Radiography

Direct to test: the trend to chest CT scanning requests through primary care. (2023)

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Type of publication:
Conference abstract

Author(s):
Nahar R.; *Bosher O.; *Makan A.; Crawford E.; Srinivasan K.; Moudgil H.;

Citation:
Thorax. Conference: British Thoracic Society Winter Meeting 2023. London United Kingdom. 78(Supplement 4) (pp A258), 2023. Date of Publication: November 2023.

Abstract:
Background/Objectives Although the concept of 'direct to test' managing patients from primary care is not new, emphasis has been on improving cancer outcomes through earlier radiological detection; evidence on how General Practitioners (GPs) currently request chest CT (computer tomography) scans dealing with a broader range of diagnoses amid the backlog of referrals into secondary care in the post COVID-19 era, is anecdotal. This work (1) documents the uptake and nature of chest CT scans requested, (2) reports on appropriateness and standard of referrals, and (3) outlines subsequent findings. Methods 12 month computer data collected retrospectively on all patients undergoing chest CT scans at this secondary care hospital; GP referrals were identified through practice codes. Results 279/1230 (23%) of chest CT scans undertaken were requested through primary care; mean age of patients was 67.6 (SD 12.2, range 20-91) years with 48% males. Uptake/ trend over the preceding 12 months are shown in figure 1, GP requests remaining low. All were HRCT (High Resolution CT) rather than staging CT used to stage lung cancer or CTPA (CT Pulmonary Angiograms) investigating pulmonary thrombo-embolic disease (PTE). 263 (94%) of requests were to establish a new finding and 16 (6%) as follow up assessing earlier detected pulmonary nodules; 178 (64%) of referrals were based on symptoms with a provisional diagnosis only proposed in 140 (50%). Referral standards adequately outlining clinical context was only found in 142 (51%) but referral pathway considered appropriate in 268 (96%) with the remainder probably best referred directly to cancer pathways. Findings included bronchiectasis (23%), emphysema (15%), interstitial (including occupational) lung disease (15%) and lung cancer (2%) but with inconclusive or no new radiological finding in 117 (42%). Conclusions Approximately 23% of chest CT scans are currently being requested through primary care; although the type of CT and most referrals are appropriate, with most lung cancer and PTEs on alternate referral pathways, there remains concern where pulmonary nodules are being followed outside of a more dedicated protocol and clinic. Benefits to the patient, how GPs manage the high number of inconclusive results, and patterns of referrals to secondary care require further assessment.

Experience as an international mammographer working in the UK comparing practice between Nigeria and UK (2023)

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Type of publication:Conference abstract

Author(s):*Okeke C.R.; *Njoku G.

Citation:Breast Cancer Research. Conference: Symposium Mammographicum Conference 2023. Glasgow United Kingdom. 25(Supplement 2) (no pagination), 2023. Date of Publication: October 2023.

Abstract:Breast cancer affects women of all races without exception even though severity and survival rate are often diverse. In Nigeria about two thirds of women with breast cancer are diagnosed at an advanced stage, with the possibility of metastatic spread (Akaro- Anthony et al., 2010). A mammographer performs breast imaging techniques that produce mammographic radiographs for diagnosis (American Society of Radiologic Technologist, 2017). In Nigeria, the breast screening programme is performed by radiographers with the additional mammogram-specific training which is comparable to what is found in the United Kingdom; however, the UK screening programme also makes use of trained assistant practitioners which is not obtainable in Nigeria (Lawal et al., 2015). The breast screening programme in Nigeria invites women between the ages of 40 to 70 years, and this is justified by the fear that in Nigeria, a higher percentage of breast cancer cases are seen in younger age groups than in developed world ((Jedy-Agba et al., 2012). The mode of invitation is through public awareness campaigns, but majority of the women in the population do not frequently participate in mammography screening due to high cost and religious belief. The screening programme in Nigeria encourages women to get screened every two years (Lawal et al., 2012). However, the UK breast screening programme advice women to have breast screening mammogram, once every 3 years and is currently inviting women between the ages of 50 and 70 years for breast screening.

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Magnetic resonance imaging before breast cancer surgery: results of an observational multicenter international prospective analysis (MIPA) (2022)

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Type of publication:Journal article

Author(s):Sardanelli F, Trimboli RM, Houssami N, Gilbert FJ, Helbich TH, Álvarez Benito M, Balleyguier C, Bazzocchi M, Bult P, Calabrese M, Camps Herrero J, Cartia F, Cassano E, Clauser P, Cozzi A, de Andrade DA, de Lima Docema MF, Depretto C, Dominelli V, Forrai G, Girometti R, Harms SE, Hilborne S, Ienzi R, Lobbes MBI, Losio C, Mann RM, Montemezzi S, Obdeijn IM, *Ozcan Umit A, Pediconi F, Pinker K, Preibsch H, Raya Povedano JL, Sacchetto D, Scaperrotta GP, Schiaffino S, Schlooz M, Szabó BK, Taylor DB, Ulus ÖS, Van Goethem M, Veltman J, Weigel S, Wenkel E, Zuiani C, Di Leo G.

Citation:European Radiology. 2022 Mar;32(3):1611-1623.

Abstract:Objectives: Preoperative breast magnetic resonance imaging (MRI) can inform surgical planning but might cause overtreatment by increasing the mastectomy rate. The Multicenter International Prospective Analysis (MIPA) study investigated this controversial issue. Methods: This observational study enrolled women aged 18-80 years with biopsy-proven breast cancer, who underwent MRI in addition to conventional imaging (mammography and/or breast ultrasonography) or conventional imaging alone before surgery as routine practice at 27 centers. Exclusion criteria included planned neoadjuvant therapy, pregnancy, personal history of any cancer, and distant metastases. Results: Of 5896 analyzed patients, 2763 (46.9%) had conventional imaging only (noMRI group), and 3133 (53.1%) underwent MRI that was performed for diagnosis, screening, or unknown purposes in 692/3133 women (22.1%), with preoperative intent in 2441/3133 women (77.9%, MRI group). Patients in the MRI group were younger, had denser breasts, more cancers ≥ 20 mm, and a higher rate of invasive lobular histology than patients who underwent conventional imaging alone (p < 0.001 for all comparisons). Mastectomy was planned based on conventional imaging in 22.4% (MRI group) versus 14.4% (noMRI group) (p < 0.001). The additional planned mastectomy rate in the MRI group was 11.3%. The overall performed first- plus second-line mastectomy rate was 36.3% (MRI group) versus 18.0% (noMRI group) (p < 0.001). In women receiving conserving surgery, MRI group had a significantly lower reoperation rate (8.5% versus 11.7%, p < 0.001). Conclusions: Clinicians requested breast MRI for women with a higher a priori probability of receiving mastectomy. MRI was associated with 11.3% more mastectomies, and with 3.2% fewer reoperations in the breast conservation subgroup. Key points: • In 19% of patients of the MIPA study, breast MRI was performed for screening or diagnostic purposes. • The current patient selection to preoperative breast MRI implies an 11% increase in mastectomies, counterbalanced by a 3% reduction of the reoperation rate. • Data from the MIPA study can support discussion in tumor boards when preoperative MRI is under consideration and should be shared with patients to achieve informed decision-making.

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Solving the preoperative breast MRI conundrum: design and protocol of the MIPA study (2020)

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Type of publication:Journal article

Author(s):Sardanelli F, Trimboli RM, Houssami N, Gilbert FJ, Helbich TH, Alvarez Benito M, Balleyguier C, Bazzocchi M, Bult P, Calabrese M, Camps Herrero J, Cartia F, Cassano E, Clauser P, de Andrade DA, de Lima Docema MF, Depretto C, Forrai G, Girometti R, Harms SE, Hilborne S, Ienzi R, Lobbes MBI, Losio C, Mann RM, Montemezzi S, Obdeijn IM, *Ozcan, Umit A., Pediconi F, Preibsch H, Raya-Povedano JL, Sacchetto D, Scaperrotta GP, Schlooz M, Szabo BK, Ulus OS, Taylor DB, Van Goethem M, Veltman J, Weigel S, Wenkel E, Zuiani C, Di Leo G.

Citation:European Radiology. 2020 Oct;30(10):5427-5436.

Abstract:Despite its high diagnostic performance, the use of breast MRI in the preoperative setting is controversial. It has the potential for personalized surgical management in breast cancer patients, but two of three randomized controlled trials did not show results in favor of its introduction for assessing the disease extent before surgery. Meta-analyses showed a higher mastectomy rate in women undergoing preoperative MRI compared to those who do not. Nevertheless, preoperative breast MRI is increasingly used and a survey from the American Society of Breast Surgeons showed that 41% of respondents ask for it in daily practice. In this context, a large-scale observational multicenter international prospective analysis (MIPA study) was proposed under the guidance of the European Network for the Assessment of Imaging in Medicine (EuroAIM). The aims were (1) to prospectively and systematically collect data on consecutive women with a newly diagnosed breast cancer, not candidates for neoadjuvant therapy, who are offered or not offered breast MRI before surgery according to local practice; (2) to compare these two groups in terms of surgical and clinical endpoints, adjusting for covariates. The underlying hypotheses are that MRI does not cause additional mastectomies compared to conventional imaging, while reducing the reoperation rate in all or in subgroups of patients. Ninety-six centers applied to a web-based call; 36 were initially selected based on volume and quality standards; 27 were active for enrollment. On November 2018, the target of 7000 enrolled patients was reached. The MIPA study is presently at the analytic phase. Key Points • Breast MRI has a high diagnostic performance but its utility in the preoperative setting is controversial. • A large-scale observational multicenter prospective study was launched to compare women receiving with those not receiving preoperative MRI. • Twenty-seven centers enrolled more than 7000 patients. The study is presently at the analytic phase.

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Managing COVID-19 illness: chest radiographs support defining both prognosis and follow up (2021)

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Type of publication:Conference abstract

Author(s):*Etel E.; *Chapman T.; *Moudgil H.; *Srinivasan K.; *Makan A.; *Crawford E.; *Ahmad N.;

Citation:European Respiratory Journal 2021; 58: Suppl. 65, PA459

Abstract:Introduction: Chest radiology is pivotal managing acute COVID-19 illness but potentially equally important to follow up. Objectives of this study were to (1) quantify those with COVID requiring follow up, (2) investigate how findings relate to severity, and (3) report abnormal radiology at follow up estimating continued demands.
Methods: Retrospective analysis of 217 patients, mean age 71.8 (SD 8.7, range 29-87) years, admitted March to May 2020 and subsequently tracked. Patients requiring >40% FiO2, and/or respiratory device support had severe disease and CXRs were normal or abnormal to COVID changes. Data analysed using statistical software reporting comparisons by chi square (X2).
Results: Initial CXRs for 123/213 (58%) patients were abnormal; 59/153 (39%) surviving admission attended follow up; others defaulted or were not requested with normal CXR or expected poor prognosis. 39 (66%) CXRs improved, 20 (34%) remained abnormal; of these, 9 patients had chest CT scans. Severe disease contributed to higher mortality, respectively 37/58 (64%) versus 46/159 (29%), X2 (df 1, n=217) 21.87, p=.0001. Comparing abnormal with normal CXR, 47/122 (39%) versus 11/91 (12%) had severe disease, X2 (df 1, n=213) 18.38, p=.000018. 55/123 (45%) versus 28/90 (31%) of those with initial abnormal CXR have since died, X2 (df 1, n=213) 4.04, p=.0044.
Conclusions: Mortality is associated with both the severity of illness and initial COVID related abnormal CXR; 58% have such changes at presentation and among the survivors having follow up radiology improves in two-thirds with approximately half the others then investigated by chest CT giving some indication to planning future services.

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CORONA (COre ultRasOund of covid in iNtensive care and Acute medicine) study: National service evaluation of lung and heart ultrasound in intensive care patients with suspected or proven COVID-19 (2022)

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Type of publication:Journal article

Author(s):Parulekar P.; Powys-Lybbe J.; Aron J.; Knight T.; Lasserson D.; Smallwood N.; Rudge G.; *Miller A.; Peck M.

Citation:Journal of the Intensive Care Society; 2022 [epub ahead of print]

Abstract:Background: Combined Lung Ultrasound (LUS) and Focused UltraSound for Intensive Care heart (FUSIC Heart – formerly Focused Intensive Care Echocardiography, FICE) can aid diagnosis, risk stratification and management in COVID-19. However, data on its application and results are limited to small studies in varying countries and hospitals. This United Kingdom (UK) national service evaluation study assessed how combined LUS and FUSIC Heart were used in COVID-19 Intensive Care Unit (ICU) patients during the first wave of the pandemic. Method(s): Twelve trusts across the UK registered for this prospective study. LUS and FUSIC Heart data were obtained, using a standardised data set including scoring of abnormalities, between 1st February 2020 to 30th July 2020. The scans were performed by intensivists with FUSIC Lung and Heart competency as a minimum standard. Data was anonymised locally prior to transfer to a central database. Result(s): 372 studies were performed on 265 patients. There was a small but significant relationship between LUS score >8 and 30-day mortality (OR 1.8). Progression of score was associated with an increase in 30-day mortality (OR 1.2). 30-day mortality was increased in patients with right ventricular (RV) dysfunction (49.4% vs 29.2%). Severity of LUS score correlated with RV dysfunction (p < 0.05). Change in management occurred in 65% of patients following a combined scan. Conclusion(s): In COVID-19 patients, there is an association between lung ultrasound score severity, RV dysfunction and mortality identifiable by combined LUS and FUSIC Heart. The use of 12-point LUS scanning resulted in similar risk score to 6-point imaging in the majority of cases. Our findings suggest that serial combined LUS and FUSIC Heart on COVID-19 ICU patients may aid in clinical decision making and prognostication.

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Interactive teaching environment for diagnostic radiography with real-time X-ray simulation and patient positioning (2022)

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Type of publication:Journal article

Author(s):Sujar, Aaron; *Kelly, Graham; García, Marcos; Vidal, Franck P

Citation:International Journal of Computer Assisted Radiology and Surgery; January 2022, 17(1), pages 85-95

Abstract:PURPOSE Traditional undergraduate radiographer training mixes academic lectures and clinical practice. Our goal is to bridge the current disconnection between theory and practice in a safe environment, avoiding the risk of radiation for both practitioners and patients. To this end, this research proposes a new software to teach diagnostic radiography using real-time interactive X-ray simulation and patient positioning. METHODS The proposed medical simulator is composed of three main modules. A fast and accurate character animation technique is in charge of simulating the patient positioning phase and adapts their internal anatomy accordingly. gVirtualXRay is an open-source X-ray simulation library and generates the corresponding radiographs in real time. Finally, the courseware allows going through all the diagnostic radiology steps from the patient positioning and the machine configuration to the final image enhancing. RESULTS A face and content validation study has been conducted; 18 radiology professionals were recruited to evaluate our software using a questionnaire. The results show that our tool is realistic in many ways (72% of the participants agreed that the simulations are visually realistic), useful (67%) and suitable (78%) for teaching X-ray radiography. CONCLUSIONS The proposed tool allows simulating the most relevant steps of the projectional radiography procedure. The virtual patient posing system and X-ray simulation module execute at interactive rates. These features enable the lectures to show their students the results of good and bad practices in a classroom environment, avoiding radiation risk.

Digital mammographic interpretation by UK radiographer mammographers: A JAFROC analysis of observer performance (2021)

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Type of publication:
Journal article

Author(s):
*Williams S.; *Aksoy U.; *Cielecki L.; Reed W.; Woznitza N.

Citation:
Radiography; Aug 2021; vol. 27 (no. 3); p. 915-919

Abstract:
Introduction: Radiologists utilise mammography test sets to bench mark their performance against recognised standards. Using a validated test set, this study compares the performance of radiographer readers against previous test results for radiologists. Method(s): Under similar test conditions radiographer readers were given an established test set of 60 mammograms and tasked to identify breast cancer, they were measured against their ability to identify, locate and give a confidence level for cancer being present on a standard set of mammographic images. The results were then compared to previously published results for radiologists for similar or the same test sets. Result(s): The 10 radiographer readers demonstrated similar results to radiologists and for lesion sensitivity were the highest scoring group. The study group score a sensitivity of 83; a specificity of 69.3 and lesion sensitivity of 74.8 with ROC and JAFROC scores of 0.86 and 0.74 respectively. Conclusion(s): Under test conditions radiographers are able to identify and accurately locate breast cancer in a range of complex mammographic backgrounds. Implications for practice: The study was performed under experimental conditions with results comparable to breast radiologists under similar conditions, translation of these findings into clinical practice will help address access and capacity issues in the timely identification and diagnosis of breast cancer.

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Assessing the adequacy of radiographs for hip fractures (2020)

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Type of publication:
Conference abstract

Author(s):
*Mulrain J.; *Omar N.; *Burston B.

Citation:
British Journal of Surgery; Jun 2020; vol. 107 ; p. 138

Abstract:
Aim: Radiographs for the assessment of femoral neck fractures are frequently inadequate for the visualisation of the proximal femur. A low centred radiograph of both hips offers enough information but is rarely achieved.We sought to determine the proportion of hip fractures where initial radiographs adequately visualised the femur to encompass the proposed surgical management.We also sought to find the proportion of patients who required repeat radiographs and whether this was affected by time of presentation. Method(s): A retrospective review of the radiographs of hip fractures presenting to our institution, over a three-month period was undertaken. The timings, number and adequacy of radiographs was assessed. Result(s): Radiographs of 89 patients were reviewed. Most radiographs were taken between 8am and 5pm. Radiographs of 58 patients were centred on the pelvis rather than the hips. Patients presenting overnight were more likely to have adequate radiographs. Despite a duplicate x-ray rate of 48%, most patients (55%) had inadequate visualisation of the proximal femur. The average excess radiation exposure by duplicate radiographs was 2.31mSv per patient. Conclusion(s): The majority of patients had inadequate visualisation of the fractured proximal femur on their radiographs.Many had excessive radiographs performed. This was not improved by increased staffing levels during daylight hours.

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An investigation into the perceived value of the College of Radiographers voluntary accreditation scheme for advanced and consultant practitioners in breast imaging (2019)

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Type of publication:
Journal article

Author(s):
*Deane L.; Robinson L.; England A.

Citation:
Radiography; Aug 2019; vol. 25 (no. 3); p. 207-213

Abstract:
Introduction: A voluntary accreditation scheme has been introduced, requiring advanced (AdP) and consultant practitioners (CP) to submit several pieces of work to the College of Radiographers (CoR). However, few individuals have opted to become voluntary accredited. This study investigated the reasons behind becoming voluntary accredited, the value that was gained and why there appears to be a lack of support for the scheme.
Method(s): An online electronic survey was conducted using a mixed methods approach. Open questions enabled individual opinions and thoughts to be expressed, Likert scale style questions allowed further understanding of the level of agreement and closed questions identified the support for and against the scheme.
Result(s): A total of 55 respondents participated, including 18 AdPs, 25 CPs, 1 consultant trainee practitioner, 5 practitioners and 6 listed as 'other'. Forty-four participants were non-accredited, citing too much clinical work; no recognition from employers and too much effort for little reward. Motivations for joining the scheme were to improve the profession; help create a new consultant post and protect the non-clinical element of the consultant role.
Conclusion(s): The CoR voluntary accreditation scheme has a small perceived value but overall, the majority of respondents believed the scheme did not warrant the work needed to apply. Concern was raised about the risk of creating a two-tier profession by the scheme's instigation. The results of this study suggest that the CoR's voluntary accreditation scheme would need to address these barriers before more practitioners would apply.