Improving practice in radiology: a quality-improvement project examining CT colonography patient dose and scanning technique.

AIM: To audit scanning technique and patient doses for computed tomography (CT) colonography (CTC) examinations in a large UK region and to identify opportunities for quality improvement. MATERIALS AND METHODS: Scanning technique and patient dose data were gathered for both contrast-enhanced and unenhanced CTC examinations from 33 imaging protocols across 27 scanners. Measurements of patient weight and effective diameter were also obtained. Imaging protocols were compared to identify technique differences between similar scanners. Scanner average doses were calculated and combined to generate regional diagnostic reference limits (DRLs) for both examinations. RESULTS: The regional DRLs for contrast-enhanced examinations were volume CT dose index (CTDIvol) of 11 and 5 mGy for the two scan phases (contrast-enhanced and either delayed phase or non-contrast enhanced respectively), and dose-length product (DLP) of 740 mGy·cm. For unenhanced examinations, these were 5 mGy and 450 mGy·cm. These are notably lower than the national DRLs of 11 mGy and 950 mGy·cm. Substantial differences in scan technique and doses on similar scanners were identified as areas for quality-improvement action. CONCLUSION: A regional CTC dose audit has demonstrated compliance with national DRLs but marked variation in practice between sites for the dose delivered to patients, notably when scanners of the same type were compared for the same indication. This study demonstrates that the national DRL is too high for current scanner technology and should be revised.

A cloud based tool for knowledge exchange on local scale flood risk.

There is an emerging and urgent need for new approaches for the management of environmental challenges such as flood hazard in the broad context of sustainability. This requires a new way of working which bridges disciplines and organisations, and that breaks down science-culture boundaries. With this, there is growing recognition that the appropriate involvement of local communities in catchment management decisions can result in multiple benefits. However, new tools are required to connect organisations and communities. The growth of cloud based technologies offers a novel way to facilitate this process of exchange of information in environmental science and management; however, stakeholders need to be engaged with as part of the development process from the beginning rather than being presented with a final product at the end. Here we present the development of a pilot Local Environmental Virtual Observatory Flooding Tool. The aim was to develop a cloud based learning platform for stakeholders, bringing together fragmented data, models and visualisation tools that will enable these stakeholders to make scientifically informed environmental management decisions at the local scale. It has been developed by engaging with different stakeholder groups in three catchment case studies in the UK and a panel of national experts in relevant topic areas. However, these case study catchments are typical of many northern latitude catchments. The tool was designed to communicate flood risk in locally impacted communities whilst engaging with landowners/farmers about the risk of runoff from the farmed landscape. It has been developed iteratively to reflect the needs, interests and capabilities of a wide range of stakeholders. The pilot tool combines cloud based services, local catchment datasets, a hydrological model and bespoke visualisation tools to explore real time hydrometric data and the impact of flood risk caused by future land use changes. The novel aspects of the pilot tool are; the co-evolution of tools on a cloud based platform with stakeholders, policy and scientists; encouraging different science disciplines to work together; a wealth of information that is accessible and understandable to a range of stakeholders; and provides a framework for how to approach the development of such a cloud based tool in the future. Above all, stakeholders saw the tool and the potential of cloud technologies as an effective means to taking a whole systems approach to solving environmental issues. This sense of community ownership is essential in order to facilitate future appropriate and acceptable land use management decisions to be co-developed by local catchment communities. The development processes and the resulting pilot tool could be applied to local catchments globally to facilitate bottom up catchment management approaches.

A framework for managing runoff and pollution in the rural landscape using a Catchment Systems Engineering approach.

Intense farming plays a key role in increasing local scale runoff and erosion rates, resulting in water quality issues and flooding problems. There is potential for agricultural management to become a major part of improved strategies for controlling runoff. Here, a Catchment Systems Engineering (CSE) approach has been explored to solve the above problem. CSE is an interventionist approach to altering the catchment scale runoff regime through the manipulation of hydrological flow pathways throughout the catchment. By targeting hydrological flow pathways at source, such as overland flow, field drain and ditch function, a significant component of the runoff generation can be managed in turn reducing soil nutrient losses. The Belford catchment (5.7 km(2)) is a catchment scale study for which a CSE approach has been used to tackle a number of environmental issues. A variety of Runoff Attenuation Features (RAFs) have been implemented throughout the catchment to address diffuse pollution and flooding issues. The RAFs include bunds disconnecting flow pathways, diversion structures in ditches to spill and store high flows, large wood debris structure within the channel, and riparian zone management. Here a framework for applying a CSE approach to the catchment is shown in a step by step guide to implementing mitigation measures in the Belford Burn catchment. The framework is based around engagement with catchment stakeholders and uses evidence arising from field science. Using the framework, the flooding issue has been addressed at the catchment scale by altering the runoff regime. Initial findings suggest that RAFs have functioned as designed to reduce/attenuate runoff locally. However, evidence suggested that some RAFs needed modification and new RAFs be created to address diffuse pollution issues during storm events. Initial findings from these modified RAFs are showing improvements in sediment trapping capacities and reductions in phosphorus, nitrate and suspended sediment losses during storm events.

Ceroid lipofuscinosis, neuronal 3, Juvenile-Batten disease: case report and literature review.

BACKGROUND: Ocularly, Batten disease is characterized by a rapid deterioration of vision, progressing to blindness within a few years. Onset typically occurs at between 5 and 10 years of age. The fundus shows a bull's eye maculopathy, diffuse pigmentary degeneration, arteriolar attenuation and optic atrophy, and an extinguished ERG. CASE REPORT AND LITERATURE REVIEW: The visual acuity and ocular health findings of a 7-year-old child, eventually diagnosed with Batten disease, are reviewed. Additionally, a review of the literature concerning the ocular and systemic manifestations of the various ceroid lipofuscinoses is presented. CONCLUSION: Batten disease is the most likely of the ceroid lipofuscinoses to be manifested in an ophthalmic practitioner's office before the diagnosis of the underlying condition. Although there currently is no treatment for this condition, making the correct diagnosis is important for appropriate low-vision management, educational planning, and genetic counseling.

Iowa's pediatric low-vision services.

BACKGROUND: Reports in the literature concerning best practice for the evaluation and management of children with visual impairments are limited, with a resulting lack of information concerning the potential for optimizing vision to enhance general development and assist with the educational needs of this population. METHOD: The development of a multidisciplinary approach to provide low-vision services for children with visual impairment has occurred over the past 18 years in Iowa. In that time, 1,348 children from around the state of Iowa have been evaluated through an itinerant low-vision service program, coordinated by the Iowa Braille School. RESULTS: A low-vision clinic model--designed to provide services (primarily) for academic students--was not meeting the needs of the pediatric low-vision population in the state. After a statewide review of the program, changes were made that have resulted in low-vision services being provided to a greater and more diverse number of students. The roles of the various members of the multidisciplinary team will be reviewed. Changes in large-print orders and use by special education teachers in the state as a direct result of the low-vision services will also be discussed. CONCLUSION: Ongoing, comprehensive multidisciplinary low-vision services--including optometric low-vision care as a key component--are necessary to help children with visual impairments meet their educational, vocational, and avocational needs. With ongoing low-vision services, unnecessary costs such as those associated with large-print materials can be reduced, thereby creating significant savings to local, state, and federal special educational services.

Driving with a visual impairment.

Driving is a highly prized activity for individuals of all ages. The decision to continue driving after a decrease in central acuity or visual field can be a source of anxiety for the individual and his or her family, as well as the ophthalmic practitioner. Although a great deal of research has been done concerning vision and driving, much controversy still surrounds this subject. This article reviews the literature concerning visual impairment and driving and makes suggestions for what should be considered when determining who should and should not continue to drive.

Iowa's pediatric low vision services.

BACKGROUND: Reports in the literature concerning the evaluation and low vision management of visually impaired children are limited, resulting in a lack of information about the characteristics and needs of this population. METHODS: A review was performed of 762 children evaluated over a 14-year period in a low vision clinic program coordinated by the Iowa Braille and Sight Saving School. RESULTS: The age, sex, ocular condition, best corrected visual acuity, habitual near point working distance, and optical devices recommended for use by these children were analyzed. CONCLUSIONS: Ongoing, comprehensive multidisciplinary low vision services are necessary to help children with visual impairments meet their educational, vocational and avocational needs. With ongoing low vision care unnecessary costs-such as those for large print material-can be avoided, therefore creating a significant savings to local or state educational services.