Neuroimaging assessments in dementia

Vanessa Newman
Dr Vanessa Newman

Dementia is the leading cause of disability in people over 60 years old. Imaging is increasingly used to diagnose dementia to complement physical, cognitive and mental examinations.

Here, Dr Vanessa Newman explores the role of imaging in detecting this cruel and debilitating illness that effects over one million people in the UK.

Dementia: a global burden

Dementia is a leading cause of disability in people aged >60 years, representing a significant burden on patients in terms of quality of life, disability and mortality associated with the condition. This further impacts caregivers, health services and society in general. According to the World Alzheimer Report 2015, it is estimated there are 46.8 million people living with dementia worldwide and this number is due to double every 20 years. Of the 9.2 million people with dementia in Europe over 1.03 million live in the UK, representing a considerable health economic burden. Furthermore, general improved life expectancy of the global population is anticipated to correspond with increased prevalence of dementia.[1,2]

The impact of dementia on informal caregivers – such as family members and friends – is substantial and can result in physical and mental illness, social isolation and poor quality of life for them. Although their participation in the care of dementia patients may alleviate burden on healthcare systems and residential care homes, informal caregiving is not without societal costs caused by absenteeism from work.[2]

Different forms of dementia

Dementia is a progressive illness that affects not only a person’s memory but also their behaviour, mood, cognition and ability to perform daily activities. Progression of dementia is associated with both genetic predisposition and lifestyle factors, including smoking, alcohol, exercise and diet. There are a number of different dementia subtypes with varying incidence in the population, including vascular dementia (VaD), dementia with Lewy bodies (DLB), frontotemporal dementia (FTD), Parkinson’s dementia (PD) and mixed dementia. However, Alzheimer’s disease (AD) is the most prevalent form, representing 62% of the dementia population.[3–6]

Diagnosing dementia

Although the majority of patients are diagnosed with dementia in later life, evidence shows that irreversible, pathological changes within the brain occur long before the onset of clinical symptoms. Gradual changes within the brain lead to progressive cognitive impairment and patients often experience a transitional period of mild cognitive impairment (MCI), during which a differential diagnosis may not be possible.[3,7–10]

Formal assessment of cognitive decline, as undertaken by dementia experts, usually includes physical, cognitive and mental examinations [e.g. the Mini Mental State Examination (MMSE)], plus a review of education and functional levels, medications and health history.[4,11]

Dementia assessment using brain biomarkers and structural imaging

There are several protein deposition biomarkers that may be used to assist in a diagnosis of dementing diseases, such as the presence of TDP-43 (FTD), Lewy bodies (DLB), alpha-synuclein (Parkinson’s disease), plus tau and β-amyloid which are typical in the pathogenesis of Alzheimer’s disease (although not exclusive to this dementia subtype).[12,13] Historically, reliable diagnoses might only be made post-mortem using histopathology. However, increasingly the imaging of biomarkers or their effect on the living brain can be made earlier on in the course of disease, before evidence of memory impairment is seen.[12,13]

Piramal blog image 1

Fig 1. Source: Jovalekic et al. EJNMMI Radiopharmacy and Chemistry (2017) 1:11. doi:10.1186/s41181-016-0015-3 (Copyright held by Piramal Lifesciences).

Cerebrospinal fluid (CSF) sampling via lumbar puncture can help detect abnormal levels of soluble β‑amyloid42, total tau (T-tau) and phosphorylated tau (p-tau181), which may assist during the diagnostic workup of dementia patients being assessed for AD.[14] However, lumbar puncture is an invasive method and some patients may refuse the procedure or are contraindicated, for example, if they receive anticoagulant medications. In addition, CSF-based analyses show variability between immunoassay platforms and biomarker concentrations, which may present challenges to clinicians.[14–17]

Brain imaging in patients can assist a clinical diagnosis by examining presence of cerebral pathologies and structural changes, including MRI and CT that can detect subcortical vascular changes. Single-photon emission CT (SPECT) measuring perfusion can help differentiate AD, VaD and FTD,[4,11] while 2-(18F)Fluoro-2-deoxy-d-glucose positron emission tomography (FDG PET) may assist in detecting impaired neuronal activity by measuring the cerebral metabolic rate of glucose. This has been used to detect abnormal patterns in the brain and the potential to predict conversion from MCI to AD or the diagnosis of AD has been demonstrated.[8,9,18–20] Both SPECT-perfusion imaging and FDG-PET are indirect measures of disease that detect characteristic changes in glucose and oxygen metabolism. However, these imaging modalities show limitations in reflecting the aetiology of prodromal or mild AD.[8,9,11,19,20]

Brain β-amyloid (Aβ) deposition and plaque formation occurs early in the pathogenesis of AD, therefore offering the potential to assist in an early clinical diagnosis of patients being evaluated for Alzheimer’s dementia and other forms of cognitive impairment. Amyloid-PET is a relatively recent imaging modality and three 18F-labelled imaging agents are licensed for use in the EU that can detect the presence of β-amyloid neuritic plaques in the living brain, with validated visual assessment methods using histopathology as the standard of truth (Fig.2).[13,21] According to published appropriate use criteria, amyloid-PET is considered to have greatest utility in a subset of dementia patients:[22–24]

  • where there is an established persistent or progressive unexplained memory impairment (unclear diagnosis); or
  • where brain Aβ is a diagnostic consideration based on core clinical criteria, and where knowledge of this pathology may alter patient management; or
  • with progressive dementia and atypical age of onset (usually <65 years of age).

Piramal blog image 2

Fig 2: 18F-labelled imaging agents have the ability to detect the presence of β-amyloid neuritic plaques in the living brain (immunohistochemistry with monoclonal 6E10 Aβ antibody).[13]

Fig. 2: Source: Jovalekic et al. EJNMMI Radiopharmacy and Chemistry (2017) 1:11. doi:10.1186/s41181-016-0015-3 (Copyright held by Piramal Lifesciences).

Amyloid-PET does not alone provide a diagnosis, rather it forms part of the greater assessment workup by clinical experts, including neurologists, psychiatrists and geriatricians. The knowledge of the presence or absence of β-amyloid plaques has been shown to support a confident differential diagnosis and a tailored patient care plan, including use of medications where appropriate. There is also added value for patients and their caregivers in knowing the cause of dementia, enabling decision-making and planning for the future including the possibility of enrolling into clinical trials.[5,6,8,22–28]

 The future of diagnostic imaging

The National Institute for Health and Care Excellence (NICE) is reviewing guidance on the organisation and delivery of diagnostic services, due for publication in August 2017. The scope of the revised guidance will encompass imaging in neurodegenerative diseases, as part of the wider radiology/nuclear medicine service in the NHS. This will affect not only patients, but all staff who use, refer and interpret diagnostic services in both primary, secondary and tertiary care.[29]

Author: Vanessa Newman (MD-V, PhD), Medical Affairs Director at Piramal Imaging Ltd

References

  1. Alzheimer-Europe, The prevalence of dementia in Europe. 2015, Alzheimer Europe: Luxembourg.
  2. Prince, M., World Alzheimer Report 2015: The Global Impact of Dementia – an analysis of prevalence, incidence, cost and trends, A.s.D.I. (ADI), Editor. 1015: London.
  3. Prince, M., World Alzheimer Report 2014: Dementia and Risk Reduction – an analysis of protective and modifyable factors, A.s.D. International, Editor. 2014, Alzheimer’s Disease International (ADI): London, UK.
  4. NICE, Clinical guideline 42: Dementia: Supporting people with dementia and their carers in health and social care. 2006, National Institute for Health and Care Excellence (NICE): London, UK.
  5. Deckers, K., et al., Target risk factors for dementia prevention: a systematic review and Delphi consensus study on the evidence from observational studies. Int J Geriatr Psychiatry, 2015. 30(3): p. 234-46.
  6. Kivipelto, M. and F. Mangialasche, Alzheimer disease: To what extent can Alzheimer disease be prevented? Nat Rev Neurol, 2014. 10(10): p. 552-3.
  7. Catafau, A.M. and Bullich, S., Amyloid PET imaging: applications beyond Alzheimer’s disease. Clin Transl Imaging, 2015. 3(1): p. 39-55.
  8. Sabri, O., et al., Florbetaben PET imaging to detect amyloid beta plaques in Alzheimer’s disease: phase 3 study. Alzheimers Dement, 2015. 11(8): p. 964-74.
  9. Sabri, O., et al., Beta-amyloid imaging with florbetaben. Clin Transl Imaging, 2015. 3(1): p. 13-26.
  10. Vos, S.J., et al., Prediction of Alzheimer disease in subjects with amnestic and nonamnestic MCI. Neurology, 2013. 80(12): p. 1124-32.
  11. Bloudek, L.M., et al., Review and meta-analysis of biomarkers and diagnostic imaging in Alzheimer’s disease. J Alzheimers Dis, 2011. 26(4): p. 627-45.
  12. Sperling, R.A., Karlawish, J., and Johnson K.A., Preclinical Alzheimer disease-the challenges ahead. Nat Rev Neurol, 2013. 9(1): p. 54-8.
  13. Jovalekic, A., et al., New protein deposition tracers in the pipeline. EJNMMI Radiopharmacy and Chemistry, 2017. 1(1).
  14. Roe, C.M., et al., Amyloid imaging and CSF biomarkers in predicting cognitive impairment up to 7.5 years later. Neurology, 2013. 80(19): p. 1784-91.
  15. Dubois, B., et al., Advancing research diagnostic criteria for Alzheimer’s disease: the IWG-2 criteria. The Lancet Neurology, 2014. 13(6): p. 614-629.
  16. Perret-Liaudet, A., et al., Risk of Alzheimer’s disease biological misdiagnosis linked to cerebrospinal collection tubes. J Alzheimers Dis, 2012. 31(1): p. 13-20.
  17. Kang, J.H., et al., Clinical utility and analytical challenges in measurement of cerebrospinal fluid amyloid-beta(1-42) and tau proteins as Alzheimer disease biomarkers. Clin Chem, 2013. 59(6): p. 903-16.
  18. Ng, S., et al., Visual Assessment Versus Quantitative Assessment of 11C-PIB PET and 18F-FDG PET for Detection of Alzheimer’s Disease. Journal of Nuclear Medicine, 2007. 48(4): p. 547-552.
  19. Perani, D., et al., A survey of FDG- and amyloid-PET imaging in dementia and GRADE analysis. Biomed Res Int, 2014. 2014: p. 785039.
  20. Piramal, NeuraCeq (florbetaben 18F) Summary of Product Characteristics. 2015, Piramal Imaging Ltd.
  21. EMA. Human Medicines: European public assessment reports. 2016 [cited 2016 July]; Available from: http://www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/landing/epar_search.jsp&mid=WC0b01ac058001d124.
  22. Johnson, K.A., et al., Appropriate use criteria for amyloid PET: a report of the Amyloid Imaging Task Force, the Society of Nuclear Medicine and Molecular Imaging, and the Alzheimer’s Association. Alzheimers Dement, 2013. 9(1): p. e-1-16.
  23. Johnson, K.A., et al., Update on appropriate use criteria for amyloid PET imaging: dementia experts, mild cognitive impairment, and education. J Nucl Med, 2013. 54(7): p. 1011-3.
  24. Scarsbrook, A. and Barrington S., Evidence-based indications for the use of PET-CT in the United Kingdom 2016, R.C.o.P. Royal College of Radiologists, Editor. 2016, RCR, RCP: London, UK.
  25. Bang, J., Spina, S., and Miller, B.L., Frontotemporal dementia. The Lancet, 2015. 386(10004): p. 1672-1682.
  26. Kobylecki, C., et al., A Positron Emission Tomography Study of [18f]-Florbetapir in Alzheimer’s Disease and Frontotemporal Dementia. Journal of Neurology, Neurosurgery & Psychiatry, 2013. 84(11): p. e2-e2.
  27. Barthel, H., Seibyl, J., and Sabri O., The role of positron emission tomography imaging in understanding Alzheimer’s disease. Expert Rev Neurother, 2015. 15(4): p. 395-406.
  28. Pontecorvo, M.J., et al., A randomized, controlled, multicenter, international study of the impact of florbetapir (<sup>18</sup>F) PET amyloid imaging on patient management and outcome. Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association. 11(7): p. P334.
  29. NICE. Dementia – assessment, management and support for people living with dementia and their carers: GUIDANCE. NICE Guidance 2016 [cited 2016 June]; Available from: https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0792.

About Vanessa Newman

Vanessa’s background is in neurology (epilepsy and Down’s syndrome) and more recently in the field of neuroimaging in dementia. She has worked at Piramal Imaging since early 2015 and during this time has had the pleasure of seeing how quickly this area of medicine is moving, with increasing methods and imaging diagnostics available for use with people living with dementia.

Date of preparation: July 2016. ©Piramal Imaging Ltd. UK/FBB/1015/0021

Piramal Imaging Ltd, Langstone Technology Park, Langstone Road, Havant, Hampshire PO9 1SA, United Kingdom

Piramal Imaging Ltd medical information enquiries: Medicalaffairs.imaging@piramal.com
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Piramal is a British Institute of Radiology corporate member.

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The Pelvic Radiation Disease Association – a voice for patients

Claire Poole

Claire Poole

Radiotherapy is an effective treatment for pelvic cancers but it is not widely known that the radiotherapy can affect healthy tissue and bone causing severe pain, incontinence and distress.

Here, Claire Poole explains what it’s like to have Pelvic Radiation Disease (PRD) and why she risked her life to raise money for the charity which has given her so much support.

 

 

Each year, in the UK, about 30,000 patients receive radiotherapy for pelvic cancers, half of whom are left with altered bowel and bladder functions that drastically impede a return to normal living.  Symptoms of severe pain, nausea and vomiting, incontinence, damage to bones, gut/stomach issues can appear shortly after treatment, or months – even years – afterwards.  Patients who report problems to their oncologists, surgeons and radiotherapists are often told that “We’ve cured your cancer so what’s the fuss about?. This response is common and also unacceptable. There are effective ways to manage late effects of pelvic radiotherapy (now recognised as PRD) and patients fortunate enough to get appropriate treatment report an average 70% improvement in symptoms.

Sky dive 1

Risking my life for PRDA

On Saturday 18th June 2016, I threw myself out of a plane at 15,000 ft. I harnessed my fearand put my life in the hands of the fantastic team at Go Skydive in Salisbury to do a tandem skydive, plummeting to earth at 125mph. I did this wacky thing to raise money for the Pelvic Radiation Disease Association (PRDA).

PRDA is a very small charity run by volunteers. The charity works so very hard trying to raise awareness of this condition among health professionals. PRD, the late effects of pelvic radiotherapy is not widely recognised by our own GPs or indeed the NHS. It has become a big part of mine, my partner, my two children, my family and friends’ lives.

I was diagnosed with cervical cancer four years ago, and had intense treatment consisting of chemotherapy, radiotherapy and internal radiotherapy. Thankfully, due to the treatment received I am still here, however, the radiotherapy treatment has changed my life. Yes it killed the cancer, but it also killed my insides.

Radiotherapy burns, it burns everything it touches. So while radiotherapy is highly effective in treating pelvic tumours, due to the nature of the treatment, it can affect tissues and other organs in the pelvic area. During my treatment not only were the cancer cells burnt and killed, but also all my healthy cells, tissues, bowel and bladder badly affected. Any cancer patient who receives radiotherapy to the pelvic area, will probably at some point experience the late effects of the cancer treatment. This could occur anything up to two to three years or longer after treatment. If this happens, as it did to myself and many other patients, we become unable to enjoy our cancer free lives. Our quality of life is hugely affected, from severe pain, nausea and vomiting, incontinence, damage to bones, gut/stomach issues. All of which can be either minor or cause you to be housebound or even hospitalised. All of which I have, and do experience.

I am a patient at the Royal Marsden and have been now for a few years. A very special man put me in touch with PRDA, a Dr Jervoise Andreyev. This wonderful man is a consultant gastroenterologist, who specialises in PRD and started PRDA. Dr Andreyev has made a huge difference to my life. Without the care of this man and his team, I would not be where I am today. I am not cured, but I am on treatments, have made lifestyle changes and I’m completing a medical trial. All with the help of Dr Andreyev, his team and PRDA.

Why did I raise money for this charity that many of you have never heard of?

I want to get PRD noticed and talked about and to publicise PRDA, to enable PRDA to help and support the thousands of other patients like me, who thought it was OK and normal, to have their quality of life taken from them just because they have had cancer. It is NOT OK. After all, we have fought so hard to beat cancer, surely we deserve to be given the best treatment and support possible, to try and live the rest of our lives happy and healthier with our families and friends?

Thank you so much for taking time in your day to read this. Please, please help me and others to raise as much money as possible to keep this wonderful charity going. To continue helping the thousands of brave, strong, beautiful women and men who need the support of PRDA in their lives”.

About the Pelvic Radiation Disease Association, (PRDA)

logo for PRDA

PRDA is  a support organisation of patients, carers and medical professionals formed in 2007 became a registered charity in 2012 (no 1147802).  We currently have 5 volunteer Trustees and 1 part-time self-employed Administrator. We publicise and increase awareness of PRD and provide support and advice to patients suffering from consequences of treatment. We inform and educate cancer nurse specialists, radiographers, oncologists, gastroenterologists, gastrointestinal surgeons, gynaecologists and urologists, about the symptoms and effects of PRD and provide clear and simple advice on how to refer patients for specialised help and treatment.

PRDA runs a telephone help line and an ‘email a nurse specialist’ advice service and are backed by a multidisciplinary team of experts to advise us on medical questions. Our website www.prda.org.uk provides support and advice for sufferers and we receive enquiries from around the world. The charity hosts support meetings covering such topics as diet, exercise, self-help, sexual health and radiography addressed by specialists on these topics – our aim is to provide help to enable people to cope better with the consequences of their treatment.

We present the charity’s work and objectives at major conferences throughout the UK via information stands and talks by patient ‘experts’ and have designed and produced literature for both patients and health professionals, working closely with other charities, particularly Macmillan Cancer support, Prostate Cancer, Beating Bowel Cancer, Bowel Cancer UK and Jo’s Trust (cervical cancer). These partnerships are essential to our work and together with Macmillan we chaired a Pan Pelvic Cancer committee of likeminded charities. In 2015 this resulted in a highly successful programme of training days for specialist helpline nurses from major cancer charities, an activity we strive to continue. We currently have an ongoing project in collaboration with Macmillan Cancer Support to list all gastroenterologists in the UK prepared to see patients with PRD.

PRDA has an active Facebook group with members both from the UK as well as other parts of the world, in particular the USA. This is a closed group and applications can be accepted via the PRDA website.

www.prda.org.uk

Registered charity number 1147802

(England & Wales) and a company limited by guarantee number 7998409

Is your radiology department part of your hospital’s disaster management plan?

Ronald Bilow

Dr Ron Bilow

When Dr Ron Bilow experienced a major emergency in his hospital, it got him thinking about the role of the radiology department.

Here he explains what led to the radiology department becoming an integral part of the organisation’s disaster management plan.

 

Sports spectators

 

What would you do if large number of these sports spectators (right) suddenly arrived at your hospital after a disaster occurred at the event?

What arenas can you identify in your vicinity that may serve as a gathering site for a large number of people? This could be in the form of sports stadiums, performance halls or amphitheaters, schools, shopping districts, hotels, airports, even restaurants and movie theaters. Is there a public transportation system near you? Are there elevated roads or railroad tracks nearby? Do you live in an area that is prone to earthquakes, fires, tornadoes, tsunamis or landslides? Whether it be from a natural event, a faulty device or other accident, or intentional harmful acts by one or more persons (as shown in the photo below) you probably need to be prepared to handle a rapid surge in patient influx at your institution.

Crowd scene at Boston marathon bombing

Allow me to continue with this brief illustrative story: I was covering the emergency radiology service at my level one trauma center one day when the administrators received a telephone call alerting us to a roof collapse, resulting in an estimated 100 potentially injured patients. What I witnessed was, simply put, amazing…efficiently coordinated preparation for the worst scenario imaginable.

The nursing staff, emergency physicians, emergency medical technicians (EMTs), clerical staff and housekeepers began preparing the emergency center (EC) for a high volume of patients by clearing out those awaiting transfer to the operating room (OR) or hospital ward, or discharge home. Additionally, extra stretchers were brought into trauma bays and hallways, and each was stripped down, sanitized and made ready with clean linens. Equipment was organized and put away, extra IV poles and blood product pumps were brought in, and each room was either verified ready or had its depleted stock replenished. In a matter of perhaps 15-20 minutes, the EC was ready to handle the onslaught. In short, predefined protocols were rapidly implemented during the incident, and most of the people knew their role.

Boston Marathon 2

Watching rescue helicopters from my office

Throughout the process, I stood in awe, yet somewhat disappointed…and even a bit uncomfortable…that I didn’t have a role…or, if I did have a role, I didn’t know what it was.

It got me thinking…as a radiologist, what is expected of me? What am/was I supposed to be doing to help prepare? What will be my role when the patients arrive? Is it merely to read whatever imaging exams are obtained, or is there some additional way I can help manage the problem?

It is clear from the above scenario, that our hospital has a plan for how best to handle the increased load after a mass casualty incident. This is known as a disaster management plan (DMP). In order to achieve that, leaders had to consider various scenarios and determine how the workers in each department should respond. It was also clear that the planning went much further than the EC. Phone calls were made to the receiving ward’s charge nurses alerting them that patients were coming out of the EC due to the pending influx of new trauma patients, per the hospital DMP. The OR was notified that they would receive patient’s waiting for surgery in their holding area. In short, things ran very smoothly, without pushback from the receiving services. Perhaps even additional staff were called in from home by one or more departments?

Whatever the case, it was also glaringly obvious that the radiology department had been left out of the planning, and in fact, nobody in radiology services had any idea how to handle or respond to a MCI and the resultant DMP activation. And the truth is, without a radiology department DMP, the hospital’s plan will fail. Imaging services will be rapidly overwhelmed due to lack of adequate resource management, and patients will suffer. It needs to be determined ahead of time how to decrease wait time for imaging services, speed up delivery of each examination, how reports will be disseminated and to whom, and who will do what work. This simply cannot be achieved without prior analysis and planning.

It is common knowledge that imaging has been increasingly used over the past few decades in the evaluation of critically ill patients, and for the most part, has become the standard of care. Through drills and real life experiences, researchers have shown how imaging services can become a severe bottleneck in implementing care during the hospital phase of a mass casualty incident. Thus, it seems essential to include technical and physician leaders from the radiology department in planning how best to manage the surge in patient volume after a disaster occurs. In our institution, we have begun the process of being incorporated in our hospital DMP, and hope to expand our role to help facilitate further excellence in the city-wide disaster response. Is it time for you to do the same?

About Dr Ronald Bilow

After graduating from The Chicago Medical School in 1996, Dr Ronald Bilow completed his residency in diagnostic radiology at Santa Barbara Cottage Hospital (Santa Barbara, California), and subsequently underwent fellowship training in Emergency Radiology at The University of Texas, Health Science Center in Houston (now the McGovern Medical School), and Musculoskeletal Radiology at the University of California, San Diego. He currently holds the position of Assistant Professor on the McGovern Medical School faculty in Houston, Texas, where he teaches medical students and both emergency medicine and diagnostic radiology residents and fellows. Dr. Bilow performs his clinical duties primarily at a level one trauma center, Memorial Hermann Health System – TMC, in Houston, Texas. He was recently appointed as radiologist member to the joint University of Texas, McGovern Medical School – Baylor University Medical School Disaster Management Planning Committee. He has been a Fellow Member of the ASER (American Society of Emergency Radiology) since 2005, and has served in numerous leadership roles including Case of the Day Director, Education Committee Chair/Co-Chair, Director at Large, Treasurer, Bylaws Committee Chair and Member, and Strategic Planning Committee Member. He has also held membership on the Annual Meeting Program Planning and Scientific Program Committees.

IMAGES

Figure 1. Photo: Nathan Bilow Photography.

Figure 2. Open source photo.

Figure 3. Photo taken by author, Ron Bilow, from his office window

 

Making the case for radiographer reporting

SONY DSC

With a steady and sustained rise in imaging workloads driven by an ageing population, new and evolving technologies, and a drive for patient-focused care, radiology departments are turning to new ways to provide services. Nick Woznitza, Clinical Academic Reporting Radiographer at Homerton University Hospital, east London, and Canterbury Christ Church University, Kent, makes the case for radiology departments meeting these ever-increasing demands through radiographer reporting.

Using the example of his experience in the neonatal department of Homerton University Hospital he explains how, with robust research and training, and the appropriate use of skill mix, departments can offer a safe, efficient and patient-focused service.

Expansion of the neonatal medicine department at Homerton produced an increase in plain imaging workload and, coupled with a shortage of consultant paediatric radiologists, meant that the neonatal X-rays did not receive a timely definitive radiology report. The neonatal unit is a large, tertiary referral facility with 46 cots, 900 admissions and 13,600 cot/days per annum in 2013–2014. In order to provide an optimal service to these vulnerable patients, it was agreed to develop a radiographer-led plain imaging neonatal reporting service.

A bespoke, intensive training programme was designed in collaboration with radiology and neonatal medicine at Homerton, Canterbury Christ Church University and the paediatric radiology department of the Royal London Hospital. The radiographer was already an established reporting radiographer, interpreting skeletal and adult chest X-rays in clinical practice, so the training programme focused on the unique physiology and pathology of neonates. Training consisted of self-directed learning, pathology and film viewing tutorials, practice reporting, and attendance at the neonatal X-ray meeting at the Royal London Hospital. This immersive experience was achieved via secondment for one and a half days a week.
Upon qualification of the reporting radiographer, all reports were double read by a consultant paediatric radiologist, to successfully manage the transition into practice whilst maintaining patient safety in line with best practice recommendations.

To ensure that the performance of the trained reporting radiographer was comparable to that of a consultant paediatric radiologist a small research study was conducted (Woznitza et al, 2014), supported by research funding from the International Society of Radiographers and Radiographic Technologists (ISRRT). This study confirmed only a small number of clinically significant reporting radiographer discrepancies (n = 5, 95% accuracy), comparable to the performance of the paediatric radiologists. This study provided further evidence that the introduction of radiographer neonatal plain imaging reporting has not adversely impacted patient safety or care.

Activity figures (July 2011 – September 2014) were obtained from the radiology information system to determine the number of X-ray examinations performed and the proportion receiving a radiographer report. An average of 285 X-rays were performed each month, however, there was a marked increase in March 2012 from 158/month (July 2011 – February 2012) to 328/month (March 2012 – September 2014). The radiographer has made a sustained, significant contribution to the reporting service, interpreting an average of 92.5% of the X-ray examinations and responsible for >95% of examinations in 20 of the 36 months.

Building on the collaboration between radiology and neonatal medicine, a weekly neonatal X-ray meeting was introduced. Facilitated by the reporting radiographer and paediatric radiologist, this forum has increased radiology–clinician engagement and in turn patient care, facilitated discussions and acts as an excellent educational resource. Recognising the importance of this meeting, the senior neonatal clinicians requested that the reporting radiographer convene the meeting when the paediatric radiologist is absent on leave.

The introduction of a radiographer neonatal X-ray reporting service demonstrates that, with collaboration and support, novel approaches can help provide solutions to increasing activity in radiology in an effective, efficient and patient focused manner without compromise on patient safety. Collaboration and team work are fundamental when undertaking service delivery change. The support of both the radiology department, under the leadership of Dr Susan Rowe, and the neonatal unit, led by Dr Zoe Smith with mentorship from Dr Narendra Aladangady, has been essential in the success of this service.

Nick Woznitza biography
Nick qualified as a diagnostic radiographer from the University of South Australia and, following several roles in rural and remote Australia, moved to the UK in 2005.

An accredited consultant radiographer with the College of Radiographers, Nick reports a range of plain imaging examinations including skeletal, chest and neonatal X-rays. He has recently taken up a clinical academic radiography role at Homerton University Hospital and Canterbury Christ Church University, with this blended role facilitating image interpretation teaching to radiographers and other health professionals and his research into the accuracy and impact of radiographer reporting.

Reference
Woznitza N, Piper K, Iliadis K, Prakash R, Santos R, Aladangady N. Agreement In Neonatal X-ray Interpretation: A Comparison Between Consultant Paediatric Radiologists and a Reporting Radiographer. International Society of Radiographers and Radiographic Technologists 18th World Congress. June 2014; Helsinki, Finland, 2014.

Is the NHS failing to leverage transformation from technology?

Adam Hill.2jpgThe NHS spends a great deal on IT but rarely embraces the service redesign opportunities this offers. Dr Adam Hill, Chief Medical Officer at Sectra, explores how this could change.

The NHS spends significant sums on its valuable IT infrastructure. But despite this investment, our health service often fails to embrace the service redesign opportunities this technology presents, with major deployments still often layered onto existing services.

Redesigning services can dramatically improve care and save substantial amounts of money. Yet missed opportunities mean that we have under-utilised assets, and all this in an era of more for less.

The real opportunity to reshape the delivery of clinical services hand in hand with the deployment of IT programmes can be seen by taking a glance at the recent history of diagnostic services within the NHS. Radiology and pathology are both service delivery specialities within modern day medicine. Consultants from neither speciality have their name above a patient’s bed, but both are mission critical diagnostic specialities, and the bedrock upon which modern day healthcare is based.

One of these specialities has already managed to embrace technology at a remarkable pace. The other has very effectively embarked on service redesign. Yet neither has achieved both—something that must happen in future in order to maximise benefits for patients, enabling a shift to a new era in which cost-effective health outcomes are commissioned.

Radiology and pathology: two sides of the diagnostic coin
Radiology has shifted to digital very rapidly in the NHS. The National Programme for IT (NPfIT) accelerated coverage of picture archiving and communication systems (PACS) to in excess of 95% within 18 months. Despite widely publicised criticism, NPfIT revolutionised the delivery of imaging diagnostic services in the UK. However, the potential to reduce inequality of care provision and improve cost-effective outcomes have been less successfully realised, ultimately impacting upon professional working conditions.

Not only does service redesign impact the health of our population at risk, but it can have any number of indirect benefits. As just one example, it could mean freeing up and consolidating vastly under-utilised real estate in the NHS. Clinicians providing a diagnostic service with a digital workflow can arguably report from an office, a hot-desk reporting hub, from home or whilst on the move with equal fidelity. But radiology is yet to really harness this opportunity.

Pathology, in contrast, has undergone a significant service redesign following the Carter Review in 2008, focused on reducing costs by 20%. However, this diagnostic service has failed to realise the impact upon equality of outcomes and cost reduction that come with implementing a digital workflow, despite the widely held anticipation that pathology will soon be the next big digitisation in healthcare.

IT infrastructure deployment can re-vision service delivery
Embracing IT infrastructure at the same time as the service redesign opportunities that new deployments offer can unlock the potential to transition clinical care provision from centralised environments, through to decentralised models and distributed networks of care.

In diagnostic services, this would mean the ability to balance workloads across a region. It would give hospitals anywhere in a region the ability to access clinicians with the right skillsets to prepare a specimen, perform an examination or report a finding.

Modern PACS systems are cross-enterprise document sharing, or XDS , enabled. They can allow federation of workflow across a region, something that has previously been balkanised by different PACS vendors. This workload balancing can allow hospitals to meet ever stringent service level agreements, whilst improving specialist job satisfaction.

Joining up tasks to join up care
Put simply the tasks of IT implementation and service redesign are currently decoupled. It is very infrequent that a hospital looks for IT to support a service transformation programme. It is equally rare that hospitals will use the deployment of an IT infrastructure project as an opportunity for service redesign to unlock efficiency savings.

We must now move away from a situation where IT is simply layered onto the existing healthcare service as a result of analysing current workflow to inform IT architecture.

The focus must now be on the use of IT to support hospitals and the people within them, whether that is the clinician, the radiology service manager, the CEO, the chief financial officer or the patient.

Innovators will embrace the opportunity to use IT to redesign healthcare, achieving affordable health outcomes today; the risk of being a late adopter is that cost efficiencies are not realised until much later, failing patients that can’t wait for our health system to meet their needs tomorrow.

*Radiology Information System/Picture Archiving and Communication System

About Dr Adam Hill

Adam is a dual-qualified Clinician and Mechanical Engineer, previously having co-founded and led a successful university-based research centre at the interface of both disciplines. Adam’s expertise is in the research, development and optimisation of medical technologies and healthcare services, with over 100 publications and 8 academic awards in the last 15 years.

Having learnt the fundamentals of his clinical trade in the NHS, Adam passed through the Royal Military Academy, Sandhurst, before serving as the doctor to the Household Cavalry Mounted Regiment. Upon retiring his commission, Adam held technical and commercial leadership positions within start-up companies spanning service delivery, skills development and, most recently, technology incubation, before working as a Management Consultant with international clients in the Lifescience and Healthcare industries. During the term of our most recent coalition Government, Adam has provided thought-leadership, advice and content to a handful of its initiatives and programmes.

Adam’s current interests include unlocking the value of networked services, believing that the whole is greater than the sum of its parts; the primacy of imaging in the realisation of personalised medicine; and powering efficiencies in care delivery through standardisation.

Sectra has a rapidly growing share of the RIS/PACS* market the UK, a powerful product portfolio, and a world-class research and development centre at the University of Linköping; these are our foundation, our building blocks and our brain trust with which we can design, develop and deploy solutions to the most complex of problems challenging our NHS customers today.

 

Skill mix in radiology: a personal tale

Chris Loughran BIR blogWhen Dr Chris Loughran published research into the benefits of trained radiographers reporting trauma radiology he was accused of committing professional suicide. But he was on a mission to spread the word.

 

 

Years ago I was appointed as Clinical Director of Radiology. I knew nothing about management and thought I had better go and learn something. I enrolled at Keele University for a diploma course in Management in Radiology. In the second year I had to write a dissertation. Scratching around for something I was inspired by Prof. Roger Dyson to consider what he termed “Clinical Radiography”, a concept that encouraged radiographers to move from the production of diagnostic images only to one where they also interpreted them.

Some research was essential and I was able to cajole three radiographers into contributing to the research effort. The aim was to determine if the diagnostic performance of the radiographers in trauma radiology could be enhanced with training, to such an extent that they could report such radiographs to a high standard. We showed that they could and the research findings were subsequently published in the BJR.1 We took the plunge even before the paper was published and with the backing of the East Cheshire NHS Trust those radiographers started to report directly to the accident department. I believe we were the first in the country to do this. The backing of the Trust Board was sought, and was essential, to ensure that in the event of error we were covered. It fulfilled my belief that radiographers could employ their talents to a greater extent—for the benefit of the department, the hospital in general and, of course, the patients.

I felt as though I was now on a mission—time to spread the word and encourage other departments to work in a similar fashion. To this end I decided to seek out further interest at a local regional radiologists meeting. Naively, I thought my proposals to expand our local in house training programme to a more established and regional exercise would be welcomed. Less time spent by radiologists on an element of the work that many were reluctant to undertake combined with better service delivery to patients seemed like an unbeatable combination. I should have known better! I had never been shouted down previously (nor since) but was that afternoon. “You’re committing professional suicide !” one colleague ferociously remarked, he’s probably forgotten, I never have. The idea clearly touched many raw nerves. So I slunk away, cowed, feeling battered and rejected. What I couldn’t really get my head round was the absolute rejection of the idea when I knew so many departments were struggling with their workloads and so many radiologists complained about it.

Despite this rejection the radiographers themselves picked up on the idea and I was asked by many organisations to speak about the research and the concept in general. I particularly remember one meeting in Nottingham where I spoke to a crowded lecture theatre. I was introduced by a radiologist, the talk went well and he very kindly remarked afterwards that I was so convincing he would buy a second hand car from me!

Later I was invited to help establish a course in radiographer reporting at Canterbury, Christ Church College. We agreed a schedule for the course and associated examination. I was privileged to be an external examiner and was mightily impressed by the very high standard that many candidates attained. Radiologists had (until then) never been examined in trauma plain film radiology to the extent these candidates were.

Of course, similar training soon followed elsewhere and it now is established practice in many departments. Indeed it has gone further with radiographers reporting other examinations including CT head scans, for example. Moreover, many adverts for radiologist positions now highlight this practice as an inducement for candidates to apply for their posts. Its moved a long way since that regional radiology meeting all those afternoons ago.

Its taught me that its not only the truth that matters but also the diligence with which it is pursued. If you believe in something keep going! As Edward Bulwer-Lytton put it, “Enthusiasm is the genius of sincerity and truth accomplishes no victories without it”.

  1. Loughran CF. Reporting of fracture radiographs by radiographers: the impact of a training programme. Br J Radiol 1994; 67: 945–50. doi: 1259/0007-1285-67-802-945

About Dr Chris Loughran

I qualified in Liverpool in 1976 and have been pursuing radiology since 1978. I trained in radiology in Liverpool. After a 2-year stint as Consultant at Broadgreen Hospital I went to the USA for a year where I was Assistant Professor in The Medical University of South Carolina, Charleston, USA. Returning to England I took up post in Macclesfield where I have been since 1986.

In my time I have been Clinical Director, Postgraduate Tutor, Associate Medical Director and Chairman of the Medical Staff Committee. I was Chairman of the Northern Branch of the BIR and BIR council member some years ago. Now I work as a clinical radiologist and am so lucky that I still enjoy the speciality as much as I did all those years ago.

 

A Radiologist in the Planning Room

DrSimcock_400x400

Dr Richard Simcock

Historically, physicians have been both radiologist and radiation oncologist, and diagnostic and therapeutic roles have sat comfortably with one physician.

Dr Richard Simcock argues that times have now changed and there is a strong case for a radiologist AND a radiation oncologist in the planning room.

Thor Stenbeck is a hero of Swedish physics. Soon after Röntgen’s first X-ray image Stenbeck could lay claim to the first documented therapeutic use (locating a bullet lodged in a skull). Later he successfully irradiated skin cancer with the first documented fractionated therapy. Stenbeck is our first example of a physician becoming both a radiologist and radiation oncologist.

Dr Thor Stenbeck

Thor Stenbeck at work

The model has been endlessly repeated. Throughout the 20th century the therapeutic and diagnostic possibilities of the magical rays were supervised by key pioneers. One of Britain’s greatest examples was Ralston Patterson. Patterson trained in radiology in Cambridge, South Africa, Aberdeen and the Mayo Clinic before leading Manchester’s Holt Institute and trailblazing for standardisation in the medical physics of therapy.

Patterson

Ralston Patterson

Patterson was an early President of the Faculty of Radiologists, later transformed into the Royal College of Radiologists (motto, “From Rays, Health”). The Royal College still accredits both radiologists and radiation (clinical) oncologists—but the world has moved on.

Today’s radiotherapy maximises therapeutic ratio by using the best of radiological imaging to accurately identify a malignant target and the organs at risk (OARs). It then uses image guidance to ensure that the bullseye of the target never drifts from the treatment beam. As technology develops so does the ability to identify and potentially spare new OARs. At the recent BIR Meeting on “Diagnostic Radiology for Advanced Head and Neck Planning” delegates heard data on “new” OARS such as cochleas and carotids as well as reviewing how to identify emerging OARs in the swallowing musculature on high-resolution CTs. The meeting buzzed with talk on MRI and PET fusion in the radiotherapy planning process as well as diffusion-weighted MRI and nuclear medicine in diagnosis.

These technologies are figuratively and literally decades apart from the images Patterson used to guide treatment and yet we cling to one relic from the age: the dual role of radiation oncologist as radiologist. This is a nonsense.

The interpretation of imaging should be performed by those most expert, and in almost every case that will be the experienced cancer radiologist. Despite this it is usually the radiation oncologist who defines the visible tumour target ( or gross tumour volume (GTV)) in radiation planning. One assumes therefore that the radiation oncologist is trained in radiology? Sadly not.

It is an embarrassing fact that the post-graduate training of the UK clinical oncologist (as specified by the RCR curriculum ) requires no training or examination in radiological anatomy nor radiology. There are examinations in statistics and cancer biology but no expectation that trainees should be formally taught how to use the imaging that they use as the eyesight of their weapon of choice. Clinical oncology trainees may however be examined in the design of a radiotherapy bunker—a fitting metaphor for this silo thinking.

Elsewhere in the world the situation is not much better. Neither the US nor Australian training schemes mandate any radiology training (although the Royal Australian and New Zealand College of Radiologists (RANZCR) are considering it). In Canada at least a 4-month radiology attachment is expected (a model followed by some UK centres e.g. Glasgow) but this is not long enough to learn a radiologist’s craft. A recent study identified 84 radiological competencies as a minimum for radiation oncologists. We need to change the model; not “Jacks of all trades” but Masters of one.

We must bring together radiological knowledge and harness it to an oncologist’s expertise. Radiologists remain essential in diagnosis, staging and response assessment. Radiation oncologists determine clinical target volumes and critically assess the final plan. The two come together to identify tumour targets and OARs; radiologist and radiation oncologist in the same room but not the same person.

The BIR meeting showed us how far we have come (and can go) in head and neck radiotherapy.

Delegates at the BIR Head and Neck event, November 2014

Delegates at the BIR Head and Neck event, November 2014

It illustrated that progress will reach its maximum potential if we collaborate as a multiprofessional team in the planning department.

Thor Stenbeck was a hero, but a century later we should not emulate him and his dual roles.

 

Find out more about BIR events

About Dr Richard Simcock MRCPI FRCR

Dr Richard Simcock has been a Consultant Clinical Oncologist at the Sussex Cancer Centre since 2004. Previously he had worked at the Sydney Cancer Centre, Australia and before that had completed five years of postgraduate specialist training in Oncology in London and the South East including Guys and St.Thomas’, Charing Cross and Mount Vernon Hospitals. He graduated from Guys and St.Thomas’ hospital in 1993.

Working closely with the surgical and nursing team Dr Simcock sees and treats patients diagnosed with early or advanced breast cancer. He advises on the role of radiation, chemotherapy, hormone, biological, and experimental treatments.
Dr Simcock prescribes and supervises courses of chemotherapy delivered by the team at the Montefiore or by home healthcare teams. In addition he prescribes, plans, and supervises radiotherapy treatment at the Royal Sussex County Hospital or at Spire Portsmouth (CPUK).

He is also involved in enrolling patients in trials of new therapies as well as trials of improved radiation therapies.

As a Head and Neck Oncologist Dr Simcock treats cancers of the larynx (voice box), tongue, tonsil and other rarer sites. He supervises, prescribes and plans curative treatments with radiotherapy and chemotherapy as well as giving post-operative radiotherapy treatments. Intensity Modulated radiotherapy is used as standard in these cases.

The advent of radiation protection through WWI radiology martyrs

Dr Adrian Thomas

As we commemorate the centenary of the outbreak of World War One and as we approach Armistice Day on 11 November, Dr Adrian Thomas, BIR Honorary Librarian, reflects on the huge impact that the WWI radiology martyrs had on the radiation protection standards we take for granted today.

 

Many things were to change in 1914 at the start of hostilities and were never quite the same afterwards. The old confidences were shaken.

One item that symbolizes this period for me is an old wrist watch given to me by Yvonne Beech. It was presented to Corporal Edward Wallwork RAMC (Royal Army Medical Corps). Wallwork was from Lancashire and had worked in the cotton industry; he came to London during the Great War, joined the RAMC and trained as a radiographer.

 

The wristwatch presented to radiographer, Corporal Walwork, by three London radiologists

The wristwatch presented to radiographer, Corporal Walwork, by three London radiologists

At the outbreak of hostilities the War Office requisitioned a newly completed five-storey warehouse, H.M. Stationery Office in Stamford Street, for a 1650-bed Red Cross military hospital. The hospital was close to Waterloo Station and was connected by a tunnel. The building today is part of King’s College London.

The silver Swiss wristwatch was presented to Wallwork by doctors Ironside Bruce (1879–1921), Stanley Melville (1867–1934) and George Harrison Orton (1873–1947).

2bThe three doctors had all served in the forces as radiologists. Before the war men wore pocket watches and only ladies wore wristwatches. It was said that a man would sooner wear a dress than a wristwatch! However, pocket watches were not practical in the trenches. The wristwatch is a typical good quality Swiss wristwatch from the end of the First World War period and the numerals and hands were designed to be filled with radium to create a luminous dial.

The presentation of the watch was as a token of appreciation for Wallwork’s work in the X-ray department of the King George Hospital from 1915 to 1919.

Patients rehabilitating at King George Hospital

Patients rehabilitating at King George Hospital

All of the three doctors were deeply involved in the BIR or its predecessor organisations and sadly all three suffered from radiation-induced disease.  Their names are recorded on the X-ray martyr’s memorial in the grounds of St George’s Hospital in Hamburg.

Ironside Bruce was on the staff of Charing Cross Hospital and the Hospital for Sick Children in Great Ormond Street. He was very talented and published widely and his well known book “A System of Radiology; with an Atlas of the Normal” came out in 1907.

The British radiological world was shocked when Bruce died of radiation-induced aplastic anaemia in 1921 at the young age of 42. The outcry resulting from his death resulted in the formation of a radiation protection committee.

George Harrison Orton was a pioneer of radiotherapy and was in charge of the X-ray department at St Mary’s Hospital in London. After his death it was said in his obituary that he was “perhaps the last martyr pioneer of radiology”. Stanley Melville worked at St George’s Hospital in London and was BIR president in 1934. Both Orton and Melville served periods as co-secretary with Sidney Russ (physicist at the Middlesex Hospital) of the newly formed British X-ray and Radium Protection Committee set up by the BIR, and radiation standards were set.

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About Dr Adrian Thomas

Dr Adrian Thomas

Dr Thomas was a medical student at University College, London. He was taught medical history by Edwin Clarke, Bill Bynum and Jonathan Miller. In the mid-1980s he was a founding member of what is now the British Society for the History of Radiology. In 1995 he organised the radiology history exhibition for the Röntgen Centenary Congress and edited his first book on radiology history.

He has published extensively on radiology history and has actively promoted radiology history throughout his career. He is currently the Chairman of the International Society for the History of Radiology.

Dr Thomas believes it is important that radiology is represented in the wider medical history community and to that end lectures on radiology history in the Diploma of the History of Medicine of the Society Apothecaries (DHMSA). He is the immediate past-president of the British Society for the History of Medicine, and the UK national representative to the International Society for the History of Medicine.

BRITISH INSTITUTE OF RADIOLOGY www.bir.org.uk

BRITISH SOCIETY OF HISTORY OF RADIOLOGY http://www.bshr.org.uk

 

Professionalism in healthcare

Anna van der GaagAnna van der Gaag, Chair, Health and Care Professions Council, explores the link between multidisciplinary teams and thriving professionalism.

The most recent British Social Attitudes Survey suggests that patient satisfaction with accident and emergency services is at a six-year low. Across professional health regulation, complaints are at an all time high. Many of these complaints are about behaviour, ethics and professional conduct. Why is this trend occurring and what can we do to address poor practice before it leads to a complaint?

It is likely that the increase in complaints and decrease in levels of satisfaction with services have multiple causes. The pressures on the system, resource issues and staff being asked to do more with less inevitably impact on the number of complaints. The growth of social media as a mechanism for comment, available 24 hours a day, internet sites like iWantGreatCare.org and Patient Opinion, which give people new opportunities to say what they think about their health professional or hospital service, are also contributing factors. We have seen a rise in complaints about breaches of confidentiality on social networking sites, and health professionals using social media as a mechanism for criticising colleagues. This type of online unprofessional behaviour is on the rise, as the lines between personal and professional lives become more blurred. Changing social norms and new ways of communicating are important influences on professionalism and how it plays out in everyday life.

The HCPC commissioned research to improve our understanding of this complex area. The first HCPC report suggests that ‘professionalism’ is seen not so much as a discrete competency but a situational judgement, a set of behaviours influenced by context, rather than a fixed characteristic. These behaviours are strongly influenced by the particular care group and peer group as well as the knowledge and skills of an individual.

The second phase of this work is ongoing, but its findings have led us to generate further debate about the centrality of ethics and conduct in day to day practice. For example, our work suggests that professionals find it more acceptable to discuss issues of competence than conduct with their peers. They find it difficult to challenge each other about how they talk to patients, whereas comments about technical aspects of competence are much more common. This depends very much upon the nature of relationships, and the level of trust and mutual respect which exists between individuals and within teams. Where there are high levels of trust and strong team working, professionalism thrives.

In his vision of the future, Don Berwick talks about the centrality of team based care where the hierarchies between professions have lost their edge, where people are genuinely respectful of each others skills and expertise and their primary aim is to work together for the good of the patient. In these environments, there is a constant search for new technologies to improve care and a respect for the patient as an equal partner in the process, with expertise, with insight, with knowledge that no professional can ever have.

Changing expectations, social norms and new technology will mean that more is demanded of us as health professionals wherever we work. We need more, not less, talk about professionalism and values in the 21st century. Radiological professionals, with their well established team-based models of care, can be leaders in these much needed conversations.

Anna van der Gaag, Chair, Health and Care Professions Council, UK

About HCPC

HCPC is a UK wide regulator of 320,000 professionals from 16 health and care professions, including radiographers and clinical scientists. Its role is to protect the public by setting and monitoring standards, quality assuring education programmes, and investigating complaints.

The 2014 Welbeck memorial lecture at UKRC in Manchester was given by Anna van der Gaag, Chair of the Health and Care Professions Council (HCPC).

Looking back on the life of Professor Robert Steiner

image Robert Steiner

Professor Robert Steiner

Robert Emil Steiner CBE MD FRCP FRCR
BIR Past President
(born 1 February 1918, died 12 September 2013)

As the world of medical imaging moves on with great rapidity, we mustn’t forget those great pioneers who helped us achieve the breakthroughs we take for granted today.

Here, Professor Graeme Bydder of the University of California, San Diego, reflects on the life of the man he knew and admired.

Robert Steiner, former professor of Radiology at the University of London and chairman of the Department of Radiology at the Royal Postgraduate Medical School, Hammersmith died after a long illness on September 12, 2013 at the age of 95.

Professor Steiner established and ran the leading academic Department of Radiology in the UK for many years. He was president of both the British Institute of Radiology and the Royal College of Radiologists and had a major role in the development of cardiac and pulmonary angiography as well as that of magnetic resonance (MR) imaging.

He was born in Prague in 1918 which was then part of the Austro-Hungarian empire, and moved with his family to Vienna at the age of three. He began studying medicine at the University of Vienna in 1935. He was about to complete his preclinical studies at the time of Anschluss, the political annexation and military occupation of Austria by Nazi Germany on March 12, 1938. Members of his medical class who expressed an objection to this simply disappeared. He needed a further two months to complete the first part of his medical degree, and after doing this, escaped through Italy to Dublin in May 1938.
He finished his medical training in Dublin in 1941 and worked in the Emergency Medical Service in the UK from 1941 to 1945. He trained in radiology at the United Sheffield Hospitals from 1944 to 1950.

He was appointed Assistant Director of Radiology at Hammersmith Hospital, London in 1950. At that time much of the equipment in the department was of pre-war vintage and the Director had radiation damage to his hands. Over the next 10 years, Professor Steiner became Director, recruited new staff, replaced equipment and established a very active teaching program.

He was appointed the first professor of Diagnostic Radiology in the University of London in 1961. He established a research program concentrating on cardiac and pulmonary angiography. This was essential for the assessment of valvular disease in the newly developing speciality of cardiac surgery. He also encouraged senior faculty within the department such as Peter Lavender, David Allison, John Laws, and Thomas Sherwood to develop their own areas of expertise to international level.

Tutorials were held on Monday evenings often with radiologists from around London bringing problem films. They were also held on Friday afternoons at 5pm in case any trainees had the idea of going home early. Private practice was banned. This meant that there was generally more consultant time available for teaching and research than at other London teaching hospitals where this was not the norm.

Professor Steiner helped train a succession of radiologists who went on to occupy senior positions in departments throughout the world. These included John Laws (Kings College), Thomas Sherwood (Cambridge), Lenny Tan (Singapore), Constantine Metreweli (Hong Kong), Andy Adams (Guy’s and St. Thomas’s), Brian Ayers (Guy’s and St. Thomas’s), Maurice Raphael (the Middlesex), John Stevens (St. Mary’s and Queen Square), Dennis Carr (the Brompton), Gary Lawler (Melbourne), Tony Leung (Sydney), Nandita deSouza (the Royal Marsden), Peter Dawson (UCH), Walter Curati (Ealing), Derek Kingsley (Queen Square), Rolf Jager (Queen Square), Takayuki Ouchi (Chiba), Alina Greco (Monaco), David Robinson (Abergavenny), Adrian Thomas (Bromley), Mary Ann Johnson (Edmonton), Susan Peterman (Atlanta) and Steven McKinstry (Belfast).

There were also paediatricians (Lilly Dubowitz, Francis Cowan, Mary Rutherford, Linda de Vries and David Edwards), and physicians (John Brown, Mark Doran, Maria Barnard, Simon Taylor-Robinson) who benefited from his training. He strongly supported research radiographers (Jackie Pennock, Linda Banks, Di Spencer, Janet Sargentoni, Anne Case, Angela Oatridge, Susan White, Elaine Williams, and Serena Counsell), scientists (Jane Cox, Jimmy Bell, David Gadian, Richard Iles, Louise Thomas), psychiatrists (Basant Puri, Eve Johnstone, David Owens), and anaesthetists (David Menon, Carol Peden, David Harris), who worked within his department as well as Margaret Kirk, Patricia Hamilton and Dulcie Rodriguez.

Professor Steiner established very fruitful collaborations and exchanges with faculty of leading radiology departments in the United States, British Commonwealth and elsewhere in the world. He hosted numerous senior radiologists on sabbatical leave including Richard Greenspan (Yale), John Doppman (National Institutes of Health), Robert Fraser (Birmingham, USA), Ian MacKay (Hartford), Michael Vermess (NIH), Harold Davidson (Oklahoma), Bob Berk (University of California, San Diego) and Moshe Graif (Tel Aviv). These visitors made a substantial contribution to the department.

He was elected president of both the British Institute of Radiology (1972-73) and the Royal College of Radiologists (1977-80), as well as the Fleischner Society (1973) an international multidisciplinary society dedicated to the diagnosis and treatment of diseases of the chest. It was named after Felix Fleischner a chest radiologist who also left Austria after Anschluss, and worked at Massachusetts General Hospital.

During the 1950s and 1960s there was what seemed an inevitable shift in radiological leadership from Sweden to the US, but quite unexpectedly Sir Godfrey Hounsfield FRS produced the first head clinical computed tomography (CT) scanner in 1971. It was a spectacular success. This was followed by body CT scanners in 1974 and 1975, and the beginning of the modern era of radiology. Britain was at the centre of it, led by a company, EMI (Electric and Musical Industries Ltd) with a remarkable record in acoustics, electronics, TV and radar going back to Alan Blumlein in the 1930s, but no previous experience in the medical field or in x-ray technology.

This was followed by the initial development of MR imaging heralded by the first image published by Paul Lauterbur in 1973. Much of the subsequent development of the technique was performed by groups in the UK based in Aberdeen, Nottingham and London (EMI). There were many difficulties and the first international conference on MR imaging held at Vanderbilt University, Nashville on October 26-27, 1980 was only a limited success mainly due to the lack of convincing clinical results. What was necessary for MR imaging to receive the large scale investment needed for future progress was a major medical application in which the new technique had a substantial advantage over state of the art CT. This Professor Steiner achieved with Ian Young FRS and his team from EMI, in the MR imaging of plaques in the brain in multiple sclerosis (MS). These were shown on a scale not previously seen except at post mortem. MS was a disease that had not previously received significant radiological attention and it seemed an improbable starting point, but MS has since become the single disease of the body most studied with MR. The system the work was done on used the first whole body cryomagnet built by Oxford Instruments, a university spin-off company founded by Lady Audrey and Sir Martin Wood FRS.

The work was remarkable in other ways. During this period EMI sold its CT business to General Electric at a knock down price following its unsuccessful venture into the US, and was trying to sell its MR business. The Medical Research Council (MRC) closed down its CT operation at Northwick Park Hospital, London in 1980 and soon after closed down its ultrasound research there. The MRC would not support clinical MR work at Hammersmith and the leader of the Hammersmith MR group, Frank Doyle suffered a catastrophic stroke before clinical studies began, and never worked again. The only significant outside support came from Gordon Higson, Director of the Scientific and Technical Services Branch of the DHSS.

The success with MS was followed by other major applications of MR including diagnosis of disease in the posterior fossa (where CT was degraded by beam hardening artefacts, 1982-3), use of the heavily T2-weighted spin echo sequence which provided very high soft tissue contrast (1982), paediatrics (no ionizing radiation, 1982-3), the first clinical study with gadolinium-DTPA (opening up the MR study of intracranial tumours, where previously the use of intravenous iodinated agents had given CT a major advantage (1984), high contrast fat signal suppressed sequences for body and musculoskeletal applications (1985). These developments helped keep the UK at the forefront of clinical MR research until, and beyond the ISMRM (International Society for Magnetic Resonance in Medicine) meeting at the Barbican, London in 1985. It also provided time for other groups to mobilise including those led by Donald Longmore (the Royal Brompton), Ian Isherwood (Manchester), Donald Hadley (Glasgow), Ian McDonald, George du Boulay and David Miller (Queen Square), Ian Kelsey Fry (St. Bartholomews, London), Jonathan Best (Edinburgh), Paul Goddard (Bristol), Adrian Dixon (Cambridge), Peter Cavanaugh (Taunton), Stephen Golding (Oxford), Philip Robinson (Leeds) and others to add to the radiological work already done by Frank Smith (Aberdeen) and Brian Worthington FRS (Nottingham). Oxford Instruments expanded rapidly and captured most of the world market for whole body cryomagnets.

The success with MR showed that the earlier success with CT could be repeated, and major developments in other areas of radiology followed including remarkable advances in ultrasound, nuclear medicine, interventional radiology, PACS and digital radiography. These helped transform the speciality of radiology and create the modern era of imaging.

Professor Steiner contributed in many different ways to these developments. He brought to the many tasks he undertook very high standards, and a wide ranging strategic vision, but it was his sense of fairness and justice that endeared him to people at all levels, and led them to trust him without reservation on personal and professional matters.

He was appointed CBE and was the recipient of the gold medals of the Royal College of Radiologists and the European Society of Radiology. He also received honourary degrees, fellowships and memberships from universities and radiological societies around the world.

He was strongly supported by his wife Gertie. She is remembered with great affection as a gracious hostess as well as a source of encouragement and wise counsel by generations of staff, faculty and visitors to the department. Gertie and Robert met in Dublin and married in Sheffield in 1945. They had two daughters, Hilary and Ann. Hilary has two children Christopher and Sarah, and one grandchild. Ann has three boys Tim, Will and Bertie. Robert had two sisters, who together with their families escaped from Vienna to Australia where they settled, and a brother Herbert who studied physics at Cambridge, and remained afterwards in England. Robert’s father and stepmother spent the war years in France, then went to England before returning to Austria.

About Professor Graeme Bydder

Graeme Bydder was born in New Zealand in 1944 and trained in medicine at the University of Otago, Dunedin. He graduated in 1969. He subsequently trained in medicine in New Zealand under Keith Macleod before receiving a Nuffield fellowship to train in CT under Louis Kreel at the MRC Clinical Research Centre, Northwick Park Hospital, London in 1978. His main work was on CT attenuation values in fatty disease of the liver, iron overload, and bone disease.

He worked at the Royal Postgraduate Medical School, Hammersmith Hospital under Frank Doyle and Professor Steiner from 1981 onwards. His main research activity was technical development and clinical application of magnetic resonance (MR) imaging in conjunction with Ian Young FRS and his team.

Professor Steiner provided strategic and tactical direction for clinical MR imaging at Hammersmith from its inception in 1981 to his final retirement in 1998.

Graeme moved to the University of California, San Diego (UCSD) in 2003 and since then has worked on MR imaging of short T2 components in tissues, qualitative and quantitative approaches to MR imaging, and MR microscopy of the musculoskeletal system.

In addition to the benefitting from working under Professor Steiner, Graeme was fortunate enough to work for two of the “three wise men” (Louis Kreel, Frank Doyle, and Jamie Ambrose) who did early experimental work on Godfrey Hounsfield’s prototype CT system and advised the DHSS to proceed with development of the technique in 1969.