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Background: Prompt identification of fracture healing is crucial for medical decision-making and clinical research. This study aims to assess the effectiveness of the Radiographic Union Score for Hip (RUSH) in subtrochanteric fractures and determine the optimal scoring threshold for fracture healing., Methods: We obtained 94 sets of X-ray films from the postoperative follow-up of 35 patients who underwent intramedullary nail fixation for subtrochanteric fractures. Six orthopedic trauma surgeons evaluated the imaging data and determined fracture healing based on subjective judgment. They then scored the X-ray images using the RUSH form. After four weeks, the same observers re-evaluated 47 randomly selected sets of radiographs. Subsequently, the observers and study designer conducted a consensus meeting where they agreed on whether the fractures had healed. We used Fleiss kappa to evaluate agreement among observers based on subjective impressions, and the intraclass correlation coefficient assessed RUSH score consistency. Regression analysis examined the relationship between scores and fracture healing consensus using a receiver operator characteristic (ROC) curve., Results: Based on overall impressions, the agreement level among orthopedic trauma surgeons for determining the healing status of subtrochanteric fractures was moderate (Kappa = 0.564, 95% CI: 0.511-0.616). However, utilizing the RUSH scoring system can improve the consistency to a substantial level of agreement (ICC = 0.748, 95% CI: 0.663-0.817). Regarding intraobserver reliability, there were significant differences among orthopedic trauma surgeons in judging fracture healing based on overall impressions. However, using the RUSH scoring form, the attending group achieved better intraobserver consistency than the resident group. Regression analysis and ROC curve analysis revealed a strong correlation between the RUSH total score, cortical bone score, cancellous bone score, and consensus on fracture healing. The AUC values are 0.769 (95% CI: 0.670-0.868), 0.779 (95% CI: 0.681-0.876), and 0.771 (95% CI: 0.674-0.867), respectively., Conclusions: Our study highlights the effectiveness of the RUSH scoring system in enhancing interobserver agreement and intraobserver consistency when evaluating subtrochanteric fracture healing in orthopedic trauma surgeons. We propose setting 21 points as the threshold for the simplified RUSH scoring system to determine fracture healing. This system includes only eight items related to cortical bone, with a total score of 24 points., (© 2024. The Author(s).)

Background: Up to now, there is no convincing evidence, that surgical treatment of deltoid ligament injuries, especially in the setting of ankle fractures, does result in improved outcome. One reason could be a missing diagnostic standard. The aim of the current systematic review was to analyze the applied diagnostic strategies for acute deltoid ligament injuries in outcome studies., Methods: MEDLINE, Scopus, Central, and EMBASE were searched through February 2022 for any original studies addressing diagnostics of acute deltoid injuries. The study was conducted per the PRISMA guidelines. The inclusion criteria were formed according to the PICOS criteria. The data assessed were study type, level of evidence, included fractures, time point and method of diagnosing deltoid ligament layers, differentiation between layers and syndesmotic injuries., Results: 31 studies were included in the final analysis. Most studies (n = 28) based their decision to treat the deltoid ligament injury on radiologic findings only, with stressed radiographs (n = 18) being the most common. The radiographs were applied at one or more time points (preoperative, before ORIF, after ORIF, after ORIF and syndesmotic repair). The most frequently assessed parameter was the Medial Clear Space (MCS, n = 27) with cut-off-values considered pathological ranging between MCS > 1 mm and MCS > 6 mm., Conclusion: Comparing the 31 studies shows that a standardized method to diagnose deltoid ligament injuries is missing. Further research is needed to establish evidence-based guidelines on how to diagnose acute deltoid ligament injuries., Trial Registration: Prospero ID: CRD42022307112., Clinical Trial Number: not applicable., (© 2024. The Author(s).)

Introduction: To reduce the risks involved with ionising radiation exposure, typical values (TVs) and diagnostic reference levels (DRLs) have been established to help keep radiation doses 'as low as reasonably practicable. TVs/DRLs provide standardised radiation dose metrics that can be used for comparative purposes. However, for paediatrics, such values should consider the size of the child instead of their age. This study aimed to establish and compare paediatric TVs for chest, abdomen and pelvis radiography., Methods: Study methods followed processes for establishing paediatric DRLs as outlined by the Health Information and Quality Authority (HIQA). Kerma-area product (KAP) values, excluding rejected images, were retrospectively acquired from the study institution's Picture Archiving and Communications System (PACS). Paediatric patients were categorised into the following weight-based groupings (5 to <15 kg, 15 to <30 kg, 30 to <50 kg, 50 to 80 kg) and stratified based on the examination that was performed (chest, abdomen, and pelvis), and where it was performed (the different X-ray rooms). Anonymised data were inputted into Microsoft Excel for analysis. Median and 3rd quartile KAP values were reported together with graphical illustrations., Results: Data from 407 X-ray examinations were analysed. For the previously identified weight categories (5 to <15 kg, 15 to <30 kg, 30 to <50 kg, 50 to 80 kg), TVs for the chest were 0.10, 0.19, 0.37 and 0.53 dGy.cm 2 , respectively. For the abdomen 0.39, 1.04, 3.51 and 4.05 dGy.cm 2 and for the pelvis 0.43, 0.87, 3.50 and 7.58 dGy.cm 2 . Between X-ray rooms TVs varied against the institutional TVs by -60 to 119 % (chest), -50 to 103 % (abdomen) and -14 and 24 %% (pelvis)., Conclusion: TVs in this study follow established trends with patient weight and examination type and are comparable with published literature. Variations do exist between individual examination rooms and reasons are multifactorial. Given that age and size do not perfectly correlate further work should be undertaken around weight-based TVs/DRLs in the paediatric setting., (Copyright © 2024. Published by Elsevier Inc.)

Radiographic measurements play a crucial role in evaluating the alignment of distal radius fractures (DRFs). Various manual methods have been used to perform the measurements, but they are susceptible to inaccuracies. Recently, computer-aided methods have become available. This review explores the methods commonly used to assess DRFs. The review introduces the different measurement techniques, discusses the sources of measurement errors and measurement reliability, and provides a recommendation for their use. Radiographic measurements used in the evaluation of DRFs are not reliable. Standardizing the measurement techniques is crucial to address this and automated image analysis could help improve accuracy and reliability., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: E.W. has owned stock in Disior Ltd, Helsinki, Finland and sold them in January 2022. N.S. has no conflicts of interest to declare.

The management of trauma is a significant part of emergency medicine practice, in a context where the number of sports accidents is rising steadily every year, with a total of 430,000 people affected in Switzerland in 2023 according to the Swiss Accident Prevention Bureau. In addition to the physical examination, radiological assessment is a cornerstone of diagnosis. Radiology of the musculoskeletal system is the most frequently requested paraclinical examination in these situations. The consequences of not recognizing radiological lesions may result in short-term consequences (haemorrhagic or neurological injuries) or long-term consequences (chronic pain, functional impairment). We therefore present examples of "pitfalls in radiology" frequently encountered in our daily clinical practice, and the use of additional exams., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

The role of radiographers in healthcare has evolved significantly from operating imaging equipment to being essential in patient care and diagnosis. In Australia, radiographers play a crucial role in image interpretation, identifying and communicating significant findings to enhance patient outcomes. Preliminary image evaluation (PIE) allows radiographers to interpret images and ensure significant findings are noted, particularly in urgent situations, complementing diagnoses when radiologist reports are unavailable. Despite their potential, many radiographers lack empowerment, leading to delays and adverse patient outcomes. This underutilisation stems from a lack of support and systemic barriers. Radiographers, with their extensive expertise in imaging, are vital for ensuring patient safety and care quality. Policy changes are needed to integrate PIE into standard workflows, allowing radiographers to fully utilise their skills. Recognising and leveraging their expertise will enhance patient care, foster collaboration, and ensure radiographers contribute fully to the healthcare team, ultimately improving patient safety and care quality.

Veterinary practitioners and other personnel involved in the examination are exposed to ionizing radiation while performing portable radiographs on horses. An online survey was distributed to all Veterinary Council of Ireland-registered practices where the self-reported practice profile is at least 20% equine work. The survey contained questions relating to radiation safety training, protocols, personal dosimetry and lead protection usage, repeat exposures, sedation, and personnel roles during the examination. The aim of the survey was to document the current radiation safety practices of equine veterinary practitioners during portable radiography. The results showed that although adherence to guidance set out by the Environmental Protection Agency (EPA) is reasonably good, compliance rates can be improved. Personal dosemeter usage and repeat rate reduction could particularly benefit from further improvement. This is of the utmost importance in ensuring that occupational radiation exposure to veterinary practitioners is kept to an absolute minimum during their daily practice., (© The Author(s) 2024. Published by Oxford University Press.)

Introduction: To minimise the risks associated with ionising radiation, it is necessary for all staff involved to employ specific techniques to reduce radiation exposure of the patient. These techniques include using compression during examinations of the pelvic region and lumbar spine, using a gonad shield, and asking women if they are pregnant. However, some staff do not use these techniques consistently. Increasing compliance requires determining why staff are non-compliant. Thus, this study aims to qualitatively investigate why radiographers do not use these techniques., Methods: This qualitative study is based on a cross-sectional electronic survey with open-ended questions. The data were analysed using an inductive qualitative content analysis with quantification of the findings. In total, 111 radiographers from 20 hospitals in Sweden participated., Results: Three categories appear related to barriers that could obstruct the radiographer from using compression, gonad shields and asking about pregnancy: patient characteristics, interaction between the patient and the radiographer and issues related to the situation and examination., Conclusions: The barriers to not using radiation protection measures varied depending on the specific measure. However, the barriers were mainly related to the patient experiencing pain, communication difficulties and cultural reasons. In addition, the lack of adequate and user-friendly equipment was seen as a barrier to applying compression and using gonad shielding., (© 2024 The Authors. Journal of Medical Radiation Sciences published by John Wiley & Sons Australia, Ltd on behalf of Australian Society of Medical Imaging and Radiation Therapy and New Zealand Institute of Medical Radiation Technology.)

Introduction: The aim of this study was to clarify the perspective of radiography science as an academic discipline. A discipline can be studied by discovering the collective use of concepts, especially core concepts. We have previously identified the core concepts as clinical practices in radiography, radiographers' profession, safe and high-quality radiation use, and technology in radiography. The relationships between these concepts have not been studied previously. In order to clarify the perspective of radiography science we have investigated further the core concepts, their interrelationships and interdependencies., Methods: Altogether, 53 dissertations meeting the inclusion criteria were selected for a qualitative document analysis. The data were first analysed deductively using an extraction matrix comprising four core concepts developed from previous studies, then relational statements were synthesised, and the statements were analysed semantically., Results: Analysis revealed the bilateral interrelationships between the concepts and their dependencies. All the concepts were used within healthcare. The rationale for radiography science research was the clinical practice of radiography and the improvement of services in a complex environment as a part of patients' pathways. Safe and high-quality radiation use was investigated as a means to deliver optimal services. Technology was studied as being functional or a means to deliver services. The perspective of the discipline was seen as the combination of humanistic interaction with advanced technology, where safety and quality were a necessity., Conclusions: Defining core concepts and their interrelations clarifies the perspective of the discipline and gives radiography researchers a way to argue their viewpoint., (© 2024 The Authors. Journal of Medical Radiation Sciences published by John Wiley & Sons Australia, Ltd on behalf of Australian Society of Medical Imaging and Radiation Therapy and New Zealand Institute of Medical Radiation Technology.)

Introduction: Implementation and application of evidence-based practice through legislation, international and national guidelines and local protocols is integral to the successful undertaking of forensic radiographic practice, because of its medico-legal role. This research aims to evaluate those organisational barriers and facilitators to its effective implementation., Methods: This scoping review was undertaken according to the JBI updated guidelines using the PCC mnemonic. A systematic search of 10 databases was undertaken to identify literature addressing the research question relating to this aspect of forensic radiography practice. Handsearching and snowballing were also included to enhance this search strategy. The search focussed on forensic imaging of paediatrics, the living and deceased., Results: Of the 301 papers initially selected, 9 articles were identified as eligible for inclusion, encompassing an international perspective. Through Inductive Content Analysis, 5 conceptual categories were developed: ineffective organisational governance, education translation, system brakes, default practice, and value-based judgement., Conclusion: The results indicate that there are many complex and multifactorial organisational issues impacting upon effective implementation of best practices within paediatric forensic imaging. There is a need to address these issues, before attempting strategies for future implementation. It is essential to recognise that there can be no one-size-fits approach, but rather tailored strategies are required recognising individual needs within the multi-disciplinary scope of forensic radiographic practice., Implications for Practice: Failure to recognise and address the identified issues impacting upon effective implementation, may have significant implications on the processes and individuals involved in the forensic imaging acquisition pathway. Successful addressing of these issues may enable the professionals involved in organisational governance to create a more conducive and receptive environment for best-practice implementation., Competing Interests: Conflict of interest statement The authors listed below certify that they have NO affiliations with or involvement in any organisation or entity with any financial interest, or non-financial interest in the subject matter of materials discussed in this manuscript., (Crown Copyright © 2023. Published by Elsevier Ltd. All rights reserved.)

Purpose: To examine whether radiologic technologists' perceptions of imaging appropriateness differed based on their primary imaging modality, work shift, shift length, and primary practice type., Methods: A national, cross-sectional study was conducted in the fourth quarter of 2019 using a simple, randomized sample of American Society of Radiologic Technologists (ASRT) members. Study participants were employed in health care settings in radiography, computed tomography (CT), mammography, or radiology leadership. Seven potential reasons for inappropriate imaging procedures (ie, patient expectations, provide patient with a feeling of being taken seriously, lack of time, expectations from relatives, compensation for insufficient clinical examination, normal findings would reassure the patient, and fear of lawsuits) were evaluated for relationships with their primary imaging modality, work shift, shift length, and primary practice type., Results: Disparities in perceived reasons affecting imaging appropriateness were found. Providing the patient with a feeling of being taken seriously was related to primary practice type ( P = .022). Lack of time was related to primary imaging modality ( P = .005) and primary practice type ( P = .006). Expectations from relatives was related to primary imaging modality ( P = .016) and primary practice type ( P = .027). Compensation for insufficient clinical examination was related to primary imaging modality ( P < .001), shift length ( P = .011), work shift ( P = .002), and primary practice type ( P < .001). Fear of lawsuits was related to primary imaging modality ( P = .001)) and work shift ( P = .002)., Discussion: The study reveals that radiologic technologists' perceptions of patient-centered factors and defensive medicine-related factors differ among imaging modalities, shift types, and practice settings. However, more research is required to determine why radiologic technologists perceive these reasons to be present, investigate whether providers feel similarly, and determine perceptual alignment with evidence-based guidelines., Conclusion: The findings suggest that attention should focus on the appropriateness of CT imaging procedures performed in hospitals during night shifts., (© 2022 American Society of Radiologic Technologists.)

Background: Establishing the etiology of community-acquired pneumonia (CAP) in children at admission is challenging. Most of the admitted children with CAP receive antibiotics. We aimed to build and validate a diagnostic tool combining clinical, analytical and radiographic features to differentiate viral from bacterial CAP, and among bacterial CAP, typical from atypical bacteria., Methods: Design-observational, multi-center, prospective cohort study was conducted in 2 phases. Settings: 24 secondary and tertiary hospitals in Spain. Patients-A total of 495 consecutive hospitalized children between 1 month and 16 years of age with CAP were enrolled. Interventions-A score with 2 sequential steps was built (training set, 70% patients, and validation set 30%). Step 1 differentiates between viral and bacterial CAP and step 2 between typical and atypical bacterial CAP. Optimal cutoff points were selected to maximize specificity setting a high sensitivity (80%). Weights of each variable were calculated with a multivariable logistic regression. Main outcome measures-Viral or bacterial etiology., Results: In total, 262 (53%) children (median age: 2 years, 52.3% male) had an etiologic diagnosis. In step 1, bacterial CAPs were classified with a sensitivity = 97%, a specificity = 48%, and a ROC's area under the curve = 0.81. If a patient with CAP was classified as bacterial, he/she was assessed with step 2. Typical bacteria were classified with a sensitivity = 100%, a specificity = 64% and area under the curve = 0.90. We implemented the score into a mobile app named Pneumonia Etiology Predictor, freely available at usual app stores, that provides the probability of each etiology., Conclusions: This 2-steps tool can facilitate the physician's decision to prescribe antibiotics without compromising patient safety., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

The aims of this study were to (1) assess reliability of leg length discrepancy (LLD) measurements at different anatomical landmarks, (2) longitudinally investigate LLD in patients within the first year following total hip arthroplasty (THA) and to (3) correlate changes in LLD with functional outcome. Ninety-nine patients with short stem THA (53.3% males, mean age: 61.0 ± 8.1 years) were prospectively included. Upright pelvic anteroposterior (a.p.) radiographs taken at 6 timepoints (preoperatively, discharge, 6, 12, 24, 52 weeks postoperatively) were used to assess LLD at 5 anatomical landmarks (iliac crest, upper sacroiliac joint, lower sacroiliac joint, tear drop figure, greater trochanter). WOMAC and Harris Hip Score (HHS) were obtained preoperatively and at 6 and 52 weeks. LLD measures significantly increased in the initial phase following THA, from discharge to 6 weeks postoperatively and remained constant thereafter. Documentation of LLDs is dependent on measurement site: LLDs varied significantly between trochanter and iliac crest to tear drop figure (p < 0.001). Functional assessments did not correlate with the occurrence of LLDs [WOMAC (p = 0.252); HHS (p = 0.798)]. Radiographic assessment of LLD following THA may not be performed early postoperatively, as measurements appear to inaccurately reflect actual LLDs at this time, potentially due incomplete leg extension and/or inhibited weight-bearing., (© 2021. The Author(s).)

Purpose: In 2-dimensional lateral cephalometric radiographs, patients with severe obstructive sleep apnea (OSA) exhibit a more crowded oropharynx in comparison with non-OSA. We tested the hypothesis that machine learning, an application of artificial intelligence (AI), could be used to detect patients with severe OSA based on 2-dimensional images., Methods: A deep convolutional neural network was developed (n = 1258; 90%) and tested (n = 131; 10%) using data from 1389 (100%) lateral cephalometric radiographs obtained from individuals diagnosed with severe OSA (n = 867; apnea hypopnea index > 30 events/h sleep) or non-OSA (n = 522; apnea hypopnea index < 5 events/h sleep) at a single center for sleep disorders. Three kinds of data sets were prepared by changing the area of interest using a single image: the original image without any modification (full image), an image containing a facial profile, upper airway, and craniofacial soft/hard tissues (main region), and an image containing part of the occipital region (head only). A radiologist also performed a conventional manual cephalometric analysis of the full image for comparison., Results: The sensitivity/specificity was 0.87/0.82 for full image, 0.88/0.75 for main region, 0.71/0.63 for head only, and 0.54/0.80 for the manual analysis. The area under the receiver-operating characteristic curve was the highest for main region 0.92, for full image 0.89, for head only 0.70, and for manual cephalometric analysis 0.75., Conclusions: A deep convolutional neural network identified individuals with severe OSA with high accuracy. Future research on this concept using AI and images can be further encouraged when discussing triage of OSA., (© 2021. The Author(s).)

Background: Accessibility to chest radiography remains a major challenge in high burden and low-income countries. The World Health Organization (WHO) guidelines acknowledge that for child contacts under 5 years, a negative symptom-based screening is sufficient to exclude active tuberculosis (TB), but in child contacts older than 5 years, a chest radiograph should be considered. We performed a systematic review and meta-analysis to assess the performance of symptom-based screening compared with chest radiography in household contacts under 15 years in low-income and middle-income countries., Methods: Screening articles published prior 1 October 2020 and data extraction were performed by 2 independent reviewers. The primary outcome was the concordance between symptom screening and chest radiography using the prevalence adjusted bias adjusted kappa coefficient (PABAK) and the proportion of asymptomatic children with negative chest radiography. The analysis was stratified by age group., Results: Of 639 identified articles, 10 were included. PABAK varied between 0.09 and 0.97 and between 0.22 and 0.98, in children less than 5 years and 5-14 years, respectively. The pooled proportion of children with both non-TB suggestive symptoms and chest radiography findings was 98.7% (96.9-99.8) in children less than 5 years and 98.1% (93.8-100) in children of age 5-14 years., Conclusions: Despite low concordance between symptom-based screening and chest radiography, most children without TB suggestive symptoms did not have chest radiography findings suggestive of TB. These results suggest that a negative symptom screening is sufficient to rule out active TB, supporting the WHO recommendation to use symptom-based screening alone when chest radiography is not available., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Children are often transferred to a Pediatric Emergency Department (PED) for definitive care after completion of diagnostic imaging. There is a paucity of data on the concordance rates of interpretation of imaging studies between referral and PED. Our objective is to describe the rates and clinical impact of discordant interpretation of X-rays and CT in children transferred to a PED., Methods: This was a retrospective cohort study of patients over a 12-month period from 12/1/2017-11/30/2018 with X-ray (XR) and CT performed prior to transfer to our PED. We compared referral radiology interpretations to those of pediatric radiologists to determine concordance. Encounters with discordant imaging interpretations were further evaluated for clinical impact (none, minor or major) based on need for additional laboratory workup, consultation, and changes in management and disposition., Results: We analyzed 899 patient encounters. There were high rates of concordance in both XR and CT interpretation (668/743; 89.9%, 95% CI 0.87-0.91 and 205/235; 87.2%, 95% CI 0.82-0.91, respectively). XR discordance resulted in minor clinical impact in 34 patients (45%, 95% CI 0.35-0.57) and a major clinical impact in 28 patients (37%, 95% CI 0.27-0.49). CT discordance resulted in minor clinical impact in 10 patients (33%, 95% CI 0.19-0.51) of patients and major clinical impact in 15 patients (50%, 95% CI 0.33-0.67). The most common discordances with major clinical impact were related to pneumonia on XR chest and appendicitis or inflammatory bowel disease on CT abdomen., Conclusions: In patients transferred to the PED, concordance of XR and CT interpretations was high. A majority of discordant interpretations led to clinical impact meaningful to the patient and emergency medicine (EM) physician. Referring EM physicians might consider the benefit of pediatric radiology consultation upon transfer, especially for imaging diagnoses related to pneumonia, appendicitis, or inflammatory bowel disease., Competing Interests: Declaration of Competing Interest Jason Miller reports no conflict of interest. Ciara Ivanics reports no conflict of interest. Kristina Zalewski reports no conflict of interest. Swati Mody reports no conflict of interest. Nirupama Kannikeswaran reports no conflict of interest., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To investigate the accuracy of X-ray and magnetic resonance imaging (MRI) measurements in evaluating the displacement of humeral lateral condyle fracture (HLCF) in different positions of the forearm based on human cadaveric HLCF models., Methods: Three human cadaveric elbow HLCF fracture models were successfully established. The wrist joint was fixed, and the forearm was rotated forward along the mid-axis. The maximum distance between the two segments of the lateral fracture gap was defined as LFS (lateral fracture space) distance, and the maximum distance between the two segments of the fracture gap at the anterior and posterior margins of the fracture model was defined as PFS (posterior fracture space). The LFS and PFS distances of the human cadaveric elbow HLCF fracture models were measured during forearm rotation at 0º, 45º, 90º, and 135º rotation using a Capture Motion System (CMS), positive and lateral elbow X-ray, coronal and sagittal MRI scans, respectively, and the CMS measurements were considered as the true fracture gap distances. The values obtained by CMS, X-ray, and MRI measurements for both LPS and PFS distances in the HLCF fracture model at each position during rotation were recorded. The LFS and PFS distances were measured by two independent orthopaedic and joint imaging physicians. The data were measured three times by each physician, and the final values were the average of the two measurements. The outcomes were determined by whether a statistical difference exists in the LFS and PFS among the CMS, X-ray, and MRI groups., Results: The interobserver agreement tests between the two observers showed good agreement in the measurements. A multiple sample ANOVA showed statistical differences in the LFS distances of HLCF measured at 0º, 45º, 90º, and 135º rotated by three radiographic measurements (P < 0.05). The LFS distances obtained by MRI and CMS measurements were greater than those obtained by X-ray measurement in all positions using the LSD test (P < 0.05), and no statistical difference was found between the CMS and MRI methods in each position (P > 0.05). The same results were observed in terms of PFS values obtained by CMS, X-ray, and MRI measurements at 0º, 45º, 90º, and 135º pronation. It was statistically different among the three groups as shown by multiple sample ANOVA (P < 0.05). The CMS and MRI measurements were greater than the X-ray measurements (P < 0.05), while no statistical difference was observed between the CMS and MRI measurements (P > 0.05)., Conclusion: X-rays often underestimate the degree of displacement of HLCF fractures; MRI measurements are closer to the true values compared with X-ray., (© 2021 The Authors. Orthopaedic Surgery published by Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd.)

Study Design: Retrospective observational study., Objective: To assess the accuracy and reliability of standing lateral lumbar radiographs for measurements of spinopelvic parameters, compared with whole-spine EOS® images., Summary of Background Data: Lateral lumbar radiographs are commonly used for measurements of spinopelvic parameters. However, variable magnifications by fan-beam x-ray projection at margins may cause measurement errors., Methods: Fifty consecutive patients with standing lateral lumbar radiographs and whole-spine EOS® images were retrospectively reviewed from March to July in 2019. Two orthopedic surgeons (observers) independently measured the spinopelvic parameters including pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and lumbar lordosis (LL) on the computers. These spinopelvic parameters of each patient were measured twice on both lateral lumbar radiograph and EOS® image by two observers with the usage of Surgimap software. The measurement difference and agreement of each parameter value between lateral lumbar radiographs and EOS® images were analyzed by paired t test and the interclass correlation coefficient (ICC) respectively. Intra- and inter-observer's reliabilities of both imaging methods were assessed by ICC., Results: The measurement difference of each spinopelvic parameter on EOS® images and lateral lumbar radiographs was less than 1° on average. Only the measurement difference of PI value revealed statistically significant (P = 0.020) with 0.9° discrepancy (95% confidential interval: 0.2-1.6), which indicated no clinical significance. The ICC values of lateral lumbar radiographs and EOS® images were more than 0.870 (range, 0.872-0.976), thus showed good to excellent measurement agreement between both imaging methods. All the ICC values for evaluating intra- and inter-observer reliability were greater than 0.960 (range, 0.963-0.993), indicating excellent reliability for observer's measurements., Conclusion: Measurements of spinopelvic parameters (PI, PT, SS, and LL) on standing lateral lumbar radiographs are accurate and reliable, which are comparable to whole-spine EOS® images.Level of Evidence: 3., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Many patients in intensive care units (ICU) require nasogastric (NG) or orogastric (OG) tubes. These patients often require a combination of sedatives that can alter level of consciousness and impair cough or gag reflexes. Such factors can lead to NG/OG tube displacement. Using a misplaced tube can lead to aspiration, lung injury, infection, and even death., Aims: To standardize ongoing verification of NG tube placement practices in our 34-bed Medical-Surgical ICU., Methods: The Johns Hopkins Nursing Model was utilized to guide this project. A literature review and critical appraisal were performed to establish NG/OG tube best practices. Best practices were implemented and assessed (via a survey and charting audits)., Results: Fifteen publications were identified and appraised as Level 4 and 5 sources. Best evidence supported that at the time of radiographic confirmation of the tube site, it should be marked with inedible ink or adhesive tape where it exits the nares; tube location should be checked at 4-hour intervals; and placement/patency should be checked in patients who complain of pain, vomiting, or coughing. Following the practice change, N = 40 nurses indicated improvement in verification of NG/OG tube knowledge, "OK to use" order was verified for 89% of patients, and 63% of tubes were marked with tape at the exit site., Linking Action to Evidence: Adherence to current, evidence-based strategies for NG/OG tube verification promotes patient safety. Monitoring practice changes is critical to determine whether a best practice is sustained. Electronic health records must be current to guide and support evidence-based nursing practice., (© 2021 Sigma Theta Tau International.)

Objectives: This study is an evaluation of the emergency department (ED) satisfaction with the current radiologic reporting system used at a major Northeastern academic medical center. The radiology reports are the main form of communication and usually the final product of any radiological investigation delivered to clinicians. The aim of this study was to improve current radiology reporting practices and to better tailor reports to match the needs and expectations of ED clinicians., Methods: A 9-question online survey was sent to ED residents, fellows, faculty, and nurse practitioners/advanced practice providers at a major Northeastern academic medical center in the United States. For the open-ended section, coding and emergent theme categorization was conducted for quantification of responses. The survey was designed to evaluate the attitudes toward the structure, style, form, and wording used in reports., Results: The response rate was 48.6% (68/140). The ED respondents were generally satisfied with radiology reports, their language, vocabulary, and clarity. They preferred the impression section to be before the findings in simple examinations and to stratify the reports according to emergency status for complex examinations. They did not like extended differential, hedge terms, and delayed reporting. Additionally, ED respondents recommended focused, fast reporting with considerable changes toward a more standardized report., Conclusions: This evaluation delivered a list of actionable recommendations. The top recommendation is to standardize reporting structure, style, and lexicon, in addition to being focused, timely, and brief.

This retrospective cohort study describes adult cervical deformity(ACD) patients with Ames-ACD classification at baseline(BL) and 1-year post-operatively and assesses the relationship of improvement in Ames modifiers with clinical outcomes. Patients ≥ 18yrs with BL and post-op(1-year) radiographs were included. Patients were categorized with Ames classification by primary deformity descriptors (C = cervical; CT = cervicothoracic junction; T = thoracic; S = coronal) and alignment/myelopathy modifiers(C2-C7 Sagittal Vertical Axis[cSVA], T1 Slope-Cervical Lordosis[TS-CL], Horizontal Gaze[Horiz], mJOA). Univariate analysis evaluated demographics, clinical intervention, and Ames deformity descriptor. Patients were evaluated for radiographic improvement by Ames classification and reaching Minimal Clinically Important Differences(MCID) for mJOA, Neck Disability Index(NDI), and EuroQuol-5D(EQ5D). A total of 73 patients were categorized: C = 41(56.2%), CT = 18(24.7%), T = 9(12.3%), S = 5(6.8%). By Ames modifier 1-year improvement, 13(17.8%) improved in mJOA, 26(35.6%) in cSVA grade, 19(26.0%) in Horiz, and 15(20.5%) in TS-CL. The overall proportion of patients without severe Ames modifier grades at 1-year was as follows: 100% cSVA, 27.4% TS-CL, 67.1% Horiz, 69.9% mJOA. 1-year post-operatively, severe myelopathy(mJOA = 3) prevalence differed between Ames-ACD descriptors (C = 26.3%, CT = 15.4%, T = 0.0%, S = 0.0%, p = 0.033). Improvement in mJOA modifier correlated with reaching 1-year NDI MCID in the overall cohort (r = 0.354,p = 0.002). For C descriptors, cSVA improvement correlated with reaching 1-year NDI MCID (r = 0.387,p = 0.016). Improvement in more than one radiographic Ames modifier correlated with reaching 1-year mJOA MCID (r = 0.344,p = 0.003) and with reaching more than one MCID for mJOA, NDI, and EQ-5D (r = 0.272,p = 0.020). In conclusion, improvements in radiographic Ames modifier grades correlated with improvement in 1-year postoperative clinical outcomes. Although limited in scope, this analysis suggests the Ames-ACD classification may describe cervical deformity patients' alignment and outcomes at 1-year., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021. Published by Elsevier Ltd.)

Background: The Commission of the European Communities (CEC) has published: European Guidelines on Quality Criteria for Diagnostic Radiographic Images. These guidelines are considered a gold standard, recommended for use in quality assurance protocols. The objectives of this study: 1) Propose a graded classification format for Danish chiropractic clinics according to the CEC-quality criteria for diagnostic radiographic images of the lumbar spine. 2) Propose a reporting principle for quality of radiographic images. 3) Document variation in radiation exposure among clinics., Methods: This is a cross-sectional study of image quality based on random sampling from 148 chiropractic clinics. Clinics were included if using: 1) Digital radiography and 2) The chiropractic picture and archiving system (KirPACS) at the Nordic Institute of Chiropractic and Clinical Biomechanics (NIKKB) in Denmark. A sample of 296 lumbar spine series were randomly collected from KirPACS (January 2018). Two independent observers reviewed 50 lumbar spine series twice with a 4-week interval, testing intra- and inter-observer reproducibility. The same observers then reviewed the remaining 246 radiographic studies. All studies were evaluated using the CEC Quality Criteria. Patient radiation dose values were retrieved from KirPACS (First quarter of 2020)., Results: A reporting and classification principle of diagnostic image quality was used in 148 chiropractic clinics. Compliance with the 22 CEC Quality Criteria had proportions ranging from 0.72-0.96 for 18 criteria, while 4 criteria specifying detail and definition ranged between 0.20-0.66. The proposed rating system (A to E) revealed: 18 A clinics, 28 B clinics, 32 C clinics, 25 D clinics and 45 E clinics (A = highest quality; E = lowest quality). The patient radiation reference dose in Denmark is 7 mGy for the AP/PA lumbar spine. Very few clinics exceed the reference dose value, approximately 50% of clinics were below 5 mGy., Conclusion: A reporting principle is proposed for a graded classification format based on the CEC-quality criteria for diagnostic radiographic images of the lumbar spine. The Quality Criteria are for the most part met satisfactorily in 148 Danish chiropractic clinics, but important image details are compromised, in most cases, because of low patient radiation doses. The results of a patient radiation dose survey enabled documentation of variation in radiation exposure among chiropractic clinics.

Introduction: Imaging is essential for the initial diagnosis and monitoring of the novel coronavirus, which emerged in Wuhan, China. This study aims to assess the insight of radiographers on how the COVID-19 pandemic has affected their work routine and if protective measures are applied., Method: A prospective observational study was conducted among radiographers registered in the Cyprus Society of Registered Radiologic Technologists & Radiation Therapy Technologists. A questionnaire composed of 28 multiple choice questions was utilised, and the data analysis was performed using SPSS software with the statistical significance assumed as p-value < 0.05., Results: Out of 350 registered radiographers, 101 responses were received. The results showed that there are statistically significant differences regarding the working hours, the feeling of stress, the work effectiveness, the average examination time, the presence of a protocol used among the different workplaces of the participants; a private radiology centre, a private hospital or a public hospital, with a p-value 0.0022, 0.015, 0.027, 0.001, 0.0001 respectively. Also, statistically significant differences were observed in the decontamination methods used for equipment (p-value 0.007), for air (p-value 0.04) and when decontamination takes place (p-value 0.00032) among the different workplaces of the participants. Nonetheless, the majority of radiographers believe that their workplace is sufficiently provided with PPE, cleaning supplies, equipment, and with cleaning personnel and are optimistic regarding the adequacy of these provisions in the next three months., Conclusion: This study showed that in the Republic of Cyprus, there are protocols regarding protective measures against COVID-19, and the radiographers are adequately trained on how to face an infectious disease outbreak. However, work is needed in order to develop protocols that reassure the safety of patients and medical personnel while managing the excess workload effectively., Implications for Practice: This study indicates the importance of applying protective measures and protocols in the radiology departments in order to minimise the spread of the virus., Competing Interests: Conflict of interest statement The authors will like to state that they have no conflict of interest., (Copyright © 2020 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.)

Skeletal survey (SS) continues to be used in the community to detect bone disease in patients with multiple myeloma (MM). While the false-negative rate is high, the specificity of SS is less well characterised. Here, we compare the diagnostic accuracy of SS compared to 18 F-FDG-PET/CT (positron emission tomography/computed tomography) in 79 patients referred to our tertiary centre with a diagnosis of smouldering MM. SS had a specificity of 83·1% (95% confidence interval: 72·0-90·5%). This study reinforces the importance of using more specific imaging techniques to avoid inaccurate diagnosis that could lead to the risks associated with unnecessary therapy in patients with smouldering MM., (Published 2020. This article is a U.S. Government work and is in the public domain in the USA.)

Background: The management of benign and borderline phyllodes tumors of the breast with a positive surgical margin is still controversial. Our aim in this study was to evaluate the impact of surgical margin status on the local recurrence rate of benign and borderline phyllodes tumors., Methods: We reviewed 205 phyllodes tumors (191 benign, 14 borderline) that were surgically excised at our hospital between 2005 and 2019. Follow-up information extending to at least 6 months after surgery was retrieved from the clinical, radiology, and pathology records., Results: The initial surgical margin was negative in 54 (26%) cases, close (≤ 1 mm) in 29 (14%) cases, and positive in 122 (60%) cases. Approximately half of the cases with a close margin and two-third of the cases with a positive margin underwent re-excision to obtain negative margins. Three (2.3%) local recurrences were observed among 131 cases with follow-up information, all three with benign phyllodes tumor. Of these three patients, one had a positive final margin, and two had negative final margins. There was no significant difference in the rate of local recurrence between PT with a positive surgical margin versus a close and negative margin., Conclusion: The study results suggest that close clinical and radiologic follow-up may provide a better course of management rather than re-excision when managing positive margins in benign and borderline phyllodes tumors., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Musculoskeletal symptoms may be due to noninflammatory causes, including genetic disorders. We aimed to examine the final genetic diagnosis in patients who presented with musculoskeletal complaints to the rheumatology department. Patients who presented to the Department of Pediatric Rheumatology and were referred to the pediatric genetic department between January 2015 and May 2019 were evaluated retrospectively. A total of 60 patients, 19 boys (31.66%), with a mean age of 12.46 ± 1.41 years were included in the study. The total consanguinity rate was 25%. The most common (29.5%) cause of referral to the pediatric genetic department was the presence of skeletal anomalies (such as camptodactyly, clinodactyly, and short stature) with accompanying joint findings. Approximately one-third of the patients (n: 19) were diagnosed and followed up by the pediatric genetics department. The diagnoses of patients were as follows: camptodactyly, arthropathy, coxa vara, and pericarditis (CACP) syndrome (n: 3); trichorhinophalangeal syndrome (n: 1); progressive pseudorheumatoid dysplasia (n: 2); LIG4 syndrome (n: 1); H syndrome (n: 1); spondyloenchondrodysplasia (SPENCD) (n: 3); and nonspecific connective tissue disorders (n: 8). In the differential diagnosis of patients who are referred to the Department of Pediatric Rheumatology with complaints of the musculoskeletal system, genetic disorders should also be considered., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Objective: This study aimed to determine the reliability levels of the radiographic union scale for tibial fractures (RUST) and the modified version of the system, mRUST, for femoral shaft fractures in pediatric and adult patients and to evaluate the value of the scores for total and each cortex in the decision making on fracture union., Methods: A total of 15 orthopedic surgeons scored the radiographs of 24 pediatric and 24 adult patients with femoral shaft fractures that were obtained at 0, 4, 8, 12, and 16 postoperative weeks treated with elastic stable intramedullary nail in pediatric patients and locked intramedullary nail in adult patients using the RUST and mRUST scores. Intra-class correlation coefficient (ICC) was used in the evaluation of reliability of the RUST and mRUST scores. The Fleiss kappa (k) coefficient was used in the agreement between evaluators regarding union decision (united or non-united). The thresholds for RUST and mRUST for radiographic union decision were determined. Receiver operating curves were created to evaluate the contribution of total and individual cortical scores in the decision of united or non-united., Results: Intra- and inter-rater reliabilities of mRUST (ICC: 0.92 and 0.86, respectively) were slightly higher than those of RUST (ICC: 0.81 and 0.77, respectively) with perfect intra- and inter-rater reliabilities for RUST (ICC: 0.92 and 0.90, respectively) and mRUST (ICC: 0.88 and 0.83, respectively) in pediatric patients and substantial intra- and inter-rater reliabilities in adult patients (ICC: 0.80 and 0.76, respectively, for mRUST, and 0.76 and 0.71, respectively, for RUST). At each time point, the mean mRUST and RUST scores were higher for pediatric fractures (p<0.001). The Fleiss k coefficient for union decision was perfect for pediatric fractures (0.88) and substantial for adult fractures (0.79). The total mRUST score had a higher predictive value of union than the total RUST score (area under the curve: 0.984 vs. 0.922 in adult fractures and 0.990 vs. 0.943 in pediatric fractures). A RUST score of ≥10 and mRUST score of ≥12 were excellent predictors of fracture union., Conclusion: Fracture union of simple two-part pediatric and adult femoral shaft fractures treated with intramedullary fixation can be reliably assessed using the RUST and mRUST scores. The diagnostic value of the mRUST score is more evident in adult fractures., Level of Evidence: Level II, Diagnostic Study.

Introduction:  The aim of this study was to compare the compliance of sacrum ultrasonography with radiography for the measuring of sacral ratio in infants., Materials and Methods:  A total of 129 infants under the age of 6 months, who were a candidate for abdominal and/or pelvic radiographs, were assessed. Sacrum ultrasonography and radiography were performed by a single radiologist using the same device. The sacral ratio was calculated for all patients undergoing ultrasonography and radiography. Agreement between two methods was calculated by Bland-Altman's chart., Results:  The mean of sacral ratio was 0.70 ± 0.11 radiographically and 0.72 ± 0.05 ultrasonographically. Based on Bland-Altman's chart, the mean difference between ultrasonography and radiology was 4.6 mm (confidence intervals of 8.18 ± 5.6)., Conclusion:  Sacrum ultrasonography could be safely used in the investigation of sacral ratio to detect sacrum abnormalities in infants., Competing Interests: None declared., (Thieme. All rights reserved.)

Competing Interests: Competing interests: Declaration of interests based on NICE’s policy on conflicts of interests (available at https://www.nice.org.uk/Media/Default/About/Who-we-are/Policies-and-procedures/code-of-practice-for-declaring-and-managing-conflicts-of-interest.pdf). Expert advisory panel members’ full statements can be viewed at: https://www.nice.org.uk/guidance/ng188/history

Systemic mastocytosis (SM) is a hematologic disease with a wide range of clinical courses ranging from an indolent condition with normal life expectancy to exceedingly aggressive disorder with a poor prognosis. The symptoms and signs of SM result from the release of mast cell mediators with heterogeneous functions, and/or organ damage from neoplastic mast cell infiltration, or both. Diagnostic criteria for SM are well-defined by the World Health Organization (WHO). However, the diagnosis of SM can be difficult when especially it is not in the differential diagnosis. Routinely used radiologic techniques (e.g., X-ray, ultrasound, CT scans can show findings such as lytic-, sclerotic- or mixed-bone lesions, splenomegaly, hepatomegaly, retroperitoneal or periportal mesenteric lymphadenopathy, and omental thickening). It is essential to emphasize that the constellation of these radiologic findings should strongly concern of SM, especially in patients who also have a skin rash, allergic reactions, gastrointestinal tract symptoms (lasting, intermittent nausea, diarrhea), paroxysmal tachycardias, unexplained weight loss, persistent bone pain, cytopenias, liver dysfunction, eosinophilia. These findings, even coincidentally noted, will likely lead to a tissue biopsy, which reveals diagnosis (as we discussed and illustrated some tissue biopsies here). Moreover, the role of MRI and new techniques such as [18-fluorodeoxyglucose positron emission computed tomography, fibroscan] in the diagnosis of SM have been discussed. Furthermore, we reviewed the use of radiologic methods to evaluate treatment response and prognostication of SM.., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objective: This study aimed to compare 2 methods of ulnar variance (UV) measurement (the perpendicular method and the circular method) and to determine whether UV changed based on the demographic characteristics (sex and age)., Methods: UV was measured on bilateral wrist radiographs of 124 patients (62 men, 62 women; mean age=48.5 years; range=18-79 years) who had no history of trauma, congenital wrist anomaly, previous wrist surgery, and wrist osteoarthritis by a single radiologist with 4 years of experience. All measurements were made on standardized radiographic images using 2 methods: the perpendicular method and the circular method. All the patients were then divided into groups based on sex and age, and the study population was determined by selecting a similar number of patients for each sex and age group., Results: The mean UV of the right and left wrists was measured as 0.33 (range=-4.3 to 5.7) mm by the perpendicular method and as 0.034 (range=-5 to 5.7) mm by the circular method. A significant difference was determined between the 2 measurement methods (p<0.001). There was a statistically significant difference between sex and UV values in the left wrist measurements by both methods (p<0.05). A significant correlation was found between the UV and age in both right and left side measurements, indicating a statistically significant difference between the methods (p<0.001)., Conclusion: The results of our study demonstrated significant differences in the UV measurement between the 2 methods. Furthermore, UV measurement may change based on age and sex. These differences should be considered in the treatment planning of patients with wrist disorders., Level of Evidence: Level IV, Therapeutic Study.

Background: Despite a strong research presence in Lancashire Teaching Hospitals National Health Service (NHS) Foundation Trust (LTHTR), allied health professionals from the organization are underrepresented in developing and publicizing research that is inspired by day-to-day clinical practice and staff experiences. Two LTHTR departments, Library and Knowledge Services (LKS) and Research and Innovation (R&I), came together to enable a group of staff to develop the knowledge and skills that they needed to access information and create new "home grown" research., Case Presentation: A clinical librarian and an academic research nurse created a research engagement program in the diagnostic radiography department at LTHTR, which included the development, delivery, and evaluation of 6 workshops. Sixteen individuals took part in these workshops, and data were collected on library usage, self-efficacy in information literacy, and research output before and after their delivery. Library membership increased by 50% among diagnostic radiography staff, literature search requests from this department increased by 133%, and all participants who attended at least 1 workshop reported an increased Information Literacy Self Efficacy Scale (ILSES) score. An increase in research activity and outputs was also attributed to the program., Conclusions: This project has resulted in a set of freely available workshop plans and support resources that can be customized for other health care professionals and has won several awards for its innovative use of departmental collaboration. Through the evaluation of the program from workshop attendees and non-attenders, we have identified impacts, outputs, and barriers to engagement in order to continue to deliver this content to other departments and embed a home grown research culture at LTHTR., (Copyright © 2021 Emily Hurt, Alison McLoughlin.)

The use of diagnostic radiography has doubled in the past two decades. Image Gently (children) and Image Wisely (adults) are multidisciplinary initiatives that seek to reduce radiation exposure by eliminating unnecessary procedures and offering best practices. Patients with an estimated glomerular filtration rate less than 30 mL per minute per 1.73 m2 may have increased risk of nephropathy when exposed to iodinated contrast media and increased risk of nephrogenic systemic fibrosis when exposed to gadolinium-based contrast agents. American College of Radiology Appropriateness Criteria can help guide specific diagnostic imaging choices. Noncontrast head computed tomography is the first-line modality when a stroke is suspected. Magnetic resonance imaging stroke protocols and computed tomography perfusion scans can augment evaluation and potentially expand pharmacologic and endovascular therapy timeframes. Imaging should be avoided in patients with uncomplicated headache syndromes unless the history or physical examination reveals red flag features. Cardiac computed tomography angiography, stress echocardiography, and myocardial perfusion scintigraphy (nuclear stress test) are appropriate for patients with chest pain and low to intermediate cardiovascular risk and have comparable sensitivity and specificity. Computed tomography pulmonary angiography is the preferred test for high-risk patients or those with a positive d-dimer test result, and ventilation-perfusion scintigraphy is reserved for patients with an estimated glomerular filtration rate less than 30 mL per minute per 1.73 m2 or a known contrast allergy. Computed tomography with intravenous contrast is preferred for evaluating adults with suspected appendicitis; however, ultrasonography should precede computed tomography in children, and definitive treatment should be initiated if positive. Ultrasonography is the first-line modality for assessing right upper quadrant pain suggestive of biliary disease. Mass size and patient age dictate surveillance recommendations for adnexal masses. Imaging should not be performed for acute (less than six weeks) low back pain unless red flag features are found on patient history. Ultrasonography should be used for the evaluation of suspicious thyroid nodules identified incidentally on computed tomography.

Introduction: Long-leg radiographs are used to plan and supervise the correction of bone deformity in patients treated with the Taylor Spatial Frame (TSF). Often radiographs are performed with malpositioning of the limb leading to wrong alignment measurements. The aim of this retrospective study was to show the usefulness of a simple device which might enhance the reproducibility of limb rotation on long-leg radiographs., Materials and Methods: We included 20 consecutive patients with TSF treatment and at least three long-leg radiographs (4.9 ± 1.3). Eight out of 20 patients received radiographs with the help of a rotation rod (device with two clamps and a carbon tube). It is placed at the most frontal tab of the reference ring while conducting the radiograph. By this means, limb rotation can be controlled. To show the usefulness of this device, two observers measured the relation of the distances between the middle of the reference ring to the medial and lateral fourth hole on the reference ring (TSF-RR). The standard deviation and range of the TSF-RR of all radiographs for each patient was calculated and compared between patients without and with the rotation rod., Results: The standard deviations of TSF-RR in patients without the rotation rod was significantly higher compared to patients with rotation rod (observer 1: p = 0.0228, observer 2: p = 0.0038). Also, the range of the TSF-RR within one patient is significant higher (observer 1: p = 0.0279, observer 2: p = 0.0038) in patients without the rotation rod compared to patients with the rotation rod., Conclusions: The variability of rotation on radiographs was lower with the rotation rod. Therefore, more reproducible and better comparable radiographs can be conducted. Radiologic exposure might be reduced as repetition of wrongly positioned limbs on radiographs are less frequent.

Introduction: Limb reconstruction using circular frames requires complex accurate measurements to achieve correction of mechanical bone axis. Inadequate imaging could ultimately lead to poor clinical outcome. Therefore, radiographs should be obtained in a standardised manner to yield accurate results. Our aim is to improve the effectiveness of post-operative imaging by obtaining precise examinations and improving the accuracy of frame correction; therefore, reducing technical repeats, radiation exposure, time waste in clinic, and achieving cost effectiveness., Methods: We implemented a simple technique for obtaining adequate imaging using standard X-ray equipment. This technique was introduced to the radiographers in the radiology department to image patients with circular frames. Images were taken by obtaining a field of view using the X-ray machine cone of light that is orthogonal to the location of interest in both the antero-posterior (AP) and lateral planes. We compared the quality of radiographs, number of repeated X-rays and radiation dose both before and after implementing our protocol RESULTS: We assessed 54 consultations before and 63 consultations after the implementation of our protocol. The results showed a reduction in inadequate radiographs from 78% to 13% department at Addenbrooke's Hospital at a statistical significance of p < 0.00001. In addition, we found a potential radiation dose reduction of 2.7-0.32mSev between the two cohorts. Our results indicate that there would also be a reduction in the cost to the department as well as time spent repeating inaccurate radiographs., Conclusion: We have been able to achieve a significant improvement in the quality of post-operative radiographic imaging and have expanded its use to adult frame patients with a background of traumatic or infectious aetiologies.

Introduction. Injury to the Lisfranc's joint, in particular to the second metatarsal-medial cuneiform (second MMC) joint, can be difficult to evaluate, especially in subtle Lisfranc injuries. The purpose of this study was to determine the value of the Lisfranc joint width (diastasis) of the adult foot in a standardized population thereby establishing a potential reference range when investigating this area for potential injury. Methods. The 2nd MMC joint in 50 men and 50 women was evaluated. Individuals with a history of foot/ankle pain, previous foot/ankle operation or fracture, or a history of systemic disease were excluded from the study. Bilateral weightbearing digital anterior-posterior and lateral radiographs were taken using a standardized method. Results. The mean 2nd MMC diastasis in 200 feet was 5.6 mm (95% CI 5.39-5.81). In the female population, the mean 2nd MMC diastasis was 5.8 mm (95% CI 5.51-6.09) as compared with 5.6 mm (95% CI 5.31-5.89) in males. The mean distance between the fifth metatarsal base and first cuneiform in the entire study population was 16.3 mm (95% CI 15.57-17.03). Conclusion. This study helps define baseline measurements of the Lisfranc joint for the general population, which can provide a standard measurement against which suspected foot injuries can be compared. Level of Evidence: Level IV.

Competing Interests: The authors report no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest.

Background: Injury of the tarsometatarsal (TMT) joint complex, known as Lisfranc injury, covers a wide range of injuries from subtle ligamentous injuries to severely displaced crush injuries. Although it is known that these injuries are commonly missed, the literature on the accuracy of the diagnostics is limited. The diagnostic accuracy of non-weight-bearing radiography (inter- or intraobserver reliability), however, has not previously been assessed among patients with Lisfranc injury., Methods: One hundred sets of foot radiographs acquired due to acute foot injury were collected and anonymised. The diagnosis of these patients was confirmed with a CT scan. In one-third of the radiographs, there was no Lisfranc injury; in one-third, a nondisplaced (< 2 mm) injury; and in one-third, a displaced injury. The radiographs were assessed independently by three senior orthopaedic surgeons and three orthopaedic surgery residents., Results: Fleiss kappa (κ) coefficient for interobserver reliability resulted in moderate correlation κ = 0.50 (95% CI: 0.45- 0.55) (first evaluation) and κ = 0.58 (95% CI: 0.52-0.63) (second evaluation). After three months, the evaluation was repeated and the Cohen's kappa (κ) coefficient for intraobserver reliability showed substantial correlation κ = 0.71 (from 0.64 to 0.85). The mean (range) sensitivity was 76.1% (60.6-92.4) and specificity was 85.3% (52.9-100). The sensitivity of subtle injuries was lower than severe injuries (65.4% vs 87.1% p = 0.003)., Conclusions: Diagnosis of Lisfranc injury based on non-weight-bearing radiographs has moderate agreement between observers and substantial agreement between the same observer in different moments. A substantial number (24%) of injuries are missed if only non-weight-bearing radiographs are used. Nondisplaced injuries were more commonly missed than displaced injuries, and therefore, special caution should be used when the clinical signs are subtle., Level of Evidence: III.

Objective: To understand the status of pre-procedural safety practices in radiological examinations at radiology residency training institutions in various Asian regions., Methods: A questionnaire based on the Joint Commission International Accreditation Standards was electronically sent to 3 institutions each in 10 geographical regions across 9 Asian countries. Questions addressing 45 practices were divided into 3 categories. A five-tier scale with numerical scores was used to evaluate safety practices in each institution. Responses obtained from three institutions in the United States were used to validate the execution rate of each surveyed safety practice., Results: The institutional response rate was 70.0% (7 Asian regions, 21 institutions). 44 practices (all those surveyed except for the application of wrist tags for identifying patients with fall risks) were validated using the US participants. Overall, the Asian participants reached a consensus on 89% of the safety practices. Comparatively, most Asian participants did not routinely perform three pre-procedural practices in the examination appropriateness topic., Conclusion: Based on the responses from 21 participating Asian institutions, most routinely perform standard practices during radiological examinations except when it comes to examination appropriateness. This study can provide direction for safety policymakers scrutinizing and improving regional standards of care., Advances in Knowledge: This is the first multicenter survey study to elucidate pre-procedural safety practices in radiological examinations in seven Asian regions.

Diagnostic reference levels (DRLs 2015) in Japan were first published in 2017, on the Japan Network for Research and Information on Medical Exposures network. Medical facilities in Japan are now presumably reconsidering radiation doses at their facilities and approaching protection optimisation through the application of DRLs 2015. However, since more than 3 years have elapsed since publication, radiation doses received by patients in Japan may have diverged from DRLs 2015. We therefore undertook the present study. Based on our questionnaire survey implemented in 2017, we estimated the entrance skin dose (ESD) under general radiography fields and the mean glandular dose (MGD) under mammography, to compile a report on the doses received by patients under general radiography fields and mammography, and to propose new DRLs as replacements for DRLs 2015. Radiation doses under general radiography fields and mammography were estimated from the results of the 2017 questionnaire survey and applied to determine new DRLs at 75% values of dose distributions in general radiography fields and at 95% values of dose distributions in mammography. Among all the modes for general radiography fields and mammography, median ESD and MGD were significantly smaller with flat panel detector systems than with computed radiography systems. Comparison of the results with DRLs 2015 values showed a trend toward decreases in all imaging methods of the general radiography fields and mammography ranging from 5.0% (child chest radiography) to 31.7% (skull radiography). Moreover, responses showed that DRLs 2015 were recognised and used for comparison at many facilities. We have described the doses received by patients in general radiography fields and mammography in 2017 and proposed new DRLs as replacements for DRLs 2015. The DRLs we proposed for general radiography fields and mammography were determined to be lower than DRLs 2015 for all modes.

Background: Graduate medical education in Singapore recently underwent significant restructuring, leading to the accreditation of residency programs by the Accreditation Council for Graduate Medical Education-International (ACGME-I). In radiology, this involved a change in teaching and quality assurance of plain film (PF) reporting. PF reported by junior residents (postgraduate year 1-3) are subject to a 50% random audit. To date, national data on junior resident performance in PF reporting have not been published., Objective: We reviewed performance in PF reporting under the current teaching and audit framework., Methods: Retrospective review of junior resident reported PF audit data from all 3 radiology residency programs in Singapore. The number of residents audited, number of PF reported and audited, and major discrepancy rates were analyzed., Results: On average, 86 440 PF were audited annually nationwide from an estimated 184 288 junior resident-reported PF. Each program trained between 4 to 24 junior residents annually (mean 15), averaging about 44 each year nationwide. A mean of 28 813 PF were audited annually in each program (range 4355-50 880). An estimated mean of 4148 PF (range 1452-9752) were reported per junior resident per year, about 346 PF per month. The major discrepancy rate ranged from 0.04% to 1.13% (mean 0.34%). One resident required remediation in the study period., Conclusions: Structured residency training in Singapore has produced a high level of junior resident competency in PF interpretation., Competing Interests: Conflict of interest: The authors declare they have no competing interests., (Accreditation Council for Graduate Medical Education 2020.)

Objectives: To estimate the variability of X-ray diagnostic reference levels (DRLs) depending on the number of X-ray devices and data per device., Methods: Dose-area products (DAP) were collected by the national nuclear control agency from the 590 devices installed in 345 medical centers in the country. From 2015 to 2017, the number of chest (postero-anterior (PA) view alone, and both postero-anterior and lateral views (PA/LAT)), abdomen, pelvis, and lumbar spine examinations collected in these centers ranged from 23,000 to 77,000. The impact of the number of devices and DAP data per device on DRLs' variabilities (95th confidence intervals divided by medians) is estimated using a bootstrapping method as a function of the number of devices and DAP per device., Results: The DRLs' variabilities ranged from 30 to 200% depending on the number of devices and DAP data per device but stabilized at 30% when the number of devices was higher than 200 for chest PA and abdomen examinations, 300 for lumbar spine and pelvis examinations, and 400 for chest PA/LAT examinations, regardless of the number of DAP data per device. Extrapolations of our results suggest that thousands of devices are necessary to reduce DRLs' variabilities to 10%., Conclusion: DAP-related DRL variabilities are high but only moderately influenced by the number of DAP data per device and of devices provided this number is higher than 200 to 400 devices according to the type of examination. Harmonization of methods of data collection between the authorities of the EU states should be recommended., Key Points: • DAP-related DRLs are not fixed values but ranges of values with at least 30% variability. • DAP-related DRLs strongly depend on the number of devices included when lower than 100. • If the number of devices included exceeds 200 to 400, the DRLs' variabilities do not depend on the number of DAP per device and should not exceed 30%.

Novel beta-coronavirus (2019-nCoV) is the cause of Coronavirus disease-19 (COVID-19), and on March 12th 2020, the World Health Organization defined COVID-19 as a controllable pandemic. Currently, the 2019 novel coronavirus (SARS-CoV-2) can be identified by virus isolation or viral nucleic acid detection; however, false negatives associated with the nucleic acid detection provide a clinical challenge. Imaging examination has become the indispensable means not only in the early detection and diagnosis but also in monitoring the clinical course, evaluating the disease severity, and may be presented as an important warning signal preceding the negative RT-PCR test results. Different radiological modalities can be used in different disease settings. Radiology Departments must be nimble in implementing operational changes to ensure continued radiology services and protect patients and staff health.

Objective: To assess the cost effectiveness of a reduced imaging follow-up protocol of distal radius fractures compared with usual care., Design: An economical evaluation conducted alongside a multicentre randomised controlled trial (RCT)., Setting: Four level-one trauma centres in the Netherlands., Participants: 341 patients participated (usual care (n=172), reduced imaging (n=169))., Interventions: Patients were randomised to usual care (routine radiography at 1, 2, 6 and 12 weeks) or a reduced imaging strategy (radiographs at 6 and 12 weeks only for a clinical indication)., Outcome Measures: Functional outcome was assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and quality-adjusted life years (QALYs) using the EuroQol-5Dimensions-3 Levels (EQ-5D-3L). Costs were measured using self-reported questionnaires and medical records, and analysed from a societal perspective. Multiple imputation, seemingly unrelated regression analysis and bootstrapping were used to analyse the data., Results: Clinical overall outcomes of both groups were comparable. The difference in DASH was -2.03 (95% CI -4.83 to 0.77) and the difference in QALYs was 0.025 (95% CI -0.01 to 0.06). Patients in the reduced imaging group received on average 3.3 radiographs (SD: 1.9) compared with 4.2 (SD: 1.9) in the usual care group. Costs for radiographic imaging were significantly lower in the reduced imaging group than in the usual care group (€-48 per patient, 95% CI -68 to -27). There was no difference in total costs between groups (€-401 per patient, 95% CI -2453 to 1251). The incremental cost-effectiveness ratio (ICER) for QALYs was -15 872; the ICER for the DASH was 198. The probability of reduced imaging being cost effective compared with usual care ranged from 0.8 to 0.9 at a willingness to pay of €20 000/QALY to €80 000/QALY., Conclusions: Implementing a reduced imaging strategy in the follow-up of distal radius fractures has a high probability of being cost effective for QALYs, without decreasing functional outcome. We, therefore, recommend imaging only when clinically indicated., Trial Registration Number: The Netherlands trial register (NL4477)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The Langenskiöld classification is the most commonly utilized classification system for the radiological features of Blount's disease. Although there is only a single study found on the interobserver variability and none found on the intraobserver variability, it is commonly used for prognostication and guiding management decisions. The aim of this study was to determine the reliability and reproducibility of the Langenskiöld classification. A retrospective review of radiographs was done of patients treated for infantile and juvenile Blount's disease at Chris Hani Baragwanath Academic Hospital from 2006 to 2016. There were 70 radiographs of acceptable quality, which were reviewed and staged on two occasions according to the Langenskiöld classification by three orthopaedic consultants and three orthopaedic surgery senior residents. Pearson correlation coefficients, percentage agreements, and κ statistics were used to evaluate both the reliability and reproducibility. Of the 70 images staged, only two (2.9%) were staged the same by all six observers, and 20 (28.6%) images differed by a single stage. The consultants had 17 (24.3%) images staged the same whereas the residents had 12 (17.1%) images staged the same. The overall κ for all six observers showed a fair agreement of 0.24. Again, the consultants had a higher κ-value compared to residents of 0.25 and 0.24, respectively. The reproducibility amongst all observers was fair with a κ-value of 0.38. The consultants had a higher mean score of 0.48 compared to 0.26 for the residents. There was only a fair overall reliability and reproducibility amongst the six observers. We recommend the Langenskiöld classification be used with caution when being used for prognostication and management planning as well as when interpreting any research relying on this classification. Level of evidence: Level III, diagnostic study.