Recent Submissions

  • Workplace factors impacting the wellbeing of diagnostic radiographers in clinical practice: A literature review

    Ismail, Yumna (2024-07-10)
    Introduction: The Coronavirus (COVID-19) pandemic resulted in an emphasis on external factors affecting the wellbeing of staff within the National Health Service. There is a national shortage of diagnostic radiographers in the United Kingdom, so maintaining the health and satisfaction of the current radiographic workforce is important. The aim of this literature review is to determine workplace-related factors affecting the wellbeing of diagnostic radiographers in their clinical practice. Methods: An interpretive phenomenological approach was selected to gain an insight of wellbeing from the perspective of radiographers and radiology managers. A systematic literature search was conducted, resulting in 10 core articles which were then thematically analysed. Results: Five themes were identified: Initial waves of COVID-19, Workload and Working Patterns, Mental Health, Sources of Support, and Recognition and Development. Discussion: COVID-19 has had a short and long-term impact on the working practices of radiographers, leading to a risk of burnout. Radiographers appreciated different forms of recognition from managers and support within their team but felt a lack of professional recognition outside the radiology department. Radiographers displayed resilience during the pandemic, using various strategies to cope with emotional challenges. A variety of external support was available to radiographers, but this was often self-directed, with in-person support difficult to access due to working patterns. Conclusion: This review highlights the lack of tailored support addressing radiographers' unique experiences. As imaging modalities have different workloads and varying emotional involvement with patients, further research to provide evidence-based interventions to improve radiographers' mental health is advised.
  • Management of a giant adrenal schwannoma

    Dales, Jolyon; Levy, Miles; Shah, Vikas (2024-07-05)
    In this case report, we present a man in his 60s who presented with an incidentally discovered right adrenal mass, which turned out to be an adrenal schwannoma. This is a very rare tumour that originates from Schwann cells and involves the peripheral nerves. The tumour was removed by open adrenalectomy, and this 15-cm adrenal schwannoma is one of the largest reported in the literature, with none >16 cm having ever been reported. This case highlights the importance of keeping an open mind about the cause of an incidentally discovered adrenal mass, which is an increasingly common way for adrenal tumours to present given the increased access to cross-sectional imaging. As well as presenting the case and the pathological basis behind adrenal schwannomas, we include a review of the literature and a general discussion about incidentally discovered adrenal masses.
  • A new radiological scoring system as a method of assessing sclerotherapy treatment response for aneurysmal bone cysts: A retrospective study

    Hussein, Mohsin (2024-02-23)
    Background A widely accepted set of imaging criteria or classification has not yet been adopted to evaluate response to treatment by percutaneous sclerotherapy for aneurysmal bone cyst (ABC). In this article, we described and illustrated the Royal Orthopaedic Hospital (ROH) scoring system which is a new, reproducible, and objective tool to evaluate the radiological response. We also reported our institutional experience in the efficacy of computed tomography (CT)-guided sclerotherapy for treating such lesions. Patients and Methods A retrospective analysis was conducted for 19 patients who underwent CT-guided sclerotherapy with doxycycline and albumin to treat ABC. Follow-up magnetic resonance imaging, at a minimum of 12 months, was assessed according to the four ROH scoring system parameters: cystic component, fluid-fluid level, presence of consolidation, and cortical integrity. The cumulative score was used to grade response as either: excellent, good, equivocal, or poor. Results Out of 19 patients with a mean age of 17.8 years, 11 cases occurred in the long bones, 5 cases in the pelvis, and 1 in each of the C3 vertebral body, scapula, and talus. The mean parameter of response score for cystic component was 2, fluid-fluid level was 1.3, consolidation was 2, and cortical integrity was 2.1. Four cases showed excellent response, 12 cases showed good response, 2 cases showed equivocal response, and 1 case showed poor response. Interrater reliability was excellent (κ = 0.9). Conclusion The ROH scoring system provides the radiologist and surgeon with an objective method to score imaging parameters of response independently and achieve a grade based on the cumulative score.
  • Oral cavity cancer and its pre-treatment radiological evaluation: a pictorial overview

    Lam, Vincent (2024-05-04)
    Purpose: Oral cavity cancer, primarily squamous cell carcinoma (SCC), is a prevalent malignancy globally, necessitating accurate clinical assessment and staging to enable effective treatment planning. Diagnosis requires biopsy and is followed by surgical resection and reconstruction as the primary therapeutic modality. Imaging plays a pivotal role during this process, aiding in the evaluation of tumour extent, nodal involvement and distant metastases. However, despite its value, both radiologists and clinicians must recognise its inherent limitations. Methods: This pictorial review article aims to illustrate the application of various imaging modalities in the pre-treatment evaluation of oral cavity SCC and highlights potential pitfalls. It underscores the importance of understanding the anatomical subsites of the oral cavity, the diverse patterns of spread tumours exhibit at each site, alongside the role of imaging in facilitating informed management strategies, while also acknowledging its limitations. Results: The review delves into fundamentals of current staging including nodal involvement, while, emphasising imaging strategies and potential limitations. Finally, it touches on the potential of novel radiomic techniques in characterising tumours and predicting treatment response. Conclusions: Pre-treatment oral cavity cancer staging reflects an ongoing quest for enhanced diagnostic accuracy and prognostic prediction. Recognising the value of imaging alongside its limitations fosters a multidisciplinary approach to treatment planning, ultimately improving patient outcomes.
  • Incidental finding of an undifferentiated sarcoma during lower limb Doppler ultrasound: a case report

    Eteng, Rajuno Ernest (2024-05)
    Introduction: Undifferentiated sarcoma is considered a rare and aggressive type of soft tissue sarcoma with the lower extremity reported as the common site for soft tissue sarcomas. Case presentation: We present a rare incidental finding of undifferentiated sarcoma during lower limb Doppler ultrasound with a presenting symptom of right thrombotic-like calf pain in a 49-year-old female. Discussion: On ultrasound, the presented undifferentiated sarcoma appeared as a large heterogeneous, oval-shaped, soft tissue mass deeply seated in the right calf with involvement of the soleus muscle. The features on ultrasound mimicked those of a hematoma; however, the possibility of the lesion being a haematoma was promptly ruled out with the demonstration of internal vascularity on colour Doppler application. The case was then referred to a sarcoma triage multidisciplinary team for a review. Magnetic resonance imaging, computed tomography and biopsy were parts of the diagnostic workup for this case, histology confirmed the soft tissue lesion to be an undifferentiated sarcoma. Emergency above knee amputation of the right leg was performed as part of the patient's treatment. Conclusion: This case report presents a rare incidental finding of undifferentiated sarcoma encountered during lower limb Doppler ultrasound causing thrombotic-like calf pain. Sonographers are encouraged to pay necessary attention and carefully examine any adjacent and incidental soft tissue lesion during lower limb Doppler ultrasound using compression, two-dimensional imaging and colour imaging, especially those that appear with characteristic features of malignancy; urgent referral should be made of such cases to a tertiary soft tissue sarcoma centre for further evaluation and management.
  • MRI reporting radiographers - has there been a progression or regression in numbers and scope of practice?

    Estall, Helen (2024-05-03)
    Introduction: The aim of this study was to determine whether there had been a progression or regression in the numbers and scope of practice of reporting radiographers in Magnetic Resonance Imaging (MRI) in the United Kingdom (UK), using data from a previous study conducted by the author in 2019/20 as a comparison. Methods: Data was gathered via a survey sent to multiple users and groups of MRI Radiographers in the UK. The survey consisted of a questionnaire, using both numerical and free text answers to enable the responders to elaborate on their scope of practice whilst also allowing numerical data to be easily analysed. The responses were analysed for patterns and comparison was made with the data from the previous survey. The questionnaire was based on three main themes of those in training, those trained and those in practice. Results: A total of 62 sites had radiographers in training (n =24) or trained (n = 125) in MRI reporting compared to 46 sites in the previous survey. The majority of responders were from England (n = 56/62) with only a few sites in Scotland (n = 4) and Wales (n = 2). There were 24 radiographers in training, a reduction compared to the previous survey and an increase in the number of radiographers trained (n = 80 to n = 125) and in practice (n = 57 to n = 84). Scope of practice had also increased with the addition of MRCPs, orbits and pituitary. Conclusion: This survey provides evidence that the number and scope of practice of MRI reporting radiographers within the UK has progressed when compared to a previous survey from 2019/20. The numbers however are still low and there remain significant geographical variations. The continued predominance of single handed practice is a concern and the reasons behind this and the slow expansion of skill mix reporting in this modality needs further investigation. Implications for practice: This study provides evidence of the number and scope of practice of the radiographer reporting of MRI examinations in the UK. It also demonstrates that there has been an increase in scope and number of radiographers reporting MRI scans, this will provide evidence and proof of concept for departments looking to initiate or increase this practice.
  • Bilateral cubonavicular and synchronous talocalcaneal tarsal coalition with stress response-case report and review of literature

    Hussein, Mohsin (2023-10-27)
    Tarsal coalition occurs in 1% of the population and represents a congenital failure of segmentation in two or more tarsal bones. It most commonly occurs at the talocalcaneal and calcaneonavicular joint. Although commonly asymptomatic, it may present with pain, rigidity, and pes planus. Cubonavicular, multiple synchronous, and bilateral coalitions are rare but an awareness is required to ensure accurate diagnosis and management. In this article, we presented the first reported case (to the best of our knowledge) of bilateral cubonavicular coalition with synchronous talocalcaneal coalition and stress response within the intermediate cuneiform.
  • Popliteal artery-related pathologies in athletes-a primer for musculoskeletal radiologists

    Thaker, Siddharth (2023-11-23)
    Vascular complications in athletes are common and mimic musculoskeletal injuries such as muscle sprains, fractures, and cartilage abnormalities. They include traumatic vascular injuries and more subtle pathologies like entrapment syndromes, pseudoaneurysms, arterial occlusions, and venous thrombosis. Such vascular complications may be occult on imaging and can be difficult for a musculoskeletal radiologist to diagnose, resulting in a lack of timely diagnosis and potentially limb-threatening consequences. Although the final diagnosis may require multidisciplinary input from orthopaedic, sports and exercise medicine, and vascular and interventional radiology inputs, a musculoskeletal radiologist with prior knowledge of such conditions can be the first to diagnose such conditions aiding the athlete's performance. A musculoskeletal radiologist should pay due attention to anatomical courses of vascular channels and look for potential causes of vascular compression, aberrant myotendinous bands, accessory muscles, etc., before concluding a computed tomography (CT) or magnetic resonance imaging (MRI) as normal. Doppler ultrasound, CT, or MR angiography are commonly employed techniques for primary evaluation, whereas digital subtraction angiography is generally reserved for troubleshooting as advanced dynamic imaging.
  • The bright Easter bunny sign: a useful aide-memoire on MRI for costotransverse joint inflammation in axial spondyloarthritis

    Bansal, T; Rennie, W J (2024-05)
    Aim: To assess the significance of the "bright Easter bunny" sign on magnetic resonance imaging (MRI) to indicate inflammatory costotransverse joint (CtJ) lesions to diagnose axial spondyloarthritis (ax-SpA). Materials and methods: Consecutive cases of patients with ax-SpA from a specialist rheumatology clinic were analysed retrospectively over two cohorts, between 2012-2014 and 2018-2020, to determine newly diagnosed patients under the Assessment of SpondyloArthritis international Society (ASAS) criteria. Biological naive adult patients who underwent spine MRI and sacroiliac imaging with full immunological work-up and a C-reactive protein reading within 3 months of the scan were included. Blinded images were reviewed by experienced musculoskeletal radiologists. Result: From the 1,284 cases that were identified, 40 cases met the inclusion criteria for this study. Seven out of the 40 cases (17.5%) identified inflammatory lesions at the CtJ with five (70%) showing concordance with the bright Easter bunny sign. Conclusion: The bright Easter bunny sign is concordant with inflammatory costotransverse enthesitis. This aide-memoire radiological sign is often on overlooked edge-of-field sections and this emphasises the need to ensure adequate coverage of the CtJ on spine MRI protocols as an important anatomical site of inflammatory change in ax-SpA assessment.
  • Association of epicardial adipose tissue with early structural and functional cardiac changes in Type 2 diabetes

    Ayton, Sarah; Bilak, Joanna; Brady, Emer; Dattani, Abhishek; Deshpande, Aparna; Graham-Brown, Matthew P M; Moss, Alastair J; McCann, Gerry P; Singh, Anvesha; Yeo, Jian (2024-05)
    Background: Dysregulated epicardial adipose tissue (EAT) may contribute to the development of heart failure in Type 2 diabetes (T2D). This study aimed to evaluate the associations between EAT volume and composition with imaging markers of subclinical cardiac dysfunction in people with T2D and no prevalent cardiovascular disease. Methods: Prospective case-control study enrolling participants with and without T2D and no known cardiovascular disease. Two hundred and fifteen people with T2D (median age 63 years, 60 % male) and thirty-nine non-diabetics (median age 59 years, 62 % male) were included. Using computed tomography (CT), total EAT volume and mean CT attenuation, as well as, low attenuation (Hounsfield unit range -190 to -90) EAT volume were quantified by a deep learning method and volumes indexed to body surface area. Associations with cardiac magnetic resonance-derived left ventricular (LV) volumes and strain indices were assessed using linear regression. Results: T2D participants had higher LV mass/volume ratio (median 0.89 g/mL [0.82-0.99] vs 0.79 g/mL [0.75-0.89]) and lower global longitudinal strain (GLS; 16.1 ± 2.3 % vs 17.2 ± 2.2 %). Total indexed EAT volume correlated inversely with mean CT attenuation. Low attenuation indexed EAT volume was 2-fold higher (18.8 cm3/m2 vs. 9.4 cm3/m2, p < 0.001) in T2D and independently associated with LV mass/volume ratio (ß = 0.002, p = 0.01) and GLS (ß = -0.03, p = 0.03). Conclusions: Higher EAT volumes seen in T2D are associated with a lower mean CT attenuation. Low attenuation indexed EAT volume is independently, but only weakly, associated with markers of subclinical cardiac dysfunction in T2D.
  • Late-onset mitochondrial encephalopathy with lactic acidosis and stroke-like episodes and the role of serial imaging

    Ambrogetti, Robert (2024-02-27)
    Mitochondria are essential for human metabolic function. Over 350 genetic mutations are associated with mitochondrial diseases, which are inherited in a matrilineal fashion. In mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS), defective mitochondrial function and resultant impaired cellular energy production compromise vascular perfusion in affected tissues. Early diagnostic criteria suggested the diagnosis should be considered in those under 40. However, a broader range of phenotypes are now recognised, including those that present for the first time later in life. The primary presenting feature in MELAS is a stroke-like episode invariably resulting in patients undergoing neuroradiological imaging. We present a case of a woman with a first presentation of a stroke-like episode and seizures in her 40s who was eventually diagnosed with MELAS. We detail her clinical presentation, treatment and diagnosis, emphasising the role of serial imaging in her diagnosis.
  • Soft tissue tumor imaging in adults: European Society of Musculoskeletal Radiology-Guidelines 2023-overview, and primary local imaging: how and where?

    Rennie, Winston (2023-12-07)
    Objectives: Early, accurate diagnosis is crucial for the prognosis of patients with soft tissue sarcomas. To this end, standardization of imaging algorithms, technical requirements, and reporting is therefore a prerequisite. Since the first European Society of Musculoskeletal Radiology (ESSR) consensus in 2015, technical achievements, further insights into specific entities, and the revised WHO-classification (2020) and AJCC staging system (2017) made an update necessary. The guidelines are intended to support radiologists in their decision-making and contribute to interdisciplinary tumor board discussions. Materials and methods: A validated Delphi method based on peer-reviewed literature was used to derive consensus among a panel of 46 specialized musculoskeletal radiologists from 12 European countries. Statements were scored online by level of agreement (0 to 10) during two iterative rounds. Either "group consensus," "group agreement," or "lack of agreement" was achieved. Results: Eight sections were defined that finally contained 145 statements with comments. Overall, group consensus was reached in 95.9%, and group agreement in 4.1%. This communication contains the first part consisting of the imaging algorithm for suspected soft tissue tumors, methods for local imaging, and the role of tumor centers. Conclusion: Ultrasound represents the initial triage imaging modality for accessible and small tumors. MRI is the modality of choice for the characterization and local staging of most soft tissue tumors. CT is indicated in special situations. In suspicious or likely malignant tumors, a specialist tumor center should be contacted for referral or teleradiologic second opinion. This should be done before performing a biopsy, without exception. Clinical relevance: The updated ESSR soft tissue tumor imaging guidelines aim to provide best practice expert consensus for standardized imaging, to support radiologists in their decision-making, and to improve examination comparability both in individual patients and in future studies on individualized strategies. Key points: • Ultrasound remains the best initial triage imaging modality for accessible and small suspected soft tissue tumors. • MRI is the modality of choice for the characterization and local staging of soft tissue tumors in most cases; CT is indicated in special situations. Suspicious or likely malignant tumors should undergo biopsy. • In patients with large, indeterminate or suspicious tumors, a tumor reference center should be contacted for referral or teleradiologic second opinion; this must be done before a biopsy.
  • Point-of-care ultrasound is a useful adjunct tool to a clinician's assessment in the evaluation of severe hyponatraemia

    Al Alaisi, Salam; Coats, Timothy; Levy, Miles; Melson, Eka; Rahman, Faizanur; Rahman, Latif; Reddy, Narendra; Sardar, Muhammad; Shafiq, Shahriar (2024-01-16)
    Introduction: Hyponatraemia is the most common electrolyte disorder in inpatients resulting mainly from an imbalance in water homeostasis. Intravascular fluid status assessment is pivotal but is often challenging given multimorbidity, polypharmacy and diuretics use. We evaluated the utility of point-of-care ultrasound (POCUS) as an adjunct tool to standard practice for fluid assessment in severe hyponatraemia patients. Methods: Patients presenting with severe hyponatremia (Serum Sodium [Na] < 120 mmol/L; Normal range: 135-145 mol/L), managed by standard care were included. Hyponatraemia biochemistry work-up and POCUS examination were undertaken. Both clinician and POCUS independently assigned one of the three fluid status groups of hypovolaemia, hypervolaemia or euvolaemia. The final diagnosis of three fluid status groups at admission was made at the time of discharge by retrospective case review. Clinician's (standard of care) and POCUS fluid assessments were compared to that of the final diagnosis at the time of discharge. Results: n = 19 patients were included. Median Na on admission was 113 mmol/L (109-116), improved to 129 ± 3 mmol/L on discharge. POCUS showed the higher degree of agreement with the final diagnosis (84%; n = 16/19), followed by the clinician (63%; n = 12/19). A trend towards higher accuracy of POCUS compared to clinician assessment of fluid status was noted (84% vs. 63%, p = 0.1611). Biochemistry was unreliable in 58% (n = 11/19) likely due to renal failure, polypharmacy or diuretic use. Inappropriate emergency fluid management was undertaken in 37% (n = 7/19) of cases based on initial clinician assessment. Thirst symptom correlated to hypovolaemia in 80% (4/5) cases. Conclusion: As subjective clinical and biochemistry assessments of fluid status are often unreliable due to co-morbidities and concurrent use of medications, POCUS can be a rapid objective diagnostic tool to assess fluid status in patients with severe hyponatraemia, to guide accurate emergency fluid management.
  • The role of imaging in the diagnosis, staging and management of the osteochondral lesions of the talus

    Khan, Imran
    Osteochondral lesions of the talus (OLT) represent an abnormality of the articular cartilage and subchondral bone. The abnormality is typically associated with trauma though the exact aetiology remains unknown. Multiple staging systems have been developed to classify the abnormality and management can vary from conservative treatment to different surgical options. Early diagnosis is essential for optimal outcome and all imaging modalities have a role to play in patient management. The aim of this article is to review the pathology, classification, multimodality imaging appearances of OLT and how the imaging affects patient management.
  • Ethnic differences in cardiac structure and function assessed by MRI in healthy South Asian and White European people: a UK Biobank Study

    Alfuhied, Aseel; Arnold, Jayanth; Ayton, Sarah; Bilak, Joanna; Brady, Emer M; Dattani, Abhishek; Gulsin, Gaurav; Graham-Brown, Matthew P; McCann, Gerry P; SIngh, Anvesha; et al.
    Background: Echocardiographic studies indicate South Asian people have smaller ventricular volumes, lower mass and more concentric remodelling than White European people, but there are no data using cardiac MRI (CMR). We aimed to compare CMR quantified cardiac structure and function in White European and South Asian people. Methods: Healthy White European and South Asian participants in the UK Biobank Imaging CMR sub-study were identified by excluding those with a history of cardiovascular disease, hypertension, obesity or diabetes. Ethnic groups were matched by age and sex. Cardiac volumes, mass and feature tracking strain were compared. Results: 121 matched pairs (77 male/44 female, mean age 58±8 years) of South Asian and White European participants were included. South Asian males and females had smaller absolute but not indexed left ventricular (LV) volumes, and smaller absolute and indexed right ventricular volumes, with lower absolute and indexed LV mass and lower LV mass:volume than White European participants. Although there were no differences in ventricular or atrial ejection fractions, LV global longitudinal strain was higher in South Asian females than White European females but not males, and global circumferential strain was higher in both male and South Asian females than White European females. Peak early diastolic strain rates were higher in South Asian versus White European males, but not different between South Asian and White European females. Conclusions: Contrary to echocardiographic studies, South Asian participants in the UK Biobank study had less concentric remodelling and higher global circumferential strain than White European subjects. These findings emphasise the importance of sex- and ethnic- specific normal ranges for cardiac volumes and function.
  • Determining the impact of an artificial intelligence tool on the management of pulmonary nodules detected incidentally on CT (DOLCE) study protocol: a prospective, non-interventional multicentre UK study

    Das, Indrajeet (2024-01-04)
    Introduction: In a small percentage of patients, pulmonary nodules found on CT scans are early lung cancers. Lung cancer detected at an early stage has a much better prognosis. The British Thoracic Society guideline on managing pulmonary nodules recommends using multivariable malignancy risk prediction models to assist in management. While these guidelines seem to be effective in clinical practice, recent data suggest that artificial intelligence (AI)-based malignant-nodule prediction solutions might outperform existing models. Methods and analysis: This study is a prospective, observational multicentre study to assess the clinical utility of an AI-assisted CT-based lung cancer prediction tool (LCP) for managing incidental solid and part solid pulmonary nodule patients vs standard care. Two thousand patients will be recruited from 12 different UK hospitals. The primary outcome is the difference between standard care and LCP-guided care in terms of the rate of benign nodules and patients with cancer discharged straight after the assessment of the baseline CT scan. Secondary outcomes investigate adherence to clinical guidelines, other measures of changes to clinical management, patient outcomes and cost-effectiveness. Ethics and dissemination: This study has been reviewed and given a favourable opinion by the South Central-Oxford C Research Ethics Committee in UK (REC reference number: 22/SC/0142).Study results will be available publicly following peer-reviewed publication in open-access journals. A patient and public involvement group workshop is planned before the study results are available to discuss best methods to disseminate the results. Study results will also be fed back to participating organisations to inform training and procurement activities.
  • Development and validation of open-source deep neural networks for comprehensive chest x-ray reading: a retrospective, multicentre study

    Hopewell, Heath; Das, Indrajeet (2023-12-08)
    Background: Artificial intelligence (AI) systems for automated chest x-ray interpretation hold promise for standardising reporting and reducing delays in health systems with shortages of trained radiologists. Yet, there are few freely accessible AI systems trained on large datasets for practitioners to use with their own data with a view to accelerating clinical deployment of AI systems in radiology. We aimed to contribute an AI system for comprehensive chest x-ray abnormality detection. Methods: In this retrospective cohort study, we developed open-source neural networks, X-Raydar and X-Raydar-NLP, for classifying common chest x-ray findings from images and their free-text reports. Our networks were developed using data from six UK hospitals from three National Health Service (NHS) Trusts (University Hospitals Coventry and Warwickshire NHS Trust, University Hospitals Birmingham NHS Foundation Trust, and University Hospitals Leicester NHS Trust) collectively contributing 2 513 546 chest x-ray studies taken from a 13-year period (2006-19), which yielded 1 940 508 usable free-text radiological reports written by the contemporary assessing radiologist (collectively referred to as the "historic reporters") and 1 896 034 frontal images. Chest x-rays were labelled using a taxonomy of 37 findings by a custom-trained natural language processing (NLP) algorithm, X-Raydar-NLP, from the original free-text reports. X-Raydar-NLP was trained on 23 230 manually annotated reports and tested on 4551 reports from all hospitals. 1 694 921 labelled images from the training set and 89 238 from the validation set were then used to train a multi-label image classifier. Our algorithms were evaluated on three retrospective datasets: a set of exams sampled randomly from the full NHS dataset reported during clinical practice and annotated using NLP (n=103 328); a consensus set sampled from all six hospitals annotated by three expert radiologists (two independent annotators for each image and a third consultant to facilitate disagreement resolution) under research conditions (n=1427); and an independent dataset, MIMIC-CXR, consisting of NLP-annotated exams (n=252 374). Findings: X-Raydar achieved a mean AUC of 0·919 (SD 0·039) on the auto-labelled set, 0·864 (0·102) on the consensus set, and 0·842 (0·074) on the MIMIC-CXR test, demonstrating similar performance to the historic clinical radiologist reporters, as assessed on the consensus set, for multiple clinically important findings, including pneumothorax, parenchymal opacification, and parenchymal mass or nodules. On the consensus set, X-Raydar outperformed historical reporter balanced accuracy with significance on 27 of 37 findings, was non-inferior on nine, and inferior on one finding, resulting in an average improvement of 13·3% (SD 13·1) to 0·763 (0·110), including a mean 5·6% (13·2) improvement in critical findings to 0·826 (0·119). Interpretation: Our study shows that automated classification of chest x-rays under a comprehensive taxonomy can achieve performance levels similar to those of historical reporters and exhibit robust generalisation to external data. The open-sourced neural networks can serve as foundation models for further research and are freely available to the research community. Funding: Wellcome Trust.
  • Image quality in whole-body MRI using the MY-RADS protocol in a prospective multi-centre multiple myeloma study

    Rennie, Winston (2023)
    Background: The Myeloma Response Assessment and Diagnosis System (MY-RADS) guidelines establish a standardised acquisition and analysis pipeline for whole-body MRI (WB-MRI) in patients with myeloma. This is the first study to assess image quality in a multi-centre prospective trial using MY-RADS. Methods: The cohort consisted of 121 examinations acquired across ten sites with a range of prior WB-MRI experience, three scanner manufacturers and two field strengths. Image quality was evaluated qualitatively by a radiologist and quantitatively using a semi-automated pipeline to quantify common artefacts and image quality issues. The intra- and inter-rater repeatability of qualitative and quantitative scoring was also assessed. Results: Qualitative radiological scoring found that the image quality was generally good, with 94% of examinations rated as good or excellent and only one examination rated as non-diagnostic. There was a significant correlation between radiological and quantitative scoring for most measures, and intra- and inter-rater repeatability were generally good. When the quality of an overall examination was low, this was often due to low quality diffusion-weighted imaging (DWI), where signal to noise ratio (SNR), anterior thoracic signal loss and brain geometric distortion were found as significant predictors of examination quality. Conclusions: It is possible to successfully deliver a multi-centre WB-MRI study using the MY-RADS protocol involving scanners with a range of manufacturers, models and field strengths. Quantitative measures of image quality were developed and shown to be significantly correlated with radiological assessment. The SNR of DW images was identified as a significant factor affecting overall examination quality. Trial registration: ClinicalTrials.gov, NCT03188172 , Registered on 15 June 2017. Critical relevance statement: Good overall image quality, assessed both qualitatively and quantitatively, can be achieved in a multi-centre whole-body MRI study using the MY-RADS guidelines. Key points: • A prospective multi-centre WB-MRI study using MY-RADS can be successfully delivered. • Quantitative image quality metrics were developed and correlated with radiological assessment. • SNR in DWI was identified as a significant predictor of quality, allowing for rapid quality adjustment.
  • Impact of changing from autopsy to post-mortem CT in an entire HM Coroner region due to a shortage of available pathologists

    Robinson, C; Morgan, B (2023-11)
    A significant problem facing routine medicolegal coroner-referred autopsies is a shortfall of pathologists prepared to perform them. This was particularly acute in Lancashire, where the coroner decided to initiate a service that relied on post-mortem computed tomography (PMCT). This involved training anatomical pathology technologists (APTs) to perform external examinations, radiographers to perform scans, and radiologists to interpret them. The service started in 2018 and now examines over 1,500 cases per year. This study outlines the PMCT process using NHS staff, with CT equipment and logistics managed by the commercial sector. It compares the demographics and outcomes of PM investigations for two 6-month periods: the autopsy service prior to 2018, and then the PMCT service. These data were then compared with previous UK PMCT data. Referrals for adult non-suspicious deaths were made in 913 cases of which 793 (87%) had PMCT between 01/10/2018 and 31/03/2019. Fifty-six cases had autopsy after PMCT, so 81% of cases potentially avoided autopsy. The PMCT service did not delay release of bodies to the next-of-kin. Comparing the cause of death given shows no difference in the proportions of natural and unnatural deaths. There was an increase in diagnosis of coronary artery disease for PMCT, with less respiratory diagnoses, a feature not previously demonstrated. These data suggest PMCT is a practical solution for potentially failing autopsy services. By necessity, this involves changes in diagnoses, as PMCT and autopsy have different strengths and weakness, but the ability to pick up unnatural death appears unaffected.
  • Impact of the COVID-19 pandemic on a post-mortem CT service for adult non-suspicious death

    James, J; Morgan, B; Richards, C; Robertson, C; West, K (2023-11)
    Due to the COVID-19 pandemic, the post-mortem computed tomography (PMCT) service was expanded from three to seven cases per day to help mortuary services and avoid invasive autopsy. Additional targeted angiography and pulmonary ventilation procedures were stopped and triage rules relaxed to allow more indications to be scanned, including those requiring toxicology. A service evaluation was performed for the first 3-months of the COVID-19 pandemic compared to the equivalent period the previous year to study the impact of these changes. It was found that, despite the increase in deaths regionally, coronial referrals remained about 100 per month, a reduction in referral rate. The number undergoing PMCT rose from 28% to 74% of cases. Turnaround time remained the same. For cases triaged to PMCT, the need for subsequent autopsy increased from 7.9% to 15.8%. No significant changes were seen in diagnosis rates, including cardiac or respiratory. There was an increase in patients with coronary death without severe coronary calcification who underwent autopsy after PMCT. These may have been diagnosed by targeted coronary angiography. Fifty-three cases requiring toxicology/biochemistry had PMCT, with 38 having PMCT only. In 8/11 (72.7%) cases with normal PMCT and toxicology as the key diagnostic test, autopsy was performed prior to results. This suggests the pathology team were reluctant to risk an "unascertained" outcome. This study shows that it is possible to increase PMCT services by widening referral criteria and by limiting the use of enhanced imaging techniques, without significantly changing diagnosis rates of key diseases; however, selectively restarting targeted angiography may help avoid autopsy in some cases.

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