Fatigue in radiology : a fertile area for future research

Fatigue in radiologists may be responsible for a large number of medical errors. This review describes the latest research on fatigue in radiology. This includes measurement methods, and recent evidence on how fatigue affects accuracy in laboratory test conditions and in clinical practice. The extensive opportunities for future research in the area are explored, including testing interventions to reduce fatigue-related error, and further understanding of which fatigue measures correlate with errors. Finally we explore the possibility of answering these questions using large population based observational studies and pragmatic integrated randomised controlled trials

The effects of a UK review of breast cancer screening on uptake : an observational before/after study

Objectives: To measure whether uptake of breast cancer screening was affected by the publication of the Marmot Review and associated press coverage. Setting: Eight NHS breast screening centres in the West Midlands of the UK. Methods: Uptake of breast cancer screening invitations was compared in the week before and after the Marmot review publication. All 12,023 women invited for screening between 23 October 2012 and 5 November 2012 were included. A mixed effects model of the predictors of screening uptake (on date invited, or within 21 days) was created. Predictors considered for inclusion were whether the allocated screening appointment was before or after publication of the review, population factors (age, index of multiple deprivation income domain by quintile, previous attendance), and interaction terms. Results: Uptake decreased after publication of the review from 65% to 62% (OR = 0.87 95%CI = 0.80–0.94), but a similar decrease was seen for the same dates on the previous year (OR = 0.85 95%CI = 0.78–0.93). Odds of attending screening were lower for women in the most deprived (uptake = 49%, OR = 0.54, 95%CI = 0.46–0.62) in comparison with the least deprived quintile (uptake = 71%). Odds of attendance also increased if the woman had ever previously attended (OR 3.9 95% CI 3.5–4.4), and decreased with each year of increasing age (OR 0.96 95% CI 0.96–0.97). There were no interactions between any of the other predictors and whether the appointment was before or after publication of the Marmot review. Conclusion: No change in uptake of breast cancer screening above normal seasonal variation was detected after publication of the Marmot review

Does preoperative axillary staging lead to overtreatment of women with screen detected breast cancer?

Aim To determine the impact of pre-operative axillary ultrasound staging in a screen detected breast cancer population Materials and Method Ultrasound and needle biopsy staging results alongside reference standard sentinel lymph node biopsy and axillary lymph node dissection were retrospectively extracted from the unit's computer records between 01/04/2008 and 31/03/2015. Axillary staging was compared with final pathology and treatment. Results Of the 215,661 screening examinations performed, 780 invasive cancers were diagnosed which had pre-operative axillary staging data, of which 162 (20.7%) were node positive. 36 (4.6%) had a heavy nodal burden (3 or more nodes). 90 (11.5%) had an abnormal axillary ultrasound and axillary biopsy of which 54 were positive for cancer (33.3% of the node positive cases) and triaged to axillary lymph node dissection avoiding a sentinel lymph node biopsy. Of these 22 (40.7%) had neoadjuvant treatment, and 32 (59.3%) proceeded directly to axillary lymph node dissection. The sensitivity of axillary ultrasound and biopsy to detect women with aheavy nodal burden (3 or more nodes) was 41.7% (15 of 36). However, 17 (53%) of the 32 women with a positive axillary biopsy had a low burden of axillary disease (≤2 positive nodes) at axillary lymph node dissection, the mean number of nodes obtained was 14.6. Conclusion Significant numbers of women are being potentially overtreated or denied entry into Positive Sentinel Node: adjuvant therapy only vs adjuvant therapy and clearance or axillary radiotherapy (POSNOC) because of routine pre-operative axillary staging

Double reading reduces miss errors in low prevalence search

Low Prevalence studies show that people miss a large proportion of targets if they appear rarely. This finding has implications for real-world tasks, such as mammography, where it is important to detect infrequently appearing cancers. We examined whether having people search in pairs in a ‘double reading’ procedure reduces miss errors in Low Prevalence search compared to when participants search the displays alone. In Experiment 1 pairs of participants searched for a mass in a laboratory mammogram task. Participants either searched the same display together (in the same room) or searched the displays independently (in separate rooms). Experiment 2 further manipulated the reading order so that paired participants either read the mammograms in the same or different orders. The results showed that, although there was no effect of reading order, double reading led to a substantial reduction in miss errors compared to single reading conditions. Furthermore, the reason for the double reading improvement differed across reading environments: when participants read the displays in a shared environment (i.e. in the same room) the improvement occurred due to an increase in sensitivity, however when participants read the display in different rooms the improvement occurred due to a change in response bias

Low prevalence search for cancers in mammograms : evidence using laboratory experiments and computer aided detection

People miss a large proportion of targets when they only appear rarely. This Low Prevalence (LP) Effect could lead to serious consequences if it occurred in the real world task of searching for cancers in mammograms. Using a novel mammogram search task, we asked participants to search for a pre-specified cancer (Experiments 1-2) or a range of masses (Experiments 3-5) under high or low prevalence conditions. Experiment 1 showed that an LP Effect occurred using these stimuli. Experiment 2 tested an over-reliance hypothesis and showed that the use of Computer Aided Detection (CAD) led to fewer missed cancers with a valid CAD prompt yet, a large proportion of cancers were missed when CAD was incorrect. Experiment 3 - 5 showed that false alarms also increased when searching for a range of masses and that CAD reduced miss errors when it correctly cued the target but increased miss errors and false alarms when it did not. Furthermore, when a mass fell outside the CAD prompt it was more likely to be misidentified. No LP Effect was observed with the addition of CAD when people were asked to search for a range of targets. Theories and implications for mammogram search are discussed

Mammography workstation design: effect on mammographer behaviour and the risk of musculoskeletal disorders

In the UK Breast Screening Programme there is a growing transition from film to digital mammography, and consequently a change in mammography workstation ergonomics. This paper investigates the effect of the change for radiologists including their comfort, likelihood of developing musculoskeletal disorders (MSD’s), and work practices. Three workstations types were investigated: one with all film mammograms; one with digital mammograms alongside film mammograms from the previous screening round, and one with digital mammograms alongside digitised film mammograms from the previous screening round. Mammographers were video-taped whilst conducting work sessions at each of the workstations. Event based Rapid Upper Limb Assessment (RULA) postural analysis showed no overall increase in MSD risk level in the switch from the film to digital workstation. Average number of visual glances at the prior mammograms per case measured by analysis of recorded video footage showed an increase if the prior mammograms were digitised, rather than displayed on a multi-viewer (p<.05). This finding has potential implications for mammographer performance in the transition to digital mammography in the UK

Predictors of differences in health services utilization for children in Nigerian communities

Health service utilization is an important component of child health promotion. Evidence shows that two-thirds of child deaths in low and middle income countries could be prevented if current interventions were adequately utilized. Aim of this study was to identify determinants of variation in health services utilization for children in communities in Nigeria. Multivariable negative binomial regression model attempting to explain observed variability in health services usage in Nigerian communities was applied to the 2013 Nigeria Demographic and Health Survey data. We included the index of maternal deprivation, gender of child, community environmental factor index, and maternal health seeking behavior, multiple childhood deprivation index and ethnicity diversity index as the independent variables. The outcome variable was under-fives’ hospital attendance rates for acute illness. Of the 7, 577 children from 896 communities in Nigeria that were sick 1, 936 (25.6%) were taken to the health care facilities for treatment. The final model revealed that both multiple childhood deprivation (incidence rate ratio [IRR] = 1.23, 95% confidence interval [CI] 1.12 to 1.35) and children living in communities with a high ethnic diversity were associated with higher rate of health service use. Maternal health seeking behaviour was associated with a significantly lower rate of health care service use. There are significant variations in health services utilization for sick children across Nigeria communities which appear to be more strongly determined by childhood deprivation factors and maternal health seeking behaviour than by health system functions

Extending the diabetic retinopathy screening interval beyond 1 year : systematic review

To determine whether the recommended screening interval for diabetic retinopathy (DR) in the UK can safely be extended beyond 1 year. Systematic review of clinical and cost-effectiveness studies. Nine databases were searched with no date restrictions. Randomised controlled trials (RCTs), cohort studies, prognostic or economic modelling studies which described the incidence and progression of DR in populations with type 1 diabetes mellitus or type 2 diabetes mellitus of either sex and of any age reporting incidence and progression of DR in relation to screening interval (vs annual screening interval) and/or prognostic factors were included. Narrative synthesis was undertaken. 14 013 papers were identified, of which 11 observational studies, 5 risk stratification modelling studies and 9 economic studies were included. Data were available for 262 541 patients of whom at least 228 649 (87%) had type 2 diabetes. There were no RCTs. Studies concluded that there is little difference between clinical outcomes from screening 1 yearly or 2 yearly in low-risk patients. However there was high loss to follow-up (13–31%), heterogeneity in definitions of low risk and variation in screening and grading protocols for prior retinopathy results. Observational and economic modelling studies in low-risk patients show little difference in clinical outcomes between 1-year and 2-year screening intervals. The lack of experimental research designs and heterogeneity in definition of low risk considerably limits the reliability and validity of this conclusion. Cost-effectiveness findings were mixed. There is insufficient evidence to recommend a move to extend the screening interval beyond 1 year