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.

Radiation Therapy for Local Cutaneous Melanoma.

While primary treatment for melanoma consists of surgical resection and chemotherapeutics, radiation can be used as either definitive or adjuvant therapy in certain clinical scenarios. This chapter aims to explore the indications for primary definitive radiotherapy as well as adjuvant treatment following resection. Delivery, dose, fractionation, and toxicity of radiation treatment will be discussed. As our understanding of melanoma tumor biology increases, the role of radiotherapy may expand for more effective treatment of oligometastatic disease.

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.

Current videofluoroscopy practice in the United Kingdom: A survey of imaging professionals.

INTRODUCTION: Videofluoroscopy (VFSS) is a frequently used radiological investigation for dysphagia and is conducted within a radiology setting by speech and language therapists (SLTs) working alongside imaging personnel (radiologists and/or radiographers). Previous surveys of SLT practice have reported variability in VFSS protocols and procedures. The aim of this study was to explore current clinical practice for VFSS from the perspective of imaging personnel engaged in VFSS within the United Kingdom. METHODS: A comprehensive online survey enabled exploration of current practices of imaging professionals. Target participants were diagnostic imaging personnel (radiographers and radiologists) with experience of working in VFSS clinics. Descriptive statistics describe and summarise the data alongside inferential statistics where appropriate. RESULTS: 54 survey participants represented 40 unique acute healthcare organisations in the UK, in addition to two respondents from the Republic of Ireland. The survey demonstrated high variance in clinical practice across all stages of the VFSS procedure. Clinicians were not always compliant with current UK guidelines and the roles and responsibilities of different professionals working within the clinics were often not clearly defined. CONCLUSION: Further research is required to develop new international, interprofessional VFSS guidelines to standardise service delivery for VFSS, improving diagnostic accuracy, efficiency and patient experience. IMPLICATIONS FOR PRACTICE: In the absence of VFSS guidelines for imaging personnel, practitioners should familiarise themselves with the UK Royal College of Speech and Language Therapists VFSS Position paper; IR (ME)R guidelines and DRLs for the client groups with which they work to guide clinics and improve practice. Clinicians should revisit protocols and clinical governance regarding safe practice in order to improve the quality of care within the VFSS clinic.

Clinical practice guidelines for videofluoroscopic swallowing studies: A systematic review.

INTRODUCTION: Clinical practice guidelines (CPGs) are expected to make evidence-based recommendations, thus guiding practice and reducing unwarranted variation. CPGs are particularly helpful in guiding complex procedures such as the Videofluoroscopic Swallowing Study (VFSS) for the assessment of dysphagia, but there is a suspected high level of variability among them. To explore the extent of this variation, this study aimed to systematically identify and appraise all VFSS CPGs available worldwide. METHODS: A systematic search of 3 academic databases and other sources was conducted to identify relevant CPGs; independent reviews of each CPG were undertaken by a Speech and Language Therapist and a Radiographer. Both reviewers completed a pre-determined checklist of expected professional content for each CPG. CPGs were then assessed for quality using the Appraisal of Guidance for Research & Evaluation II (AGREE II) instrument. Findings from the professional content review and the methodological quality review were synthesised to inform an assessment of suitability of each CPG to inform clinical practice. RESULTS: Seven VFSS CPGs were identified worldwide, none of which were co-designed by radiographers or aimed at a radiographer audience. Each differs in their professional content, recommendations, underpinning evidence base and professional focus. Average AGREE ll scores across the quality domains vary considerably, ranging from 93 to 22%. No CPGs scored highly on all six AGREE II domains. CONCLUSION: There is no standardisation between VFSS guidelines. Six CPGs are not recommended for clinical use; only one of the seven identified CPGs is recommended for use following significant modification. IMPLICATIONS FOR PRACTICE: The lack of a comprehensive, evidence-based guideline encourages unwarranted variation in clinical practice which potentially compromises clinical care. Further research is needed to define VFSS best practice.

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.

The CanPain SCI Clinical Practice Guidelines for Rehabilitation Management of Neuropathic Pain after Spinal Cord: introduction, methodology and recommendation overview.

STUDY DESIGN: Clinical practice guidelines. OBJECTIVES: The objective was to develop the first Canadian clinical practice guidelines for the management of neuropathic pain in people with spinal cord injury (SCI). SETTING: The guidelines are relevant for inpatient and outpatient SCI rehabilitation settings in Canada. METHODS: The guidelines were developed in accordance with the Appraisal of Guidelines for Research and Evaluation II tool. A Steering Committee and Working Group reviewed the relevant evidence on neuropathic pain management (encompassing screening and diagnosis, treatment and models of care) after SCI. The quality of evidence was scored using Grading of Recommendations Assessment, Development and Evaluation (GRADE). A consensus process was followed to achieve agreement on recommendations and clinical considerations. RESULTS: The Working Group developed 12 recommendations for screening and diagnosis, 12 recommendations for treatment and 5 recommendations for models of care. Important clinical considerations accompany each recommendation. CONCLUSIONS: The Working Group recommendations for the management of neuropathic pain after SCI should be used to inform practice.

The CanPain SCI Clinical Practice Guidelines for Rehabilitation Management of Neuropathic Pain after Spinal Cord: Recommendations for treatment.

STUDY DESIGN: Clinical practice guidelines. OBJECTIVES: To develop the first Canadian clinical practice guidelines for treatment of neuropathic pain in people with spinal cord injury (SCI). SETTING: The guidelines are relevant for inpatient and outpatient SCI rehabilitation settings in Canada. METHODS: The CanPainSCI Working Group reviewed the evidence for different treatment options and achieved consensus. The Working Group then developed clinical considerations for each recommendation. Recommendations for research are also included. RESULTS: Twelve recommendations were developed for the management of neuropathic pain after SCI. The recommendations address both pharmacologic and nonpharmacologic treatment modalities. CONCLUSIONS: An expert Working Group developed recommendations for the treatment of neuropathic pain after SCI that should be used to inform practice.

The CanPain SCI Clinical Practice Guideline for Rehabilitation Management of Neuropathic Pain after Spinal Cord: recommendations for model systems of care.

STUDY DESIGN: Clinical practice guidelines. OBJECTIVES: The project objectives were to develop the first Canadian recommendations on a model of care for the management of at- and below-level neuropathic pain in people with spinal cord injury (SCI). SETTING: The guidelines are relevant for inpatient and outpatient SCI rehabilitation settings in Canada. METHODS: On the basis of a review of the Accreditation Canada standards, the Steering Committee developed questions to guide the CanPainSCI Working Group when developing the recommendations. The Working Group agreed on recommendations through a consensus process. RESULTS: The Working Group developed five recommendations for the organization of neuropathic pain rehabilitation care in people with SCI. CONCLUSIONS: The Working Group recommendations for a model of care for at- and below-level neuropathic pain after SCI should be used to inform clinical practice.

The CanPain SCI Clinical Practice Guidelines for Rehabilitation Management of Neuropathic Pain after Spinal Cord: screening and diagnosis recommendations.

STUDY DESIGN: Clinical practice guidelines. OBJECTIVES: To develop the first Canadian clinical practice guidelines for screening and diagnosis of neuropathic pain in people with spinal cord injury (SCI). SETTING: The guidelines are relevant for inpatient and outpatient SCI rehabilitation settings in Canada. METHODS: The CanPainSCI Working Group reviewed evidence to address clinical questions regarding screening and diagnosis of neuropathic pain after SCI. A consensus process was followed to achieve agreement on recommendations and clinical considerations. RESULTS: Twelve recommendations, based on expert consensus, were developed for the screening and diagnosis of neuropathic pain after SCI. The recommendations address methods for assessment, documentation tools, team member accountability, frequency of screening and considerations for diagnostic investigation. Important clinical considerations accompany each recommendation. CONCLUSIONS: The expert Working Group developed recommendations for the screening and diagnosis of neuropathic pain after SCI that should be used to inform practice.

Cerebral Thrombotic Complications Related to l-Asparaginase Treatment for Acute Lymphoblastic Leukemia: Retrospective Review of 10 Cases.

l-Asparaginase is a potent antileukemia agent and an essential part of treatment protocols for acute lymphoblastic leukemia. However, toxicity limits dose escalation, especially in adults. This includes a significant risk of thrombosis, which remains an important source of avoidable morbidity and mortality. Here, we provide a detailed report of 10 cases of cerebral thrombotic complications that occurred over a 5-year period at 4 large tertiary referral hospitals. To our knowledge, this is the first report of this type in the published literature.

Prevalence of Trichomonas vaginalis, Mycoplasma genitalium and Ureaplasma urealyticum in men with urethritis attending an urban sexual health clinic.

We conducted a study to determine the prevalence of Trichomonas vaginalis (TV), Mycoplasma genitalium (MG) and Ureaplasma urealyticum (UU) in men with urethritis, attending an urban sexual health clinic, in order to inform screening and treatment policies. Men attending an urban sexual health clinic between June 2011 and January 2012 were evaluated. Urine samples were collected from men with urethritis and tested for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (GC) and TV using transcription-mediated amplification and for MG and UU using polymerase chain reaction. Eighty-three samples were analysed. The prevalence of CT was 33.7% (28/83), GC was 16.8% (14/83), TV was 3.6% (3/83), MG was 12.0% (10/83) and UU was 4.8% (4/83). Fifteen men had recurrent urethritis. Of these, three were found to have had TV, five to have had MG and none to have had UU, at initial presentation. Given the prevalence of MG in this study, there is an urgent need for further larger studies looking at optimal treatment regimens and screening strategies in urethritis.

Efficacy of ultrasound-guided transversus abdominis plane blocks for post-cesarean delivery analgesia: a double-blind, dose-comparison, placebo-controlled randomized trial.

BACKGROUND: The analgesic benefit of TAP (transversus abdominis plane) blocks for cesarean delivery pain remains controversial. We compared the analgesic efficacy of two doses of local anesthetic for TAP blocks after cesarean delivery. METHODS: Sixty women having cesarean delivery under spinal anesthesia were randomized to receive ultrasound-guided TAP blocks using either high-dose ropivacaine (3mg/kg), low-dose ropivacaine (1.5mg/kg) or placebo. Patients received intrathecal 0.75% bupivacaine 10-12mg, fentanyl 10µg and morphine 150µg and standard multimodal analgesia. The primary outcome was the difference in pain with movement using a numeric rating scale at 24h. Other outcomes included time to first request for analgesia, pain scores at 6, 12, 36, 48h and at 6 and 12weeks, opioid consumption, adverse effects, quality of recovery, and satisfaction. RESULTS: There were no differences between groups in the primary outcome. Mean ± SD pain scores (0-10) with movement at 24h were: high-dose ropivacaine 3.6±1.5, low-dose ropivacaine 4.6±2.1 and placebo 4.1±1.7. With respect to secondary outcomes, the mean ± SD pain scores at 6h were lower in the high-dose group 2.0±1.8 compared to the low-dose 3.4±2.7 and placebo groups 4.2±2.0 (P=0.009). Pain scores at 12h were also lower in the high-dose group 2.2±2.0 compared to the low-dose group 4.1±2.7 and placebo group 4.0±1.3 (P=0.011). There was no difference in other outcomes between groups. CONCLUSIONS: Neither high- or low-dose TAP blocks as part of a multimodal analgesia regimen including intrathecal morphine improved pain scores with movement at 24h after cesarean delivery when compared to placebo TAP blocks. High-dose TAP blocks may improve pain scores up to 12h after cesarean delivery.

Prevention of post-dural puncture headache in parturients: a systematic review and meta-analysis.

Post-dural puncture headaches (PDPHs) present an important clinical problem. We assessed methods to decrease accidental dural punctures (ADPs) and interventions to reduce PDPH following ADP. Multiple electronic databases were searched for randomised clinical trials (RCTs) of parturients having labour epidurals, in which the studied intervention could plausibly affect ADP or PDPH, and the incidence of at least one of these was recorded. Forty RCTs (n = 11,536 epidural insertions) were included, studying combined spinal-epidurals (CSEs), loss of resistance medium, prophylactic epidural blood patches, needle bevel orientation, ultrasound-guided insertion, epidural morphine, Special Sprotte needles, acoustic-guided insertion, administration of cosyntropin, and continuous spinal analgesia. The RCTs for CSE, loss of resistance medium, and prophylactic epidural blood patches were meta-analysed. Five methods reduced PDPH: prophylactic epidural blood patch {four trials, median quality score = 2, risk difference = -0.48 [95% confidence interval (CI): -0.88 to -0.086]}, lateral positioning of the epidural needle bevel upon insertion (one trial, quality score = 1), Special Sprotte needles [one trial, quality score = 5, risk difference = -0.44 (95% CI: -0.67 to -0.21)], epidural morphine [one trial, quality score = 4, risk difference = -0.36 (95% CI -0.59 to -0.13)], and cosyntropin [one trial, quality score = 5, risk difference = -0.36 (95% CI -0.55 to -0.16)]. Several methods potentially reduce PDPH. Special Sprotte needles, epidural morphine, and cosyntropin are thus far each supported by a single, albeit good quality trial. Prophylactic blood patches are supported by three trials, but these had flawed methodology. Mostly, trials were of limited quality, and further well-conducted, large studies are needed.

Regional pulmonary blood flow in the lung of the chicken.

It is known that alterations in respiratory gases in birds can cause a nonhomogenous redistribution of pulmonary blood flow between the 2 separate gas-exchanging regions of the avian lung, the paleopulmo (PALEO) and neopulmo (NEO); however, the effect of alterations in respired gas content on the distribution of pulmonary blood flow in birds, such as the chicken, that possess a highly developed NEO is not known. This study used a colorimetric microsphere method to determine the effects of hypoxia and hypercapnia on the relative distribution of pulmonary blood flow in anesthetized chickens (Gallus domesticus) during control (normoxic) and experimental (hypoxic or hypercapnic) conditions, where the relative regional distribution of blood flow in the lung is expressed as the ratio NEO/PALEO. Administration of a hypoxic gas mixture (16.0% O(2)) produced a 13.4% increase in NEO/PALEO, and, administration of a hypercapnic gas mixture (5.0% CO(2)) resulted in a 27.8% increase in NEO/PALEO. Our results are consistent with a mechanism in which the regional redistribution of pulmonary blood flow is mediated by local intrapulmonary factors.

Detection of Bartonella henselae IgM in serum of experimentally infected and naturally exposed cats.

BACKGROUND: Results of Bartonella henselae blood culture, polymerase chain reaction (PCR) assay on blood, or IgG antibody assays do not always correlate with the presence or absence of clinical disease in cats, and B. henselae IgG antibodies in serum do not always correlate with bacteremia. However, little is known concerning Bartonella spp. IgM antibodies in naturally exposed cats. HYPOTHESIS: Bartonella spp. IgM antibodies in serum are associated with fever, stomatitis, and bacteremia based on PCR assay results in experimentally infected or client-owned cats. ANIMALS: Stored sera from cats experimentally infected with B. henselae by exposure to Ctenocephalides felis, client-owned cats with and without fever, and client-owned cats with and without stomatitis were studied. METHODS: A Bartonella spp. IgM ELISA was titrated with samples from experimentally infected cats and then test sera from client-owned cats were assayed. Associations among IgM ELISA results, clinical findings, and bacteremia as defined by Bartonella spp. PCR assay were assessed. RESULTS: All experimentally infected cats developed Bartonella spp. IgM antibodies. Bartonella spp. IgM antibody assay results were not always in agreement with PCR assay results in client-owned cats (60%). Bartonella spp. DNA in blood, IgM antibodies, and IgG antibodies were not associated with the presence of fever or stomatitis. CONCLUSIONS AND CLINICAL IMPORTANCE: Because Bartonella spp. IgM antibodies as measured by this assay were not associated with fever or stomatitis and were not always in agreement with PCR assay results, there appears to be little need for assessing individual client-owned cats for this antibody class alone.