Reporting radiographers' interpretation and use of the British Society of Thoracic Imaging's coding system when reporting COVID-19 chest x-rays

The extended and advanced clinical practices of radiographers worldwide: A scoping review

AIMS

This scoping review aimed to (1) map the global evidence on extended and advanced clinical practices (ACP) performed by radiographers, and (2) provide an overview of the pillars (clinical practice, leadership and management, education, and research) they relate to, as well as the radiology areas and the geographical location where they were developed.

METHODS

Articles were searched in MEDLINE, CINAHL and Embase, and grey literature in ProQuest Dissertation and Theses. Studies concerning radiographers or healthcare professionals with an equivalent title (e.g., radiation technologist) performing extended role or an ACP, regardless of their medical imaging setting or country were included. The review was undertaken following JBI methodological guidance for scoping reviews. The titles and abstracts of the retrieved studies, and then the full texts of the selected papers were assessed by two independent reviewers.

RESULTS

A total of 2617 records were identified, of which 174 articles were included. Most of them reported practices performed in the UK (63 %), and less in Canada (19 %) and Australia (6 %). Advanced or extended practices were linked to all four pillars, but most concerned the clinical practice pillar. The main activities for this pillar were radiograph reporting (22 %), patient assessment and management (consultation) in radiotherapy (RT; 21 %), RT treatment planning (14 %) and ultrasound practice (13 %). Studies have also shown radiographers performing breast biopsies, medication prescription, and ultrasound and CT scan reports. The main fields of radiology concerned by the changing roles were radiotherapy (42 %) and conventional radiography (36 %).  CONCLUSION: Extended or advanced practices are achieved through a wide variety of activities around the world. This scoping review constitutes a knowledge base on the evolution of the practices of radiographers and should contribute to their recognition and development.

Reporting radiographers in Europe survey: Support, role satisfaction, and advanced clinical practice within the European federation of radiographer society (EFRS) member countries

INTRODUCTION

Increasing number of radiographers are undertaking image reporting throughout Europe. However, there are variations in practice and experience in European countries. The study aim was to investigate reporting radiographer's perceptions in relation to support for their role and workload satisfaction and elements of advanced practice that may also be undertaken.

METHODS

Following institutional ethical approval an online 34 item questionnaire survey was circulated via social media; Twitter, Facebook, and LinkedIn in a 12-week period in 2022 across Europe. The survey data were managed by the online secure database REDCap (Research Electronic Data Capture). Data was collected across a range of questions, of which those relating to support for, and barriers to radiographer reporting, role and job satisfaction, and other role elements are reported here.

RESULTS

A response level of 345 individual reporting radiographers replied to the survey from 15 European countries; some questions were optional and therefore had a lower response rate. There was consensus about the need for support from radiologists and management, protected time, and funding to support the reporting role. The majority of respondents received additional pay for taking on this role and expressed satisfaction with their role and workload. In relation to elements of advanced practice, the majority of respondents were involved in educational and managerial activities, and there was interest, but limited involvement, in research.

CONCLUSION

There was a consensus about the support needed, and perceived barriers to, radiographer reporting, between reporting radiographers from different countries. Whilst there is some commonality in relation to activities such as supervision and education, there was clearer variety in relation to opportunities for research between the respondents, perhaps reflecting the differences between reporting as a standalone role development and reporting as part of an advanced clinical practice role.

IMPLICATIONS FOR PRACTICE

As there is increasingly an emphasis on advanced clinical practice, reporting radiographers are likely to require support to develop their skills so that they can actively participate in the broader activities associated with this role, including education, leadership, and research.

Effects of tuberculosis and/or HIV-1 infection on COVID-19 presentation and immune response in Africa

Few studies from Africa have described the clinical impact of co-infections on SARS-CoV-2 infection. Here, we investigate the presentation and outcome of SARS-CoV-2 infection in an African setting of high HIV-1 and tuberculosis prevalence by an observational case cohort of SARS-CoV-2 patients. A comparator group of non SARS-CoV-2 participants is included. The study includes 104 adults with SARS-CoV-2 infection of whom 29.8% are HIV-1 co-infected. Two or more co-morbidities are present in 57.7% of participants, including HIV-1 (30%) and active tuberculosis (14%). Amongst patients dually infected by tuberculosis and SARS-CoV-2, clinical features can be typical of either SARS-CoV-2 or tuberculosis: lymphopenia is exacerbated, and some markers of inflammation (D-dimer and ferritin) are further elevated (p < 0.05). Amongst HIV-1 co-infected participants those with low CD4 percentage strata exhibit reduced total, but not neutralising, anti-SARS-CoV-2 antibodies. SARS-CoV-2 specific CD8 T cell responses are present in 35.8% participants overall but undetectable in combined HIV-1 and tuberculosis. Death occurred in 30/104 (29%) of all COVID-19 patients and in 6/15 (40%) of patients with coincident SARS-CoV-2 and tuberculosis. This shows that in a high incidence setting, tuberculosis is a common co-morbidity in patients admitted to hospital with COVID-19. The immune response to SARS-CoV-2 is adversely affected by co-existent HIV-1 and tuberculosis.

AI for COVID-19 Detection from Radiographs: Incisive Analysis of State of the Art Techniques, Key Challenges and Future Directions

Background and objective

In recent years, Artificial Intelligence has had an evident impact on the way research addresses challenges in different domains. It has proven to be a huge asset, especially in the medical field, allowing for time-efficient and reliable solutions. This research aims to spotlight the impact of deep learning and machine learning models in the detection of COVID-19 from medical images. This is achieved by conducting a review of the state-of-the-art approaches proposed by the recent works in this field.

Methods

The main focus of this study is the recent developments of classification and segmentation approaches to image-based COVID-19 detection. The study reviews 140 research papers published in different academic research databases. These papers have been screened and filtered based on specified criteria, to acquire insights prudent to image-based COVID-19 detection.

Results

The methods discussed in this review include different types of imaging modality, predominantly X-rays and CT scans. These modalities are used for classification and segmentation tasks as well. This review seeks to categorize and discuss the different deep learning and machine learning architectures employed for these tasks, based on the imaging modality utilized. It also hints at other possible deep learning and machine learning architectures that can be proposed for better results towards COVID-19 detection. Along with that, a detailed overview of the emerging trends and breakthroughs in Artificial Intelligence-based COVID-19 detection has been discussed as well.

Conclusion

This work concludes by stipulating the technical and non-technical challenges faced by researchers and illustrates the advantages of image-based COVID-19 detection with Artificial Intelligence techniques.

Difficulties associated with access to training and clinical support for Reporting Radiographers - A narrative evidence synthesis

OBJECTIVES

This narrative synthesis of evidence identifies and explores issues that impact upon the expansion or effectiveness of Reporting Radiographers working in all diagnostic modalities within the United Kingdom (UK). The publication focuses on accessibility to training for prospective Reporting Radiographers as well as clinical support within and beyond training.

KEY FINDINGS

Fifteen studies informed the themes of this article, they were published between 2014 and 2021. Reporting Radiographers often found it difficult find support during training and once qualified, this was usually due to the availability and workload of supervising staff. Although resistance and obstruction were experienced by many. Concerns relating to pay, promotion and interest were expressed by some respondents whilst access to courses and finance were highlighted as areas of variance across the UK.

CONCLUSION

Inadequate support of Reporting Radiographers is impairing expansion of the specialism, whilst impacting capability and morale. This increases risk of patient harm, delays to care and inefficiency, it also threatens the sustainability of services. Negative interactions between Reporting Radiographers and Radiologists or managers is disappointing considering development of the specialism; evidence of Reporting Radiographer effectiveness and current collaboration between Royal College of Radiologists and Society of Radiographers. Issues raised in relation to pay/promotion and litigation could be clarified with ease, this should be considered when guidance is updated. Access to finance and courses is a major barrier in some regions of the UK. Scope exists for further exploration of training. England has used grants to facilitate uptake, these may prove to be an important tool in other countries.

IMPLICATIONS FOR PRACTICE

Drivers to increase recruitment should be implemented alongside measures to facilitate accessibility to training and improvements to support infrastructure.

Thoracic imaging tests for the diagnosis of COVID-19

BACKGROUND

Our March 2021 edition of this review showed thoracic imaging computed tomography (CT) to be sensitive and moderately specific in diagnosing COVID-19 pneumonia. This new edition is an update of the review.

OBJECTIVES

Our objectives were to evaluate the diagnostic accuracy of thoracic imaging in people with suspected COVID-19; assess the rate of positive imaging in people who had an initial reverse transcriptase polymerase chain reaction (RT-PCR) negative result and a positive RT-PCR result on follow-up; and evaluate the accuracy of thoracic imaging for screening COVID-19 in asymptomatic individuals. The secondary objective was to assess threshold effects of index test positivity on accuracy.

SEARCH METHODS

We searched the COVID-19 Living Evidence Database from the University of Bern, the Cochrane COVID-19 Study Register, The Stephen B. Thacker CDC Library, and repositories of COVID-19 publications through to 17 February 2021. We did not apply any language restrictions.

SELECTION CRITERIA

We included diagnostic accuracy studies of all designs, except for case-control, that recruited participants of any age group suspected to have COVID-19. Studies had to assess chest CT, chest X-ray, or ultrasound of the lungs for the diagnosis of COVID-19, use a reference standard that included RT-PCR, and report estimates of test accuracy or provide data from which we could compute estimates. We excluded studies that used imaging as part of the reference standard and studies that excluded participants with normal index test results.

DATA COLLECTION AND ANALYSIS

The review authors independently and in duplicate screened articles, extracted data and assessed risk of bias and applicability concerns using QUADAS-2. We presented sensitivity and specificity per study on paired forest plots, and summarized pooled estimates in tables. We used a bivariate meta-analysis model where appropriate.

MAIN RESULTS

We included 98 studies in this review. Of these, 94 were included for evaluating the diagnostic accuracy of thoracic imaging in the evaluation of people with suspected COVID-19. Eight studies were included for assessing the rate of positive imaging in individuals with initial RT-PCR negative results and positive RT-PCR results on follow-up, and 10 studies were included for evaluating the accuracy of thoracic imaging for imagining asymptomatic individuals. For all 98 included studies, risk of bias was high or unclear in 52 (53%) studies with respect to participant selection, in 64 (65%) studies with respect to reference standard, in 46 (47%) studies with respect to index test, and in 48 (49%) studies with respect to flow and timing. Concerns about the applicability of the evidence to: participants were high or unclear in eight (8%) studies; index test were high or unclear in seven (7%) studies; and reference standard were high or unclear in seven (7%) studies. Imaging in people with suspected COVID-19 We included 94 studies. Eighty-seven studies evaluated one imaging modality, and seven studies evaluated two imaging modalities. All studies used RT-PCR alone or in combination with other criteria (for example, clinical signs and symptoms, positive contacts) as the reference standard for the diagnosis of COVID-19. For chest CT (69 studies, 28285 participants, 14,342 (51%) cases), sensitivities ranged from 45% to 100%, and specificities from 10% to 99%. The pooled sensitivity of chest CT was 86.9% (95% confidence interval (CI) 83.6 to 89.6), and pooled specificity was 78.3% (95% CI 73.7 to 82.3). Definition for index test positivity was a source of heterogeneity for sensitivity, but not specificity. Reference standard was not a source of heterogeneity. For chest X-ray (17 studies, 8529 participants, 5303 (62%) cases), the sensitivity ranged from 44% to 94% and specificity from 24 to 93%. The pooled sensitivity of chest X-ray was 73.1% (95% CI 64. to -80.5), and pooled specificity was 73.3% (95% CI 61.9 to 82.2). Definition for index test positivity was not found to be a source of heterogeneity. Definition for index test positivity and reference standard were not found to be sources of heterogeneity. For ultrasound of the lungs (15 studies, 2410 participants, 1158 (48%) cases), the sensitivity ranged from 73% to 94% and the specificity ranged from 21% to 98%. The pooled sensitivity of ultrasound was 88.9% (95% CI 84.9 to 92.0), and the pooled specificity was 72.2% (95% CI 58.8 to 82.5). Definition for index test positivity and reference standard were not found to be sources of heterogeneity. Indirect comparisons of modalities evaluated across all 94 studies indicated that chest CT and ultrasound gave higher sensitivity estimates than X-ray (P = 0.0003 and P = 0.001, respectively). Chest CT and ultrasound gave similar sensitivities (P=0.42). All modalities had similar specificities (CT versus X-ray P = 0.36; CT versus ultrasound P = 0.32; X-ray versus ultrasound P = 0.89). Imaging in PCR-negative people who subsequently became positive For rate of positive imaging in individuals with initial RT-PCR negative results, we included 8 studies (7 CT, 1 ultrasound) with a total of 198 participants suspected of having COVID-19, all of whom had a final diagnosis of COVID-19. Most studies (7/8) evaluated CT. Of 177 participants with initially negative RT-PCR who had positive RT-PCR results on follow-up testing, 75.8% (95% CI 45.3 to 92.2) had positive CT findings. Imaging in asymptomatic PCR-positive people For imaging asymptomatic individuals, we included 10 studies (7 CT, 1 X-ray, 2 ultrasound) with a total of 3548 asymptomatic participants, of whom 364 (10%) had a final diagnosis of COVID-19. For chest CT (7 studies, 3134 participants, 315 (10%) cases), the pooled sensitivity was 55.7% (95% CI 35.4 to 74.3) and the pooled specificity was 91.1% (95% CI 82.6 to 95.7).

AUTHORS' CONCLUSIONS

Chest CT and ultrasound of the lungs are sensitive and moderately specific in diagnosing COVID-19. Chest X-ray is moderately sensitive and moderately specific in diagnosing COVID-19. Thus, chest CT and ultrasound may have more utility for ruling out COVID-19 than for differentiating SARS-CoV-2 infection from other causes of respiratory illness. The uncertainty resulting from high or unclear risk of bias and the heterogeneity of included studies limit our ability to confidently draw conclusions based on our results.

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

INTRODUCTION

The chest x-ray (CXR) is the most commonly performed x-ray examination in England, UK. Reporting radiographers provide a cost-effective and safe solution for managing CXR backlogs, but not all Trusts support this service development. This study aimed to establish the service enablers and challenges associated with training and employing radiographers to report CXR images in acute hospital sites in England, UK.

METHODS

Approval for this electronic survey was granted in 84 of 146 (58%) Trusts approached. The survey was open for 10 weeks during August to October 2020, comprising of qualitative and quantitative questions. Data was exported in to an Excel spreadsheet where manual thematic analysis was performed. Descriptive statistics were also generated.

RESULTS

Sample size was 75 (89% response rate). Thirty-three departments (44%) had at least one trainee. Most departments (n = 53, 71%) employ at least one CXR reporting radiographer. A total of 121/160 (76%) radiographers report CXRs. Number of reporting sessions shows progression. Factors enabling training and employment arise from service improvements, financial pressures, and developing the workforce. The main challenges relate to staffing issues with a number of associated sub-themes. A small faction indicated lack of radiographer interest to report CXRs due to litigation worries; possibly uncovering a new and emerging issue.

CONCLUSION

Enablers and challenges associated with radiographers reporting CXRs are similar to previous studies. The growth of CXR reporting radiographers and reporting sessions indicates a continuing reliance on radiographers to contributing to managing CXR backlogs.

IMPLICATIONS FOR PRACTICE

It is recommended that potential trainees are explicitly informed of the legal protection that will be provided, to prevent accountability concerns impacting on the continuing progression in this area of advanced practice.

Thoracic imaging tests for the diagnosis of COVID-19

BACKGROUND

The respiratory illness caused by SARS-CoV-2 infection continues to present diagnostic challenges. Our 2020 edition of this review showed thoracic (chest) imaging to be sensitive and moderately specific in the diagnosis of coronavirus disease 2019 (COVID-19). In this update, we include new relevant studies, and have removed studies with case-control designs, and those not intended to be diagnostic test accuracy studies.

OBJECTIVES

To evaluate the diagnostic accuracy of thoracic imaging (computed tomography (CT), X-ray and ultrasound) in people with suspected COVID-19.

SEARCH METHODS

We searched the COVID-19 Living Evidence Database from the University of Bern, the Cochrane COVID-19 Study Register, The Stephen B. Thacker CDC Library, and repositories of COVID-19 publications through to 30 September 2020. We did not apply any language restrictions.

SELECTION CRITERIA

We included studies of all designs, except for case-control, that recruited participants of any age group suspected to have COVID-19 and that reported estimates of test accuracy or provided data from which we could compute estimates.

DATA COLLECTION AND ANALYSIS

The review authors independently and in duplicate screened articles, extracted data and assessed risk of bias and applicability concerns using the QUADAS-2 domain-list. We presented the results of estimated sensitivity and specificity using paired forest plots, and we summarised pooled estimates in tables. We used a bivariate meta-analysis model where appropriate. We presented the uncertainty of accuracy estimates using 95% confidence intervals (CIs).

MAIN RESULTS

We included 51 studies with 19,775 participants suspected of having COVID-19, of whom 10,155 (51%) had a final diagnosis of COVID-19. Forty-seven studies evaluated one imaging modality each, and four studies evaluated two imaging modalities each. All studies used RT-PCR as the reference standard for the diagnosis of COVID-19, with 47 studies using only RT-PCR and four studies using a combination of RT-PCR and other criteria (such as clinical signs, imaging tests, positive contacts, and follow-up phone calls) as the reference standard. Studies were conducted in Europe (33), Asia (13), North America (3) and South America (2); including only adults (26), all ages (21), children only (1), adults over 70 years (1), and unclear (2); in inpatients (2), outpatients (32), and setting unclear (17). Risk of bias was high or unclear in thirty-two (63%) studies with respect to participant selection, 40 (78%) studies with respect to reference standard, 30 (59%) studies with respect to index test, and 24 (47%) studies with respect to participant flow. For chest CT (41 studies, 16,133 participants, 8110 (50%) cases), the sensitivity ranged from 56.3% to 100%, and specificity ranged from 25.4% to 97.4%. The pooled sensitivity of chest CT was 87.9% (95% CI 84.6 to 90.6) and the pooled specificity was 80.0% (95% CI 74.9 to 84.3). There was no statistical evidence indicating that reference standard conduct and definition for index test positivity were sources of heterogeneity for CT studies. Nine chest CT studies (2807 participants, 1139 (41%) cases) used the COVID-19 Reporting and Data System (CO-RADS) scoring system, which has five thresholds to define index test positivity. At a CO-RADS threshold of 5 (7 studies), the sensitivity ranged from 41.5% to 77.9% and the pooled sensitivity was 67.0% (95% CI 56.4 to 76.2); the specificity ranged from 83.5% to 96.2%; and the pooled specificity was 91.3% (95% CI 87.6 to 94.0). At a CO-RADS threshold of 4 (7 studies), the sensitivity ranged from 56.3% to 92.9% and the pooled sensitivity was 83.5% (95% CI 74.4 to 89.7); the specificity ranged from 77.2% to 90.4% and the pooled specificity was 83.6% (95% CI 80.5 to 86.4). For chest X-ray (9 studies, 3694 participants, 2111 (57%) cases) the sensitivity ranged from 51.9% to 94.4% and specificity ranged from 40.4% to 88.9%. The pooled sensitivity of chest X-ray was 80.6% (95% CI 69.1 to 88.6) and the pooled specificity was 71.5% (95% CI 59.8 to 80.8). For ultrasound of the lungs (5 studies, 446 participants, 211 (47%) cases) the sensitivity ranged from 68.2% to 96.8% and specificity ranged from 21.3% to 78.9%. The pooled sensitivity of ultrasound was 86.4% (95% CI 72.7 to 93.9) and the pooled specificity was 54.6% (95% CI 35.3 to 72.6). Based on an indirect comparison using all included studies, chest CT had a higher specificity than ultrasound. For indirect comparisons of chest CT and chest X-ray, or chest X-ray and ultrasound, the data did not show differences in specificity or sensitivity.

AUTHORS' CONCLUSIONS

Our findings indicate that chest CT is sensitive and moderately specific for the diagnosis of COVID-19. Chest X-ray is moderately sensitive and moderately specific for the diagnosis of COVID-19. Ultrasound is sensitive but not specific for the diagnosis of COVID-19. Thus, chest CT and ultrasound may have more utility for excluding COVID-19 than for differentiating SARS-CoV-2 infection from other causes of respiratory illness. Future diagnostic accuracy studies should pre-define positive imaging findings, include direct comparisons of the various modalities of interest in the same participant population, and implement improved reporting practices.

Évaluation d'un dispositif de continuité pédagogique à distance mis en place auprès d'étudiants MERM pendant le confinement sanitaire lié au COVID-19

Introduction

The specific context related to the COVID-19 pandemic necessitated the implementation of distance learning continuity for students. In France, teachers and radiography students in initial training, not specially prepared for this, had to adapt. An evaluation of the system was proposed to the students.

Materials and methods

An anonymous online questionnaire with 4 main sections (pedagogy, communication, learning and concerns) was sent to 91 students at the end of the semester.

Results

91 responses were received. The slideshows with sound or presented during a virtual class are appreciated by the students. Online quizzes are ideal for learning/reviewing. For assessments, individual assignments and online questionnaires are appreciated. Teacher/student interaction via e-mail or video conferencing was considered satisfactory by the large majority of students. Student-student interactions via social networks, for course explanations or document exchange, are very suitable. The majority of students felt they were working a lot and much more compared to face-to-face teaching. Less than half of the students worked more than 20 h per week. Their motivation varied widely. Organizational habits were disrupted, but the autonomy granted was appreciated. The students were mainly concerned about the health of their loved ones and not about their own health.

Discussion

The use of distance education tools requires teacher commitment and technical skills. The frequency of communication by e-mail and/or videoconference between members of the teaching team and students must be adapted to the situation. Exchanges by e-mail allow for traceability, while videoconferencing allows direct interaction and a way out of isolation. Autonomy, appreciated by the students, was nevertheless combined with a strong variation in motivation; the anxiety-provoking period in which pedagogical continuity was built up may explain this contradictory observation.

Conclusion

The results obtained largely confirm the data in the literature. The experience gained through this survey should lead teachers to continue their reflection by test/integrating and evaluating distance education systems, while continuing face-to-face activities.

Diagnostic radiographers' experience of COVID-19, Gauteng South Africa

Introduction

As of July 2020, South Africa (SA) had the fifth highest number of COVID-19 infections in the world, with the greatest contributor of these infections, being the province of Gauteng. Diagnostic radiographers in Gauteng providing chest CT, chest radiograph and MRI services are frontline workers experiencing these unprecedented times. Therefore, this study undertook to explore diagnostic radiographers’ experiences of COVID-19.

Methods

A qualitative approach using an asynchronous opened-ended online questionnaire was used to explore diagnostic radiographers’ experiences of COVID-19. Responses from purposively sampled diagnostic radiographers in Gauteng SA, underwent thematic analysis.

Results

Sixty diagnostic radiographers representing both the private and public health sector responded to the questionnaire. Thematic analysis revealed three themes: new work flow and operations, effect on radiographer well-being and radiographer resilience.

Conclusion

Besides experiencing a shift in their professional work routine and home/family dynamics, diagnostic radiographers’ well-being has also been impacted by COVID-19. Adapting to the “new way of work” has been challenging yet their resilience and dedication to their profession, providing quality patient care and skill expertise is their arsenal to combat these challenges.

Implications for practice

Understanding the impact of COVID-19 on diagnostic radiographers will allow radiology departments’ management, hospital management, professional bodies and educational institutions to re-evaluate provision of resources, training, employee wellness programs as well as policies and procedures.