Jonn Terje Geitung

MR urography: the future gold standard in paediatric urogenital imaging?

Background. Examination of the paediatric urogenital tract is traditionally performed using methods that utilise ionising radiation, such as intravenous urography (IVU), computerised tomography (CT), voiding cystourethrography (VCU), and scintigraphy, in addition to ultrasound (US). Objective. To determine the potential and effectiveness of MR urography (MRU) in infants and children. Materials and methods. 44 MRU examinations were prospectively performed in 39 patients (21 infants, mean age 3.5 months, and 18 children, mean age 6 years 2 months) with known or suspected pathology of the urinary tract. Non-enhanced, fast spin-echo sequences (TSE) were performed in all patients. In 70 % of the patients a contrast-enhanced, fast gradient-echo sequence (TFE) was included. The dynamic sequence was prolonged and supplemented with furosemide provocation in some patients with suspected urinary-tract obstruction. Results. Nine percent of examinations were non-diagnostic or interrupted due to movement. MRU contributed additional information in 66 %. Nine patients with suspected urinary-tract obstruction were examined with both contrast-enhanced MRU and scintigraphy. Three MRU examinations were less informative and one equal to scintigraphy when obstruction was the diagnosis. When using a technique with a prolonged dynamic sequence, including frusemide provocation, four MRU examinations were equal and one was superior to scintigraphy. Conclusions. MRU has the potential to replace traditional diagnostic methods which use ionising radiation in paediatric patients. Further studies are needed before definite conclusions can be drawn.

Pancreatic carcinoma: MR, MR angiography and dynamic helical CT in the evaluation of vascular invasion.

OBJECTIVE To assess the value of MR angiography in combination with contrast-enhanced MR imaging, and to compare MR imaging including MR angiography with dynamic contrast-enhanced dual phase helical CT in the preoperative assessment of vascular invasion in patients with suspected pancreatic carcinoma. METHODS AND MATERIAL MR imaging only, MR imaging including MR angiography and dynamic contrast-enhanced dual phase helical CT images of 48 patients who were operated due to suspicion of pancreas cancer were correlated with the surgery results in terms of vascular invasion. Pathologic diagnosis were pancreatic adenocarcinoma in 31 patients of which nine had surgically confirmed vascular invasion. Sensitivity, specificity, predictive values (including 95% confidence intervals) and accuracy of MR imaging only, MR imaging including MR angiography and helical CT were calculated. RESULTS Sensitivity, specificity, positive and negative predictive values and accuracy were 56, 100, 100, 85, 87%; 67, 100, 100, 88, 90% and 67, 100, 100, 88, 90%, respectively, for MR imaging only, MR imaging including MR angiography and helical CT in the adenocarcinoma group. The corresponding figures in the overall study group were 56, 97, 83, 90, 90%; 67, 97, 86, 93, 92% and 67, 97, 86, 93, 92%. Confidence intervals (95%) showed that the differences in the diagnostic efficacy of the techniques were not statistically significant in the overall study group, but the confidence intervals were undefined in the adenocarcinoma group due to the small sample size. CONCLUSION Diagnostic efficacy of MR imaging when combined with MR angiography is equal to that of dynamic contrast-enhanced dual phase helical CT in the assessment of vascular invasion of pancreatic tumors.

Teleradiology and picture archiving and communications systems: changed pattern of communication between clinicians and radiologists.

In a few years all radiology departments in Norwegian hospitals will have a picture archiving and communications system (PACS). This depends on telecommunications with great capacity for transmitting radiology images. The new technology questions the need for daily meetings between radiologists and clinicians, ‘clinico-radiological conferences’. Qualitative interviews were performed with 23 resource persons experienced with problems related to PACS and teleradiology. The response rate was 91 %. In all, 29% answered that the clinico-radiological conferences could be abolished, 52% replied no and 19% replied both yes and no. The clinico-radiological conferences could be abolished for some clinical departments, but only after consultation between radiology and clinical departments. If the conferences are abolished, clinicians and radiologists may spend more time on treatment and interpretation, with a probable productivity gain.

Pancreaticobiliary diseases: Comparison of 2D single-shot turbo spin-echo MR cholangiopancreatography with endoscopic retrograde cholangiopancreatography

Purpose: To compare the diagnostic value of MR cholangiopancreatography (MRCP) to that of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of various obstructive and nonobstructive pancreaticobiliary diseases. Material and Methods: We retrospectively reviewed 153 patients who had undergone both MRCP and ERCP. Breath-hold, heavily T2-weighted images using 2D single-shot turbo spin-echo technique were obtained. MRCP and ERCP results were correlated with the final clinical diagnoses. Accuracy of MRCP and ERCP in the diagnosis of pancreaticobiliary diseases, detecting the cause and site of biliary obstruction, if present, and distinguishing malignant from benign cause of obstruction were compared. Results: Success rates of MRCP and ERCP were 98.7% and 89.5%, respectively. The accuracy of MRCP and ERCP in detecting the site of biliary obstruction was 89.7% and 96.2%, and in detecting the cause of biliary obstruction 69.2% and 71.8%, respectively. The sensitivity, specificity and likelihood ratios for positive and negative tests for MRCP and ERCP in distinguishing malignant biliary obstruction from benign causes were 86.4%, 82.4%, 4.9, 0.2 and 88.6%, 94.1%, 15.1, 0.1, respectively. Concordance between the two tests was 91% (kappa coefficient 0.82, standard error of kappa 0.113, p<0.001). In the group of nonobstructive biliary diseases, accuracy of MRCP and ERCP in detecting cholecystolithiasis were 100% and 73.7%, and in detecting pancreatitis 57% and 14%, respectively. Conclusion: 2D single-shot turbo spin-echo MRCP can be performed as a complement to ERCP and can replace ERCP in high-risk patients and in case of unsuccessful cannulation.

A practical approach to interpretation of MRI of the temporomandibular joint

Background: Temporomandibular disorders (TMDs) such as pain, joint sounds, and impaired movement are common, and magnetic resonance imaging (MRI) is now the method of choice for diagnostic assessment. Purpose: To describe MR criteria chosen and the amount of temporomandibular joint (TMJ) pathology registered when examining MR images from patients referred to a university hospital for imaging of their TMJs. Material and Methods: The TMJs of 152 consecutive patients, 102 women and 40 men, referred for MRI during an 18 month period were imaged with a 1.5 T imaging system. Twelve asymptomatic students, seven women and five men, gave informed consent and acted as a control group. Results: Moderate to extensive disk displacement was registered in 53% of the patients’ TMJs, and 38% of the disks were deformed. Degenerative changes registered were flattening of the condyle heads in 50% of the TMJs and erosion of their cortical surfaces in 30%. Osteophytes were present in 31% of the condyles and bone marrow edema in 30%. Marked to extensive effusion in synovial compartments was registered in 39% of the studied TMJs. In the control group, none of the TMJs showed anterior disk displacement, deformed disks or degenerative changes, but 8 of the 24 joints showed marked effusion. A tendency for a higher amount of disk displacement and deformation was seen among young age groups and more degenerative changes in older age groups, but differences among groups were not significant when tested with chi-square analysis. Conclusion: Defined MR criteria that allow for comparative assessment are presented. According to these criteria, a large proportion of the patients referred for MR examination showed morphologic changes indicating TMJ pathology.

Hospital Admissions from Nursing Homes: Rates and Reasons

Hospital admissions from nursing homes have not previously been investigated in Norway. During 12 months all hospital admissions (acute and elective) from 32 nursing homes in Bergen were recorded via the Norwegian ambulance register. The principal diagnosis made during the stay, length of stay, and the ward were sourced from the hospitals data register and data were merged. Altogether 1,311 hospital admissions were recorded during the 12 months. Admissions from nursing homes made up 6.1% of the total number of admissions to medical wards, while for surgical wards they made up 3.8%. Infections, fractures, cardiovascular and gastri-related diagnoses represented the most frequent admission diagnoses. Infections accounted for 25.0% of admissions, including 51.0% pneumonias. Of all the admissions, fractures were the cause in 10.2%. Of all fractures, hip fractures represented 71.7. The admission rate increased as the proportion of short-term beds increased, and at nursing homes with short-term beds, admissions increased with increasing physician coverage. Potential reductions in hospitalizations for infections from nursing homes may play a role to reduce pressure on medical departments as may fracture prevention. Solely increasing physician coverage in nursing homes will probably not reduce the number of hospitalizations.

Psychoactive drugs in seven nursing homes

AIMS We wanted to pinpoint any differences in treatment between participating nursing homes, investigate which drugs are currently prescribed most frequently for long-term patients in nursing homes, estimate prevalence of administration for the following drug groups: neuroleptics, antidepressants, antidementia agents, opioids and the neuroleptics/anti-Parkinsons drug combination, and study comorbidity correlations. We also wanted to study differences in the administration of medications to patients with reduced cognitive functions in relation to those with normal cognition. METHODS Information about 513 patients was collected from seven nursing homes in the city of Bergen, Norway, during the period March-April 2008. This consisted of copying personal medication records, weighing, recording the previous weight from records, electrocardiography, anamnestic particulars of any stroke suffered, recording if there is cognitive impairment or not and analyzing a standardized set of blood samples. RESULTS Considerable treatment differences existed between nursing homes, both percentage patients and Defined Daily Dosages. Patients with reduced cognitive functions were prescribed less drugs in general, except neuroleptics. Of all patients, 41.5% were given antidepressants, 24.4% neuroleptics, 22.0% benzodiazepines, 8.0% anticholinesterases and 5.0% memantine. The ratio of traditional to atypical neuroleptics was 122:23. In all, 30.0% of the patients taking neuroleptics were on more than one drug and 35.0% of the patients had opioids by way of regular or as-needed drugs, ratio 14.6%:28.7%. Of 146 patients on neuroleptics, five patients had anti-Parkinsons drugs too. The average use of regular drugs for patient with intact cognition was 7.1 drugs, and for patients with reduced cognitive functions 5.7 drugs. CONCLUSIONS There are differences in treatment with psychoactive drugs between nursing homes. Patients with reduced cognitive functions receive less cardiovascular drugs than patients with normal cognition. The reason for this still remains unclear. Improvement strategies are needed. The proportion of patients per institution on selected drugs can serve as a feedback parameter in quality systems.

A noncontrast-enhanced pulse sequence optimized to visualize human peripheral vessels

The purpose of this paper is to present a pulse sequence optimized to visualize human peripheral vessels. The optimized MR technique is a 3D multi-shot balanced non-SSFP gradient echo pulse sequence with fat suppression. Several imaging parameters were adjusted to find the best compromise between the contrast of vascular structures and muscle, fat, and bone. Most of the optimization was performed in the knee and calf regions using multi-channel SENSE coils. To verify potential clinical use, images of both healthy volunteers and volunteers with varicose veins were produced. The balanced non-SSFP sequence can produce high-spatial-resolution images of the human peripheral vessels without the need for an intravenous contrast agent. Both arteries and veins are displayed along with other body fluids. Due to the high spatial resolution of the axial plane source or reconstructed images, the need for procedures to separate arteries from veins is limited. We demonstrate that high signals from synovial joint fluid and cystic structures can be suppressed by applying an inversion prepulse but at the expense of reduced image signal-to-noise and overall image quality.

Secretin-Stimulated Magnetic Resonance Cholangiopancreatography of Patients with Unclear Disease in the Pancreaticobiliary Tract

Purpose: To explore the usefulness of secretin-stimulated magnetic resonance cholangiopancreatography (S-MRCP) on different pathological entities in the pancreaticobiliary tract (PBT) Material and Methods: Sixty-two patients with unclear disease in the PBT were examined with S-MRCP as the final radiological procedure. Nine groups of referral diagnoses were identified, and clinical outcome was evaluated. Results: In five patients with suspected pancreatic duct injury after blunt abdominal trauma, a negative predictive value of 100% was found after a median of 3.5 months of follow-up. In 22 patients with residual pain after cholecystectomy, investigated for sphincter of Oddi dysfunction (SOD), delayed dilatation of the PD and pain were documented in four patients. Three of these were treated with endoscopic papillotomy (EPT), and no recurrences were found during an average of 13.6 months of follow-up. Five cases of pancreas divisum not previously seen were identified, and of 12 patients with suspected postoperative stenosis, five were successfully treated after being identified with S-MRCP. Useful information was obtained in most of the patients, i.e., findings not observed in previous radiological examinations or clarifying uncertain previous findings. Nine patients were referred to other non-radiological examinations, identifying that the origin of disease was outside the PBT. Conclusion: S-MRCP has the potential to become the final part of diagnostic workup in difficult PBT diseases, but further investigation of usefulness regarding different referral reasons is mandatory.

Can Electronic Tools Help Improve Nursing Home Quality

Background. Nursing homes face challenges in the coming years due to the increased number of elderly. Quality will be under pressure, expectations of the services will rise, and clinical complexity will grow. New strategies are needed to meet this situation. Modern clinical information systems with decision support may be part of that. Objectives. To study the impact of introducing an electronic patient record system with decision support on the use of warfarin, neuroleptics and weighing of patients, in nursing homes. Methods. A prevalence study was performed in seven nursing homes with 513 subjects. A before-after study with internal controls was performed. Results. The prevalence of atrial fibrillation in the seven nursing homes was 18.8%. After intervention, the proportion of all patients taking warfarin increased from 3.0% to 9.8% (P = 0.0086), neuroleptics decreased from 33.0% to 21.5% (P = 0.0121), and the proportion not weighed decreased from 72.6% to 16.0% (P < 0.0001). The internal controls did not change significantly. Conclusion. Statistics and management data can be continuously produced to monitor the quality of work processes. The electronic health record system and its system for decision support can improve drug therapy and monitoring of treatment policy.