, ultrasonography findings of hyperechoic cortex in normal-sized kidneys should not be ignored. CONCLUSION: Renal impairment from blood chemistry in addition to hyperechoic kidneys may be the key to diagnosing secondary amyloidosis in a patient with bronchiectasis, a rare association but important to recognise.

National audit of seven-day working care in radiology.

OBJECTIVES: To evaluate the extent to which our current provision of diagnostic and interventional radiology services matches existing clinical demand and future government proposals as set out in the Royal College of Radiologists published guidance on providing seven-day acute care. METHODS: In June 2018, all UK radiology department audit leads were sent a questionnaire designed to assess compliance for each standard of the Royal College of Radiologists published guidance on providing seven-day acute care. RESULTS: 135 hospitals (68%) responded. Of those that responded, 96% of departments have a diagnostic radiologist rota for clinicians to discuss acute cases and review imaging and 48% of departments do not have a fully staffed consultant rota 24 h a day, seven days a week for interventional radiology. There is significant variance in MRI radiographer availability within departments, ranging from 18.8% during Saturday/Sunday evening/overnight up to a maximum of 63.9% during Saturday daytime. 11% of departments participate in a regional out of hours cross-organisation reporting rota. 40% of departments have no 24/7 RIS technical support and 34% have no PACS technical support out of hours. CONCLUSION: There is a wide variation in practice across radiology departments in the UK. Although there are some standards that the majority of hospitals are achieving, there is a significant short-fall in fundamental aspects of providing acute seven-day care. The multifactorial nature in which these problems have arisen means there is no easy solution to combat these issues. There is a requirement for significant investment and political commitment to improve staffing and infrastructure in order to address the current situation. ADVANCES IN KNOWLEDGE: A UK wide evaluation of the current provision of seven-day working in radiology showing 54% of hospitals do not have a UK working-time regulations compliant Interventional radiology rota, severe lack of availability of acute MRI out of hours and significant deficiencies in providing technical support out of hours. A sustainable and efficient seven-day service is currently not being provided.

Imaging in myeloma: a Royal College of Radiologists national survey of current imaging practice.

AIMS: To evaluate current national imaging practice in myeloma with reference to National Institute for Health and Care Excellence (NICE) guidelines (NG35, 2016) and compare results with an initial survey conducted in 2017 (61 participating sites). MATERIALS AND METHODS: All UK radiology departments treating myeloma patients and with a Royal College of Radiologists (RCR) Audit Lead were invited to participate. Data were collected using an online questionnaire. Descriptive statistics were performed. RESULTS: One hundred and fourteen hospitals supplied data (54% return rate). Skeletal survey (SS) remains the most-commonly performed first-line imaging test for suspected/confirmed myeloma or plasmacytoma (39%, 45/114 hospitals), followed by whole-body magnetic resonance imaging (WBMRI) (27%, 31/114) and whole-body computed tomography (WBCT) (19%, 22/114). Integrated positron-emission tomography/CT (PET/CT) was first-line in 14% (16/114). The NICE recommended initial investigation, WBMRI, is currently offered in 27% of surveyed hospitals (<10% in 2017). Ongoing challenges to implementing WBMRI include scanner availability, financial constraints, reporting time, and radiologist training. CONCLUSION: Despite NICE recommendations regarding WBMRI in diagnosis/follow-up of myeloma, SS (poor sensitivity and specificity) remains the most commonly performed first-line test. Radiologists, haematologists, and patients should continue to emphasise the superiority and benefit of modern and more accurate imaging, such that they are prioritised in clinical service planning.

The diagnostic performance of ultrasound-guided core biopsy in the diagnosis of head and neck lymphoma: results in 226 patients.

Many clinical guidelines for investigating lymphomas advise that surgical excision biopsy (SEB) should be performed for a confident diagnosis. It is increasingly recognized in clinical practice that ultrasound-guided core needle biopsy (USCNB) is a reliable diagnostic technique. We aimed to investigate the diagnostic efficacy of USCNB in head and neck lymphoma. A retrospective analysis of all diagnosed head and neck lymphomas between 2013 and 2018 was performed. Patient records, radiology and histopathology reports along with the biopsy technique: fine needle aspiration cytology (FNAC), USCNB, and SEB used were reviewed. The technique providing diagnosis and leading to initiation of treatment was identified. Two-hundred and thirty patients and 267 biopsy samples were included. A total of 226 patients underwent USCN. In 215 of 226 (95.1%) USCNB patients were fully diagnostic allowing for initiation of oncological treatment; 11 patients required a subsequent SEB to provide diagnosis. In four patients, SEB was the only investigation performed. Of the USCNB total number of procedures (number of patients n=230 is the same coincidentally as the number of USCNB procedures), 215 of 230 (93.5%) were fully diagnostic samples. In the majority of cases, USCNB provided a definitive diagnosis allowing initiation of oncological treatment, avoiding the need for SEB. USCNB should be considered the first-line diagnostic modality in appropriate cases, as it reduces time to initiate treatment, costs and avoids patients having to undergo unnecessary surgery and possible complications.

A national audit of radiology practice in cancer multidisciplinary team meetings.

AIM: A national audit reviewing compliance of imaging departments with the Royal College of Radiologist (RCR) standards for cancer multidisciplinary team meetings (MDTMs). MATERIALS AND METHODS: The audit consisted of a generic and subspecialty component completed for breast, colorectal, and lung cancer MDTMs. RESULTS: The study achieved the highest response from a RCR national audit with 145/191 (76%) hospitals responding. Compliance with the RCR standards was suboptimal, particularly relating to MDTM attendance, documentation, and reviewing MDTM imaging. Comprehensive radiology MDTM attendance occurred in 52-65%, a supplementary report denoting staging/treatment plans happened in 15-26%, and late additions were discussed frequently without prior review of imaging (44-77%). Contributing factors maybe 13% of radiologists had no programmed activity for MDTMs in their job plan and a perceived negative impact of increasing MDTM referrals (51%). Adjuncts to improve MDTM workload, such as treatment pathways/algorithms (breast/colorectal 54%) and pro-forma (43-50%), were poorly implemented. Discrepancies with the original imaging report highlighted at MDTMs were well documented (92-94%) and frequently presented at discrepancy meetings (70-81%). Learning from involvement in MDTM was well communicated with 76-84% providing peer feedback. CONCLUSIONS: Radiologists are unable to comprehensively attain the RCR MDTM standards on providing and documenting a specialist opinion on the imaging. Increasing referrals to the MDTM appears the predominant factor and differentiating complex cases that benefit from MDTM discussion from those that can be managed via treatment pathways is required. Improved utilisation of pre-MDTMs/pro-forma and information technology in MDTMs may further aid radiologists to provide consistent high-quality contribution towards MDTMs.

Royal College of Radiologists national audit evaluating the provision of imaging in the severely injured patient and compliance with national guidelines.

AIM: To evaluate the provision of imaging in severely injured patients and com pliance with national guidelines. MATERIALS AND METHODS: Two data collection tools were sent to all Royal College of Radiologist audit leads in radiology departments with an emergency department throughout the UK. The first focused on configuration of radiology departments, number of patients scanned for major trauma and service configuration for major trauma. The second focused on reporting times for 30 patients scanned for major trauma. RESULTS: Eighty-five out of 191 (45%) eligible departments responded: 16 (19%) from major trauma centres, 52 (61%) from trauma units and 17 (20%) from other hospitals with an emergency department. Data were collected for 2,161 scans: 450 from major trauma centres, 1,400 from trauma units and 311 from emergency departments. Seven hundred and eighty-four (36%) scans were performed in hours and 1361 (63%) out of hours. Two hundred and forty (11%) scans had a primary survey report documented, of which 53 (22%) were unavailable to clinicians after 20 minutes. Time to final consultant report was within 1 hour for 1,033 (48%) scans and within 2 hours for an additional 540 (25%) scans. 34/85 (40%) departments have registrars first on call for major trauma who report scans out of hours and have a consultant final report the next day. CONCLUSIONS: This study highlights significant deficiencies in care and imaging of severely injured patients within major trauma centres and trauma units. Infrastructure and staffing have been underfunded and under resourced to meet rapidly changing best practice requirements in the management of major trauma.

Age-related neurochemical and behavioural changes in D409V/WT GBA1 mouse: Relevance to lewy body dementia.

Heterozygous mutations in GBA1, the gene which encodes the lysosomal enzyme glucocerebrosidase (GCase), are a strong genetic risk factor for the development of Lewy body dementia (LBD). Until this point however, recapitulation of the symptoms and pathology of LBD has been limited to a homozygous GBA1 mouse model which genetically and enzymatically reflects the lysosomal storage disorder Gaucher's disease. This study reports for the first time cognitive impairment by two independent behavioural tests in heterozygous GBA1 mutant mice (D409V/WT) which demonstrate significant cognitive impairment by the age of 12 months. Furthermore, reductions in GBA1 GCase enzyme activity within the brain reflects levels seen in sporadic and GBA1 mutant LBD patients. While there is no overt deposition of Lewy bodies within the hippocampus, alterations to cholinergic machinery and glial proliferation are evident, both pathological features of LBD. Interestingly, we also describe the novel finding of significantly reduced GBA2 GCase enzyme activity specifically within the hippocampus. This suggests that reduced GBA1 GCase enzyme activity dis-equilibrates the finely balanced glycosphingolipid metabolism pathway and that reductions in GBA2 GCase enzyme could contribute to the pathological and behavioural effects seen. Overall, this study presents evidence to suggest that pathological hallmarks associated with LBD specifically affecting brain regions intrinsically linked with cognition are present in the D409V/WT mice. In the absence of Lewy body deposition, the D409V/WT mice could be considered an early pre-clinical model of LBD with potential for drug discovery. Since few robust pre-clinical models of LBD currently exist, with further characterization, the mouse model described here may contribute significantly to developments in the LBD field.

Current applications of ultrasound-guided wire localization in head and neck surgery.

Ultrasound-guided wire localization (USGWL) was originally developed for the removal of impalpable breast lesions. More recently, USGWL has been described in head and neck surgical practice and it has a number of applications in this field, with the potential to guide surgical exploration and the benefits of reducing operative time and morbidity. This technical note describes the use of preoperative USGWL to facilitate the removal of an impalpable neck node. A review of the current literature relating to the present applications of this technique in head and neck surgery is reported, highlighting its advantages and disadvantages.

Bicycle helmets are protective against facial injuries, including facial fractures: a meta-analysis.

Cycling is a popular activity. However there are risks associated with cycling, including facial injury. Helmets are often worn to prevent head injury. Evidence for their protection against facial injury is limited. This meta-analysis investigated the effect of bicycle helmets on the incidence of facial injury. The PubMed/MEDLINE, Google Scholar, and Cochrane Library databases were searched. Studies included were observational and involved adult participants. Paediatric studies, studies on helmet legislation, and those combining facial injuries with other injury types were excluded. The studies were evaluated by two reviewers. Risk of bias was assessed using the RevMan bias assessment tool. Odds ratios (OR) were extracted for facial injuries and facial fractures. Two meta-analyses were performed using these categories. Nine of the 102 studies identified were included. Helmets were protective against facial injury (OR 0.69, 95% confidence interval 0.63-0.75, P<0.0001). Five studies reported facial fracture rates; helmets were protective against these also (OR 0.79 95% confidence interval 0.70-0.90, P=0.0003). There are no randomized controlled trials on this topic and the number of studies available is small. Bicycle helmets offer protection against facial injuries and this should be considered by cyclists when deciding whether or not to use one.

Setting up a parathyroid multidisciplinary team meeting: one year's experience, outcomes and learning points.

OBJECTIVE: A parathyroid multidisciplinary team meeting was set up at East Sussex Healthcare Trust, from November 2014 to November 2015, in order to improve and streamline services for patients with parathyroid pathology. METHODS: Data were collected on all new referrals for hyperparathyroidism, and on the outcomes for each patient discussed at the meeting, including the number of operations and management outcomes. A survey was sent out to the members of the multidisciplinary team meeting to determine their perception of its effectiveness. RESULTS: Seventy-nine new referrals were discussed throughout the year; 43 per cent were recommended for surgery, 41 per cent had a trial of conservative or medical management before re-discussion, and 16 per cent required further imaging. Ninety-two per cent of patients underwent an ultrasound, single-photon emission computed tomography/computed tomography or nuclear medicine (sestamibi) scan prior to the meeting. All ultrasound scans were performed by a consultant radiologist. CONCLUSION: The multidisciplinary team meeting has been successful, with perceived benefits for patients, improved imaging evaluation and efficiency of referral pathways, leading to more appropriate patient management.

RCR audit of compliance with UK guidelines for the prevention and detection of acute kidney injury in adult patients undergoing iodinated contrast media injections for CT.

AIM: To determine radiology departmental compliance with current UK guidance on contrast-induced acute kidney injury (CI-AKI) and to provide data on the incidence of clinically significant post-contrast AKI (PC-AKI) in computed tomography (CT) practice. MATERIALS AND METHODS: A questionnaire was sent to all UK acute National Health Service (NHS) providers (NHS boards in Scotland, local health boards in Wales, NHS trusts in England and health and social care trusts in Northern Ireland) to assess compliance of provider protocols with current UK guidelines for the prevention, recognition, and management of CI-AKI. Audit data were collected for 40 consecutive fit outpatients and 40 consecutive acutely unwell patients/inpatients from hospitals within each participating provider to assess clinical compliance. RESULTS: Eighty-nine of 172 (52%) health service providers responded, and data on 7,159 contrast-enhanced CT examinations were provided. Compliance with guidelines was poor with wide variation in clinical practice. The observed incidence of clinically significant (requiring treatment or resulting in death) PC-AKI was zero in 3,590 outpatients, although two patients developed AKI due to other causes (sepsis and progressive malignancy). Fourteen out of 3,569 (0.4%) patients in the inpatient group developed clinically significant PC-AKI, and a further 17 patients were identified who met the Kidney Disease Improving Global Outcomes (KDIGO) definition of AKI (Electronic Supplementary Material Appendix S1), but did not require active treatment, giving an overall incidence of AKI of 0.9%. In patients at high risk due to impaired renal function prior to the scan, there was no difference in the median serum creatinine (SCr) before and after contrast medium administration in either group. CONCLUSION: Health service provider protocols and clinical practice demonstrate poor compliance with current UK guidance on CI-AKI. A very low incidence of PC- AKI was demonstrated.

Ultrasound-guided wire localisation to facilitate removal of an abnormal neck lymph node - a technical note.

BACKGROUND: Ultrasound-guided wire localisation is a technique that is well established in breast surgery, but is not well described in head and neck practice. It can be used to locate impalpable lesions for surgical removal, without the need for more extensive surgery. METHOD: This paper describes a case where the technique was used to assist in the removal of an impalpable but radiologically abnormal lymph node. CONCLUSION: The technique offers a safe and effective method for removing lesions within the head and neck.

The effect of routine radiological reporting of thyroid incidentalomas on rates of thyroid needle biopsy, thyroid surgery and detection of thyroid malignancy.

OBJECTIVE: This study looked at the effect of a changing radiology reporting policy to routinely review the thyroid gland where visible and report on any thyroid lesion, recommending further investigation as appropriate. CONTEXT: Incidentaloma is a term used to describe a lesion found on imaging unrelated to the clinical issue under investigation. There is variability in the radiological reporting of thyroid incidentalomas and conflicting recommendations as to how these lesions should be managed. DESIGN: Data were collected retrospectively during a two-year period, including 12 months before and 12 months after the change in reporting policy and categorized according to whether the lesion under investigation was a thyroid incidentaloma or a symptomatic thyroid lesion. PATIENTS: All patients undergoing ultrasound-guided fine-needle aspiration cytology or core biopsy were included. MEASUREMENTS: The effects of the change in policy were analysed including rates of needle biopsy, rates of malignancy and subsequent surgical intervention. RESULTS: There was a 122% increase in thyroid incidentalomas undergoing needle biopsy, the majority of these were detected on computed tomography. The number of malignancies increased from 1 to 4 from year 1 to year 2. All patients were >35 years old. One patient had a positron emission tomography (PET)-detected cancer, two of four of the non-PET-detected malignancies were <1.5 cm. CONCLUSION: This study posits that routine radiological reporting of thyroid incidentalomas, with further investigation when clinically appropriate, is warranted. The results suggest that lesion size and CT characteristics are not reliable criteria to triage patients for investigation/biopsy.