Bridging the communication gap between radiographers and patients to improve chest radiography image acquisition: A multilingual solution in the COVID-19 pandemic

IntroductionA chest X-ray (CXR), taken in full inspiration, is important to ensure pathology in the lungs will not be missed. To achieve this, effective communication on breathing instructions for patients is crucial. During the COVID-19 pandemic, radiographers in Sengkang General Hospital (SKH) were challenged when performing CXR for the patients whose native language is not English. Most of these patients were foreign workers living in the same dormitory which had formed the largest COVID-19 cluster in Singapore. These dormitory residents found it difficult to understand and adhere to breathing instructions, resulting in a suboptimal degree of inspiration when the CXRs were taken. This may ultimately affect the diagnostic value of the radiographs. This paper aims to share and evaluate how radiographers tackled this issue and continued to acquire fully-inspired CXR for the dormitory residents despite the language barrier.MethodsUsing a combination of online survey and retrospective analysis of the rejection rates of CXR done over the period of early April to early June, a team of radiographers evaluated the effectiveness of using audio recordings in managing the issue of not achieving a fully inspired CXR for patients due to language barrier.ResultsThe rejection rate for CXR due to suboptimal inspiration decreased from 26% to 9% upon implementation of the audio recordings. 92.3% of the CXRs taken within this period also fulfilled the criteria of a fully-inspired CXR, as evidenced by having at least 9 posterior ribs seen above the right hemi-diaphragm. Survey results found a fairly balanced number of radiographers who agreed and disagreed that a fully-inspired CXR was achieved for most of their patients after utilisation of translation manuals and audio recordings.ConclusionAfter the implementation of audio recordings, the decrease in rejection rate of CXR and an audit which demonstrated that CXR quality was upheld had proven that the radiographers successfully achieved fully-inspired CXR for suspected COVID-19 patients. This confirmed that using pre-recorded audio instructions was an efficient intervention albeit being a one-way communication, leads to more accurate imaging results, aligning with existing literature on communication experiences between radiographers and patients. Moreover, the decreased rejection rate of CXRs had increased department efficiency consequently reducing departmental expenses in the long run.Implications of practiceGiven that we have an ageing population and the vast majority of the elderly converse in their various dialects, positive feedback from radiographers presented opportunities to expand the translation manual and audio recordings to include local dialects. These can be seamlessly integrated in CXR and other procedures in the hospital setting. To ensure that the translations are culturally sensitive, attention should be paid to the translation process of instructions into other languages and local dialects by enlisting the help of native speakers.     

Correlation of chest radiography findings with the severity and progression of COVID-19 pneumonia

PurposeAim is to assess the temporal changes and prognostic value of chest radiograph (CXR) in COVID-19 patients.Material and methodsWe performed a retrospective study of confirmed COVID-19 patients presented to the emergency between March 07–17, 2020. Clinical & radiological findings were reviewed. Clinical outcomes were classified into critical & non-critical based on severity. Two independent radiologists graded frontal view CXRs into COVID-19 pneumonia category 1 (CoV-P1) with <4 zones and CoV-P2 with ≥4 zones involvement. Interobserver agreement of CoV-P category for the CXR preceding the clinical outcome was assessed using Kendall's τ coefficient. Association between CXR findings and clinical deterioration was calculated along with temporal changes of CXR findings with disease progression.ResultsSixty-two patients were evaluated for clinical features. 56 of these (total: 325 CXRs) were evaluated for radiological findings. Common patterns were progression from lower to upper zones, peripheral to diffuse involvement, & from ground glass opacities to consolidation. Consolidations starting peripherally were noted in 76%, 93% and 48% with critical outcomes, respectively. The interobserver agreement of the CoV-P category of CXRs in the critical and non-critical outcome groups were good and excellent, respectively (τ coefficient = 0.6 & 1.0). Significant association was observed between CoV-P2 and clinical deterioration into a critical status (χ2 = 27.7, p = 0.0001) with high sensitivity (95%) and specificity (71%) within a median interval time of 2 days (range: 0–4 days).ConclusionInvolvement of predominantly 4 or more zones on frontal chest radiograph can be used as predictive prognostic indicator of poorer outcome in COVID-19 patients.     

Agreement between expert thoracic radiologists and the chest radiograph reports provided by consultant radiologists and reporting radiographers in clinical practice: Review of a single clinical site

IntroductionTo compare the clinical chest radiograph (CXR) reports provided by consultant radiologists and reporting radiographers with expert thoracic radiologists.MethodsAdult CXRs (n = 193) from a single site were included; 83% randomly selected from CXRs performed over one year, and 17% selected from the discrepancy meeting. Chest radiographs were independently interpreted by two expert thoracic radiologists (CTR1/2).Clinical history, previous and follow-up imaging was available, but not the original clinical report. Two arbiters compared expert and clinical reports independently. Kappa (Ƙ), Chi Square (χ²) and McNemar tests were performed to determine inter-observer agreement.ResultsCTR1 interpreted 187 (97%) and CTR2 186 (96%) CXRs, with 180 CXRs interpreted by both experts. Radiologists and radiographers provided 93 and 87 of the original clinical reports respectively. Consensus between both expert thoracic radiologists and the radiographer clinical report was 70 (CTR1; Ƙ = 0.59) and 70 (CTR2; Ƙ = 0.62), and comparable to agreement between expert thoracic radiologists and the radiologist clinical report (CTR1 = 76, Ƙ = 0.60; CTR2 = 75, Ƙ = 0.62). Expert thoracic radiologists agreed in 131 cases (Ƙ = 0.48). There was no difference in agreement between either expert thoracic radiologist, when the clinical report was provided by radiographers or radiologists (CTR1 χ = 0.056, p = 0.813; CTR2 χ = 0.014, p = 0.906), or when stratified by inter-expert agreement; radiographer McNemar p = 0.629 and radiologist p = 0.701.ConclusionEven when weighted with chest radiographs reviewed at discrepancy meetings, content of CXR reports from trained radiographers were indistinguishable from content of reports issued by radiologists and expert thoracic radiologists.     

Impact of the COVID-19 pandemic on clinical radiography practice in low resource settings: The Ghanaian radiographers’ perspective

IntroductionThe COVID-19 pandemic has altered the professional practice of all healthcare workers, including radiographers. In the pandemic, clinical practice of radiographers was centred mostly on chest imaging of COVID-19 patients and radiotherapy treatment care delivery to those with cancer. This study aimed to assess the radiographers’ perspective on the impact of the pandemic on their wellbeing and imaging service delivery in Ghana.MethodsA cross-sectional survey of practising radiographers in Ghana was conducted online from March 26th to May 6th, 2020. A previously validated questionnaire that sought information regarding demographics, general perspectives on personal and professional impact of the pandemic was used as the research instrument. Data obtained was analysed using Microsoft Excel® 2016.ResultsA response rate of 57.3% (134/234) was obtained. Of the respondents, 75.4% (n = 101) reported to have started experiencing high levels of workplace-related stress after the outbreak. Three-quarters (n = 98, 73.1%) of respondents reported limited access to any form of psychosocial support systems at work during the study period. Half (n = 67, 50%) of the respondents reported a decline in general workload during the study period while only a minority (n = 18, 13.4%) reported an increase in workload due to COVID-19 cases.ConclusionThis national survey indicated that majority of the workforce started experiencing coronavirus-specific workplace-related stress after the outbreak. Albeit speculative, low patient confidence and fear of contracting the COVID-19 infection on hospital attendance contributed to the decline in general workload during the study period.Implications for practiceIn order to mitigate the burden of workplace-related stress on frontline workers, including radiographers, and in keeping to standard practices for staff mental wellbeing and patient safety, institutional support structures are necessary in similar future pandemics.     

A novel use for routine CBCT imaging during radiotherapy to detect COVID-19

IntroductionThoracic CT is a useful tool in the early diagnosis of patients with COVID-19. Typical appearances include patchy ground glass shadowing. Thoracic radiotherapy uses daily cone beam CT imaging (CBCT) to check for changes in patient positioning and anatomy prior to treatment through a qualitative assessment of lung appearance by radiographers. Observation of changes related to COVID-19 infection during this process may facilitate earlier testing improving patient management and staff protection.MethodsA tool was developed to create overview reports for all CBCTs for each patient throughout their treatment. Reports contain coronal maximum intensity projection (MIP's) of all CBCTs and plots of lung density over time. A single therapeutic radiographer undertook a blinded off-line audit that reviewed 150 patient datasets for tool optimisation in which medical notes were compared to image findings. This cohort included 75 patients treated during the pandemic and 75 patients treated between 2014 and 2017. The process was repeated retrospectively on a subset of the 285 thoracic radiotherapy patients treated between January–June 2020 to assess the efficiency of the tool and process.ResultsThree patients in the n = 150 optimisation cohort had confirmed COVID-19 infections during their radiotherapy. Two of these were detected by the reported image assessment process. The third case was not detected on CBCT due to minimal density changes in the visible part of the lungs.Within the retrospective cohort four patients had confirmed COVID-19 based on RT-PCR tests, three of which were retrospectively detected by the reported process.ConclusionThe preliminary results indicate that the presence of COVID-19 can be detected on CBCT by therapeutic radiographers.Implications for practiceThis process has now been extended to clinical service with daily assessments of all thoracic CBCTs. Changes noted are referred for oncologist review.     

Application of deep learning to identify COVID-19 infection in posteroanterior chest X-rays

IntroductionThe objective of this study was to assess seven configurations of six convolutional deep neural network architectures for classification of chest X-rays (CXRs) as COVID-19 positive or negative.MethodsThe primary dataset consisted of 294 COVID-19 positive and 294 COVID-19 negative CXRs, the latter comprising roughly equally many pneumonia, emphysema, fibrosis, and healthy images. We used six common convolutional neural network architectures, VGG16, DenseNet121, DenseNet201, MobileNet, NasNetMobile and InceptionV3. We studied six models (one for each architecture) which were pre-trained on a vast repository of generic (non-CXR) images, as well as a seventh DenseNet121 model, which was pre-trained on a repository of CXR images. For each model, we replaced the output layers with custom fully connected layers for the task of binary classification of images as COVID-19 positive or negative. Performance metrics were calculated on a hold-out test set with CXRs from patients who were not included in the training/validation set.ResultsWhen pre-trained on generic images, the VGG16, DenseNet121, DenseNet201, MobileNet, NasNetMobile, and InceptionV3 architectures respectively produced hold-out test set areas under the receiver operating characteristic (AUROCs) of 0.98, 0.95, 0.97, 0.95, 0.99, and 0.96 for the COVID-19 classification of CXRs. The X-ray pre-trained DenseNet121 model, in comparison, had a test set AUROC of 0.87.DiscussionCommon convolutional neural network architectures with parameters pre-trained on generic images yield high-performance and well-calibrated COVID-19 CXR classification.     

Adult chest radiograph reporting by radiographers: Preliminary data from an in-house audit programme

AimTo examine the adult chest radiograph (CXR) reporting performance of a reporting radiographer in clinical practice using different audit systems; single radiologist and two radiologists, with clinical review of discordant cases.Materials and methods100 chest radiographs (CXRs) were drawn randomly from a consecutive series of 4800 CXRs which had been reported during a nine month period at a district general hospital by a radiographer after two years of training. Diagnostic outcomes were normal or abnormal, and agreement with the reporting radiographer or not. There was 50% duplication of CXRs reported between three radiologists. Concordance rates were determined for the radiographer-radiologist and inter-radiologist interpretations. Independent clinical review of discordant cases was performed to establish the final diagnosis.ResultsNinety-nine cases were reviewed, with 40 cases deemed abnormal by at least one radiologist. Consensus was found with the radiographers report in 59 normal and 33 abnormal CXRs reviewed by two radiologists (96.7% and 86.8% respectively). Seven CXR reports were discrepant with clinical review: mediastinal lymphadenopathy was missed by both radiologist and radiographer; linear atelectasis was reported by two radiologists but not the radiographer. Three cases were over-interpreted and on two occasions at least one radiologist agreed with the radiographer. There was very high concordance between the radiographer and each radiologist, 96%, 96% and 92% respectively.ConclusionsThis study suggested that regular audit, which incorporates case note review and discrepant reporting within a multidisciplinary setting, should contribute to safe practice.     

A case–control evaluation of pulmonary and extrapulmonary findings of incidental asymptomatic COVID-19 infection on FDG PET-CT

Objectives:To describe the findings of incidental asymptomatic COVID-19 infection on FDG PET-CT using a case–control design.Methods:Incidental pulmonary findings suspicious of asymptomatic COVID-19 infection on FDG PET-CT were classified as a confirmed (positive RT-PCR test) or suspected case (no/negative RT-PCR test). Control cases were identified using a 4:1 control:case ratio. Pulmonary findings were re-categorised by two reporters using the BSTI classification. SUV metrics in ground glass opacification (GGO)/consolidation (where present), background lung, intrathoracic nodes, liver, spleen and bone marrow were measured.Results:7/9 confirmed and 11/15 suspected cases (COVID-19 group) were re-categorised as BSTI 1 (classic/probable COVID-19) or BSTI 2 (indeterminate COVID-19); 0/96 control cases were categorised as BSTI 1. Agreement between two reporters using the BSTI classification was almost perfect (weighted κ = 0.94). SUV_max GGO/consolidation (5.1 vs 2.2; p < 0.0001) and target-to-background ratio, normalised to liver SUV_mean (2.4 vs 1.0; p < 0.0001) were higher in the BSTI 1 & 2 group vs BSTI 3 (non-COVID-19) cases. SUV_max GGO/consolidation discriminated between the BSTI 1 & 2 group vs BSTI 3 (non-COVID-19) cases with high accuracy (AUC = 0.93). SUV metrics were higher (p < 0.05) in the COVID-19 group vs control cases in the lungs, intrathoracic nodes and spleen.Conclusion:Asymptomatic COVID-19 infection on FDG PET-CT is characterised by bilateral areas of FDG avid (intensity > x2 liver SUV_mean) GGO/consolidation and can be identified with high interobserver agreement using the BSTI classification. There is generalised background inflammation within the lungs, intrathoracic nodes and spleen.Advances in knowledge:Incidental asymptomatic COVID-19 infection on FDG PET-CT, characterised by bilateral areas of ground glass opacification and consolidation, can be identified with high reproducibility using the BSTI classification. The intensity of associated FDG uptake (>x2 liver SUV_mean) provides high discriminative ability in differentiating such cases from pulmonary findings in a non-COVID-19 pattern. Asymptomatic COVID-19 infection causes a generalised background inflammation within the mid-lower zones of the lungs, hilar and central mediastinal nodal stations, and spleen on FDG PET-CT.     

Spanish radiographers’ concerns about the COVID-19 pandemic

IntroductionThe current outbreak of COVID-19 has caused worldwide healthcare and social emergency in which healthcare professionals were under extreme work conditions while being fearful of becoming infected or spreading the disease to their relatives. The perceived threat of COVID-19 has the potential to cause severe psychological maladjustment. The aim of the study is to explore Spanish radiographers’ concerns about the COVID-19 pandemic.MethodsThis study was quantitative, observational and cross-sectional. The sample was made up of 546 radiographers working in Spain during the outbreak. The instrument used for analysis was an ad hoc questionnaire with socio-demographic questions and the questionnaire on perception of threat from COVID-19 validate to spanish healthcare professionals.ResultsThe sample consisted of 70.1% of female, 29.7% of male and 0.2% undeclare sex participants. The results showed a high level of a perceived threat from COVID-19 (7.57 ± 0.088), furthermore we observed a high level of threat about the possibility of infecting family members (8.49 ± 0.25), patients (8.33 ± 0.086), and coworkers (8.35 ± 0.084). Furthermore, females have a higher level of a perception of threat to spread infection between patients (r = ?0.136; p = 0.001) and coworkers (r = ?0.118; p = 0.006), than males.ConclusionCOVID-19 pandemic is perceived as a serious threat, being especially concerned about the threat of spreading the infection to family, coworkers, and patients. The perception of risk depends partly on professionals’ gender and family responsibilities.Implications for practiceOur findings suggest that it is recommended that healthcare professionals receive formation to reinforce and improve their emotional competencies for coping successfully with potentially stressful situations like COVI19 pandemic.     

Systematic review and meta-analysis of chest radiograph (CXR) findings in COVID-19

Chest radiography (CXR) is most likely to be the utilized modality for diagnosing COVID-19 and following up on any lung-associated abnormalities. This review provides a meta-analysis of the current literature on CXR imaging findings to determine the most common appearances of lung abnormalities in COVID-19 patients in order to equip medical researchers and healthcare professionals in their efforts to combat this pandemic. Twelve studies met the inclusion criteria and were analyzed. The inclusion criteria consisted of: (1) published in English literature; (2) original research study; (3) sample size of at least 5 patients; (4) reporting clinical characteristics of COVID-19 patients as well as CXR imaging features; and (5) noting the number of patients with each corresponding imaging feature. A total of 1948 patients were included in this study. To perform the meta-analysis, a random-effects model calculated the pooled prevalence and 95% confidence intervals of abnormal CXR imaging findings. Seventy-four percent (74%) (95% CI: 51–92%) of patients with COVID-19 had an abnormal CXR at the initial time of diagnosis or sometime during the disease course. While there was no single feature on CXR that was diagnostic of COVID-19 viral pneumonia, a characteristic set of findings were obvious. The most common abnormalities were consolidation (28%, 95% CI: 8–54%) and ground-glass opacities (29%, 95% CI: 10–53%). The distribution was most frequently bilateral (43%, 95% CI: 27–60%), peripheral (51%, 95% CI: 36–66%), and basal zone (56%, 95% CI: 37–74%) predominant. Contrary to parenchymal abnormalities, pneumothorax (1%, 95% CI: 0–3%) and pleural effusions (6%, 95% CI: 1–16%) were rare.     

COVID-19 follow-up: Chest X-ray findings with clinical and radiological relationship three months after recovery

IntroductionTo evaluate the radiological sequelae of coronavirus disease (COVID-19) in a mid-term follow-up and investigate their relationship with clinical-radiological findings.MethodsThis prospective study included COVID-19 patients who underwent a CXR three months after discharge. The relationship between CXR score at three months after discharge and clinical findings and previous CXR scores, at admission and before the discharge, were evaluated. Then, based on mid-term follow-up CXR score, patients were divided in Group A (score = 0) and Group B (score≥1), and clinical-radiological findings were compared between two Groups. Finally, we calculated the CXR scores at admission and before the discharge with the highest sensitivity and specificity to predict normal and abnormal CXR score at mid-term follow-up.ResultsThe study included 119 patients, mean age 65.9 ± 14.6 years. The oxygen saturation (Sa_O2) (p = 0.0006), the days of hospitalization (p < 0.0001) and the CXR score before the discharge (p = 0.0091) were independent factors to predict the mid-term follow-up CXR score. The Group A, 59 (49.6%) patients, had CXR scores at admission and before the discharge lower than Group B. The CXR scores at admission and before the discharge with the highest sensitivity and specificity to predict normal and abnormal CXR score at mid-term follow-up were, respectively, 3 and 2 (p < 0.0001).ConclusionsThe radiological abnormalities were present in about half patients three months after discharge, which had higher age, previous CXR scores and longer hospitalization. The S_O2, days of hospitalization and previous CXR scores were independent factors for predicting the CXR at three months.Implications for practiceThe radiologist with CXR could play a central role in mid to long-term follow-up of COVID-19, assessing the radiological sequelae of patients and identifying those who might require a closer follow-up.     

UK reporting radiographers’ perceptions of AI in radiographic image interpretation – Current perspectives and future developments

IntroductionRadiographer reporting is accepted practice in the UK. With a national shortage of radiographers and radiologists, artificial intelligence (AI) support in reporting may help minimise the backlog of unreported images. Modern AI is not well understood by human end-users. This may have ethical implications and impact human trust in these systems, due to over- and under-reliance. This study investigates the perceptions of reporting radiographers about AI, gathers information to explain how they may interact with AI in future and identifies features perceived as necessary for appropriate trust in these systems.MethodsA Qualtrics® survey was designed and piloted by a team of UK AI expert radiographers. This paper reports the third part of the survey, open to reporting radiographers only.Results86 responses were received. Respondents were confident in how an AI reached its decision (n = 53, 62%). Less than a third of respondents would be confident communicating the AI decision to stakeholders. Affirmation from AI would improve confidence (n = 49, 57%) and disagreement would make respondents seek a second opinion (n = 60, 70%). There is a moderate trust level in AI for image interpretation. System performance data and AI visual explanations would increase trust.ConclusionsResponses indicate that AI will have a strong impact on reporting radiographers’ decision making in the future. Respondents are confident in how an AI makes decisions but less confident explaining this to others. Trust levels could be improved with explainable AI solutions.Implications for practiceThis survey clarifies UK reporting radiographers’ perceptions of AI, used for image interpretation, highlighting key issues with AI integration.     

Structured reporting of chest CT provides high sensitivity and specificity for early diagnosis of COVID-19 in a clinical routine setting

Objectives:Although chest CT has been widely used in patients with COVID-19, its role for early diagnosis of COVID-19 is unclear. We report the diagnostic performance of chest CT using structured reporting in a routine clinical setting during the early phase of the epidemic in Germany.Methods:Patients with clinical suspicion of COVID-19 and moderate-to-severe symptoms were included in this retrospective study. CTs were performed and reported before RT-PCR results (reference standard) became available. A structured reporting system was used that concluded in a recently described five-grade score (“CO-RADS”), indicating the level of suspicion for pulmonary involvement of COVID-19 from 1 = very low to 5 = very high. Structured reporting was performed by three Radiologists in consensus.Results:In 96 consecutive patients (50 male, mean age 64), RT-PCR was positive in 20 (21%) cases. CT features significantly more common in RT-PCR-positive patients were ground-glass opacities as dominant feature, crazy paving, hazy margins of opacities, and multifocal bilateral distribution (p < 0.05). Using a cut-off point between CO-RADS 3 and 4, sensitivity was 90%, specificity 91%, positive predictive value 72%, negative predictive value 97%, and accuracy 91%. ROC analysis showed an AUC of 0.938.Conclusions:Structured reporting of chest CT with a five-grade scale provided accurate diagnosis of COVID-19. Its use was feasible and helpful in clinical routine.Advances in knowledge:Chest CT with structured reporting may be a provisional diagnostic alternative to RT-PCR testing for early diagnosis of COVID-19, especially when RT-PCR results are delayed or test capacities are limited.     

MRI reporting radiographers - A survey assessment of number and areas of practice within the United Kingdom

IntroductionThe aim of this study was to determine a baseline assessment of the national picture of MRI reporting radiographers within the United Kingdom.MethodA questionnaire was utilised using both open and closed questions, the twenty questions were based on four main themes of those in training, those trained, those no longer reporting and post qualification sign off and expectations. The questionnaire was sent out to multiple special interest and MRI specific groups.ResultsResponses were received from 46 trusts (n = 46) between September 2019 and May 2020. The majority of respondents were from English Trusts (n = 40/46). 31 radiographers from 21 different trusts were training in MRI reporting with the majority of those training to report thoraco-lumbar spines and knees. 80 radiographers from 38 trusts had completed training with 77 of those being trained at one south of England University. 57 radiographers from 35 trusts were in practice with the majority of these reporting thoraco-lumbar spines and knees.ConclusionThis survey provides an insight into the current status of MRI reporting radiographers in the UK. Although courses have been available since 2003, numbers are still low and there are significant geographical and working practice variations. Defined standards of practice and the implementation of a central register would benefit both those in practice and those looking to implement a MRI reporting radiographer service.Implications for practiceThis study gives some baseline evidence of the number and scope of practice of MRI reporting radiographers in the UK.