Quantifying Radiology Resident Fatigue: Analysis of Preliminary Reports.

Background Workloads in radiology departments have constantly increased over the past decades. The resulting radiologist fatigue is considered a rising problem that affects diagnostic accuracy. Purpose To investigate whether data mining of quantitative parameters from the report proofreading process can reveal daytime and shift-dependent trends in report similarity as a surrogate marker for resident fatigue. Materials and Methods Data from 117 402 radiology reports written by residents between September 2017 and March 2020 were extracted from a report comparison tool and retrospectively analyzed. Through calculation of the Jaccard similarity coefficient between residents' preliminary and staff-reviewed final reports, the amount of edits performed by staff radiologists during proofreading was quantified on a scale of 0 to 1 (1: perfect similarity, no edits). Following aggregation per weekday and shift, data were statistically analyzed by using simple linear regression or one-way analysis of variance (significance level, P < .05) to determine relationships between report similarity and time of day and/or weekday reports were dictated. Results Decreasing report similarity with increasing work hours was observed for day shifts (r = -0.93 [95% CI: -0.73, -0.98]; P < .001) and weekend shifts (r = -0.72 [95% CI: -0.31, -0.91]; P = .004). For day shifts, negative linear correlation was strongest on Fridays (r = -0.95 [95% CI: -0.80, -0.99]; P < .001), with a 16% lower mean report similarity at the end of shifts (0.85 ± 0.24 at 8 am vs 0.69 ± 0.32 at 5 pm). Furthermore, mean similarity of reports dictated on Fridays (0.79 ± 0.35) was lower than that on all other weekdays (range, 0.84 ± 0.30 to 0.86 ± 0.27; P < .001). For late shifts, report similarity showed a negative correlation with the course of workweeks, showing a continuous decrease from Monday to Friday (r = -0.98 [95% CI: -0.70, -0.99]; P = .007). Temporary increases in report similarity were observed after lunch breaks (day and weekend shifts) and with the arrival of a rested resident during overlapping on-call shifts. Conclusion Decreases in report similarity over the course of workdays and workweeks suggest aggravating effects of fatigue on residents' report writing performances. Periodic breaks within shifts potentially foster recovery. © RSNA, 2021.

Gamification of Electronic Learning in Radiology Education to Improve Diagnostic Confidence and Reduce Error Rates.

OBJECTIVE. The purpose of this study is to validate an electronic learning, or e-learning, concept featuring gamification elements, rapid case reading, and instant feedback. SUBJECTS AND METHODS. An e-learning concept was devised that offered game levels for the purpose of providing training in the detection of pneumothorax in 195 cases, with questions read in rapid succession and instant feedback provided for each case. The user's task was to locate the pneumothorax on chest radiographs and indicate its presence by clicking a mouse. The game level design included an entry test consisting of 15 cases, training levels with increasing difficulty that involved 150 cases, and a final test that including 30 cases (the 15 cases from the entry test plus 15 new cases). A total of 126 candidates were invited via e-mail to participate and were asked to complete a survey before and after playing the game, which is known as RapRad. The level of diagnostic confidence and the error rate before and after playing the game were compared using a Wilcoxon signed rank test. RESULTS. Fifty-nine of 126 participants (47%) responded to the first survey and finished the game. Of these 59 participants, 29 (49%) responded to the second survey after completing the game. Diagnostic confidence in pneumothorax detection improved significantly, from a mean (± SD) score of 4.3 ± 2.1 on the entry test to a final score of 7.3 ± 2.1 (p < 0.01) after playing RapRad, with the score measured on a 10-point scale, with 10 denoting the highest possible score. Of the participants, 93% indicated that they would use the game for learning purposes again, and 87% indicated that they had fun using RapRad (7% had a neutral response and 6% had a negative response). The error rate (i.e., the number of failed attempts to answer a question correctly) significantly decreased from 39% for the entry test to 22% for the final test (p < 0.01). CONCLUSION. Our e-learning concept is capable of improving diagnostic confidence, reducing error rates in training pneumothorax detection, and offering fun in interaction with the platform.

State-of-the-art multimodality approach to assist ablations in complex anatomies-From 3D printing to virtual reality.

Imaging of the heart anatomy plays an important role, especially in catheter ablation for the treatment of arrhythmias in adults with congenital heart disease (ACHD). We present a comprehensive overview of the current state-of-the-art modalities available to plan and guide catheter ablation in an ACHD patient. In addition to the clinical assessment of the computed tomography and the integration of 3D reconstructions into the electroanatomical mapping system, 3D printing and virtual reality assessment showed its value in preprocedural planning of the intervention.

Quantifying the Effects of Structured Reporting on Report Turnaround Times and Proofreading Workload in Neuroradiology.

RATIONALE AND OBJECTIVES: To assess the effects of a change from free text reporting to structured reporting on resident reports, the proofreading workload and report turnaround times in the neuroradiology daily routine. MATERIALS AND METHODS: Our neuroradiology section introduced structured reporting templates in July 2019. Reports dictated by residents during dayshifts from January 2019 to March 2020 were retrospectively assessed using quantitative parameters from report comparison. Through automatic analysis of text-string differences between report states (i.e. draft, preliminary and final report), Jaccard similarities and edit distances of reports following read-out sessions as well as after report sign-off were calculated. Furthermore, turnaround times until preliminary and final report availability to clinicians were investigated. Parameters were visualized as trending line graphs and statistically compared between reporting standards. RESULTS: Three thousand five hundred thirty-eight reports were included into analysis. Mean Jaccard similarity of resident drafts and staff-reviewed final reports increased from 0.53 ± 0.37 to 0.79 ± 0.22 after the introduction of structured reporting (p < .001). Both mean overall edits on draft reports by residents following read-out sessions (0.30 ± 0.45 vs. 0.09 ± 0.29; p < .001) and by staff radiologists during report sign-off (0.17 ± 0.28 vs. 0.12 ± 0.23, p < .001) decreased. With structured reporting, mean turnaround time until preliminary report availability to clinicians decreased by 20.7 minutes (246.9 ± 207.0 vs. 226.2 ± 224.9; p < .001). Similarly, final reports were available 35.0 minutes faster on average (558.05 ± 15.1 vs. 523.0 ± 497.3; p = .002). CONCLUSION: Structured reporting is beneficial in the neuroradiology daily routine, as resident drafts require fewer edits in the report review process. This reduction in proofreading workload is likely responsible for lower report turnaround times.

Clinical acceptance of advanced visualization methods: a comparison study of 3D-print, virtual reality glasses, and 3D-display.

BACKGROUND: To compare different methods of three-dimensional representations, namely 3D-Print, Virtual Reality (VR)-Glasses and 3D-Display regarding the understanding of the pathology, accuracy of details, quality of the anatomical representation and technical operability and assessment of possible change in treatment in different disciplines and levels of professional experience. METHODS: Interviews were conducted with twenty physicians from the disciplines of cardiology, oral and maxillofacial surgery, orthopedic surgery, and radiology between 2018 and 2020 at the University Hospital of Basel. They were all presented with three different three-dimensional clinical cases derived from CT data from their area of expertise, one case for each method. During this, the physicians were asked for their feedback written down on a pencil and paper questionnaire. RESULTS: Concerning the understanding of the pathology and quality of the anatomical representation, VR-Glasses were rated best in three out of four disciplines and two out of three levels of professional experience. Regarding the accuracy of details, 3D-Display was rated best in three out of four disciplines and all levels of professional experience. As to operability, 3D-Display was consistently rated best in all levels of professional experience and all disciplines. Possible change in treatment was reported using 3D-Print in 33%, VR-Glasses in 44%, and 3D-Display in 33% of participants. Physicians with a professional experience of more than ten years reported no change in treatment using any method. CONCLUSIONS: 3D-Print, VR-Glasses, and 3D-Displays are very well accepted, and a relevant percentage of participants with less than ten years of professional work experience could imagine a possible change in treatment using any of these three-dimensional methods. Our findings challenge scientists, technicians, and physicians to further develop these methods to improve the three-dimensional understanding of pathologies and to add value to the education of young and inexperienced physicians.

Performance of a deep learning tool to detect missed aortic dilatation in a large chest CT cohort.

Purpose: Thoracic aortic (TA) dilatation (TAD) is a risk factor for acute aortic syndrome and must therefore be reported in every CT report. However, the complex anatomy of the thoracic aorta impedes TAD detection. We investigated the performance of a deep learning (DL) prototype as a secondary reading tool built to measure TA diameters in a large-scale cohort. Material and methods: Consecutive contrast-enhanced (CE) and non-CE chest CT exams with "normal" TA diameters according to their radiology reports were included. The DL-prototype (AIRad, Siemens Healthineers, Germany) measured the TA at nine locations according to AHA guidelines. Dilatation was defined as >45 mm at aortic sinus, sinotubular junction (STJ), ascending aorta (AA) and proximal arch and >40 mm from mid arch to abdominal aorta. A cardiovascular radiologist reviewed all cases with TAD according to AIRad. Multivariable logistic regression (MLR) was used to identify factors (demographics and scan parameters) associated with TAD classification by AIRad. Results: 18,243 CT scans (45.7% female) were successfully analyzed by AIRad. Mean age was 62.3 ± 15.9 years and 12,092 (66.3%) were CE scans. AIRad confirmed normal diameters in 17,239 exams (94.5%) and reported TAD in 1,004/18,243 exams (5.5%). Review confirmed TAD classification in 452/1,004 exams (45.0%, 2.5% total), 552 cases were false-positive but identification was easily possible using visual outputs by AIRad. MLR revealed that the following factors were significantly associated with correct TAD classification by AIRad: TAD reported at AA [odds ratio (OR): 1.12, p < 0.001] and STJ (OR: 1.09, p = 0.002), TAD found at >1 location (OR: 1.42, p = 0.008), in CE exams (OR: 2.1-3.1, p < 0.05), men (OR: 2.4, p = 0.003) and patients presenting with higher BMI (OR: 1.05, p = 0.01). Overall, 17,691/18,243 (97.0%) exams were correctly classified. Conclusions: AIRad correctly assessed the presence or absence of TAD in 17,691 exams (97%), including 452 cases with previously missed TAD independent from contrast protocol. These findings suggest its usefulness as a secondary reading tool by improving report quality and efficiency.

Design and Additive Manufacturing of a Biomimetic Customized Cranial Implant Based on Voronoi Diagram.

Reconstruction of cranial defects is an arduous task for craniomaxillofacial surgeons. Additive manufacturing (AM) or three-dimensional (3D) printing of titanium patient-specific implants (PSIs) made its way into cranioplasty, improving the clinical outcomes in complex surgical procedures. There has been a significant interest within the medical community in redesigning implants based on natural analogies. This paper proposes a workflow to create a biomimetic patient-specific cranial prosthesis with an interconnected strut macrostructure mimicking bone trabeculae. The method implements an interactive generative design approach based on the Voronoi diagram or tessellations. Furthermore, the quasi-self-supporting fabrication feasibility of the biomimetic, lightweight titanium cranial prosthesis design is assessed using Selective Laser Melting (SLM) technology.

A guideline for 3D printing terminology in biomedical research utilizing ISO/ASTM standards.

First patented in 1986, three-dimensional (3D) printing, also known as additive manufacturing or rapid prototyping, now encompasses a variety of distinct technology types where material is deposited, joined, or solidified layer by layer to create a physical object from a digital file. As 3D printing technologies continue to evolve, and as more manuscripts describing these technologies are published in the medical literature, it is imperative that standardized terminology for 3D printing is utilized. The purpose of this manuscript is to provide recommendations for standardized lexicons for 3D printing technologies described in the medical literature. For all 3D printing methods, standard general ISO/ASTM terms for 3D printing should be utilized. Additional, non-standard terms should be included to facilitate communication and reproducibility when the ISO/ASTM terms are insufficient in describing expository details. By aligning to these guidelines, the use of uniform terms for 3D printing and the associated technologies will lead to improved clarity and reproducibility of published work which will ultimately increase the impact of publications, facilitate quality improvement, and promote the dissemination and adoption of 3D printing in the medical community.

Fully automated guideline-compliant diameter measurements of the thoracic aorta on ECG-gated CT angiography using deep learning.

BACKGROUND: Manually performed diameter measurements on ECG-gated CT-angiography (CTA) represent the gold standard for diagnosis of thoracic aortic dilatation. However, they are time-consuming and show high inter-reader variability. Therefore, we aimed to evaluate the accuracy of measurements of a deep learning-(DL)-algorithm in comparison to those of radiologists and evaluated measurement times (MT). METHODS: We retrospectively analyzed 405 ECG-gated CTA exams of 371 consecutive patients with suspected aortic dilatation between May 2010 and June 2019. The DL-algorithm prototype detected aortic landmarks (deep reinforcement learning) and segmented the lumen of the thoracic aorta (multi-layer convolutional neural network). It performed measurements according to AHA-guidelines and created visual outputs. Manual measurements were performed by radiologists using centerline technique. Human performance variability (HPV), MT and DL-performance were analyzed in a research setting using a linear mixed model based on 21 randomly selected, repeatedly measured cases. DL-algorithm results were then evaluated in a clinical setting using matched differences. If the differences were within 5 mm for all locations, the cases was regarded as coherent; if there was a discrepancy >5 mm at least at one location (incl. missing values), the case was completely reviewed. RESULTS: HPV ranged up to ±3.4 mm in repeated measurements under research conditions. In the clinical setting, 2,778/3,192 (87.0%) of DL-algorithm's measurements were coherent. Mean differences of paired measurements between DL-algorithm and radiologists at aortic sinus and ascending aorta were -0.45±5.52 and -0.02±3.36 mm. Detailed analysis revealed that measurements at the aortic root were over-/underestimated due to a tilted measurement plane. In total, calculated time saved by DL-algorithm was 3:10 minutes/case. CONCLUSIONS: The DL-algorithm provided coherent results to radiologists at almost 90% of measurement locations, while the majority of discrepent cases were located at the aortic root. In summary, the DL-algorithm assisted radiologists in performing AHA-compliant measurements by saving 50% of time per case.

Diagnostic accuracy and clinical implications of robotic assisted MRI-US fusion guided target saturation biopsy of the prostate.

MRI-targeted prostate biopsy improves detection of clinically significant prostate cancer (PCa). However, up to 70% of PCa lesions display intralesional tumor heterogeneity. Current target sampling strategies do not yet adequately account for this finding. This prospective study included 118 patients who underwent transperineal robotic assisted biopsy of the prostate. We identified a total of 58 PCa-positive PI-RADS lesions. We compared diagnostic accuracy of a target-saturation biopsy strategy to accuracy of single, two, or three randomly selected targeted biopsy cores and analysed potential clinical implications. Intralesional detection of clinically significant cancer (ISUP ≥ 2) was 78.3% for target-saturation biopsy and 39.1%, 52.2%, and 67.4% for one, two, and three targeted cores, respectively. Target-saturation biopsies led to a more accurate characterization of PCa in terms of Gleason score and reduced rates of significant cancer missed. Compared to one, two, and three targeted biopsy cores, target-saturation biopsies led to intensified staging procedures in 21.7%, 10.9, and 8.7% of patients, and ultimately to a potential change in therapy in 39.1%, 26.1%, and 10.9% of patients. This work presents the concept of robotic-assisted target saturation biopsy. This technique has the potential to improve diagnostic accuracy and thus individual staging procedures and treatment decisions.

The microenvironment differentially impairs passive and active immunotherapy in chronic lymphocytic leukaemia - CXCR4 antagonists as potential adjuvants for monoclonal antibodies.

Direct contact with stromal cells protects chronic lymphocytic leukaemia (CLL) B cells from chemotherapy-induced apoptosis in vitro. Blockade of CXCR4 signalling antagonizes stroma-mediated interactions and restores CLL chemosensitivity. In vivo, administration of CXCR4 antagonists effectively mobilizes haematopoietic progenitor cells. Therefore, combinations of CXCR4 blockade and cytoreductive treatment with selective activity on CLL cells may avoid potential haematotoxicity. Hence, we tested CXCR4 antagonists in the context of passive and active immunotherapeutic approaches. We evaluated how efficiently rituximab, alemtuzumab and cytotoxic T cells killed CLL cells cocultured with stromal cells in the presence and absence of a CXCR4 antagonist. Stromal cell contact attenuated rituximab- and alemtuzumab-induced complement-dependent cytotoxicity of CLL cells. Addition of CXCR4 antagonists abrogated the protective effect of stroma. In contrast, stromal cells did not impair antibody-dependent cell-mediated cytotoxicity and cytotoxicity induced by activated T cells. Destruction of microtubules in CLL target cells restored the protective effect of stroma coculture for CLL cells during Natural Killer cell attack by preventing mitochondrial relocalization towards the immunological synapse. Our data identify the combination of CXCR4 antagonists with passive - but not active - immunotherapy as a promising potential treatment concept in CLL.

"Green Fingerprint" Project: Evaluation of the Power Consumption of Reporting Stations in a Radiology Department.

RATIONALE AND OBJECTIVES: To quantify the power or energy consumption of reporting stations in a radiology department and to consider a hypothetical scenario to reduce energy waste. METHODS: We measured the energy consumption of 36 radiology reporting stations over a mean time frame of about 194 days and then extrapolated results to 1 year. Reporting stations were configured (by default) to enter a stand-by mode after 4 hours of inactivity. A hypothetical scenario was calculated in which stand-by was skipped and the reporting stations were shut down after 1 hour of inactivity. RESULTS: Data from four stations was corrupted. The overall power consumption of the 32 remaining reporting stations was 53,170 kWh/a, equivalent to 12 family households (4500 kWh/a per household in Switzerland in 2014) or 97.2 barrels of oil. We identified three main power consumption patterns of the reporting stations: mainly off, mainly on, and always off. The on-mode consumption per year was 40,763 kWh/a, the stand-by consumption was 10,010 kWh/a, and the off-mode consumption was 2397 kWh/a. The reporting stations spent half of their on-mode time awaiting the initiation of stand-by, resulting in a wait-time consumption of 18,243 kWh/a. With the hypothetical scenario, we achieved an energy consumption saving of 23,692 kWh/a, a reduction of about 45% of the initial energy consumption, equivalent to 5 households or 40.8 barrels of oil consumed. CONCLUSION: The power consumption of the reporting stations is not negligible. Reducing energy waste in the radiology department can be established through simple changes in device configuration which will simultaneously promote energywise habits. ADVANCES IN KNOWLEDGE: Minor changes to the settings of the reporting stations in a radiology department can result in significant long-term energy savings and promote energy-wise habits.

3D-Printed Visualization of a Complex Coronary-Venous Fistula With Additional Feeders From the Descending Aorta.

In a 32-year-old patient with chest pain, a large, complex coronary-venous fistula with additional feeders from the descending aorta was detected with computed tomography. Multimodality imaging, including multicolor 3-dimensional printing, allowed precise anatomic visualization of the origin, course and drainage site of the fistula. The patient was treated conservatively. (Level of Difficulty: Advanced.).

Effects of Steam Sterilization on 3D Printed Biocompatible Resin Materials for Surgical Guides-An Accuracy Assessment Study.

Computer-assisted surgery with three-dimensional (3D) printed surgical guides provides more accurate results than free-hand surgery. Steam sterilization could be one of the factors that affect the dimensions of surgical guide resin materials, leading to inaccuracies during surgeries. The purpose of this study was to evaluate the effects of steam sterilization on the dimensional accuracy of indication-specific hollow cube test bodies, manufactured in-house using Class IIa biocompatible resin materials (proprietary and third-party). To evaluate the pre- and post-sterilization dimensional accuracy, root mean square (RMS) values were calculated. The results indicate that, in all the groups, steam sterilization resulted in an overall linear expansion of the photopolymeric resin material, with an increase in outer dimensions and a decrease in inner dimensions. The effects on the dimensional accuracy of test bodies were not statistically significant in all the groups, except PolyJet Glossy (p > 0.05). The overall pre- and post-sterilization RMS values were below 100 and 200 µm, respectively. The highest accuracies were seen in proprietary resin materials, i.e., PolyJet Glossy and SLA-LT, in pre- and post-sterilization measurements, respectively. The dimensional accuracy of third-party resin materials, i.e., SLA-Luxa and SLA-NextDent, were within a comparable range as proprietary materials and can serve as an economical alternative.

A massacre of early Neolithic farmers in the high Pyrenees at Els Trocs, Spain.

Violence seems deeply rooted in human nature and an endemic potential for such is today frequently associated with differing ethnic, religious or socio-economic backgrounds. Ethnic nepotism is believed to be one of the main causes of inter-group violence in multi-ethnic societies. At the site of Els Trocs in the Spanish Pyrenees, rivalling groups of either migrating early farmers or farmers and indigenous hunter-gatherers collided violently around 5300 BCE. This clash apparently resulted in a massacre of the Els Trocs farmers. The overkill reaction was possibly triggered by xenophobia or massive disputes over resources or privileges. In the present, violence and xenophobia are controlled and sanctioned through social codes of conduct and institutions. So that, rather than representing an insurmountable evolutionary inheritance, violence and ethnic nepotism can be overcome and a sustainable future achieved through mutual respect, tolerance and openness to multi-ethnic societies.

Three-dimensional Assessment of the Breast: Validation of a Novel, Simple and Inexpensive Scanning Process.

BACKGROUND/AIM: Methods to assess three-dimensionally the breast surface are increasingly used in plastic and reconstructive surgery. The aim of this study was to validate the use of the Structure Sensor 3D scanner (Occipital, Inc., Boulder, CO, USA) connected to an iPad Pro (Apple, Inc., Cupertino, CA, USA) as a novel, inexpensive and handheld three-dimensional scanning process. MATERIALS AND METHODS: Surface images of a medical human female anatomy torso model of rigid plastic were repeatedly acquired with Structure Sensor 3D scanner and compared with those obtained using two clinically established 3D imaging systems. Digital measurements of vector and surface breast distances were analyzed using Mimics® Innovation Suite 20 medical imaging software (Materialise, Leuven, Belgium). RESULTS: The analysis of variance (ANOVA) revealed no statistically significant difference among measurements obtained using different scanning processes for all the variables examined (p>0.05). CONCLUSION: The study demonstrates analogous practicability and reliability for surface image acquisition using the newly introduced Structure Sensor 3D scanner and other clinically established scanners.