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We consider two types of events, identified by decreases in Dst below a threshold value and increases in the equatorial mass density at geosynchronous altitudes, ρeq, above a threshold value using the Takahashi et al. [2010] dataset. From the Dst events and 1-day averages, we find that there is a statistically weak and small-amplitude difference between ρeq on the day of the event and the days before and after. When hourly averages are considered, a significant peak is found to occur six hours after event onset, and the primary factor that determines the post-onset peak amplitude in ρeq is elevated F10.7. In addition, for hourly averages, ρeq following the onset of a Dst event depends on the north-south component of the interplanetary magnetic field, Bz after the time of onset, with higher average Bz four hours after the event onset corresponding to larger ρeq value 7-11 hours after onset. From the ρeq events, we find a weak dependence on Bz after the onset of an event, with higher average Bz four hours after the event onset corresponding to larger ρeq values 24-36 hours after onset.

Background There has been a drive to raise the standard of management of acute upper gastrointestinal bleeding (AUGIB) in the UK, including three previous audits, sponsored by the British Society of Gastroenterology (BSG). Objective To review the results of the latest BSG/National Health Service (NHS) England national survey of endoscopy services in England between 2014 and 2015. Method All NHS hospitals accepting acute admissions in England (168) were invited to respond to the survey. Results Overall, 142 hospitals (84%) returned data. 85% of hospitals used a validated risk assessment score at the time of patient9s admission. While 80% of hospitals provided a 24/7 endoscopy service for unstable patients, and another 10% were in network to provide an acute service, only 60% performed an endoscopy within 24 hours for stable acute admissions or inpatients with AUGIB. 11% of hospitals operated an out-of-hours ad hoc rota. 43% felt that pressure from routine work affected their ability to offer a next-day oesophagogastroduodenoscopy service, while 20% of hospitals struggled to recruit endoscopists. 28% of units reported that the previous national audit performed in 2013 had a positive influence on service development. Conclusions This survey has revealed significant deficiencies in provision of services for patients with AUGIB in England, without a significant increase in number of hospitals providing an emergency AUGIB service since the last national audit in 2013.

Purpose: Mammographic density has been demonstrated to predict breast cancer risk. It has been proposed that it could be used for stratifying screening pathways and recommending additional imaging. Volumetric density tools use the recorded compressed breast thickness (CBT) of the breast measured at the x-ray unit in their calculation, however the accuracy of the recorded thickness can vary. The aim of this study was to investigate whether inaccuracies in recorded CBT impact upon volumetric density classification and to examine whether the current quality control (QC) standard is sufficient for assessing mammographic density. Methods: Raw data from 52 digital screening mammograms were included in the study. For each image, the clinically recorded CBT was artificially increased and decreased to simulate measurement error. Increments of 1mm were used up to ±15% error of recorded CBT was achieved. New images were created for each 1mm step in thickness resulting in a total of 974 images which then had Volpara Density Grade (VDG) and volumetric density percentage assigned. Results: A change in VDG was recorded in 38.5% (n= 20) of mammograms when applying ±15% error to the recorded CBT and 11.5 % (n= 6) were within the QC standard prescribed error of ±5mm. Conclusion: The current QC standard of ±5mm error in recorded CBT creates the potential for error in mammographic density measurement. This may lead to inaccurate classification of mammographic density. The current QC standard for assessing mammographic density should be reconsidered.

Multistage processing of automated breast ultrasound lesions recognition is dependent on the performance of prior stages. To improve the current state of the art, we propose the use of end-to-end deep learning approaches using fully convolutional networks (FCNs), namely FCN-AlexNet, FCN-32s, FCN-16s, and FCN-8s for semantic segmentation of breast lesions. We use pretrained models based on ImageNet and transfer learning to overcome the issue of data deficiency. We evaluate our results on two datasets, which consist of a total of 113 malignant and 356 benign lesions. To assess the performance, we conduct fivefold cross validation using the following split: 70% for training data, 10% for validation data, and 20% testing data. The results showed that our proposed method performed better on benign lesions, with a top “mean Dice” score of 0.7626 with FCN-16s, when compared with the malignant lesions with a top mean Dice score of 0.5484 with FCN-8s. When considering the number of images with Dice score [Formula: see text] , 89.6% of the benign lesions were successfully segmented and correctly recognised, whereas 60.6% of the malignant lesions were successfully segmented and correctly recognized. We conclude the paper by addressing the future challenges of the work.

Breast cancer is the most commonly diagnosed cancer in women with a lifetime risk of 1 in 8 in the UK. The disease is associated with considerable morbidity and mortality. The UK breast screening program has been in place for almost 30 years and has evolved with improved diagnostic imaging. The overall benefits of the screening program are subject to continued heated debate with multiple potential harms. The aim of this review is to provide the non-breast specialist health-care professional an overview of the evolution of the breast screening program, a summary of the evidence of the benefits, and a description of the harms. In addition, the diagnostic methods currently employed as well as potential future changes to the screening program and imaging techniques will be covered.

Post-mortem autopsy examinations are a time-consuming and costly activity, which have declining public acceptability. Post-mortem imaging can provide a reproducible and prompt adjunct to post-mortem examinations and can negate the need for a formal invasive examination in certain cases. Post-mortem imaging is an emerging field with growing interest in establishing imaging as a standard element of the post-mortem examination. Currently in the UK there is no nationally agreed curriculum or coordinated training in post-mortem imaging. Standardised training would need to be developed and validated by both national pathology and radiology speciality colleges. Despite increasing interest and publications in this area there remains a shortage of published literature concerning implementation. Further research is needed to refine technology and protocols for the use of imaging in the post-mortem setting. This review describes a potential nationwide post-mortem imaging service based on standardised costs, image protocols and practice, delivered in specialist centres within mortuaries following specific training of key staff members. Quality assurance and auditing exercises would ensure a robust and consistent service.

Several years ago, the International Economics Committee of the ACR began a study of comparisons among nations regarding the practice of radiology. This article is the second in a series. The purpose here is to compare the use across countries of imaging modalities in the screening algorithms of a variety of common diseases. In conjunction with the initial study, this will allow radiologists to understand in greater detail how health system practices differ among a selected set of nations. In this study, a standardized survey was administered to committee members from 10 countries in the developed and developing world. As with the prior study, there were both striking differences and similarities, even among a small cohort of nations that are all (except India) members of the Organisation for Economic Co-operation and Development. For example, breast cancer screening with mammography involves similar radiographic techniques for screening evaluations and has similarly high levels of insurance coverage, but the recommended ages at initial screening and end of screening differ. Other diseases, such as lung cancer and abdominal aortic aneurysm, have variable, but overall lower, levels of estimated participation among surveyed countries and significantly lower insurance coverage. Although this data set relies on survey data from individual practitioners, it provides an important perspective of the role of radiology in screening programs. Given the increasing pressure from domestic and foreign governments to reign in health care costs, the comparative differences in screening programs, and especially their use of (often costly) imaging techniques, may be a harbinger for future health policy decisions in the United States and abroad.

OBJECTIVE: To compare the clinical and functional outcomes of US-guided (USG) vs landmark-guided (LMG) injection for the treatment of adults with shoulder pathology. METHOD: MEDLINE, AMED and Embase in addition to unpublished literature databases were searched from 1950 to August 2011. Studies were included if they were randomized or non-randomized controlled trials comparing USG vs LSG injections for the treatment of adults with shoulder pathology. Two reviewers independently performed data extraction and appraisal of the studies. Meta-analyses were performed where possible and when inappropriate a narrative review of the data was presented. RESULTS: Six papers including 307 patients were reviewed; 142 received LMG injections and 165 received USG injections. There was a statistically significant difference in favour of USG for pain at 6 weeks (standardized mean difference 1.03; 95% CI 0.12, 1.93; P = 0.03). There was no statistically significant difference between the injection methods with respect to shoulder function (standardized mean difference 0.33; 95% CI -0.59, 1.25; P = 0.48). There was a significant difference between interventions for shoulder abduction at 6 weeks in favour of the USG method (mean difference 2.81; 95% CI 0.67, 4.95; P = 0.01). No other movements showed a statistically significant difference. CONCLUSION: There is a statistically significant difference in pain and abduction between LMG and USG steroid injections for adults with shoulder pathology. However, these differences are small and may not represent clinically useful differences. The current evidence base is limited by a number of important methodological weaknesses, which should be considered when interpreting these findings. The cost-effectiveness of the intervention should be considered in the design of future studies.

Background The term “superficial femoral vein” is felt to be potentially misleading and dangerous in the context of deep venous thrombosis (DVT) of the lower limb, with the preferred term now being “femoral vein.” The purpose of this work was to identify a means of reducing its use in reports of lower limb sonographic scans for DVT. Methods A retrospective search of the reports for all lower limb sonographic scans for the detection of DVT in 2011 was performed using the Radiology Information System to identify the baseline rate of use of the term. Nontargeted and subsequently targeted e-mails were then sent to reporters of such sonographic scans over a 6-month follow-up period, and the results were reevaluated. Results The baseline rate of use of the term was 17% before any intervention. It decreased to 10% following nontargeted intervention, and to 6% following targeted e-mail intervention. There were no cases of patients coming to harm as a result of the use of the term during the study period. Conclusions A simple and inexpensive system of e-mails to reporters resulted in a decline in the rate of use of the misleading term “superficial femoral vein.” © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 42:472–474, 2014

The purpose of this article is to present a novel algorithm for the detection of masses in mammographic computer-aided diagnosis systems. Four key points provide the novelty of our approach: (1) the use of eigenanalysis for describing variation in mass shape and size; (2) a Bayesian detection methodology providing a mathematical sound framework, flexible enough to include additional information; (3) the use of a two-dimensional principal components analysis approach to facilitate false positive reduction; and (4) the incorporation of breast density information, a parameter correlated with the performance of most mass detection algorithms and which is not considered in existing approaches. To study the performance of the system two experiments were carried out. The first is related to the ability of the system to detect masses, and thus, free-response receiver operating characteristic analysis was used, showing that the method is able to give high accuracy at a high specificity (80% detection at 1.40 false positives per image). Second, the ability of the system to highlight the pixels belonging to a mass is studied using receiver operating characteristic analysis, resulting in A z = 0.89 ± 0.04 . In addition, the robustness of the approach is demonstrated in an experiment where we used the Digital Database for Screening Mammographydatabase for training and the MammographicImage Analysis Society database for testing the algorithm.

Aim To compare magnetic resonance imaging (MRI)-derived breast density measurements using automatic segmentation algorithms with radiologist estimations using the Breast Imaging Reporting and Data Systems (BI-RADS) density classification. Materials and methods Forty women undergoing mammography and dynamic breast MRI as part of their clinical management were recruited. Fat–water separated MRI images derived from a two-point Dixon technique, phase-sensitive reconstruction, and atlas-based segmentation were obtained before and after intravenous contrast medium administration. Breast density was assessed using software from Advanced MR Analytics (AMRA), Linkoping, Sweden, with results compared to the widely used four-quartile quantitative BI-RADS scale. Results The proportion of glandular tissue in the breast on MRI was derived from the AMRA sequence. The mean unenhanced breast density was 0.31±0.22 (mean±SD; left) and 0.29±0.21 (right). Mean breast density on post-contrast images was 0.32±0.19 (left) and 0.32±0.2 (right). There was “almost perfect” correlation between pre- and post-contrast breast density quantification: Spearman's correlation rho=0.98 (95% confidence intervals [CI]: 0.97–0.99; left) and rho=0.99 (95% CI: 0.98–0.99; right). The 95% limits of agreement were −0.11–0.08 (left) and −0.08–0.03 (right). Interobserver reliability for BI-RADS was “substantial”: weighted Kappa k=0.8 (95% CI: 0.74–0.87). The Spearman correlation coefficient between BI-RADS and MRI breast density was rho=0.73 (95% CI: 0.60–0.82; left) and rho=0.75 (95% CI: 0.63–0.83; right) which was also “substantial”. Conclusion The AMRA sequence provides a fully automated, reproducible, objective assessment of fibroglandular breast tissue proportion that correlates well with mammographic assessment of breast density with the added advantage of avoidance of ionising radiation.

In the UK, breast cancer represents the most commonly diagnosed cancer in females and carries with it a significant morbidity and mortality. An established national screening programme is in place to identify those with the disease at an early stage in order to optimise treatment and prognosis. This article provides an overview for the non-breast specialist clinician whose practice regularly deals with women who may be the subject of the screening programme. It outlines the diagnostic methods employed in the screening programme, the controversies that have surrounded it and the evolving technologies that will improve detection and diagnostic accuracy.

The purpose of this study was to examine the relationship between breast arterial calcification (BAC), commonly found on mammography, and cardiovascular disease and its risk factors.The study population, nested within the European Prospective Investigation of Cancer-Norfolk (EPIC-Norfolk) cohort study, consisted of 1,590 women older than 55 years, not taking hormone replacement therapy, and with available screening mammograms. Mammograms were coded by three radiologists for presence or absence of BAC. History of coronary heart disease (CHD), stroke, and diabetes and risk factors for cardiovascular disease (including smoking status, body mass index [BMI], blood pressure, diabetes, and glycosylated hemoglobin [HbA1c]) were independently measured from health examinations in the EPIC study.The prevalence of BAC was 16.0%. Women with BAC were significantly older than those without it. BAC was associated with prevalent CHD, but not stroke. The odds ratio of having CHD was 2.54 (95% confidence interval, 1.03-6.30). The sensitivity and specificity were 32.4% and 85.5%, respectively. Except for smoking, which showed an inverse association, there was no consistent significant association of BAC with cardiovascular disease risk factors including BMI, diabetes, HbA1c, or lipids.BAC found on mammograms was associated with prevalent CHD after adjustment for age, but with low sensitivity. BAC may provide additional information toward identifying cardiovascular disease risk among otherwise healthy women.

Objective: Literature speculates that visual image quality (IQ) and compression force levels may be directly related. This small study investigates whether a relationship exists between compression force levels and visual IQ. Method: To investigate how visual IQ varies with different levels of compression force, 39 clients were selected over a 6 year screening period that had received markedly different amounts of compression force on each of their three sequential screens. Images for the 3 screening episodes for all women were scored visually using 3 different IQ scales. Results: Correlation coefficients between the 3 IQ scales were positive and high (0.82, 0.9 and 0.85). For the scales, the IQ scores their correlation does not vary significantly, even though different compression levels had been applied. Kappa IQ scale 1: 0.92, 0.89, 0.89. ANOVA IQ scale 2: p ¼ 0.98, p ¼ 0.55, p ¼ 0.56. ICC IQ scale 3: 0.97, 0.93, 0.91. Conclusion: For the 39 clients there is no difference in visual IQ when different amounts of compression are applied. We believe that further work should be conducted into compression force and image quality as ‘higher levels’ of compression force may not be justified in the attainment of suitable visual image quality.

Aim To compare image quality of lateral skull radiographs using computerised radiography (CR) with or without the use of secondary radiation grids. Methods and materials 100 adult patients referred for lateral skull radiography from the accident and emergency department were randomised so 50 were examined using a secondary radiation grid and 50 without. Three consultant radiologists blinded to the randomisation then individually reviewed the image quality depending on a set of pre-determined criteria. Results There is no statistical difference in image quality between lateral skulls exposed with or without the use of a secondary radiation grid when applied to computerised radiography. Conclusion Secondary radiation grids can be removed for lateral skull radiography, using CR with no deterioration in image quality.

Background\ud The application of compression force in mammography is more heavily influenced by the practitioner rather than the client. This can affect client experience, radiation\ud dose and image quality. This research investigates practitioner compression force variation over a 6 year screening cycle in three different screening units.\ud \ud Methods:\ud Recorded data included: practitioner code, applied compression force(N), breast thickness(mm), BI-RADS® density category. Exclusion criteria included: previous\ud breast surgery, previous/ongoing assessment, breast implants. 975 clients (2925) client visits, 11,700 mammogram images) met inclusion criteria across three sites.\ud Data analysis assessed practitioner variation of compression force and breast thickness.\ud \ud Results:\ud Practitioners across three breast screening sites behave differently in the application of compression force. Two of the three sites demonstrate variability within\ud themselves, though they demonstrated no significant difference in mean, first and third quartile compression force and breast thickness values CC(p>0.5), MLO(p>0.1)\ud between themselves. However, the third site (where mandate dictates a minimum compression force is applied) greater consistency was demonstrated; a significant\ud difference in mean, first and third quartile compression force and breast thickness values(p\ud \ud Conclusion:\ud Stabilisation of variations in compression force may have a positive impact on image quality, radiation dose reduction, re-attendance levels and potentially cancer detection. The large variation in compression forces could negatively impact on client experience between the units and within a unit.\ud Further research is required to establish best practice guidelines for compression force within mammography.\ud Keywords: Compression force, Breast compression, Compression variability

Breast cancer is the most frequently diagnosed cancer in women. However, the exact cause(s) of breast cancer still remains unknown. Early detection, precise identification of women at risk, and application of appropriate disease prevention measures are by far the most effective way to tackle breast cancer. There are more than 70 common genetic susceptibility factors included in the current non-image-based risk prediction models (e.g., the Gail and the Tyrer-Cuzick models). Image-based risk factors, such as mammographic densities and parenchymal patterns, have been established as biomarkers but have not been fully incorporated in the risk prediction models used for risk stratification in screening and/or measuring responsiveness to preventive approaches. Within computer aided mammography, automatic mammographic tissue segmentation methods have been developed for estimation of breast tissue composition to facilitate mammographic risk assessment. This paper presents a comprehensive review of automatic mammographic tissue segmentation methodologies developed over the past two decades and the evidence for risk assessment/density classification using segmentation. The aim of this review is to analyse how engineering advances have progressed and the impact automatic mammographic tissue segmentation has in a clinical environment, as well as to understand the current research gaps with respect to the incorporation of image-based risk factors in non-image-based risk prediction models.

INTRODUCTION The delivery of health care around the world is remarkably diverse in 2015. A comparison of the approximately 200 national entities on the planet reveals marked differences in national measures, both on the input side, such as health care spending, and in outcomes, such as life span. Using the percentage of gross domestic product as a metric for comparing health care spending, the current variation among nations is almost an order of magnitude, from the Marshall Islands and the United States at close to 20% to Myanmar at about 2% [1]. Outcomes are also highly variable, with an almost 2-fold difference in life span between the best and worst nations [2]. Within the nations represented in this report, the longest lived is Japan, and yet that nation spends significantly less of its gross domestic product on health care than the United States, which spends the highest fraction of gross domestic product of nations in this group [3]. This is a reminder that simplistic comparisons and correlations may miss important insights into how medical systems work. Almost all nations struggle to some degree with challenges in managing their commitment to the health of their citizens. These challenges include deciding how much to spend on health care as well as how to measure outcomes (and the impact health care has on those

A two-dimensional hybrid simulation is carried out for the global structure of the magnetosheath. Quasi-perpendicular magnetosonic/fast mode waves with large-amplitude in-phase oscillations of the magnetic field and the ion density are seen near the bow shock transition. Alfven/ion-cyclotron waves are observed along the streamlines in the magnetosheath, and the wave power peaks in the middle magnetosheath. Antiphase oscillations in the magnetic field and density are present away from the shock transition. Transport ratio analysis suggests that these oscillations result from mirror mode waves. Since fluid simulations are currently best able to model the global magnetosphere and the pressure in the magnetosphere is inherently anisotropic (parallel pressure p parallel to not equal perpendicular pressure pr), it is of some interest to see if a fluid model can be used to predict the anisotropic pressure evolution of a plasma. Here the predictions of double adiabatic theory, the bounded anisotropy model, and the double polytropic model are tested using the two-dimensional hybrid simulation of the magnetosheath. Inputs to the models from the hybrid simulation are the initial post bow shock pressures and the time-dependent density and magnetic field strength along streamlines of the plasma. The success of the models is evaluated on the basis of how well they predict the subsequent evolution of p(parallel to) and P-perpendicular to. The bounded anisotropy model, which encorporates a bound on p(perpendicular to)/p(parallel to) due to the effect of ion cyclotron pitch angle scattering, does a very good job of predicting the evolution of pr; this is evidence that local transfer of energy due to waves is occurring. Further evidence is the positive identification of ion-cyclotron waves in the simulation. The lack of such a good prediction for the evolution of p(parallel to) appears to be due to the model's lack of time dependence for the wave-particle interaction and its neglect of the parallel heat flux. Estimates indicate that these effects will be less significant in the real magnetosheath, though perhaps not negligible.

A pilot study to detect volume changes of cerebral structures in growth hormone (GH)-deficient adults treated with GH using serial 3D MR image processing and to assess need for segmentation prior to registration was conducted.Volume MR scans of the brain were obtained in five patients and six control subjects. Patients were scanned before and after 3 and 6 months of therapy. Control subjects were scanned at the same intervals. A phantom was used to quantify scaling errors. Second and third volumes were aligned with the baseline by maximizing normalized mutual information and transformed using sinc interpolation. Registration was performed with and without brain segmentation and correction of scaling errors. Each registered, transformed image had the original subtracted, generating a difference image. Structural change and effects of segmentation and scaling error correction were assessed on original and difference images. The radiologists' ability to detect volume change was also assessed.Compared with control subjects, GH-treated subjects had an increase in cerebral volume and reduction in ventricular volume (p = 0.91 x 10(-3)). Scale correction and segmentation made no difference (p = 1 and p = 0.873). Structural changes were identified in the difference images but not in the original (p = 0.136). The radiologists detected changes200 microm.GH treatment in deficient patients results in cerebral volume changes detectable by registration and subtraction of serial MR studies but not by standard assessment of images. This registration method did not require prior segmentation.

Aims(1) To establish whether gastroenterologists wish to train in abdominal ultrasound according to the Royal College of Radiologists’ document,Guidance for the training in ultrasound of medical non-radiologists. (2) To determine whether the ultrasound workload generated by gastroenterologists differs from that by other clinicians.MethodsA postal questionnaire was sent to all 278 gastroenterology trainees. The indications and findings of 100 consecutive gastroenterologist requested scans were compared with 100 scans requested sequentially by other clinicians through a teaching hospital radiology department.Results82% of the survey forms were returned. 77% of trainees wished to train in abdominal ultrasound and 68% were prepared to train in the manner outlined in the guideline document. However, 86% felt that they would ideally prefer not to assess renal or pelvic pathology, restricting to hepatobiliary diagnosis only. 73% of trainees did not anticipate that a further scan by a radiologist would be required. Comparison of gastroenterology scans with those requested by other clinicians revealed a relative excess of hepatobiliary indications and findings, and a notable paucity of renal and pelvic pathology in gastroenterology practice.ConclusionsThere is general interest in abdominal ultrasound training among gastroenterology trainees and broad acceptance of the guideline document. However, most trainees perceive a focus of training restricted to hepatobiliary disease to be most appropriate. The case mix study provides support for this viewpoint. It is suggested that a more focused ultrasound training for gastroenterologists be considered.

Hormone replacement therapy protects from cardiovascular disease at the menopause in part by reduction of menopausal pro-atherogenic serum lipid changes. Tibolone has beneficial effects on lipids, although serum high density lipoprotein levels decrease. This study aimed primarily to establish the effects of long-term administration of tibolone on a new surrogate marker for cardiovascular disease risk, the measurement of carotid artery intima-media thickness (CIMT) using high-resolution ultrasound.Measurement of CIMT and assessment of carotid atherosclerotic plaques were undertaken in 31 women on tibolone and 30 voluntary controls from an ongoing open-label study of tibolone.The two groups were comparable, except for mean age and prevalence of current smokers. Repeatability of CIMT measurements was acceptable (CV, 10.0%). CIMT was significantly thicker in those with atherosclerotic plaques and increased systolic blood pressure. Prevalence of plaques was raised in those who had ever smoked, and those with elevated systolic blood pressure. There was no influence of tibolone on CIMT, whether plaques were present or not.This reliable technique demonstrates associations between CIMT and established risk factors. CIMT was significantly thicker in those with existing plaques. We did not demonstrate an effect of long-term tibolone use on either CIMT or prevalence of plaques.

A computer-based system is routinely used for home reporting of nuclear medicine scans performed out of hours in our unit. To report ventilation/perfusion scans (V/Q) adequately, chest radiographs are also digitized and transferred to the home personal computer. One hundred consecutive V/Q scans and their corresponding chest X-rays were reported on a personal computer and on a lightbox by two radiologists and two nuclear physicians. This study shows that ventilation/perfusion scans can be reliably reported from computer screen images. The loss of data when chest X-rays are digitized to a 512 x 512 matrix, however, results in considerable misinterpretation and the digitized chest X-ray may, at best, be unhelpful and, at worst, result in an incorrect V/Q scan report.

To evaluate prospectively the efficacy of plastic-covered metallic endoprostheses in patients with malignant esophageal fistulas and perforations.Thirty-nine patients with incurable esophageal carcinoma who developed esophagorespiratory fistulas (n = 20) or perforations (n = 19) were treated with plastic-covered metallic stents.Covered Wallstent endoprostheses were placed in 36 patients and covered Gianturco stents in three. All 19 perforations and 18 of 20 fistulas were successfully closed (clinical success rate, 95%). Symptoms of aspiration or dysphagia improved in all successfully treated patients. Mean survival was 81.8 days (range, 1-370 days). One patient with a closed perforation developed a fistula 16 weeks later and was treated with a second, overlapping stent; three patients with recurrent fistulas were treated with additional esophageal stents (one patient) or tracheal stents (two patients). In four patients, stent migration (two Gianturco and two Wallstent endoprostheses) necessitated placement of an additional stent.Covered metallic stents offer effective treatment for perforations and fistulas in patients with esophageal malignancy. Patients with recurrent fistulas can be treated with additional stents. Fistulas close to the upper esophageal sphincter may be closed with placement of parallel covered metallic stents in the esophagus and trachea.

The term "superficial femoral vein" is felt to be potentially misleading and dangerous in the context of deep venous thrombosis (DVT) of the lower limb, with the preferred term now being "femoral vein." The purpose of this work was to identify a means of reducing its use in reports of lower limb sonographic scans for DVT.A retrospective search of the reports for all lower limb sonographic scans for the detection of DVT in 2011 was performed using the Radiology Information System to identify the baseline rate of use of the term. Nontargeted and subsequently targeted e-mails were then sent to reporters of such sonographic scans over a 6-month follow-up period, and the results were reevaluated.The baseline rate of use of the term was 17% before any intervention. It decreased to 10% following nontargeted intervention, and to 6% following targeted e-mail intervention. There were no cases of patients coming to harm as a result of the use of the term during the study period.A simple and inexpensive system of e-mails to reporters resulted in a decline in the rate of use of the misleading term "superficial femoral vein."

The application of breast compression in mammography may be more heavily influenced by the practitioner\ud rather than the client. This could affect image quality and will affect client experience. This study builds on\ud previous research to establish if mammography practitioners vary in the compression force they apply over a six year period.\ud \ud This longitudinal study assessed 3 consecutive analogue screens of 500 clients within one screening centre in\ud the UK. Recorded data included: practitioner code, applied pressure (daN), breast thickness (mm), BI-RADS®\ud density category and breast dose. Exclusion criteria included: previous breast surgery, previous/ongoing\ud assessment, breast implants. 344 met inclusion criteria. Data analysis: assessed variation of compression force\ud (daN) and breast thickness (mm) over 3 sequential screens to determine whether compression force and breast\ud thickness were affected by practitioner variations.\ud Compression force over the 3 screens varied significantly; variation was highly dependent upon the practitioner\ud who performed the mammogram. Significant thickness and compression force differences over the 3 screens\ud were noted for the same client (0.31). When practitioners from different compression force groups\ud performed 3 screens, maximum compression force variations were higher and significantly different (p

To the Editor We should like to thank Drs Grimbergen and Den Heeten for taking the time to read our article [1] and to write a letter [2]. We are pleased our work is generating discussion and in particular that the optimisation of compression force in mammography continues to attract interest in order to improve image quality, minimise radiation dose and enhance the patient/client experience. We were interested to read their critique of the literature generally in relation to the terminology which is used in many publications, including our article. We accept we have used colloquialisms that are common in clinical practice and are not necessarily the correct physics terms. We apologise for using clinical terminology and we hope this does not distract the reader from the underlying value of our work. We were interested to learn about Siemens Opcomp® (Erlangen, Germany); however, we did not investigate this technology. The unit on which our study was carried out was Hologic™ Selenia (West Sussex, UK). Drs Grimbergen and Den Heeten commented “the large variability of the breast dimensions between females is not taken into account. In our view, the thickness difference vs pressure should be considered, taking the individual dimensions of the breast into account.” This is a useful observation, and we thank the authors for this comment. Although the initial breast thickness was measured, it was decided to normalise the data, as described in the paper, as breast thickness on its own may not correctly represent the breast volume. Instead, we decided to concentrate on the change in thickness that the compression force offered. The different paddle sizes were considered separately; however, individual dimensions of the breasts were not measured. Therefore, breast thickness vs pressure could not be assessed. We were very interested to read about the work Drs Grimbergen and Den Heeten are doing in trying to prove that pressure is a better entity to standardise in mammography. We wish them every success with this. On searching the internet, we found that they are Chief Scientific Officer and Chief Technical Officer of Sigmascreening (Amsterdam, Netherlands); this medical device company is promoting a new paddle design/prototype [http://www.sigmascreening.nl/product (accessed 30 April 2013)]. Sigmascreening's website indicates that research studies have been done with their prototype, but unfortunately we could not find any peer reviewed journal publications related to it. We did identify some abstracts, and they appear to provide encouraging information. However, we are unable to comment on their approach as limited data exist for us to give an informed opinion. As new data are published, we look forward to constructive discussion about the relative merits of their approach. Yours etc., P HOGG, MPhil, BSc (Hons) M TAYLOR, MSc, BSc (Hons) K SZCZEPURA, MSc, BSc (Hons) C MERCER, MSc, BSc (Hons) E DENTON, FRCR, FRCP

In four patients presenting in childhood with varying degrees of hypopituitarism, magnetic resonance imaging (MRI) showed a reduction in size of the normal pituitary fossa contents and an absent or very narrow stalk. A high signal intensity, enhancing area at the base of the stalk, having the appearances and signal characteristics of the posterior pituitary, was seen in each case. We discuss the case histories and MR findings in our patients and review the relevant literature.

Objective: This preliminary study determines\ud whether the absolute amount of breast compression\ud in mammography varies between\ud and within practitioners.\ud Methods: Ethics approval was granted. 488\ud clients met the inclusion criteria. Clients were\ud imaged by 14 practitioners. Collated data included\ud Breast Imaging Reporting and Data\ud System (BI-RADS) density, breast volume,\ud compression and practitioner code.\ud Results: A highly significant difference in\ud mean compression used by different practitioners\ud (p,0.0001 for each BI-RADS density)\ud was demonstrated. Practitioners applied compression\ud in one of three ways using either low,\ud intermediate or high compression force, with\ud no significant difference in mean compression\ud within each group (p50.99, p50.70, p50.54,\ud respectively). Six practitioners showed a significant\ud correlation (p,0.05) between compression\ud and BI-RADS grade, with a tendency\ud to apply less compression with increasing\ud BI-RADS density. When compression was\ud analysed by breast volume there was a wide\ud variation in compression for a given volume.\ud The general trend was the application of\ud higher compression to larger breast volumes\ud by all three practitioner groups.\ud Conclusion: This study presents an insight\ud into practitioner variation of compression\ud application in mammography. Three groups\ud of practitioners were identified: those who\ud used low, intermediate and high compression\ud across the BI-RADS density grades. There\ud was wide variation in compression for any\ud given breast volume, with trends of higher\ud compression demonstrated for increasing\ud breast volumes. Collation of further studies\ud will facilitate a new perspective on the analysis\ud of practitioner, client and equipment\ud variables in mammography imaging.\ud Advances in knowledge: For the first time, it\ud has been practically demonstrated that practitioners\ud vary in the amount of compression\ud applied to breast tissue during routine\ud mammography.

It has been shown that the probability to develop breast cancer is strongly correlated with the appearance of tissue in mammographic images. This appearance incorporates both greylevel and tissue pattern aspects and models of local texture information, which incorporate both greylevel and spatial aspects, can as such be related to mammographic risk assessment. Here we represent texture by the variation in local greylevel configuration/appearance in histogram format for which the distribution varies with texture appearance. The histogram information can be directly used to classify mammograms according to standard mammographic risk estimation models (e.g. BIRADS). Results on the MIAS database indicate a correct classification of 70% (which increases to 84% for high/low risk classification), which is comparable with existing methods. Variation of the classification results with respect to some of the model parameters are discussed, which indicate the robustness of the methodology. In addition future directions, to improve the classification results are discussed.

Mammographic risk assessment is becoming more important in decision making within screening mammography and computer aided diagnosis. Strong evidence shows that characteristic mixtures of breast tissues as seen on mammography, referred to as mammographic parenchymal patterns, provide crucial information about breast cancer risk. One approach to automatic mammographic risk assessment concentrates on mammographic parenchymal pattern segmentation, to quantify the relative proportion of different breast tissues. This paper presents a clinical evaluation of mammographic parenchymal pattern segmentation based on Tabar's tissue modelling, using the Mammographic Image Analysis Society (MIAS) database. The segmentation assessment results show a strong correlation with increasing Tabar and Birads risk categories. In addition, the segmentation assessment is linked to the correct/incorrect automatic mammographic risk classification, which indicated that good segmentation results tend to lead to correct mammographic risk estimation.

Various registration approaches have been adopted to correlate areas in mammograms and detect differences. These differences are likely to be associated with the development of an abnormality. Most of these methods rely on corresponding landmarks between images. Obtaining these landmarks turns out to be the most difficult task and plays an important role in the alignment accuracy. Manual landmark generation is a tedious and time-consuming task when the number of landmarks is large and, moreover, introduces variability in placing the landmarks (two consecutive experiments with the same images could have different landmarks and errors). Therefore, a large number of these methods are based on automatically extracting and corresponding landmarks from mammographic images. The landmarks include breast boundary, pectoral muscle, salient regions extracted using wavelets, isointensity contours or steerable filters, and crossing points of horizontal and vertical structures. This chapter presents an approach to extract correspondence in mammographic images based on anatomical features that appear as linear structures (i.e., fibrous tissue, ducts, and vessels). Correspondence is used here in two different applications: for mammographic image registration and for tracking linear structures. Registration is applied to temporal and contralateral mammograms of the same woman. A framework for the detection of abnormal structures based on registration is developed, and some initial promising results are given. Tracking of linear structures (see Section 14.6) is performed for the same breast over several screening rounds. This could be used to assess and model the development of architectural changes and abnormal structures. By being able to track regions back in time, the available information helps to improve early detection of subtle abnormalities that are initially missed by radiologists. One could argue that contralateral registration based on the linear structures in the left and right breasts should not be performed because linear structures present large differences. However, it is generally accepted that overall duct, vessel, and tissue structure shows similarities between left and right breasts of the same woman. Figure 14.1 illustrates those similarities in temporal and contralateral images. The aim is to use these similarities to guide the registration process.

Strong evidence shows that characteristic patterns of breast tissues as seen on mammography, referred to as mammographic parenchymal patterns, provide crucial information about breast cancer risk. Quantitative evaluation of the characteristic mixture of breast tissues can be used as for mammographic risk assessment as well as for quantification of change of the relative proportion of different breast tissue patterns. This paper investigates mammographic segmentation based on spatial moments and prior information of mammographic building blocks (i.e. nodular, linear, homogenous, and radiolucent) as described by Tabar's tissue models to describe parenchymal patterns. The algorithm extracted texture features from a set of sub-sampled mammographic patches. Tabar's mammographic building blocks were modelled as statistical distribution of clustered filter responses based on spatial moments. Evaluation was based on the Mammographic Image Analysis Society (MIAS) database. The experimental results indicated that the developed methodology is capable of modelling complex mammographic images and can deal with intraclass variation and noise aspects. The results show realistic segmentation on tissue specific regions with respect to breast anatomy and Tabar's tissue models. In addition, the segmentation results were used for mammographic risk based classification of the entire MIAS database resulting in ∼70% correct low/high risk classification.

Objective Health services contribute significantly to carbon dioxide (CO2) emissions and, while services in the UK are beginning to address this, the focus has been on reducing energy consumption rather than road transport, a major component of emissions. We aimed to compare the distances travelled by patients attending mobile breast screening clinics compared to the distance they would need to travel if screening services were centralized. Methods Anonymized postcode records were analysed to determine driving distances potentially saved through attendance at 20 mobile breast screening clinics rather than at two centralized locations. Based on assumptions for the typical car used, the CO2 emissions were calculated for the current case of decentralized service through mobile clinics compared to a hypothetical case where only centralized services are available over one complete three-year cycle of breast screening invitations. Results The availability of mobile breast screening clinics for the 60,675 women who underwent screening over a three-year cycle led to a return journey distance savings of 1,429,908 km. Taking into account the CO2 emissions of the tractor unit used for moving the mobile clinics around, this equates to approximately 75 tonnes of CO2 saved in any one year. Conclusions Decentralizing health care delivery can potentially provide substantial reductions in emissions at the same time as improving the patient experience. Thus, the ‘care close to home’ agenda can simultaneously improve health outcomes and the environment.

Studies reported in the literature indicate that the increase in the breast density is one of the strongest indicators of developing breast cancer. In this paper, we present an approach to automatically evaluate the density of a breast by segmenting its internal parenchyma in either fatty or dense class. Our approach is based on a statistical analysis of each pixel neighbourhood for modelling both tissue types. Therefore, we provide connected density clusters taking the spatial information of the breast into account. With the aim of showing the robustness of our approach, the experiments are performed using two different databases: the well-known Mammographic Image Analysis Society digitised database and a new full-field digital database of mammograms from which we have annotations provided by radiologists. Quantitative and qualitative results show that our approach is able to correctly detect dense breasts, segmenting the tissue type accordingly.

The purpose of this article is to present a novel algorithm for the detection of masses in mammographic computer-aided diagnosis systems. Four key points provide the novelty of our approach: (1) the use of eigenanalysis for describing variation in mass shape and size; (2) a Bayesian detection methodology providing a mathematical sound framework, flexible enough to include additional information; (3) the use of a two-dimensional principal components analysis approach to facilitate false positive reduction; and (4) the incorporation of breast density information, a parameter correlated with the performance of most mass detection algorithms and which is not considered in existing approaches. To study the performance of the system two experiments were carried out. The first is related to the ability of the system to detect masses, and thus, free-response receiver operating characteristic analysis was used, showing that the method is able to give high accuracy at a high specificity (80% detection at 1.40 false positives per image). Second, the ability of the system to highlight the pixels belonging to a mass is studied using receiver operating characteristic analysis, resulting in A(z) = 0.89 +/- 0.04. In addition, the robustness of the approach is demonstrated in an experiment where we used the Digital Database for Screening Mammography database for training and the Mammographic Image Analysis Society database for testing the algorithm.

Mammographic density and serum sex hormone levels are important risk factors for breast cancer, but their associations with one another are unclear. We studied these phenotypes, together with single nucleotide polymorphisms (SNP) in genes related to sex hormone metabolism, in a cross-sectional study of 1,413 postmenopausal women from the European Prospective Investigation into Cancer and Nutrition-Norfolk. All women were >1 year postmenopausal and had not taken hormone replacement therapy for >3 months before sampling. Serum levels of 7 sex hormones [estradiol, testosterone, sex hormone-binding globulin (SHBG), androstenedione, 17-OH-progesterone, estrone, and estrone sulfate] and 15 SNPs in the CYP17, CYP19, EDH17B2, SHBG, COMT, and CYP1B1 genes were studied. Mammograms nearest in time to the blood sampling were identified through the national breast screening program and visually assessed by three radiologists using the Boyd six-category and Wolfe four-category scales. We found a weak positive association between mammographic density and SHBG levels (P = 0.09) but no association with any other hormones. None of the SNPs, including those shown previously to be associated with estradiol or SHBG, showed significant associations with density. We conclude that mammographic density is largely independent of postmenopausal steroid hormone levels, indicating that these risk factors have, to a large extent, an independent etiology and suggesting that they may be independent predictors of breast cancer risk. (Cancer Epidemiol Biomarkers Prev 2006;15(8):1502-08)

We have developed an approach to the separation of background texture and structures in images. This technique is based on the statistical difference between local and median co-occurrence matrices. In this paper we investigate if the classification of mammographic parenchymal patterns can be improved if anatomical structures can be removed from the image and the classification is based only on the background texture information. A comparison of two techniques — one developed by Byng, the other developed by Karssemeijer — applied to the original and reconstructed images is presented. To validate our approach, we use a dataset where each mammogram has been classified by experts using two different approaches: Wolf grades and the six classes described by Boyd.

This work presents a novel method to establish correspondence in MR images taken at different times which allows the tracking of regions of interest through time-series and dynamic MR studies. This is developed as an hybrid correspondence approach, where a correlation measure and a point based method are used. Evaluation results are obtained using simulated deformation of the breast volume. In addition, registration and tracking results using real data are shown.

This paper presents a novel approach to tackle the problem of multi- modality correspondence in mammography. More precisely, this work focuses on finding a methodology to correspond areas in X-ray and MR images of the same breast. If correspondence between modalities is achieved, this information can be combined into a model providing a better understanding of the region of interest. Initial results show the validity of our approach although further evaluation is needed.

We have investigated a combination of statistical modelling and expectation maximisation for a texture based approach to the segmentation of mammographic images. Texture modelling is based on the implicit incorporation of spatial information. Statistical modelling is used for data generalisation and noise removal purposes. Expectation maximisation modelling of the spatial information in combination with the statistical modelling are compared to expectation maximisation modelling based on single grey-level values. The developed segmentation results are used for two specific applications which are registration of mammographic images and mammographic risk assessment.

Spacecraft-borne and ground-based magnetometers frequently detect magnetospheric micropulsations in the period range 0.2–10 s, termed Pc 1–2, and attributed to electromagnetic ion cyclotron waves driven by temperature anisotropy (T^ > T ||). Previous surveys of Pc 1 occurrence locations have been limited to L < 9. We present AMPTE/IRM observations of the distribution of Pc 1 waves out to the magnetopause, for a limited region of MLT = 10–14. The probability of wave occurrence Pwav is large (> 0.15) between L = 7–12, peaking at L = 8–10 (Pwav ~ 0.25). When the L-value is normalized to the magnetopause position Lmp, however, the highest probabilities of Pc 1 wave occurrence are close to the magnetopause, with Pwav ~0.25 for Lnorm = L/Lmp = 0.8–1.0. These results are consistent with increased convective growth rate at large L and with the greater effect of magnetosphere compression close to the magnetopause. On the other hand, we only directly observe magnetic field compression for at most about 25% of the wave events.Key words. Magnetospheric physics (magnetospheric configuration and dynamics; MHD waves and instabilities; plasma waves and instabilities)

s / Clinical Radiology 69 (2014) S23eS24 S24 the role of the radiologist, IR(ME)R, the usefulness of radiologists’ input in MDTs and discussions with radiologists. Results: 96% of respondents felt that a key role is the reporting of scans. 19% felt undertaking interventional procedures is one of the largest roles. Only 13% of junior doctors were aware of IR(ME)R, compared with 62% of doctors post-FY1 and 100% of radiologists questioned. 96% found discussions about tests useful. 100% found MDT participation useful. Conclusion: These results demonstrate that hospital doctors’ perceptions of the key roles of radiologists are variable. Knowledge of IR(ME)R amongst juniors is poor, which could be addressed using interventions such as teaching and leaflets. Most respondents found discussionwith radiologists in clinical encounters useful and the value of this should be emphasised. Radiologists: forever in the shadows? Authors: Muhammad A. Zamir, Mohamed Khalifa, Junaid Patel, Usman Raja, Ahmed Wobi Presenter: Muhammad Zamir Purpose: Objectively assess public awareness of the role of the radiologist. Methods and materials: Multicentre survey with quantitative and qualitative questionnaire. Results: 80% of respondents had undergone a radiological investigation although 38% had not heard of the term ’radiology’; 64% believed that radiologists were qualified radiographers and 72% assumed that GPs/referrers reported their scan. 66% said it was ’important’ or ’very important’ as to who reported their scan. Conclusion: Modern medicine leans heavily on radiology for diagnosis and patient turnover in radiology departments is increasing. Despite this, the general public is not familiar with radiology or radiologists and the fact that they are qualified medical practitioners. Radiologists have traditionally had nominal publicity compared to clinical specialists but the results are surprising. The presupposition that referrers/GPs are responsible for scan reports can lead to pressure on clinicians and patient misinformation. The American College of Radiology has spearheaded a campaign entitled “Face of Radiology” to revise perception of radiologists. A campaign in the UK would enhance public understanding of the “who, what and why” related to radiology. In particular, the medical background of radiologists and role in theMDTmust be emphasised enabling patients to acknowledge that their investigation is integral for diagnosis and management. This awareness will ultimately lead to a satisfactory patient-centred experience. Impact of cancer symptom awareness campaigns on diagnostic testing and treatment Authors: Abigail Bentley, Erika Denton, Lucy Ironmonger, Sean Duffy Presenter: Erika Denton Purpose: ’Be Clear on Cancer’ aims to raise awareness of cancer symptoms and improve early diagnosis. The first national lung campaign (MayJune 2012), encouraged people with a 3 week cough to visit their GP. Understanding the impact of such campaigns on health services, including imaging activity, is vital. Methods and materials: Data on chest x-rays (CXR) and chest/ abdominal CT scans were collected via the Diagnostic Imaging Dataset (DID). The number of tests was compared between April and MayJuly 2012, adjusting for submitting organisations and working days. A control of the same period in 2013 was used (DID does not hold data for 2011). Results: GP-referred CXRs and CT scans increased by 19% and 16% respectively (p < 0.01) during May-July, compared with April, but decreased by 17% and 6% respectively (p < 0.05) during the same period in 2013. A 9% increase in lung cancer diagnoses was seen (p < 0.01) with a 3 percent point increase in the proportion of non-small cell cases diagnosed at stage 1 (p < 0.01). The proportion of patients having surgical resection as a first definitive treatment increased from 13.7% to 16.0% (p < 0.01). Conclusion: A substantial butmanageable increase in testswas seen during and following the campaign, complementing changes in other metrics, including a positive shift in stage distribution. Efforts to achieve early diagnosis are vital and require support from a range of health professionals. Any qualified provider of ultrasound e can it compete with integrated service provision and services with access to specialist opinion? Authors: Christopher Ball, Anthony Higginson Presenter: Christopher Ball Purpose: An accurate sonography report can reliably detect common causes of abdominal pain (1). A report containing uncertainty causes confusion and has been shown to be more prevalent in unsupervised reports in comparison with specialist radiologist reports (2). The aim is to evaluate the effect of access to specialist ultrasound opinion and contrast ultrasound on the diagnostic pathway of patients and quantify the value added added by an integrated service. Methods and materials: Calculate the number of patients without cancer discussed at the hepatobiliary MDT meeting as a result of ultrasound reports. Determine the number of unnecessary tests performed involving interventional procedures or ionising radiation, including computed tomography. Results: A retrospective search identified 6873 abdominal ultrasound examinations 1486 referrals to an outsourced treatment centre and 5397 to an NHS trust with subspecialist opinion. Therewas a 20 fold reduction in patients without cancer being discussed in a cancer meeting when the pathway includes access to a radiologist with specialist interest and access to contrast enhanced ultrasound examinations. There was also a 10 fold reduction in uncertainty from specialist opinion. Conclusion: Access to specialist opinion has a measurable impact on patient pathways reducing unnecessary further investigations on patients who have no serious pathology.

OBJECTIVE. This article describes some of the major influences that have improved the way health services in England are delivered over the past 10 years and the impact this has had on imaging services. In particular, we will describe the impact of these changes on the delivery of musculoskeletal imaging services.CONCLUSION. The National Health Service (NHS) is reaping the benefits of these changes, with waiting times at the lowest ever recorded. The changes have been delivered with increased investment as well as service modernization and workforce change.

PURPOSE: A new nonrigid registration method, designed to reduce the effect of movement artifact in subtraction images from breast MR, is compared with existing rigid and affine registration methods. METHOD: Nonrigid registration was compared with rigid and affine registration methods and unregistered images using 54 gadolinium-enhanced 3D breast MR data sets. Twenty-seven data sets had been previously reported normal, and 27 contained a histologically proven carcinoma. The comparison was based on visual assessment and ranking by two radiologists. RESULTS: When analyzed by two radiologists independently, all three registration methods gave better-quality subtraction images than unregistered images (p < 0.01), but nonrigid registration gave significantly better results than the rigid and affine registration methods (p < 0.01). There was no significant difference between rigid and affine registration methods. CONCLUSION: Nonrigid registration significantly reduces the effects of movement artifact in subtracted contrast-enhanced breast MRI. This may enable better visualization of small tumors and those within a glandular breast

Objective To perform a calibration study to provide data to help improve consistency in the pressure that is applied during mammography. Methods Automatic readouts of breast thickness accuracy vary between mammography machines; therefore, one machine was selected for calibration. 250 randomly selected patients were invited to participate; 235 agreed, and 940 compression data sets were recorded (breast thickness, breast density and pressure). Pressure (measured in decanewtons) was increased from 5 daN through 1-daN intervals until the practitioner felt that the pressure was appropriate for imaging; at each pressure increment, breast thickness was recorded. Results Graphs were generated and equations derived; second-order polynomial trend lines were applied using the method of least squares. No difference existed between breast densities, but a difference did exist between “small” (15×29 cm) and “medium/large” (18×24/24×30 cm) paddles. Accordingly, data were combined. Graphs show changes in thickness from 5...