Informed consent guidelines for ionising radiation examinations: A Delphi study.

INTRODUCTION: Informed consent for ionising radiation medical imaging examinations is currently undertaken inconsistently in Australian radiographic practice. There is no uniform informed consent process, and opinions vary about how it should be undertaken, and by whom, if indeed it needs to be undertaken at all. To ensure that patients' rights are maintained, the informed consent process must be consistent, proactive in the provision of information, and must empower the patient to formulate and ask questions about their care, and to make voluntary decisions. METHODS: The Delphi technique utilises a group of experts whose individual responses are used to create a collective consensus on a process. This ten-expert (five radiographer, five radiologist) Delphi study examined a basic modelling of the process of informed consent for ionising radiation medical imaging examinations and made recommendations for an ideal process. RESULTS: A series of consensus statements were developed, seeking to rectify areas of the process that were inconsistent, unclear, or ethically unsound. These statements were then considered alongside current codes of professional practice, and Australian law on the duty of disclosure. A model of the ideal process was then developed using these consensus statements and adhering to codes of practice. CONCLUSION: The final process model has a continuity of care and a continuity of information provision. The model eliminates the radiographer as a delegatee, and emphasises physician involvement. The referrer and the radiologist have a shared responsibility of providing risk disclosure information. IMPLICATIONS FOR PRACTICE: For a non-pregnant adult, the ionising radiation dose from conventional radiography is considered insignificant, and does not require risk disclosure, ameliorating the time commitment needed for the process.

Barriers and pathways to informed consent for ionising radiation imaging examinations: A qualitative study.

INTRODUCTION: Informed consent for ionising radiation medical imaging examinations represents a recent change to medical imaging practice. This practice has not had a definitive and authoritative integration into clinical practice, and lack of direction has caused many health care professionals to be unsure of an appropriate consent methodology. Consent practices have been undertaken inconsistently and sometimes poorly. This research sought to investigate what barriers exist to meaningful informed consent, and what pathways are suggested to overcome these barriers. These views are then discussed in the context of practical health care consent practices. METHODS: A semi-structured interview explored the views of radiographers and radiologists on the practice of disclosing the ionising radiation risk of a clinical medical imaging examination. Qualitative data was analysed using a nominal method of quantitative transformation. Responses were reviewed, and a set of definitive themes constructed. Participants considered the influences, logistics and barriers to the informed consent process. Participants were then asked what pathways might be developed that would improve the process. RESULTS: Twenty-one (21) radiographer participants and nine (9) radiologists were interviewed. The barriers to consent identified issues of time constraints, lack of a unified message, and patient presentations. Pathways suggested included limiting the scope of the consent practice, sharing the consent responsibility, and formulation of definitive consent guidelines. CONCLUSION: A unified, definitive series of guidelines for informed consent for ionising radiation examinations would alleviate many of the identified barriers. Having the consent process consistently begin with the referring doctor would facilitate more meaningful consent.

Describing ionising radiation risk in the clinical setting: A systematic review.

INTRODUCTION: Meaningfully explaining the risk of an ionising radiation examination is a challenging undertaking. Patients must contextualise the risk against the expected benefit of the imaging examination, often in a situation of heightened emotion. This systematic review seeks to explore the literature to identify what techniques are advocated for disclosing the risk to patients of ionising radiation from clinical medical imaging examinations. METHODS: A systematic review of peer-reviewed literature was undertaken. Electronic databases were searched to identify peer-reviewed, full-text articles published in English from 1990. Original articles discussing techniques for disclosing ionising radiation risks in the clinical setting were included. The reference lists of the included articles were searched for unpublished articles and reports of use. RESULTS: Sixteen papers out of 5959 unique titles met the inclusion criteria. The data was extracted independently by two researchers and assessed for quality using the Joanna Briggs Institute critical appraisal tools. CONCLUSION: The two most commonly cited techniques for disclosing ionising radiation risk is to compare risk to the risk of common life events, and to describe risk as an additive risk to the baseline risk of cancer. The most commonly cited communication strategy was a graphical representation of the data, but simple language is also advocated. The use of a pictograph represents a technique which satisfied the advocated techniques of most articles.

Medical imaging and informed consent - Can radiographers and patients agree upon a realistic best practice?

INTRODUCTION: For radiographers, gaining informed consent with our patients represents a challenging undertaking. Reconciling the need to gain meaningful consent with time pressures represents one challenge, as does differing expectations of how risk communication should be undertaken. Different methods and thresholds of risk disclosure are considered, with the aim of finding a realistic best practice. METHODS: A cross-sectional study of radiographers and members of the public was undertaken. Participants were asked their preferences for how they would like to receive ionising radiation risk information. This included the health care professional(s) most suited to provide the information, the media through which the information was delivered, and the technique for delivering the information. In addition, participants were asked to consider hypothetical scenarios in which they were a patient receiving an ionising radiation examination, and to give the threshold of ionising radiation cancer risk which they would consider material. These scenarios considered variations in the cancer-onset time, and the accuracy of the test. RESULTS: One hundred and twenty-one (121) radiographer participants and one hundred and seventy two (172) members of the public met the inclusion criteria and completed the survey. There was strong agreement in the most appropriate media, and person, to disclose risk, as well as what represents a significant risk. There was considerable agreement in risk delivery technique. However, some of the agreed-upon strategies may be challenging to achieve in clinical practice. CONCLUSION: Radiographers and patients fundamentally agree upon risk communication strategies, but implementing some strategies may prove clinically challenging.

Ionising radiation risk disclosure: When should radiographers assume a duty to inform?

INTRODUCTION: Autonomy is a fundamental patient right for ethical practice, and informed consent is the mechanism by which health care professionals ensure this right has been respected. The ethical notion of informed consent has evolved alongside legal developments. Under Australian law, a provider who fails to disclose risk may be found to be in breach of a duty of disclosure, potentially facing legal consequences if the patient experiences harm that is attributable to an undisclosed risk. These consequences may include the common law tort of negligence. Ionising radiation, in the form of a medical imaging examination, has the potential to cause harm. However, stochastic effects cannot be attributable to a specific ionising radiation event. What then is the role of the Australian medical imaging service provider in disclosing ionising radiation risk? METHODS: The ethical and legal principles of informed consent, and the duty of information provision to the patient are investigated. These general principles are then applied to the specific and unusual case of ionising radiation, and what responsibilities apply to the medical imaging provider. Finally, the legal, professional and ethical duties of the radiographer to disclose information to their patients are investigated. RESULTS: Australian law is unclear as to whether a radiographer has a common law responsibility to disclose radiation risk. There is ambiguity as to whether stochastic ionising radiation risk could be considered a legal disclosure responsibility. CONCLUSION: While it is unlikely that not disclosing risk will have medicolegal consequences, doing so represents sound ethical practice.

Review of Eastern coral snake (Micrurus fulvius fulvius) exposures managed by the Florida Poison Information Center Network: 1998-2010.

CONTEXT: Envenomation by the Eastern coral snake is rare but may be associated with significant morbidity. While effective, acquisition of North American Coral Snake Antivenin (NACSAV) is difficult because production was discontinued for many years. OBJECTIVE: The purpose of this study is to characterize coral snake exposures in Florida and determine the effects of varying treatment paradigms on patient outcomes. METHODS: This study is an observational case series of cases received at Florida poison centers. Included cases were Eastern coral snake exposures occurring between January 1, 1998 and October 31, 2010. Excluded cases included those found to be unrelated or those not followed for at least 24 h post envenomation. Case comments were reviewed to obtain data. Comparisons were made between asymptomatic patients receiving empiric antivenom therapy (empiric group) and those asymptomatic patients who received antivenom upon developing signs of systemic envenomation (withhold group). RESULTS: Of the 553 cases identified, 387 were included in the final analysis. According to case comments, 56.3% of patients had no reported systemic symptoms. Most commonly, patients were reported to have pain (40.6%), paresthesias (28.4%), nausea (12.7%), and emesis (11.4%). NACSAV was administered to 252 patients (65%). Of those patients receiving NACSAV, 18.25% were reported to have had an adverse reaction. Patients in the withhold group (n = 106) had significantly fewer minor, moderate, and major outcomes than patients in the empiric group (n = 134, p < 0.01). DISCUSSION: While patients in the withhold group had favorable outcomes compared with those in the empiric group, this strategy cannot be applied to all patients presenting asymptomatic to healthcare facilities due to study limitations. CONCLUSION: Further studies are needed to determine what treatment strategy is most appropriate for asymptomatic patients presenting to healthcare facilities.

Molecular genetic evidence for different clonal origin of components of human renal angiomyolipomas.

Renal angiomyolipoma is a benign neoplasm composed of variable proportions of blood vessels, smooth muscle, and adipose tissue. Smooth muscle, adipose tissue, blood vessels, and adjacent normal kidney tissue were separately microdissected from sections prepared from formalin-fixed, paraffin-processed tissues from angiomyolipomas from 18 women. X chromosome inactivation analysis using the methylation pattern at exon 1 of the human androgen receptor gene on chromosome Xq11-12 was used to study the clonal origin of each component. Nonrandom inactivation of X chromosomes was found in six of the 15 informative tumors. The smooth muscle and adipose tissue showed differing patterns of nonrandom inactivation of X chromosomes in five angiomyolipomas and the same pattern of nonrandom inactivation of X chromosomes in one. Samples from the blood vessels showed random inactivation of X chromosomes in all informative cases. Our data showed that the adipose tissue and smooth muscle cells of renal angiomyolipoma are both monoclonal but may arise independently. The coexistence of tumor subclones with morphologic heterogeneity can lead to the formation of a clinically detectable tumor.

Molecular evidence for the independent origin of extra-ovarian papillary serous tumors of low malignant potential.

BACKGROUND: Molecular data suggest that peritoneal tumors in women with advanced-stage ovarian papillary serous adenocarcinoma are monoclonal in origin. Whether the same is true for ovarian tumors of low malignant potential is not known. We compared peritoneal and ovarian tumors from women with advanced-stage ovarian papillary serous tumors of low malignant potential to determine whether the peritoneal tumors arose from the same clone as the ovarian tumors. METHODS: We studied the clonality of 73 peritoneal and ovarian tumors from 18 women with advanced-stage ovarian papillary serous tumors of low malignant potential. Formalin-fixed, paraffin-embedded tumors and representative normal tissues were sectioned and stained with hematoxylin-eosin, representative sections from separate tumors were manually microdissected, genomic DNA was extracted from the microdissected tumors, and the polymerase chain reaction was used to amplify a CAG polymorphic site in the human androgen receptor locus on the X chromosome to determine the inactivation pattern of the X chromosome and the clonality of the tumors. RESULTS: The pattern of X-chromosome inactivation could be determined from the tumors of 13 of 18 patients. Of the 13 patients, seven (54%) had nonrandom inactivation of the X chromosome, and six of the seven had different inactivation patterns in the peritoneal and ovarian tumors. Three of these patients also had different patterns of nonrandom X-chromosome inactivation in tumors from each ovary. The remaining six patients had random patterns of X-chromosome inactivation in the peritoneal and ovarian tumors. CONCLUSIONS: Our data suggest that peritoneal and ovarian tumors of low malignant potential arise independently.

Cytokeratin 7 and cytokeratin 20 in primary urinary bladder carcinoma and matched lymph node metastasis.

BACKGROUND: -Cytokeratin 7 (CK7) and cytokeratin 20 (CK20) are 2 types of intermediate filament protein. Expression of CK7 is seen in the majority of primary urinary bladder carcinomas. CK20 is restricted to superficial and occasional intermediate cells of the normal urothelium of the bladder. Aberrant CK20 expression has been documented in urothelial carcinoma and has proved useful as an ancillary diagnostic aid for urinary bladder tumor. Our hypothesis is that the pattern of CK7 and CK20 expression in metastatic urothelial carcinoma duplicates the expression of the same markers in the primary tumors. Therefore, immunohistochemical staining of metastatic tumors for these 2 markers may be helpful for differential diagnosis in ambiguous metastatic tumor deposits. OBJECTIVE: -To determine the concordance of CK7 and CK20 expression in primary bladder urothelial carcinoma and the matched lymph node metastasis. DESIGN: -We studied 26 patients with lymph node metastases who underwent radical cystectomy and bilateral lymphadenectomy for bladder carcinoma. Immunohistochemical staining for CK7 and CK20 was performed on formalin-fixed paraffin-embedded tissues containing primary cancers and lymph node metastases. RESULTS: -In all cases, there was a concordant expression of CK20 in the primary cancer and its matched lymph node metastasis. Twelve cases (46%) showed positive CK20 immunoreactivity in the primary tumor and its matched lymph node metastases, whereas 14 cases (54%) were negative for CK20 in both the primary tumor and lymph node metastasis. All cases showed positive CK7 immunoreactivity in the primary cancers and matched lymph node metastases. CONCLUSIONS: -CK20 immunoreactivity is reliably observed in metastases from bladder cancer when the primary tumor expresses CK20.

Preparing for expected bioterrorism attacks.

The threat of bioterrorism in the United States is increasing. Health professionals, especially "front-line" practitioners, must be able to recognize the potential for major impacts from a bioterrorism event. Although an effective attack could produce numbers of casualties equivalent to those resulting from a nuclear weapon, an unannounced attack would be unlikely to be recognized immediately. Health workers may be the first to recognize an attack. However, only limited assistance is available to aid local community medical organizations in planning for bioterrorism. Military medical personnel have had more experience in planning for terrorist activities than many of their civilian colleagues. Their experience may be invaluable to local civilian treatment facilities in developing practical plans to meet the unique aspects of bioterrorism. In addition to considering agent-specific medical problems and requirements, it is particularly important for plans to address command and control, communication, and coordination if the resultant response is to be effective.

Lens opacifications detected by slitlamp biomicroscopy are associated with exposure to organic nitrate explosives.

CONTEXT: Unusual cataracts (flecks) have been reported to occur at very low levels of trinitrotoluene exposure, but prevalence estimates vary widely. Cataracts have not been reported among workers in the United States exposed to organic nitrate explosives. OBJECTIVES: To determine the prevalence of unusual cataracts in a population of workers in the United States exposed to organic nitrate explosives, to determine whether associations exist with reported cataract risk factors, and to determine if other eye effects (eg, retinal hemorrhage) are associated with exposure. DESIGN: Cohort prevalence study. SETTING: A university-based ophthalmologic clinic. SUBJECTS: Sixty-one workers from an explosives plant comprised the exposed group. The comparison group consisted of 56 workers using chemicals other than organic nitrate explosives. OUTCOME MEASURES: The primary outcome measure was opacifications (flecks) of the crystalline lens, graded clinically on a scale of 0 to 4 +. Additional measures included visual acuity, applanation tonometry, and clinical evaluation using standard examination techniques. RESULTS: Sixty-three percent of the workers had anterior cortical lens opacifications in a pattern of peripheral flecks. Exposed subjects were 18 times more likely to exhibit changes than those not exposed, a statistically significant association (95% confidence interval [CI], 5.0-65.0; P<.001). A statistically significant association with the duration of exposure was also found. CONCLUSIONS: Asymptomatic, low-grade cataracts (flecks) were identified in 63% of the workers exposed to pentolite. No other eye effects were found to be associated with exposure. Cataracts were not associated with other known risk factors, but were associated with the duration of exposure. Biomicroscopy is widely available and useful for detecting changes in the asymptomatic stages.

Nonsmall cell lung adenocarcinoma metastatic to the vitreous without fundus lesions.

A 76-year-old man presented with vitritis in the absence of visible fundus lesions. Vitreal cytologic analysis revealed adenocarcinoma; immunostaining was consistent with a pulmonary origin. This case highlights the need to exclude metastasis to the vitreous in a patient with an oncologic history, even in the absence of visible posterior segment lesions. It also illustrates the utility of immunostaining to better determine the tissue of origin when a metastatic lesion is encountered.

Exposure at home to airborne concentrations of nitrogen mustard during topical application for the treatment of mycosis fungoides: a case study.

BACKGROUND: Although effective at treating mycosis fungoides (MF), nitrogen mustard (HN(2)) creates potential exposure risks to those who administer it, including health care workers and family members. OBJECTIVE: The main objective was to examine the potential for nontarget individuals to be exposed to HN(2) vapors during and shortly after treatment with HN(2) in a home environment. METHODS: Air concentrations of HN(2) were measured during the topical treatment of MF in a patients home. RESULTS: The results demonstrate that eye and mucous membrane irritation may occur at HN(2) levels commonly encountered during the treatment of MF in the home, hospital or health clinic. Because no exposure thresholds have been developed for HN(2), the exposure thresholds of a surrogate chemical (sulfur mustard) were used. CONCLUSIONS: The study findings show that eye and mucous membrane irritation may occur at HN(2) levels below the exposure thresholds of the surrogate chemical. Recommendations for controlling exposures to HN(2) in the home are given.

Abdominal and pelvic needle aspiration biopsies: can we perform them well when using small needles?

BACKGROUND: The aim of this study was to compare abdominal fine-needle aspirations (FNAs) performed with large (>/=20-gauge) or small (

Use of the Iowa Self-Assessment Inventory with older hospitalized patients.

This study examined the utility of the Iowa Self-Assessment Inventory (ISAI) as a multidimensional screening tool for older adults in the acute care hospital setting. A sample of 98 patients age 60 and older were administered the ISAI, the Short Geriatric Depression Scale, and the Mini-Mental State Examination. The findings suggest the ISAI is useful for screening for depression but does not detect differences in cognition. However, qualitative data and literature review support the continued search for a holistic, humanistic screening tool to increase the quality and effectiveness of patient care.

[Hydronephrosis caused by congenital stenosis of the ureteropelvic junction. Hynes-Anderson technic]. / Hidronefrosis por estenosis congénita de la unión ureteropiélica. Técnica de Hynes-Anderson.

The need for the routine use of indwelling ureteral stents in the repair of congenital stenosis of the ureteropelvic junction by the Hynes-Anderson operation is not clearly established. The authors feel that it is indicated only in cases presenting severe parenchymal lesions. The indwelling stents can originate different complications, which may be detrimental for the outcome of the operation, in both the short and long term.