Bringing together Science, Faith and Cancer Care

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The Revd. Canon Dr. Mike Kirby, Chair of the BIR Oncology and Radiotherapy Special Interest Group, has a wealth of experience as a senior radiotherapy physicist, working on national guidance, developing clinical practice and teaching radiography students. As if this doesn’t keep him busy enough he has also taken on the role of Canon Scientist at Liverpool Cathedral where he is working to encourage dialogue and discussion about science and faith. Here he explains what the role involves.

I began work in the UK’s National Health Service more than 30 years ago, as a Radiotherapy Physicist at the Christie Hospital, Manchester UK.  Alongside my routine clinical work, my main research interest was in electronic portal imaging and portal dosimetry.  I then helped set up Rosemere Cancer Centre in Preston, UK from 1996 as deputy Head of Radiotherapy Physics and Consultant Clinical Scientist there.  During that time I contributed to and edited national guidance documents such as IPEM Reports 92, 93 and 94 and the multidisciplinary work, ‘On-target’.

My work moved back to the Christie in 2007 and as Head of Radiotherapy Physics and Consultant Clinical Scientist for the Satellite Centres, I helped to lead their development in Oldham and Salford as part of the Christie Network. My research and development work has primarily focused on electronic portal imaging, developing clinical practice and equipment development.

Mike Kirby4

More recently my focus has been on teaching and learning for radiotherapy education as a lecturer (Radiotherapy Physics), especially using VERT, for Radiotherapy programmes in the School of Health Sciences, Liverpool University; but always with a focus on the wider picture of radiotherapy development having served on both IPEM and BIR committees throughout my whole professional career.

 

Alongside my scientific work, I am a priest in the Church of England; having trained and studied at Westcott House and the Universities of Cambridge and Cumbria, I hold graduate and postgraduate degrees in Theology.

Mike Kirby

My ministry has mainly been in the Cathedrals of Blackburn, Chester, and Liverpool (Anglican) where I was Cathedral Chaplain.  I have recently (Feb 2020) become a Residentiary Canon of Liverpool Cathedral, with the title of Canon Scientist the primary aim of which is to encourage dialogue and discussion about science and faith.

 I am a member of the Society of Ordained Scientists and have given numerous talks on Science and Faith to schools, colleges, churches and other institutions.  These have included organising lecture series with world renowned speakers at Blackburn (2016) and Chester (2018) cathedrals; a third series was delivered at Liverpool Cathedral in May 2019, and a fourth series is planned for May 2020.

My role is to consider all sciences (physical, clinical, social) in ecumenical and multi-faith environments.  So I will look to work with initiatives already developing in other Christian traditions, other faiths and secular organisations to discuss current challenges, such as climate change, medical ethics, health initiatives and information for cancer, dementia and mental health issues etc..

Mike Kirby2.jpg

My work will be part of the clear faith objectives of the cathedral as a place of encounter for everyone, through events and initiatives within the cathedral, but also beyond.  This will include services focusing on health issues and pastoral challenges (such as bereavement and loss); events engaging with science, its wonders and challenges; fostering further relationships with local and wider communities on science and healthcare education, and with academic and scientific institutions too; encouraging scientific and ethical engagement with schools and colleges, as I have done so previously in both Chester and Blackburn dioceses.

I will be encouraging Christians and Christian leaders to understand science and engage with it more, alongside other national projects such as the recently announced ECLAS (Engaging Christian Leaders in an Age of Science) project of Durham and York universities and the Church of England.  As a self-supporting minister (one whose paid employment is outside of the church), I will also look to encourage and highlight the tireless work of many others who already do this within the diocese and the wider national church.

Within all of this, I have always seen my vocation as being one within God’s service, for all people, with my work for cancer patients being right at the heart of it.

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If you have any questions for Mike, you can send him an email at sigs@bir.org.uk

Mike is the co-author of the international student textbook on On-treatment Verification Imaging: a Study Guide for IGRT, through CRC press/Taylor and Francis with Kerrie-Anne Calder. They are both contributors to the updated UK national guidance on IGRT due out in 2020.

Mike, with the support of the SIG, has helped to organise a range of events for radiographers, physicists, dosimetrists, radiologists and oncologists. See the full programme here

 

Review – The Unofficial Guide to Radiology: 100 Practice Chest X-Rays with Full Colour Annotations and Full X-Ray Reports

Tom Campion

The Unofficial Guide to Radiology won the BIR/Philips

Trainee award for Excellence in 2015.   Tom Campion, radiology trainee at Bart’s Hospital, London and Valandis Kostas, Senior Radiographer from Guy’s and St Thomas’ Hospital  reflect on the latest addition to the series which focuses on chest x-ray interpretation and is designed to support professionals and students.

Valandis KostasA follow-up to the Unofficial Guide to Radiology, and part of the Unofficial Guide to Medicine series, this new book The Unofficial Guide to Radiology: 100 Practice Chest X-rays, with full colour annotations and full X-ray reports  has at its heart the inspiring idea that the development of educational resources should be driven by those who use them. The result is a fantastic resource for reporting radiographers, medical students, junior doctors in any specialty, providing a comprehensive and practical approach to chest x-ray interpretation.

41Vnk61P4sL._SX352_BO1,204,203,200_Right from the start, the book’s cover is self-explanatory and is easily perceived to be about chest X-ray interpretations.   The 100 chest X-ray cases are presented in a test-yourself format, with the images and case history presented on one page and the interpretation and report on the next.

The cases are separated in three coloured divisions: Standard (orange), Intermediate (purple) and Advanced (blue). The first page provides the reader with a short clinical indication followed by the associated chest X-ray in high quality, all in one page. The second page then evaluates the technical features, again using a colour code scheme which is then diagrammatically presented on the same chest X-ray, but on a smaller scale. It may be coincidence that the orange, purple and blue technical features can also be perceived as standard, intermediate and advanced technical points to look out for from a radiographer’s perspective. Finally, there is a short but precise summary demonstrating a report of the chest X-ray followed by further management for the patient.

The image quality is excellent in comparison to most other available textbooks, with crisp full-page images allowing the detail of the images to be explored – crucial in the days of PACS when every possible abnormality can be magnified a hundredfold.

Each ‘answer’ page has a consistent format, embedding a sensible interpretation pathway, and a clear layout highlighting both normal and abnormal findings. The consistency, and the detailed and comprehensive annotations, allows the reader to build up an idea of ‘normal’ over the course of the cases, continuously reinforcing important structures to check on every radiograph.

The multidisciplinary approach to development also comes through strongly, with suggested first management steps in response to each radiograph placing the interpretation firmly in the pragmatic clinical world. However, the ‘reporting’ style employed also develops familiarity with the language of radiologists; if this can sometimes seems overly formal or formulaic, it serves a purpose in ensuring that clinicians and radiologists are on the same page.

The clinical cases provided are realistic and are what you expect to find whether in Accident and Emergency and/or outpatient, GP clinics. From pathologies to pneumothoraxes, fractures to line insertions, most scenarios are covered in this book.

Valandis Kostas strongly recommends this book to all grade and advanced radiographers. He observes that the book provides the patient pathway link from clinical presentation to radiology, to treatment and type of follow up imaging required i.e. CT and/or chest clinic referral. The layout enables understanding of the acquired chest x-ray, vital for best practice.

He particularly applauded the section on quality of the chest X-ray, using the similar 10 point image quality check radiographers use in their clearance of X-rays they undertake. Patient I.D, rotation, penetration and inspiration are a few examples. Furthermore, the case layout educates radiographers the importance of these checks to aid image interpretation for diagnosis whilst encouraging learning about chest pathologies. This will eliminate the repetitious perception of the chest X-ray and it will encourage radiographers to maintain high quality chest radiographs for accurate diagnosis and reduce false negatives and false positives.

The clinical details provided in the case vignettes are of a level of detail that surpasses most of those seen in clinical practice; hopefully, the detail provided here will also serve to demonstrate to clinicians who read the book how fundamental these details are, and serve as a resource on helpful requesting as well as interpretation of chest radiographs.

An important area for radiographers and radiologists that is not covered in as much detail is the inadequate chest x-ray, and perhaps the book could be improved by including a few examples of misses/near misses from poor quality radiographs in order to educate readers on when a repeat X-ray is required.

Tom Campion, trainee radiologist  would happily recommend the book to anyone whose job involves X-ray reporting as it delivers a solid foundation in interpretation skills and serves  as both a thoughtfully structured introduction to the beginner and a handy reference to the more experienced.

Both Valandis and Tom felt that the book would make a great app or online tool  in the future.

The Unofficial Guide to Radiology £19.99

https://www.amazon.co.uk/Unofficial-Guide-Radiology-Practice-Annotations/dp/1910399019

Images: (Top left) Tom Campion, (top right) Valandis Kostas.

AUTHORS:

by Mohammed Rashid Akhtar MBBS BSc (Hons) FRCR (Author), Na’eem Ahmed MBBS BSc (Author), Nihad Khan MBBS BSc (Author)

EDITORS:

Mark Rodrigues MBChB(Hons) BSc(Hons) FRCR (Editor), Zeshan Qureshi BM BSc (Hons) MSc MRCPCH (Editor)

 

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

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Has imaging become too effective?

Adrian Dixon

Professor Adrian Dixon has a worldwide reputation as an academic and a radiologist and has published extensively on body and musculoskeletal CT and MR imaging.

He will deliver the BIR Toshiba Mayneord Eponymous Lecture called “Has imaging become too effective?” at UKRC on 7 June 2016 at 13:00.

Read this fascinating interview with him and get a taster of this “not-to-be-missed” presentation.

You will be delivering the BIR Toshiba Lecture at UKRC this June. Your lecture is called “Has imaging become too effective?” Can you give us a “taster” of what you mean by this?

“You should say what you mean!” as the March Hare said in “Alice’s Adventures in Wonderland”.

What do people mean by “effective”? Effectiveness is only an appropriate term if qualified. Modern imaging certainly is effective at increasing the diagnostic confidence about a diagnosis and excluding certain diagnostic possibilities. It has taken a long while to prove that it is effective in saving lives. It has become so effective that, in many conditions, an image can be rendered to make the diagnosis obvious to the man in the street.

And clinicians now tend to refer for imaging without stopping to think! It has also become so effective in demonstrating probably innocuous lesions that the worried well can become even more of a hypochondriac! In some societies this can lead to over usage, excessive radiation exposure and increased costs.

If imaging is “too effective” – is radiology still a worthwhile career choice?

Yes! It is the most fascinating of all medical careers and every day a radiologist should see something that he or she has never quite seen before. The radiologist is the ultimate medical detective and cannot conceivably get bored. Indeed radiologists get reimbursed to solve crossword puzzles on elaborate play stations!

What have been the three biggest challenges for you in your career?

Radiologists have had to learn and relearn their skills at frequent intervals during their careers. Radiology will only survive as a specialty if the radiologist knows more about the images, the technical aspects and the interpretative pitfalls than their clinical colleagues.

Did you ever meet Godfrey Hounsfield (inventor of CT imaging) and what were your memories of him?

opening of scannerI did indeed meet Sir Godfrey on numerous occasions. His humility and “boffin style” of science greatly appealed. Some of the stories at the numerous events surrounding his memorial service were truly fascinating, including his inability to accept any machine which he could not understand without taking it to bits and then reassembling it!

 

Given the financial pressures on healthcare, will the required investment in the latest imaging technology be affordable?

Some of the developments in personalised medicine may be unaffordable. Generic contrast agents will continue to be used in large volumes. The cost of creating “one off” agents may prove unjustifiable.

Why would you encourage someone to join the BIR?

Because of the fun of interdisciplinary discussion and the pride of being a small part of the oldest radiological society!

Does spending more money on equipment mean a better health service?

I passionately believe that prompt access to imaging makes a major contribution to excellent healthcare. But that does not necessarily mean that every hospital has to have every machine at the top of the range. A rolling programme of equipment replacement is an essential part of delivering a high-quality radiological service.

The most difficult thing I’ve dealt with at work is…

An electrical power cut during the middle of a tricky adrenal CT-guided biopsy!

If Wilhelm Roentgen could time travel to Addenbrooke’s hospital, what would he be most impressed with?

The sheer size and the number of staff of the radiology department!

When its 2050, what will we say is the best innovation of the 21st century in healthcare?

Data mining and health statistics.

Who has been the biggest influence on your life? What lessons did that person teach you?

All my previous bosses have influenced my career. I have learnt something from each of them. All of them stimulated me to ask the question “why are we doing things this way”? “Can it be done better”?

My proudest achievement is…

Helping to make the Addenbrooke’s Radiology department one of the most modern in the UK.

What advice would you pass on to your successor?

Never give up, try, try and try again and remember “the more you practice, the luckier you get”.

What is the best part of your job?

That I have been lucky to have had a succession of challenges in the various roles that I have held, all of which have kept me on my toes.

What is the worst part of your job?

Leaving salt of the earth friends as I have moved from role to role.

If you could go back 20 years and meet your former self, what advice would you give yourself?

Do not worry so much – it will all be alright on the night.

Adrian Dixon

Adrian Dixon

What might we be surprised to know about you?

That I support Everton Football Club.

How would you like to be remembered?

For influencing the careers of younger colleagues – hopefully to their benefit!

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Professor Dixon will deliver the BIR Toshiba Mayneord Eponymous Lecture called “Has imaging become too effective?” at UKRC on 7 June 2016 at 13:00.

Book your place at UKRC (early bird rate ends 15 April 2016)

 

Toshiba-leading-innovation-jpg-large Thank you to Toshiba for supporting the BIR Mayneord Eponymous Lecture

 

 

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

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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.