OBJECTIVE: To evaluate the effects of the Enhancing Quality Using the Inspection Program (EQUIP) on quality control (QC) and quality assurance (QA) at an academic medical center.
METHODS: EQUIP audit logs for technologist image quality review as well as mammography unit QA and QC formed the basis for study data. One randomly selected screening mammogram was evaluated by the lead interpreting physician (LIP) using EQUIP criteria for each technologist for each imaging site worked, initially semiannually and then monthly. One randomly selected screening mammogram interpreted by each interpreting physician (IP) for each imaging site was evaluated on a semiannual basis. Quarterly, the LIP reviewed QA and QC logs for each mammography unit with deficiencies further investigated.
RESULTS: Of 214 965 eligible screening mammograms performed, 5955 (2.8%) underwent EQUIP image quality review. Five were found to be technically inadequate (0.08%, 5955/214 965). The LIP identified 20 significant interpretive differences compared with the clinical interpretation resulting in 10 biopsies and 7 previously undetected malignancies, with supplemental cancer detection rate of 1.2/1000 cases reviewed. Two hundred ninety mammography unit QA/QC reviews identified 31 potential deficiencies, 29 of which were due to human documentation error (93.4%).
CONCLUSIONS: EQUIP review of both IP and technologists\' quality and mammography unit QA/QC logs as performed identified few deficiencies. EQUIP policies should be evaluated at each institution and modified to best utilize resources and provide opportunities for meaningful quality improvement. Although not an EQUIP focus, supplemental cancer detection was observed as might be expected with double reading.

OBJECTIVE: To evaluate the ability of a long-term technologist coaching program to sustain gains in mammography quality made by a previously implemented quality improvement (QI) initiative.
METHODS: Mammography quality metrics from July 2014 to June 2020 were reviewed. Numbers of screening mammograms performed/audited, monthly average mammogram overall quality pass rates, changes in facilities/staffing, and technical recall rates were evaluated. Performance metrics at baseline (July 2013), during the improvement (July 2014 to January 2015), postimprovement (February 2015 to August 2015), and sustained coaching periods (after initiation of the technologist coaching model, from September 2015 to June 2020) were compared.
RESULTS: During the postimprovement and sustained coaching periods, 93% (501/541) and 90% (8902/9929) of audited mammograms, respectively, met overall passing criteria, achieving or exceeding the QI goal of 90%, and results for both periods were significantly higher than that during the improvement period (74%, 1098/1489), at P < 0.0001 and P < 0.0001, respectively. The technical recall rates during the improvement and postimprovement periods were 2.6% (85/3321) and 1.7% (54/3236), respectively; the rate during the sustained coaching period was significantly lower than these, at 1.2% (489/40 440) (P < 0.0001 and P = 0.0232, respectively). Sustained quality passing rates and lower technical recall rates were observed despite statistically significantly increases in screening volumes.
CONCLUSIONS: A technologist coaching program resulted in sustained high mammographic quality for almost 5 years.

UNASSIGNED: To identify causes of technical repeats, determine whether differences exist between mobile and fixed mammography units, and evaluate the rate of improvement on repeat imaging.
UNASSIGNED: IRB approval was obtained for retrospective review of Enhancing Quality Using the Inspection Program (EQUIP) logs of screening mammography technical repeats performed from March 2017 to December 2018 at a hospital breast imaging center and from April 2017 to December 2018 on mobile mammography units. Frequency tables and Fisher\'s exact tests were used for statistical analysis.
UNASSIGNED: Technical deficiencies were reported in 483 cases and reviewed by two or three auditors. Auditors identified no technical deficiencies in 31 cases, which were excluded. The remaining 452 cases were assigned a technical recall category: motion, positioning/excluded tissue, skin folds, artifacts, undercompression, or contrast (under/overexposure). Motion was the most common technical recall category (253/452, 56.0%). Positioning/excluded tissue was the second most common reason (150/452, 33.2%). Statistically significant differences in technical deficiencies were identified between mammograms performed on mobile versus fixed mammography units for motion (94/143, 65.7% vs 159/309, 51.5%, respectively, P = 0.0058), skin folds (16/143, 11.2% vs 15/309, 4.8%, respectively, P = 0.02), and positioning/excluded tissue (30/143, 21% vs 120/309, 38.8%, respectively, P = 0.00016). Most recalls improved with repeat imaging (auditor 1: 451/483, 93% and auditor 2: 387/483, 80%).
UNASSIGNED: Motion and positioning/excluded tissue are the most common reasons for screening mammography technical recalls. The reasons for technical recall differ between patients imaged on mobile and fixed mammography units, likely because of differences in each location\'s patient population.

The MqsRA toxin-antitoxin system is a component of the Escherichia coli stress response. Free MqsR, a ribonuclease, cleaves mRNAs containing a 5\'-GC-3\' sequence causing a global shutdown of translation and the cell to enter a state of dormancy. Despite a general understanding of MqsR function, the molecular mechanism(s) by which MqsR binds and cleaves RNA and how one or more of these activities is inhibited by its cognate antitoxin MqsA is still poorly understood. Here, we used NMR spectroscopy coupled with mRNA cleavage assays to identify the molecular mechanism of MqsR substrate recognition and the MqsR residues that are essential for its catalytic activity. We show that MqsR preferentially binds substrates that contain purines in the -2 and -1 position relative to the MqsR consensus cleavage sequence and that two residues of MqsR, Tyr81, and Lys56 are strictly required for mRNA cleavage. We also show that MqsA inhibits MqsR activity by sterically blocking mRNA substrates from binding while leaving the active site fully accessible to mononucleotides. Together, these data identify the residues of MqsR that mediate RNA cleavage and reveal a novel mechanism that regulates MqsR substrate specificity.

OBJECTIVE: The Enhancing Quality Using the Inspection Program (EQUIP) initiative was launched to improve clinical image quality. The purpose of this study was to determine if the implementation of the EQUIP reporting system resulted in an increased number of extra views performed at the technologists\' discretion during screening mammography.
METHODS: Following IRB approval at a single comprehensive cancer center, patients who underwent screening mammography with combination full-field digital mammography plus digital breast tomosynthesis during a 6-month period before (January 2017 to June 2017) and after (January 2018 to June 2018) EQUIP implementation were identified. For each patient, both screening mammograms were retrospectively reviewed by 1 of 3 subspecialized breast radiologists (3-10 years of experience). The following data were recorded: demographics, breast density, surgical history, technologist, number and type of extra views, final BI-RADS assessment, radiologist-assigned indication for the view, and radiologist-assigned necessity of the view. McNemar\'s test for paired data was computed with p value of <0.05 considered statistically significant.
RESULTS: Of 820 patients, 370 (45%) had additional views in 2018 compared to 317 (39%) in 2017. After EQUIP, patients were 38% more likely to have additional views (OR = 1.38, 95% CI = 1.11-1.73). The total number of additional views in 2018 was 636 compared to 530 in 2017 (20% increase). Among patients with extra views in both years, the number of additional views per patient did not significantly increase post EQUIP implementation (OR = 1.18, 95% CI = 0.73-1.92). The most common extra view was exaggerated craniocaudal lateral, and the most common reason cited by the reviewing radiologist was lateral fibroglandular tissue at the edge of the images. Most of the extra views performed in 2018 were not performed in 2017 and over half were deemed unnecessary. Eight of eleven technologists demonstrated an increased frequency of screening mammograms with extra views performed post EQUIP.
CONCLUSIONS: Following EQUIP implementation, screening mammography patients were significantly more likely to have extra views performed at the technologists\' discretion. Our findings emphasize the importance of ongoing technologist education and radiologist feedback.

Screening mammography aims to identify small, node-negative breast cancers when they are still curable while maintaining an acceptable range of false-positive recalls and biopsies. The mammography audit is a powerful tool to help radiologists understand their performance with respect to that goal. This article defines audit terms and describes how to use collected and derived data to perform a mammography audit. Accepted benchmarks are discussed as well as their applicability to radiologists and breast imaging practices in the United States. Special considerations regarding volumes and radiologist characteristics are explored, because these factors may affect audit results.

Toxin-antitoxin (TA) systems are broadly distributed modules whose biological roles remain mostly unknown. The mqsRA system is a noncanonical TA system in which the toxin and antitoxins genes are organized in operon but with the particularity that the toxin gene precedes that of the antitoxin. This system was shown to regulate global processes such as resistance to bile salts, motility, and biofilm formation. In addition, the MqsA antitoxin was shown to be a master regulator that represses the transcription of the csgD, cspD, and rpoS global regulator genes, thereby displaying a pleiotropic regulatory role. Here, we identified two promoters located in the toxin sequence driving the constitutive expression of mqsA, allowing thereby excess production of the MqsA antitoxin compared to the MqsR toxin. Our results show that both antitoxin-specific and operon promoters are not regulated by stresses such as amino acid starvation, oxidative shock, or bile salts. Moreover, we show that the MqsA antitoxin is not a global regulator as suggested, since the expression of csgD, cspD and rpoS is similar in wild-type and ΔmqsRA mutant strains. Moreover, these two strains behave similarly in terms of biofilm formation and sensitivity to oxidative stress or bile salts.IMPORTANCE There is growing controversy regarding the role of chromosomal toxin-antitoxin systems in bacterial physiology. mqsRA is a peculiar toxin-antitoxin system, as the gene encoding the toxin precedes that of the antitoxin. This system was previously shown to play a role in stress response and biofilm formation. In this work, we identified two promoters specifically driving the constitutive expression of the antitoxin, thereby decoupling the expression of antitoxin from the toxin. We also showed that mqsRA contributes neither to the regulation of biofilm formation nor to the sensitivity to oxidative stress and bile salts. Finally, we were unable to confirm that the MqsA antitoxin is a global regulator. Altogether, our data are ruling out the involvement of the mqsRA system in Escherichia coli regulatory networks.

Quality and patient safety are essential to the practice of radiology. \"Quality is our image\" is the slogan for the American College of Radiology (ACR), which has embraced the quality and safety movement as a central tenet. The impact of advances in radiology on diagnosis and management of complex medical disorders cannot be understated. Nevertheless, these revolutionary technologies do come at a cost. Increasing utilization of advanced imaging in emergency departments throughout the country poses challenges both in terms of appropriate use and management of radiation dose. The indispensable place advanced imaging plays in diagnosis has necessitated guidelines and accountability to protect patients and radiology staff. In this series, we have created a concise discourse on what we have determined to be the essentials of the economics of quality and safety as it pertains to radiology. In this first article, we summarize the accreditation programs in radiology, their legislative background, and the associated financial and market responses that have subsequently resulted. We discuss the progression from historical predecessors to the passage of the Mammography Quality and Safety Act (MQSA), which served as a model for subsequent laws governing the quality and safety of other imaging modalities. These laws have had real economic implications for radiology practices seeking to meet new increasingly stringent guidelines. We also break down the costs of participation in the ACR accreditation and center of excellence programs.

OBJECTIVE: The purpose of this project was to achieve sustained improvement in mammographic breast positioning in our department.
METHODS: Between June 2013 and December 2016, we conducted a team-based performance improvement initiative with the goal of improving mammographic positioning. The team of technologists and radiologists established quantitative measures of positioning performance based on American College of Radiology (ACR) criteria, audited at least 35 mammograms per week for positioning quality, displayed performance in dashboards, provided technologists with positioning training, developed a supportive environment fostering technologist and radiologist communication surrounding mammographic positioning, and employed a mammography positioning coach to develop, improve, and maintain technologist positioning performance. Statistical significance in changes in the percentage of mammograms passing the ACR criteria were evaluated using a two-proportion z test.
RESULTS: A baseline mammogram audit performed in June 2013 showed that 67% (82/122) met ACR passing criteria for positioning. Performance improved to 80% (588/739; p < 0.01) after positioning training and technologist and radiologist agreement on positioning criteria. With individual technologist feedback, positioning further improved, with 91% of mammograms passing ACR criteria (p < 0.01). Seven months later, performance temporarily decreased to 80% but improved to 89% with implementation of a positioning coach. The overall mean performance of 91% has been sustained for 23 months. The program cost approximately $30,000 to develop, $42,000 to launch, and $25,000 per year to maintain. Almost all costs were related to personnel time.
CONCLUSIONS: Dedicated performance improvement methods may achieve significant and sustained improvement in mammographic breast positioning, which may better enable facilities to pass the recently instated Enhancing Quality Using the Inspection Program portion of a practice\'s annual Mammography Quality Standards Act inspections.

Counterselection is a genetic engineering technique to eliminate specific genetic fragments containing selectable marker genes. Although the technique is widely used in bacterial genome engineering and plasmid curing experiments, the repertoire of the markers usable in Escherichia coli is limited. Here we developed a novel counterselection method in E. coli based on antisense RNA (asRNA) technology directed against toxin-antitoxin (TA) modules. Under normal conditions, excess antitoxin neutralizes its cognate toxin and thus the module is stably maintained in the genome. We hypothesised that repression of an antitoxin gene would perturb cell growth due to the toxin being released. We designed asRNAs corresponding to all 19 type II antitoxins encoded in the E. coli genome. asRNAs were then conditionally expressed; repression of MqsA in the MqsR/MqsA module had the greatest inhibitory effect, followed by RnlB in the RnlA/RnlB module. The utility of asRNA(MqsA) as a counterselection marker was demonstrated by efficient plasmid curing and strain improvement experiments.