Accident and emergency and general practitioner plain radiograph reporting by radiographers and radiologists: a quasi-randomized controlled trial.

Two specially trained radiographers at York District Hospital have been reporting appendicular plain radiograph X-ray examinations for Accident and Emergency (A&E) patients since February 1995. This study explores the potential for further expanding their reporting role. This was achieved by assessing the two radiographers' and a group of consultant radiologists' ability to report on a retrospectively selected random stratified sample of 400 A&E and General Practitioner (GP) plain radiograph X-ray examinations for all body areas. Using receiver operating characteristic (ROC) curve analyses there was no statistically significant difference at the 5% level between the area under the ROC curves for the radiographers and consultant radiologists when reporting A&E or GP plain radiographs. It may be feasible to expand the reporting role of suitably trained radiographers to include plain radiograph X-ray examinations for all A&E patients and for GP patients, with no detriment to the quality of reports.

Testicular microlithiasis: prevalence and tumor risk in a population referred for scrotal sonography.

OBJECTIVE: Considerable accrued evidence points to an association between testicular microlithiasis, intratubular germ cell neoplasia, and testicular tumor. This study assesses both the prevalence of testicular microlithiasis revealed on sonography in a referred population and the concurrent tumor risk. MATERIALS AND METHODS: Over a 32-month period (April 1996 through November 1998), 4892 scrotal sonographic examinations were performed in 4819 patients at four referral centers. All patients underwent high-resolution (7- to 10-MHz) imaging. Using a computerized word search (n = 4102; testicular microlithiasis, calcification, microliths, calcific foci, tumor, neoplasm, cancer, hyperecho, hypoecho, heterogen, and carcinoma) and manual retrieval (n = 790), cases of tumor, testicular microlithiasis (>5 microliths per sonogram), and testicular microlithiasis plus tumor were pulled and retrospectively reviewed. The presence and type of tumor were confirmed at histology after orchidectomy. RESULTS: Fifty-four tumors were found among 4892 scrotal sonograms (28 seminomas, 14 teratomas, 8 mixed germ cell tumors, 2 Leydig cell tumors, and 2 non-Hodgkin's lymphomas). Testicular microlithiasis was present in 33 patients, giving a prevalence of 0.68%. Concurrent tumor and testicular microlithiasis were detected in seven patients, a relative risk of tumor in testicular microlithiasis was 21.6-fold (95% confidence limits: 10. 6-fold, 44.2-fold). In one patient with testicular microlithiasis, a previous orchidectomy for mixed germ cell tumor had been performed (not included in the relative risk calculation). CONCLUSION: In a referred population of 4819 patients the prevalence of testicular microlithiasis was 0.68% and the relative risk of concurrent tumor was 21.6-fold. Sonographic surveillance of testicular microlithiasis cases for tumor is mandatory.

Personnel exposure rates during simulated biopsies with a real-time CT scanner.

RATIONALE AND OBJECTIVES: Real-time computed tomography (CT) has the potential to expedite and improve CT-guided needle biopsies by allowing cross-sectional images to be viewed in real time as a needle is advanced toward the target lesion. A major concern about this procedure is the scattered and leaked radiation to which the operator is exposed. This study was undertaken to determine the exposure rates around a CT scanner during CT-guided needle biopsies and to identify the areas of greatest personnel exposure. MATERIALS AND METHODS: Pig and human cadavers were used to simulate patients undergoing a CT-guided needle biopsy. Various anatomic biopsy sites were used. The radiologist's exposure was assessed by timing the procedure and measuring the exposure rates around the CT scanner with an ionization-chamber survey meter. Ion-chamber measurements multiplied by the time the radiologist spent performing several mock biopsies were compared with film dosimeter results. Doses to the hands, wrists, and whole body were measured with ring, wrist, body, and collar film dosimeters. RESULTS: The average time required to perform a single biopsy was about 1 minute. The dose to the radiologist performing the simulated biopsies was calculated to be 123 mR, 68 mR, 14 mR, and less than 0.5 mR to the fingers, wrist, collar, and body, respectively, as calculated from ionization-chamber and time measurements. These exposure rates correlate well with the film dosimeter readings accumulated during the mock procedures. CONCLUSION: The dose received by the radiologist performing a CT-guided biopsy was comparable to that of other interventional procedures. In addition, operating from the head of the machine (ie, distal to the bed) appeared to markedly reduce personnel exposure, due to the shielding in the gantry of the CT scanner used in the study.

A comparative analysis of radiological and surgical placement of central venous catheters.

PURPOSE: To compare the differences in practice and outcome of all radiologically and surgically placed central venous catheters retrospectively over a 2-year period simultaneously, at a single institution. METHODS: A total of 253 Hickman catheters were inserted in 209 patients; 120 were placed radiologically in 102 patients and 133 were placed surgically in 107 patients. The indication was chemotherapy in 76% of radiological and in 47% of surgical cases; the remainder were for total parenteral nutrition and venous access. RESULTS: There were 6 (4.5%) primary surgical failures and a further 17 (13%) surgical cases requiring multiple placement attempts. Pneumothorax occurred once (0.8%) surgically and four times (3.3%) radiologically. There were no radiological primary misplacements but there were five (3.7%) surgical ones. Catheter or central vein thrombosis occurred in four (3.3%) radiological and five (3.7%) surgical cases. The rate of infection per 1000 catheter-days was 1.9 in radiologically placed catheters and 4.0 in surgically placed ones (p < 0.001). Average catheter life-span was similar for the two placement methods (100 +/- 23 days). CONCLUSION: Radiological placement is consistently more reliable than surgical placement. There are fewer placement complications and fewer catheter infections overall.

Pulsatile lower limb venous Doppler flow: prevalence and value in cardiac disease diagnosis.

The purpose of this study was to assess the frequency and significance of pulsatile Doppler waveforms in lower limb veins. We used Doppler sonographic data from the common femoral vein. In the first of two groups, the findings in 250 patients were correlated with the presence of cardiac decompensation on concurrent chest radiographs. In the second group, the findings in 81 patients were correlated with the presence of tricuspid regurgitation on Doppler echocardiograms. A venous Doppler sonographic examination was considered normal if spontaneous anterograde phasic flow was present and pulsatile if flow had a cyclic retrograde component. In group 1, 21% had pulsatile waveforms whereas 24% had cardiac decompensation. In group 2, 36% had pulsatile waveforms and 43% had tricuspid regurgitation. A statistically significant correlation was found between the presence of these abnormal waveforms and cardiac decompensation or tricuspid regurgitation, with sensitivities of 57% and 54%, specificities of 91% and 78%, positive predictive values of 66% and 66%, negative predictive values of 87% and 69%, and accuracies of 82% and 68%, respectively. In a subgroup of 55 patients who had both tests for correlation and in whom both were in agreement, the sensitivity of venous Doppler sonographic examination for detecting pathologic cardiac conditions was 79%, specificity was 87%, positive predictive value was 83%, negative predictive value was 84%, and accuracy was 84%. In 77 patients with pulsatile waveforms, including 24 without concurrent chest radiographs or echocardiograms, 63 (82%) had no prior history of cardiac disease. When correlated separately with chest radiograph or Doppler echocardiography, the test is not very sensitive in the diagnosis of cardiac disease; however, when both correlating tests are performed and are in agreement, all diagnostic parameters of the venous Doppler sonographic test, including sensitivity, become fairly high. The presence of pulsatile lower limb venous Doppler flow should alert the sonologist that a pathologic cardiac condition may be the culprit, especially in patients who have no such prior diagnosis.

Curved needle technique for the avoidance of interposed structures in CT-guided percutaneous fine needle biopsy.

A previously unreported technique by which interposed structures can be avoided in CT-guided percutaneous fine needle biopsy is described. Fine gauge biopsy needles are curved before insertion, either directly or through a coaxial guidance needle. The are described by the needle allows an intervening structure to be avoided.

Paraovarian and paratubal cysts: preoperative diagnosis using transabdominal and transvaginal sonography.

OBJECTIVE: Paraovarian and paratubal cysts constitute about 10% of adnexal masses. Our purpose was to determine whether pathologically proven examples of these lesions were correctly identified during preoperative transabdominal and transvaginal sonographic evaluations. METHODS: Between 1990 and 1994, 15 women with 10 paraovarian cysts and 5 paratubal cysts undewent preoperative sonography. The sonograms were performed using transabdominal and transvaginal probes. Mean interval before surgery was 22 days (range: 1-96 days). The sonographic interpretation at the time of the examination was correlated with the pathological findings. RESULTS: In only 1 of 15 patients was a paraovarian or paratubal cyst suggested before surgery. Paraovarian cysts were misdiagnosed as ovarian cysts. Because of the microscopic size of paratubal cysts in our series, none was diagnosed before surgery and these were usually an incidental finding in patients with ovarian masses. CONCLUSIONS: In our experience, paraovarian and paratubal cysts are difficult to diagnose before surgery with the use of transabdominal and transvaginal sonography. We speculate that when there is close proximity of a paraovarian cyst to the ovary, an ovarian cystic mass cannot reliably be differentiated from a paraovarian cyst.

Incidental kill of dunlin and killdeer by strychnine.

Strychnine poisoning of 36 dunlin (Calidris alpina) and two killdeer (Charadrius vociferus) in Yolo County, California (USA) was documented from 11 to 17 December 1990. Birds were found dead on a field containing treated wheat seeds (337 micrograms strychnine/g seed) in postures consistent with the known physiopathology of strychnine poisoning: rapid rigor mortis, wings folded over backs, straightened toes, and fecal material extruding from vents. Five dunlin and two killdeer were necropsied, and their crop and stomach contents were analyzed by high performance liquid chromatography for the presence of strychnine. The mean (+/- SD) actual unabsorbed strychnine concentration per amount stomach content for the five dunlin was 110 (+/- 108) micrograms/g and for the two killdeer, 210 (+/- 109) micrograms/g. Shorebirds have not been identified previously as victims of pesticides.

Implantation metastasis alongside an intraperitoneal chemotherapy catheter in ovarian carcinoma.

An elderly woman with recurrent ovarian malignancy was treated with intraperitoneal chemotherapy, administered via a subcutaneously buried catheter. She developed the unusual complication of a metastasis along the course of this catheter.

Sonography of acute appendicitis in pregnancy.

BACKGROUND: Clinical evaluation of acute appendicitis is difficult in pregnant patients. Delay in diagnosis is associated with increased fetal mortality. The purpose of our study was to assess the value of sonography in the diagnosis of acute appendicitis in pregnant women. METHODS: We obtained sonograms in 22 pregnant women suspected of acute appendicitis. All sonograms were performed using graded-compression to detect an enlarged appendix. The sonographic criteria for acute appendicitis were detection of a noncompressible blindended and tubular multilayered structure of maximal diameter greater than 6 mm. RESULTS: The sonographic findings were correlated with surgical findings in seven cases and clinical follow-up in 15 cases. Acute appendicitis was diagnosed by sonography in three of 22 patients, and in all but one was confirmed by surgical and pathologic findings. In the remaining 19 patients, 15 improved on clinical followup; three were shown to have a normal appendix at surgery and one had focal acute inflammation at the tip of the appendix. CONCLUSIONS: Our experience suggests that graded-compression sonography is a useful procedure in pregnant patients suspected of acute appendicitis and has a similar accuracy as in nonpregnant women, especially in the first and second trimester.

Predictive value of normal endovaginal sonography in excluding disease of the female genital organs and adnexa.

Endovaginal sonograms of all patients that were interpreted normal during 1990 (12 months) were reviewed. Fifty-nine patients with normal EVS (age range, 18 to 63 years; average, 35 years) were followed either clinically for at least 12 months (average, 23 months) (N = 33) or until a definite diagnosis was established by a definitive procedure (N = 26). Of the 33 patients followed clinically, a definite diagnosis was established in nine, whereas in the remaining patients the symptoms resolved without further evaluation. Of the 26 undergoing definitive procedures, a diagnosis was established (six patients) or the procedure revealed normal pelvic organs (20 patients). A missed diagnosis on EVS was defined as failure to see pathologic lesions in the female pelvic genital organs or adnexa. According to our definition, five lesions were missed by EVS. The negative predictive value from a normal EVS was 92%, using patient outcome as the reference standard.

Satisfaction of search in the detection of plain-film abnormalities in abdominal contrast studies.

RATIONALE AND OBJECTIVES: Satisfaction of search (SOS) occurs when a lesion is "missed" after detecting another lesion in the same radiograph. The authors investigated the SOS effect in abdominal contrast studies. METHODS: The authors measured detection of 23 plain film abnormalities in 43 patients who had plain film and contrast examinations. Each plain-film and contrast study was examined independently by 10 radiologists in two sessions, with receiver operating characteristic (ROC) curve areas estimated with the computer program RSCORE-J (University of Iowa, Iowa City, IA) for each condition. RESULTS: Observers more often missed plain film abnormalities present on contrast studies but also made fewer false-positive (FP) responses. There was no change in ROC area, but decision criteria grew more conservative. CONCLUSIONS: The reduction of detecting plain-film abnormalities in contrast examinations differs from the SOS effect of other imaging studies. The reduction in true-positive (TP) and false-positive (FP) rates suggests that a different cause may underlie these misses.

Presacral abscesses: percutaneous transperineal drainage with use of bone landmarks and fluoroscopic guidance.

Presacral abscesses developed in two men (aged 59 and 76 years) after abdominoperineal resection. Computed tomography was performed to demonstrate the distance from the abscess to the perineum and the distance of the abscess anterior to the sacrum. Then, lateral and anteroposterior fluoroscopy was performed to guide transperineal drainage catheter placement. No complications occurred, and clinical outcome was successful in both cases.

Complications of intraarterial digital subtraction angiography in patients investigated for cerebral vascular disease.

395 patients (236 males, mean age 55.6 years: 159 females, mean age 52.2 years) with suspected transient ischaemic attacks or previous strokes underwent intraarterial digital subtraction angiography (IADSA) over a 3-year period ending in March 1991. All procedures were performed via the femoral approach and the majority consisted of arch studies followed by selective catheterization. 253 (64.1%) of the patients had extracranial vascular disease confirmed at angiography. A retrospective analysis of the patients' records was made to extract all possible complications. Complications were defined as any untoward symptoms or signs occurring within 48 h and which could have been related to the angiogram. Neurological complications occurred in 15 (3.89%) patients. 10 (2.5%) patients had transient complications which resolved completely within 24 h. In three (0.8%) patients the neurological deficit was reversible, recovering fully within 6 days. Two (0.52%) patients were left with residual disability from stroke at 10 days. The permanent neurological complication rate is in the lower range of the rates recorded in previous conventional angiographic studies. We conclude that IADSA is a relatively safe and reliable form of investigation in patients with suspected cerebral vascular disease.