Multi-centre digital radiography reject analysis for different clinical room use types: The establishment of local reject reference levels for public hospital departments.

INTRODUCTION: Reject analysis in digital radiography helps guide the training of staff to reduce patient radiation dose and improve department efficiency. The purpose of this study was to perform a multi-centre, vendor agnostic reject analysis across different room usage types, and to provide benchmarks for comparison. METHODS: Retrospective reject and exposure log data were collected via USB from fixed general X-ray systems across multiple Australian sites, for collation and analysis. The overall reject rate, local reject reference level, absolute and relative reject rates for body part categories, reject rates by room usage types and the reject rate for each reason of rejection were calculated. RESULTS: Data were collected from 44 X-ray systems, across 11 hospitals. A total of 2,031,713 acquired images and 172,495 rejected images were included. The median reject rate was 9.1%. The local reject reference level (LRRL), set as the 75th percentile of all reject rates, was 10.6%. Median reject rates by room type were emergency (7.4%), inpatients + outpatients (9.6%), outpatients (9.2%), and hybrid (10.1%). The highest absolute reject rates by body part were chest (2.1%) and knee (1.4%). The highest relative rates by body part were knee (18.1%) and pelvis (17.2%). The most frequent reasons for image rejection were patient positioning (76%) and patient motion (7.5%). CONCLUSIONS: The results compare well with previously published data. The range of reject rates highlights the need to analyse typical reject rates in different ways. With analysis feedback to participating sites and the implementation of standardised reject reasons, future analysis should monitor whether reject rates reduce.

The associated factors for radiation dose variation in cardiac CT angiography.

OBJECTIVE:: This study aimed to examine the associated factors for dose variation and influence cardiac CT angiography (CCTA) dose benchmarks in current CT imaging centres. METHODS:: A questionnaire was distributed to CT centres across Australia and Saudi Arabia. All participating centres collected data for adults who underwent a CCTA procedure. The questionnaire gathered information about the examination protocol, scanning parameters, patient parameters, and volume CT dose index (CTDI vol) and dose-length product (DLP). A stepwise regression analysis was performed to assess the contribution of tube voltage (kV), padding time technique, cross-sectional area (CSA) of chest and weight to DLP. RESULTS:: A total of 17 CT centres provided data for 423 CCTA examinations. The median CTDIvol, DLP and effective dose were 18 mGy, 256 mGy.cm and 5.2 mSv respectively. There was a statistically significant difference in DLP between retrospective and prospective ECG-gating modes (p = 0.001). Median DLP from CCTA using padding technique was 61% higher than CCTA without padding (p = 0.001). The stepwise regression showed that kV was the most significant predictor of DLP followed by padding technique then CSA while patient weight did not statistically significantly predict DLP. Correlation analysis showed a strong positive correlation between weight and CSA (r = 0.78), and there was a moderate positive correlation between weight and DLP (r = 0.42), as well as CSA and DLP (r = 0.48). CONCLUSION:: Findings show radiation dose variations for CCTA. The associated factors for dose variation found in this study are scanning mode, kV, padding time technique and CSA of the chest. This results support the need to include CSA measurements in future dose survey and for setting DRLs. ADVANCES IN KNOWLEDGE:: The study provides baseline information that helps to understand the associated factors for dose variations and high doses within and between centres performing CCTA.

DIAGNOSTIC REFERENCE LEVELS FOR CARDIAC CT ANGIOGRAPHY IN AUSTRALIA.

This study aims to assess patient radiation dose from cardiac computed tomography angiography (CCTA) with the aim of proposing a national diagnostic reference levels (NDRLs) for CCTA procedures in Australia. A questionnaire was used to retrospectively gather baseline information related to CCTA scanning and patient parameters in CT centres across the country. The 75th percentile of both volumetric CT dose index (CTDIvol) and dose length-product (DLP) was used as DRL values for CCTA. A DRL for CT calcium scoring test was also determined. NDRLs were compared with international published data. Data sets of 338 patients from nine CT centres were used for analysis. The CCTA DRL for the CTDIvol and the DLP were 22 mGy and 268 mGy cm, respectively. The CT calcium scoring test DRL for DLP was 137 mGy cm. The DRL values for CCTA in Australia have been recommended for the first time. DRLs are lower than those in most published studies due to the implementation of dose-saving technologies such as prospective ECG-gated mode and iterative reconstruction algorithms. Considerable variations remain in patient doses between hospitals for the most frequently used CCTA protocols, indicating the potential for DRLs to prompt dose optimisation strategies in CT facilities.

ESTABLISHING DIAGNOSTIC REFERENCE LEVELS FOR CARDIAC COMPUTED TOMOGRAPHY ANGIOGRAPHY IN SAUDI ARABIA.

Cardiac computed tomography angiography (CCTA) is a commonly used diagnostic imaging tool for cardiovascular disease. Despite constant improvements to imaging technologies, the radiation dose to patients remains a concern when using this procedure. Diagnostic reference levels (DRLs) are used as a trigger to identify and alert individual facilities that are using high doses during CT. This study aims to assess patient radiation dose and establish new national DRLs (NDRL) associated with CCTA in Saudi clinical practices. A structured booklet survey was designed for recording patient and scanning protocols during CCTA procedures. The data were collected retrospectively from the participating centres. NDRLs for CCTA were defined as the 75th and 25th of volumetric CT dose index (CTDIvol) and dose length product (DLP). Specific DRLs based on two main ECG-gating modes were also proposed. Data sets related to 197 CCTAs with a mean weight of 77 kg were analysed in detail. The DRL values for CTDIvol and DLP for prospective gating mode and retrospective gating mode were 29 and 62 mGy and 393 and 1057 mGy cm, respectively. NDRLs for CCTA in Saudi Arabia are comparable or slightly lower than European DRLs due to the current use of dose-saving technology. There are major variations in patient doses during CCTA due to differences in CT scanners, scanning modes and departmental CCTA protocols.

DIAGNOSTIC REFERENCE LEVELS IN CARDIAC COMPUTED TOMOGRAPHY ANGIOGRAPHY: A SYSTEMATIC REVIEW.

Cardiac computed tomography angiography (CCTA) is a commonly used diagnostic tool for cardiovascular disease. Despite constant improvements to imaging technologies, the radiation dose to patients from CCTA remains a concern when using this procedure. There remains a need for optimisation of CCTA procedures and accurate dose monitoring to reduce the potential risk of cancer. Establishing diagnostic reference levels (DRLs) allows for the assessment of radiation dose variations, enabling strategies aimed at standardising doses across radiological centres. This systematic review explores the literature on CCTA methodologies that have been used to establish DRLs. A search was carried out using the Web of Science, SCOPUS, Medline, CINAHL and EMBASE databases. Reference lists of published articles were also assessed to identify further articles. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was employed to evaluate articles for relevance. Articles were included if they assessed DRLs in CCTA. The search resulted in 448 articles, of which, six were included after a thorough screening process. The literature demonstrates a wide dose variation in reported CCTA DRLs ranging from 671 to 1510 mGy cm in DLP. Where reported, CTDIvol DRLs ranged from 26 to 70 mGy. Differences were found in the methodologies used for establishing CCTA DRLs, including the sampling methodology used for identifying suitable patients and scanning protocols. This current review emphasises the need for an international standardisation for DRLs establishment methods, to provide a more comparable global measurement of dose variations across CT sites.

A review of implantable cardioverter defibrillator failures during radiation therapy in three Sydney hospitals.

INTRODUCTION: In recent years, using radiation energies greater than 10 MV in patients with implantable cardioverter defibrillators (ICDs) has been contra-indicated due to the risk of a power on reset (POR) occurring. The ICD is often greater than 30 cm from the treatment field and subject to scatter radiation only. The aim of this study was to use recent patient cases to verify published failure rates and treatment recommendations. METHOD: Five patients with ICDs who experienced a device malfunction during radiation therapy treatments were identified in three Sydney hospitals between 2008 and 2012. The types of treatments delivered during these events were assessed. Further assessment of all ICD patients at one Sydney hospital during this time was carried out to assess the rate of ICD failure during high energy treatments using 18 MV. RESULTS: All ICDs that suffered malfunctions were exposed to scatter radiation only. All were exposed to partial or exclusive irradiation using 18 MV photons. Accumulated doses to the ICDs were estimated to be well below accepted dose limits found in literature. One centre reported a 22.2% rate of POR during exposure to 18 MV radiation therapy during this time frame. CONCLUSIONS: Where possible, radiation therapy using energies greater than 10 MV should be avoided for ICD patients. While the use of these energies carries a risk of failure, it must be weighed against potential benefit to the patient requiring treatment if no alternatives are available. Stringent monitoring of these patients, including regular cardiac device checks and ECG monitoring is recommended if treatment is to proceed with energies greater than 10 MV.

Operator eye doses during computed tomography fluoroscopic lung biopsy.

The aim of this work was to examine the peak entrance surface air kerma (peak ESAK) to the eyes during CT fluoroscopy lung biopsy, and the impact of lead glasses, exposure parameters, head rotation, and height on peak ESAK to the eyes. Two phantoms simulating the patient and radiologist were used, and 108 exposures were made using a 16-slice Toshiba Alexion CT scanner (Toshiba Medical Systems, Nasu, Japan). ESAK to the phantom radiologist's right eye was measured using an Unfors Xi dosimeter (RaySafe, Billdal, Sweden) with and without lead glasses at two kilovoltages (120 kVp and 135 kVp) and three milliampere settings (10 mA, 20 mA, and 30 mA. A paired t test was used to compare peak ESAK to the eye at different angles, heights, and kVp and mA with and without lead glasses. Peak ESAK was higher without compared to with lead glasses (p ⩽ 0.001). The peak ESAK to the eyes increased as the phantom radiologist rotated toward the gantry without lead glasses, from 2.42 µGy at 120° to 10.54 µGy at 30° (p = 0.001). No significant difference was noted in peak ESAK with change in phantom radiologist height (p > 0.05). An increase from 120 kVp to 135 kVp resulted in 23% and 26% increases in peak ESAK with and without lead glasses respectively (p = 0.001). An increase of tube current from 10 mA to 20 mA almost doubled peak ESAK (p = 0.005). Findings demonstrate that lead glasses reduce ESAK to the eyes, and that increased kVp, mA, and eye rotation to the gantry increase ESAK to the eyes.

An Investigation into the Consistency in Mammographic Density Identification by Radiologists: Effect of Radiologist Expertise and Mammographic Appearance.

The aim of this work is to investigate how radiologist expertise and image appearance may have an impact on inter-reader variability of mammographic density (MD) identification. Seventeen radiologists, divided into three expertise groups, were asked to manually segment the areas they consider to be MD in 40 clinical images. The variation in identification of MD for each image was quantified by finding the range of segmentation areas. The impact of radiologist expertise and image appearance on this variation was explored. The range of areas chosen by participating radiologists varied from 7 to 73% across the 40 images, with a mean range of 35 ± 13%. Participants with high expertise were more likely to choose similar areas to one another, compared to participants with medium and low expertise levels (mean range were 19 ± 10%, 29 ± 13% and 25 ± 14 %, respectively, p < 0.0001). There was a significantly higher average grey level for the area segmented by all radiologists as MD compared to the area of variation, with mean grey level value for 8-bit images being 146 ± 19 vs. 99 ± 14, respectively. MD segmentation borders were consistent in areas where there was a sharp intensity change within a short distance. In conclusion, radiologists with high expertise tend to have a higher agreement when identifying MD. Tissues which have a lower contrast and a less visually sharp gradient change at the interface between high density tissue and adipose background lead to inter-reader variation in choosing mammographic density.

Precision imaging-its impact on image quality and diagnostic confidence in breast ultrasound examinations.

OBJECTIVE: To determine the effect of noise-reducing innovation-precision imaging (PI)-on image quality and diagnostic efficacy in breast ultrasound. METHODS: The study, which assessed four levels of PI from zero to three, consisted of two parts: image quality assessment and diagnostic efficacy evaluation. For the first part, 247 sets of ultrasound images displayed at each PI level were evaluated by 6 experienced breast imaging observers, by rating image quality using visual grading analysis on a 1-4 scale. For the diagnostic efficacy part 51 breast lesions were displayed at each PI level and scored 1-6 to generate a receiver operating characteristic (ROC) curve. These images were evaluated by radiologists and sonographers. Analyses were performed using non-parametric Friedman and Wilcoxon signed rank tests and a multireader multicase methodology. RESULTS: Statistically, higher scores of image quality were observed with increased levels of PI than with the zero setting (p < 0.001). The ROC analysis did not demonstrate any significant change in diagnostic efficacy, with mean scores for all observers being 0.79, 0.80, 0.81 and 0.81 for settings zero, one, two and three, respectively. CONCLUSION: This study suggested a perceived improvement in image quality with increasing levels of PI; however, no changes in diagnostic efficacy were noted. The importance of looking at the impact of new imaging technologies in a multifaceted way is emphasized. ADVANCES IN KNOWLEDGE: To our knowledge, this is the first article investigating the impact of the PI algorithm on ultrasound image quality and breast lesion characterization.

Mammographic density and cancer detection: does digital imaging challenge our current understanding?

RATIONALE AND OBJECTIVES: To investigate the impact of breast density on the performance of radiologists when mammograms are digitally acquired and displayed. MATERIALS AND METHODS: A total of 150 craniocaudal digital mammograms including 75 cases with cancer were examined by 14 radiologists divided into two groups: those who read more (six) and less (eight) than 2000 mammograms per year. Cases were classified as low or high mammographic density. For both types of cases, detection of cancers within and outside the dense fibroglandular tissue was investigated. The performance of radiologist was measured using jack-knife free-response receiver operating characteristic (JAFROC) figure of merit (FOM). RESULTS: Radiologists with over 2000 annual reads had significantly higher JAFROC FOM (P = .03) for high (0.76) mammographic density compared to low (0.70) mammographic density cases. When lesions overlaid the fibroglandular tissue, cases with high mammographic density compared to low mammographic density displayed increased location sensitivity for all radiologists (P = .03) and for those radiologists reading more than 2000 mammograms annually (P = .04), whereas JAFROC FOMs increased for all radiologists (P = .05). No significant changes were observed when the lesion was outside the fibroglandular region. CONCLUSIONS: Increased mammographic density improves the performance of experienced radiologists when using digital mammograms. This finding, which does not align with those previously reported for film screen systems, may be because of windowing/leveling opportunities available with digital images.

How mammographic breast density affects radiologists' visual search patterns.

RATIONALE AND OBJECTIVES: To determine the impact of mammographic breast density on the visual search process of radiologists when reading digital mammograms. MATERIALS AND METHODS: Institutional review board approval was obtained. A set of 149 craniocaudal digital mammograms were read by seven radiologists, and observer search patterns were recorded. Total time examining each case, time to first hit the lesion, dwell time, and number of hits per area were calculated. The nonparametric Mann-Whitney U test was used for statistical evaluation. RESULTS: In both low- and high-mammographic density cases, significant increases were observed in the time to first hit lesions when they were located outside, compared to overlying fibroglandular dense tissue (P = .001). Significantly longer dwell time (P = .003) and greater number of fixations (P = .0003) were observed when the lesions were situated within--rather than outside--the dense fibroglandular tissue. CONCLUSIONS: Increased mammographic breast density changes radiologists' visual search patterns. Dense areas of the parenchyma attracted greater visual attention in both high- and low-mammographic density cases, resulting in faster detection of lesions overlying the fibroglandular dense tissue, along with longer dwell times and greater number of fixations, as compared to lesions located outside the dense fibroglandular regions.

Markers of good performance in mammography depend on number of annual readings.

PURPOSE: To explore relationships between reader performance and reader characteristics in mammography for specific radiologist groupings on the basis of annual number of readings. MATERIALS AND METHODS: The institutional review board approved the study and waived the need for patient consent to use all images. Readers gave informed consent. One hundred sixteen radiologists independently reviewed 60 mammographic cases: 20 cases with cancer and 40 cases with normal findings. Readers located any visualized cancer, and levels of confidence were scored from 1 to 5. A jackknifing free response operating characteristic (JAFROC) method was used, and figures of merit along with sensitivity and specificity were correlated with reader characteristics by using Spearman techniques and standard multiple regressions. RESULTS: Reader performance was positively correlated with number of years since qualification as a radiologist (P ≤ .01), number of years reading mammograms (P ≤ .03), and number of readings per year (P ≤ .0001). The number of years since qualification as a radiologist (P ≤ .004) and number of years of reading mammograms (P ≤ .002) were negatively related to JAFROC values for radiologists with annual volumes of less than 1000 mammographic readings. For individuals with more than 5000 mammographic readings per year, JAFROC values were positively related to the number of years that the reader was qualified as a radiologist (P ≤ .01), number of years of reading mammograms (P ≤ .002), and number of hours per week of reading mammograms (P ≤ .003). Number of mammographic readings per year was positively related with JAFROC scores for readers with an annual volume between 1000 and 5000 readings (P ≤ .03). Differences in JAFROC scores appear to be more related to specificity than location sensitivity, with the former demonstrating significant relationships with four of the five characteristics analyzed, whereas no relationships were shown for the latter. CONCLUSION: Radiologists' determinants of performance are associated with annual reading volumes. Ability to recognize normal images is a discriminating factor in individuals with a high volume of mammographic readings.

Quantitative measures confirm the inverse relationship between lesion spiculation and detection of breast masses.

OBJECTIVE: To identify specific mammographic appearances that reduce the mammographic detection of breast cancer. MATERIALS AND METHODS: This study received institutional board review approval and all readers gave informed consent. A set of 60 mammograms each consisting of craniocaudal and mediolateral oblique projections were presented to 129 mammogram Breastscreen readers. The images consisted of 20 positive cases with single and multicentric masses in 16 and 4 cases, respectively (resulting in a total of 24 cancers), and readers were asked to identify and locate the lesions. Each lesion was then ranked according to a detectability rating (ie, the number of observers who correctly located the lesion divided by the total number of observers), and this was correlated with breast density, lesion size, and various descriptors of lesion shape and texture. RESULTS: Negative and positive correlations between lesion detection and density (r = -0.64, P = .007) and size (r = 0.65, P = .005), respectively, were demonstrated. In terms of lesion size and shape, there were significant correlations between the probability of detection and area (r = 0.43, P = .04), perimeter (r = 0.66, P = .0004), lesion elongation (r = 0.49, P = .02), and lesion nonspiculation (r = 0.78, P < .0001). CONCLUSIONS: The results of this study have identified specific lesion characteristics associated with shape that may contribute to reduced cancer detection. Mammographic sensitivity may be adversely affected without appropriate attention to spiculation.

A comparison between the electronic magnification (EM) and true magnification (TM) of breast phantom images using a CDMAM phantom.

PURPOSE: To provide a comparison between the image quality of electronically magnified (EM) and geometric, or true, magnification (TM) mammographic images. MATERIALS AND METHODS: One Computed Radiography (CR), one Digital Radiography (DR) and two screen-film (S-F) imaging systems were investigated. A Contrast-Detail Mammography (CDMAM) phantom was used as a test object. Three contact images and three sets of TM images with a magnification factor of 1.8 were taken on all systems. Software was used to zoom the contact images by a factor of 1.8 to produce EM images. Two observers evaluated all of the images. An Image Quality Figure and contrast detail curve were used to analyze the observer data and Mann-Whitney U-tests were performed to determine the statistical significance of the results. RESULTS: No significant differences were found between soft copy and hard copy for any imaging modality. No significant difference in contrast detail detectability (CDD) was seen between EM images from the two digital systems and TM images on S-F systems. The results for the DR EM images and S-F TM images also showed no differences. The CDD of DR TM images was significantly better than both EM and S-F TM images. CONCLUSION: Digitally zoomed images offer the same level of CDD as S-F TM images, and so may be viably used in their place. DR systems offer greater CDD than conventional S-F images, when comparing the TM images. This implies that doses can be greatly reduced for TM views using DR systems, while maintaining acceptable image quality.

Breast tissue classification using x-ray scattering measurements and multivariate data analysis.

This study utilized two radiation scatter interactions in order to differentiate malignant from non-malignant breast tissue. These two interactions were Compton scatter, used to measure the electron density of the tissues, and coherent scatter to obtain a measure of structure. Measurements of these parameters were made using a laboratory experimental set-up comprising an x-ray tube and HPGe detector. The breast tissue samples investigated comprise five different tissue classifications: adipose, malignancy, fibroadenoma, normal fibrous tissue and tissue that had undergone fibrocystic change. The coherent scatter spectra were analysed using a peak fitting routine, and a technique involving multivariate analysis was used to combine the peak fitted scatter profile spectra and the electron density values into a tissue classification model. The number of variables used in the model was refined by finding the sensitivity and specificity of each model and concentrating on differentiating between two tissues at a time. The best model that was formulated had a sensitivity of 54% and a specificity of 100%.

The use of Compton scattering to differentiate between classifications of normal and diseased breast tissue.

This study describes a technique for measuring the electron density of breast tissue utilizing Compton scattered photons. The Kalpha2 line from a tungsten target industrial x-ray tube (57.97 keV) was used and the scattered x-rays collected at an angle of 30 degrees . At this angle the Compton and coherent photon peaks can be resolved using an energy dispersive detector and a peak fitting algorithm. The system was calibrated using solutions of known electron density. The results obtained from a pilot study of 22 tissues are presented. The tissue samples investigated comprise four different tissue classifications: adipose, malignancy, fibroadenoma and fibrocystic change (FCC). It is shown that there is a difference between adipose and malignant tissue, to a value of 9.0%, and between adipose and FCC, to a value of 12.7%. These figures are found to be significant by statistical analysis. The differences between adipose and fibroadenoma tissues (2.2%) and between malignancy and FCC (3.4%) are not significant. It is hypothesized that the alteration in glucose uptake within malignant cells may cause these tissues to have an elevated electron density. The fibrotic nature of tissue that has undergone FCC gives the highest measure of all tissue types.

(R)-2-(4-Phenylbutyl)dihydrobenzofuran derivatives as melatoninergic agents.

(R)-2-(4-Phenylbutyl)dihydrobenzofuran derivatives (e.g., 3 and 4) were synthesized as novel melatoninergic ligands with significantly lower vasoconstrictive activity in vitro in the rat tail artery. Binding affinity assays were performed on cloned human MT1 and MT2 receptors stably expressed in NIH3T3 cells.

N-[2-[2-(4-Phenylbutyl)benzofuran-4-yl]cyclopropylmethyl]acetamide: an orally bioavailable melatonin receptor agonist.

N-[2-[2-(4-Phenylbutyl)benzofuran-4-yl]cyclopropylmethyl]acetamide 3a was synthesized as an orally bioavailable agonist at MT1 and MT2 melatonin receptors with significantly low vasoconstrictive activity.

Synthesis and structure-activity relationship of novel benzoxazole derivatives as melatonin receptor agonists.

A series of benzoxazole derivatives was synthesized and evaluated as melatoninergic ligands. The binding affinity of these compounds for human MT(1) and MT(2) receptors was determined using 2-[(125)I]-iodomelatonin as the radioligand. From this series of benzoxazole derivatives, compounds 14 and 17 were identified as melatonin receptor agonists.

4-Substituted anilides as selective melatonin MT2 receptor agonists.

A series of 4-substituted anilides with human melatonergic affinity is reported. Butyramides 26, 39, 42, 52, 57, and 58 all demonstrated subnanomolar MT(2) binding affinity and MT(2) selectivity of at least 70-fold over the MT(1) receptor. Compound 26 demonstrated full agonism at the MT(2) receptor.