Radiographer abnormality flagging systems in the UK - A preliminary updated assessment of practice.

INTRODUCTION: Radiographer abnormality flagging systems have been in use in the UK for over 30 years, with the guidance of the Society and College of Radiographers indicated that the preliminary clinical evaluation (PCE), or comment, be the preferred system of choice. This study aimed to provide an updated assessment of current practice based upon a previous 2008 study. METHODS: A cross-sectional online survey was disseminated via Twitter and aimed at departmental and reporting leads. It requested information on the types of flagging and reporting systems operated, scope of the systems employed, required education of participants, and the role of audit. RESULTS: Responses were received from 31 Trusts within the UK. Red dot systems were employed in 90% (n = 28) of sites, with 26% (n = 8) undertaking PCE. Skeletal radiographs were most commonly reviewed (90%; n = 28) followed by chest (58%; n = 18) and abdomen (32%; n = 10). Only 13% (n = 4) sites indicated if the image was normal but 71% (n = 22) allowed the radiographer to indicate if they were unsure. There was marked variation in the educational requirements and use of audit. CONCLUSION: Compared to 2008 there appears to be quite minimal change in practices in the UK. There does appear to be some increase in the use of flagging systems generally and a higher proportion of PCE systems in comparison to red dot but the use of education and audit does not necessarily show much development in the past 15 years. IMPLICATIONS FOR PRACTICE: Significant conclusions cannot be drawn due to limited sample size, however, it may support further study and consideration in relation to implementation and potentially standardisation of abnormality detection systems may be justified.

The efficacy of preliminary clinical evaluation for emergency department chest radiographs with trauma presentations in pre- and post-training situations.

INTRODUCTION: The chest X-ray (CXR) is the most frequently performed radiographic examination. This study evaluates radiographers' ability to localise traumatic CXR pathology and provide a preliminary clinical evaluation (PCE) for these cases. METHODS: This observer study was performed in a district general hospital in the United Kingdom (UK). A 58-case image bank was used with 20 positive cases. Participants were awarded a maximum of three points, based on abnormality recognition and descriptive accuracy. Localisation data were recorded with ROCView. Training was delivered via short online recorded tutorials covering an introduction of a systematic search strategy for CXR, how to recognise the common abnormalities covered in the tests, how to structure a PCE and multiple practice cases to review at participants' own pace. Pre- and post-training data was recorded. RESULTS: Nine participants completed the study. Overall, pooled sensitivity remained consistent (78.9%-78.8%) following training, specificity and accuracy showed improvement of 79.0%-89.9% and 78.9%-86.0% respectively. An increase in the number of correct localisations and PCE scores were also evident. Participants performed better at correctly identifying a pneumothorax compared to skeletal abnormalities. CONCLUSION: Improvements in performance were evident for most participants' abnormality localisations and PCE scores, following the training intervention. The study highlighted areas of CXR PCE that may require further training, such as detecting superimposed or subtle abnormalities. IMPLICATIONS FOR PRACTICE: This study provides additional support for the development of PCE systems in additional areas of imaging practice.

What information is required in a preliminary clinical evaluation? A service evaluation.

INTRODUCTION: The preliminary clinical evaluation (PCE) abnormality flagging system is a progression from the red dot system. The need for a PCE service may be reduced by immediate "hot" reporting services, however, PCE can be valuable in those Trusts that do not have a "hot reporting"service, as well as in the out of hours setting. This study aimed to identify what information clinicians require within the PCE to aid decision making. METHODS: Emergency Department (ED) clinicians and Radiology reporters were approached to complete a paper survey seeking their preferences on various aspects of the What, Where, How model, regarding their usefulness. Questions were a combination of multiple choice, Likert scale, and free-text. RESULTS: Thirty participants (20 ED clinicians and 10 Radiology Reporters) provided a 100% response rate. Overall, Where was considered to be most significant (n = 18, 60%), followed by What (n = 11, 37%). Half of participants (n = 15, 50%) considered How to be least significant. ED clinicians found all aspects of the What, Where, How useful, in particular the Where, but to a slightly lesser extent regarding how much displacement was involved. Overall, the information ranked as least useful was how much movement, followed by direction of movement, and type of fracture. The preferred style for a PCE comment is a bullet format. CONCLUSION: PCE content should accommodate the preferences of ED referrers. Our findings suggest clinicians want information pertaining to what the abnormality is (i.e. the type of injury), where it was (more specific than simply which bone) and if displacement is present. IMPLICATIONS FOR PRACTICE: These findings add to the current knowledge base and provide support to the local department when implementing the PCE system.

Radiographers reporting chest X-ray images: Identifying the service enablers and challenges in England, UK.

INTRODUCTION: The chest x-ray (CXR) is the most commonly performed x-ray examination in England, UK. Reporting radiographers provide a cost-effective and safe solution for managing CXR backlogs, but not all Trusts support this service development. This study aimed to establish the service enablers and challenges associated with training and employing radiographers to report CXR images in acute hospital sites in England, UK. METHODS: Approval for this electronic survey was granted in 84 of 146 (58%) Trusts approached. The survey was open for 10 weeks during August to October 2020, comprising of qualitative and quantitative questions. Data was exported in to an Excel spreadsheet where manual thematic analysis was performed. Descriptive statistics were also generated. RESULTS: Sample size was 75 (89% response rate). Thirty-three departments (44%) had at least one trainee. Most departments (n = 53, 71%) employ at least one CXR reporting radiographer. A total of 121/160 (76%) radiographers report CXRs. Number of reporting sessions shows progression. Factors enabling training and employment arise from service improvements, financial pressures, and developing the workforce. The main challenges relate to staffing issues with a number of associated sub-themes. A small faction indicated lack of radiographer interest to report CXRs due to litigation worries; possibly uncovering a new and emerging issue. CONCLUSION: Enablers and challenges associated with radiographers reporting CXRs are similar to previous studies. The growth of CXR reporting radiographers and reporting sessions indicates a continuing reliance on radiographers to contributing to managing CXR backlogs. IMPLICATIONS FOR PRACTICE: It is recommended that potential trainees are explicitly informed of the legal protection that will be provided, to prevent accountability concerns impacting on the continuing progression in this area of advanced practice.

Bounding Global Aerosol Radiative Forcing of Climate Change.

Aerosols interact with radiation and clouds. Substantial progress made over the past 40 years in observing, understanding, and modeling these processes helped quantify the imbalance in the Earth's radiation budget caused by anthropogenic aerosols, called aerosol radiative forcing, but uncertainties remain large. This review provides a new range of aerosol radiative forcing over the industrial era based on multiple, traceable, and arguable lines of evidence, including modeling approaches, theoretical considerations, and observations. Improved understanding of aerosol absorption and the causes of trends in surface radiative fluxes constrain the forcing from aerosol-radiation interactions. A robust theoretical foundation and convincing evidence constrain the forcing caused by aerosol-driven increases in liquid cloud droplet number concentration. However, the influence of anthropogenic aerosols on cloud liquid water content and cloud fraction is less clear, and the influence on mixed-phase and ice clouds remains poorly constrained. Observed changes in surface temperature and radiative fluxes provide additional constraints. These multiple lines of evidence lead to a 68% confidence interval for the total aerosol effective radiative forcing of -1.6 to -0.6 W m-2, or -2.0 to -0.4 W m-2 with a 90% likelihood. Those intervals are of similar width to the last Intergovernmental Panel on Climate Change assessment but shifted toward more negative values. The uncertainty will narrow in the future by continuing to critically combine multiple lines of evidence, especially those addressing industrial-era changes in aerosol sources and aerosol effects on liquid cloud amount and on ice clouds.

An analysis of the structure and brevity of preliminary clinical evaluations describing traumatic abnormalities on extremity x-ray images.

INTRODUCTION: The preliminary clinical evaluation (PCE) system involves the radiographer providing an immediate comment highlighting an abnormality on the x-ray image. This can be a valuable service development though it must be recognised that the structure of the PCE may impede its usefulness. This study aimed to assess radiographers' ability to form a concise description of radiographic abnormalities by evaluating their structure and brevity. METHOD: A convenience sampling approach was used and the study was open to all radiographers (n = 48) in a United Kingdom (UK) hospital. Participants provided a PCE for 35 abnormal appendicular cases, which were assessed for the number of words used, lexical density and Gunning-Fog index; comparisons were made with a gold standard. PCE accuracy was evaluated with a scoring system and statistical analysis was completed with SPSS. RESULTS: 21 participants took part. The mean (SD,range) words used was greater than the gold standard (9.5 (3.89,14.9) vs 5.6 (1.46,7)). The mean (SD,range) lexical density was lower than the gold standard (73.8 (4.02,20.1) vs 100 (0,0)), and the mean Gunning-Fog index was also lower (15.1 (3.79,18.3) vs 20.7 (6.82,22.6)). The mean (SD,range) PCE score was 2.8 (0.34,1.17), compared to 5 (0,0) for the gold standard, and this was a statistically significant difference (t (21) = -29,p = .001). CONCLUSION: Participants used too many words in their PCE comments with reduced descriptive content that did not match the reading level of the gold standard. Areas for suggested improvement in practice include introduction of a comment-forming model with additional education. These findings provide an interesting addition to the growing PCE knowledge base. IMPLICATIONS FOR PRACTICE: Dedicated training prior to implementation and participation, to standardise comment structure, could improve the effectiveness of the PCE system.

Fetal ventricular strain in uncomplicated and selective growth-restricted monochorionic diamniotic twin pregnancies and cardiovascular response in pre-twin-twin transfusion syndrome.

OBJECTIVES: Our primary aim was to confirm whether intertwin discordance in ventricular strain and ductus venosus (DV) time intervals predicts twin-twin transfusion syndrome (TTTS). Secondary aims were to create gestational-age ranges for ventricular strain in uncomplicated monochorionic diamniotic (MCDA) twin pregnancies without selective intrauterine growth restriction (sIUGR) and to characterize the relationship of ventricular strain with gestational age in MCDA twin pregnancies with sIUGR that did not develop TTTS. METHODS: In the period 2015-2018, we enrolled 150 MCDA twin pregnancies consecutively into this prospective, blinded study of global longitudinal left and right ventricular strain. With the observer blinded to twin pairing and pregnancy outcome, videoclips of the four-chamber view, which had been recorded during ultrasound surveillance in the usual window for development of TTTS (16-26 completed gestational weeks), underwent offline measurement of strain. Uncomplicated MCDA twin pregnancies, without sIUGR, were used to test the association between strain, gestational age and estimated fetal weight using mixed-effects multilevel regression. Inter-rater reliability was tested in 208 strain measurements in 31 fetuses from pregnancies which did not develop TTTS and within-fetus variation was assessed in 16 such fetuses, in which multiple four-chamber views were taken on the same day. The effect of sIUGR on strain in otherwise uncomplicated MCDA twin pregnancy was analyzed. MCDA twin pregnancies were defined as 'pre-TTTS' when, having been referred for TTTS evaluation, they did not satisfy Quintero staging criteria, but subsequently developed TTTS requiring laser treatment. MCDA pregnancies which did not develop TTTS comprised the 'non-TTTS' group. Cardiovascular parameters measured in these cases included tissue Doppler parameters and DV early filling time as a percentage of the cardiac cycle (DVeT%). Intertwin strain and DVeT% discordance was compared between non-TTTS and pre-TTTS cases, matched for gestational age. RESULTS: Paired strain data were available for intertwin comparison in 127/150 MCDA twin pregnancies, comprising 14 pre-TTTS and 113 non-TTTS pregnancies, after exclusions. Scans were collected at a median frame rate of 97 (range, 28-220) Hz. Laser therapy was performed at a median gestational age of 20.6 (range, 17.2-26.6) weeks. There were no group differences in right (RV) or left (LV) ventricular strain discordance between 68/113 non-TTTS and 13/14 pre-TTTS MCDA twin pregnancies < 20 completed gestational weeks (RV, P = 0.338; LV, P = 0.932). DVeT% discordance > 3.6% was found in eight of 13 pre-TTTS pregnancies. In non-TTTS pregnancies, the estimated variability in ventricular strain within each twin during the day was high (RV, 19.7; LV, 12.9). However, within each pair (intertwin variation), variability was low (RV, 5.5; LV, 2.9). Interclass correlation reflecting the proportion of total variability represented by the variability between twin pairs was low (RV, 0.22; LV, 0.18). Both RV (P < 0.001) and LV (P = 0.025) strain showed a negative association with gestational age. Among non-TTTS MCDA twin pregnancies, LV strain was, on average, higher by 1.83 in sIUGR compared with normally grown fetuses (P = 0.023), with no statistically significant difference in RV strain (P = 0.271). CONCLUSIONS: Although ventricular strain has been reported previously as a possible predictor of developing TTTS, in this blinded, prospective study, we found no significant intergroup differences in ventricular strain in pre-TTTS compared with age-matched non-TTTS MCDA twin pregnancies. We recommend using DVeT% discordance as a more practical screening tool in MCDA twin pregnancies. This study also provides new information on the changes with gestational age, and the biological and technical variation, of global longitudinal ventricular strain in uncomplicated MCDA twin pregnancies and those with isolated sIUGR. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

A survey assessment of reporting radiographers' scope of practice in the West Midlands region of the United Kingdom.

INTRODUCTION: Radiographers have been providing reporting solutions for a number of years. Given the persistent radiologist vacancies and the increased demand on imaging services, the utilisation of reporting radiographers is widespread across England. Capacity and demand issues may lead to reporting boundaries being extended. The aim was to generate an updated appraisal of participants' scopes of practice in the West Midlands of region of England. METHOD: Reporting radiographers at 11 healthcare institutions across the West Midlands region were invited to participate in an online survey. Topics covered included reporting scope of practice, onward referrals and suggestion of treatments. Descriptive statistics were generated in Microsoft Excel and free responses were analysed manually. RESULTS: Response rate was 47% (40/86). The majority (n = 34, 85%) report Emergency Department skeletal examinations, only 12 (30%) report adult chests and only three (8%) report paediatric chests. Of those permitted to refer to other modalities, 85% (n = 23/27) actively do so. Of those permitted to refer to specialist teams, 97% (n = 31/32) actively do so. Only 23% of all participants (n = 9/40) suggest treatments in their reports. CONCLUSION: An increased number of participants report chest and abdominal examinations than previously identified. Restrictions in paediatric scopes of practice and adult GP chest examinations are also evident. Participants stated they do include recommendations in their reports by referring to other modalities and for specialist opinions. Suggesting treatment is not common practice and is considered an area for further advancement.

Ageing in corrective services: from the perspective of prison chaplains.

The number of older inmates in New South Wales prisons has increased over the past ten years but it is unclear whether corrective services can cater for the increase. The current study reports the results of a qualitative study about ageing in prison. Eight prison chaplains from four corrective facilities in NSW were interviewed using a semi-structured interview schedule. The results of a thematic analysis revealed four main themes: the system, the services, the environment and the inmate. The themes reveal a system that is not designed to cope with an ageing population. Inmates become resentful of what has happened to them rather than for the damage they have done to somebody else. The system lacks processes and programmes to enable proper rehabilitation. The issues raised by the chaplains in terms of services, the environment and the inmates decrease the possibility that an older inmate will adapt to the environment and successfully age in place.

Newly qualified radiographers' perceptions of their abnormality detection abilities and the associated training they received at undergraduate level.

INTRODUCTION: Abnormality detection system use across National Health Service (NHS) hospitals is widespread with radiographer participation considered as fundamental to the role. The "red dot" system is evolving towards the preliminary clinical evaluation (PCE) system. Newly qualified radiographers will be expected to be able to provide accurate descriptive comments. Confidence and training issues may hinder implementation of the PCE system. METHOD: An online quantitative survey approach was used. Participants were sought from 24 major trauma centres (MTC) across England. The sample frame was defined as radiographers who had been qualified less than 2 years. Approval to approach was granted by all local Research & Development departments. Cross-tabulation and correlational statistical analyses were undertaken. RESULTS: Approval to approach radiographers was granted in 17 of the 24 MTCs yielding 85 participants, 63 females and 22 males. The large majority are confident with their red dot skills. Strong correlation exists between university training and PCE confidence. However, almost a third of participants are not confident in describing abnormalities. Thirty percent of participants thought PCE training at university was not suitable, and 55% thought PCE training on placement was not suitable. CONCLUSION: While red dot training at university and placement is considered suitable as it positively affects confidence, participants' views on PCE training are more variable. At university PCE training positively influences confidence in describing abnormalities, but commenting training on placement is recognised as an area for improvement. A larger study is suggested to gain further understanding of any issues hindering widespread PCE implementation.

Electronic control of coherence in a two-dimensional array of photonic crystal surface emitting lasers.

We demonstrate a semiconductor PCSEL array that uniquely combines an in-plane waveguide structure with nano-scale patterned PCSEL elements. This novel geometry allows two-dimensional electronically controllable coherent coupling of remote vertically emitting lasers. Mutual coherence of the PCSEL elements is verified through the demonstration of a two-dimensional Young's Slits experiment. In addition to allowing the all-electronic control of the interference pattern, this type of device offers new routes to power and brightness scaling in semiconductor lasers, and opportunities for all-electronic beam steering.

Depressive symptoms among help-seeking Latinas in a disadvantaged, urban, northeastern community mental health center.

This study examined racial/ethnic differences in self-reported depressive symptoms in a clinical population at a northeastern community mental health center. Two hundred eighty-two individuals presenting for mental health intake completed the Beck Depression Inventory-II in either English or Spanish. Latinas reported higher severity of depressive symptoms compared to both African Americans and non-Latina whites. Latinas showed higher levels on both the somatic and the affective/cognitive scales of the BDI-II. These findings differ somewhat from previous reports, some of which suggest that Latinas exhibit elevation specifically in somatic symptoms. Findings are discussed in terms of their implications for assessment and treatment.

Maternal and infant predictors of attendance at Neonatal Follow-Up programmes.

BACKGROUND: Neonatal Follow-Up (NFU) programmes provide health services for families of infants at high risk of developmental problems following difficult or extremely premature birth: yet, up to 30% of families do not attend these programmes with their infants. METHODS: The study objective was to determine maternal and infant factors that predicted attendance at NFU programmes. Utilizing Andersen's Behavioural Model of Health Services Use, a prospective two-phase multi-site descriptive cohort study was conducted in three Canadian Neonatal Intensive Care Units (NICU) that refer to two affiliated NFU programmes. In Phase 1, 357 mothers completed standardized questionnaires that addressed maternal and infant factors, prior to their infants' NICU discharge. In Phase 2, attendance at NFU was followed at three time points over a 12-month period. Factors of interest included predisposing factors (e.g. demographic characteristics and social context); enabling factors (e.g. social support, travel distance, and income); and infant illness severity (i.e. needs factors). Multivariate logistic regression was used to estimate the odds ratio for each independent factor. RESULTS: Mothers parenting alone, experiencing higher levels of worry about maternal alcohol or drug use, or at greater distances from NFU were less likely to attend. Mothers experiencing higher maternal stress at the time of the infant's NICU hospitalization were more likely to attend NFU. No infant factors were predictive of NFU attendance. CONCLUSIONS: Mothers at risk of not attending NFU programmes with their infants require better identification, triage, referral and additional support to promote engagement with NFU programmes and improved quality of life for their high-risk infants.

Comparison of the effect of intratesticular lidocaine/bupivacaine vs. saline placebo on pain scores and incision site reactions in dogs undergoing routine castration.

Post-operative pain scores and incision site reactions were compared in healthy dogs undergoing routine castration at a county animal shelter and assigned to two treatment groups, namely: (1) lidocaine/bupivacaine (1mg/kg lidocaine+1mg/kg bupivacaine mixture; n=17), or (2) placebo (0.9% saline; n=16), administered via intratesticular injection. Dogs were injected with an equivalent volume of solution based on bodyweight. Premedication, induction and anesthetic maintenance protocols were identical in all animals. Pain scores were assessed at 15min, 60min, 120min and 24h post-recovery from anesthesia. Surgical site evaluation based on swelling and bruising was evaluated at 24h. The addition of lidocaine/bupivacaine did not impact pain scores compared to the saline placebo (P>0.05). Incision site reactions were statistically similar between the two groups.

Who is paying the price? Loss of health insurance coverage early in psychosis.

OBJECTIVE: Discontinuities in health insurance coverage may make it difficult for individuals early in psychosis to receive the services that are critical in determining long-term outcome. This study reports on the rates and continuity of insurance coverage among a cohort of early-psychosis patients enrolled in Specialized Treatment Early in Psychosis (STEP) at the Connecticut Mental Health Center. METHODS: Insurance status at baseline, six months, and 12 months was collected from 82 participants from a combination of self-reports, clinical chart review, clinician reports, and a database maintained by the state Department of Social Services. RESULTS: A total of 34 participants did not know whether they had health insurance or did not appear for follow-up assessments at six and 12 months. Among the remaining 48 participants, at baseline 18 had private insurance, 13 had public insurance, and 16 had no insurance. By the 12-month assessment, 13 (72%) privately insured and five (38%) publicly insured participants had lost coverage; less than one-third of the 48 participants (N=14) maintained continuous coverage. CONCLUSIONS: Specialty services for individuals experiencing early psychosis should address the difficulty of maintaining health insurance coverage during a period of illness in which continuity of care is critical to recovery.

Working out the kinks: testing the feasibility of an electronic pain diary for adolescents with arthritis.

BACKGROUND: Current approaches to evaluating pain in children with chronic arthritis suffer from methodological problems. A real-time data capture approach using electronic diaries has been proposed as a new standard for pain measurement. However, there is limited information available regarding the development and feasibility of this approach in children. OBJECTIVES: The aim of the present study was to pilot test the e-Ouch electronic pain diary in terms of compliance and acceptability in adolescents with arthritis to further refine the prototype. METHODS: A descriptive study design -- with two iterative phases of testing, modifying the prototype and retesting -- was used. A purposive sample of 13 adolescents with mild to severe pain and disability was drawn from a large rheumatology clinic in a university-affiliated pediatric tertiary care centre in Canada over a four-week period in December 2004. Participants were signalled with an alarm to use the diary three times per day for a two-week period. Adolescents completed an electronic diary acceptability questionnaire. RESULTS: Overall mean compliance rates for phases 1 and 2 were 72.9% and 70.5%, respectively. Compliance was affected by the timing of data collection and technical difficulties. Children rated the diary as highly acceptable and easy to use. Phase 1 testing revealed aspects of the software program that affected compliance, which were subsequently altered and tested in phase 2. No further technical difficulties arose in phase 2 testing. CONCLUSIONS: Feasibility testing is a crucial first step in the development of electronic pain measures before use in clinical and research practice.

A review of systematic reviews on pain interventions in hospitalized infants.

BACKGROUND: Hospitalized infants undergo multiple, repeated painful procedures. Despite continued efforts to prevent procedural pain and improve pain management, clinical guidelines and standards frequently do not reflect the highest quality evidence from systematic reviews. OBJECTIVE: To critically appraise all systematic reviews on the effectiveness of procedural pain interventions in hospitalized infants. METHODS: A structured review was conducted on published systematic reviews and meta-analyses of pharmacological and nonpharmacological interventions of acute procedural pain in hospitalized infants. Searches were completed in the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, CINAHL and PsycINFO. Two reviewers independently selected articles for review and rated the methodological quality of the included reviews using a validated seven-point quality assessment measure. Any discrepancies were resolved by a third reviewer. RESULTS: Of 1469 potential systematic reviews on interventions for painful procedures in hospitalized infants, 11 high-quality reviews were included in the analysis. Pharmacological interventions supported by research evidence included premedication for intubation, dorsal penile nerve block and EMLA (AstraZeneca Canada, Inc) for circumcision, and sucrose for single painful procedures. Non-nutritive sucking, swaddling, holding, touching, positioning, facilitative tucking, breast feeding and supplemental breast milk were nonpharmacological interventions supported for procedural pain. CONCLUSION: There is a growing number of high-quality reviews supporting procedural pain management in infants. Ongoing research of single, repeated and combined pharmacological and nonpharmacological interventions is required to provide the highest quality evidence to clinicians for decision-making on optimal pain management.