Patient dose optimization in plain radiography based on standard exposure factors.

A computational technique for assessing patient dose in plain radiography is described allowing a large number of examinations to be assessed and enabling dose optimization to be promoted. Entrance surface dose (ESD) was calculated for more than 1500 standard exposure settings in an initial dose assessment. Validation of the technique showed good agreement with thermoluminescent dosimetry and showed broad agreement between the standard exposures and the exposure settings used in practice. The dose assessment was repeated 18 months later using the same techniques for almost 2000 standard exposure settings. In both cases, calculated doses showed good compliance with national diagnostic reference levels where available. Suggested investigation levels were established and set at twice the mean dose for each of 47 examinations. Radiology departments were encouraged to review and optimize doses exceeding these levels. The computed mean ESD in the review study was less than the corresponding value in the initial study in 37 of the 47 examinations. The dose reduction was attributable partly to equipment replacement, but primarily to optimization of exposure settings. The technique employed here provides a valid and cost effective method of complying with statutory requirements for the assessment of representative patient dose and is useful in assisting the ongoing process of dose optimization.

Ultrasound measured renal length versus low dose CT volume in predicting single kidney glomerular filtration rate.

Ultrasound measured renal length and CT measured renal volume are potential surrogate markers for single kidney glomerular filtration rate (SKGFR). The aims of this study are to determine: (1) the repeatability of ultrasound measured length and low radiation dose spiral CT measured volume; (2) the relationship between renal length and volume; and (3) whether length and/or volume is a predictor of SKGFR. 69 patients with suspected renal artery stenosis underwent ultrasound renal length measurement, CT evaluation of renal volume and assessment of SKGFR. 40 patients had ultrasound measurement of length and CT evaluation of volume performed twice on two separate visits. 25 patients also had ultrasound measured renal parenchymal thickness and area. The region of interest was drawn around the kidneys and a threshold set to subtract renal peripelvic fat and renal pelvis. The volume from each slice was summed to obtain the total volume for each kidney. The limits of agreement for ultrasound measured renal length were -1.6 cm to 1.52 cm and that for CT renal volume were -33 ml to 32 ml. There was significant correlation between ultrasound measured length and CT volume (r=0.74, p<0.01). Volume was a better predictor of SKGFR (r(2)=0.57) than length (r(2)=0.48). The combined parameters of ultrasound measured length, area and parenchymal thickness were a better predictor of volume (r(2)=0.81) and SKGFR (r(2)=0.58) than ultrasound measured length on its own. The low dose CT technique was reasonably reproducible and renal volume measurements correlate better with SKGFR than length. Ultrasound predictions of renal volume and SKGFR can be improved by incorporating cross-sectional area and parenchymal thickness. Further investigation is required to refine our low dose CT technique.

3D gadolinium-enhanced MRI venography: evaluation of central chest veins and impact on patient management.

AIM: To assess the value of a simplified 3D gadolinium-enhanced magnetic resonance imaging (MRI) venography for central chest veins. MATERIALS AND METHODS: In this retrospective study of 24 patients, the MRI findings and medical records were reviewed to determine whether MRI results correlated with subsequent findings, and to determine the effect on clinical management. 3D steady state gradient-echo sequence, fast imaging with steady state precession (FISP), was used. We employed a simplified protocol not requiring bolus timing or subtraction to achieve rapid data acquisition and hence good compliance in this group of frail patients. Following intravenous administration of a bolus of gadolinium, two acquisitions were obtained in order to ensure adequate opacification of all veins. Individual partitions and maximum intensity projections were then analysed to determine whether the veins were patent, stenosed or occluded. RESULTS: The indications for MRI were to assess the patency of central veins for the purpose of cannulation or arteriovenous fistula formation in 17 patients. Out of the 12 patients who proceeded to an intervention, MRI venography successfully predicted an appropriate site in 10 patients. In the remaining seven patients, MRI venography was valuable in confirming or excluding the clinical suspicion of central venous thrombosis and directly influenced the management in five patients. CONCLUSION: 3D gadolinium-enhanced MRI venography is a valuable means of providing a global representation of the central venous system and guiding subsequent central venous cannulation.

Biochemical and biophysical markers of endothelial dysfunction in adults with hypopituitarism and severe GH deficiency.

Adult hypopituitarism is known to be associated with reduced life expectancy related to excess vascular events, and endothelial dysfunction is present in patients with this condition. We studied the relationship between biophysical and biochemical markers of endothelial dysfunction, including E-selectin, intercellular cell adhesion molecule-1, von Willebrand factor, and thrombomodulin in 52 adult patients with hypopituitarism and severe GH deficiency (<2 ng/ml on provocative testing) compared with 54 age-, sex-, and smoking-matched normal controls. We also examined endothelium-dependent dilatation of the brachial artery to postischemic occlusion and carotid artery morphology (intima-media thickness) by high-resolution ultrasonography. The patients were stable on conventional hormone replacement therapy but not on GH therapy, and none of the subjects had a known risk factor for vascular disease. Levels of E-selectin [57 +/- 3 vs. 49 +/- 2 ng/ml (mean +/- SEM)] (P < 0.043), intercellular cell adhesion molecule-1 (308 +/- 11 vs. 266 +/- 10 ng/ml) (P < 0.001), thrombomodulin (49 +/- 3 vs. 35 +/- 2 ng/ml) (P < 0.001), and von Willebrand factor (132 +/- 7% vs. 105 +/- 5%) (P < 0.004) were significantly higher in patients than in controls. Brachial artery endothelium-dependent dilatation was significantly lower in patients than in controls [4.7% (0.00-9.77) vs. 10.5% (6.4-16.2) (median, interquartile range)] (P < 0.001). This difference in endothelium-dependent dilatation was more marked in female patients than in controls (P < 0.003), although it disappeared when estrogen-sufficient female patients were compared with controls (P = 0.31). However, the female patients who were not replaced with estrogen continued to show a striking difference compared with estrogen-deficient control females (P < 0.004). There was no difference in carotid intima-media thickness between patients of either sex and controls. On univariate analysis, brachial artery endothelium-dependent dilatation correlated inversely with intercellular cell adhesion molecule-1 (r = -0.225, P < 0.033). Intercellular cell adhesion molecule-1 correlated positively with E-selectin (r = 0.466, P < 0.0001) and negatively with IGF-I (r = -0.238, P < 0.016). E-selectin correlated with thrombomodulin (r = 0.215, P < 0.034) and von Willebrand factor (r = 0.218, P < 0.03) and negatively with IGF-I (r = -0.255, P < 009). Thrombomodulin correlated positively with von Willebrand factor (r = 0.422, P < 0.0001) and inversely with IGF-I (r = -0.266, P < 0.008). These correlations persisted after correction for age, sex, body mass index, and waist to hip ratio, with the exception of IGF-I, which now correlated with thrombomodulin only. These results confirm significant endothelial dysfunction in hypopituitarism and provide insight into the relationship of biochemical and biophysical markers of early atherosclerosis in hypopituitary GH-deficient adults. The negative correlation of IGF-I with some biochemical markers of endothelial dysfunction and the predictive nature of GH deficiency in stepwise regression analysis in this study supports the hypothesis that GH deficiency may play a role in these abnormalities. Future studies will determine whether GH treatment can reverse these abnormalities. Furthermore, the more significant endothelium-dependent dilatation abnormality in the female estrogen-deficient subjects compared with those who were estrogen replete suggests that estrogen replacement in these patients is a crucial element in protecting against vascular disease.

Comparison of CT angiography with conventional arterial angiography in aortoiliac occlusive disease.

This study compared the results of conventional and CT angiography of the aortoiliac segment in 35 patients with occlusive disease. Disease severity was graded into five categories. Two assessors independently assessed the segment from the distal abdominal aorta to the proximal superficial femoral artery and a consensus was formed. There was interobserver agreement in 87% of segments for conventional angiography and in 78% for CT angiography. Comparison of the two modalities gave identical grading in 84% of segments. Dissimilar grading was found in 16%, with a roughly equal number of undergrading and overgrading. CT angiography has the advantages of being minimally invasive, requiring only an intravenous injection of contrast medium and imaging surrounding soft tissues. Multiplanar reconstruction aids the visualization of asymmetrical stenoses, and collateral blood supply is readily appreciated. However, CT angiography may fail to demonstrate short stenoses owing to limited z-axis resolution.

Effective dose to children and adolescents from radiopharmaceuticals.

Published values of tissue weighting factors for adolescents and children derived from the life-span study of the atomic bomb survivors have been used to calculate the effective dose to patients aged 1, 5, 10 and 15 years undergoing a common paediatric procedure requiring one of the following radiopharmaceuticals: 99Tcm-mercaptoacetyltriglycine (MAG3), 99Tcm-diethylenetriaminepentaacetic acid (DTPA), 99Tcm-dimercaptosuccinic acid (DMSA), 99Tcm-pertechnetate, 99Tcm-iminodiacetic acid (IDA) derivatives, 99Tcm-hexamethylpropyleneamineoxine (HMPAO), 99Tcm-labelled leukocytes, 99Tcm-labelled erythrocytes, 99Tcm-phosphates, 99Tcm-methyloxyisobutylisonitrile (MIBI), 201Tl-chloride, sodium 123I-iodide, 123I-metaiodobenzylguanidine (MIBG) and 67Ga-citrate. Administered activities for each age group were based on ARSAC maximum usual values for adult patients and scaling factors listed by the European Association of Nuclear Medicine for different body weights. These effective doses were compared to values derived from ICRP whole-population tissue weighting factors and found to differ by -33% to +71% of these values, and by less than +/- 20% for two-thirds of the procedures. Because these differences were considerably less than the uncertainties in the estimates of organ absorbed dose, we conclude that these published age-specific tissue weighting factors should not be used for the estimation of effective dose to children and adolescents following the administration of radiopharmaceuticals, and that whole-population factors should continue to be used for these estimations.

Biliary imaging by spiral CT cholangiography--a retrospective analysis.

CT cholangiography employs spiral CT scanning after the administration of biliary contrast medium to generate three-dimensional images of the biliary tract. A retrospective review of 61 patients who had undergone CT cholangiography was performed to determine the technical efficacy and the clinical utility of the technique. The results of CT cholangiography were analysed retrospectively to determine technical success rate of the imaging procedure and to correlate imaging diagnosis with results of other diagnostic procedures and with clinical follow-up. 60 of the 61 examinations produced technically satisfactory images. 21 of these examinations showed bile duct abnormalities. (12 stones, 6 duct dilatation to papillary level, 2 post-operative strictures and 1 case of sclerosing cholangitis). The remaining 39 cases showed no bile duct abnormality. In 59 of the 60 cases, subsequent investigations and follow-up supported the CT cholangiographic diagnosis. CT cholangiography is a robust technique for imaging of the biliary tract and is a valuable addition to the battery of non-invasive biliary investigations.

Radiological outcome in ankylosing spondylitis: use of the Stoke Ankylosing Spondylitis Spine Score (SASSS).

We investigated the role of the Stoke Ankylosing Spondylitis Spine Score (SASSS) in a longitudinal cohort study of 53 patients with AS, assessed 9 yr apart, and its relation to clinical, functional and laboratory measures of disease activity and outcome. We also examined the long-term predictive value of quantitative sacroiliac scintigraphy (QSS). SASSS correlated closely with clinical measures, including occiput-wall distance (OWD) (P < 0.001) and modified Schober (P < 0.001). QSS was significantly correlated with final X-ray score (P < 0.05). SASSS changed significantly (P < 0.001) over the study period; two patterns of change in spine score were discernible, one with little change in radiological score and the other showing marked progression. The SASSS is a useful, valid score, which correlates with clinical outcomes measures and which has identified specific patterns of radiographic progression in AS.

MRI characteristics of chondroblastoma.

We report a retrospective study of MR imaging of 16 patients with histologically proven chondroblastoma, 12 at primary presentation and four clinically suspected recurrences. In all the primary cases MR imaging showed a lobulated low signal intensity (SI) rim. Low SI foci within the tumour were present in 11 out of the 12 cases and corresponded to calcification seen on radiographs or CT. Bone marrow oedema was also present in 11 out of 12 cases and an adjacent joint effusion in eight out of 12. The STIR sequence was of particular value, giving optimal delineation of marrow and soft tissue oedema. Of the suspected recurrences one showed peritumoral oedema and was subsequently proven histologically. Three showed no peritumoral oedema and subsequent histology was negative in these cases. The presence or absence of oedema may be a useful indicator of tumour activity although further study is required.

Smoking and outcome in ankylosing spondylitis.

In view of the recognised influence of smoking on the disease course of psoriasis and ulcerative colitis, and the association of these diseases with seronegative spondyloarthritis, we investigated a possible effect on outcome in ankylosing spondylitis. Thirtyone non-smokers, 12 exsmokers, and 10 smokers, with definite ankylosing spondylitis of a median duration of 20 years, were studied using clinical values (modified Schober, finger floor distance, total spinal movement), radiological (lumbar spine x-ray score), functional index, and laboratory assessment (ESR, CRP, Igs). There were statistically significant differences in the outcome between smokers and non-smokers for finger floor distance (p < 0.01), Schober test (p < 0.01), total spinal movement (p < 0.001), occiput-wall distance (p < 0.01), functional index (p < 0.01), stiffness (p < 0.01), and spine x-ray scores (p < 0.02). There was no statistically significant difference between the groups with regard to disease duration or age at onset. We conclude that smoking is associated with poor long term outcome in patients with ankylosing spondylitis.

Multiple-infected diagnostic specimens from foot and mouth disease endemic regions.

The current routine diagnostic procedures for foot and mouth disease (FMD) virus antigen detection combine the use of an indirect sandwich enzyme-linked immunosorbent assay (ELISA) with virus isolation and amplification on cell culture. Several field samples recently received by the World Reference Laboratory for Foot and Mouth Disease which were initially diagnosed as containing a single virus type have subsequently been found to contain an additional virus type. Examples are given of the results of ELISAs performed on certain Saudia Arabian samples; these examples illustrate the problem which such multiple-infected samples present for laboratory diagnosis.

Technical note: femoral angiography using the reverse shuffle technique.

We report our findings using the "reverse shuffle" technique of stepping table femoral angiography. This technique represents a simple modification of the conventional stepping table sequence entailing a reverse table movement allowing acquisition of early and late films in the distal positions. It was developed in order to minimize the number of runs required in each examination. In a retrospective study 52/53 (98%) of angiograms using the reverse shuffle technique required only a single run compared with 30/51 (58%) using the conventional technique. We believe that the reverse shuffle should be used where possible when stepping table angiography is performed. Furthermore, the incorporation of a reverse table movement may also be advantageous in angiography using automated digital subtraction angiography (DSA) stepping systems.

An enzyme-linked immunosorbent assay for the detection of marine caliciviruses.

An indirect, sandwich enzyme-linked immunosorbent assay (ELISA) for the detection of antigens of vesicular exanthema, San Miguel sea lion viruses and other marine caliciviruses is described. The assay which uses rabbit and guinea-pig antisera to purified antigens of each calicivirus serotype has high sensitivity and is almost totally type-specific.

Mirizzi syndrome treated by percutaneous stone removal.

We report a case of Mirizzi syndrome due to a cystic duct stone occurring in a 66-year-old man in the presence of multiple debilitating medical conditions which precluded surgery. The patient was successfully treated by percutaneous stone removal and made a swift and uneventful recovery. This is the first report of Mirizzi syndrome due to a ductal stone being treated in this manner.

Freeze-drying foot-and-mouth disease virus antigens. II. For use in the ELISA.

Live and inactivated preparations of foot-and-mouth disease virus strains 01 BFS 1860 and A22 IRQ 24/64 were freeze-dried in the presence or absence of additive solutions and assessed for their reactivity by ELISA at intervals over a six month storage period at various temperatures and also after reconstitution and subsequent storage with or without glycerination. The type specificity of all antigen preparations was maintained throughout the study period and the potency of antigens, judged by titration in ELISA, remained constant during the freeze-drying procedure and throughout subsequent storage at -20 degrees C and 4 degrees C with or without additives having been made to virus suspensions prior to freeze-drying. This was also the case with antigens reconstituted and stored at either -20 degrees C with glycerol or at 4 degrees C without glycerol. Certain additive solutions were necessary, however, to preserve the activity of antigens stored at the elevated temperature of 37 degrees C. The reactivity of all freeze-dried antigens was not unduly affected in the liquid-phase blocking ELISA using bovine convalescent antisera of each of the seven serotypes of foot-and-mouth disease virus and known negative, non-immune bovine sera. The results suggest that shipment and long-term storage of freeze-dried foot-and-mouth disease virus antigens is possible for use in the ELISA in the absence of refrigeration. This has attractive advantages for reducing both shipment and storage costs of antigens and for the development of ELISA kits for the diagnosis of foot-and-mouth disease virus.

Freeze-drying foot-and-mouth disease virus antigens. I. Infectivity studies.

The ability of foot-and-mouth disease virus strains type O1 BFS 1860 and type A22 IRQ 24/64 to retain infectivity after freeze-drying with or without additives being made to virus suspensions was studied. The infectivity titres of freeze-dried antigens was assessed at intervals over a six month storage period at various temperatures and also after reconstitution to the liquid phase and storage with or without glycerination. Certain additive solutions were necessary to prevent degradation of virus during the freeze-drying procedure which reduced any loss of infectivity caused by storage of products at 4 degrees C and 20 degrees C. Additive solutions composed of 10% sucrose and 5% lactalbumin hydrolysate; 10% skimmed milk; 4% peptone and 1% gelatin; and 5% dextran, 1% sodium glutamate and 5% sucrose all prolonged the keeping qualities of virus at the elevated temperature of 37 degrees C. The results indicate that short-term storage and shipment of freeze-dried foot-and-mouth disease virus antigens is possible without the need for refrigeration, thereby reducing transportation and storage costs. Reconstituted antigens survived better after glycerination and storage at -20 degrees C than did non-glycerinated samples stored at 4 degrees C.

Use of inactivated foot-and-mouth disease virus antigen in liquid-phase blocking ELISA.

A liquid-phase blocking ELISA is used by the World Reference Laboratory for Foot-and-Mouth Disease for the quantification of antibodies to foot-and-mouth disease virus. The potential for using inactivated FMDV antigens in the assay has been assessed by titrating bovine convalescent sera to all seven serotypes and comparing the titres obtained with live or inactivated antigens. The titres were similar indicating that either live or inactivated antigens can be used in the liquid-phase blocking ELISA. Removing the need to use live antigens in tests for FMD antibody would reduce disease security risk and widen the acceptability of kits for FMD antibody detection and assay.