CXR Reports Research Articles

A chest radiograph scoring system in patients with severe acute respiratory infection: a validation study.

BackgroundThe term severe acute respiratory infection (SARI) encompasses a heterogeneous group of respiratory illnesses. Grading the severity of SARI is currently reliant on indirect disease severity measures such as respiratory and heart rate, and the need for oxygen or intensive care. With the lungs being the primary organ system involved in SARI, chest radiographs (CXRs) are potentially useful for describing disease severity. Our objective was to develop and validate a SARI CXR severity scoring system.MethodsWe completed validation within an active SARI surveillance project, with SARI defined using the World Health Organization case definition of an acute respiratory infection with a history of fever, or measured fever of ≥ 38 °C; and cough; and with onset within the last 10 days; and requiring hospital admission. We randomly selected 250 SARI cases. Admission CXR findings were categorized as: 1 = normal; 2 = patchy atelectasis and/or hyperinflation and/or bronchial wall thickening; 3 = focal consolidation; 4 = multifocal consolidation; and 5 = diffuse alveolar changes.Initially, four radiologists scored CXRs independently. Subsequently, a pediatrician, physician, two residents, two medical students, and a research nurse independently scored CXR reports. Inter-observer reliability was determined using a weighted Kappa (κ) for comparisons between radiologists; radiologists and clinicians; and clinicians. Agreement was defined as moderate (κ > 0.4–0.6), good (κ > 0.6–0.8) and very good (κ > 0.8–1.0).ResultsAgreement between the two pediatric radiologists was very good (κ = 0.83, 95 % CI 0.65–1.00) and between the two adult radiologists was good (κ = 0.75, 95 % CI 0.57–0. 93).Agreement of the clinicians with the radiologists was moderate-to-good (pediatrician:κ = 0.65; pediatric resident:κ = 0.69; physician:κ = 0.68; resident:κ = 0.67; research nurse:κ = 0.49, medical students: κ = 0.53 and κ = 0.56).Agreement between clinicians was good-to-very good (pediatrician vs. physician:κ = 0.85; vs. pediatric resident:κ = 0.81; vs. medicine resident:κ = 0.76; vs. research nurse:κ = 0.75; vs. medical students:κ = 0.63 and 0.66).Following review of discrepant CXR report scores by clinician pairs, κ values for radiologist-clinician agreement ranged from 0.59 to 0.70 and for clinician-clinician agreement from 0.97 to 0.99.ConclusionsThis five-point CXR scoring tool, suitable for use in poorly- and well-resourced settings and by clinicians of varying experience levels, reliably describes SARI severity. The resulting numerical data enables epidemiological comparisons of SARI severity between different countries and settings.

P90 Catch - Community Access To Ct Chest

Introduction Rates of lung cancer diagnosis for two week wait (2WW) referrals are although referrals are increasing. Many 2WW’s are potentially exposed to unnecessary anxiety as the referral requires the G. P. to inform the patient of the possibility of cancer. CATCH ( C ommunity A ccess T o CT Ch est) is a new protocol of care that has been developed by the Salford lung cancer team in collaboration with the Salford C. C. G. whereby abnormal low reports are communicated to G. P.s with instructions for them to request a CT scan, which is then fast tracked allowing rapid performance and reporting of the scan with appropriate advice to the GP. Methods A d-base was set up to capture the performance of CATCH from its introduction on 05.02.2014 to 05.07.2014. Demographic details were collected for dates of CXR, report, CT request, CT report, relevant outcomes and 2WW activity for same time (2011–2014). Participating patients were interviewed by telephone using a structured questionnaire (supported by a postal questionnaire for non-responders). Results 53 patients underwent an abnormal with advice to enter into the CATCH protocol and of these 7 bypassed CATCH having been referred directly into the 2WW system by their G. P.s. For the 46 patients completing CATCH, seven (15%) urgent 2WW referrals were recommended. In the remaining 39 patients, 28 required no follow up, 9 non-urgent referral to the chest clinic and 2 repeat community CXRs. Timelines for performance of CT scans were acceptable (see Table) and detected cancer in 5/46 (10.9%) and were normal in 8/46 (17.4%). 23–26 patients interviewed to date rated the service overall as either very good or excellent. During same points in 2011, 2012, 2013 and 2014 2WW numbers were 69, 84, 89 and 81 respectively. Conclusions Our provisional data support the role of CATCH as a new system of care for managing low risk CXR reports that might otherwise be referred into growing 2WW clinics. Thus far, the protocol moves at a rapid pace and has been well received by the patient (although we await the results of the postal survey in due course).

Adult chest radiograph reporting by radiographers: Preliminary data from an in-house audit programme

AimTo examine the adult chest radiograph (CXR) reporting performance of a reporting radiographer in clinical practice using different audit systems; single radiologist and two radiologists, with clinical review of discordant cases. Materials and methods100 chest radiographs (CXRs) were drawn randomly from a consecutive series of 4800 CXRs which had been reported during a nine month period at a district general hospital by a radiographer after two years of training. Diagnostic outcomes were normal or abnormal, and agreement with the reporting radiographer or not. There was 50% duplication of CXRs reported between three radiologists. Concordance rates were determined for the radiographer-radiologist and inter-radiologist interpretations. Independent clinical review of discordant cases was performed to establish the final diagnosis. ResultsNinety-nine cases were reviewed, with 40 cases deemed abnormal by at least one radiologist. Consensus was found with the radiographers report in 59 normal and 33 abnormal CXRs reviewed by two radiologists (96.7% and 86.8% respectively). Seven CXR reports were discrepant with clinical review: mediastinal lymphadenopathy was missed by both radiologist and radiographer; linear atelectasis was reported by two radiologists but not the radiographer. Three cases were over-interpreted and on two occasions at least one radiologist agreed with the radiographer. There was very high concordance between the radiographer and each radiologist, 96%, 96% and 92% respectively. ConclusionsThis study suggested that regular audit, which incorporates case note review and discrepant reporting within a multidisciplinary setting, should contribute to safe practice.

P26 Utility of the chest X-ray in the era of IGRA testing for latent TB prior to anti-TNF therapy

IntroductionAnti-TNF therapies are associated with increased risk of reactivation of latent Mycobacterium tuberculosis infection (LTBI). Screening for LTBI is recommended prior to commencing anti-TNF therapy. BTS guidelines for screening incorporate...

Automated identification of pneumonia in chest radiograph reports in critically ill patients.

BackgroundPrior studies demonstrate the suitability of natural language processing (NLP) for identifying pneumonia in chest radiograph (CXR) reports, however, few evaluate this approach in intensive care unit (ICU) patients.MethodsFrom a total of 194,615 ICU reports, we empirically developed a lexicon to categorize pneumonia-relevant terms and uncertainty profiles. We encoded lexicon items into unique queries within an NLP software application and designed an algorithm to assign automated interpretations (‘positive’, ‘possible’, or ‘negative’) based on each report’s query profile. We evaluated algorithm performance in a sample of 2,466 CXR reports interpreted by physician consensus and in two ICU patient subgroups including those admitted for pneumonia and for rheumatologic/endocrine diagnoses.ResultsMost reports were deemed ‘negative’ (51.8%) by physician consensus. Many were ‘possible’ (41.7%); only 6.5% were ‘positive’ for pneumonia. The lexicon included 105 terms and uncertainty profiles that were encoded into 31 NLP queries. Queries identified 534,322 ‘hits’ in the full sample, with 2.7 ± 2.6 ‘hits’ per report. An algorithm, comprised of twenty rules and probability steps, assigned interpretations to reports based on query profiles. In the validation set, the algorithm had 92.7% sensitivity, 91.1% specificity, 93.3% positive predictive value, and 90.3% negative predictive value for differentiating ‘negative’ from ‘positive’/’possible’ reports. In the ICU subgroups, the algorithm also demonstrated good performance, misclassifying few reports (5.8%).ConclusionsMany CXR reports in ICU patients demonstrate frank uncertainty regarding a pneumonia diagnosis. This electronic tool demonstrates promise for assigning automated interpretations to CXR reports by leveraging both terms and uncertainty profiles.

Just-in-Time Cost-Effective Off-the-Shelf Remote Telementoring of Paramedical Personnel in Bedside Lung Sonography—A Technical Case Study

Remote telementored ultrasound (RTMUS) is a new discipline that allows a remote expert to guide variably experienced clinical responders through focused ultrasound examinations. We used the examination of the pleural spaces after tube thoracostomy (TT) removal by a nurse with no prior ultrasound experience as an illustrative but highly accurate example of the technique using a simple cost-effective system. The image outputs of a handheld ultrasound machine and a head-mounted Web camera were input into a customized graphical user interface and streamed over a freely available voice over Internet protocol system that allowed two-way audio and visual communication between the novice examiner and the remote expert. The bedside nurse was then guided to examine the anterior chest of a patient who had recently had bilateral TTs removed. The team sought to determine the presence or absence of any recurrent pneumothoraces using the standard criteria for the ultrasound diagnosis of post-removal pneumothorax (PTXs). An upright chest radiograph (CXR) was obtained immediately after the RTMUS examination. The RTMUS system enabled the novice user to learn how to hold the ultrasound probe, where to place it on the chest, and thereafter to diagnose a subtle unilateral PTX characterized as "tiny" on the subsequent formal CXR report. As ultrasound has almost limitless clinical utility, using simple but advanced informatics and communication technologies has potential to improve worldwide healthcare delivery. RTMUS could be used both to enhance the information content as well as to digitally document important physiologic findings in any clinical encounter wherever a portable ultrasound and Internet connectivity are available.

P54 Impact of a rapid access system for early referral of suspected TB cases

IntroductionEarly diagnosis and treatment of infectious tuberculosis (TB) is an important strategy for controlling the burden of disease by minimising the spread of infection and secondary disease in close contacts....

Validation Study of an Automated Electronic Acute Lung Injury Screening Tool

ObjectiveThe authors designed an automated electronic system that incorporates data from multiple hospital information systems to screen for acute lung injury (ALI) in mechanically ventilated patients. The authors evaluated the accuracy of this system in diagnosing ALI in a cohort of patients with major trauma, but excluding patients with congestive heart failure (CHF). DesignSingle-center validation study. Arterial blood gas (ABG) data and chest radiograph (CXR) reports for a cohort of intensive care unit (ICU) patients with major trauma but excluding patients with CHF were screened prospectively for ALI requiring intubation by an automated electronic system. The system was compared to a reference standard established through consensus of two blinded physician reviewers who independently screened the same population for ALI using all available ABG data and CXR images. The system's performance was evaluated (1) by measuring the sensitivity and overall accuracy, and (2) by measuring concordance with respect to the date of ALI identification (vs. reference standard). MeasurementsOne hundred ninety-nine trauma patients admitted to our level 1 trauma center with an initial injury severity score (ISS) ≥ 16 were evaluated for development of ALI in the first five days in an ICU after trauma. Main ResultsThe system demonstrated 87% sensitivity (95% confidence interval [CI] 82.3–91.7) and 89% specificity (95% CI 84.7–93.4). It identified ALI before or within the 24-hour period during which ALI was identified by the two reviewers in 87% of cases. ConclusionsAn automated electronic system that screens intubated ICU trauma patients, excluding patients with CHF, for ALI based on CXR reports and results of ABGs is sufficiently accurate to identify many early cases of ALI.

Impact of chest CT on the clinical management of immunocompetent emergency department patients with chest radiographic findings of pneumonia

The purpose of this study is to assess the impact on clinical decision making of chest computed tomography (CT) in immunocompetent emergency department (ED) patients with chest radiographic (CXR) findings of pneumonia. We retrospectively identified 1,373 patients from our ED who underwent chest CT between 7/05 and 6/06. Report of CXR within 24 h before CT were reviewed to identify patients with findings of pneumonia. The following were the exclusion criteria: recommendation of CT on CXR report and immunocompromised status on chart review. Fifty-one patients met the inclusion criteria: 26 women and 25 men, with a mean age of 60 (range 29-103) years. Age- and sex-matched controls from the ED with CXR findings of pneumonia who did not undergo CT were identified. Charts were reviewed for clinical presentation, management, and follow-up. Patient and control groups were compared using Fisher exact and paired Student's t tests. The patients were sicker than the controls with more signs and symptoms including auscultation abnormalities, 64 (33 of 51) vs 47% (24 of 51), abnormal sputum 32 (16 of 51) vs 0%, hypoxemia 22 (11 of 51) vs 2% (1 of 51), weight loss, 20 (10 of 51) vs 4% (2 of 51), and night sweats, 16 (8 of 51) vs 2% (1 of 51; p < 0.05 each). Clinical management, (based on CT findings in 31% [16 of 51]), was more extensive for patients than controls: antibiotics initiated 82 (41 of 51) vs 47% (24 of 51), antibiotics changed 29 (15 of 31) vs 0%, procedures performed 24 (12 of 51) vs 0%, and mean length of stay was 8 days vs less than 1 (p < 0.05, each). Sixteen percent (8 of 51) of the patients had alternative/additional diagnosis based on CT: pulmonary embolism, lung cancer, hypersensitivity pneumonitis, multiple myeloma, renal cell carcinoma, small bowel obstruction, lung nodule, and endobronchial mass (n = 1, each). Eight percent (4 of 51) of the patients and no controls were diagnosed with tuberculosis (p = 0.06). Immunocompetent ED patients with CXR findings of pneumonia who underwent chest CT were sicker than those who were not imaged with CT. Chest CT was often useful in guiding therapy or providing an alternative diagnosis.

ICD-10 codes are a valid tool for identification of pneumonia in hospitalized patients aged ⩾65 years

This study examines the validity of using ICD-10 codes to identify hospitalized pneumonia cases. Using a case-cohort design, subjects were randomly selected from monthly cohorts of patients aged > or = 65 years discharged from April 2000 to March 2002 from two large tertiary Australian hospitals. Cases had ICD-10-AM codes J10-J18 (pneumonia); the cohort sample was randomly selected from all discharges, frequency matched to cases by month. Codes were validated against three comparators: medical record notation of pneumonia, chest radiograph (CXR) report and both. Notation of pneumonia was determined for 5098/5101 eligible patients, and CXR reports reviewed for 3349/3464 (97%) patients with a CXR. Coding performed best against notation of pneumonia: kappa 0.95, sensitivity 97.8% (95% CI 97.1-98.3), specificity 96.9% (95% CI 96.2-97.5), positive predictive value (PPV) 96.2% (95% CI 95.4-97.0) and negative predictive value (NPV) 98.2% (95% CI 97.6-98.6). When medical record notation of pneumonia is used as the standard, ICD-10 codes are a valid method for retrospective ascertainment of hospitalized pneumonia cases and appear superior to use of complexes of symptoms and signs, or radiology reports.

CT pulmonary angiogram (CTPA) and V/Q lung scanning practice with reference to the most recent British Thoracic Society (BTS) guidelines for the management of suspected acute pulmonary embolism

Methods All CTPA and all V/Q scans done over a 3 month period were retrospectively reviewed for diagnosis of pulmonary embolism (PE) and possible abnormalities on concomitant chest radiographs. Results Ninety-eight (48 male, 50 female, mean age 68.6 years) patients underwent CTPA. Ninety (91%) of these were diagnostic, 80 showed no evidence of pulmonary embolism and 10 were positive for PE. 8 (8.2%) scans were non-diagnostic. Only 35 (35.5%) of CXR were reported by a radiologist, 20 (58%) of these were abnormal. One hundred and seventy-six (72 male, l04 female, mean age 62.1 years) patients underwent V/Q scanning. There were 31 (17%) high, 24 (14%) indeterminate, 51 (29%) low probability and 70 (40%) normal perfusion scans. One hundred and thirty (74%) cases had a reported CXR: 68% of these were abnormal. A weak association was seen between normal CXR and normal perfusion scan, no association was seen between CXR report and non-normal perfusion scans. Nineteen patients underwent V/Q scanning as well as CTPA. There were two positive, 14 negative and 3 indeterminate CTPA and 3 high, 11 indeterminate and 5 low probability V/Q scans in this group. Conclusion The relatively low rate of indeterminate V/Q scans (14%) is comparable to CTPA (8% non-diagnostic). CTPA, however, has a higher positive and negative predictive value when compared to all V/Q and close adherence to the most recent BTS guidelines, i.e. clinical probability for every patient could improve V/Q accuracy further.

The Value of Baseline Chest Radiograph Reports in the Care of Elderly Patients in an Emergency Department

The authors used a before/after research design to determine the impact of written reports of baseline chest radiographs (CXRs) on the care of elderly patients during 48 emergency department visits. Internal medicine housestaff completed questionnaires that included inquiries about their treatment plans for the patients both before and after they reviewed reports of baseline CXR results. The investigators compared these answers to determine the proportion of patients for whom baseline CXR reports changed patient management. In addition, three faculty reviewers used the nominal group process, a consensus analysis approach, to measure treatment changes and to estimate benefit to the patients from the alterations in management. The housestaff indicated that written baseline CXR reports caused them to change treatment plans during only 2 (4%) of the 48 visits. In both cases, they provided aggressive treatment for congestive heart failure because of baseline CXR results. The faculty reviewers could find only one case in which baseline CXR findings might have changed their management plans. Moreover, they were not convinced that the treatment changes indicated by the housestaff actually benefitted the patients. These results suggest that written reports of baseline CXRs do not improve the care of acutely ill patients in an emergency department setting.