Test-set results can predict participants' development in breast-screen cancer detection: An observational cohort study.

Background and Aim: Test-sets are standardized assessments used to evaluate reader performance in breast screening. Understanding how test-set results affect real-world performance can help refine their use as a quality improvement tool. The aim of this study is to explore if mammographic test-set results could identify breast-screening readers who improved their cancer detection in association with test-set training. Methods: Test-set results of 41 participants were linked to their annual cancer detection rate change in two periods oriented around their first test-set participation year. Correlation tests and a multiple linear regression model investigated the relationship between each metric in the test-set results and the change in detection rates. Additionally, participants were divided based on their improvement status between the two periods, and Mann-Whitney U test was used to determine if the subgroups differed in their test-set metrics. Results: Test-set records indicated multiple significant correlations with the change in breast cancer detection rate: a moderate positive correlation with sensitivity (0.688, p < 0.001), a moderate negative correlation with specificity (-0.528, p < 0.001), and a low to moderate positive correlation with lesion sensitivity (0.469, p = 0.002), and the number of years screen-reading mammograms (0.365, p = 0.02). In addition, the overall regression was statistically significant (F (2,38) = 18.456 p < 0.001), with an R² of 0.493 (adjusted R² = 0.466) based on sensitivity (F = 27.132, p < 0.001) and specificity (F = 9.78, p = 0.003). Subgrouping the cohort based on the change in cancer detection indicated that the improved group is significantly higher in sensitivity (p < 0.001) and lesion sensitivity (p = 0.02) but lower in specificity (p = 0.003). Conclusion: Sensitivity and specificity are the strongest test-set performance measures to predict the change in breast cancer detection in real-world breast screening settings following test-set participation.

Association between Family History of Breast Cancer and Breast Density in Saudi Premenopausal Women Participating in Mammography Screening.

BACKGROUND: Mammographic density and family history of breast cancer (FHBC) are well-established independent factors affecting breast cancer risk; however, the association between these two risk factors in premenopausal-screened women remains unclear. The aim of this study is to investigate the relationship between mammographic density and FHBC among Saudi premenopausal-screened women. METHODS: A total of 446 eligible participants were included in the study. Mammographic density was assessed qualitatively using the Breast Imaging Reporting and Data System (BIRADS 4th edition). Logistic regression models were built to investigate the relationship between mammographic density and FHBC. RESULTS: Women with a family history of breast cancer demonstrated an 87% greater chance of having dense tissue than women without a family history of breast cancer (95% CI: 1.14-3.08; p = 0.01). Having a positive family history for breast cancer in mothers was significantly associated with dense tissue (adjusted odds ratio (OR): 5.6; 95% CI: 1.3-24.1; p = 0.02). CONCLUSION: Dense breast tissue in Saudi premenopausal women undergoing screening may be linked to FHBC. If this conclusion is replicated in larger studies, then breast cancer risk prediction models must carefully consider these breast cancer risk factors.

See something, say something: the coroner's perspective.

The communicating safely policy, publicised by the catchphrase See Something, Say Something was released by the Medical Radiation Practice Board of Australia in 2019. It was developed to support medical radiation practitioners (MRPs) upholding the obligation to communicate urgent or unexpected findings in a timely manner, when identified on medical images. Prior to this policy being part of the professional capabilities, several untimely deaths occurred-the majority of whose causal factors could have been mitigated if imaging findings were urgently communicated by MRPs. This commentary summarises three coronial inquests that involved MRPs, discusses how these coronial findings are reflected in the communicating safely policy and provides some recommendations for the profession to ensure this policy is enacted in clinical practice.

Clinical history and incidental abnormality detection in endodontic cone beam computed tomography.

Purpose: To assess the effect of clinical history on incidental abnormality detection, false positive (FP) marks, and diagnostic confidence in endodontic cone beam computed tomography (CBCT) imaging. Approach: A reader performance study using a free-response, factorial study design was undertaken, which accounted for changes in the independent variables: native case type, native case severity, reader type, and reading modality. Twenty-three readers interpreted 26 cases (18 diseased and 8 non-diseased) twice, once with and once without access to clinical history. Each case had at least one incidental abnormality that was not a native endodontic finding. Lesion localization (LL), non-localizations (FPs), and diagnostic confidence (rating 2, 3, or 4: lowest, middle, and highest, respectively) of incidental abnormalities were analyzed. Results: Clinical history increased the detection of incidental abnormalities in non-diseased subtle cases (76 versus 59, p=0.04). Reader experience and monthly CBCT reading volume did not affect incidental abnormality detection. FPs were neither affected by clinical history nor reader characteristics. The highest confidence rating was most often used in each case type when clinical history was available. For this rating, history had significantly greater LLs in subtle diseased (53 versus 41, p=0.03) and non-diseased images (53 versus 33, p=0.02). Conclusions: Clinical history improved the detection of incidental endodontic abnormalities in non-diseased subtle CBCT images and did not affect the number of FP marks. Reader confidence in correctly identified abnormalities was higher with clinical history when disease and non-disease were subtle but was not associated with an improvement in diagnostic performance.

Determinants of an integrated cervical cancer screening services in primary healthcare: sharing lessons from Kisumu, Kenya.

Background: The successful integration of cervical cancer screening service (CCASS) into primary healthcare's routine services depends on locality-specific and context-based service determinants. Objective: This paper aims to identify the abovementioned determinants and discusses how health administrators can manage their influence on CCASS delivery at the primary healthcare level. Methods: We conducted in-depth face-to-face interviews using a structured questionnaire with CCASS nurse providers and managers in four randomly selected primary health facilities. Information on the method(s) of screening utilised, the challenges faced, and the changes observed in CCASS provision were collected. Service managers were asked how they managed unplanned CCASS disruption, factors influencing CCASS replication, and aftercare support to cancer-affected women. Nurse providers were interviewed on the management of CCASS awareness and critical changes required to sustain CCASS service effectiveness. We used a constant interactive and inductive approach for data analysis. Results: Nine thematic categories of CCASS determinants were identified: 'cultural', 'socioeconomic', 'individual', 'health system', 'evidence-based operations', 'outcome-based resourcing', 'workflow improvement and standardisation', 'inclusive partner's management', 'utilisation'. These determinants were grouped into three domains: 'conceptual', 'outcomes', and 'growth' domains, to correspond to clusters of determinants that are likely to influence the CCASS lifecycle in its formative, continuous delivery or productivity, and reproductive phases. Conclusions: The findings show that sustaining an efficient integrated CCASS delivery at the PHC level requires phase-appropriate continuous adaptive improvements of service determinants within that locality. Results: Nine thematic categories of CCASS determinants were identified: 'cultural', 'socioeconomic', 'individual', 'health system', 'evidence-based operations', 'outcome-based resourcing', 'workflow improvement and standardisation', 'inclusive partner's management', 'utilisation'. These determinants were grouped into three domains: 'conceptual', 'outcomes', and 'growth' domains, to correspond to clusters of determinants that are likely to influence the CCASS lifecycle in its formative, continuous delivery or productivity, and reproductive phases. Conclusions: The findings show that sustaining an efficient integrated CCASS delivery at the PHC level requires phase-appropriate continuous adaptive improvements of service determinants within that locality.

Reliability of radiologists' first impression when interpreting a screening mammogram.

Previous studies showed that radiologists can detect the gist of an abnormality in a mammogram based on a half-second image presentation through global processing of screening mammograms. This study investigated the intra- and inter-observer reliability of the radiologists' initial impressions about the abnormality (or "gist signal"). It also examined if a subset of radiologists produced more reliable and accurate gist signals. Thirty-nine radiologists provided their initial impressions on two separate occasions, viewing each mammogram for half a second each time. The intra-class correlation (ICC) values showed poor to moderate intra-reader reliability. Only 13 radiologists had an ICC of 0.6 or above, which is considered the minimum standard for reliability, and only three radiologists had an ICC exceeding 0.7. The median value for the weighted Cohen's Kappa was 0.478 (interquartile range = 0.419-0.555). The Mann-Whitney U-test showed that the "Gist Experts", defined as those who outperformed others, had significantly higher ICC values (p = 0.002) and weighted Cohen's Kappa scores (p = 0.026). However, even for these experts, the intra-radiologist agreements were not strong, as an ICC of at least 0.75 indicates good reliability and the signal from none of the readers reached this level of reliability as determined by ICC values. The inter-reader reliability of the gist signal was poor, with an ICC score of 0.31 (CI = 0.26-0.37). The Fleiss Kappa score of 0.106 (CI = 0.105-0.106), indicating only slight inter-reader agreement, confirms the findings from the ICC analysis. The intra- and inter-reader reliability analysis showed that the radiologists' initial impressions are not reliable signals. In particular, the absence of an abnormal gist does not reliably signal a normal case, so radiologists should keep searching. This highlights the importance of "discovery scanning," or coarse screening to detect potential targets before ending the visual search.

Periapical Radiography versus Cone Beam Computed Tomography in Endodontic Disease Detection: A Free-response, Factorial Study.

AIM: To assess and compare reader performance in interpreting digital periapical (PA) radiography and cone beam computed tomography (CBCT) in endodontic disease detection, using a free-response, factorial model. MATERIALS AND METHODS: A reader performance study of 2 image test sets was undertaken using a factorial, free-response design, accounting for the independent variables: case type, case severity, reader type, and imaging modality. Twenty-two readers interpreted 60 PA and 60 CBCT images divided into 5 categories: diseased-subtle, diseased-moderate, diseased-obvious, nondiseased-subtle, and nondiseased-obvious. Lesion localization fraction, specificity, false positive (FP) marks, and the weighted alternative free-response receiver operating characteristic figure of merit were calculated. RESULTS: CBCT had greater specificity than PA in the obvious nondiseased cases (P = .01) and no significant difference in the subtle nondiseased category. Weighted alternative free-response receiver operating characteristic values were higher for PA than CBCT in the subtle diseased (P = .02) and moderate diseased (P = .01) groups with no significant difference between in the obvious diseased groups. CBCT had higher mean FPs than PA (P < .05) in subtle diseased cases. Mean lesion localization fraction in the moderate diseased group was higher in PA than CBCT (P = .003). No relationships were found between clinical experience and all diagnostic performance measures, except for in the obvious diseased CBCT group, where increasing experience was associated mean FP marks (P = .04). CONCLUSIONS: Reader performance in the detection of endodontic disease is better with PA radiography than CBCT. Clinical experience does not impact upon the accuracy of interpretation of both PA radiography and CBCT.

Do Reader Characteristics Affect Diagnostic Efficacy in Screening Mammography? A Systematic Review.

To examine reader characteristics associated with diagnostic efficacy in the interpretation of screening mammograms. A systematic search of the literature was conducted using databases such as Cochrane, Scopus, Medline, Embase, Web of Science, and PubMed. Search terms were combined with "AND" or "OR" and included: "Radiologist's characteristics AND performance"; "radiologist experience AND screening mammography"; "annual volume read AND diagnostic efficacy"; "screening mammography performance OR diagnostic efficacy". Studies were included if they assessed reader performance in screening mammography interpretation, breast readers, used a reference standard to assess the performance, and were published in the English language. Twenty-eight studies were reviewed. Increasing reader's age was associated with lower false positive rates. No association was found between gender and performance. Half of the studies showed no association between years of reading mammograms and performance. Most studies showed that high reading volume was more likely to be associated with increased sensitivity, cancer detection rates (CDR), lower recall rate, and lower false positive rates. Inconsistent associations were found between fellowship training in breast imaging and reader performance. Specialization in breast imaging was associated with better CDR, sensitivity, and specificity. Limited studies were available to establish the association between performance and factors such as time spent in breast imaging (n = 2), screening focus (n = 1), formal rotation in mammography (n = 1), owner of practice (n = 1), and practice type (n = 1). No individual characteristics is associated with versatility in diagnostic efficacy, albeit reading volume and specialization in breast imaging appear to be associated with with increased sensitivity and CDR without significantly affecting other performance metrics.

Exposure index in digital radiography: initial results of awareness and knowledge from Nigerian digital radiography practices.

INTRODUCTION: Exposure Index (EI) is incorporated into Digital Radiography (DR) systems to indicate incorrect exposure to enable matching exposure to the desired speed class of operation. However, knowledge of the utilization of EI by radiographers in a low-income country has not been investigated. METHODS: A pre-tested questionnaire designed using Google forms, with open and close-ended questions was shared online with radiographers working with DR systems in public and private health facilities in some cities located in southern Nigeria. The 32-item questionnaire had two parts: Part A focused on socio-demographic characteristics and Part B focused on the respondents' awareness and knowledge of EI in DR systems. A 5-point Likert scale with 5 test items was used to assess the respondents' knowledge of EI. Statistical analyses were conducted using the Statistical Package for Social Sciences (SPSS) version 21.0. The probability value of p < 0.05 was considered statistically significant. RESULTS: About 8.3% of the respondents had good knowledge of EI in DR systems in spite of the awareness level of 24.7%. The absence of the EI concept in DR curriculum for undergraduates, the lack of EI software in DR systems, and equipment training by the vendor engineers were reasons for the low level of knowledge of EI in DR systems. CONCLUSION: There is low awareness and knowledge of EI by radiographers in this study, which suggests the need to maximize the benefits of EI concepts by ensuring its integration into clinical radiography practice and curriculum for undergraduates program, to improve knowledge, awareness, and practice in DR.

Reducing Unnecessary Biopsies Using Digital Breast Tomosynthesis and Ultrasound in Dense and Nondense Breasts.

Aim: To compare digital breast tomosynthesis (DBT) and ultrasound in women recalled for assessment after a positive screening mammogram and assess the potential for each of these tools to reduce unnecessary biopsies. Methods: This data linkage study included 538 women recalled for assessment from January 2017 to December 2019. The association between the recalled mammographic abnormalities and breast density was analysed using the chi-square independence test. Relative risks and the number of recalled cases requiring DBT and ultrasound assessment to prevent one unnecessary biopsy were compared using the McNemar test. Results: Breast density significantly influenced recall decisions (p < 0.001). Ultrasound showed greater potential to decrease unnecessary biopsies than DBT: in entirely fatty (21% vs. 5%; p = 0.04); scattered fibroglandular (23% vs. 10%; p = 0.003); heterogeneously dense (34% vs. 7%; p < 0.001) and extremely dense (39% vs. 9%; p < 0.001) breasts. The number of benign cases needing assessment to prevent one unnecessary biopsy was significantly lower with ultrasound than DBT in heterogeneously dense (1.8 vs. 7; p < 0.001) and extremely dense (1.9 vs. 5.1; p = 0.03) breasts. Conclusion: Women with dense breasts are more likely to be recalled for assessment and have a false-positive biopsy. Women with dense breasts benefit more from ultrasound assessment than from DBT.

Diagnostic Efficacy across Dense and Non-Dense Breasts during Digital Breast Tomosynthesis and Ultrasound Assessment for Recalled Women.

Background: To compare the diagnostic efficacy of digital breast tomosynthesis (DBT) and ultrasound across breast densities in women recalled for assessment. Methods: A total of 482 women recalled for assessment from January 2017 to December 2019 were selected for the study. Women met the inclusion criteria if they had undergone DBT, ultrasound and had confirmed biopsy results. We calculated sensitivity, specificity, PPV, and AUC for DBT and ultrasound. Results: In dense breasts, DBT showed significantly higher sensitivity than ultrasound (98.2% vs. 80%; p < 0.001), but lower specificity (15.4% vs. 55%; p < 0.001), PPV (61.3% vs. 71%; p = 0.04) and AUC (0.568 vs. 0.671; p = 0.001). In non-dense breasts, DBT showed significantly higher sensitivity than ultrasound (99.2% vs. 84%; p < 0.001), but no differences in specificity (22% vs. 33%; p = 0.14), PPV (69.2% vs. 68.8%; p = 0.93) or AUC (0.606 vs. 0.583; p = 0.57). Around 73% (74% dense and 71% non-dense) and 77% (81% dense and 72% non-dense) of lesions assigned a RANZCR 3 by DBT and ultrasound, respectively, were benign. Conclusion: DBT has higher sensitivity, but lower specificity and PPV than ultrasound in women with dense breasts recalled for assessment. Most lesions rated RANZCR 3 on DBT and ultrasound are benign and may benefit from short interval follow-up rather than biopsy.

An Exploratory Study of Allied Health Students' Experiences of Electronic Medical Records During Placements.

BACKGROUND: Allowing students to access and document in electronic medical records (eMRs) during clinical placements is viewed as critical for ensuring that graduates have a high level of digital proficiency prior to entering the workforce. Limited studies have explored student access to eMRs in health disciplines outside of medicine and nursing. OBJECTIVE: Our main objective was to examine allied health students' experiences and perceptions of the opportunity to develop eMR competencies during their placement, across a range of allied health disciplines and placement settings. METHODS: An explanatory sequential design was used, comprising a quantitative survey (n = 102) followed by qualitative semi-structured interviews (n = 6) with senior allied health students to explore their experiences and perceptions of eMR access during placements. RESULTS: Of the 93 students who responded to the question about their placement eMR, nine (10%) reported their placement site did not use an eMR and four students reported that they were not allowed to access the eMR during their placement. Most students (64%, 54 out of 84) accessed the system using their own credentials, but 31% (26 out of 84) used someone else's log-in and password. Students were satisfied with the eMR training and support received while on placement, but there was significant variability across sites on the level of training and support provided. All students believed that eMR access was beneficial for learning and preparation for work, improved delivery of care, taking ownership of work, and feeling responsible for patient care. CONCLUSION: Providing students with access to eMRs during placements is fundamental to the development of a student's professional identity and to recognizing their role in the delivery of interprofessional patient care. For graduates to be equipped to effectively contribute to multi-disciplinary care in a digital health environment, universities need to work with practice partners to standardize and formalize eMR access, registration, training, and support, and to provide students with early exposure and training on eMRs in university courses.

A machine learning model based on readers' characteristics to predict their performances in reading screening mammograms.

OBJECTIVES: Proposing a machine learning model to predict readers' performances, as measured by the area under the receiver operating characteristics curve (AUC) and lesion sensitivity, using the readers' characteristics. METHODS: Data were collected from 905 radiologists and breast physicians who completed at least one case-set of 60 mammographic images containing 40 normal and 20 biopsy-proven cancer cases. Nine different case-sets were available. Using a questionnaire, we collected radiologists' demographic details, such as reading volume and years of experience. These characteristics along with a case set difficulty measure were fed into two ensemble of regression trees to predict the readers' AUCs and lesion sensitivities. We calculated the Pearson correlation coefficient between the predicted values by the model and the actual AUC and lesion sensitivity. The usefulness of the model to categorize readers as low and high performers based on different criteria was also evaluated. The performances of the models were evaluated using leave-one-out cross-validation. RESULTS: The Pearson correlation coefficient between the predicted AUC and actual one was 0.60 (p < 0.001). The model's performance for differentiating the reader in the first and fourth quartile based on the AUC values was 0.86 (95% CI 0.83-0.89). The model reached an AUC of 0.91 (95% CI 0.88-0.93) for distinguishing the readers in the first quartile from the fourth one based on the lesion sensitivity. CONCLUSION: A machine learning model can be used to categorize readers as high- or low-performing. Such model could be useful for screening programs for designing a targeted quality assurance and optimizing the double reading practice.

Breast cancer detection across dense and non-dense breasts: Markers of diagnostic confidence and efficacy.

BACKGROUND: The impact of radiologists' characteristics has become a major focus of recent research. However, the markers of diagnostic efficacy and confidence in dense and non-dense breasts are poorly understood. PURPOSE: This study aims to assess the relationship between radiologists' characteristics and diagnostic performance across dense and non-dense breasts. MATERIALS AND METHODS: Radiologists specialising in breast imaging (n = 128) who had 0.5-40 (13±10.6) years of experience reading mammograms were recruited. Participants independently interpreted a test set containing 60 digital mammograms (40 normal and 20 abnormal) with similarly distributed breast densities. Diagnostic performance measures were analysed via Jamovi software (version 1.6.22). RESULTS: In dense breasts, breast-imaging fellowship completion significantly improved specificity (p = 0.004), location sensitivity (p = 0.01) and the area under the curve (AUC) of the receiver operating characteristic (p = 0.03). Only participation in BreastScreen reading significantly improved all performance metrics: specificity (p = 0.04), sensitivity (p = 0.005), location sensitivity (p < 0.001) and AUC (p < 0.001). Reading > 100 mammograms weekly significantly improved sensitivity (p = 0.03), location sensitivity (p = 0.001), and AUC (p = 0.03).In non-dense breasts, breast fellowship completion significantly improved sensitivity (p = 0.02), location sensitivity (p = 0.04) and AUC (p = 0.002). Participation in BreastScreen reading and reading > 100 mammograms weekly significantly improved only sensitivity (p = 0.002 and p = 0.003, respectively) and location sensitivity (p < 0.001 and p < 0.001, respectively). CONCLUSION: Participating in screening programs, breast fellowships and reading > 100 mammograms weekly are important indicators of the diagnostic performance of radiologists across dense and non-dense breasts. In dense breasts, optimal performance resulted from participation in a breast screening program.

The Effect of Clinical History on Diagnostic Imaging Interpretation - A Systematic Review.

RATIONALE AND OBJECTIVES: To provide updated information on the effect of clinical history on diagnostic image interpretation and to provide study methodology and design recommendations for future studies assessing the effect of clinical history on diagnostic image performance. MATERIALS AND METHODS: A literature search of Medline, Embase, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases was conducted from database inception to July 21, 2020. Studies comparing diagnostic imaging performance with and without clinical history, using observers reading images under both conditions that used an independent reference standard were included. RESULTS: Twenty-two studies met the inclusion criteria, with 15 showing clinical history improved diagnostic performance. One study reported a decrease in diagnostic performance with clinical history and the remaining six studies found no significant change in performance. Two studies used the free response paradigm with both reporting clinical history increased location sensitivity, decreased specificity and had no overall change in diagnostic performance. The disease spectrum of included cases was largely unreported and a balanced reading design was not used in 19 studies. CONCLUSION: Most published studies found that clinical history improved diagnostic performance. More recent studies accounting for abnormality location and multiple abnormalities showed an increase in false positives and no significant change in overall diagnostic performance with clinical history.

Are chest X-rays valuable for patients presenting to emergency departments with acute abdominal pain?

BACKGROUND: Emergency department patients presenting with acute abdominal pain are often prescribed a chest X-ray; however, the value of chest X-rays in acute abdominal pain is poorly understood. The aim of this study was to assess the value of chest X-rays in acute abdominal pain. METHODS: A retrospective analysis of 944 chest X-rays performed for acute abdominal pain was conducted. Patient clinical information, radiology reports, and findings of other diagnostic investigations were also collected. MedCal® software was used to calculate diagnostic performance of chest X-rays. A Chi-Square test was used to assess the association between positive chest X-ray findings and both age and gender. RESULTS: Of the 944 chest X-rays identified as satisfying inclusion factors, only 10 cases (approximately 1%) demonstrated pathology that was likely to be the cause of the abdominal pain. Further analysis demonstrated the following performance metrics at 95%CI: sensitivity (12.8; 8.78-17.72); specificity (100; 98.4-100); positive predictive value (100%); negative predictive value (52.76; 51.54-53.98); accuracy (55.82; 51.17-60.40). CONCLUSION: Chest X-ray has limited sensitivity and diagnostic value in patients presenting to the emergency department with abdominal pain and does not appear to be a useful diagnostic investigation for abdominal pain.

Do referral guidelines recommend chest x-rays for patients with abdominal pain? A review.

BACKGROUND: Chest X-rays (CXRs) are often requested for patients who present to emergency with abdominal pain, but its benefit to patient management remains unclear. Several guidelines have been developed to ensure that imaging investigations have the highest diagnostic impact. This study aims to compare referral guidelines to establish their recommendations and circumstances for recommendations regarding CXRs for patients with abdominal pain. METHODS: A systematic search of the literature was performed using Medline (via OVID), PubMed, Google, and Google Scholar. Referral guidelines were included if they provided recommendations for imaging of abdominal pain, were based on published evidence, and were broadly utilised. Data related to their recommendations for CXR for abdominal pain was recorded and analysed. RESULTS: Three guidelines supported the use of CXRs in the case of suspected perforation. Two guidelines included CXR for patients presenting with blunt abdominal trauma and severe abdominal pain requiring admission. One of the guidelines included use of CXRs for patients presenting with suspected small bowel obstruction, cholecystitis, and penetrating trauma. Two guidelines recorded no circumstances where the use of CXRs were recommended. CONCLUSION: Published evidence-based guidelines allow for the use of CXRs for patients presenting with abdominal pain in very limited circumstances.