Clinical academic radiographers - A challenging but rewarding career

OBJECTIVES

To explain what a clinical academic career can be, what it can lead to for the individual, profession and most importantly the patient, and why these roles are so important to radiography.

KEY FINDINGS

Multiple challenges to the adoption of clinical academic careers exist, including achievable measurable outcomes, visibility & senior support, and balancing different time demands. Equally the rewards are wide ranging and can advance both the individual and profession through role extension opportunities, increased career progression, patient benefits, and academic and research skills.

CONCLUSION

Clinical academic careers can provide advantages for the individual, department, profession and most importantly the patient with advanced clinical practice through evidenced based research.

IMPLICATIONS FOR PRACTICE

Improving clinical academic careers within Radiography will promote research participation and increase radiographic roles in patient-centred research delivery and development. Combining evidenced based research with academic skills will lead to improved patient care and better clinical outcomes.

The Portsmouth protocol for intra-operative ultrasound of the small bowel in Crohn's disease

AIM

Bowel preservation is paramount in Crohn's disease surgery as affected patients are typically young adults at risk of having several abdominal surgical procedures during their lifetime. Intra-operative assessment of the extent and location of Crohn's disease is not standardized and is left to a mixture of the surgeon's experience, tactile feedback, macroscopic appearance and preoperative imaging. The aim of this study was to describe the technical steps of a standardized protocol for intra-operative ultrasound assessment of the small bowel in patients undergoing surgery for ileocolic Crohn's disease.

METHOD

After laparoscopic mobilization of the bowel, a periumbilical incision is performed for extracorporeal division of the mesentery and the resection and anastomosis. A gastrointestinal consultant radiologist, with expertise in Crohn's disease imaging and abdominal ultrasound, performs full intra-operative assessment of the small bowel by applying a sterile ultrasound probe directly to the bowel, prior to resection being performed by the surgeon. The bowel is assessed through the wound protector with a sterile technique and the length, location and number of segments is documented together with further quantitative assessment using the METRIC (MR enterography or ultrasound in Crohn's disease) scoring guide.

RESULTS

A step-by-step protocol for intra-operative ultrasound evaluation of the entire small bowel is described.

CONCLUSIONS

A standardized approach to intra-operative evaluation of the extent and location of Crohn's disease is desirable. Intra-operative ultrasound may provide added value for assessment of proximal and multifocal Crohn's disease.

Feasibility of intraoperative ultrasound of the small bowel during Crohn's disease surgery

BACKGROUND

Intraoperative assessment of the extent and location of Crohn's disease is not standardised and relies on a mixture of surgeons' experience, tactile feedback and macroscopic appearance. To overcome this variability, we developed a protocol for full intraoperative ultrasound scan of the small bowel and we here report the results of "Assessing the Feasibility and Safety of Using Intraoperative Ultrasound in Ileocolic Crohn's Disease-The IUSS CROHN Study".

METHODS

This is a prospective single centre observational study with enrolment of all patients undergoing elective surgery for terminal ileal Crohn's disease from January 2019 to March 2020. Patients underwent laparoscopic ileocolic resection, according to a standardised technique. Ultrasound intraoperative quantitative assessment was performed according to the METRIC (MREnterography or ulTRasound in Crohn's disease) scoring guide.

RESULTS

Intraoperative ultrasound was successfully performed in 6 patients from the ileocaecal valve to the proximal jejunum. The median time required was 23.5 min (range 17-37 min) as compared to 6.5 min (5-12 min) required for the macroscopic evaluation performed by the surgeon. In 3 patients, intraoperative ultrasound identified more disease than surgical evaluation.

CONCLUSIONS

This feasibility study demonstrated the safety of intraoperative ultrasound and allowed the development of a standardised protocol for intraoperative ultrasound and the data collection required to inform a randomised multicentre study.

Estimating the protection afforded by foot-and-mouth disease vaccines in the laboratory

Foot-and-mouth disease (FMD) vaccines must be carefully selected and their application closely monitored to optimise their effectiveness. This review covers serological techniques for FMD vaccine quality control, including potency testing, vaccine matching and post-vaccination monitoring. It also discusses alternative laboratory procedures, such as antigen quantification and nucleotide sequencing, and briefly compares the approaches for FMD with those for measuring protection against influenza virus, where humoral immunity is also important. Serology is widely used to predict the protection afforded by vaccines and has great practical utility but also limitations. Animals differ in their responses to vaccines and in the protective mechanisms that they develop. Antibodies have a variety of properties and tests differ in what they measure. Antibody-virus interactions may vary between virus serotypes and strains and protection may be affected by the vaccination regime and the nature and timing of field virus challenge. Finally, tests employing biological reagents are difficult to standardise, whilst cross-protection data needed for test calibration and validation are scarce. All of this is difficult to reconcile with the desire for simple and universal criteria and thresholds for evaluating vaccines and vaccination responses and means that oversimplification of test procedures and their interpretation can lead to poor predictions. A holistic approach is therefore recommended, considering multiple sources of field, experimental and laboratory data. New antibody avidity and isotype tests seem promising alternatives to evaluate cross-protective, post-vaccination serological responses, taking account of vaccine potency as well as match. After choosing appropriate serological tests or test combinations and cut-offs, results should be interpreted cautiously and in context. Since opportunities for experimental challenge studies of cross-protection are limited and the approaches incompletely reflect real life, more field studies are needed to quantify cross-protection and its correlation to in vitro measurements.

Inheritance in tetraploid yeast revisited: segregation patterns and statistical power under different inheritance models

In their recent article, Albertin et al. (2009) suggest an autotetraploid origin of 10 tetraploid strains of baker's yeast (Saccharomyces cerevisiae), supported by the frequent observation of double reduction meiospores. However, the presented inheritance results were puzzling and seemed to contradict the authors' interpretation that segregation ratios support a tetrasomic model of inheritance. Here, we provide an overview of the expected segregation ratios at the tetrad and meiospore level given scenarios of strict disomic and tetrasomic inheritance, for cases with and without recombination between locus and centromere. We also use a power analysis to derive adequate sample sizes to distinguish alternative models. Closer inspection of the Albertin et al. data reveals that strict disomy can be rejected in most cases. However, disomic inheritance with strong but imperfect preferential pairing could not be excluded with the sample sizes used. The possibility of tetrad analysis in tetraploid yeast offers a valuable opportunity to improve our understanding of meiosis and inheritance of tetraploids.

A psychophysiological marker of attention deficit/hyperactivity disorder (ADHD)--defining the EEG consistency index

This study continues our research to further validate the idea that ADHD (Attention Deficit/Hyperactivity Disorder) interferes with transition from one task to another and this interference can be quantified by a Consistency Index (CI) derived from a specific mathematical representation of EEG data. We reanalyze 32 previously reported data sets present new data for 35 boys and girls, ages 7-12, ADHD or control. Each data set contains EEG, recorded and digitized while participants perform consecutive 10-min tasks: video, reading, and math. For boys, the CI in ADHD was four times lower than in controls, p < .005, for girls this difference was two times, p < .05. ADHD/control classification based on the CI coincided with the DSM-IV criteria for 88% of the boys and for 67% of the girls. Post hoc analysis indicated that the classification utility of the CI diminished with age. A CI below 40% could be a discriminating, reliable, and reproducible marker of ADHD in young boys.

Clinicopathological correlation in biopsy-proven atherosclerotic nephropathy: implications for renal functional outcome in atherosclerotic renovascular disease

BACKGROUND

Atherosclerotic renovascular disease (ARVD) is commonly associated with renal failure. It is now recognized that intrarenal damage, (ischaemic or atherosclerotic nephropathy) is a major contributor to the renal impairment in these patients. In this study the impact of histological changes upon renal functional outcome was investigated in patients with atherosclerotic nephropathy.

METHODS

The Hope Hospital renal biopsy database (1985-1998) was interrogated for patients with histology compatible with atherosclerotic nephropathy. Case-note review enabled the assessment of several clinical parameters and outcomes, including change in creatinine clearance per year (DeltaCrCl (ml/min/year)), blood pressure control, dialysis need, and death. Renal parenchymal damage was analysed by morphometric analysis (of interstitial fibrosis and glomerulosclerosis) and a semi-quantitative chronic damage score (score 0-3 (normal-severe) for each of glomerulosclerosis, interstitial fibrosis, tubular atrophy, and arteriolar hyalinosis; maximum=12). Patients were stratified into two groups who had either deteriorating (group 1) or stable (group 2) renal function during follow-up.

RESULTS

Twenty-five patients (age 64.7+/-10.5, range 43-83 years; 17 male, eight female) were identified. Sixteen patients had undergone angiography; two had significant (>50%) renal artery stenosis. Mean follow-up was 25.6+/-14.8 (range 5-50) months. Group 1 patients had DeltaCrCl -7.4+/-6.8 ml/min/year, n=14 and group 2 patients had DeltaCrCl 4.8+/-7.0 ml/min/year, n=11. Four patients in group 1 developed end-stage renal disease and five patients died (three in group 1 and two in group 2). At study entry, group 1 patients had worse renal function (CrCl 27.6+/-17.6 vs 36.0+/-33.9, NS), greater proteinuria (1.2 vs 0.5 g/24 h, NS), and higher systolic blood pressure (167.1+/-30.8 mmHg vs 150.6+/-37.8, NS) compared with group 2 patients. Group 1 patients showed more glomerulosclerosis (51.6 vs 24.9%, P:<0.01), greater proportional interstitial volume (44.9 vs 33.9%, P:<0.02), and higher overall chronic damage score (P:<0.05) than those in group 2. There was a significant correlation between renal functional outcome and chronic damage score, glomerulosclerosis and proportional interstitial volume for the entire patient cohort.

CONCLUSION

In patients with atherosclerotic nephropathy the severity of histopathological damage is an important determinant and predictor of renal functional outcome.

Isolated sarcoid granulomatous interstitial nephritis: review of five cases at one center

AIMS

To identify any clinical or biochemical parameters which determine prognostic outcome in isolated sarcoid granulomatous interstitial nephritis presenting with renal failure.

METHODS

A review of five cases of renal failure due to isolated sarcoid granulomatous interstitial nephritis, which presented to Hope Hospital over the 7-year period 1994 to 2000. Follow-up averaged 35 months with a range of 11 to 73 months.

RESULTS

Only one patient had an elevated serum ACE at presentation, reflecting the suboptimal sensitivity of this test as a marker in sarcoidosis and the limited extent of disease in these patients. Four of the five cases had a marked improvement in creatinine clearance within 10 days of starting oral prednisolone. Two patients required acute hemodialysis on presentation. Their renal failure responded to treatment with steroids, enabling withdrawal of dialysis within 10 days. All patients remained dialysis-independent although serum creatinine levels rose during follow-up. One patient experienced a relapse that responded to an increased dose of steroid.

CONCLUSIONS

Serum ACE is not reliable in the diagnosis of renal failure due to sarcoid interstitial nephritis and the diagnosis can only be made on renal biopsy. First-line treatment with oral prednisolone results in a rapid improvement in creatinine clearance although prolonged treatment may be needed to prevent a relapse.

The EEG consistency index as a measure of ADHD and responsiveness to medication

The primary diagnostic procedure for Attention-Deficit/Hyperactivity Disorder (ADHD) is the clinical interview, because psychological, neuropsychological, and neurological tests to date have not had sufficient specificity. Currently, there is no objective means to measure severity of ADHD, or the extent to which it is benefited by various dosages of medication. We recently reported that a certain EEG profile, the Consistency Index, occurring during the transition between two easy cognitive tasks clearly differentiated ADHD from non-ADHD boys between the ages of 8 and 12. The current study replicated this with older males (19-25) using different tasks, and a double blind, placebo versus Ritalin controlled crossover design. Seven ADHD subjects were found to have a significantly lower Consistency Index than 6 non-ADHD males while transitioning from 2 Simple tasks during placebo condition, while only the ADHD subjects demonstrated a significant improvement in their Consistency Index while on Ritalin. Similar but nonsignificant trends were observed while transitioning across Hard tasks.

The role of top management in supporting the use of information technology in Australian hospitals

The progressive use of information systems and information technology has the potential to transform the way complex organisations are managed and the way they operate. This article reports the findings of a study undertaken to examine the importance of various factors related to the progressive use of information technology in Australian hospitals. Our analysis of data from 84 hospitals shows that hospital size has a significant positive relationship with the progressive use of information technology, as does the chief executive officer's attitude to information technology; however chief executive officer participation in information technology activities does not. The implications of these findings for the role of top management are discussed.

Women, work and health: issues and implications for worksite health promotion

This paper identifies issues related to worksite health promotion programs for women by examining ways that work factors, health behaviors, family roles and responsibilities, and women's health are linked. Work conditions may affect women uniquely, as in the case of chemical exposure affecting reproductive health; disproportionately, such as the interaction between work and family roles; or differently from men, as in women's experience of stress in the workplace. The focus is on the differences and uniqueness of working women's health. Drawing on a public health perspective, implications for consideration by worksite health promotion programs specialist, human resource managers, and researchers are presented.

Organochlorines and mercury in pilot whale blubber consumed by Faroe islanders

Some 22,000 pilot whales (Globicephala melaena) were taken in the Faroe Islands between 1970 and 1992. It is known that tissues from these animals are widely consumed by the islanders. The position of these animals at the apex of a direct marine food chain renders them liable to accumulate toxic chemicals, such as metals and organochlorines. Although the consumption of contaminating metals in pilot whale tissues has been studied, the significance of blubber as a dietary source of organochlorine compounds has not been fully considered. This study reports levels of organochlorine and mercury contamination in the blubber of pilot whales taken in two Faroese kills. Published estimates of pilot whale tissue consumption are used to evaluate dietary organochlorine intake in relation to established national and international guidelines and clinical studies conducted in the North American Great Lakes.

Femoral artery thrombosis after open reduction of an acetabular fracture

The increasingly popular ilioinguinal anterior approach for select fractures of the acetabulum provides excellent exposure with minimal soft tissue dissection. Vascular complications reported with this procedure, although infrequent, are usually quite pronounced in their presentation. The authors encountered a more subtle case of femoral artery thrombosis secondary to vessel retraction while using this approach. The susceptibility of major vessels to thrombus formation is noteworthy. The precautions, and the close postoperative monitoring necessary to detect such vascular lesions, are emphasized.

Difficulties in localization and treatment of insulinomas in type 1 multiple endocrine adenomatosis (MEA)

A 15 year old girl with a family history of type 1 multiple endocrine adenomatosis presented with reversible neurological disturbances, hypoglycaemia and hyperinsulinaemia. Initial radiology was normal, but portal venous sampling suggested an insulinoma in the tail of the pancreas which was removed with conservation of the spleen. Hypoglycaemia persisted despite high doses of diazoxide and intravenous dextrose. A second laparotomy revealed a pancreatic endocrine tumour and sub-total pancreatectomy was performed. Histology revealed islet cell microadenomatosis. Hypoglycaemia persisted despite treatment with somatostatin analogues and 40% intravenous dextrose was required to maintain normoglycaemia. A possible lesion near the splenic hilum on computed tomographic scan was reported as a splenunculus although further peripheral, hepatic and portal venous sampling suggested hepatic or systemic lesions. A positron emission scan and selective visceral angiography suggested a lesion in the left upper quadrant. Acute lactic acidosis, rhabdomyolysis and renal failure supervened. Post mortem revealed the putative 'splenunculus' to be a residual insulinoma, whilst the splenic vein was thrombosed, accounting in part for discrepant venous sampling data. Hyperinsulinaemia in type 1 multiple endocrine adenomatosis may require more aggressive surgical and hormonal intervention than when dealing with solitary insulinomas. Insulinomas may mimic developmental abnormalities on computed tomographic scanning.

Components of fitness become effectively neutral in equilibrium populations

If, because of trade-offs or similar considerations, components of fitness are negatively correlated in equilibrium populations, they may then exhibit no correlation with total fitness. Lack of correlation with fitness is a fundamental characteristic of selective neutrality. Hence, selectively important traits become subsumed under neutral traits when the definition of neutrality is extended to include factors (genetic or phenotypic) that "behave as if they are neutral."

Concentration-response relationships for salicylate-induced ototoxicity in normal volunteers

1. Ototoxicity is a common and troublesome side-effect of high-dose aspirin treatment but there has been little previous study of the relationships between the degree of ototoxicity and the plasma concentrations of salicylate. 2. In order to investigate the relationships between aspirin dose, total and unbound plasma salicylate concentrations and ototoxicity, eight normal volunteers were dosed with aspirin 1.95, 3.25, 4.55 and 5.85 g day-1 for 1 week at each dose level, the doses being administered in random order and double-blind, 2 weeks apart. 3. Ototoxic effects measured were hearing loss in decibels (dB) over six frequencies and tinnitus intensity, estimated both by electronic matching and a fixed interval scale (FIS). Measurements were taken after steady-state concentrations of salicylate had been achieved. 4. Total and unbound plasma salicylate concentrations increased disproportionately with increasing daily doses of aspirin. The increase in the unbound salicylate was relatively greater since the percentage of salicylate unbound in plasma increased over the dose range investigated from a mean of 3.9% to 10.4%. 5. Hearing loss and tinnitus intensity increased progressively with the aspirin dosage and increasing concentrations of total and unbound plasma salicylate concentrations. These ototoxic symptoms were observed at lower concentrations of total salicylate than previously reported. 6. There was a linear relationship between hearing loss and unbound salicylate concentrations. 7. Further work is required to test the hypothesis that unbound plasma salicylate concentration is a better predictor of salicylate-induced ototoxicity than total plasma salicylate concentration.

The ejection click of valvular pulmonic stenosis

Ten patients with valvular pulmonic stenosis were studied by simultaneous external phonocardiograms and intracardiac pressure recordings during successive respiratory cycles to examine the mechanism of the respiratory variation in the ejection click. Selective cineangiograms were performed in four. During inspiration right ventricular end-diastolic pressure (RVEDP) exceeded the pressure in the pulmonary artery (+2.7 mm) and no ejection click was recorded. During expiration RVEDP was lower than the pressure in the pulmonary artery (-3.6 mm) and a click was recorded. The click was present throughout the respiratory cycle when pulmonary artery diastolic pressure consistently exceeded RVEDP. Clicks were associated with sudden "doming" of the valve demonstated by cineangiography. These data support the valvular origin of the ejection click in pulmonic stenosis and provide the following explanation for the respiratory variation: Inspiratory increase in venous return causes the valve leaflets to move to an open or "domed" position. Ventricular systole at this time produces no sound since there is no slack. With expiration pulmonary artery pressure exceeds RVEDP. Ventricular systole at this time produces an opening motion of the closed, slack leaflets. The click occurs when the opening motion is suddenly checked.