Exploring radiographers' experience with mobile X-ray of patients in their homes.

INTRODUCTION: To offer citizens with frailty or dementia living in nursing homes or other institutions a less stressful and anxious X-ray examination, a Danish hospital offers to perform the examination in the citizen's residence. This has changed the working procedure for the radiographers performing the examination. The aim of this study was to explore if the radiographers self-perceived competencies have changed whilst working in the mobile X-ray unit and if so, how these competencies are utilised within the department-based medical imaging team. METHOD: This study had a qualitative design following a hermeneutic approach. Individual semi structured interviews included nine radiographers, four radiographers working in the mobile X-ray unit and five radiographers working exclusively in the medical imaging team. RESULTS: Radiographers who worked in the mobile X-ray unit did acquire new competencies such as better communication and creative positioning skills. All nine participants recognised the advantage of sharing experiences and competencies with colleagues, and recommended a formal forum to do so. They sought opportunities for the use of the mobile X-ray unit to be more widespread within their own region, and within the profession. CONCLUSION: This study indicates that radiographers working with mobile X-ray unit gained new competencies in communication and positioning, but without spread of new knowledge to colleagues in the medical imaging team. IMPLICATION FOR PRACTICE: The use of home-based mobile X-ray is a new way to provide health care services and gain new competencies for the radiographers to focus on patient centred care.

Anode heel effect: Does it impact image quality in digital radiography? A systematic literature review.

INTRODUCTION: The anode heel effect can be used to optimize image quality and/or patient dose in digital radiography (DR). In film-screen radiography, the effect can equalize optical density in regions of varying attenuation. Clinical experience suggests that the implementation of DR has led to less awareness of anode orientation. Post-processing is assumed to compensate, but may also alter image impression and potentially obscure image details. Published evidence was examined for the influence of the anode heel effect on image quality in DR. METHOD: A systematic literature search was carried out using PubMed, Embase, and Web of Science databases. Title and abstracts were screened blinded by three authors, according to in-/exclusion criteria, followed by full-text analysis for final inclusion. Studies where technical and/or visual image quality were reported, was included. All studies were analyzed and assigned quality scores, according to relevant questions. The authors devised a scoring system based on reported information pertaining to reproducibility, interpretation, and generalizability of the methods and conclusions. RESULTS: Five studies were included of heterogeneous design, each with methodological shortcomings. Only a few anatomical areas were covered. Very few patients were examined, and in no studies were images evaluated by radiologists or reporting radiographers. Relevant information such as post-processing, image quality criteria and analysis was insufficient in most studies, making reproduction difficult. Results were contradictory, especially concerning technical vs visual image quality. CONCLUSION: Limited published evidence was found quantifying the influence of the anode heel effect on image quality using DR technology. More methodologically, robust studies are needed. The published evidence neither proves nor disproves the impact of the heel effect on image quality in DR. IMPLICATIONS FOR PRACTICE: Based on a systematic review, no firm recommendations for anode orientation relating to image quality in DR can be provided.

Exploring the patient perspectives of mobile X-ray in nursing homes - A qualitative explorative pilot study.

INTRODUCTION: For patients with dementia, behaviour and reactions to stimuli can change and an X-ray examination in the hospital can have be a frightening experience. The aim of this study was to identify the experiences and perspectives of patients with dementia and their caregivers on receiving a mobile x-ray examination in nursing homes. METHODS: This study was designed as a qualitative study using patient observation and semi structured interviews, with a phenomenology-hermeneutic approach. In total, 23 patients were observed during X-ray examinations in nursing homes, and six semi structured interviews were conducted with the caregivers who participated in the examination. RESULTS: The observations and interviews indicated that a known environment, a recognizable framework and calmness were central for a patient with dementia. The patients appeared calm and relaxed during the examination in their usual environment (nursing homes) where there are less stimuli and impressions based of the observations. CONCLUSION: Mobile X-ray examinations for patients with dementia living in nursing homes had a positive impact on patients' reactions towards the X-ray examination. The examinations were performed in the patients' usual and safe environments, where impressions and stimuli were less disturbing for patients with dementia. IMPLICATIONS FOR PRACTICE: The mobile x-ray unit can be of benefit for patients suffering from dementia and result in less impact. The patients living in nursing homes have the opportunity to be examined in their familiar environment, because of the mobile x-ray unit.

The analgesic effect of a popliteal plexus blockade after total knee arthroplasty: A feasibility study.

INTRODUCTION: An obturator nerve block (ONB) and a femoral triangle block (FTB) provide effective analgesia after total knee arthroplasty (TKA) without impeding the ambulation, although the ONB produces motor blockade of the hip adductor muscles. The popliteal plexus (PP) in the popliteal fossa is formed by contribution from the tibial nerve and the posterior obturator nerve, innervating intraarticular genicular structures and the posterior capsule of the knee. We hypothesised that a popliteal plexus block (PPB) as a supplement to an FTB would reduce pain after TKA without anaesthetising motor branches from the sciatic nerve in the popliteal fossa. AIM: To assess the analgesic effect of adding a PPB to an FTB in 10 subjects with significant pain after TKA. METHODS: All subjects underwent unilateral TKA with spinal anaesthesia and received an FTB. The cutaneous sensation and the postoperative pain were assessed. The primary outcome was the proportion of subjects with pain above numeric rating scale (NRS) 3 followed by a reduction to NRS 3 or below after conducting a PPB. RESULTS: Ten subjects with a median pain of NRS 5.5 (interquartile range [IQR] 4-8) after unilateral TKA received a PPB. All 10 subjects experienced a reduction in pain to NRS 3 or below (NRS 1.5 [IQR 0-3]) within a mean time of 8.5 (95% CI 6.8-10.2) minutes. Three subjects were completely pain free after the PPB. The ankle muscle strength was not affected. CONCLUSIONS: The PPB provided effective pain relief without affecting the ankle muscle strength in all 10 subjects with significant pain after TKA and an FTB.

Identification and Characterization of a Nationwide Danish Adult Common Variable Immunodeficiency Cohort.

In this study, we identified all adults living in Denmark diagnosed with common variable immunodeficiency (CVID) and characterized them according to clinical presentation and EUROclass classification. Using a retrospective, cross-sectional design, possible CVID patients were identified in the Danish National Patient Register and Centers in Denmark treating patients with primary immunodeficiencies. The CVID diagnosis was verified by review of medical records. One-hundred-seventy-nine adults with CVID were identified. This corresponds to a prevalence of 1:26,000. The median age at onset of symptoms was 29 years with no sex difference. The median age at diagnosis was 40 years. Males were diagnosed earlier with a peak in the fourth decade of life, whereas females were diagnosed later with a peak in the sixth decade. The median diagnostic delay was seven years. Recurrent sinopulmonary infections were seen in 92.7% of the patients. The prevalence of non-infectious complications was similar to that of previously reported cohorts: bronchiectasis (35.8%), splenomegaly (22.4%), lymphadenopathy (26.3%), granulomatous inflammation (3.9%) and idiopathic thrombocytopenic purpura (14.5%). Non-infectious complications were strongly associated with B cell phenotype, with all having a reduced number of isotype-switched memory B cells. One-hundred-seventy (95%) were treated with immunoglobulin replacement therapy, primarily administered subcutaneously. According to international guidelines, diagnostic evaluation was inadequate in most cases. This study emphasizes the need for improved diagnostic criteria and more awareness of CVID as a differential diagnosis. Diagnosis and management of CVID patients is a challenge requiring specialists with experience in the field of PID.

Practicability of avoiding hypothermia in resuscitation room phase in severely injured patients.

Hypothermia in severely injured patients is a high demanding situation resulting from an effect of injury severity, surrounding temperature at trauma site and admittance. This article reviews the possible options to combat hypothermia in the resuscitation room with respect to practicability. This review summarizes available passive and active re-warming techniques and trys to offer a practicable chronology to restore normothermia. Resources should be applied depending on the availability of each institution and manifestation of hypothermia, but there is a strong demand for improvements with respect to practicability, convenience and safety for the patient.

Fractional flow reserve derived from coronary CT angiography in stable coronary disease: a new standard in non-invasive testing?

Fractional flow reserve (FFR) measured during invasive coronary angiography is the gold standard for lesion-specific decisions on coronary revascularization in patients with stable coronary artery disease (CAD). Current guidelines recommend non-invasive functional or anatomic testing as a gatekeeper to the catheterization laboratory. However, the "holy grail" in non-invasive testing of CAD is to establish a single test that quantifies both coronary lesion severity and the associated ischemia. Most evidence to date of such a test is based on the addition of computational analysis of FFR to the anatomic information obtained from standard-acquired coronary CTA data sets at rest (FFRCT). This review summarizes the clinical evidence for the use of FFRCT in stable CAD in context to the diagnostic performance of other non-invasive testing modalities. Key Points • The process of selecting appropriate patients for invasive coronary angiography is inadequate • Invasive fractional flow reserve is the standard for assessing coronary lesion-specific ischemia • Fractional flow reserve may be derived from standard coronary CT angiography (FFR CT ) • FFR CT provides high diagnostic performance in stable coronary artery disease.

Cost-effectiveness of ultrasound vs nerve stimulation guidance for continuous sciatic nerve block.

BACKGROUND: This study assessed the cost-effectiveness of ultrasound (US) vs nerve stimulation (NS) guidance for continuous sciatic nerve block in Danish elective patients undergoing major foot and ankle surgery. METHODS: > A cost-effectiveness analysis was conducted alongside a randomized controlled trial. A total of 100 consecutive patients were randomly assigned to either traditional electrical NS or US technique for catheter insertion guidance. Information on effects and costs were collected prospectively. An incremental cost-effectiveness ratio (ICER) was calculated as the extra cost per extra successful nerve block. The robustness of the ICER was investigated using 4000 non-parametric bias-corrected bootstrap replicates to calculate the likelihood that US leads to better effect and lower costs compared with NS guidance. RESULTS: The mean ICER was negative, indicating that US was a dominating technology providing both higher quality and lower costs. The likelihood of US being more effective and cheaper than NS was estimated to 84.7%. CONCLUSIONS: In this trial, US was cost-effective. Assuming that the results are fairly generalizable, US should be the preferred catheter insertion technique in larger anaesthesia departments.

Gene expression is differently affected by pimecrolimus and betamethasone in lesional skin of atopic dermatitis.

BACKGROUND: Topical corticosteroids and calcineurin inhibitors are well-known treatments of atopic dermatitis (AD) but differ in their efficacy and side effects. We recently showed that betamethasone valerate (BM) although clinically more efficient impaired skin barrier repair in contrast to pimecrolimus in AD. OBJECTIVE: This study elucidates the mode of action of topical BM and pimecrolimus cream in AD. METHODS: Lesional AD skin samples after topical treatment with either BM or pimecrolimus were subjected to gene expression profile analysis. RESULTS: Betamethasone valerate resulted in a significant reduction in mRNA levels of genes encoding markers of immune cells and inflammation, dendritic cells, T cells, cytokines, chemokines, and serine proteases, whereas pimecrolimus exerted minor effects only. This corroborates the clinical finding that BM reduces inflammation more effectively than pimecrolimus. Genes encoding molecules important for skin barrier function were differently affected. Both BM and pimecrolimus normalized the expression of filaggrin and loricrin. BM, but not pimecrolimus, significantly reduced the expression of rate-limiting enzymes for lipid synthesis and the expression of involucrin and small proline-rich proteins, which covalently bind ceramides. This may explain the lack of restoration of functional stratum corneum layers observed after BM treatment. CONCLUSION: The gene expression profiles are consistent with our previous findings that corticosteroids may exert a more potent anti-inflammatory effect but may impair the restoration of the skin barrier. Corticosteroids are still the main treatment for severe and acutely exacerbated AD; pimecrolimus may be preferable for long-term treatment and stabilization.

A Monte Carlo investigation of contaminant electrons due to a novel in vivo transmission detector.

A novel transmission detector (IBA Dosimetry, Germany) developed as an IMRT quality assurance tool, intended for in vivo patient dose measurements, is studied here. The goal of this investigation is to use Monte Carlo techniques to characterize treatment beam parameters in the presence of the detector and to compare to those of a plastic block tray (a frequently used clinical device). Particular attention is paid to the impact of the detector on electron contamination model parameters of two commercial dose calculation algorithms. The linac head together with the COMPASS transmission detector (TRD) was modeled using BEAMnrc code. To understand the effect of the TRD on treatment beams, the contaminant electron fluence, energy spectra, and angular distributions at different SSDs were analyzed for open and non-open (i.e. TRD and block tray) fields. Contaminant electrons in the BEAMnrc simulations were separated according to where they were created. Calculation of surface dose and the evaluation of contributions from contaminant electrons were performed using the DOSXYZnrc user code. The effect of the TRD on contaminant electrons model parameters in Eclipse AAA and Pinnacle(3) dose calculation algorithms was investigated. Comparisons of the fluence of contaminant electrons produced in the non-open fields versus open field show that electrons created in the non-open fields increase at shorter SSD, but most of the electrons at shorter SSD are of low energy with large angular spread. These electrons are out-scattered or absorbed in air and contribute less to surface dose at larger SSD. Calculated surface doses with the block tray are higher than those with the TRD. Contribution of contaminant electrons to dose in the buildup region increases with increasing field size. The additional contribution of electrons to surface dose increases with field size for TRD and block tray. The introduction of the TRD results in a 12% and 15% increase in the Gaussian widths used in the contaminant electron source model of the Eclipse AAA dose algorithm. The off-axis coefficient in the Pinnacle(3) dose calculation algorithm decreases in the presence of TRD compared to without the device. The electron model parameters were modified to reflect the increase in electron contamination with the TRD, a necessary step for accurate beam modeling when using the device.

Coronary dual source multi detector computed tomography in patients suspected of coronary artery disease: prevalence of incidental extra-cardiac findings.

OBJECTIVES: (1) To establish the prevalence of incidental extra-cardiac findings (ECFs) in coronary multi detector computed tomography (CCT) performed in a large, homogeneous cohort of patients suspected of coronary artery disease (CAD). (2) To examine whether any association can be established between ECFs and pretest risk as determined by conventional risk factors for CAD, the Diamond-Forrester risk model or coronary artery calcium scores. (3) To assess cost related to extra-cardiac examinations. DESIGN: Retrospective study of consecutive patients who had CCT performed. A large field of view was recreated from the non-enhanced CT scan and evaluated by a radiologist for incidental ECFs. SUBJECTS: Patients with chest pain referred to CTA by a cardiologist. RESULTS: In 1383 patients a total of 481 ECFs were indentified, 378 minor (meaning no follow-up was needed) and 103 major ECFs (ECF followed up clinically and/or with additional imaging), in a total of 393 (28%) patients. 85 (6%) patients had one major ECF and 9 (0.7%) patients had two major ECFs. In 19 (4 cases of malignancy) patients the major ECF had therapeutic consequences. Significant positive associations were found between age and smoking, respectively and the presence of ECFs. The cost estimate of saving one life from malignant disease based on ECF examinations is 40,190€. CONCLUSION: Incidental extra-cardiac findings are common, sometimes revealing serious, even malignant disease. Diagnostic follow-up of major ECFs seems to be cost-effective in a Danish clinical setting. We recommend investigating a large field of view for incidental ECFs following CCT.

The skin's barrier.

The skin provides an effective barrier between the organism and the environment, preventing the invasion of pathogens and fending off chemical and physical assaults, as well as the unregulated loss of water and solutes. In this review we provide an overview of several components of the physical barrier, as well as how barrier function is regulated and altered in association with dermatoses. The physical barrier localized primarily in the stratum corneum (SC) and consists of protein-enriched cells (corneocytes with cornified envelope and cytoskeletal elements, as well as corneodesmosomes) and lipid-enriched intercellular domains. The nucleated epidermis, with its tight, gap and adherens junctions, additional desmosomes and cytoskeletal elements, also contributes to the barrier. Lipids are synthesized in the keratinocytes during epidermal differentiation and are then extruded into the extracellular domains, where they form lipid-enriched extracellular layers. The cornified cell envelope, a robust protein/lipid polymer structure, is located below the cytoplasmic membrane on the exterior of the corneocytes. Ceramides A and B, forming the backbone for the subsequent addition of free ceramides, free fatty acids and cholesterol in the SC, are covalently bound to cornified envelope proteins. Filaggrin is cross-linked to the cornified envelope and aggregates keratin filaments into macrofibrils. Cytokines, cAMP and calcium influence the formation and maintenance of barrier function. Changes in lipid composition and epidermal differentiation lead to a disturbed skin barrier, which allows the entry of environmental allergens, immunological reaction and inflammation in atopic dermatitis. A disturbed skin barrier is an important component in the pathogenesis of contact dermatitis, ichthyosis, psoriasis, and atopic dermatitis.

Nail infection by Aspergillus ochraceopetaliformis.

Aspergillus ochraceopetaliformis is a rare fungal species that has not yet been identified as a proven human pathogen. Here we report a case of a toenail infection in a healthy woman caused by this fungus. Species identification was performed by scrutinizing the phenotypic and genetic characteristics of distinct isolates obtained at different times during the course of the infection. Treatment with terbinafine plus ciclopiroxolamine was effective.

[Rational treatment of first-degree burns]. / Rationale Behandlung von Patienten mit Verbrennungen 1. Grades.

First-degree burns are the most common type of burn, but are often inadequately treated. The methods of treatment and the course of healing are poorly documented owing to the fact that first-degree burns are generally not considered to be a serious injury. First-degree burns can be caused by thermal injury or UV irradiation (sunburn). The pathophysiology and the therapeutic approach are similar, although the damage follows a different time course for each injury--immediate damage after contact with hot objects, liquids or fire, delayed damage after sun exposure. After initial cooling with water, aqueous emulsions with small amounts of well-tolerated lipids (O/W emulsions) are best suited for treating first-degree burns or sunburn. Water evaporates producing cooling and reducing inflammation; the lipids accelerate the repair of the damaged skin barrier and reduce drying. Foam sprays and lotions are ideal because they are easy and painless to apply. The use of topical corticosteroids is not recommended, as superiority to the vehicle has not been shown.

Routine X-ray control of upper central venous lines: Is it necessary?

BACKGROUND: Insertion of central venous catheters (CVCs) is a procedure associated with a varying risk of complications, depending on the setting and the skill of the clinician who undertakes the procedure. The aim of this study was to monitor the complication rate of CVC insertion and evaluate the value of routine chest X-ray control. METHODS: Anesthesiologists at eight hospitals filled in a questionnaire immediately after insertion of a CVC. The post-procedural clinical evaluation, including expected complications, was compared to actual radiological findings. Chest X-ray was ordered by the anesthesiologist, and described by staff radiologists. RESULTS: The clinicians had from 2 months to 30 years of experience as anesthesiologists, and trainees inserted 34% and specialists 66% of the catheters, using landmark techniques. Over a period of 2 months, 473 CVC-insertion procedures were included in the investigation. Two patients (0.4%) had a pneumothorax: one was among the 11 cases in which the clinician suspected complications after the procedure, and another was found in a high-risk patient 13 h after CVC insertion. Both patients were treated successfully with chest tubes. The favorite approach was right vena jugularis interna with 324 (69%) catheters; of these patients one had a pneumothorax, catheter-tip placement was correctly predicted in 317 (97%), and no catheters were repositioned. CONCLUSION: In the hands of trained clinicians, insertion of CVCs is a safe procedure. We found no value of routine X-ray control and omission of routine chest X-ray must be considered.

Effects of lactic and acetic acid salts on quality characteristics of enhanced pork during retail display.

The objective of this study was to evaluate the sensory and physical characteristics of pork chops from loins enhanced to 110% of original weight with either (1) potassium lactate, potassium diacetate, phosphate and salt, (2) sodium lactate, phosphate and salt, (3) potassium lactate, phosphate and salt, (4) sodium acetate, phosphate and salt, or (5) phosphate and salt. A trained sensory panel evaluated pork flavor, saltiness, bitterness, soapy flavor, acid flavor, juiciness and tenderness of cooked chops. Visual color of raw chops was also evaluated. After 96 h in display, chops enhanced with lactate/diacetate had significantly lower (P<0.01) aerobic plate counts than control (unpumped) chops, or those pumped with other solutions. Lactate/diacetate-enhanced chops maintained higher a* and b* values during display, and had less visual discoloration after 96 h display. Chops pumped with lactate, acetate or the lactate/diacetate mixture were more tender and juicy, and had more pork flavor than controls or those pumped with phosphate/salt only. There appears to be a significant advantage to using a lactate/diacetate enhancement solution over either lactate or acetate alone.

Determination of field size limitations in stereotactic and intensity modulated radiotherapy.

For dose measurement in small photon fields, different detectors are currently in use: TLD, semiconductor, diamond-detector, film, etc. But for absolute dosimetry, ionization chambers show the most advantages. To meet the basic dosimetrical requirements for lateral electron equilibrium the field size F must not remain under specified values: i.e. 5.2 x 5.2 cm2 for 15 MeV X-bremsstrahlung. As well as increasing the focus-chamber-distance, changing the physical density of the build-up material in the close vicinity of the chamber will be helpful to determine the output factor OF for smaller fields. By means of a correction factor, k(mat), this is taken into account. For a 6 MeV X and a 15 MeV X-bremsstrahlung of linear accelerators the lower limit of the field size F is determined: F > or = 0.8 cm. This value is mainly dependent on the diameter of the focal-spot (phi = 3 mm) of the treatment unit including design characteristics of the treatment head. Beside the dosimetrical aspects, some geometrical parameters have to be considered, when accuracy of dose application should remain on the same level as in medium and large field treatment (4 cm < or = F < or = F(max)). To keep dose-volume errors as low as +/- 10 % (diameter of PTV: 20 mm), the mean total error delta of CT-scanning (delta(p)), planning (delta(pl)), patient positioning (delta(x)), and treatment unit instabilities (delta(m)) should not exceed +/- 0.8 mm.

LDL receptor mutation genotype and vascular disease phenotype in heterozygous familial hypercholesterolaemia.

Patients with homozygous familial hypercholesterolaemia (FH) caused by receptor-negative, low-density lipoprotein (LDL) receptor gene mutations have higher concentrations of LDL-cholesterol in plasma and earlier onset of cardiovascular disease (CVD) than patients homozygous for receptor-defective, LDL receptor mutations. In contrast, it is uncertain whether the severity of atherosclerotic disease differs in heterozygous FH caused by receptor-negative and receptor-defective mutations. The present authors investigated the influence of LDL receptor mutation type on the clinical phenotype in 31 patients with heterozygous FH caused by the receptor-negative, Trp23-stop mutation and in 31 patients heterozygous for the receptor defective Trp66-Gly mutation. Untreated levels of plasma LDL-cholesterol and calculated cholesterol-years score did not differ significantly between the two groups of patients. Detection of vascular disease was based on two approaches: (1) measurement of coronary calcification by spiral computed tomography (CT) scanning; and (2) ultrasonic measurement of carotid intima-media thickness (IMT). Age was significantly correlated to the presence of coronary calcification, but controlling for relevant cofactors, there was no evidence that the receptor-negative mutation caused more calcification than the receptor-defective mutation. Furthermore, carotid IMT was significantly influenced by plasma concentrations of Lp(a) and triglycerides, as well as by age, sex and smoking status, but again, there was no statistically significant effect of LDL receptor gene mutational type. The similarity in vascular phenotypes was probably caused by a similar life-long burden of LDL-cholesterol in the two groups of patients.