Search tips
Search criteria

Results 1-25 (1665810)

Clipboard (0)

Related Articles

1.  Primary care referrals for lumbar spine radiography: diagnostic yield and clinical guidelines. 
BACKGROUND: Primary care requests for radiographs of the lumbar spine have come under increasing scrutiny. Guidelines aiming to reduce unnecessary radiographs by limiting referrals to patients at high risk of serious disease have been widely distributed. Trial evidence suggests that guidelines can reduce radiography referrals. It is not clear whether this reduction has been achieved in routine practice. AIM: This study, using routine data, was conducted to measure trends in pnmary care referrals for lumbar spine radiography at two hospitals between 1994 and 1999. DESIGN OF STUDY: Analysis of primary care requests for lumbar spine radiography from computerised records. SETTING: Addenbrooke's Hospital, Cambridge (1 July 1994 to 30 June 1999), and Ipswich General Hospital (1 July 1995 to 30 June 1999), United Kingdom. METHOD: All primary care requests for lumbar radiography were identified electronically from computerised information systems. A random sample of 2100 radiography reports were classified according to clinical importance. These classifications were used to examine whether the proportion of radiographs demonstrating potentially more serious findings had increased between 1994 and 1999. RESULTS: There was no evidence that primary care referrals for radiography of the lumbar spine had decreased between 1994 and 1999 at either hospital. General practitioners did not progressively refer more high-risk patients for lumbar radiography. Only a small proportion of patients had important radiographic findings that might warrant specialist referral or specific therapy. CONCLUSION: The implementation of diagnostic guidelines offers much to the NHS. However in these two hospitals, the reduction in radiograph utilisation evident in trials was not achieved. Guideline development is a resource intensive process; distribution must be supported by more effective implementation strategies.
PMCID: PMC1314323  PMID: 12051212
2.  Randomized controlled trial of the effect of the Royal College of Radiologists' guidelines on general practitioners' referrals for radiographic examination. 
BACKGROUND. The Royal College of Radiologists' guidelines aim to encourage more appropriate use of diagnostic radiology and so reduce the use of clinically unhelpful x-ray examinations. AIM. The object of this study was to conduct a randomized controlled trial of the introduction of the guidelines into general practice. METHOD. A total of 62 practices (170 general practitioners) referring patients to St George's Hospital, London for diagnostic radiology were randomly allocated into two groups. Guidelines were sent to the 30 practices in the intervention group. Radiological referral patterns were compared in both groups before and after the introduction of guidelines. RESULTS. Practices which had received guidelines requested significantly fewer examinations of the spine, and made a significantly higher proportion of requests which conformed to the guidelines compared with practices which had not received the guidelines. There were no significant differences in the proportion of forms giving physical findings or in the proportion of positive findings at radiology. CONCLUSION. Introduction of guidelines can influence general practitioners' radiological referrals in the short term. Wider use of guidelines might help to reduce unnecessary irradiation of patients.
PMCID: PMC1238864  PMID: 8204331
3.  A cross sectional study of requests for knee radiographs from primary care 
Knee pain is the commonest pain complaint amongst older adults in general practice. General Practitioners (GPs) may use x rays when managing knee pain, but little information exists regarding this process. Our objectives, therefore, were to describe the information GPs provide when ordering knee radiographs in older people, to assess the association between a clinical diagnosis of osteoarthritis (OA) and the presence of radiographic knee OA, and to investigate the clinical content of the corresponding radiologists' report.
A cross sectional study of GP requests for knee radiographs and their matched radiologists' reports from a local radiology department. Cases, aged over 40, were identified during an 11-week period. The clinical content of the GPs' requests and radiologists' reports was analysed. Associations of radiologists' reporting of i) osteoarthritis, ii) degenerative disease and iii) individual radiographic features of OA, with patient characteristics and clinical details on the GPs' requests, were assessed.
The study identified 136 cases with x ray requests from 79 GPs and 11 reporting radiologists. OA was identified clinically in 19 (14%) of the requests, and queried in another 31 (23%). The main clinical descriptor was pain in 119 cases (88%). Radiologists' reported OA in 22% of cases, and the features of OA were mentioned in 63%. Variation in reporting existed between radiologists. The commonest description was joint space narrowing in 52 reports (38%). There was an apparent although non significant increase in the reporting of knee OA when the GP had diagnosed or queried it (OR 1.95; 95% CI 0.76, 5.00).
The features of radiographic OA are commonly reported in those patients over 40 whom GPs send for x ray. If OA is clinically suspected, radiologists appear to be more likely to report its presence. Further research into alternative models of referral and reporting might identify a more appropriate imaging policy in knee disorders for primary care.
PMCID: PMC1963327  PMID: 17683606
4.  Erect chest radiography in the setting of the acute abdomen: essential tool or an unnecessary waste of resources? 
It has been suggested that changes to the training schemes of junior doctors and the increased pressure on emergency departments to manage their patients within a limited time might increase the number of unnecessary investigations performed on emergency admission patients. This, in turn, may lead to an increased number of investigations with normal results. In this study we try to analyse the role of the chest X-ray (CXR) as a diagnostic tool in patients presenting with acute abdominal pain.
A retrospective study was performed of the request forms and results of all chest radiography performed on patients admitted on the emergency surgical intake with acute abdominal pain through utilisation of the prospec-tively maintained electronic radiology database. The indications were compared to the guidelines published by the Royal College of Radiologists (RCR) which have been adopted as the standard of care.
A total of 334 chest X-rays were identified of which only 23 (7%) had new findings. Four (1%) patients had free gas under the diaphragm. Of the CXRs, 258 (77%) were reported normal whilst 53 (16%) had old changes which were described in their hospital records and previous radiographs. Of the CXRs with new findings, only 20 were clinically significant and, of these, four (1%) were surgically significant.
The majority of CXRs performed on emergency surgical admissions with abdominal pain are unnecessary. By obtaining a clear history, performing a thorough clinical examination and following the RCR guidelines most of the CXRs could be avoided. This would lead to less radiation exposure, reduce delays to diagnosis, and provide significant financial savings.
PMCID: PMC3229383  PMID: 20650038
Chest radiograph; Acute abdomen
5.  Development of a plain radiograph requesting algorithm for patients presenting with acute abdominal pain 
Radiologists at a large teaching hospital felt that plain radiograph imaging was being performed inappropriately for patients admitted with acute abdominal pain. They felt requests were either not indicated or CT was a more appropriate first line radiological investigation in certain circumstances.
An audit was performed looking at plain radiograph imaging requests for emergency admissions under general surgery, using Royal College of Radiologists (RCR) guidelines as the standard. The audit revealed that only 80% of plain radiograph requests met RCR guidelines. It also showed that 33% of acute admissions undergoing plain radiograph imaging proceeded to CT within forty-eight hours. These findings lead to the development of a plain radiograph algorithm. This aimed to improve plain radiograph imaging requests and to increase the use of CT as an earlier or first line radiological investigation where appropriate.
Outcome of discussion at local and regional clinical governance meetings was that earlier CT would be useful in specific circumstances. The algorithm provides a framework for appropriately expediting CT in patients presenting with acute abdominal pain where bowel obstruction or perforation was suspected. However, consultant surgeons felt that in patients presenting with acute abdominal pain, the plain abdominal radiograph often demonstrates findings associated with specific diagnoses not specifically indicated by RCR guidelines. If RCR guidelines for plain radiograph imaging are broadened, radiological interpretation would examine for a broader range of findings and, when combined with other clinical information, diagnoses can be made, thus avoiding the need for further imaging or explorative surgery.
PMCID: PMC3533591  PMID: 23289083
Radiograph; abdominal pain; algorithm; Royal College Radiologists guidelines
6.  Abdominal Radiograph Requesting in the Setting of Acute Abdominal Pain: Temporal Trends and Appropriateness of Requesting 
The biannual turnover of house surgeons has long been dreaded by paramedical staff because of fears of increased workloads generated by ‘untrained’ junior doctors. The aim of this study was to address this issue by examining both the quantity and quality of requests made for emergency abdominal radiographs made by ‘experienced’ house surgeons during the month of July and by the ‘novices’ during August.
All adult patients undergoing abdominal radiography (AXR) following admission as emergencies via the surgical directorate with abdominal signs were identified prospectively. The reports of the AXRs were reviewed to determine the total number of requests and the number of positive findings for the two groups. In addition, the hand-written request forms were recovered to determine the suitability of the requests according to nationally-accepted guidelines produced by the Royal College of Radiologists (RCR).
During the study period, a total of 252 radiographs were performed consisting of 98 in July and 154 in August. The number of unreported films in each month were similar at 11 (11.2%) and 16 (10.4%), respectively, leaving 87 reported radiographs in July and 138 in August. There was no difference in the number of radiographs with positive findings (excluding degenerative spinal disease) for July (n = 19; 22%) and August (n = 33; 24%). Of the 225 reported films, RCR guidelines were followed in only 73 (32%) of 225 cases. When guidelines were adhered to, positive findings were identified in 56 (76.7%) of 73 cases whereas when guidelines were not followed positive findings were seen in only 13/139 (8.9%) of AXRs.
We have demonstrated that the popular myth of the ‘August syndrome’ is unsubstantiated at least using the surrogate marker of abdominal radiograph requests. The worrying finding of a high number of unacceptable indications for the performance of abdominal radiographs deserves urgent attention both in terms of its financial implications and with regards reducing radiation exposure. A programme of education is proposed to emphasise the RCR guidelines with re-audit to assess adherence to the guidelines.
PMCID: PMC1963673  PMID: 16719997
Abdominal radiograph; Guidelines; Acute abdominal pain
7.  Should accident and emergency nurses request radiographs? Results of a multicentre evaluation. 
OBJECTIVE--To evaluate whether waiting time in accident and emergency (A&E) departments is shortened when experienced nurses request peripheral limb radiographs before a patient is assessed by a doctor. DESIGN--Simultaneous prospective trial in four A&E departments in the United Kingdom with doctors and nurses requesting radiographs; 2000 patients were randomly allocated to either a "Nurse First" or "Doctor First" category. SUBJECTS--Patients older than 5 years presenting with recent peripheral limb injuries. MAIN OUTCOME MEASURES--Timing of the various stages of a patient's passage through the A&E department comparing the orthodox route with a group of patients in whom an experienced A&E nurse had the option of requesting a radiograph before a medical assessment. RESULTS--There was a significant reduction in the time spent in A&E when no radiograph was requested (P << 0.001). The mean time saved in the "Doctor First" (DF) group was 51 min, and in the "Nurse First" (NF) group 36 min. For those who were sent for an x ray 14 min was saved by getting the patient to see the nurse first. However, because the overall referral rate for x rays was greater in the NF group, (78% of patients compared with 74% of the DF group, a significant 4% increase (P = 0.05) this potential benefit was largely lost. Overall the average waiting time in the DF group of 92.5 min (95% confidence interval: 89.2 to 96.1 min) was reduced to 88.5 min (95% CI:85.2 to 91.8 min) in the NF group, a non-significant saving of 4 min. There was no overall difference between the proportion of relevant abnormalities reported by the radiologists for the DF or NF groups (G2 = 0.739, 1df, P = 0.30); however, there was a significant association between the number of relevant abnormalities reported by the radiologists and the different hospitals (G2 = 9.7626, 3df, P = 0.02). Hospital C had the highest abnormality rate reported by the radiologists in both the DF (45%) and the NF (51%) groups. The most time saved in A&E was in the DF category when comparing those who did not have an x ray [58 (CI 54-63) min] with those who did [109 (CI 104-114) min], a saving of 51 min. The corresponding time saved in the NF category between those who did not have an x ray [59 (CI 53-65) min] and those who did [95 (CI 91-99) min] was 36 min. CONCLUSIONS--14 min can be saved by getting the patient to see the nurse first; however, because nurses in three out of four hospitals requested more radiological examinations than doctors, overall only 4 min waiting time was saved when peripheral limb radiographs were requested by nurses. The findings are somewhat against expectations but do identify that specific training and constant monitoring is essential if nurses are to request peripheral limb radiographs, as reflected in hospital C results.
PMCID: PMC1342643  PMID: 8653256
8.  Ionising radiation (medical exposure) regulations (Northern Ireland) 2000 and their implications for Accident and Emergency (A&E) doctors in training. 
The Ulster Medical Journal  2001;70(1):19-21.
With the introduction of the Ionising Radiation (Medical Exposure) Regulations (Northern Ireland) 2000 (IRMER) the medical practitioner faces greater accountability when requesting radiological investigations. The referrer (usually a doctor or dentist) must supply sufficient medical data to justify radiation exposure to a patient. These regulations can lead to criminal prosecution if breached. Our objectives were to identify the level of unjustified requests for plain abdominal radiography among A&E doctors and whether there is a statistically significant difference in the justification of request between doctors of differing experience. We reviewed and prepared statistical analysis of 100 A&E request forms for plain abdominal radiography. Royal College of Radiologist Guidelines were used as a "Gold standard" for justification of the investigation. A&E doctors of less than six months experience are at greater risk of breaching these regulations when requesting plain abdominal films, when compared to more experienced doctors. This is a serious issue which should be addressed at undergraduate and pre-registration level in addition to ongoing audit.
PMCID: PMC2449209  PMID: 11428319
9.  Ultrasonography compared with intravenous urography in the investigation of adults with haematuria. 
BMJ : British Medical Journal  1990;301(6760):1074-1076.
OBJECTIVE--To compare ultrasonography with intravenous urography in the investigation of adults with haematuria. DESIGN--Prospective study entailing the examination of all patients with both investigations concurrently. The investigations were performed independently on routine lists by different duty radiologists. Each was aware of the details of the request form but not of the findings of the other investigation. SETTING--Radiology department of a teaching hospital. PATIENTS--155 Consecutive adult patients (aged 18-93) referred from general practitioners and hospital outpatient clinics with a history of haematuria. FOLLOW UP--When results of both examinations proved normal no clinical or radiological follow up was sought. All abnormal findings of either investigation were correlated with results of subsequent imaging studies or operative findings. RESULTS--81 Patients (52%) had normal findings on urography and ultrasonography. Overall, the findings of ultrasonography concurred with those of urography in 144 cases (93%). Among the discrepant findings of the two investigations ultrasonography missed two ureteric calculi; one was in a non-dilated ureter, and in the other case ultrasonography detected the secondary ureteric dilatation. Ultrasound examination alone detected four bladder tumours not visible on urography with sizes ranging from 5 to 21 mm, representing one fifth of the 20 cystoscopically proved bladder tumours detected in the series. Ultrasonography detected all the 22 neoplastic lesions discovered in the study (20 bladder, two renal). Ultrasonography clarified the nature of renal masses evident in three urograms (simple cysts). CONCLUSIONS--Ultrasonography is a safe and accurate method of investigating the urinary tract in adults with haematuria. When combined with a single plain abdominal radiograph it proved to be superior to urography as the primary imaging study in this series. Ultrasonography should certainly be preferred to urography if cystoscopy is not planned. No urothelial tumours of the upper urinary tract were found in the series, reflecting their rarity. For those patients in whom ultrasonography and plain radiography have shown no abnormality and in whom cystoscopic appearances are normal urography would be advisable to exclude urothelial tumours of the upper urinary tract.
PMCID: PMC1664237  PMID: 2249070
10.  Ultrasonography compared with intravenous urography in investigation of urinary tract infection in adults. 
BMJ : British Medical Journal  1990;301(6745):221-224.
OBJECTIVE--To compare ultrasonography with intravenous urography for investigating adults with proved urinary tract infection. DESIGN--Prospective study of patients presenting consecutively for radiological investigation of urinary tract infection between October 1988 and December 1989. Both investigations were performed concurrently and performed independently on routine lists by different duty radiologists, each of whom knew the details on the request form but not the findings of the other investigation. SETTING--Radiology department of a teaching hospital. PATIENTS--158 Consecutive adults (89 women, 69 men; mean age 49.7 (range 18-83)) referred from general practitioners and hospital outpatient clinics with a history of proved urinary tract infection. INTERVENTIONS--Urography and ultrasonography performed concurrently. When both examinations gave normal findings no clinical or radiological follow up was sought. All abnormal findings detected with either investigation were confirmed by subsequent imaging studies or by operative procedures. MAIN OUTCOME MEASURE--Accuracy of detection of abnormalities of urinary system by ultrasonography compared with urography. RESULTS--113 Patients (72%) had normal urographic and ultrasonic findings. Overall, ultrasonography concurred with the findings of urography in 149 (94%) patients, and when a single abdominal radiograph was included in the procedure, in 152 (96%). Ultrasonography missed only one important diagnosis, that of mild papillary necrosis in normal sized kidneys in a diabetic patient. It detected one early bladder tumour not visible on urography and was able to clarify the nature of renal masses (simple cysts) evident on three urograms. CONCLUSION--Ultrasonography provides a safe and accurate method of imaging the urinary tract in adults with infection. Combined with a plain abdominal radiograph, it should replace urography as the initial imaging investigation in these patients. Major savings would result from adopting this policy, and the risks to patients from ionising radiation and intravenous contrast media would be appreciably reduced.
PMCID: PMC1663557  PMID: 2203487
11.  Lumbar Interbody Fusion Outcomes in Degenerative Lumbar Disease : Comparison of Results between Patients Over and Under 65 Years of Age 
To evaluate the clinical and radiological outcomes of lumbar interbody fusion and its correlation with various factors (e.g., age, comorbidities, fusion level, bone quality) in patients over and under 65 years of age who underwent lumbar fusion surgery for degenerative lumbar disease.
One-hundred-thirty-three patients with lumbar degenerative disease underwent lumbar fusion surgery between June 2006 and June 2007 and were followed for more than one year. Forty-eight (36.1%) were older than 65 years of age (group A) and 85 (63.9%) were under 65 years of age (group B). Diagnosis, comorbidities, length of hospital stay, and perioperative complications were recorded. The analysis of clinical outcomes was based on the visual analogue scale (VAS). Radiological results were evaluated using plain radiographs. Clinical outcomes, radiological outcomes, length of hospital stay, and complication rates were analyzed in relation to lumbar fusion level, the number of comorbidities, bone mineral density (BMD), and age.
The mean age of the patients was 61.2 years (range, 33-86 years) and the mean BMD was -2.2 (range, -4.8 to -2.8). The mean length of hospital stay was 15.0 days (range, 5-60 days) and the mean follow-up was 23.0 months (range, 18-30 months). Eighty-five (64.0%) patients had more than one preoperative comorbidities. Perioperative complications occurred in 27 of 133 patients (20.3%). The incidence of overall complication was 22.9% in group A, and 18.8% in group B but there was no statistical difference between the two groups. The mean VAS scores for the back and leg were significantly decreased in both groups (p < 0.05), and bony fusion was achieved in 125 of 133 patients (94.0%). There was no significant difference in bony union rates between groups A and B (91.7% in group A vs. 95.3% in group B, p = 0.398). In group A, perioperative complications were more common with the increase in fusion level (p = 0.027). Perioperative complications in both groups A (p = 0.035) and B (p = 0.044) increased with an increasing number of comorbidities.
Elderly patients with comorbidities are at a high risk for complications and adverse outcomes after lumbar spine surgery. In our study, clinical outcomes, fusion rates, and perioperative complication rates in older patients were comparable with those in younger populations. The number of comorbidities and the extent of fusion level were significant factors in predicting the occurrence of postoperative complications. However, proper perioperative general supportive care with a thorough fusion strategy during the operation could improve the overall postoperative outcomes in lumbar fusion surgery for elderly patients.
PMCID: PMC3030080  PMID: 21286477
Elderly patients; Lumbar interbody fusion; Comorbidities; Complications
12.  Diagnostic and therapeutic efficacy of barium meal examination: a prospective evaluation in general practice. 
BMJ : British Medical Journal  1989;299(6713):1443-1445.
OBJECTIVE--To assess the efficacy of barium meal examinations in managing patients with dyspepsia in general practice. DESIGN--Prospective study by questionnaires completed by general practitioners before and within three to six months after the barium meal examination. Information was requested about the patients' symptoms, current treatment, reason for requesting the examination, and the working diagnosis, including degree of certainty and, after the examination, about any change in diagnosis, diagnostic confidence, or management and to determine whether the examination was judged to be helpful or not. SETTING--Inner city health district. PATIENTS--133 Patients with dyspepsia referred by general practitioners for outpatient barium meal examination, 31 of whom failed to attend for the examination, or refused it on arrival, or did not have fully completed questionnaires. Two patients were not available for follow up. MAIN OUTCOME MEASURES--Prevalence of radiological abnormalities and the influence of the examination result on management, particularly changes in drug treatment. RESULTS--Fully completed pairs of questionnaires were available for 100 patients, 58 of whom were aged below 50. Most of the barium meal reports (64) were to confirm the clinical diagnosis; only 22 were to exclude serious disease. Ninety nine patients were already receiving treatment, with 39 taking an H2 receptor antagonist. Fifty eight barium meal examinations showed abnormalities (31 major abnormalities); there were no cancers and in only 18 patients was the working diagnosis changed as a result of the findings. Although the barium meal result increased management confidence (63 patients) and allayed patients' anxiety (46), changes in management attributed directly to the examination occurred in only 22 patients. Management changes were minor, usually comprising interchange of antacids and H2 receptor antagonists. CONCLUSIONS--Young patients (aged below 50) with dyspepsia are still being overinvestigated. Although barium meal examination improves diagnostic confidence and allays patients' anxiety, fully utilising communication skills at the initial consultation might allay anxiety more economically.
PMCID: PMC1838301  PMID: 2575413
13.  Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial 
BMJ : British Medical Journal  2001;322(7283):400-405.
To test the hypothesis that radiography of the lumbar spine in patients with low back pain is not associated with improved clinical outcomes or satisfaction with care.
Randomised unblinded controlled trial.
73 general practices in Nottingham, north Nottinghamshire, southern Derbyshire, north Lincolnshire, and north Leicestershire. 52 practices recruited participants to the trial.
421 patients with low back pain of a median duration of 10 weeks.
Radiography of the lumbar spine.
Main outcome measures
Roland adaptation of the sickness impact profile, visual analogue scale for pain, health status, EuroQol, satisfaction with care, use of primary and secondary care services, and reporting of low back pain at three and nine months after randomisation.
The intervention group were more likely to report low back pain at three months (relative risk 1.26, 95% confidence interval 1.00 to 1.60) and had a lower overall health status score and borderline higher Roland and pain scores. A higher proportion of participants consulted their doctor in the three months after radiography (1.62, 1.33 to 1.97). Satisfaction with care was greater in the group receiving radiography at nine but not three months after randomisation. Overall, 80% of participants in both groups at three and nine months would have radiography if the choice was available. An abnormal finding on radiography made no difference to the outcome, as measured by the Roland score.
Radiography of the lumbar spine in primary care patients with low back pain of at least six weeks' duration is not associated with improved patient functioning, severity of pain, or overall health status but is associated with an increase in doctor workload. Guidelines on the management of low back pain in primary care should be consistent about not recommending radiography of the lumbar spine in patients with low back pain in the absence of indicators for serious spinal disease, even if it has persisted for at least six weeks. Patients receiving radiography are more satisfied with the care they received. The challenge for primary care is to increase satisfaction without recourse to radiography.
PMCID: PMC26570  PMID: 11179160
14.  Should all elective knee radiographs requested by general practitioners be performed weight-bearing? 
SpringerPlus  2014;3:707.
The aims of this study were to: [1] Assess the number of patients with suspected knee osteoarthritis that underwent repeat weight-bearing(WB) knee radiographs in the orthopaedic clinic following initial non-WB radiograph requested by their general practitioner (GP). [2] Confirm whether repeating WB knee views changed radiology reports. [3] Determine the number of London trusts with protocols for routinely performing WB views. A Retrospective cohort study of 1968 patients aged >40 years referred to a London teaching hospital for knee radiographs over 12 months. Radiographs were identified as WB/non-WB. Subsequent repeat WB views performed in those that went on to have an orthopaedic consultation were also documented. A consultant musculoskeletal radiologist reported both images. A proforma containing a likert scale of severity for commonly reported abnormalities in knee osteoarthritis and criteria from the Kellgren and Lawrence scale was used for reporting. London NHS Trusts were surveyed to identify if protocols were in place for performing WB views. A total of 1,968 patients underwent knee radiographs, of which 1922 (97.7%) had initial non-WB radiographs. Of the 56 patients in this group that underwent required repeat WB radiographs, joint space narrowing was reported as more severe on WB versus non-WB radiographs (p = 0.035). Only 54% of departments routinely performed WB radiographs. Few patients (2.3%) referred by GPs have WB radiographs requested. Some of those referred for a specialist opinion required repeat WB views. Nearly half of London hospitals do not routinely perform WB radiographs. This represents a significant financial burden to the NHS, increased radiation exposure and wasted patient/clinician time. We propose that all GP requested knee radiographs be performed as WB unless otherwise stated.
Electronic supplementary material
The online version of this article (doi:10.1186/2193-1801-3-707) contains supplementary material, which is available to authorized users.
PMCID: PMC4265640  PMID: 25525568
Weight bearing; Knee radiograph; Knee osteoarthritis
15.  Use of small bowel imaging for the diagnosis and staging of Crohn’s disease—a survey of current UK practice 
The British Journal of Radiology  2011;84(1002):508-517.
This study used a postal survey to assess the current use of small bowel imaging investigations for Crohn’s disease within National Health Service (NHS) radiological practice and to gauge gastroenterological referral patterns.
Similar questionnaires were posted to departments of radiology (n = 240) and gastroenterology (n = 254) identified, by the databases of the Royal College of Radiologists and British Society of Gastroenterologists. Questionnaires enquired about the use of small bowel imaging in the assessment of Crohn’s disease. In particular, questionnaires described clinical scenarios including first diagnosis, disease staging and assessment of suspected extraluminal complications, obstruction and disease flare. The data were stratified according to patient age.
63 (27%) departments of radiology (20 in teaching hospitals and 43 in district general hospitals (DGHs)) and 73 (29%) departments of gastroenterology replied. These departments were in 119 institutions. Of the 63 departments of radiology, 55 (90%) routinely performed barium follow-though (BaFT), 50 (80%) CT, 29 (46%) small bowel ultrasound (SbUS) and 24 (38%) small bowel MRI. BaFT was the most commonly used investigation across all age groups and indications. SbUS was used mostly for patients younger than 40 years of age with low index of clinical suspicion for Crohn’s disease (in 44% of radiology departments (28/63)). MRI was most frequently used in patients under 20 years of age for staging new disease (in 27% of radiology departments (17/63)) or in whom obstruction was suspected (in 29% of radiology departments (18/63)). CT was preferred for suspected extraluminal complications or obstruction (in 73% (46/63) and 46% (29/63) of radiology departments, respectively). Gastroenterological referrals largely concurred with the imaging modalities chosen by radiologists, although gastroenterologists were less likely to request SbUS and MRI.
BaFT remains the mainstay investigation for luminal small bowel Crohn’s disease, with CT dominating for suspected extraluminal complications. There has been only moderate dissemination of the use of MRI and SbUS.
PMCID: PMC3473626  PMID: 21081570
16.  The effect of introducing guidelines for cervical spine radiographs in the accident and emergency department. 
OBJECTIVE: To assess the effect of guidelines for x ray requests on requests for cervical spine x rays. SETTING: Accident and emergency (A&E) department of tertiary referral centre. METHODS: Guidelines for all x ray requests were introduced in the (A&E) department of the Royal Infirmary of Edinburgh in February 1992. The effect of the guidelines on requests for cervical spine x rays was assessed by retrospective review of all such x rays taken over two 30 d periods, before and after the introduction of the guidelines. Junior staff had been in post for 3 months during both periods assessed. Films were reviewed for quality by a consultant radiologist. RESULTS: Guidelines reduced the number of inappropriate requests significantly; however, 26% of requests were still unnecessary. The standard of radiography improved but 49% of x rays remained inadequate, usually because the C7/T1 level was not demonstrated on the lateral view. The A&E doctors correctly interpretated the radiographs in 95% of examinations. CONCLUSIONS: Guidelines reduce inappropriate x ray requests. Further improvements can be expected with continued education.
PMCID: PMC1342606  PMID: 8821225
17.  The role of cumulative physical work load in lumbar spine disease: risk factors for lumbar osteochondrosis and spondylosis associated with chronic complaints 
OBJECTIVES—To investigate the relation with a case-control study between symptomatic osteochondrosis or spondylosis of the lumbar spine and cumulative occupational exposure to lifting or carrying and to working postures with extreme forward bending.
METHODS—From two practices and four clinics were recruited 229 male patients with radiographically confirmed osteochondrosis or spondylosis of the lumbar spine associated with chronic complaints. Of these 135 had additionally had acute lumbar disc herniation. A total of 197 control subjects was recruited: 107 subjects with anamnestic exclusion of lumbar spine disease were drawn as a random population control group and 90 patients admitted to hospital for urolithiasis who had no osteochondrosis or spondylosis of the lumbar spine radiographically were recruited as a hospital based control group. Data were gathered in a structured personal interview and analysed using logistic regression to control for age, region, nationality, and other diseases affecting the lumbar spine. To calculate cumulative forces to the lumbar spine over the entire working life, the Mainz-Dortmund dose model (MDD), which is based on an overproportional weighting of the lumbar disc compression force relative to the respective duration of the lifting process was applied with modifications: any objects weighing ⩾5 kg were included in the calculation and no minimum daily exposure limits were established. Calculation of forces to the lumbar spine was based on self reported estimates of occupational lifting, trunk flexion, and duration.
RESULTS—For a lumbar spine dose >9×106 Nh (Newton×hours), the risk of having radiographically confirmed osteochondrosis or spondylosis of the lumbar spine as measured by the odds ratio (OR) was 8.5 (95% confidence interval (95% CI) 4.1 to 17.5) compared with subjects with a load of 0 Nh. To avoid differential bias, forces to the lumbar spine were also calculated on the basis of an internal job exposure matrix based on the control subjects' exposure assessments for their respective job groups. Although ORs were lower with this approach, they remained significant.
CONCLUSIONS—The calculation of the sum of forces to the lumbar spine is a useful tool for risk assessment for symptomatic osteochondrosis or spondylosis of the lumbar spine. The results suggest that cumulative occupational exposure to lifting or carrying and extreme forward bending increases the risk for developing symptomatic osteochondrosis or spondylosis of the lumbar spine.

Keywords: case-control study; physical work load; lumbar osteochondrosis; lumbar spondylosis
PMCID: PMC1740072  PMID: 11600730
18.  Direct access exercise electrocardiography: a new service that improves the management of suspected ischaemic heart disease in the community. 
British Heart Journal  1994;71(6):531-535.
OBJECTIVE--To assess the safety and value of an exercise electrocardiography service for the diagnosis of suspected ischaemic heart disease to which general practitioners have direct access. DESIGN--Direct access to a hospital exercise electrocardiography service was offered on a trial basis to 122 general practitioners in a defined urban area. Maximal exercise tests were performed according to the modified Bruce protocol and the results were dispatched promptly to the referring doctors who were responsible for the subsequent management of their patients. SETTING--All general practices in north and west Belfast (combined list size about 180,000) and the regional medical cardiology centre. PATIENTS--212 request forms were received in a two year period and 192 eligible patients attended for exercise testing. All patients were suspected to have pain due to myocardial ischaemia, were aged < or = 65, and had no contraindications to exercise testing. MAIN OUTCOME MEASURES--Proportion of general practitioners who used the service. Proportion of exercise tests that were positive. Referring doctors' assessment of the service. RESULTS--43% of general practitioners referred patients and 34 tests (18%) were positive. No complications occurred. The pretest likelihood of ischaemic heart disease, assessed by the referring doctor, was high in 48 (25%), moderate in 82 (43%), and low in 62 (32%). A high pretest likelihood of ischaemic heart disease predicted a positive test result with a sensitivity of 50% and specificity of 80%. General practitioners decided to refer 19 (10%) patients to a hospital cardiology department for further assessment, including 16 of the 34 who had a positive exercise test. In most cases the service was found to be helpful and 97% of patients would have been referred directly to a hospital cardiology clinic if it had not been available. CONCLUSIONS--Direct access exercise electrocardiography for patients with suspected ischaemic heart disease is safe, feasible, and helpful to general practitioners. This service seems to reduce the number of patients referred to cardiology outpatient clinics and to facilitate the management of these patients in the community.
PMCID: PMC1025447  PMID: 8043332
19.  Radiology reporting: a general practitioner's perspective 
The British Journal of Radiology  2010;83(985):17-22.
Unlike hospital-based clinicians, general practitioners (GPs) lack direct contact with radiologists, and the radiology report is usually the sole method of communication from the radiologist to the GP. It is important to gain feedback regarding what GPs perceive as a good-quality radiology report, especially in the current climate of competition for provision of radiology services. The aims of this study are to determine the level of GP satisfaction with radiology reports, their perception of optimum report content and their preferences regarding the level of detail and report format. A questionnaire was sent to 100 GPs referring to our Trust for radiology services. GPs were generally satisfied with the content and clarity of reports that they receive, and gave suggestions on how reports could be improved. The majority of GPs were unfamiliar with the normal size ranges of frequently measured anatomical structures. Radiologists' recommendations for further treatment, referral and non-radiological investigation were viewed as valuable report components. When asked to rank preferences for ultrasound reports for the same patient with differing formats and levels of detail, GPs favoured detailed reports in a tabulated format. In conclusion, the majority of GPs like detailed reports and value the radiologist's opinion outside the remit of imaging when suggesting further patient management. Reporting the size of a structure without explanation of its significance can potentially cause confusion. It is important to know if GPs are satisfied with the radiology reports they receive so that we can uphold high communication standards and ultimately improve patient care.
PMCID: PMC3487261  PMID: 19470574
20.  Triage nurse requested x rays—are they worthwhile? 
Objective—To study an established triage nurse x ray requesting system to determine whether sending defined groups of patients for radiography before assessment by doctors or emergency nurse practitioners (ENPs) resulted in shorter waiting times for patients without compromising quality of care.
Methods—Prospective randomised controlled study of "walking wounded" patients attending a district general hospital. Data were collected over two separate two week periods, six months apart, in the middle of two senior house officer appointment periods. A total of 675 patients were entered into the study. Analysis of results was achieved using standard statistical methods.
Results—Altogether 335 patients were in the nurse x ray group and 340 in the control group. The triage categories of the groups were similar. A 36% mean time reduction of 37.2 min (95% confidence interval 30.2 to 44.2, p=0.000) from time of triage to time of treatment decision was achieved in the nurse requested group. Triage nurses requested 8% (p=0.002) fewer x rays than doctors or ENPs and had a 6% higher positive "hit" rate (p=0.03).
In 7.8% (26 cases), patients in the triage nurse group were judged to require radiographs or further views by the doctor or ENP; of these, 11 cases showed a positive finding on radiography. The time from triage to assessment by doctor or ENP was not lengthened by prior requesting of radiography (nurse x ray group 64.4 min, control group 63.7 min, p=0.79).
Conclusions—A triage nurse x ray requesting system speeds up the progress of walking wounded patients through the department without compromising service quality. Further benefits are staff and patient satisfaction and a greater sense of team working for all staff.
PMCID: PMC1725357  PMID: 10718230
21.  Use of Radiological Facilities by General Practitioners 
British Medical Journal  1974;3(5933):732-734.
The 11,360 direct referrals to diagnostic radiological facilities by general practitioners in the Aberdeen area during 1973 were studied. These represented about 12% of the adult radiology performed in the main x-ray departments of the city, and barium meal examinations amounted to half of all such outpatient contrast examinations. Chest x-ray and barium meal examinations were the most frequently used procedures.
Some abnormality was detected at 34% of all examinations, and the barium meal examinations requested by general practitioners showed a similar percentage of abnormal findings to those requested by Aberdeen hospital doctors.
The average referral rate for all practices was 24·6 per 1,000 practice population per year. Singlehanded general practitioners referred fewer patients for diagnostic radiology than those working in group practices, and rural practitioners referred fewer than urban general practitioners. This trend was emphasized at a distance greater than 15 miles from the city.
PMCID: PMC1611820  PMID: 4416823
22.  Mid-range outcomes in 64 consecutive cases of multilevel fusion for degenerative diseases of the lumbar spine 
Orthopedic Reviews  2010;2(1):e3.
In the treatment of multilevel degenerative disorders of the lumbar spine, spondylodesis plays a controversial role. Most patients can be treated conservatively with success. Multilevel lumbar fusion with instrumentation is associated with severe complications like failed back surgery syndrome, implant failure, and adjacent segment disease (ASD). This retrospective study examines the records of 70 elderly patients with degenerative changes or instability of the lumbar spine treated between 2002 and 2007 with spondylodesis of more than two segments. Sixty-four patients were included; 5 patients had died and one patient was lost to follow-up. We evaluated complications, clinical/radiological outcomes, and success of fusion. Flexion-extension and standing X-rays in two planes, MRI, and/or CT scans were obtained pre-operatively. Patients were assessed clinically using the Oswestry disability index (ODI) and a Visual Analogue Scale (VAS). Surgery performed was dorsolateral fusion (46.9%) or dorsal fusion with anterior lumbar interbody fusion (ALIF; 53.1%). Additional decompression was carried out in 37.5% of patients. Mean follow-up was 29.4±5.4 months. Average patient age was 64.7±4.3 years. Clinical outcomes were not satisfactory for all patients. VAS scores improved from 8.6±1.3 to 5.6±3.0 pre- to post-operatively, without statistical significance. ODI was also not significantly improved (56.1±22.3 pre- and 45.1±26.4 post-operatively). Successful fusion, defined as adequate bone mass with trabeculation at the facets and transverse processes or in the intervertebral segments, did not correlate with good clinical outcomes. Thirty-five of 64 patients (54%) showed signs of pedicle screw loosening, especially of the screws at S1. However, only 7 of these 35 (20%) complained of corresponding back pain. Revision surgery was required in 24 of 64 patients (38%). Of these, indications were adjacent segment disease (16 cases), pedicle screw loosening (7 cases), and infection (one case). At follow-up of 29.4 months, patients with radiographic ASD had worse ODI scores than patients without (54.7 vs. 36.6; P<0.001). Multilevel fusion for degenerative disease still has a high rate of complications, up to 50%. The problem of adjacent segment disease after fusion surgery has not yet been solved. This study underscores the need for strict indication guidelines to perform lumbar spine fusion of more than two levels.
PMCID: PMC3143945  PMID: 21808698
lumbar spine; multilevel fusion; complication; degenerative disease; adjacent segment disease; implant loosening; topping off.
23.  The diagnostic yield of magnetic resonance imaging (MRI) of the brain and spine requested by general practitioners: comparison with hospital clinicians. 
The rate of diagnosis of radiologically significant abnormalities in outpatients following requests of magnetic resonance imaging (MRI) of the brain and spine by general practitioners was compared with the rate following MRI scan requests by hospital clinicians. A similar rate of significant pathology was diagnosed in both groups in both the brain and the spine. Under carefully controlled conditions, open-access MRI scanning of the brain and spine can contribute to effective patient management.
PMCID: PMC1313478  PMID: 10621993
24.  What is the effect of reporting all emergency department radiographs? 
Objectives: To evaluate the effect of formal radiological reporting of all emergency department (ED) radiographs on clinical practice and patient outcome, and to consider whether a selective reporting policy might prove safe and effective.
Methods: All radiographs taken in a single ED over a six month period were prospectively studied simultaneously in both the emergency and radiology departments to detect cases where a radiograph that was considered normal by ED staff was then reported as abnormal by the reporting radiologist. Whenever such a discrepancy occurred the patient's records were scrutinised to ascertain the source of the discrepancy, with a gold standard interpretation derived from senior clinical review and additional investigations where indicated. The clinical impact of the radiologist's formal report was then assessed. Accuracy of interpretation was considered in relation to the grade of ED staff and the radiographic examination obtained.
Results: During the study period, 19 468 new patient attendances to the ED generated 11 749 radiographic examinations. Discrepancies were detected in 175 patients (1.5% of all radiographic examinations). Of these, 136 (1.2%) were subsequently shown to have been incorrectly interpreted in the ED (ED false negatives), with 40 patients (0.3%) undergoing a change in management as a result. In the remaining 39 the ED interpretation was judged to be correct (radiology false positives), with 16 patients undergoing further investigations or visits to the ED to confirm this.
Conclusions: The formal reporting of ED radiographs by the radiology department detects a number of clinically important abnormalities that have been overlooked. However, this formal reporting also generates a number of incorrect interpretations that may lead to further unnecessary investigations. Some groups of ED radiographs (such as those interpreted by an ED consultant and films of the fingers and toes) may not require formal radiological reporting. The adoption of a selective reporting policy may reduce the reporting workload of the radiology department without compromising patient care.
PMCID: PMC1726029  PMID: 12533366
25.  Variation in emergency department use of cervical spine radiography for alert, stable trauma patients 
OBJECTIVE: To, assess the emergency department use of cervical spine radiography for alert, stable adult trauma patients in terms of utilization, yield for injury and variation in practices among hospitals and physicians. DESIGN: Retrospective survey of health records. SETTING: Emergency departments of 6 teaching and 2 community hospitals in Ontario and British Columbia. PATIENTS: Consecutive alert, stable adult trauma patients seen with potential cervical spine injury between July 1, 1994, and June 30, 1995. MAIN OUTCOME MEASURES: Total number of eligible patients, referral for cervical spine radiography (overall, by hospital and by physician), presence of cervical spine injury, patient characteristics and hospitals associated with use of radiography. RESULTS: Of 6855 eligible patients, cervical spine radiography was ordered for 3979 (58.0%). Only 60 (0.9%) patients were found to have an acute cervical spine injury (fracture, dislocation or ligamentous instability); 98.5% of the radiographic films were negative for any significant abnormality. The demographic and clinical characteristics of the patients were similar across the 8 hospitals, and no cervical spine injuries were missed. Significant variation was found among the 8 hospitals in the rate of ordering radiography (p < 0.0001), from a low of 37.0% to a high of 72.5%. After possible differences in case severity and patient characteristics at each hospital were controlled for, logistic regression analysis revealed that 6 of the hospitals were significantly associated with the use of radiography. At 7 hospitals, there was significant variation in the rate of ordering radiography among the attending emergency physicians (p < 0.05), from a low of 15.6% to a high of 91.5%. CONCLUSIONS: Despite considerable variation among institutions and individual physicians in the ordering of cervical spine radiography for alert, stable trauma patients with similar characteristics, no cervical spine injuries were missed. The number of radiographic films showing signs of abnormality was extremely low at all hospitals. The findings suggest that cervical spine radiography could be used more efficiently, possibly with the help of a clinical decision rule.
PMCID: PMC1227493  PMID: 9176419

Results 1-25 (1665810)