Implementing supplementary breast cancer screening in women with dense breasts: Insights from European radiographers and radiologists.

INTRODUCTION: In response to the critical need for enhancing breast cancer screening for women with dense breasts, this study explored the understanding of challenges and requirements for implementing supplementary breast cancer screening for such women among clinical radiographers and radiologists in Europe. METHOD: Fourteen (14) semi-structured online interviews were conducted with European clinical radiologists (n = 5) and radiographers (n = 9) specializing in breast cancer screening from 8 different countries: Denmark, Finland, Greece, Italy, Malta, the Netherlands, Switzerland, United Kingdom. The interview schedule comprised questions regarding professional background and demographics and 13 key questions divided into six subgroups, namely Supplementary Imaging, Training, Resources and Guidelines, Challenges, Implementing supplementary screening and Women's Perspective. Data analysis followed the six phases of reflexive thematic analysis. RESULTS: Six significant themes emerged from the data analysis: Understanding and experiences of supplementary imaging for women with dense breasts; Challenges and requirements related to training among clinical radiographers and radiologists; Awareness among radiographers and radiologists of guidelines on imaging women with dense breasts; Challenges to implement supplementary screening; Predictors of Implementing Supplementary screening; Views of radiologists and radiographers on women's perception towards supplementary screening. CONCLUSION: The interviews with radiographers and radiologists provided valuable insights into the challenges and potential strategies for implementing supplementary breast cancer screening. These challenges included patient and staff related challenges. Implementing multifaceted solutions such as Artificial Intelligence integration, specialized training and resource investment can address these challenges and promote the successful implementation of supplementary screening. Further research and collaboration are needed to refine and implement these strategies effectively. IMPLICATIONS FOR PRACTICE: This study highlights the urgent need for specialized training programs and dedicated resources to enhance supplementary breast cancer screening for women with dense breasts in Europe. These resources include advanced imaging technologies, such as MRI or ultrasound, and specialized software for image analysis. Moreover, further research is imperative to refine screening protocols and evaluate their efficacy and cost-effectiveness, based on the findings of this study.

Low dose CTPA using a low kV technique combined with high IR: A clinical study.

INTRODUCTION: To investigate optimising a computerised tomography pulmonary angiogram (CTPA) scan protocol in terms of radiation dose and image quality using a low kV technique combined with high iterative reconstruction (IR) parameters (>50%) and apply the optimised protocol in clinical practice on patients irrespective of their body weight. METHODS: CTPA examinations were performed on 64 patients equally divided into control and experimental groups. Patients in the control group were scanned using the current protocol (100 kV with 50% IR) while patients in the experimental group were scanned using an optimised protocol (80 kV with 60%IR). The radiation dose indices volume computerised tomography dose index (CTDIvol), dose length product (DLP), size specific dose estimates (SSDE) and effective dose (ED) were recorded. Subjective image quality was evaluated by 3 radiologists through absolute visual grading analysis (VGA) using an image quality scoring tool. The resultant image quality scores were analysed using Visual Grading Characteristics (VGC). Objective image quality was recorded in terms of contrast-to-noise-ratio (CNR) and signal-to-noise-ratio (SNR). RESULTS: The application of the optimised protocol resulted in a statistically significant (p < 0.05) reduction in mean CTDIvol (-49%), DLP (-48%), SSDE (-52%) and ED (-49%). Objective image quality was significantly (p < 0.05) improved both in CNR (32%) and SNR (13%). Subjective image quality scores were higher for the current protocol but variation between the two protocols was not significant (p = 0.650). CONCLUSIONS: When applying the low kV technique combined with high IR parameters, a significant dose reduction may be achieved while still maintaining diagnostic image quality. IMPLICATIONS FOR PRACTICE: The low kV technique combined with high IR parameters is an effective optimisation technique which can be easily implemented for the CTPA protocol.

Optimisation of the CT pulmonary angiogram (CTPA) protocol using a low kV technique combined with high iterative reconstruction (IR): A phantom study.

INTRODUCTION: This study aims to optimise the current CTPA protocol at a public general hospital in Malta using lower kV combined with high Iterative Reconstruction (IR) (>50%). METHODS: The research consisted of a 2-phase anthropomorphic phantom study. Phase 1: radiation dose evaluation of 6 experimental protocols consisting of the low kV technique and high IR values and comparison with the current protocol. Phase 2: image evaluation. Objective image quality was evaluated in terms of contrast to noise ratio (CNR) and signal to noise ratio (SNR). Subjective image quality evaluation was performed by 3 radiologists undertaking Absolute Visual Grading Analysis (VGA). Resultant image quality scores were analysed using Visual Grading Characteristics (VGC). RESULTS: All experimental protocols achieved significant (p < 0.05) dose reductions. SNR and CNR improved in almost all protocols, however, differences were not significant (p > 0.05). In subjective image quality analysis, the current protocol provided significant superior image quality (AUC > 0.5; p < 0.05) when compared to the experimental protocols consisting of 80 kV with 70%, 80%, 90% and 100% IR. The only two experimental protocols yielding comparable image quality to the current protocol were 80 kV with 50% IR (AUC: 0.195; p: 0.137) and 80 kV with 60% IR (AUC: 0.554; p: 0.624). The protocol yielding the greatest decrease in radiation dose being 80 kV with 60% IR. CONCLUSIONS: The optimal IR value was 60%. When applying the optimal experimental protocol (80 kV combined with 60% IR), a significant dose reduction was achieved while maintaining diagnostic image quality. IMPLICATIONS FOR PRACTICE: The low kV technique combined with high IR parameter is easily implemented and involves no additional cost and equipment.

Detection of incidental adrenal nodules on computed tomography by radiographers.

INTRODUCTION: This research investigated whether radiographers' age, qualifications, shift rotations and years of post-qualification experience as a radiographer affect the detection rate of incidental adrenal nodules, also known as adrenal incidentalomas in Malta. Additionally, local statistics of adrenal incidentaloma findings were evaluated. METHODS: This research consisted of two phases and employed a non-experimental, cross-sectional quantitative approach. Phase 1 comprised of a self-designed data collection sheet to retrospectively determine the occurrence of recalled computed tomography (CT) examinations resulting from an adrenal incidentaloma finding during a six-month period between July 2020 and December 2020. In phase 2, a self-designed questionnaire with anonymised CT scan images (n = 30) displayed on ViewDex (Viewer for Digital Evaluation of X-ray images) was prospectively completed by CT radiographers (n = 23) to identify adrenal incidentalomas on the images. RESULTS: In phase 1, adrenal incidentalomas were present in 1.4% of contrast-enhanced CT (CECT) examinations (n = 12139), out of which, 79.8% were not acknowledged by the radiographers on the initial scans and patients had to be recalled for a dedicated adrenal CT scan. In phase 2, a statistically significant (p < 0.05) relationship was determined between the radiographers' qualifications, shift rotations and years of post-qualification experience as a radiographer, with their detection rate of adrenal incidentalomas. CONCLUSION: Findings suggest that radiographers' qualifications, shift rotations and years of post-qualification experience were found to be statistically significant factors affecting their detection rate of adrenal incidentalomas. These could have contributed to one of the reasons for recalling patients, which in turn results in an added burden to both the patient and the Radiology Department. IMPLICATIONS FOR PRACTICE: Detection of adrenal incidentalomas by radiographers has a direct impact on clinical practice. If identified during the initial CT examination and a further delay scan is performed, this will benefit patients by reducing the risks of additional radiation and potential risks from contrast media administration; prompt diagnosis and treatment. While the Radiology Department benefits in terms of cost effectiveness, work load and appointment scheduling.

Evaluating the use of anti-scatter grids in adult knee radiography.

INTRODUCTION: Anti-scatter grids efficiently reduce scatter radiation from reaching the imaging receptor, enhancing image quality; however, the patient radiation dose increases in the process. There is disagreement regarding the thickness thresholds for which anti-scatter grids are beneficial. This study aims to establish a thickness threshold for the use of anti-scatter grids to optimise adult knee radiography. METHODS: The study consisted of two phases. In Phase 1 phantom knee radiographs were acquired at varying thicknesses (10-16 cm) and tube voltages (60-80 kV). For each thickness and tube voltage, images with and without an anti-scatter grid were obtained. In Phase 2, two radiologists and three radiographers, evaluated the image quality of these images. Visual Grading Analysis (VGA) scores were analysed using Visual Grading Characteristics (VGC) based on the visualisation of five anatomic criteria. RESULTS: The average DAP decreased by 72.1% and mAs by 73.1% when removing the anti-scatter grid. The VGC revealed that overall images taken with an anti-scatter grid have better image quality (AUC ≥0.5 for all comparisons). However, the anti-scatter grids could be removed for thicknesses 10, 12 and 14 cm in conjunction with using 80 kVp,. CONCLUSION: Anti-scatter grids can be removed when imaging adult knees between 10 and 12 cm using any kVp setting since the radiation dose is reduced without significantly affecting image quality. For thicknesses >12 cm, the use of anti-scatter grids significantly improves image quality; however, the radiation dose to the patient is increased. The exception is at 14 cm used with 80 kVp, where changes in image quality were insignificant. IMPLICATIONS FOR PRACTICE: Optimisation by removing anti-scatter grids in adult knee radiography seems beneficial below 12 cm thickness with any kVp value. Since the average knee thickness ranges between 10 and 13 cm, anti-scatter grid can be removed for most patients. Nevertheless, further studies are recommended to test if this phantom-based threshold applies to human subjects.

Evaluating the use of higher kVp and copper filtration as a dose optimisation tool in digital planar radiography.

INTRODUCTION: To identify the potential of beam hardening techniques, specifically the use of higher kilo voltage (kV) and copper (Cu) filtration, to optimise digital planar radiographic projections. The study assessed the suitability of such techniques in radiation dose reductions while maintaining diagnostic image quality for four common radiographic projections: antero-posterior (AP) abdomen, AP-knee, AP-lumbar spine, and lateral lumbar spine. METHODS: Anthropomorphic phantom radiographs were obtained at varying kVp (standard kVp, +10 kVp, and +20 kVp) and varying Cu filtration thickness (0 mm, 0.1 mm, and 0.2 mm Cu). The Dose Area Product (DAP), mAs and time (s) were recorded as an indication of the emitted radiation dose. Image quality was assessed objectively via Contrast-Noise-Ratio (CNR) calculations and subjectively via Visual Grading Analysis (VGA) performed by radiographers and radiologists. RESULTS: Optimised exposure protocols were established for the AP-abdomen (100 kVp with 0.2 mm Cu), AP-knee (85 kVp, and 0.1 mm Cu), AP-lumbar spine (110 kVp and 0.2 mm Cu), and lateral lumbar spine (110 kVp and 0.2 mm Cu). This strategy resulted in respective DAP reductions of 71.98%, 62.50%, 64.51% and 71.85%. While CNR values decreased as beam hardening techniques were applied, VGA demonstrated either a lack of statistical variation or improved image quality between the standard and the optimised exposure protocols. CONCLUSIONS: DAP reductions without compromising image quality can be achieved through beam hardening for the AP-abdomen, AP-knee, AP-lumbar spine, and lateral lumbar spine projections. IMPLICATIONS FOR PRACTICE: Beam hardening techniques should be considered as an optimisation strategy in medical imaging departments. Research into the applicability of this strategy for other radiographic projections is recommended.

Optimisation of the AP abdomen projection for larger patient body thicknesses.

INTRODUCTION: This study aims to identify optimal exposure parameters, delivering the lowest radiation dose while maintaining images of diagnostic quality for the antero-posterior (AP) abdomen x-ray projection in large patients with an AP abdominal diameter of >22.3 cm. METHODOLOGY: The study was composed of two phases. In phase 1, an anthropomorphic phantom (20 cm AP abdominal diameter) was repetitively radiographed while adding 3 layers (5 cm thick each) of fat onto the phantom reaching a maximum AP abdominal diameter of 35 cm. For every 5 cm thickness, images were taken at 10 kVp (kilovoltage peak) intervals, starting from 80 kVp as the standard protocol currently in use at the local medical imaging department, to 120 kVp in combination with the use of automatic exposure control (AEC). The dose area product (DAP), milliampere-second (mAs) delivered by the AEC, and measurements to calculate the signal to noise ratio (SNR) and contrast to noise ratio (CNR) were recorded. Phase 2 included image quality evaluation of the resultant images by radiographers and radiologists through absolute visual grading analysis (VGA). The resultant VGA scores were analysed using visual grading characteristics (VGC) curves. RESULTS: The optimal kVp setting for AP abdominal diameters at: 20 cm, 25 cm and 30 cm was found to be 110 kVp increased from 80 kVp as the standard protocol (with a 56.5% decrease in DAP and 76.2% in mAs, a 54.2% decrease in DAP and 76.2% decrease in mAs and a 29.2% decrease in DAP and 59.7% decrease in mAs, respectively). The optimal kVp setting for AP abdominal diameter at 35 cm was found to be 120 kVp increased from 80 kvp as the standard protocol (with a 50.7% decrease in DAP and 73.4% decrease in mAs). All this was achieved while maintaining images of diagnostic quality. CONCLUSION: Tailoring the exposure parameters for large patients in radiography of the abdomen results in a significant reductions in DAP which correlates to lower patient doses while still maintaining diagnostic image quality. IMPLICATIONS FOR CLINICAL PRACTICE: This research study and resultant parameters may help guide clinical departments to optimise AP abdomen radiographic exposures for large patients in the clinical setting.

Computed tomography diagnostic reference levels for adult brain, chest and abdominal examinations: A systematic review.

OBJECTIVES: Radiation dose variation within and among Computed Tomography (CT) centres is commonly reported. This work systematically reviewed published articles on adult Diagnostic Reference Levels (DRLs) for the brain, chest and abdomen to determine the causes and extent of variation. A systematic literature search and review was performed in selected databases containing leading journals in radiography, radiology and medical physics using carefully defined search terms related to CT and DRLs. The quality of the included articles was determined using the Effective Public Health Practise Project tool for quantitative studies. KEY FINDINGS: The 54 articles reviewed include: 45 studies using human data, 8 studies using phantom data, and one study with both human and phantom data. The main comparator in between studies was the dose indices used in reporting DRLs. DRL variations of up to a factor of 2 for the same procedure were noted in phantom studies, and up to a factor of 3 in human studies. Sources of variation include the type of scanner, the age of the scanner, differences in protocols, variations in patients, as well as variations in study design. Different combinations of dose indices were reported: volume computed tomography dose index (CTDIvol) and dose length product (DLP) (59%); DLP only (11%); weighted computed tomography dose index (CTDIw) and DLP (9%); CTDIvol only (7%); CTDIvol, DLP and effective dose (ED) (6%); CTDIw only (4%); CTDIvol, DLP and size specific dose estimate (SSDE) (1%) and CTDIw, CTDIvol and DLP (1%). The use of different dose indices limited dose comparison between studies. CONCLUSION: The study noted a 2-3 fold variation in DRLs between studies for the same procedure. The causes of variation are reported and include study design, scanner technology and the use of different dose indices. IMPLICATIONS FOR PRACTICE: There is a need for standardisation of CT DRLs in line with the International Commission on Radiological Protection recommendations to reduce dose variation and facilitate dose comparison.

Optimisation of the lateral lumbar spine projection using an air-gap technique.

INTRODUCTION: Lumbar spine radiography is considered as having a high radiation dose compared to other planar radiography examinations. The aim of this study was to investigate the feasibility of replacing an antiscatter grid with an air gap technique to achieve dose reduction for lateral lumbar spine radiography while maintaining image quality on a direct digital radiography (DDR) system. METHODS: In phase 1, an experimental study using an anthropomorphic phantom identified the optimal airgap technique. In phase 2, lateral projections of the lumbar spine were performed on 50 patients randomly assigned equally into a control group (using the antiscatter grid) and an experimental group (using the airgap technique). The dose area product (DAP) was recorded, keeping other variables constant. Image quality evaluation was performed by 5 radiologists performing Absolute Visual Grading Analysis (VGA) using an image quality score tool, with resultant scores analysed using Visual Grading Characteristics (VGC). RESULTS: A 10 cm airgap in conjunction with a source to image distance (SID) of 121 cm was found as the optimal airgap technique. The clinical application of this technique resulted in a statistically significant (p < 0.05) reduction in DAP of 72%. Image quality scores were higher for the antiscatter grid but variation between the two techniques was not significant (p > 0.05). CONCLUSION: Replacing the antiscatter grid with an airgap technique in lateral lumbar spine digital radiography, provides a significant dose reduction whilst still maintaining diagnostic image quality. IMPLICATIONS FOR PRACTICE: The airgap technique is a simple and easy technique to implement and radiographers should find no difficulties in applying it, as It involves no additional cost and no additional equipment.

Establishment of image quality for MRI of the knee joint using a list of anatomical criteria.

INTRODUCTION: The Commission of the European Communities published image quality criteria for imaging modalities. However, none were established for magnetic resonance imaging (MRI). Such criteria are warranted due to the complexity and health and safety risks associated with MRI. The purpose of this study was to establish image quality criteria for MRI examinations of the knee, providing harmonisation of image quality, improving practice and reducing risks. METHODS: Image quality criteria were established following a literature review and validation by experts. The evaluation of the quality of randomly selected MR images (n = 10) with normal findings was performed by Maltese radiographers working at a local MRI institution. The visualisation of the developed anatomical criteria was performed by rating the visibility of each criterion using visual grading analysis. RESULTS: Results of the Friedman and Binomial tests on image quality rating scores, highlighted those anatomical criteria for each scan plane which scored significantly lower (p ≤ 0.05) than the threshold score of 3. This score was identified as the score below which anatomical structures would not be sufficiently visualised to enable adequate diagnosis. CONCLUSION: A set of image quality anatomical criteria have been successfully developed to provide image quality standards enabling the visualisation of the complex anatomical structures of the knee joint. This concept can be applied to other MRI examinations.

Comparison of in vivo vs. frozen vs. Thiel cadaver specimens in visualisation of anatomical structures of the ankle on proton density Magnetic Resonance Imaging (MRI) through a visual grading analysis (VGA) study.

PURPOSE: The use of cadavers for medical education purposes and for radiology research methodologies which involve subjective image quality evaluation of anatomical criteria is well documented. The aim of this study was to quantify the impact of cadaver tissue preservation in producing MR images that are representative of living tissue by comparing the visualisation of anatomical structures of the ankle obtained from live and cadaver (fresh frozen and Thiel embalmed) specimens through a visual grading analysis (VGA) study. METHODS: A VGA study was conducted on an image data set consisting of 4 coronal proton density weighted (PDw) sequences obtained from ankles of a live patient and those of a cadaveric specimen, of which the right ankle was frozen and the left Thiel embalmed. RESULTS: Comparison of the image quality scores obtained from: the live patient vs. the Thiel specimen indicate a significant difference (p ≤ 0.05) between the scores in favour of the Thiel specimen; between the live patient vs. the frozen specimen indicate a significant difference (p ≤ 0.05) in favour of the frozen specimen and between the frozen vs. the Thiel specimen indicate a significant difference (p ≤ 0.05) in favour of the Thiel specimen. CONCLUSIONS: The advantages of the use of cadavers (frozen or Thiel embalmed) has been shown to also apply for use with proton density (PD) MR imaging. The preservation of cadavers especially using Thiel is a suitable alternative for MRI optimisation and protocol development purposes.

A retrospective audit of the first screening round of the Maltese breast screening programme.

PURPOSE: To analyse whether the screening performance parameters of the Maltese National Breast Screening Programme first screening round met requirements set by European standards. The association between screening age and results of screening performance parameters was also investigated. METHOD: Quantitative methodology was used to review examinations of women who were recalled for a technical recall or further assessment rates. All accessible members of the population recalled during the first round were retrospectively reviewed resulting in a sample of 2300 recalled examinations. RESULTS: Malta's first screening round met the European Guidelines recommendations for technical repeat rate (0.26%), early recall rate (0.45%), breast cancer detection rate (13.77 per 1000 women) and Positive Predictive Value of screening test (7.58%). However, local recall rate (18.53%) and further assessment rate (18.27%) were higher than recommended. The Chi square test showed a statistically significant difference (p ≤ 0.05) in recall rates between the compared age groups, as younger women (51-55 years) were more likely to have a negative diagnosis after the initial mammogram whereas older women (56-60 years) were more likely to be recalled. There was no age discrepancy (p ≥ 0.05) in local breast cancer detection rate and positive predictive value of screening test. CONCLUSION: Although the Maltese first screening round performed well, this study found deficiencies in recall and further assessment rates, which according to literature may result in psychological morbidity and inefficient use of screening resources. This study also concluded that when a cohort is analysed, age is not as significant as the screening round itself (first/subsequent).

Use of provisional prostheses with osseointegration.

The ingenuity that has characterized the fabrication of provisional prostheses has been readily adapted to the osseointegration technique. Implant abutments do not need protection during final prosthesis fabrication stages as teeth do. However, compelling arguments can be made in favor of esthetic, comfortable, and functional provisional prostheses supported by implants, even if they are worn for only a few weeks. The prosthodontic contribution to a patient's quality of life throughout all stages of treatment is thereby enhanced.

Osseointegrated implants for partially edentulous patients. Interim considerations.

Osseointegration is a clinical application of a biologically investigated host bone response to the placement of threaded unalloyed titanium implants using a meticulous surgical procedure. Its documented successful use as an analogue for the periodontal ligament in endentulous patients has already profoundly altered the predicament of being edentulous. Its application as a treatment modality for partial edentulism offers exciting challenges for the dentist. This article reviewed preliminary experiences from the University of Toronto's Clinical Osseointegration Unit in this area. Although it is tempting to extrapolate the successful longitudinal clinical applications with edentulous patients to partially edentulous ones, discretion and prudence demand that dentists remember that osseointegration for routine treatment of partially edentulous patients is still in its infancy. Until the results from long-term clinical trials in different centres are published, the dental profession cannot yet subsume the versatility and routine application of this exciting technique.