Paediatric upper limb trauma: what can we do to support a change in radiographic referral practice?

Referral practices for upper limb trauma radiography in children vary. Knowledge of the influence of mechanism of injury and functional anatomy on trauma presentation can reduce unnecessary referrals for multiple concurrent radiographic examinations.

Using Personalized Avatars as an Adjunct to an Adult Weight Loss Management Program: Randomized Controlled Feasibility Study.

BACKGROUND: Obesity is a global public health concern. Interventions rely predominantly on managing dietary intake and increasing physical activity; however, sustained adherence to behavioral regimens is often poor. The lack of sustained motivation, self-efficacy, and poor adherence to behavioral regimens are recognized barriers to successful weight loss. Avatar-based interventions achieve better patient outcomes in the management of chronic conditions by promoting more active engagement. Virtual representations of self can affect real-world behavior, acting as a catalyst for sustained weight loss behavior. OBJECTIVE: We evaluated whether a personalized avatar, offered as an adjunct to an established weight loss program, can increase participant motivation, sustain engagement, optimize service delivery, and improve participant health outcomes. METHODS: A feasibility randomized design was used to determine the case for future development and evaluation of avatar-based technology in a randomized controlled trial. Participants were recruited from general practitioner referrals to a 12-week National Health Service weight improvement program. The main outcome measure was weight loss. Secondary outcome measures were quality-of-life and self-efficacy. Quantitative data were subjected to descriptive statistical tests and exploratory comparison between intervention and control arms. Feasibility and acceptability were assessed through interviews and analyzed using framework approach. Health Research Authority ethics approval was granted. RESULTS: Overall, 10 men (n=7, 70% for routine care and avatar and n=3, 30% for routine care) and 33 women (n=23, 70% for intervention and n=10, 30% for routine care) were recruited. Participants' initial mean weight was greater in the intervention arm than in the routine care arm (126.3 kg vs 122.9 kg); pattern of weight loss was similar across both arms of the study in T0 to T1 period but accelerated in T1 to T2 period for intervention participants, suggesting that access to the self-resembling avatar may promote greater engagement with weight loss initiatives in the short-to-medium term. Mean change in participants' weight from T0 to T2 was 4.5 kg (95% CI 2.7-6.3) in the routine care arm and 5.3 kg (95% CI 3.9-6.8) in the intervention arm. Quality-of-life and self-efficacy measures demonstrated greater improvement in the intervention arm at both T1 (105.5 for routine care arm and 99.7 for intervention arm) and T2 (100.1 for routine care arm and 81.2 for intervention arm). Overall, 13 participants (n=11, 85% women and n=2, 15% men) and two health care professionals were interviewed about their experience of using the avatar program. CONCLUSIONS: Participants found using the personalized avatar acceptable, and feedback reiterated that seeing a future self helped to reinforce motivation to change behavior. This feasibility study demonstrated that avatar-based technology may successfully promote engagement and motivation in weight loss programs, enabling participants to achieve greater weight loss gains and build self-confidence. TRIAL REGISTRATION: ISRCTN Registry 17953876; https://doi.org/10.1186/ISRCTN17953876.

Renal stone detection using a low kilo-voltage paediatric CT protocol - a porcine phantom study.

INTRODUCTION: Reducing tube voltage is an effective dose saving method in computed tomography (CT) assuming tube current is not concurrently increased. Recent innovations in scanner technology now enable CT tube voltage reduction to 70 kV thereby increasing opportunities for dose reduction in paediatric patients, but it is unclear if the increased image noise associated with 70 kV impacts on ability to visualise renal stones accurately. The purpose was to assess detectability of nephrolithiasis using a bespoke paediatric phantom and low kV, non-contrast CT and to assess inter-observer agreement. METHODS: Forty-two renal stones of different size and chemical composition were inserted into porcine kidneys and positioned in a bespoke, water-filled phantom mimicking a 9-year-old child weighing approximately 33kg. The phantom was scanned using 120 and 70 kV CT protocols, and the detectability of the stones was assessed by three radiologists. Absolute agreement and Fleiss' kappa regarding detectability were assessed. RESULTS: The mean diameter of renal stones as measured physically was 4.24 mm ranging from 1 to 11 mm. Four stones were missed by at least one observer. One observer had a sensitivity of 93 and 95% at 70 and 120 kV, respectively, while the sensitivity for observers 2 and 3 was 98% at both kV levels. Specificity was 100% across readers and kV levels. Absolute agreement between the readers at 70 kV was 92% (kappa = 0.86) and 98% (kappa = 0.96) at 120 kV indicating a strong agreement at both kV levels. CONCLUSIONS: The results suggest that lowering the kV does not affect the detection rate of renal stones and may be a useful dose reduction strategy for assessment of nephrolithiasis in children.

Can Dual Energy CT with Fast kV-Switching Determine Renal Stone Composition Accurately?

RATIONALE AND OBJECTIVES: To determine whether a single source computed tomography (CT) system utilizing fast kV switching and low dose settings can characterize (diameter and chemical composition) renal stones accurately when compared infrared spectroscopy. MATERIALS AND METHODS: The chemical composition of 15 renal stones was determined using Fourier transform infrared spectroscopy. The stones were inserted into a porcine kidney and placed within a water tank for CT scanning using both fast kV switching dual energy and standard protocols. Effective atomic number of each stone was measured using scanner software. Stone diameter measurements were repeated twice to determine intra-rater variation and compared to actual stone diameter as measured by micro CT. RESULTS: The chemical composition of three stones (one calcium phosphate and two carbonite apatite) could not be determined using the scanner software. The composition of 10/12 remaining stones was correctly identified using dual energy computed tomography (83% absolute agreement; k = 0.69). No statistical difference (p = 0.051) was noted in the mean stone diameter as measured by clinical CT and micro CT. CONCLUSION: Dual energy computed tomography using fast kV switching may potentially be developed as a low dose clinical tool for identifying and classifying renal stones in vivo supporting clinical decision-making.

Artificial intelligence in diagnostic imaging: impact on the radiography profession.

The arrival of artificially intelligent systems into the domain of medical imaging has focused attention and sparked much debate on the role and responsibilities of the radiologist. However, discussion about the impact of such technology on the radiographer role is lacking. This paper discusses the potential impact of artificial intelligence (AI) on the radiography profession by assessing current workflow and cross-mapping potential areas of AI automation such as procedure planning, image acquisition and processing. We also highlight the opportunities that AI brings including enhancing patient-facing care, increased cross-modality education and working, increased technological expertise and expansion of radiographer responsibility into AI-supported image reporting and auditing roles.

An Evaluation of Image Acquisition Techniques, Radiographic Practice, and Technical Quality in Neonatal Chest Radiography.

BACKGROUND: Neonatal chest radiography is a frequently performed diagnostic examination, particularly in preterm infants where anatomical and/or biochemical immaturity impacts on respiratory function. However, the quality of neonatal radiographic images has been criticized internationally and a prevailing concern has been that radiographers (radiologic technologists) fail to appreciate the unique nature of neonatal and infant anatomical proportions. The aim of this study was to undertake a retrospective evaluation of neonatal chest radiography image acquisition techniques against key technical criteria. METHODS: One hundred neonatal chest radiographs, randomly selected from those acquired in 2014, were retrospectively evaluated. Inclusion criteria for radiograph were as follows: anterior-posterior supine; within 30 days of birth; and with all preprocessed collimation boundaries visible. Image evaluation was systematically undertaken using an image assessment tool. To test for statistical significance, Student's t-test, χ2 test, and logistic regression were undertaken. RESULTS: Only 47% of the radiographs were considered straight in both upper and lower thoraces. The cranial collimation border extended beyond the upper border of the third cervical vertebra in 30% of cases, and the caudal border extended below the lower border of the first lumbar vertebra in 20% of cases, suggesting high possibility of neonatal overirradiation. Upper thorax rotation was significantly associated with head position (χ2 = 10.907; P < .001) as has been stated in many published textbooks internationally, but arm position had no apparent influence on rotation of the upper thorax (χ2 = 5.1260; P = .275). Birth weight was associated with accurate midline centering of central ray (logistic regression; OR = 1.0005; P = .009; CI, 1.00139-1.000957) with greater accuracy observed in images of neonates with higher birth weight. CONCLUSION: This study has highlighted areas for neonatal chest radiography improvement. Importantly, the findings bring into question commonly advocated radiographic techniques relating to arm positioning and assessment of rotation while confirming the importance of other technical factors. These findings begin the work toward developing the evidence base to underpin neonatal chest radiograph acquisition, but further prospective work and multicenter/multinational data comparison are required to confirm the findings.

The use of history to identify anterior cruciate ligament injuries in the acute trauma setting: the 'LIMP index'.

OBJECTIVE: To identify the injury history features reported by patients with anterior cruciate ligament (ACL) injuries and determine whether history may be used to identify patients requiring follow-up appointments from acute trauma services. METHODS: Multisite cross-sectional service evaluation using a survey questionnaire design conducted in the UK. The four injury history features investigated were 'leg giving way at the time of injury', 'inability to continue activity immediately following injury', 'marked effusion' and 'pop (heard or felt) at the time of injury'(LIMP). RESULTS: 194 patients with ACL injury were identified, of which 165 (85.5%) attended an acute trauma service. Data on delay was available for 163 (98.8%) of these patients of which 120 (73.6%) had a follow-up appointment arranged. Patients who had a follow-up appointment arranged waited significantly less time for a correct diagnosis (geometric mean 29 vs 198 days; p<0.001) and to see a specialist consultant (geometric mean 61 vs 328 days; p<0.001). Using a referral threshold of any two of the four LIMP injury history features investigated, 95.8% of patients would have had a follow-up appointment arranged. CONCLUSIONS: Findings support the value of questioning patients on specific injury history features in identifying patients who may have suffered ACL injury. Using a threshold of two or more of the four LIMP history features investigated would have reduced the percentage of patients inappropriately discharged by 22.2%. Evidence presented suggests that this would significantly reduce the time to diagnosis and specialist consultation minimising the chance of secondary complications.

Does radiography advanced practice improve patient outcomes and health service quality? A systematic review.

OBJECTIVE: To investigate the impact of radiographer advanced practice on patient outcomes and health service quality. METHODS: Using the World Health Organization definition of quality, this review followed the Centre for Reviews and Dissemination guidance for undertaking reviews in healthcare. A range of databases were searched using a defined search strategy. Included studies were assessed for quality using a tool specifically developed for reviewing studies of diverse designs, and data were systematically extracted using electronic data extraction pro forma. RESULTS: 407 articles were identified and reviewed against the inclusion/exclusion criteria. Nine studies were included in the final review, the majority (n = 7) focusing on advanced radiography practice within the UK. Advanced practice activities considered were radiographer reporting, leading patient review clinics and barium enema examinations. The articles were generally considered to be of low-to-moderate quality, with most evaluating advanced practice within a single centre. With respect to specific quality dimensions, the included studies considered cost reduction, patient morbidity, time to treatment and patient satisfaction. No articles reported data relating to time to diagnosis, time to recovery or patient mortality. CONCLUSION: Radiographer advanced practice is an established activity both in the UK and internationally. However, evidence of the impact of advanced practice in terms of patient outcomes and service quality is limited. ADVANCES IN KNOWLEDGE: This systematic review is the first to examine the evidence base surrounding advanced radiography practice and its impact on patient outcomes and health service quality.

Assessing Sagittal Rotation on Posteroanterior Chest Radiographs: The Effect of Body Morphology on Radiographic Appearances.

BACKGROUND: Chest radiography is one of the most commonly performed radiographic examinations worldwide. Routinely acquired in the erect posteroanterior (PA) position, a chest radiograph displays substantial amounts of medical information when accurate patient positioning is achieved. However, a rotated PA chest radiograph has reduced diagnostic quality and appearances may mask or mimic chest pathology. Radiographic assessment of patient rotation around the sagittal plane has traditionally been undertaken by assessing the distance between the medial end of the clavicles and a line drawn through the spinous processes at the level of the clavicles. This approach continues to be advocated in radiographic technique textbooks internationally although no identified author has provided criteria to determine when a rotated PA chest radiograph should be repeated; determined the relationship between perceived clavicle to spinous process distance and actual degree of patient rotation; or considered the impact of body morphology, in particular the anteroposterior thoracic diameter, on radiographic appearances of rotation. OBJECTIVES: To determine the impact of anteroposterior chest diameter on radiographic appearances of sagittal rotation on PA chest radiographs. DESIGN: Experimental study. METHODS AND SETTINGS: Sixty computed tomography thorax examinations, stratified for gender, were reviewed and data aggregated to determine average anteroposterior (AP) thoracic dimensions. A bespoke experimental unit was constructed specifically to enable testing of the impact of sagittal rotation on radiographic appearances. The experimental unit was situated within a calibrated circular frame enabling 360° rotation at 1° intervals around a central rotational point. The experimental unit components were varied in 1 cm intervals from 9 cm to 15 cm around the central rotation point to reflect varying AP chest diameters. At each interval, images were acquired at 0, 2, 5, 7, 10, and 15° sagittal rotation using a horizontal central ray, consistent centring point, and a source-image distance of 180 cm. RESULTS: A clear linear relationship between AP thoracic diameter and the radiographic appearances of sagittal rotation was noted. Considering significant rotation to be when the medial end of clavicle overlaps the spinous process on the radiographic image, this appearance occurred at a much smaller degree of rotation on wide AP thoracic diameters (15 cm, 5°) than narrower AP thoracic diameters (9 cm, 10°). CONCLUSIONS: The routine application of the distance between the medial end of the clavicles and a line drawn through the spinous processes at the level of the clavicles as a method of assessing degree of sagittal rotation, diagnostic image quality, and need for repeat is flawed. Persistence in the application of this approach without cognisance of the impact of body morphology on radiographic appearances will result in persons with large AP thoracic diameters being more likely to have a PA chest radiograph repeated for a specified degree of rotation than persons with smaller AP thoracic diameters.

Emergency department image interpretation accuracy: The influence of immediate reporting by radiology.

INTRODUCTION: The misinterpretation of radiographs is recognised as a key source of emergency department (ED) errors, regardless of clinician profession. This article compares ENP and medical staff accuracy in the interpretation of musculoskeletal trauma X-rays between immediate and delayed radiology reporting pathways. METHOD: The data for this study was drawn from a larger pragmatic randomized controlled trial of immediate reporting. Patients were recruited and randomly assigned to immediate or delayed reporting arms and treated according to group assignment. Image interpretive accuracy between ED staff groups and arms was undertaken together with an assessment of the influence of immediate reporting on patient pathways and journey times. RESULTS: Six hundred and seventy-four radiographic examinations were performed (598 patients). There was a significant reduction in the interpretive errors in the immediate reporting arm for all ED clinicians (proportional difference=4.2%; 95% CI [0.017,0.068]; p=0.001), but no significant difference in proportion of interpretive errors was evident between ENPs and medical staff. Patient journey times, discharge and referral rates were not significantly different between study arms, although admission rates varied for medical staff collectively. CONCLUSION: ENP X-ray interpretation accuracy is comparable with that of medical staff, but immediate reporting was seen to reduce errors without increasing patient journey times.

Paper 1: Conceptualizing the Transition from Advanced to Consultant Practitioner: Career Promotion or Significant Life Event?

BACKGROUND: The diversification of nursing and allied health profession (AHP) roles has seen unprecedented growth as organizations have sought to optimize limited health care resources. Within the UK health care system, the nonmedical consultant is viewed as the pinnacle of the clinical career ladder. Yet, nearly 15 years after their introduction, recruitment to these positions remains slow. Criticisms of nonmedical consultant practice include a lack of role clarity, a failure to work across the four domains of consultant practice, a lack of suitable applicants, and poor preparedness of new appointments. Although there is evidence exploring the nature and effectiveness of established consultant roles, little research addresses the development phase of aspiring consultants. OBJECTIVES: To explore the transitional journey experienced by trainee consultant radiographers as they move from advanced to consultant practitioner within a locally devised consultant development programme. DESIGN: Longitudinal qualitative enquiry. METHODS AND SETTINGS: Five trainee consultant radiographers were recruited to a locally devised consultant practice development program within a single UK hospital trust. Semistructured interviews were undertaken at 1, 6, and 12 months with the trainees. RESULTS: A challenging journey was recounted involving five key emotional stages that occurred in a consistent and predictable order (ie, elation, denial, doubt, crisis, and recovery). The identified stages had close parallels with Hopson's Life Events model, suggesting that transition to consultant practice is a significant life event rather than a straightforward job promotion. CONCLUSIONS: Current emphasis on the four domains of practice, although providing a clear framework for expected external role outcomes, overlooks the importance of the internal or subjective career development on the perceived success or failure of the role. Employers, educators, and professional bodies have a responsibility to facilitate aspirational consultants to explore and enhance their internal career development, offering more time to define themselves and their role with support to guide them through the transition journey.

Paper 2: Conceptualizing the Transition from Advanced to Consultant Practitioner: Role Clarity, Self-perception, and Adjustment.

BACKGROUND: Interest in the influence of emotions on behaviour, decision making, and leadership has accelerated over the last decade. Despite this, the influence of emotions on career advancement and behaviour within radiography and radiotherapy has largely been ignored. The ease of transition from one work role to another within an individual's career may be influenced by previous experience, personal characteristics, organizational environment, culture, and the nature of the role itself. Consequently, the transition from the often well-defined role of advanced or specialist practitioner to the more fluid role of consultant practitioner is associated with changing emotions as reported in the first part of this two-part series. What remains unexplored are the emotional triggers that pre-empt each stage in the transition cycle and how our understanding of these might support the successful implementation of consultant practitioner roles. OBJECTIVES: To explore the emotional triggers that pre-empted each stage in the transitional journey of trainee consultant radiographers as they moved from advanced to consultant practitioner within a locally devised consultant development program. DESIGN: Longitudinal qualitative enquiry. METHODS AND SETTINGS: Five trainee consultant radiographers were recruited to a locally devised consultant practice development program within a single UK hospital trust. Semistructured interviews were undertaken at 1, 6, and 12 months with the trainees. RESULTS: Although all trainee consultant radiographers experienced the emotional events described in the first part of this two-part series in a predictable order (ie, elation, denial, doubt, crisis, and recovery), the timing of the events was not consistent. Importantly, four emotional triggers were identified, and the dominance of these and the reaction of individuals to them determined the emotional well-being of the individual over time. CONCLUSIONS: This study provides a unique and hitherto unexplored insight into the transition journey from advanced or specialist practitioner. Importantly, the findings suggest that commonly adopted supportive change interventions may, in fact, trigger the negative emotions they are intended to alleviate and disable rather than enable role transition.

Estimating the effect of nonresponse bias in a survey of hospital organizations.

Nonresponse bias in survey research can result in misleading or inaccurate findings and assessment of nonresponse bias is advocated to determine response sample representativeness. Four methods of assessing nonresponse bias (analysis of known characteristics of a population, subsampling of nonresponders, wave analysis, and linear extrapolation) were applied to the results of a postal survey of U.K. hospital organizations. The purpose was to establish whether validated methods for assessing nonresponse bias at the individual level can be successfully applied to an organizational level survey. The aim of the initial survey was to investigate trends in the implementation of radiographer abnormality detection schemes, and a response rate of 63.7% (325/510) was achieved. This study identified conflicting trends in the outcomes of analysis of nonresponse bias between the different methods applied and we were unable to validate the continuum of resistance theory as applied to organizational survey data. Further work is required to ensure established nonresponse bias analysis approaches can be successfully applied to organizational survey data. Until then, it is suggested that a combination of methods should be used to enhance the rigor of survey analysis.

Accident and emergency radiography: A comparison of radiographer commenting and 'red dotting'.

PURPOSE: The College of Radiographers has called for 'Red Dot' schemes to evolve and has recommended the development of radiographer commenting. The implementation of a radiographer comment scheme assumes that radiographers previously participating in 'red dot' schemes have been accurately recognising radiographic abnormalities and are, therefore, able to comment upon, and describe, such radiographic appearances. Research evidence to support such an assumption is sparse. This study compares the ability of radiographers attending a short course on musculoskeletal trauma to 'red dot' and comment on A&E radiographic appearances. METHODS: This study adopted a pre-test, post-test approach. One hundred and twenty one radiographers attending a short course on musculoskeletal trauma (Bradford Red Dot Course) were invited to undertake an assessment of their ability to recognise ('red dot') and describe (comment upon) radiographic abnormalities at the start and end of the short course. RESULTS: One hundred and fifteen radiographers (n=115/121; 95.0%) completed both the pre- and post-training assessments. Post-training mean scores per case improved on average by 9.8% [p=0.012; 95% CI: 2.4, 17.1] for 'red dots' and 12.7% [p=0.007; 95% CI: 3.8, 21.5] for commenting. However, the difference between mean 'red dot' and commenting scores remained similar with mean radiographer comment scores being 13.7% less than mean 'red dot' scores pre-training and 10.8% less post-training. CONCLUSIONS: The results of this study indicate that the accuracy of radiographer comments was significantly reduced when compared to the accuracy of 'red dots' for the same radiographic images. The clinical significance of these findings for departments wanting to move from a 'red dot' system to a radiographer commenting scheme is that without appropriate training and audit, the quality of service and assistance to the A&E department could be significantly reduced.

Requesting and interpreting trauma radiographs: a role extension for accident & emergency nurses.

Government supported expansion of the nursing role within Accident & Emergency (A&E) departments in the United Kingdom (UK) has begun to break down the traditional barriers to professional practice. Today, many nurses working within A&E departments are both requesting and interpreting radiographic examinations as part of their normal working practice. However, role expansion does not occur without increased responsibility. Unsatisfactory requests for radiography and inaccurate radiographic interpretation may result in inappropriate patient treatment, misuse of resources, patient recall and litigation. Nurses undertaking these role extensions need to ensure that their levels of knowledge and skill to perform the role are appropriate and adequately supported. This article summarises the results of a national questionnaire survey of A&E nurse managers that aimed to identify current working practices, including education, training and limitations to practice, with respect to the requesting and interpretation of trauma radiographs by A&E nurses.

Interpreting trauma radiographs.

BACKGROUND: Many accident and emergency clinicians regard the radiographic image as an extension of the clinical examination, as a provisional diagnosis, based on clinical signs and symptoms, can be confirmed or refuted by inspection of X-rays. However, the value of radiography in this context is not determined by the actual presence of trauma or pathology on the radiograph, but is dependent on the ability of a clinician to identify any trauma or pathology present. Traditionally, the responsibility for interpreting radiographic images within the accident and emergency environment in the United Kingdom (UK) has been with medical clinicians. However, expansion of the nursing role has begun to change the boundaries of professional practice and now many nurses are both requesting and interpreting trauma radiographs. AIM: To ascertain the ability of accident and emergency doctors and nurses to interpret trauma radiographs, and identify whether there is a consistent standard of interpretive accuracy that could be used as a measure of competence. METHODS: A literature review was conducted using the Cochrane Library, Medline and CINAHL databases and the keywords radiographic interpretation, radiographic reporting, accident and emergency and emergency/nurse practitioner. FINDINGS: The ability of accident and nursing doctors and nurses to interpret trauma radiographs accurately varies markedly, and no identified published study has established an appropriate level of accuracy that should be achieved in order to demonstrate satisfactory competence in the interpretation of radiographic images. CONCLUSIONS: Determining a measure of interpretive accuracy that can be used to assess ability to interpret radiographic trauma images is fraught with difficulties. Consequently, nurses may attempt to prove their skills by directly comparing their abilities to those of their medical colleagues. However, as a result of marked variation in the ability of senior house officers to interpret trauma radiographs, a similar ability does not automatically imply that a satisfactory level of ability has been achieved.

The child's right to consent to x-ray and imaging investigations: issues of restraint and immobilization from a multidisciplinary perspective.

Children's rights in healthcare are determined by law but strongly influenced by Piagetian theory and the related personal attitudes of healthcare professionals. While a greater priority has been given to children's rights through the United Nations Convention and in the United Kingdom by means of particular legislation, this does not necessarily translate into child-centred practice. The restraint and immobilization of children are significant issues for health professionals who care for children. This paper argues that professional guidance and healthcare law are ambiguous in this regard, failing to offer direct, objective guidance to the personnel involved. A further degree of complexity is added, if when considering the child's wishes, they differ from those of their parents. It is recommended that an effective resolution of these issues and their consequences demands that healthcare professionals familiarize themselves with the legal and ethical implications of restraining or immobilizing children, and develop a systematic approach to this aspect of practice.