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Standardized ultrasonography with cine-loop documentation: diagnostic variability in liver and kidney examinations
Linköping University, Department of Medical and Health Sciences, Division of Radiological Sciences. Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Center for Medical Image Science and Visualization (CMIV).
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Ultrasound examination of the abdomen is often a first choice at radiology departments due to the lack of ionizing radiation. For diagnostic accuracy and economic benefits there has been a need for new routines in this area that incorporate the benefits of an radiographer or sonographer performing a multitude of ultrasound examinations following strictly standardized examination protocols and documentation forms made by cine-loops that will give the radiologist access to all relevant information needed for an accurate postexamination diagnosis.

Aim: The overall objective of this thesis was to evaluate the diagnostic variability in examinations of the kidneys and liver that use a standardized ultrasound method along with video documentation of the entire examination and off-line review by radiologists. More specifically, we wanted to compare the agreement between readers and between operators.

Design and method: This thesis is based on four quantitative studies using standardized protocols for kidney, liver and gallbladder examinations. In paper I, including 64 patients, and paper IV, including 98 patients, the patients were prospectively enrolled and the  examinations were retrospectively reviewed. The patients in papers I and IV were examined by one radiographer (sonographer) and one radiologist during the same session. In paper I, findings using the standardized ultrasound method were compared with traditional bedside assessments by a radiologist. In paper IV, the patients were examined using only the standardized method. In paper II, including 98 patients, and in paper III, including 115 patients, the patients were examined by one sonographer using the standardized method and the examinations were reviewed by two or three radiologists.

Results: In paper I, no significant systematic differences were found between the findings using the standardized method and the traditional bedside assessment.

Paper II showed good intra- and inter-observer agreement between three experienced radiologists when reviewing examinations conducted using the standardized method.

In paper III we verified good inter-observer agreement between two radiologists reviewing ultrasound examinations using the standardized technique in patients who had undergone surgery for colorectal cancer. Intravenous contrast was used and the injection of contrast medium increased the visibility of liver lesions.

In paper IV, we observed that using a standardized cine-loop technique, there was a slightly better inter-operator agreement than inter-reader agreement.

Conclusion: The satisfactory agreement shown in all four studies suggests that the new workflow method using standardized ultrasound examinations and stored cine-loops, performed by a radiographer or sonographer and analyzed off-line by a radiologist, is a promising technique. The results are less affected when a radiologist examiner is replaced by a radiographer or sonographer than when the reviewer is replaced by a different radiologist.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2015. , 64 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1483
National Category
Radiology, Nuclear Medicine and Medical Imaging
Identifiers
URN: urn:nbn:se:liu:diva-124676DOI: 10.3384/diss.diva-124676ISBN: 978-91-7685-946-9 (print)OAI: oai:DiVA.org:liu-124676DiVA: diva2:901984
Public defence
2016-01-29, Berzeliussalen, Campus US, Linköping, 09:00 (English)
Opponent
Supervisors
Available from: 2016-02-10 Created: 2016-02-09 Last updated: 2016-02-10Bibliographically approved
List of papers
1. Radiographer-acquired and radiologist-reviewed ultrasound examination: agreement with radiologist’s bedside evaluation
Open this publication in new window or tab >>Radiographer-acquired and radiologist-reviewed ultrasound examination: agreement with radiologist’s bedside evaluation
2011 (English)In: Acta Radiologica, ISSN 0284-1851, E-ISSN 1600-0455, Vol. 52, no 1, 70-74 p.Article in journal (Refereed) Published
Abstract [en]

Background: Growing demand for ultrasound examinations and higher quality requirements motivate searching for routines combining the diagnostic accuracy of radiologist-performed examinations with the economical advantages of sonographer-performed examinations. One possible approach is to use strictly standardized acquisition and documentation schemes that give the radiologist access to all relevant information after the examination.

Purpose: To compare a recently introduced routine, combining acquisition by a radiographer, documentation as standardized cine-loops, and review by a radiologist (‘standardized method’), with the formerly used routine where the diagnosis is made bedside by the radiologist (‘traditional  method’).

Material and Methods: In 64 policlinic patients, the kidneys (n ¼ 27) or the gallbladder (n ¼ 37) were examined with both the standardized and the traditional method. The radiologists’ findings of hydronephrosis, tumors, cysts, echogenicity changes, and cortical thickness (in the kidneys), and wall thickness, concrements, and polyps (in the gallbladder) were compared between the methods with respect to agreement (proportion of agreement and kappa coefficient) as well as systematic differences (McNemar’s test).

Results: The findings at the gallbladder examination showed a median agreement of 97% (86–100%; kappa ¼ 0.64–1.00), and those at the kidney examination, an agreement of 90% (78–100%; kappa ¼ 0.69–1.00). There were no significant systematic differences between the methods.

Conclusion: The satisfactory agreement in this preliminary study indicates that the new workflow with ultrasound examinations performed by a radiographer and analyzed off-line by a radiologist is promising, and motivates further studies.

Place, publisher, year, edition, pages
Informa Healthcare, 2011
Keyword
Ultrasound, radiographer, radiologist, comparison, diagnostic
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-67047 (URN)10.1258/ar.2010.090260 (DOI)000290498800013 ()
Available from: 2011-03-25 Created: 2011-03-25 Last updated: 2016-02-10Bibliographically approved
2. Do Radiologists Agree on Findings in Radiographer-Acquired Sonographic Examinations?
Open this publication in new window or tab >>Do Radiologists Agree on Findings in Radiographer-Acquired Sonographic Examinations?
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2013 (English)In: Journal of ultrasound in medicine, ISSN 0278-4297, E-ISSN 1550-9613, Vol. 32, no 3, 513-518 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES:

Sonographic examinations are usually regarded as observer dependent, but a recently introduced method using documentation with cine loops acquired in a standardized way attempts to address this problem. The aim of this study was to evaluate the intraobserver and interobserver agreement of sonographic liver examinations using strictly standardized examination protocols with cine loop documentation.

METHODS:

Ninety-eight outpatients were examined by a radiographer using the standardized method. Three radiologists, each with 10 to 20 years of experience in sonography, reviewed the cine loops retrospectively. After 4 weeks, the review was repeated; the 3 radiologists were blinded to the initial reading. The κ coefficient was used to analyze intraobserver and interobserver agreement, and agreement in percent was also calculated.

RESULTS:

The intraobserver agreement was highest for concrements in the gallbladder (κ= 0.91-0.96) and lowest when assessing the need for further examination (κ = 0.38-0.64). For increased liver echogenicity, κ varied between 0.73 and 0.92 and for skip areas between 0.73 and 0.90. The interobserver agreement was also highest for concrements in the gallbladder (κ = 0.84-1.00) and lowest for the need for further examination (κ = -0.12-0.46). For most other findings, substantial intraobserver agreement was found.

CONCLUSIONS:

For sonographic examinations performed according to a standardized examination protocol by a radiographer and viewed by an experienced radiologist, good interobserver agreement was found, except for judgments of the need for further examinations.

Place, publisher, year, edition, pages
American Institute of Ultrasound in Medicine, 2013
Keyword
agreement, liver examination, observer, radiologist, sonography
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-90759 (URN)10.7863/jum.2013.32.3.513 (DOI)000315835900016 ()23443192 (PubMedID)
Note

On the day of the defence date of the Ph.D. Thesis the status of this artilce was Manuscript and the title was Do radiologists agree on findings in radiographer-acquired ultrasound liver examinations?

Available from: 2013-04-05 Created: 2013-04-05 Last updated: 2017-12-06
3. Visualization of liver lesions in standardized video-documented ultrasonography - inter-observer agreement and effect of contrast injection
Open this publication in new window or tab >>Visualization of liver lesions in standardized video-documented ultrasonography - inter-observer agreement and effect of contrast injection
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2015 (English)In: Medical ultrasonography, ISSN 1844-4172, E-ISSN 2066-8643, Vol. 17, no 4, 437-443 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to evaluate the inter-observer agreement and effect of contrast injection on the visibility of liver lesions by radiologists reviewing ultrasound examinations acquired by a radiographer using a standardized examination protocol. Material and method: A retrospective review was conducted by two radiologists, independently of each other, of 115 ultrasound examinations of the liver with standardized examination protocols between January 2008 and December 2012. All patients included in the study had undergone surgery for colorectal cancer. Patients attending the two-year follow-up were included. Results: Focal findings, the most common of which were cysts, were seen in 42-43 out of the 115 patients before intravenous contrast and in 46-47 patients after intravenous contrast (p=0.012). The inter-observer agreement for focal findings was 86.1% before contrast, and 90.4% after contrast (n.s.), and the corresponding kappa values were 0.72 and 0.84, respectively. Conclusion: A good inter-observer agreement between two radiologists reviewing ultrasound examinations (standardized ultrasound cine-loop method acquired by a radiographer) after surgery for colorectal cancer was obtained. Injection of contrast medium increased the visibility of liver lesions.

Place, publisher, year, edition, pages
Cluj-Napoca, Romania: Societatea Romana de Ultrasonografie in Medicina si Biologie, 2015
Keyword
liver; contrast-enhanced ultrasound; inter-observer agreement; standardized examination
National Category
Radiology, Nuclear Medicine and Medical Imaging
Identifiers
urn:nbn:se:liu:diva-123790 (URN)10.11152/mu.2013.2066.174.vis (DOI)000365549400004 ()26649336 (PubMedID)
Available from: 2016-01-11 Created: 2016-01-11 Last updated: 2017-11-30Bibliographically approved
4. Do radiologists agree when reviewing ultrasound examinations performed by a sonographer and a radiologist?
Open this publication in new window or tab >>Do radiologists agree when reviewing ultrasound examinations performed by a sonographer and a radiologist?
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Ultrasound examinations are usually performed by a radiologist or, in suitable cases, by a sonographer or radiographer. Standardized scanning protocols and cine-loop documentation may permit the transfer of tasks from a radiologist to a sonographer or radiographer.

Purpose: To study the diagnostic variability in standardized ultrasound examinations of the kidney by comparing inter-reader agreement between two radiologists who reviewed examinations acquired by a sonographer and a radiologist, as well as inter-operator agreement between the sonographer and the radiologist.

Material and methods: After approval by the local research ethics committee, 98 adult patients, aged from 18 to 92, referred for diagnostic renal sonographic examination and were prospectively enrolled. Both kidneys were imaged using standardized scanning protocols, and the entire examination was documented with cine-loops. Two radiologists reviewed the examinations for different types of pathology, including tumors, cysts, decreased cortical thickness, increased echogenicity and hydronephrosis. Inter-reader and inter-operator agreement was evaluated with kappa coefficient and intra-class correlation.

Results: The most common finding was cysts, which were found in 32 to 40 cases. Tumors were found in three to 10 cases. With one exception, the kappa values for inter-operator agreement (0.65–1.00) were higher than those for inter-reader agreement (0.31–1.00). With two exceptions, no systematic differences between operators or between observers were found.

Conclusion: Using a standardized cine-loop technique, we found slightly better interoperator agreement than inter-reader agreement. This suggests that it may be easier to exchange an operator than to exchange a reader.

Keyword
Cine-loop imaging, renal sonography, agreement
National Category
Radiology, Nuclear Medicine and Medical Imaging
Identifiers
urn:nbn:se:liu:diva-124674 (URN)
Available from: 2016-02-09 Created: 2016-02-09 Last updated: 2016-02-10Bibliographically approved

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