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How to make the best use of clinical radiology services

How to make the best use of clinical radiology services. Roger Laitt Clinical Director Radiology Salford Royal Hospitals Foundation Trust. Guidelines Making the best use of clinical radiology services 6 th Ed 2007 – RCR Clinico-radiological dialogue. Guidelines.

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How to make the best use of clinical radiology services

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  1. How to make the best use of clinical radiology services Roger Laitt Clinical Director Radiology Salford Royal Hospitals Foundation Trust

  2. Guidelines • Making the best use of clinical radiology services 6th Ed 2007 – RCR • Clinico-radiological dialogue

  3. Guidelines • A useful investigation is one in which the result, positive or negative, will inform clinical management and/or add confidence to the clinician’s diagnosis • A significant number of investigations do not fulfill these aims and with plain films and CT may add unecessarily to patient irradiation

  4. This becomes more important with access to more complex investigations that use increased resource AND RADIATION

  5. Low dose examinations are most common • Infrequent high dose studies make the major contribution to collective population dose • CT use rising and contributes at least half the collective dose from all X-ray exams • REQUESTS FOR CT MUST BE JUSTIFIED

  6. Chief causes of misuse of Radiology • Repeating investigations that have already been done – HAS IT BEEN DONE ALREADY? • Investigations that are unlikely to affect patient management – DO I NEED IT? • Investigating too early – DO I NEED IT NOW? • Doing the wrong investigation – IS THIS THE BEST INVESTIGATION? • Failing to provide adequate clinical information –HAVE I EXPLAINED THE PROBLEM? • Over investigating – ARE THEY ALL NEEDED?

  7. Imaging techniques • Computed tomography • Multidetector (spiral) technology • Large volume of data from a single breath hold • Can review images in multiple planes • Opened up many new applications • High radiation dose • Consider MRI or US in thinner patients and children • Applications • Intracranial disorders particularly if acute + angiography • Chest and abdomen • CT Urography replacing IVUs • Cancer staging • As guide for biopsies and drainage procedures

  8. Magnetic Resonance Imaging • No radiation and so should be used in preference to MR if similar yield • All requests require justification • Increasingly used as a surrogate for clinical exam. • Safety in first trimester unknown • Recognised contraindications • Metallic FB in orbits • Pacemakers • Some implanted devices • Applications • Neuroimaging including Spines • MSK • Liver • Pelvis • Angiography

  9. Ultrasound • Safe • Cheap • Accessible • Same day service • Operator dependant • Compliments other modalities • First line test • Applications • Obstetrics • Gynaecology • Abdominal • MSK • Vascular • Interventional

  10. CLINICAL SCENARIOS

  11. NECK PAIN AND BRACHALGIA • MRI • Plain films only indicated in specific circumstances

  12. CHRONIC BACK PAIN • MRI • Plain films only indicated in specific circumstances

  13. SUSPECTED OSTEOPOROTIC COLLAPSE • Lateral XR thoracic and lumbar spine • MRI distinguishes between acute and chronic collapse. Important with vertebroplasty • DEXA

  14. Painful shoulder ? Impingement/rotator cuff • Ultrasound • MRI • Plain films only in special circumstances

  15. Transient ischaemic attack • MRI within 24 hours (50%) – NICE 2008 • Duplex or non invasive angiography (80%) within 24 hours for those at high risk • Surgery within 2 weeks where appropriate

  16. Dementia or memory disorders • MRI – NICE 2007 • CT can be used

  17. Suspected ureteric colic • CT urography, low dose technique • IVU only indicated when CT not possible • US + KUB, pregnancy

  18. Proven UTI in children • US • AXR not indicated as calculi rare • Expert US key investigation • Nuclear Medicine • Acute or chronic • DMSA and MAG3

  19. Palpable abdominal mass • US • CT if US inconclusive or with staging • AXR • Rarely of value

  20. CONCLUSIONS • Role of imaging is changing • Increasing availability changes way imaging used • Partly target driven • NICATS • Defensive • Surrogate for clinical examination • Traditional pathways challenged • Role of plain films needs to be understood • Radiology departments important at interface between Primary and Secondary care • Guidelines important but they are only a guide • Encourages good practice and avoids unnecessary waste of resource and ionising radiation exposure • COMMUNICATION IS EVERTHING

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