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The interplay of structures in the finger that facilitate movement is complex and not yet fully understood. Subtle finger injuries are often missed during the initial assessment in the Emergency Department, because clinical examination of the acutely injured hand can be difficult. The consequences of unrecognized finger injuries can be devastating for the patient. Ultrasound imaging of tendons is a useful investigative tool although little has been published regarding the reliability of finger tendon measurements. The overall objective of this project was to establish if bedside ultrasound imaging of tendons was possible and useful in the setting of acute injury. The project was divided into two studies.In the first study, 65 apparently normal volunteers were scanned to allow the principal investigator to practise and refine the ultrasound technique. The dimensions of the Extensor Digitorum Longus and two flexor tendons combined (Flexor Digitorum Profundus and Flexor Digitorum Superficialis) were measured in both transverse and longitudinal sections. Fifteen of the volunteers had their left middle fingers scanned twice within 48 hours to establish the test to retest reliability of tendon measurement. The established scanning technique was simple to perform and the scans, including both static and real time images, were completed within five minutes. All volunteers were able to tolerate a full scan. Measurement of tendon width showed fair to good reliability (Intra class correlation [ICC] of flexor tendons = 0.66, ICC of extensor tendon = 0.54). However measurement of the depth of all the tendons was unreliable test to retest (ICC < 0.37).In the second study, 30 patients who presented to the Emergency Department at Lismore Base Hospital with hand injuries were scanned for evidence of tendon injury and tendon gliding restriction. The patient’s ability to tolerate ultrasound examination was investigated. The scan findings were compared with the clinical findings and then to the operation report or to the patient’s self reported outcome, one month after injury.Patients were willing to undergo ultrasound examination regardless of the extent of their injury. There was a significant difference (p = 0.04) in scan tolerance related to the site of injury with 50% of those with extensor surface injuries having completed scans in comparison to 36% with flexor surface injuries and 9.1% of finger tip injuries. Injury mechanism was not related to scan tolerance.Excluding a partial tendon laceration was technically difficult due to the presence of anisotropy artefact. However, all complete tendon lacerations were successfully identified prior to surgery. The gliding of the tendons was easy to visualize and abnormal gliding was found to be a marker of tendon injury.The overall results show that ultrasound imaging of finger tendons at the bedside in the Emergency Department is a feasible examination to perform. The addition of ultrasound examination, however, did not identify any cases of tendon injury not already suspected on routine clinical examination.Therefore, this pilot study suggests that routine use of ultrasound examination to detect finger tendon injury in the Emergency Department setting will not prove to be a useful investigation. There may be a role for ultrasound as a screening tool as the gliding of normal tendons differed noticeably from the gliding of injured tendons. The presence of normal tendon gliding may be helpful in identifying those patients that are safe to be discharged from the Emergency Department without further evaluation.

<p>The protection of the unborn child in pregnant women from ionizing radiation is very important because the foetus is particularly sensitive to the effects of radiation. In case of pregnant members of staff working with ionising radiation, the unborn child is treated as a member of the general public, and a dose limit of 1 mSv during pregnancy is applied in order to protect the foetus.</p><p>The purpose of this work was to collect relevant information on exposure conditions and entrance doses of occupationally exposed workers in diagnostic radiology and nuclear medicine, and to give guidelines on how to estimate foetal doses for pregnant staff in such workplaces.</p><p>With X-ray procedures, an accumulated dose of 2 mSv during pregnancy, measured on the trunk (breast or waist) and behind a lead apron, is sufficient to ensure a foetal dose below 1 mSv. For staff working with nuclear medicine, the corresponding limit is 1.5 mSv taking into account external exposure from 99mTc. When internal contamination cannot be neglected, additional precautions need to be considered.</p>

<p>Atherosclerosis is a serious threat to public health and a major cause of morbidity and mortality. In this doctoral research, the feasibility of using whole-body magnetic resonance angiography (WBMRA) was studied as a principal aim both in patients and in an epidemiological setting. Secondary aims were to create a score for assessment of the degree of atherosclerosis with the use of WBMRA and to investigate the correlation between this score and various cardiovascular (CV) risk factors. </p><p>WBMRA was found feasible both in atherosclerotic patients and in an elderly population from the Prospective Investigation of the Vasculature in Uppsala Seniors (PIVUS). All subjects except one completed the examination without any adverse events. A large proportion (93-99%) of the vessel segments could be evaluated and the results of a smaller comparison between WBMRA and conventional invasive x-ray angiography were reasonable regarding the assessed degree of maximum stenosis or occlusion. This indicates the safety and robustness of the WBMRA method.</p><p>Unsuspected significant vascular abnormalities were found in patients with atherosclerotic symptoms and significant vascular abnormalities were present in elderly subjects without any self-reported vascular disease. The prevalence rates of vascular abnormalities in the carotid, renal, and inflow and runoff arteries of the lower limbs were estimated in an elderly population. A total atherosclerotic score (TAS) reflecting the degree of luminal narrowing was created for the WBMRA method and was significantly related to Framingham risk score (FRS) and to the amount of abdominal visceral adipose tissue, interleukin-6, and leptin and was inversely significantly related to adiponectin. </p><p>Studies with outcome data of the PIVUS cohort are needed for further validation of the WBMRA method and to determine whether TAS can be used as an adjunct for CV risk assessment. Meanwhile, the correlation with FRS indicates that TAS could be of value for this purpose.</p>

Atherosclerosis is a serious threat to public health and a major cause of morbidity and mortality. In this doctoral research, the feasibility of using whole-body magnetic resonance angiography (WBMRA) was studied as a principal aim both in patients and in an epidemiological setting. Secondary aims were to create a score for assessment of the degree of atherosclerosis with the use of WBMRA and to investigate the correlation between this score and various cardiovascular (CV) risk factors. WBMRA was found feasible both in atherosclerotic patients and in an elderly population from the Prospective Investigation of the Vasculature in Uppsala Seniors (PIVUS). All subjects except one completed the examination without any adverse events. A large proportion (93-99%) of the vessel segments could be evaluated and the results of a smaller comparison between WBMRA and conventional invasive x-ray angiography were reasonable regarding the assessed degree of maximum stenosis or occlusion. This indicates the safety and robustness of the WBMRA method. Unsuspected significant vascular abnormalities were found in patients with atherosclerotic symptoms and significant vascular abnormalities were present in elderly subjects without any self-reported vascular disease. The prevalence rates of vascular abnormalities in the carotid, renal, and inflow and runoff arteries of the lower limbs were estimated in an elderly population. A total atherosclerotic score (TAS) reflecting the degree of luminal narrowing was created for the WBMRA method and was significantly related to Framingham risk score (FRS) and to the amount of abdominal visceral adipose tissue, interleukin-6, and leptin and was inversely significantly related to adiponectin. Studies with outcome data of the PIVUS cohort are needed for further validation of the WBMRA method and to determine whether TAS can be used as an adjunct for CV risk assessment. Meanwhile, the correlation with FRS indicates that TAS could be of value for this purpose.

The protection of the unborn child in pregnant women from ionizing radiation is very important because the foetus is particularly sensitive to the effects of radiation. In case of pregnant members of staff working with ionising radiation, the unborn child is treated as a member of the general public, and a dose limit of 1 mSv during pregnancy is applied in order to protect the foetus. The purpose of this work was to collect relevant information on exposure conditions and entrance doses of occupationally exposed workers in diagnostic radiology and nuclear medicine, and to give guidelines on how to estimate foetal doses for pregnant staff in such workplaces. With X-ray procedures, an accumulated dose of 2 mSv during pregnancy, measured on the trunk (breast or waist) and behind a lead apron, is sufficient to ensure a foetal dose below 1 mSv. For staff working with nuclear medicine, the corresponding limit is 1.5 mSv taking into account external exposure from 99mTc. When internal contamination cannot be neglected, additional precautions need to be considered.

Background: Teleradiology is currently being explored to enhance services for patients seeking emergency neurosurgical diagnoses in Ontario, Canada. Design: Systematic review of literature and cost-consequence analysis. Data sources: Medline, Embase, Cochrane, and Database of Abstracts of Reviews of Effects. Methods: Studies published between 1950 and 2008 describing remote consultations for neurosurgical assessments were retrieved. Two reviewers selected studies through multi-staged content screening and extracted data. Results 12 of 3765 studies met the inclusion criteria: two were randomized controlled trials and ten were case series. Teleradiology [88% (207/236)] and video-conferencing [89% (213/239] consultations produced higher diagnostic accuracy than telephone consultations [64% (150/235), p<0.001]. Savings varied by location and were based on avoided costs for ground and air transportation and hospitalization. Conclusions: There is limited evidence of clinical benefit of teleradiology. Savings associated with reduction in patient transfer rates depend on transportation mode and may be attenuated by higher operational costs.

Background: Teleradiology is currently being explored to enhance services for patients seeking emergency neurosurgical diagnoses in Ontario, Canada. Design: Systematic review of literature and cost-consequence analysis. Data sources: Medline, Embase, Cochrane, and Database of Abstracts of Reviews of Effects. Methods: Studies published between 1950 and 2008 describing remote consultations for neurosurgical assessments were retrieved. Two reviewers selected studies through multi-staged content screening and extracted data. Results 12 of 3765 studies met the inclusion criteria: two were randomized controlled trials and ten were case series. Teleradiology [88% (207/236)] and video-conferencing [89% (213/239] consultations produced higher diagnostic accuracy than telephone consultations [64% (150/235), p<0.001]. Savings varied by location and were based on avoided costs for ground and air transportation and hospitalization. Conclusions: There is limited evidence of clinical benefit of teleradiology. Savings associated with reduction in patient transfer rates depend on transportation mode and may be attenuated by higher operational costs.

BackgroundIn this study, we describe a Quality Improvement (QI) intervention in three radiology departments within the Swedish health care system, with a special focus on access and methodology. AimThe goals for the QI-intervention were to implement best practice for patients with suspected colon cancer, and reduce the Turn Around Time (TAT).The aim of the study was to identify relevant factors for successful QI in order to further develop the organisation to create a system of continuous QI (CQI) for the radiological service. MethodsInitially, a multiprofessional QI-team was formed. To identify waste and areas for improvement, process mapping and lead time analysis were conducted during a collaborative learning approach. A focus group interview was carried out with the participants in the QI-intervention and the local managers, and a qualitative content analysis of the focus group transcript was performed. ResultsBest practise was gradually introduced, and overall access was improved, but TAT was not changed. Four key factors for CQI were revealed; Communication, Engagement, Context, and Patient- and Customer focus. Moreover, the impact of providing useful and reliable measurements to the frontline staff was found to be high DiscussionThe lack of decreased TAT indicates that further redesign of the radiology process is needed. As the impact of measurements was considered high, an improved system for obtaining and providing useful information to all parts in the organization is essential. Moreover, the infrastructure for CQI needs to be developed further, e.g. by clarifying roles, educating in improvement knowledge, and developing multiprofessional meetings. Finally, motivating and engaging staff is crucial to improve healthcare. It is important with a deeper understanding what triggers this, patient centeredness could be one.