Is herniography useful?

Herniography has been used for 25 years in the diagnosis of occult herniation but has not gained widespread acceptance in the UK, despite studies confirming its high sensitivity and specificity for occult hernias and an excellent record of safety and patient acceptability. The traditional approach in the UK to suspected occult groin herniation has been surgical exploration. This study examined the use of herniography in a single district general hospital to assess its impact in limiting unnecessary groin explorations and allowing discharge of patients without hernias. The case notes of 90 successive patients referred for herniography by the department of general surgery in a single UK district general hospital over an 18-month period were reviewed. Eighty-seven completed examinations were analysed in which 23 hernias were diagnosed in 20 patients. Thirteen patients have undergone hernia repair with resolution of symptoms. There were no false positive examinations, although two inguinal hernias were incorrectly diagnosed radiologically as femoral hernias; there were two false negative examinations where additional hernias were found at laparoscopic repair. There were no reported complications. Twenty-four patients were discharged directly from the surgical clinic after a negative herniogram. Thirty patients were referred to other specialities. No patient had undergone groin exploration after a negative herniogram. Herniography is a useful tool in assessing obscure groin pain and potential occult herniation. It can reliably rule out the presence of a hernia and avoid the need for surgical exploration. Many patients with a negative herniogram can be reassured and discharged, whilst others may be referred on to other specialities safe in the knowledge that an occult hernia has been excluded.

The use of radiological guidelines to achieve a sustained reduction in the number of radiographic examinations of the cervical spine, lumbar spine and knees performed for GPs.

AIM: To determine if the use of request guidelines can achieve a sustained reduction in the number of radiographic examinations of the cervical spine, lumbar spine and knee joints performed for general practitioners (GPs). METHODS: GPs referring to three community hospitals and a district general hospital were circulated with referral guidelines for radiography of the cervical spine, lumbar spine and knee, and all requests for these three examinations were checked. Requests that did not fit the guidelines were returned to the GP with an explanatory letter and a further copy of the guidelines. Where applicable, a large-joint replacement algorithm was also enclosed. If the GP maintained the opinion that the examination was indicated, she or he had the option of supplying further justifying information in writing or speaking to a consultant radiologist. RESULTS: Overall the number of radiographic examinations fell by 68% in the first year, achieving a 79% reduction in the second year. For knees, lumbar spine and cervical spine radiographs the total reductions were 77%, 78% and 86%, respectively. CONCLUSION: The use of referral guidelines, reinforced by request checking and clinical management algorithms, can produce a dramatic and sustained reduction in the number of radiographs of the cervical spine, lumbar spine and knees performed for GPs.

Comparison of two strengths of iohexol and iothalamate in urography.

Iohexol and iothalamate were studied in 2 strengths and compared with results from a previous trial of Iopamidol and 4 ionic agents. Scoring was consistent from trial to trial. No worthwhile increase in density was achieved at high doses using nonionics and pyelographic distention was less than for ionic media. The timing of the nephrogram was the same for ionics and nonionics. There is no need to adopt a different film sequence for nonionic media. Urticarial reactions were identical for all 4 media studied in this trial. Nonionic media perform as well as other media; at lower doses they are much better than meglumine salts of ionic media.

Mammographic parenchymal patterns: value as a predictor of hormone dependency and survival in breast cancer.

The relation between the parenchymal pattern of the breasts as demonstrated on a mammogram and the estrogen-receptor status of the primary tumor in 337 patients with operable invasive breast cancer has been studied. These factors have also been correlated with the response to endocrine therapy in 92 patients who subsequently developed secondary disease. It has been shown that patients with a DY pattern are more likely to develop tumors that are estrogen-receptor (ER) positive (p = 0.01). Patients with secondary disease who have a DY pattern are more likely to respond to endocrine therapy (p = 0.001). The DY pattern has been shown to be at least as good an indicator of the probability of response to endocrine therapy as the estrogen-receptor status, and a combination of the two factors better than either taken singly. In a series of 141 postmenopausal women, the DY pattern, as determined at the time of mastectomy, was associated with significantly improved survival (p = 0.001). Mammographic parenchymal pattern could form the basis for selecting patients for endocrine therapy where no estrogen-receptor assay is available.

The relationship of background mammographic pattern to hormone dependency in breast cancer.

We have studied the relationship between mammographic parenchymal pattern of the breast and oestrogen receptor (ER) status in the primary tumour in 337 patients with operable invasive breast cancer, and the response to endocrine therapy in patients subsequently developing secondary disease. Patients with dysplastic (DY) parenchymal pattern are significantly more likely to develop tumours which are ER-positive. In 92 patients who subsequently developed secondary disease, those whose primary tumour arose in a DY pattern breast were significantly more likely to respond to endocrine therapy irrespective of their ER status.