The BMJ Awards 2017: ImagingBMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1239 (Published 13 March 2017) Cite this as: BMJ 2017;356:j1239
- Nigel Hawkes, freelance journalist, London, UK
Play specialist supported MRI
Young children who need magnetic resonance imaging present a problem to the imaging team. “An MRI scanner is claustrophobic and very noisy,” says Irene O’Donnell, play services manager at University College London Hospital. “The number of paediatric MRIs has been rising, and so were the number of children who couldn’t complete them, meaning that they had to be scanned again under general anaesthetic. This causes distress to the children and pressure on anaesthesia and scanning lists, as well as taking up paediatric day care beds.”
A trial using a play specialist one day a week to help children by explaining the procedure through the medium of play proved successful. Out of 90 patients aged between 3 and 13 years who were supported by the play specialist, 86 completed the scan successfully. Nine had been booked for general anaesthesia but didn’t need it, saving £8000 (€9000; $10 000).
One successful technique is to show the children a scale model of the scanner, complete with a moving table and accompanied by the noise it makes. “It’s a really valuable tool. It removes fear of the unknown and children can practise with a Playmobil figure,” she says. “Sometimes we take them to visit the scanner, and we now have a DVD player that will work inside the scanner so they can watch a video during the procedure—a fantastic resource for a 5 year old who might have to have a scan lasting 45 minutes.”
Play specialists now work two days a week in the department, achieving a scan success rate of 94%. Waiting times are shorter and the cost of the play specialist’s time is covered by more efficient use of the scanner, while the risks of general anaesthesia are avoided in most cases.
Renal transplant imaging team
When living donors donate kidneys, preoperative imaging is needed to identify anatomical details so that the surgeon is not taken by surprise in the middle of the transplant operation. Before 2012, explains Sapna Puppala, a consultant at Leeds Teaching Hospital NHS Trust, the large area of Yorkshire served by the trust did this in a haphazard manner.
An audit of scans for 110 donors who had magnetic resonance angiography or (in a few cases) computed tomography (CT), found that 16% failed to identify renal arteries correctly, 9% got renal veins wrong, and 2.7% misidentified ureters. “When a surgeon expects one blood vessel and finds two, it complicates things,” Puppala says. None of the donors had been scanned for renal tumours using specialised techniques; nor had the scans been discussed in a formal multidisciplinary meeting including imaging experts.
The system was transformed by changing the imaging protocols, improving awareness among all Yorkshire imagers of the required standards, and organising team meetings in every case. When the audit was repeated for cases between 2014 and 2016, only one accessory renal artery had been missed—and that was identified at the team meeting. Surgeons had experienced no unexpected findings during operations.
“Today we have a streamlined service where we’re all talking to one another, and when there are complications, clinicians have named imagers to contact,” shesays. “We have a lean, structured service that delivers much better results, and it didn’t cost anything. If I did it again, I would have more radiologists on board and ensure remote conferencing facilities to enable regional imagers to join in.”
Endovaginal MRI in cervical cancer
Young women with early cancer of the cervix can sometimes be spared the loss of fertility by precise surgery to remove the tumour rather than the whole uterus. But assessing whether this is likely to be possible depends on detailed imaging of the tumour in advance. The Royal Marsden Hospital in London has about 30 such referrals a year, and surgeons there asked for better images so they could safely reduce the extent of surgery.
Nandita DeSouza, professor of translational imaging at the Institute of Cancer Research, led the development of an MRI coil (the signal receiver) that can be placed in the vagina, much closer to the area being imaged. “It’s like having a good aerial on a radio: you get a much better signal,” she says. “If you can see exactly what you are dealing with, you can assess if the fertility sparing surgery is possible.”
The development required a team of 10 to develop, manufacture, and test a device suitable for the hospital’s Phillips scanner. In 47 patients with cancer confined to the cervix, the team showed the technique had an accuracy of 87% for an experienced reader, and in 31 of these cases the images altered surgical management. Surgeons were enthusiastic and now will not perform fertility sparing surgery without these images.
“The first devices were reusable, but we’re now planning to trial disposable coils with the outer housing made by 3D printing,” DeSouza says. She expects them to cost £200-£300 each if manufactured commercially. Although the device developed in London was specific to the Phillips scanner, it can be redesigned for use with other machines.
Colon cancer exclusion pathway
Achieving the two week target for diagnosing suspected colon cancer—the target embraced by the NHS in 2012—is impossible using colonoscopy, in the view of Mosheir Elabassy, medical lead for imaging at University Hospitals of Leicester NHS Trust. Despite increasing staff considerably, the hospital “failed miserably,” he says. They managed to see only 70% of patients within the target of two weeks, causing considerable anxiety in patients, delaying the use of colonoscopy for bowel cancer screening and other conditions, and attracting penalties for breaching the target.
“Something had to be done,” he says. “We created a new pathway where all patients were sent straight for CT virtual colonoscopy, a procedure that detects a similar rate of colon cancers and polyps to colonoscopy but at no risk of perforation of the colon.” All 2400 patients referred in 2016 were examined within two weeks, achieving 100% of the target. “NHS England says that by 2020, 90% should be examined within two weeks,” he says. “We’re already achieving 99.3%.”
The cost is lower, too. For 2400 patients the old colonoscopy pathway would cost £1.1m whereas the new pathway costs £636 000, a saving of £480 000 to the clinical commissioning group. The benefits to patients are just as important. Cancer is found in only 5% of those referred, and the remaining 95% no longer have to undergo an intrusive and uncomfortable intervention with recognised clinical risks. The CT scans have the additional advantage of picking up disease outside the colon.
Clinical research imaging centre and the Scot-Heart trial
Routine tests used to diagnose heart disease in people complaining of chest pain are less than perfect. But thanks to the development in Edinburgh of a research imaging centre and a subsequent randomised controlled trial of CT coronary angiography (CTCA), the picture is now much clearer and clinical practice is changing.
The centre is a partnership between the University of Edinburgh and NHS Lothian, explains Scott Semple, reader in medical imaging at the university. Established at a cost of £18m in 2009, the centre set up a CTCA service and conducted a trial in which 4146 patients with angina were randomised to standard care or standard care plus CTCA. Methods were devised to reduce the radiation dose to a level five times lower than that used in comparable US institutions.
The SCOT-HEART trial, published in the Lancet in 2015, found that CTCA changed the diagnosis and treatments in a quarter of patients and led to a threefold reduction in standard invasive angiography. With appropriate treatments, the rates of coronary death and non-fatal heart attacks were halved. “We’ve since followed up for more than three years and the same level of benefit has been maintained,” says David Newby, director of the centre, who led the trial. “Heart disease has many tests, all of which are OK-ish. But CTCA is the best of all.”
Guidelines from the National Institute for Health and Care Excellence now recommend CTCA as the first line investigation. So the trial has led to a new model for testing people with chest pain. “It will take some time to be adopted everywhere,” Newby says. “It’s rather like the change that was made from clot busting drugs to angiography for patients presenting with heart attacks. It doesn’t happen overnight.”
The Imaging Team of the Year award is sponsored by Alliance Medical. The awards ceremony takes place on 4 May at the Park Plaza Hotel, Westminster. To find out more go to thebmjawards.com.
Provenance and peer review: Commissioned; not externally peer reviewed.
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.