CXR Interpretation Research Articles

Predictive Accuracy of Chest Radiographs in Diagnosing Tachypneic Children.

To test the predictive accuracy and reporting reproducibility of digital chest radiographs under low-resource conditions. One hundred thirty four tachypneic children who presented to two Indian hospitals were enrolled. Based on review of 16 variables recorded in the Emergency Room (ER) by a senior pediatrician, children were given one of the four clinical diagnoses: pneumonia, wheezy disease, mixed and non-respiratory. Every child also had a digital CXR. It was interpreted by ER physician, pediatrician and two independent radiologists. All used the same standardized interpretation system (one or more of: normal, minor patches, major patches, hyperinflation, lobar change, pleural effusion). The 10% of CXRs showing pleural effusions reliably predicted pneumonia and disease severity. For all other CXR findings, the correlation between CXR interpretation and clinical diagnosis was moderate to poor. Apart from pleural effusions, inter-observer agreements between interpretations made by ER physician, pediatrician and radiologist were also poor (kappa <0.4). With the exception of pleural effusions, CXR findings, interpreted by a radiologist, had moderate to poor power to predict respiratory diagnosis or disease severity defined by a pediatrician. Value of CXRs was further reduced by poor inter-observer agreement. When investigating tachypneic children under low-resource conditions, CXRs should be used with a clear understanding of their limitations.

Is Pneumonia Among Children in Developing Countries a Different Disease From the 1 Among Patients in the Same Age Group in Developed Countries?

Is Pneumonia Among Children in Developing Countries a Different Disease From the 1 Among Patients in the Same Age Group in Developed Countries?

Reader Variability in Identifying Pulmonary Nodules on Chest Radiographs From the National Lung Screening Trial

To measure reader variability related to the evaluation of screening chest radiographs (CXRs) for findings of primary lung cancer. From the National Lung Screening Trial (NLST), 100 cases were randomly selected from baseline CXR examinations for retrospective interpretation by 9 NLST radiologists; images with noncalcified lung nodules (NCNs) or other abnormalities suspicious for lung cancer as determined by the original NLST reader were oversampled. Agreement on the presence of pulmonary nodules and abnormalities suspicious for cancer and recommendations for follow-up were assessed by the multirater κ statistic. The multirater κ statistic for interreader agreement on the presence of at least 1 NCN was 0.38. Rates at which readers reported the presence of at least 1 NCN ranged from 32% to 63% (mean, 41%); among 16 subjects with NCN and a cancer diagnosis within 1 year of the CXR examination, an average of 87% (range, 81% to 94%) of cases were classified as suspicious for cancer across all readers. The multirater κ for agreement on follow-up recommendations was 0.34; pairwise κ values ranged from 0.15 to 0.64 (mean, 0.36). For all subjects, readers recommended a follow-up procedure classified as high level (computed tomography, fluorodeoxyglucose-positron emission tomography, or biopsy) 42% of the time on average (range, 30% to 67%); this increased to 84% (range, 52% to 100%) when readers reported an NCN and 88% (range, 82% to 94%) for subjects with cancer. Reader agreement for screening CXR interpretation and follow-up recommendations is fair overall but is high for malignant lesions.

The debate on CXR utilization and interpretation is only just beginning: A Pro/Con Debate

The CXR is the most commonly performed radiographic examination worldwide. Its ease of performance, apparent ease of interpretation and low radiation dose, alongside its great spatial resolution would suggest that it should be the first investigation performed in all patients presenting with thoracic disease. But, the advent of ever-improving multislice CT and increasing scanner availability has resulted in some patients being referred directly for scanning, bypassing the CXR. This has resulted in an inexorable rise in the number of scans performed, with an increase in patient radiation exposure and concerns among legislators and physicians that the number of scans needs to be regulated. A key role in the reduction of unnecessary scanning in patients with thoracic disease is the understanding of the place of the CXR, its ability to help in disease detection and monitoring, and its limitations.

A Structured Educational Curriculum for Residents in the Anesthesia Preoperative Evaluation Clinic

Background: Less than 50% of anesthesia residency programs implement a structured educational curriculum in preanesthesia evaluation for residents. It is unclear whether residents’ knowledge base increases after a structured educational curriculum. We hypothesized that residents’ knowledge base in preanesthesia evaluation would increase after a structured educational curriculum in the Anesthesia Preoperative Evaluation Clinic (APEC). Description: To evaluate this, seventy-six anesthesia residents were assigned to a two-week rotation in APEC with a structured curriculum in preanesthesia evaluation. The anesthesia residents were tested before (pretest) and after (posttest) the APEC rotation. Residents completed a post-rotation questionnaire to evaluate the curriculum. Evaluation: Posttest mean scores were higher than those of the pretest (p<0.05) except for CXR interpretation. Residents evaluated the curriculum and gave a score of 4/5 for perceived achievement of curricular goals for increasing knowledge. Conclusions: A structured curriculum in preoperative evaluation increases anesthesia residents’ knowledge base, except for CXR interpretation.

Relative value of amino-terminal pro-B-type natriuretic peptide testing and radiographic standards for the diagnostic evaluation of heart failure in acutely dyspneic subjects

To define more clearly the relationship between the information provided by the chest radiograph (CXR) and the natriuretic peptide (NT-proBNP) test as part of the evaluation of dyspneic patients presenting to the emergency department with suspected acute heart failure (HF), we evaluated the PRIDE cohort of 599 patients with and without HF, focusing on blinded NT-proBNP and unblinded CXR information. Clinical characteristics and diagnostic performance for each test were compared. We found that NT-proBNP measurement is superior to routine CXR interpretation for diagnosis or exclusion of acute HF and that normal CXR results should not be used to exclude HF in this population.

Discordance in interpretation of chest radiographs between pediatric intensivists and a radiologist: Impact on patient management

Purpose When radiologists are not available, chest radiographs (CXRs) of pediatric intensive care unit (PICU) patients are commonly interpreted by pediatric intensivists. We prospectively investigated the frequency of errors in CXR interpretation by pediatric intensivists and their impact on patient management. Materials and Methods Chest radiographs of PICU patients were evaluated by 5 pediatric intensivists then by a pediatric radiologist (the “gold standard”). If the interpretation of the radiologist and intensivist differed, an independent intensivist determined whether a management change took place. A pediatric pulmonologist determined how many intensivist interpretations were different from the radiologist's interpretations. Results Seven hundred twenty-eight radiographic findings were identified by the radiologist in 460 CXRs. There were 33 interpretation errors by the intensivists (4.5% of the findings in 7.1% of the CXRs). Only 3/33 error corrections (0.45% of the findings in 0.7% of the CXRs) resulted in change in patient management. Conclusions Errors in interpretation of CXRs by pediatric intensivists were common but less than that in other series, probably because of education of the pediatric intensivists through daily rounds with the radiologist. Although interpretation errors that affected patient management were rare, their clinical importance supports the growing practice of 24/7 remote radiograph reading by radiologists.

Training and Assessment of CXR/Basic Radiology Interpretation Skills: Results From the 2005 CDIM Survey

Background: Despite published literature demonstrating deficiencies in chest radiograph (CXR)/basic radiology interpretation skills of 4th-year medical students, studies and subsequent curricula regarding the training needed to obtain these skills are lacking. Terms such as clinical exposure and radiology teaching have been used to describe the experience for these basic interpretive skills, but best practice methods of delivery, let alone common methods, have yet to be defined. Purpose: The objective is to describe the current methods of teaching and assessing CXR/basic radiology interpretation skills across institutions on the 3rd-year internal medicine (IM) clerkship. Methods: In 2005, the Clerkship Directors in Internal Medicine (CDIM), an international organization representing U.S. and Canadian medical schools, surveyed its institutional members. Twelve questions on the survey dealt with X-ray interpretation. Results: Eighty-eight of 109 members (81%) responded to the survey. Overall, 81% of respondents felt that CXR interpretation is an important clinical skill for medical students. Seventy-six percent indicated that instruction in these skills occurs on the IM clerkship. The most cited methods of instruction were lectures (56%) and teaching rounds (48%). Most schools spent on average of 2 to 4 hr during the IM clerkship on formal radiology instruction. Only 33% indicated that radiology interpretation skills are assessed during the clerkship. The most common assessment methods were written examination (19%) and OSCE (19%). Conclusion: Substantive data regarding attainment and assessment of CXR/basic radiology interpretation skills in the undergraduate curriculum are lacking. Our study provides preliminary descriptive data regarding CXR instruction and assessment on the 3rd-year IM clerkship.

PLACEMENT OF ph/IMPEDANCE PROBES DURING UPPER ENDOSCOPY IN CHILDREN

Background: Many pediatric institutions combine upper endoscopy with pH probe placement. A phone survey of 42 endoscopy suites in the U.S. suggest that in most cases, probe placement is determined by formulas based on height such as Strobel's formula and is verified by anatomical markers, most commonly vertebral bodies T7-T9 seen on subsequent CXR. Endoscopy allows the accurate determination of the distal limits of the lower esophageal sphincter and hence can be used for sensor placement without the need for confirmatory CXR. Methods: Between March 2004 and June 2005 one hundred and twenty one probes were placed following endoscopy. Position was considered acceptable if pH sensor was between T7 and T9 by confirmatory CXR. 57 were placed under direct visualization (DV) and 64 were placed using formula technique (FT). By DV the sensor was placed 3 cm, 4cm and 5cm above the lower esophageal sphincters for ages 0-5 years, 6-12 years and above 13 years respectively. A simple two-contingency table analysis test was used to compare the number of probes that required adjustment by each technique. Results: The age range for the DV cohort was 4 to 192 months (median age 36 months) and by the FT 1 to 216 months (median age 72 months). Four cases (7%) required adjustment with the DV technique and 42 (65%) by the FT. p value by Fisher Exact Test analysis was <.005 and is statistically significant. Apart from routine difficulty of passing the probe through the nasopharynx, no adverse effects were noted in the DV group. One patient in the FT had a probe placed in the bronchus. The cost of portable CXR and radiological interpretation was US $115.00 (2005). One hundred and forty eight endoscopy/ph/impedance studies were performed in 2005 amounting to a financial burden of US $17,020. Conclusions: Following endoscopy, placing pH sensors under direct visualization is accurate, safe, reduces unnecessary exposure to radiation and is an economically sound practice.

COMPETENCY IN CHEST RADIOGRAPHY: A COMPARISON OF MEDICAL STUDENTS, RESIDENTS AND FELLOWS

PURPOSE: Accurate interpretation of chest radiographs (CXR) is essential since house officers are required to make clinical decisions based on their readings. We sought to evaluate CXR interpretation competency at different levels of training and to determine if specific factors are associated with successful interpretation.

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Aims: Despite the wide assumption that an X-ray viewing box provides the ideal illumination, doctors on post take ward rounds frequently use any available light to view X-rays, arguably resulting in errors of interpretation. We assessed the strength of agreement between the interpretation of emergency X-rays by the duty surgical team, utilizing the nearest light (ceiling fluorescent tube or window), with that of the consultant radiologist's definitive X-ray report (utilizing light box). Methods: The abdominal (AXR) and chest (CXR) X-rays of 100 consecutive patients admitted as surgical emergencies, and necessitating emergency radiology, were studied prospectively. The strengths of agreement between the surgeons' interpretations and the radiologists' reports (taken as ‘gold standard’) were determined using the weighted kappa statistics (κw). Disagreements were chased and clinical relevance assessed. Results: Surgeons performed well, kappa statistics showing excellent agreement with radiologists' interpretations. The major difference in AXR findings was the identification of faecal loading, which surgeons diagnosed more often. Treatment of these ‘false positives’ often yielded an excellent clinical result. For CXR interpretation, radiologists found more pathology than surgeons, but none were found to be relevant and, when a surgeon identified an abnormality, it was almost universally confirmed on reporting. Conclusion: Surgeons on a busy ward round utilizing any light source match radiologists using an X-ray box when assessing radiological findings. The routine reporting of any emergency X-ray (and resultant loss from ward in many cases) may not be necessary.

The Benefit of Lateral Radiographs in an Intensive Care Unit

The portable anteroposterior (AP) radiograph (CXR) is an essential component of clinical management in the intensive care unit (ICU). In view of the immobility of patients, and overlying tubes, wires, and catheters, lateral (LAT) CXRs are infrequently ordered. We constructed a portable acrylic (Plexiglas) CXR cassette holder and were able to obtain reproducible quality LAT CXRs in the ICU. Of the 72 simultaneously obtained AP and LAT CXRs, 60 were technically acceptable for interpretation. We found an 11 percent incidence of either unexpected conditions or we were able to improve on the AP CXR interpretation. Lateral CXRs should be obtained routinely in the ICU in select patients.