The use of dose quantities in radiological protection: ICRP publication 147 Ann ICRP 50(1) 2021.

The International Commission on Radiological Protection has recently published a report (ICRP Publication 147;Ann. ICRP50, 2021) on the use of dose quantities in radiological protection, under the same authorship as this Memorandum. Here, we present a brief summary of the main elements of the report. ICRP Publication 147 consolidates and clarifies the explanations provided in the 2007 ICRP Recommendations (Publication 103) but reaches conclusions that go beyond those presented in Publication 103. Further guidance is provided on the scientific basis for the control of radiation risks using dose quantities in occupational, public and medical applications. It is emphasised that best estimates of risk to individuals will use organ/tissue absorbed doses, appropriate relative biological effectiveness factors and dose-risk models for specific health effects. However, bearing in mind uncertainties including those associated with risk projection to low doses or low dose rates, it is concluded that in the context of radiological protection, effective dose may be considered as an approximate indicator of possible risk of stochastic health effects following low-level exposure to ionising radiation. In this respect, it should also be recognised that lifetime cancer risks vary with age at exposure, sex and population group. The ICRP report also concludes that equivalent dose is not needed as a protection quantity. Dose limits for the avoidance of tissue reactions for the skin, hands and feet, and lens of the eye will be more appropriately set in terms of absorbed dose rather than equivalent dose

Determinants of the number of mammography units in 31 countries with significant mammography screening

In the 2000s, most of the female population of industrialised countries had access to mammography breast cancer screening, but with variable modalities among the countries. We assessed the number of mammography units (MUs) in 31 European, North American and Asian countries where significant mammography activity has existed for over 10 years, collecting data on the number of such units and of radiologists by contacting institutions in each country likely to provide the relevant information. Around 2004, there were 32 324 MU in 31 countries, the number per million women ranging from less than 25 in Turkey, Denmark, the Netherlands, the United Kingdom, Norway, Poland and Hungary to more than 80 in Cyprus, Italy, France, the United States and Austria. In a multivariate analysis, the number of MUs was positively associated with the number of radiologists (P=0.0081), the number of women (P=0.0023) and somewhat with the country surface area (P=0.077). There is considerable variation in the density of MU across countries and the number of MUs in service are often well above what would be necessary according to local screening recommendations. High number of MUs in some countries may have undesirable consequences, such as unnecessarily high screening frequency and decreased age at which screening is started

Association between Radiologists' Experience and Accuracy in Interpreting Screening Mammograms

<p>Abstract</p> <p>Background</p> <p>Radiologists have been observed to differ, sometimes substantially, both in their interpretations of mammograms and in their recommendations for follow-up. The aim of this study was to determine how factors related to radiologists' experience affect the accuracy of mammogram readings.</p> <p>Methods</p> <p>We selected a random sample of screening mammograms from a population-based breast cancer screening program. The sample was composed of 30 women with histopathologically-confirmed breast cancer and 170 women without breast cancer after a 2-year follow-up (the proportion of cancers was oversampled). These 200 mammograms were read by 21 radiologists routinely interpreting mammograms, with different amount of experience, and by seven readers who did not routinely interpret mammograms. All readers were blinded to the results of the screening. A positive assessment was considered when a BI-RADS III, 0, IV, V was reported (additional evaluation required). Diagnostic accuracy was calculated through sensitivity and specificity.</p> <p>Results</p> <p>Average specificity was higher in radiologists routinely interpreting mammograms with regard to radiologists who did not (66% vs 56%; p < .001). Multivariate analysis based on routine readers alone showed that specificity was higher among radiologists who followed-up cases for which they recommended further workup (feedback) (OR 1.37; 95% CI 1.03 to 1.85), those spending less than 25% of the working day on breast radiology (OR 1.49; 95% CI 1.18 to 1.89), and those aged more than 45 years old (OR 1.33; 95% CI 1.12 to 1.59); the variable of average annual volume of mammograms interpreted by radiologists, classified as more or less than 5,000 mammograms per year, was not statistically significant (OR 1.06; 95% CI 0.90 to 1.25).</p> <p>Conclusion</p> <p>Among radiologists who read routinely, volume is not associated with better performance when interpreting screening mammograms, although specificity decreased in radiologists not routinely reading mammograms. Follow-up of cases for which further workup is recommended might reduce variability in mammogram readings and improve the quality of breast cancer screening programs.</p

Patient-Centered Outcomes Measurement: Does It Require Information From Patients?

Purpose: Since collecting outcome measure data from patients can be expensive, time-consuming, and subject to memory and nonresponse bias, we sought to learn whether outcomes important to patients can be obtained from data in the electronic health record (EHR) or health insurance claims. Methods: We previously identified 21 outcomes rated important by patients who had advanced imaging tests for back or abdominal pain. Telephone surveys about experiencing those outcomes 1 year after their test from 321 people consenting to use of their medical record and claims data were compared with audits of the participants’ EHR progress notes over the time period between the imaging test and survey completion. We also compared survey data with algorithmically extracted data from claims files for outcomes for which data might be available from that source. Results: Of the 16 outcomes for which patients’ survey responses were considered to be the best information source, only 2 outcomes for back pain and 3 for abdominal pain had kappa scores above a very modest level of ≥ 0.2 for chart audit of EHR data and none for algorithmically obtained EHR/claims data. Of the other 5 outcomes for which claims data were considered to be the best information source, only 2 outcomes from patient surveys and 3 outcomes from chart audits had kappa scores ≥ 0.2. Conclusions: For the types of outcomes studied here, medical record or claims data do not provide an adequate source of information except for a few outcomes where patient reports may be less accurate

The presence of postmenopausal bleeding as prognostic parameter in patients with endometrial cancer: a retrospective multi-center study

Abstract Background To date, there is no consensus on the utility of screening procedures for the early detection of endometrial cancer. The value of transvaginal ultrasound for screening of asymptomatic endometrial cancer has been discussed controversially. This study was conducted to evaluate whether asymptomatic patients with endometrial cancer have a better prognosis than symptomatic patients with endometrial cancer diagnosed after postmenopausal bleeding. Methods In the present multi-center study, the effect of the presence of postmenopausal bleeding on prognosis was evaluated retrospectively in 605 patients with endometrial cancer using patients' files. 543 patients (133 patients were asymptomatic, 410 patients were symptomatic) with endometrioid endometrial cancer were enrolled in all further analysis. Student's t-test, Cox regression analysis and Kaplan-Meier analysis were used were appropriate. Results Presence/absence of a postmenopausal bleeding was not associated with tumor stage (p = 0.2) and age at diagnosis (p = 0.5). Asymptomatic patients with endometrial cancer had a significantly higher rate of well and moderate-differentiated tumors compared to symptomatic patients (p = 0.008). In univariable and multivariable survival analysis, tumor stage, tumor grade, and patients' age at diagnosis, but not presence/absence of a postmenopausal bleeding, were associated with disease free and overall survival. Conclusion Asymptomatic patients with endometrial cancer have a higher rate of well differentiated tumors compared to patients with a postmenopausal bleeding prior to diagnosis. The prognosis of both groups of patients was similar.</p

Mammography Facility Characteristics Associated With Interpretive Accuracy of Screening Mammography

BackgroundAlthough interpretive performance varies substantially among radiologists, such variation has not been examined among mammography facilities. Understanding sources of facility variation could become a foundation for improving interpretive performance.MethodsIn this cross-sectional study conducted between 1996 and 2002, we surveyed 53 facilities to evaluate associations between facility structure, interpretive process characteristics, and interpretive performance of screening mammography (ie, sensitivity, specificity, positive predictive value [PPV1], and the likelihood of cancer among women who were referred for biopsy [PPV2]). Measures of interpretive performance were ascertained prospectively from mammography interpretations and cancer data collected by the Breast Cancer Surveillance Consortium. Logistic regression and receiver operating characteristic (ROC) curve analyses estimated the association between facility characteristics and mammography interpretive performance or accuracy (area under the ROC curve [AUC]). All P values were two-sided.ResultsOf the 53 eligible facilities, data on 44 could be analyzed. These 44 facilities accounted for 484 463 screening mammograms performed on 237 669 women, of whom 2686 were diagnosed with breast cancer during follow-up. Among the 44 facilities, mean sensitivity was 79.6% (95% confidence interval [CI] = 74.3% to 84.9%), mean specificity was 90.2% (95% CI = 88.3% to 92.0%), mean PPV1 was 4.1% (95% CI = 3.5% to 4.7%), and mean PPV2 was 38.8% (95% CI = 32.6% to 45.0%). The facilities varied statistically significantly in specificity (P &lt; .001), PPV1 (P &lt; .001), and PPV2 (P = .002) but not in sensitivity (P = .99). AUC was higher among facilities that offered screening mammograms alone vs those that offered screening and diagnostic mammograms (0.943 vs 0.911, P = .006), had a breast imaging specialist interpreting mammograms vs not (0.932 vs 0.905, P = .004), did not perform double reading vs independent double reading vs consensus double reading (0.925 vs 0.915 vs 0.887, P = .034), or conducted audit reviews two or more times per year vs annually vs at an unknown frequency (0.929 vs 0.904 vs 0.900, P = .018).ConclusionMammography interpretive performance varies statistically significantly by facility

Early detection of breast, cervical, ovarian and endometrial cancers in low resource countries: an integrated approach

The incidence of breast and gynecological cancers continues to increase in low and middle resource countries [LRC'S and MRC's] with a disproportionately higher mortality rate compared to that in high resource countries. This has been attributed to factors such as an increased life span due to better control of communicable diseases and improved nutrition, as well as lifestyle and reproductive changes. A lack of public awareness and understanding of these cancers, absence of an organized screening program and a lack of accessible and effective treatment options, is responsible for the higher mortality rate. A practical approach of a combined program of integrating a well woman examination with screening for breast and cervical cancer and diagnostic evaluation for Ovarian and Endometrial cancer in symptomatic women is proposed in this article which can serve as a model to be studied for efficacy in low resource countries

General practitioners' evaluation of community psychiatric services: responsiveness to change of the General Practitioner Experiences Questionnaire (GPEQ)

<p>Abstract</p> <p>Background</p> <p>Instruments have been developed to assess professional views of the quality of care but have rarely been tested for responsiveness to change. The objective of this study was to test the responsiveness of the General Practitioner Experiences Questionnaire (GPEQ) for the measurement of Community Mental Health Centres in Norway.</p> <p>Methods</p> <p>National surveys were conducted in Norway in 2006 (n = 2,415) and 2008 (n = 2,209) to measure general practitioners' evaluation of community mental health centres. GPs evaluated the centres by means of a postal questionnaire, consisting of questions focused on centre quality and cooperation with GPs. As part of the national surveys 75 GPs in 2006 and 66 GPs in 2008 evaluated Hamar community mental health centre. Between the surveys, several quality improvement initiatives were implemented which were directed at cooperation with and guidance for GPs in Stange municipality, one of eight municipalities in Hamar centre catchment area. The main outcome measures were changes in GPEQ scores from 2006 to 2008 for GPs evaluating Hamar community mental health centre from Stange municipality, and changes in scores for GPs in the other seven municipalities and nationally which were assessed for statistical significance.</p> <p>Results</p> <p>GPs in Stange municipality rated Hamar community mental health centre significantly better on the guidance scale in 2008 than in 2006; on a 0-100 scale where 100 represents the best possible experiences the score was 26.5 in 2006 and 58.3 in 2008 (p < 0.001). Apart from one item about workforce situation, none of the other scales and items showed significant changes. The control group from the other seven municipalities gave significantly poorer rating for the emergency situation scale, the workforce situation scale and seven items in 2008 than in 2006. The national results showed small differences between 2006 and 2008, even though several scales and items were significantly different. A question about changes in centre performance over the last 2-3 years showed that 82% of GPs from Stange municipality reported that Hamar community mental health centre had improved, compared to only 36% from the other seven municipalities and 40% nationally which was statistically significant.</p> <p>Conclusions</p> <p>Following the implementation of an initiative designed to enhance service quality, the GPEQ identified expected changes in the guidance scale for the intervention group, indicating that the instrument is responsive to change. The worsening of services for GPs in the control group evaluating Hamar centre warrants further study.</p

Overdiagnosis and overtreatment of breast cancer: Rates of ductal carcinoma in situ: a US perspective

The incidence of breast ductal carcinoma in situ (DCIS) in the USA exceeds that of other countries. This cannot be explained entirely by the frequency of mammographic screening in the USA and may result from differences in the interpretation of mammograms and/or the frequency with which biopsies are obtained. Although the percentage of DCIS patients treated with mastectomy has decreased, the absolute number is unchanged and the use of lumpectomy with whole-breast radiotherapy has increased in inverse proportion to the decrease in mastectomy. Treatment of DCIS with tamoxifen is still limited

Appropriateness of admission and days of stay in pediatric hospital in Ancona, Italy

Background: In Italy, hospital admission costs account for nearly 42% of total health expenditure; in the Marche region, this share exceeds 50%. High costs of hospitalization, however, can be partly explained by inappropriate use. The aim of this research was to assess the risk factors associated with inappropriate hospital admissions and stay for acute pediatric patients. Methods: Clinical records of children from 30 days to 14 years of age admitted to the wards of orthopedics, pediatrics, pediatric isolation, pediatric surgery and pediatric oncohematology at Salesi Pediatric Hospital of Ancona throughout 2004 were reviewed. The Italian Pediatric Appropriateness Evaluation Protocol (PRUO) was used as a tool for assessing inappropriateness of admission and days of stay. Results: Overall 21.7% (95% CI = 16.1%–22.4%) of hospital admissions and 30.3% (95% CI = 26.0%–34.9%) of days of stay were judged to be inappropriate. Multiple logistic regression analysis indicated that inappropriate admission was significantly associated with type of admission, discharge ward and place of residence. Inappropriateness of stay was significantly higher if admission was to a medical ward and if admission itself was judged inappropriate. Conclusions: In a socioeconomic context in which reducing waste is necessary, ineffective health care interventions are no longer tolerable. As a tool capable of integrating each patient’s specific features with those of the health care process, the pediatric PRUO could be a valid tool in the hands of managers for monitoring the appropriateness of admission and stay