Who writes guidelines,and who should?

AIM: To confirm or refute the impression that diagnostic radiology was often not represented on guideline writing committees, despite the fact that guidelines often made statements with implications for radiological practice. MATERIALS AND METHODS: We took two approaches. Firstly we examined all published Scottish Intercollegiate Guidelines Network (SIGN) guidelines and extracted the disease topic, the number of authors and peer reviewers, the number that were radiologists, and independently decided whether, given the content, radiologist input at the writing or review stage was necessary. We also searched for all guidelines on management of stroke worldwide (a single disease topic with major radiological implications) and extracted the proportion of authors that were radiologists. RESULTS: Of 47 SIGN guidelines on different diseases, 11 (23%) had a radiologist in the authorship (13/594, 2.2% total authors), and 5/47 (11%) had a radiologist specialist reviewer (10/529, 1.8% total reviewers). Independent review of the guidelines' content suggested that 76% of guidelines should have had a radiologist author and 91% a radiologist reviewer (discrepancy 53% and 80% respectively). Amongst 22 guidelines on acute stroke management in the world literature with 202 authors (where stated), there were only two radiologists (1%), both on one guideline which was specifically to do with imaging of stroke (5% of all stroke guidelines identified). CONCLUSION: Diagnostic radiology is poorly represented on guideline writing committees, although frequently guidelines have implications for radiological practice. Radiologists should try to be more involved in guideline production.     

Muscle reflexes in motion: how, what, and why?

Methods have been developed to study excitatory and inhibitory reflexes during human movements because dramatic task-dependent changes occur between different voluntary activities, and phase-dependent changes occur within cyclic movements. Interestingly, segmental reflexes are relatively unimportant for standing balance, although reflex responses are strong, yet they contribute substantially to force in several muscles during walking, when some reflex responses are weaker.     

Endovascular Renal Artery Denervation: Why, When, and How?

Endovascular renal artery denervation (ERAD) is a new procedure to reduce renal and systemic sympathetic overactivity in hypertensive patients. The role of sympathetic overactivity is recognized since a long time as being one the contributor of human hypertension. In support of this view, several studies in experimental models of hypertension in animal as well as hypertensive human subjects have demonstrated that sympathetic overactivity plays a central role in hypertension catheter based renal denervation is now possible, and this procedure may provide a useful adjunct for the management of patients with drug-resistant primary hypertension. Following a cohort study, the results of an open label randomized control trial have been published showing very encouraging results. The purpose of this paper is to help interventionalists to better understand the medical and technical issues related to this new intervention. It is most likely that as underlined in a recent editorial several other technical approaches may appear in the future, however because this is the only technique that is available today, we will focus on radiofrequency based technique.     

Fluorescence guided surgery and tracer-dose,fact or fiction?

Introduction

Fluorescence guidance is an upcoming methodology to improve surgical accuracy. Challenging herein is the identification of the minimum dose at which the tracer can be detected with a clinical-grade fluorescence camera. Using a hybrid tracer such as indocyanine green (ICG)-^99mTc-nanocolloid, it has become possible to determine the accumulation of tracer and correlate this to intraoperative fluorescence-based identification rates. In the current study, we determined the lower detection limit of tracer at which intraoperative fluorescence guidance was still feasible.

Methods

Size exclusion chromatography (SEC) provided a laboratory set-up to analyze the chemical content and to simulate the migratory behavior of ICG-nanocolloid in tissue. Tracer accumulation and intraoperative fluorescence detection findings were derived from a retrospective analysis of 20 head-and-neck melanoma patients, 40 penile and 20 prostate cancer patients scheduled for sentinel node (SN) biopsy using ICG-^99mTc-nanocolloid. In these patients, following tracer injection, single photon emission computed tomography fused with computed tomography (SPECT/CT) was used to identify the SN(s). The percentage injected dose (% ID), the amount of ICG (in nmol), and the concentration of ICG in the SNs (in μM) was assessed for SNs detected on SPECT/CT and correlated with the intraoperative fluorescence imaging findings.

Results

SEC determined that in the hybrid tracer formulation, 41 % (standard deviation: 12 %) of ICG was present in nanocolloid-bound form. In the SNs detected using fluorescence guidance a median of 0.88 % ID was present, compared to a median of 0.25 % ID in the non-fluorescent SNs (p-value?<?0.001). The % ID values could be correlated to the amount ICG in a SN (range: 0.003–10.8 nmol) and the concentration of ICG in a SN (range: 0.006–64.6 μM).

Discussion

The ability to provide intraoperative fluorescence guidance is dependent on the amount and concentration of the fluorescent dye accumulated in the lesion(s) of interest. Our findings indicate that intraoperative fluorescence detection with ICG is possible above a μM concentration.

     

Central fatigue and neurotransmitters, can thermoregulation be manipulated?

Fatigue is a complex phenomenon that can be evoked by peripheral and central factors. Although it is obvious that fatigue has peripheral causes such as glycogen depletion and cardiovascular strain, recent literature also focuses on the central origin of fatigue. It is clear that different brain neurotransmitters--such as serotonin, dopamine and noradrenaline--are implicated in the occurrence of fatigue, but manipulation of these neurotransmitters produced no conclusive results on performance in normal ambient temperature. Exercise in the heat not only adds an extra challenge to the cardiorespiratory system, but also to the brain. This provides a useful tool to investigate the association between exercise-induced hyperthermia and central fatigue. This review focuses on the effects of pharmacological manipulations on performance and thermoregulation in different ambient temperatures. Dopaminergic reuptake inhibition appears to counteract hyperthermia-induced fatigue in 30 °C, while noradrenergic neurotransmission shows negative effects on performance in both normal and high temperature, and serotonergic manipulations did not lead to significant changes in performance. It is, however, unlikely that one neurotransmitter system is responsible for the delay or onset of fatigue. Further research is required to determine the exact mechanisms of fatigue in different environmental conditions.     

Chronotype and self?reported sleep,alertness, and mental health in U.S. sailors

Service members are at risk for sleep and psychological conditions affecting their readiness. Chronotype ("morningness" or "eveningness") is strongly associated...     

Imaging in scoliosis: what,why and how?

Scoliosis may be a spinal manifestation of underlying disease and although most cases of scoliosis are idiopathic, imaging plays a very important role in determining the underlying aetiology and in monitoring the changes of the deformity that take place with growth. As a clinical problem scoliosis may present directly to the radiology department through a primary healthcare referral, or it may be referred from the paediatric, orthopaedic, spinal and neurosurgical hospital services. Growth affects all types of scoliosis irrespective of cause. There are no reliable predetermined algorithmic steps in the management of scoliosis, and treatment decisions require the inclusion of multiple extrinsic (e.g age, menarche) and intrinsic (curve magnitude, vertebral anomaly) factors. It is important to remember that most of what is known about curve behaviour and its progression applies to idiopathic scoliosis, and it is inappropriate to apply these criteria to the other specific types of scoliosis. It is imperative that radiation techniques are used judiciously to minimize the radiation burden. Although magnetic resonance imaging (MRI) has had a significant impact in the understanding of the scoliotic deformity, it is still evolving and it may well eventually play a very important role in uncovering the underlying aetiology of 'idiopathic' scoliosis.     

Parathyroid scintigraphy: when, how, and why? A concise systematic review

In recent years, preoperative imaging has become essential in the evaluation of sporadic primary hyperparathyroidism (HPT) for selecting good candidates for minimally invasive HPT. Its role in patients with secondary/tertiary HPT is under investigation. Imaging is mandatory before reoperative parathyroid surgery for persistent or recurrent HPT, whatever the setting. This review provides detailed information regarding the nuclear imaging methods (dual phase, subtraction), the role of SPECT and SPECT/CT, and the clinical results of parathyroid scintigraphy in different clinical situations.     

Genomics, proteomics, MEMS and SAIF: which role for diagnostic imaging?

In these three words--genomics, proteomics and nanotechnologies--is the future of medicine of the third millennium, which will be characterised by more careful attention to disease prevention, diagnosis and treatment. Molecular imaging appears to satisfy this requirement. It is emerging as a new science that brings together molecular biology and in vivo imaging and represents the key for the application of personalized medicine. Micro-PET (positron emission tomography), micro-SPECT (single photon emission computed tomography), micro-CT (computed tomography), micro-MR (magnetic resonance), micro-US (ultrasound) and optical imaging are all molecular imaging techniques, several of which are applied only in preclinical settings on animal models. Others, however, are applied routinely in both clinical and preclinical setting. Research on small animals allows investigation of the genesis and development of diseases, as well as drug efficacy and the development of personalized therapies, through the study of biological processes that precede the expression of common symptoms of a pathology. Advances in molecular imaging were made possible only by collaboration among scientists in the fields of radiology, chemistry, molecular and cell biology, physics, mathematics, pharmacology, gene therapy and oncology. Although until now researchers have traditionally limited their interactions, it is only by increasing these connections that the current gaps in terminology, methods and approaches that inhibit scientific progress can be eliminated.     

Clinical prediction rules in trauma imaging: who, how, and why?

Clinical prediction rules are multifactorial tools used to aid in clinical decision making. In radiology, clinical prediction rules are an important method for determining who should undergo imaging and, in combination with cost-effectiveness analysis, how imaging should be performed. To be useful, clinical prediction rules should be clinically important, have face validity, be reproducible and easy to use, be clinically relevant, and suggest a course of action. To insure generalizability, clinical prediction rules should also be validated in subjects distinct from those used to develop the rule. In this review, several examples from trauma imaging are used to demonstrate the development, validation, and use of clinical prediction rules.     

Pelvic Congestion Syndrome,Who Should We Treat and How?

Pelvic congestion syndrome (PCS) is a condition that is difficult to diagnose but causes distress to a significant number of women. It is not difficult to treat by embolization but the technique is still evolving and results are by no means perfect. Nevertheless, the results of endovascular treatment are at least equivalent to those of surgery and better than conventional medical therapy. This paper will review the techniques and results reported for treatment of pelvic congestion syndrome.     

What do patients know about ultrasound,CT and MRI?

OBJECTIVES: To establish the level of patient knowledge of ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI); to describe patient information-seeking behaviour before attendance; and to assess patients' understanding of the main aspects of scanning examinations. DESIGN: Survey of people attending for ultrasound, CT and MRI using a questionnaire, including 12 statements on simple aspects of procedures, to be indicated as true or false. SETTING: Radiology department of an acute teaching hospital NHS Trust in the north-east of Scotland. PARTICIPANTS: A convenience sample of 500 out-patient, non-emergency first time attenders for ultrasound (300), computed tomography (150), and magnetic resonance imaging (50). RESULTS: An 82% response rate to the questionnaire was achieved. Less than half the patients (48.9%, 182/372) indicated they knew the type of investigation they had been referred for. When responses were compared with referral letters, 64% (238/372) were incongruent. Few participants hadsought information (32%, 120/372), but of those who had the main source was family and friends (72%, 86/120). Seven participants searched the Internet. Eighty-two percent (308/372) of participants reported having been given an explanation of why an investigation was necessary. The majority of participants (67.8%, 251/372) expected to receive their results within 2 weeks. The mean score on the 12 true/false knowledge statements was 3.8, and 17% (65/372) answered 'Don't know' to all the statements. One person answered all questions correctly. CONCLUSIONS: Patients were not well informed regarding these investigations. This has significant implications for information-giving strategies and informed consent.