Impact of a digital training platform and tailored education on the chest image interpretation performance of healthcare professionals.

INTRODUCTION: With the use of expert consensus a digital training tool was developed which proved useful when teaching radiographers how to interpret chest images. The training tool included A) a search strategy and B) an educational video programme to communicate the search strategies using eye tracking technology. METHODS: A multi-reader multi-case study was undertaken to assess the effectiveness of a training tool and study day. The interventions were designed to cover a range of potential pathological presentations. Participants, physiotherapists and nurse practitioners working at a cardiothoracic Intensive Care Unit (ICU), were asked to interpret 20 chest images at the beginning of the study and following access to each intervention. Participants received access to the training tool at different times for a period of 4-6 weeks. A study day was then be provided to all participants and interpretations of a different dataset were completed by all. Each participant was asked to complete a questionnaire to gain perceptions of the training provided. RESULTS: Twenty-eight participants interpreted a total of 1680 chest radiographs. Improvements in specificity were noted across the participants. Sensitivity fell in both groups following both training interventions. CONCLUSION: Face to face learning and digital components are potentially useful in professional development and revision in chest x-ray interpretation for non-medical healthcare professionals working in an ICU setting. IMPLICATIONS FOR PRACTICE: The training tool and study day may be useful as image interpretation revision aids or to accompany formal methods of education.

Variation in radiographic protocols in paediatric interventional cardiology.

The aim of this work is to determine current radiographic protocols in paediatric interventional cardiology (IC) in the UK and Ireland. To do this we investigated which imaging parameters/protocols are commonly used in IC in different hospitals, to identify if a standard technique is used and illustrate any variation in practice. A questionnaire was sent to all hospitals in the UK and Ireland which perform paediatric IC to obtain information on techniques used in each clinical department and on the range of clinical examinations performed. Ethical and research governance approval was sought from the Office for Research Ethics Committees Northern Ireland and the individual trusts. A response rate of 79% was achieved, and a wide variation in technique was found between hospitals. The main differences in technique involved variations in the use of an anti-scatter grid and the use of additional filtration to the radiation beam, frame rates for digital acquisition and pre-programmed projections/paediatric specific programming in the equipment. We conclude that there is no standard protocol for carrying out paediatric IC in the UK or Ireland. Each hospital carries out the IC procedure according to its own local protocols resulting in a wide variation in radiation dose.

An analysis of radiation dose reduction in paediatric interventional cardiology by altering frame rate and use of the anti-scatter grid.

The purpose of this work is to investigate removal of the anti-scatter grid and alteration of the frame rate in paediatric interventional cardiology (IC) and assess the impact on radiation dose and image quality. Phantom based experimental studies were performed in a dedicated cardiac catheterisation suite to investigate variations in radiation dose and image quality, with various changes in imaging parameters. Phantom based experimental studies employing these variations in technique identified that radiation dose reductions of 28%-49% can be made to the patient with minimal loss of image quality in smaller sized patients. At present, there is no standard technique for carrying out paediatric IC in the UK or Ireland, resulting in the potential for a wide variation in radiation dose. Dose reductions to patients can be achieved with slight alterations to the imaging equipment with minimal compromise to the image quality. These simple modifications can be easily implemented in clinical practice in IC centres.

The effect of a digital training tool to aid chest image interpretation: Hybridising eye tracking technology and a decision support tool.

INTRODUCTION: Eye tracking technology, checklists and search strategies have been demonstrated as useful aids in image interpretation. A training tool was developed, by the research team, which included these features. This study aimed to evaluate the effect of the training tool on participant image interpretation performance. METHODS: The study was carried out with reporting radiographers who had either commenced training in chest image interpretation (n = 12) or were trained in musculoskeletal image interpretation (n = 23) (total n = 35). Participants were allocated to a control or intervention group. Participants completed an initial assessment at recruitment and re-attended nine months later for a follow-up assessment. The intervention group were given unlimited access to a digital training tool. During assessments participants interpreted 20 chest images whilst using eye tracking technology (total of 1400 images were interpreted). A confidence level was obtained from participants on their diagnosis and a questionnaire, to obtain demographic data, was completed following the assessment. RESULTS: Improvements were seen in the confidence of intervention group participants (p < 0.05). False Positive (FP) scores decreased for both the control and intervention group (p < 0.05), this decrease was from 4.20 to 3.20 for the control group and from 5.87 to 3.27 for the intervention group. True Negative (TN) scores increased, from 5.13 to 6.73 for the intervention group (p < 0.05). Mean decision time decreased for both the control and intervention group. CONCLUSION: The tool led to positive effects on participant performance and could be a useful aid in chest image interpretation learning. IMPLICATIONS FOR PRACTICE: Improvements in performance were observed with a digital tool. The tool could improve image interpretation methods and training.

Implementing a holistic approach to a radiographer-led Hysterosalpingogram (HSG) service: A review of impact and patient perception.

INTRODUCTION: Radiographer role development has touched boundaries across the multidisciplinary team and more recently branched into the field of gynaecology. Radiographers are now able to perform tasks that were traditionally performed by radiologists and gynaecologists to implement a radiographer-led Hysterosalpingogram (HSG) service. The aims of the study were to (i) implement a radiographer-led HSG service with a view to decreasing waiting times. (ii) To determine ladies perceptions and satisfaction levels. METHOD: Local clinical guidelines were developed with the radiologist/gynaecologist and trainee HSG radiographers. A robust system of work was initiated which required maintaining comprehensive log books to record examinations performed and reports written. These were audited and compared with those of the radiologist. Audit cycles were monitored through Q Pulse to ensure good practise was maintained. Patient satisfaction surveys were developed and distributed to 100 consecutive ladies attending for HSG over a 6 month period from January-July 2017. RESULTS: The radiographer-led service has increased the number of appointment slots offered for HSG's throughout the year as the service now runs every week. HSG's were performed by 5 staff members but now only require 3 staff. A 75% response rate was achieved from the questionnaire survey and shows high patient satisfaction levels. Ladies reported being better informed about their examination resulting in decreased anxiety, concerns and discomfort. CONCLUSION: The implementation of this service has successfully reduced waiting lists for HSG examinations from 14 to 0 weeks. The Trust has saved £15,000 on staff salaries per annum since the service started.

Digital training platform for interpreting radiographic images of the chest.

INTRODUCTION: Time delays and errors exist which lead to delays in patient care and misdiagnosis. Reporting clinicians follow guidance to form their own search strategy. However, little research has tested these training guides. With the use of eye tracking technology and expert input we developed a digital training platform to be used in chest image interpretation learning. METHODS: Two sections of a digital training platform were planned and developed; A) a search strategy training tool to assist reporters during their interpretation of images, and B) an educational tool to communicate the search strategies of expert viewers to trainees by using eye tracking technology. RESULTS: A digital training platform for use in chest image interpretation was created based on evidence within the literature, expert input and two search strategies previously used in clinical practice. Images and diagrams, aiding translation of the platform content, were incorporated where possible. The platform is structured to allow the chest image interpretation process to be clear, concise and methodical. CONCLUSION: A search strategy was incorporated within the tool to investigate its use, with the possibility that it could be recommended as an evidence based approach for use by reporting clinicians. Eye tracking, a checklist and voice recordings have been combined to form a multi-dimensional learning tool, which has never been used in chest image interpretation learning before. The training platform for use in chest image interpretation learning has been designed, created and digitised. Future work will establish the efficacy of the developed approaches.

Radiation dose in paediatric cardiac catheterisation: A systematic literature review.

OBJECTIVES: It is believed that children are more sensitive to ionising radiation than adults. This work reviewed the reported radiation dose estimates for paediatric cardiac catheterisation. A systematic literature review was performed by searching healthcare databases for studies reporting radiation dose using predetermined key words relating to children having cardiac catheterisation. The quality of publications was assessed using relevant Critical Appraisal Skills Programme questions and their reported radiation exposures were evaluated. KEY FINDINGS: It is only in recent years that larger cohort observations have been undertaken. Although radiation dose from paediatric cardiac catheterisation has decreased in recent years, the literature indicated that it remains varied and potentially substantial. CONCLUSION: Standardisation of weight categories and procedure types such as those recommended by the PiDRL project could help compare current and future radiation dose estimates.

Morphology of the inferior colliculus in C57BL/6J and CBA/J mice across the life span.

Basic anatomical features were evaluated in the inferior colliculus (IC) of C57BL/6J and CBA/J mice across the adult life span (1.5 to 30 months of age). C57BL/6J mice exhibit progressive age-related cochlear pathology and become severely hearing-impaired during the second year of life; CBA/J mice exhibit little hearing loss as they age. Age had little effect on the size of the IC, the size of IC neurons, or the packing density of IC neurons and there was no evidence of age-related neuron loss. However, old CBA/J mice developed numerous spongiform lesions throughout the brainstem. The absence of morphological changes in the IC of hearing-impaired C57BL/6J mice supports the hypothesis that features such as the size of neurons, survival of neurons, and volume of the neuropil are not affected by chronic sensorineural pathology in central auditory nuclei (e.g., as the IC) that do not receive direct input from primary afferent fibers. The data from both strains taken together indicate that certain basic anatomical properties of the mouse IC persist in the face of aging.

Age-related cochlear hair cell loss is enhanced in mice lacking copper/zinc superoxide dismutase.

Age-related hearing loss in humans and many strains of mice is associated with a base-to-apex gradient of cochlear hair cell loss. To determine if copper/zinc superoxide dismutase (Cu/Zn SOD) deficiency influences age-related cochlear pathology, we compared hair cell losses in cochleas obtained from 2-, 7-, and 17- to 19-month-old wild type (WT) mice with normal levels of Cu/Zn SOD and mutant knockout (KO) mice with a targeted deletion of Sod1, the gene that codes for Cu/Zn SOD. WT and KO mice exhibited similar patterns of hair cell loss with age, i.e., a baso-apical progression of hair cell loss, with greater loss of outer hair cells than inner hair cells. Within each age group, the magnitude of loss was much greater in KO mice compared to WT mice. The results indicate that Cu/Zn SOD deficiency potentiates cochlear hair cell degeneration, presumably through metabolic pathways involving the superoxide radical.

Plasticity of auditory cortex associated with sensorineural hearing loss in adult C57BL/6J mice.

The representation of frequency was mapped in the primary auditory cortex (AI) of C57BL/6J (C57) mice during young adulthood (1.5-2 months) when hearing is optimal, and at 3, 6, and 12 months of age, a period during which progressive, high frequency, sensorineural hearing loss occurs in this strain. Maps were also obtained from CBA/CaJ mice which retain good hearing as they age. In AI of young adult C57 mice and CBA mice, characteristic frequencies (CFs) of multiple-unit clusters were easily identified with extracellular recordings, and a general tonotopic organization was observed from dorsal (high frequency) to ventral and caudal (low frequency). In individual cases there appeared to be deviations from the above tonotopic organization, despite the fact that inbred mice are genetically invariant. As progressive loss of high frequency sensitivity ensued peripherally, a substantially increased representation of middle frequencies was observed in AI. There was no apparent change in the surface area of the auditory cortex despite the elimination of high frequencies, and virtually the entire auditory cortex became devoted to the middle frequencies (especially 10-13 kHz) for which sensitivity remained high. Similar age-related changes were not observed in normal-hearing CBA mice. These findings indicate that plasticity in the representation of frequency in AI is associated with high frequency hearing loss in C57 mice.

Morphology of the dorsal cochlear nucleus in C57BL/6J and CBA/J mice across the life span.

The morphology of the dorsal cochlear nucleus (DCN) was evaluated across the life span in inbred C57BL/6J (C57) and CBA/J (CBA) mice using 5 age groups (young adult to very old). C57 mice exhibit progressive cochlear sensorineural pathology and hearing loss during middle age; CBA mice have only modest sensorineural pathology late in life. DCN layers I, II, and III were evaluated histologically with serial sections stained for Nissl and fibers. DCN volume decreased with age in C57 mice, but the change began earliest and was most pronounced in layer III. In CBA mice, volume increased during the first year of life and decreased only in the oldest mice. All major DCN cell types were found in both strains at all ages. There was an age-related decrease in the mean size of neurons in C57 mice that was first observed in layer III. In CBA mice, only a nonsignificant trend toward smaller neurons was observed in the oldest mice. An age-related decline in the number of neurons in layer III (but not in layers I and II) occurred in C57 mice. Aged CBA mice exhibited no significant loss of DCN neurons. Thus, age-related changes in the DCN were much more pronounced in C57 mice than in CBA mice, and the changes in C57 mice were most pronounced in layer III. Because layer III receives most of the DCN's primary auditory input, it would be directly affected by age-related hearing loss and degeneration of spiral ganglion cells in C57 mice. This suggests that the age-related changes observed in DCN layer III of C57 mice are affected by progressive peripheral degenerative changes; when peripheral loss is minimal (CBA mice), less substantial age-related changes are observed.

Auditory nerve fiber responses following chronic cochlear de-efferentation.

The aim of the present study was to examine the role of the olivocochlear system in auditory processing by examining the long-term effects of cochlear de-efferentation on auditory nerve response properties in adult chinchillas. Spontaneous rates, response thresholds, tuning curves, discharge rate-level functions, and adaptation of single auditory nerve fibers were measured in chinchillas with complete cochlear de-efferentation produced by sectioning the olivocochlear bundle in the internal auditory meatus. De-efferentation was verified as successful on the basis of acetylcholinesterase staining of surface preparations of the organ of Corti. Following chronic de-efferentation, there was a striking decrease in spontaneous rate, consistent with earlier observations in cats. In addition, the present study shows that complete de-efferentation results in: (1) increased driven discharge rates and decreased dynamic range of discharge rate-level functions, (2) larger onset-to-steady state ratio of discharge rate at moderate intensities, and (3) a hypersensitive tail of the tuning curve. These effects, largely confined to neurons that were most sensitive to frequencies between 2-8 kHz, indicate that the cochlear efferent system is important in maintaining normal function (e.g., frequency and intensity selectivity) of the auditory periphery by modulating auditory nerve fiber response properties.

Cu/Zn SOD deficiency potentiates hearing loss and cochlear pathology in aged 129,CD-1 mice.

Copper/zinc superoxide dismutase (Cu/Zn SOD) is a first-line defense against free radical damage in the cochlea and other tissues. To determine whether deficiencies in Cu/Zn SOD increase age-related hearing loss and cochlear pathology, we collected auditory brainstem responses (ABRs) and determined cochlear hair cell loss in 13-month-old 129/CD-1 mice with (a) no measurable Cu/Zn SOD activity (homozygous knockout mice), (b) 50% reduction of Cu/Zn SOD (heterozygous knockout mice), and (c) normal levels of Cu/Zn SOD (wild-type mice). ABRs were obtained by using 4-, 8-, 16-, and 32-kHz tone bursts. Cochleas were harvested immediately after testing, and separate counts were made of inner and outer hair cells. Compared with wild-type mice, homozygous and heterozygous knockout mice exhibited significant threshold elevations and greater hair cell loss. Phenotypic variability was higher among heterozygous knockout mice than among wild-type or homozygous knockout mice. Separate groups of wild-type and homozygous knockout mice were examined for loss of spiral ganglion cells and eighth nerve fibers. At 13 months of age, both wild-type and knockout mice had significantly fewer nerve fibers than did 2-month-old wild-type mice, with significantly greater loss in aged knockout mice than in aged wild-type mice. Thirteen-month-old knockout mice also had a significant loss of spiral ganglion cells compared with 2-month-old wild-type mice. The results indicate that Cu/Zn SOD deficiencies increase the vulnerability of the cochlea to damage associated with normal aging, presumably through metabolic pathways involving the superoxide radical.

Faster recovery in central than in peripheral auditory system following a reversible cochlear deafferentation.

Included among the exciting findings in auditory neuroscience are (i) central plasticity after peripheral injury and (ii) regeneration of auditory nerve fibres following excitotoxic damage. The present study extends our understanding of auditory system plasticity by examining changes in peripheral and central physiology as the cochlea recovers from temporary deafferentation due to excitotoxicity. Application of kainic acid (60 mM) to the round window membrane substantially depressed responses from both auditory nerve and brain stem (inferior colliculus), without affecting distortion-product otoacoustic emissions from the inner ear. The auditory nerve input/output functions recovered over a 30-day period whereas recovery of brainstem response amplitudes occurred within five days. In contrast to amplitudes, thresholds at both peripheral and central levels recovered simultaneously, within five days after kainic acid application. The results indicate that (i) cochlear afferent neurons can recover after excitotoxic damage; (ii) response threshold itself, either central or peripheral, is not sufficient to assess the integrity of the auditory periphery; (iii) the central auditory system can recover more rapidly than the periphery; and (iv) the system can maintain its function in the normal range as peripheral function continues to improve.

Targeted mutation of the gene for cellular glutathione peroxidase (Gpx1) increases noise-induced hearing loss in mice.

Reactive oxygen species (ROS) and oxidative stress have been implicated in cochlear injury following loud noise and ototoxins. Genetic mutations that impair antioxidant defenses would be expected to increase cochlear injury following acute insults and to contribute to cumulative injury that presents as age-related hearing loss. We examined whether genetically based deficiency of cellular glutathione peroxidase, a major antioxidant enzyme, increases noise-induced hearing loss in mice. Two-month-old "knockout" mice with a targeted inactivating mutation of the gene coding for glutathione peroxidase (Gpx1) and wild type controls were exposed to broadband noise for one hour at 110 dB SPL. Auditory brainstem response (ABR) thresholds at test frequencies ranging from 5 to 40 kHz were obtained two and four weeks after exposure to determine the stable permanent component of the hearing loss. Depending on test frequency, (compared with controls) Gpx1 knockout mice showed up to 16 dB higher ABR thresholds prior to noise exposure, and up to 15 dB greater noise-induced hearing loss, compared with normal control. Within the cochlear base, there was also a significant contribution of the knockout to inner and outer hair cell loss, as well as nerve fiber loss. Our results support a link between genetic impairment of antioxidant defenses, vulnerability of the cochlea injury, and cochlear degeneration. Such impairment produces characteristics expected of some mutations associated with age-related hearing loss and offers one possible mechanism for their action.

Recovery of kainic acid excitotoxicity in chinchilla cochlea.

The present study examines the recovery of the inner hair cell (IHC)/auditory nerve synapse following cochlear excitotoxicity induced by kainic acid (KA). Three hours after KA treatment, there was massive swelling of type I afferent endings under the IHCs. Five to ten days later, the pattern of IHC innervation appeared to be normal. Distortion-product otoacoustic emissions were normal during the whole experiment. The amplitude of the auditory nerve compound action potential (CAP) was significantly reduced immediately after KA treatment and then recovered over a 30-day period. However, it only took five days for the evoked response from the inferior colliculus (IC) to recover from a substantial depression. In contrast to amplitudes, thresholds for the CAP and IC recovered at the same rate and returned to normal within 5 days after KA. Single auditory nerve fibers were also assessed at various times after the KA treatment. Ten days after KA, these fibers had almost normal thresholds, tuning, spontaneous, and driven discharge rates. The results indicate that (1) excitotoxically damaged cochlear afferent neurons can rapidly regenerate and establish viable synapses with the IHCs, and (2) the central auditory system recovers more rapidly than the periphery.

The role of antioxidants in protection from impulse noise.

The hearing loss from exposure to noise and ototoxic drugs share a number of audiological and pathological similarities. Recent research has shown that reactive oxygen species (ROS) may be a common factor in both noise- and drug-induced hearing loss. This review describes three experiments that point to ROS as a causative factor in both noise- and drug-induced hearing loss and antioxidants as a protective agent. In the first experiment, the ears of chinchillas were treated with R-N6-phenylisopropyladenoisine (R-PIA) and exposed to 150-dB impulse noise. The treated ears developed substantially less permanent hearing loss (PTS) and hair cell loss than the untreated ears. One interpretation of this experiment is that R-PIA increases the availability of glutathione (GSH). In the second experiment, the role of GSH was specifically examined. The ears of chinchillas were treated with glutathione monoethylester (GEE), a pro-GSH drug that has been shown to readily cross cell membranes and increase GSH levels. The GEE-treated ears had significantly less PTS and hair-cell loss than the nontreated ear. Previous research has shown that moderate levels of noise exposure can increase a subject's resistance to noise, and also increase the availability of antioxidant enzymes in the cochlea. In the third experiment, chinchillas were given a series of "toughening" exposures (i.e., 6 h of a 0.5-kHz OB noise at 95 dB for 10 days). After the series of "toughening" exposures, the subjects were treated with carboplatin, a drug that causes massive inner-hair-cell lesions in the chinchilla. The animals receiving the 10-day toughening exposure developed less PTS and hair-cell loss than the control animals.

Selective loss of inner hair cells and type-I ganglion neurons in carboplatin-treated chinchillas. Mechanisms of damage and protection.

Carboplatin preferentially destroys inner hair cells (IHCs) and type-I spiral ganglion neurons while sparing outer hair cells (OHCs). Loss of IHCs and type-I ganglion cells is associated with a significant reduction of the compound action potential (CAP). However, the cochlear microphonic (CM) potential and distortion product otoacoustic emissions (DPOAEs) remain normal, indicating that the OHCs are functionally intact. In the vestibular system, carboplatin selectively destroys type-I hair cells and their afferent neurons. Damage of type-I vestibular hair cells and their afferent terminals is associated with significant depression of nystagmus induced by cold, caloric stimulation. Histochemical studies revealed a rapid decrease in succinate dehydrogenase (SDH) staining in IHCs soon after carboplatin treatment, and staining intensity remained depressed in surviving IHCs for at least 1 month after carboplatin treatment. These results suggest that carboplatin depresses the metabolic function in surviving IHCs. Several lines of evidence suggest that free radicals may contribute to carboplatin-induced sensory cell damage. Intracochlear infusion of L-buthionine-[S,R]-sulfoximine (BSO), which depletes intracellular glutathione (GSH), increases IHC and OHC loss. Previous in vitro studies have shown that neurotrophin 4/5 (NT-4/5) promotes the survival of spiral ganglion neurons from cisplatin ototoxicity. In vivo perfusion of NT-4/5 promoted the survival of spiral ganglion neurons, but did not protect the hair cells.

Responses of inferior colliculus neurons in C57BL/6J mice with and without sensorineural hearing loss: effects of changing the azimuthal location of an unmasked pure-tone stimulus.

Azimuth functions (discharge rates evoked by tone bursts as a function of stimulus azimuth) were obtained from neurons in the inferior colliculus (IC) of C57 mice aged 2, 7 and 12 months. Because of a gene that affects the cochlea, C57 mice exhibit high-frequency sensorineural hearing loss at 7 and 12 months. Azimuth functions were examined for differences that might be related to the decline in localization acuity that accompanies hearing loss in this strain. Irrespective of age group, nearly all neurons in the central area of the IC were sensitive to the azimuth of a best frequency (BF) stimulus, as revealed by azimuth functions in which firing rates varied by more than 50% from maximum to minimum at one or more intensities. The age groups were similar in many respects (e.g., there were no significant differences in the proportion of functions meeting the criterion for direction sensitivity, the proportion of neurons with direction sensitive functions over a range of intensities, azimuth function shapes, the locations or stability of 'borders' separating angles evoking high versus low discharge rates). However, in 7- and 12-month-olds: the proportion of IC neurons in which the strongest excitatory driving was evoked by ipsilateral stimulation was significantly larger; azimuth function borders were more likely to be 'reversed' (i.e., the high rates being evoked by the more ipsilateral angle); and a greater proportion of azimuth functions met the criterion for direction sensitivity only minimally. The findings suggest that binaural excitatory-inhibitory interactions are altered in IC neurons of hearing-impaired mice.

Responses of inferior colliculus neurons in C57BL/6J mice with and without sensorineural hearing loss: effects of changing the azimuthal location of a continuous noise masker on responses to contralateral tones.

Extracellular recordings were obtained from inferior colliculus neurons of young adult (2-month-old) C57 mice with normal hearing and middle-aged (6-month-old) C57 mice with sensorineural hearing loss as they responded to best frequency (BF) tones (signal) in the presence of a continuous background noise (masker). Rate/level functions were obtained for the signal alone, noise bursts alone, and the signal in continuous noise as a function of masker location. For both groups of mice, thresholds for BF tones were significantly elevated in the presence of noise at all three noise locations. Separating the signal and masker sources significantly improved masked tone thresholds of 2-month-old mice but not hearing-impaired mice. The decreased ability of middle-aged mice to benefit from separation of the signal and masker sources may reflect alterations in binaural processing as a result of sensorineural hearing loss.