Svarsskrivning. Elin Trägårdh Klinisk fysiologi, SUS Malmö

Transkript

1 Svarsskrivning Elin Trägårdh Klinisk fysiologi, SUS Malmö

2 Svar The report of an imaging procedure is often the only communication from the interpreting physician to the caregiver, and is the final and perhaps the most critical component of an imaging procedure

3 Images Nuclear cardiology interpretation of images Report Clinical interpretation of report Clinical decision

4 Förstår remittenterna våra svar? Svarsstudie 6 nuklearmedicinare 23 kliniker 60 remissvar Resultat 12/23 kliniker uppfattar ischemiska områden som mindre än vad nuklearmedicinaren som skrev svaret menade Trägårdh et al, EJNMMI Res 2012

5 Exempel på lättolkat fall Belastning Arbetar 97 W motsvarande 88% av förväntad. Begränsas av bentrötthet och andfåddhet. Ingen bröstsmärta. Maximal hjärtfrekvens 169 /min (107% av förväntad maxpuls). Blodtryck i vila 150/80 mmhg. Vid 92 W 200/- mmhg. Vilo-EKG: normalt. I arbete inga signifikanta STförändringar, enstaka SVES i vila efter arbete. Scintigrafi Homogent isotopupptag vid belastning. Vänster kammares ejektionsfraktion uppmäts till 80%. Slutdiastolisk volym beräknas till 70 ml. Bedömning Ingen belastningsutlöst myokardischemi. Inga perfusionsdefekter tydande på genomgången infarkt. Normal systolisk vänsterkammarfunktion.

6 Exempel på lättolkat fall Belastning Belastning med Adenosin med lätt cykling. Vilo-EKG: Sinusrytm. Trög R-progression anteroseptalt. Under adenosininfusion dyspné. Ingen bröstsmärta. Scintigrafi Homogent isotopupptag i vila. Vid adenosin med lätt arbete tillkomst av måttligt/uttalat nedsatt isotopupptag i ett stort område inferiort från apex till basen, med inferolateral utbredning apikalt och midventrikulärt och inferoseptal utbredning basalt. Vänster kammares ejektionsfraktion cirka en timme efter adenosin med lätt arbete uppmäts till cirka 60%. Slutdiastolisk volym beräknas till cirka 160 ml. Bedömning Patologisk myokardscintigrafi. Belastningsutlöst myokardischemi inom ett stort område inferiort. Inga perfusionsdefekter tydande på genomgången infarkt.

7 Exempel på svårtolkat fall Belastning Belastning med Adenosin. Vilo-EKG: Normalt. Under adenosininfusion Lätt ST-sänkning V4-V5, som mest 1 mm. Scintigrafi Homogent isotopupptag i vänsterkammarväggen i vila. Med adenosin relativt kraftigt nedsatt upptag i en stor del av laterala väggen, med utbredning inferolateralt vid apex till antero-lateralt vid basen. Vänster kammares ejektionsfraktion uppmäts till 70%. Slutdiastolisk volym beräknas till 180 ml. Bedömning Relativt kraftigt nedsatt coronar flödesreserv i laterala delen av vänsterkammarväggen. Inga perfusionsdefekter tydande på tidigare infarkt. Lätt förstorad vänsterkammare med normal EF.

8 Förstår remittenterna våra svar? 40 läkare använde 16 uttryck/ord för att beskriva sannolikheten för metastaser metastas?; går ej att utesluta; misstanke; kan vara metastasbetingat; kan vara; kan inte uteslutas; måste misstänkas; inger misstanke; stark misstanke; ser skyldig ut; relativt klar misstanke; troligtvis; misstänkt; metastassuspekt; sannolikt; klart misstänkt

9 Förstår vi själva våra svar? Sannolikhet för myokardischemi eller infarkt på en skala Misstänkt Möjligen föreligger Kan ej uteslutas Kan föreligga Kan representera Ojämnt upptag som kan utgöra

10 Kommande publikation om svarsskrivning Reporting nuclear cardiology. A joint expert statement by the European Association of Nuclear Medicine (EANM), and the Section on Nuclear Cardiology and Cardiac CT, European Society of Cardiology (ESC), and the European Council of Nuclear Cardiology (ECNC)

11 Kommande publikation om svarsskrivning LIST OF CONTENT Introduction Terminology to be used in the report Structured reports Images in the report The preliminary report Myocardial perfusion imaging Viability Hybrid imaging MIBG Blood pool imaging HEADLINES OF A SECTION MYOCARDIAL PERFUSION IMAGING Demographics Clinical indications Stress testing data Tracer administration Image acquisition Image interpretation Conclusion of the report Date and signature

12 Kommande publikation om svarsskrivning General language: It is strongly recommended that: The report is written in a simple way, if possible, without use of technical terms Qualitative descriptions (e.g. small, medium-sized, large or slightly, moderately, severely reduced) should be replaced, if possible, by quantified data Protective expressions (e.g. is likely, cannot be excluded) are used as little as possible

13 Kommande publikation om Conclusion of the report svarsskrivning The conclusion must address and as clearly as possible answer the clinical question from the indication. A statement must be given whether the study is normal, abnormal or non-diagnostic. Results from the present study should be compared with previous studies if available. Information about technical errors, sub-optimal quality, or abnormal extra-cardiac tracer uptake should be mentioned. Further diagnostic investigation may be suggested.

14 Tracer distribution Must be included Should be included May be included Normal A brief description Abnormal Presence of defect(s) Other comments to perfusion distribution abnormalities Location of defect(s) Relation to LV segments Preferably using the 17 segment model [9] Extent of defect(s) Quantification as % or a % interval of the LV 1 ; alternatively in descriptive terms ( large, small etc) Severity of defect(s) Reversibility of defect(s) Quantification of regional perfusion in PET Quantified in summed stress/rest/difference scores 2 ; alternatively, or also, in descriptive terms ( mild, severe etc.) Reversible (stress induced), fixed (permanent, irreversible) or mixed (partially reversible) defect(s) Suggestion of single- or MV disease Relation to coronary anatomy (reservations regarding anatomy variations without angiography in the current patient) Absolute values in ml/min/g tissue at rest/ during hyperaemia, including reference values. Coronary flow reserve in units.

15 Conclusion Must be included Should be included May be included MPI Defect suggesting stress induced ischaemia or scar tissue. Location, extension, severity Defect: Extent and severity quantified Relation of defect to coronary anatomy Gated MPI Stress and rest LVEF and change from rest to stress. Reference values for LVEF LV dilatation, TID. LV volumes Discrepancies between perfusion and wall motion.

16 Exempel 1. Demographics <Site administrative data, contact information> <Patient name, identification number/date of birth, gender> Clinical indication Suspicion of coronary artery disease. Stress testing data Adenosine stress testing was performed with low-level exercise (50W) during adenosine infusion (6 min). Tracer administration 600 MBq 99mTc-Tetrofosmin was injected after 4 min of infusion. Findings Homogeneous tracer distribution throughout the myocardium at stress. LV ejection fraction: 70% (normal > 60%). Normal LV volumes and normal wall motion and wall thickening. No rest study was performed. Conclusion No stress induced ischemia. No myocardial infarction. Normal LV function.

17 Exempel 2 Demographics <Site administrative data, contact information> <Patient name, identification number/date of birth, gender> Clinical indication Suspicion of coronary artery disease. Stress testing data The patient performed a bicycle exercise test. Maximum workload 125 W (4METs). Heart rate increased from 72 to maximum 153 beats/min (92% of maximum predicted heart rate). Blood pressure increased from 145/95 mmhg to maximum 195/- mmhg. The patient experienced moderate chest pain during peak exercise. The test was terminated due to fatigue and dyspnoea. During exercise 2 mm ST-depression was observed in leads V4-V6. Tracer administration 600 MBq 99mTc-Tetrofosmin at peak exercise and 600 MBq at rest. Findings Rest study: Homogeneous tracer distribution throughout the myocardium. Stress study: Severely decreased tracer uptake in a large area of the left ventricle including the whole anterior wall, apex and apical lateral region (segments 1, 7, 13, 16, 17). Gated SPECT imaging showed normal myocardial thickening and wall motion at rest. LVEF was 65% (normal > 60%), but decreased during stress to 55%. Moderate hypokinesia and moderately decreased antero-lateral wall thickening during stress. Normal LV volumes both at rest and after stress. Conclusion Severe, stress-induced ischaemia in the whole anterior wall, apex and apical lateral region, approx 25% of the LV. No sign of myocardial infarction. Global and regional LV systolic function was normal at rest, but EF decreased significantly after exercise, and regional systolic function was reduced after exercise.

18 Sammanfattning Undvik ord som gör svaret vagare ( kan inte uteslutas, möjligen föreligger ) Kort, tydlig konklusion, som besvarar frågeställningen. Översätt fysiologin till kliniska termer Verka för lika svar, oavsett tolkande läkare. T.ex. strukturerade svar Diskutera era svar med vanliga remittentgrupper