Interpretation Of Chest Radiographs Research Articles

Measuring the Effects of Education in Detecting Lung Cancer on Chest Radiographs: Utilization of a New Assessment Tool.

This study was designed to evaluate the effect of group and individualized educational lectures to accurately interpret chest radiographs of lung cancer patients and to introduce a new educational tool in evaluating skills for reading chest radiographs. Utilizing "hotspot" technology will be instrumental in measuring the effect of education in interpreting chest radiographs. There were 48 participants in the study. Chest radiographs of 100 lung cancer patients and 11 healthy patients taken at various time points were used for evaluation. Using "hotspot" technology, lesions on each radiograph were outlined. Values were taken at baseline, after which the group received lectures. Several days later, they underwent exam 2. Exam 3 was conducted after individualized lectures. A final exam was taken after the participants underwent individualized training within 2months. Scores significantly improved after the individual lessons (p < 0.001). This improvement in performance decreased in the final examination. Statistically significant differences were observed between exam 2 vs. exam 3 and exam 3 vs. the final exam (p < 0.001, p < 0.001). Participants demonstrated more improvement in detecting lesions in abnormal chest radiographs than in identifying normal ones. Although there was significant improvement in detecting abnormal radiographs by the end of the study (p < 0.001), no improvement was observed in detecting normal ones. We measured lung cancer detection rate using a new "hotspot" detection tool for chest radiographs. With the proposed scoring system, this tool could be objectively used in evaluating the educational effects.

Impact of radiology reports on timely tuberculosis diagnosis

PurposeAs tuberculosis becomes less common in higher income countries, clinician familiarity with the disease is declining. Little is known about how chest radiograph interpretations affect tuberculosis care. We sought to...

Reliability and validity of the World Health Organization reading standards for paediatric chest radiographs used in the field in an impact study of Pneumococcal Conjugate Vaccine in Kilifi, Kenya.

BackgroundRadiologically-confirmed pneumonia (RCP) is a specific end-point used in trials of Pneumococcal Conjugate Vaccine (PCV) to estimate vaccine efficacy. However, chest radiograph (CXR) interpretation varies within and between readers. We measured the repeatability and reliability of paediatric CXR interpretation using percent agreement and Cohen’s Kappa and the validity of field readings against expert review in a study of the impact of PCV on pneumonia.MethodsCXRs were obtained from 2716 children admitted between 2006 and 2014 to Kilifi County Hospital, Kilifi, Kenya, with clinically-defined severe or very-severe pneumonia. Five clinicians and radiologists attended a three-day training course on CXR interpretation using a WHO standard. All CXRs were read once by two local primary readers. Discordant readings and 13% of concordant readings were arbitrated by a panel of three expert radiologists. To assess repeatability, a 5% median random sample was presented twice. Sensitivity and specificity of the primary readers’ interpretations was estimated against the ‘gold-standard’ of the arbitrators’ results.ResultsOf 2716 CXRs, 2 were uninterpretable and 159 were evaluated twice. The percent agreement and Kappa for RCP were 89% and 0.68 and ranged between 84–97% and 0.19–0.68, respectively, for all pathological findings. Intra-observer repeatability was similar to inter-observer reliability. Sensitivities of the primary readers to detect RCP were 69% and 73%; specificities were 96% and 95%.ConclusionIntra- and inter-observer agreements on interpretations of radiologically-confirmed pneumonia are fair to good. Reasonable sensitivity and high specificity make radiologically-confirmed pneumonia, determined in the field, a suitable measure of relative vaccine effectiveness.

Low accuracy and confidence in chest radiograph interpretation amongst junior doctors and medical students.

Accurate chest X-ray (CXR) interpretation is an essential skill in clinical practice. Previous studies have shown poor accuracy and confidence rates (CR) of CXR interpretation by junior doctors and medical students. We presented 10 chest radiographs via an online questionnaire to Australian medical students and junior doctors, who were asked to identify the radiographic abnormality from a list of 15 options and to rate their confidence for each answer. Of 67 complete responses, junior doctors achieved a mean score of 57.6% and medical students 56.1%, with CR of 67 versus 58% respectively. There was a significant positive relationship between accuracy and CR among junior doctors (Pearson's coefficient + 0.798, P = 0.006) and students (Pearson's coefficient + 0.716, P = 0.020). This study identified similarities in strength and weakness in CXR interpretation between medical students and junior doctors. There was a positive association between test scores and self-rated confidence scores.

Impact of donor chest radiography on clinical outcome after lung transplantation.

BackgroundOrgan donation guidelines recommend a “clear” conventional bedside chest radiograph before lung transplantation despite only moderate accuracy for cardiopulmonary abnormalities.PurposeTo evaluate the influence of donor image interpretation on lung transplantation outcome in recipients by following early and late complications, one-year survival, and to correlate imaging findings and blood gas analysis with lung transplantation outcome in recipients.Material and MethodsIn 35 lung donors from a single institution clinical reports and study reviews of imaging findings of the mandatory bedside chest radiographs and blood gas analyses were compared with clinical outcome in 38 recipients. Hospitalization time, peri- and postoperative complications, early complications (primary graft dysfunction, infection), 30-day and one-year survival, and forced expiratory volume in 1 s percentage of predicted normal value (FEV1%) at one-year follow-up were analyzed.ResultsFindings in clinical reports and study reviews differed substantially, e.g. regarding reported decompensation, edema, infection, and atelectasis. No correlation was shown between imaging findings in clinical report or study review and blood gas analyses in the lung donors compared to postoperative outcome in recipients.ConclusionThe interpretation of the mandatory chest radiograph in its present form does not influence one-year outcome in lung transplantation. Larger imaging studies or a change in clinical routine including computed tomography may provide evidence for future guidelines.

Interruptions Increase Time and Decrease Accuracy of Chest Radiograph Interpretation

Interruptions Increase Time and Decrease Accuracy of Chest Radiograph Interpretation

The Impact of Interruptions on Chest Radiograph Interpretation: Effects on Reading Time and Accuracy

The objective of this study was to experimentally test the effect of interruptions on image interpretation by comparing reading time and response accuracy of interrupted case reads to uninterrupted case reads in resident and attending radiologists. Institutional review board approval was obtained before participant recruitment from an urban academic health-care system during January 2016-March 2016. Eleven resident and 12 attending radiologists examined 30 chest radiographs, rating their confidence regarding the presence or the absence of a pneumothorax. Ten cases were normal (ie, no pneumothorax present), 10 cases had an unsubtle pneumothorax (ie, readily perceivable by a nonexpert), and 10 cases had a subtle pneumothorax. During three reads of each case type, the participants were interrupted with 30 seconds of a secondary task. The total reading time and the accuracy of interrupted and uninterrupted cases were compared. A mixed-factors analysis of variance was run on reading time and accuracy with experience (resident vs attending) as a between-subjects factor and case type (normal, unsubtle, or subtle) and interruption (interruption vs no interruption) as within-subjects factors. Interrupted tasks had significantly longer reading times than uninterrupted cases (P = .032). During subtle cases, interruptions reduced accuracy (P = .034), but during normal cases, interruptions increased accuracy (P = .038). Interruptions increased reading times and increased the tendency for a radiologist to conclude that a case is normal for both resident and attending radiologists, demonstrating that interruptions reduce efficiency and introduce patient safety concerns during reads of abnormal cases.

Discrepancies in Radiograph Interpretation Between Pediatric Radiologists and Pediatric Intensivists in the Pediatric or Neonatal Intensive Care Unit

BackgroundIn pediatric intensive care units (PICUs) and neonatal intensive care units (NICUs), patient management decisions are sometimes based on preliminary interpretations of radiographs by pediatric intensivists (PIs) before a formal interpretation by a pediatric radiologist (PR). ObjectiveTo quantify and classify discrepancies in radiographic interpretation between PRs and PIs in the PICU and NICU. Materials and MethodsThis institutional review board–approved multi-institutional prospective study included three PRs and PIs at two PICUs and three NICUs. Interpretations of chest and abdominal radiographs by PIs and PRs were recorded on online forms and compared. Discrepancies in interpretations were classified as “miss,” “misinterpretation,” or “overcall.” The discrepancies were also categorized as “actionable” or “nonactionable” based on extrapolation of the ACR actionable reporting work group’s list of actionable findings. ResultsIn 960 radiographic interpretations, the total, nonactionable, and actionable discrepancy rates between PRs and PIs were 34.7%, 26.8%, and 7.9%, respectively. The most common actionable discrepancies were line or tube positions and identification and interpretation of parenchymal opacities in the lungs. Identification of air leaks in the PICU and differentiation of normal from abnormal bowel gas patterns in the NICU followed in frequency. Air leaks accounted for 1% of total discrepancies and 11% of actionable discrepancies. Most discrepancies were nonactionable and included retrocardiac atelectasis and mischaracterization of neonatal lung disease in the PICU and NICU, respectively. ConclusionAlthough the total discrepancy rate was high, most discrepancies were nonactionable. Actionable discrepancies were predominantly due to line and tube position, which should be an area of focused education.

Radiological diagnosis of pneumoperitoneum in children with typhoid intestinal perforation

Background: Typhoid fever is a severe systemic illness caused by the gram-negative bacillus Salmonella typhi and transmitted by the faecal-oral route. This study sought to determine the value of plain abdominal and chest radiographs in detecting pneumoperitoneum in children with typhoid intestinal perforation (TIP). Methods: A retrospective review of plain abdominal and chest radiographs of children who had surgery for TIP between June 2009 and December 2011 in our unit. All the films were reviewed by the same radiologist who was blinded to the intraoperative findings, for the presence or absence of various signs of pneumoperitoneum. Data were collected on a structured questionnaire and analysed using SPSS version 15.0. Results: Radiographs of 54 children were reviewed. Their ages ranged from 3 years to 13 years (median 7 years). Thirty-three of them were boys and 21 were girls (male-to-female ratio 1.57:1). Pneumoperitoneum was detected in 47 patients (87%). In the erect abdominothoracic films, air under the right hemidiaphragm was detected in 16 of 41 cases (39%), and extraluminal or intraperitoneal air-fluid levels in 31 of 41 cases (75.6%). In the supine abdominal films, the commonest sign of pneumoperitoneum was the right upper quadrant gas sign (23 of 50 cases; 46%). Conclusions: A careful interpretation of plain abdominal and chest radiographs in the child suspected to have TIP, would lead to more accurate diagnosis of pneumoperitoneum. Keywords: pneumoperitoneum; typhoid intestinal perforation; radiographs; children; air–fluid levels

Interpretation of chest radiographs

It is vital that every junior doctor has a thorough knowledge of the fundamentals of interpreting chest radiographs. Frequently, hospital-based trainees in general practice need to make a decision regarding patient treatment on an unreported chest X-ray. This article covers the basic interpretation of chest radiographs and the most common pathologies encountered.

The impact of Video Assisted learning (VAL) on slow learners

Background: Every medical graduate after completion of his course is posted in the emergency room where he/she faces many chest emergencies. In some chest emergencies a small intervention can be life-saving. In view of evidence based clinical practice every medical graduate should be confident to diagnose chest emergencies (e.g. Tension pneumothorax, massive pleural effusion, periodical effusion etc.) on radiographs, where an immediate intervention is necessary. Video Assisted learning (VAL) improves the performance of learners as it addresses a variety of learning styles. Video can be as good as an instructor in communicating facts or demonstrating procedures to assist in mastery learning where a student can view complex clinical or mechanical procedures as many times as they need to. In this study the advantages of video assisted learning would be used to enhance the academic output of learners. Method : 60 medical students of 6th semester were exposed to video assisted learning after traditional didactic lecture teaching on chest emergencies in the discipline of Radiology. Pretest OSCE was conducted in the form of interpretation of chest radiographs and post test OSCE was conducted after the intervention (VAL) Results: The average pretest score was 25.2 (31.5%) and average post test score was 48.15(60.18%). Based on the pretest scores, students were divided into three groups, i.e. Top one-third students, Middle one-third students and Bottom one-third students (i.e. slow learners). The pretest and post test results were compared as mean scores of the groups, with Paired t test. The difference in the scores was found to be statistically significant in all the groups (p value less than 0.001). The students perceived VAL as a good instructor which improves the understanding of complex case scenarios. Conclusion: Video assisted learning is an effective medium for teaching learning in graduate medical education.

Rib anomalies – a case and an overview of the literature.

Anatomic rib variants (numeric and structural) are reported to occur in less than 2 % of the general population and are rarely of any clinical significance. Frequently noticed developmental rib anomalies include fused and bifid ribs, cervical ribs and rib dysplasia. Occasionally they can cause problems when interpreting chest radiographs, therefore it is important for radiologists to be familiar with them and consider rib variants in differential diagnosis.The following case report presents an 88-year old female with a left bifid intrathoracic rib.

Diagnostic Outcomes After Chest Radiograph Interpretation in Patients With Suspected Tuberculosis and Negative Sputum Smears in a High-Burden Human Immunodeficiency Virus and Tuberculosis Setting.

Evaluation of patients with suspected tuberculosis and negative sputum smears for acid-fast bacilli (AFB) is challenging, especially in high human immunodeficiency virus coinfection settings where sputum smears have lower sensitivity for detecting AFB. We examined the utility of chest radiographs for detecting smear-negative pulmonary tuberculosis. Three hundred sixty sputum smear-negative patients who were referred from primary care clinics in the KwaZulu-Natal province of South Africa were evaluated. Chest radiographs were read by experienced pulmonologists using a previously validated Chest X-Ray Reading and Recording System (CRRS). Agreement between observers using CRRS was high at 91% with a Cohen's kappa of 0.64 (95% confidence interval [CI] = 0.52-0.76). Against a reference standard of sputum culture, sensitivity was 93% (95% CI = 86%-97%), whereas specificity was 14% (95% CI = 10%-19%). Performance against clinical diagnosis (following World Health Organization guidelines) was similar with sensitivity of 92% (95% CI = 88%-95%) and specificity of 20% (95% CI = 13%-28%). The low specificity of CRRS in this setting indicates poor diagnostic utility for detecting pulmonary tuberculosis.

Does the Use of a Checklist Help Medical Students in the Detection of Abnormalities on a Chest Radiograph?

The interpretation of chest radiographs is a complex task that is prone to diagnostic error, especially for medical students. The aim of this study is to investigate the extent to which medical students benefit from the use of a checklist regarding the detection of abnormalities on a chest radiograph. We developed a checklist based on literature and interviews with experienced thorax radiologists. Forty medical students in the clinical phase assessed 18 chest radiographs during a computer test, either with (n = 20) or without (n = 20) the checklist. We measured performance and asked participants for feedback using a survey. Participants that used a checklist detected more abnormalities on images with multiple abnormalities (M = 50.1%) than participants that could not use a checklist (M = 41.9%), p = 0.04. The post-experimental survey shows that on average, participants considered the checklist helpful (M = 3.25 on a five-point scale), but also time consuming (M = 3.30 on a five-point scale). In conclusion, a checklist can help medical students to detect abnormalities in chest radiographs. Moreover, students tend to appreciate the use of a checklist as a helpful tool during the interpretation of a chest radiograph. Therefore, a checklist is a potentially important tool to improve radiology education in the medical curriculum.

PERCH in Perspective: What Can It Teach Us About Pneumonia Etiology in Children?

The pneumonia team at the Bill & Melinda Gates Foundation congratulates the Pneumonia Etiology Research for Child Health (PERCH) study on delivering on their grant to collect high-quality data from thousands of children with World Health Organization–defined severe and very severe pneumonia and from controls in 9 diverse sites in 7 low- and middle-income countries. This supplement sets the foundation to understanding this complex study by providing an in-depth description of the study methodology, including discussion of key aspects such as antibiotic pretreatment, chest radiograph interpretation, utility of induced sputum in children, measurement of pathogen density, and use of C-reactive protein, and how these affect pneumonia etiology.

Standardized Interpretation of Chest Radiographs in Cases of Pediatric Pneumonia From the PERCH Study.

Background.Chest radiographs (CXRs) are a valuable diagnostic tool in epidemiologic studies of pneumonia. The World Health Organization (WHO) methodology for the interpretation of pediatric CXRs has not been evaluated beyond its intended application as an endpoint measure for bacterial vaccine trials.Methods.The Pneumonia Etiology Research for Child Health (PERCH) study enrolled children aged 1–59 months hospitalized with WHO-defined severe and very severe pneumonia from 7 low- and middle-income countries. An interpretation process categorized each CXR into 1 of 5 conclusions: consolidation, other infiltrate, both consolidation and other infiltrate, normal, or uninterpretable. Two members of a 14-person reading panel, who had undertaken training and standardization in CXR interpretation, interpreted each CXR. Two members of an arbitration panel provided additional independent reviews of CXRs with discordant interpretations at the primary reading, blinded to previous reports. Further discordance was resolved with consensus discussion.Results.A total of 4172 CXRs were obtained from 4232 cases. Observed agreement for detecting consolidation (with or without other infiltrate) between primary readers was 78% (κ = 0.50) and between arbitrators was 84% (κ = 0.61); agreement for primary readers and arbitrators across 5 conclusion categories was 43.5% (κ = 0.25) and 48.5% (κ = 0.32), respectively. Disagreement was most frequent between conclusions of other infiltrate and normal for both the reading panel and the arbitration panel (32% and 30% of discordant CXRs, respectively).Conclusions.Agreement was similar to that of previous evaluations using the WHO methodology for detecting consolidation, but poor for other infiltrates despite attempts at a rigorous standardization process.

2.2 CHEST RADIOGRAPH INTERPRETATION

2.2 CHEST RADIOGRAPH INTERPRETATION

Evaluation of a chest radiograph reading and recording system for tuberculosis in a HIV-positive cohort

To assess the impact of introducing a chest radiograph reading and recording system (CRRS) with a short training session, on the accuracy and inter-reader variability of tuberculosis (TB) interpretation of chest radiographs (CXRs) by a group of non-expert readers in a human immunodeficiency virus (HIV)-positive cohort. A set of 139 CXRs was reviewed by a group of eight physicians pre- and post-intervention at two clinics in Shan State, Myanmar, providing HIV/TB diagnosis and treatment services. The results were compared against the consensus of expert radiologists for accuracy. Overall accuracy was similar pre- and post-intervention for most physicians with an average area under the receiver operating characteristic curve difference of 0.02 (95% confidence interval: -0.03, 0.07). The overall agreement among physicians was poor pre- and post-intervention (Fleiss κ=0.35 and κ=0.29 respectively). The assessment of agreement for specific disease patterns associated with active TB in HIV-infected patients showed that for intrinsically subtle findings, the agreement was generally poor but better for the more intrinsically obvious disease patterns: pleural effusion (Cohen's kappa range = 0.37-0.67) and milliary nodular pattern (Cohen's kappa range = 0.25-0.52). This study demonstrated limited impact of the introduction of a CRRS on CXR accuracy and agreement amongst non-expert readers. The role in which CXRs are used for TB diagnosis in a HIV-positive cohort in similar clinical contexts should be reviewed.

Does training improve diagnostic accuracy and inter-rater agreement in applying the Berlin radiographic definition of acute respiratory distress syndrome? A multicenter prospective study

BackgroundPoor inter-rater reliability in chest radiograph interpretation has been reported in the context of acute respiratory distress syndrome (ARDS), although not for the Berlin definition of ARDS. We sought to examine the effect of training material on the accuracy and consistency of intensivists’ chest radiograph interpretations for ARDS diagnosis.MethodsWe conducted a rater agreement study in which 286 intensivists (residents 41.3%, junior attending physicians 35.3%, and senior attending physician 23.4%) independently reviewed the same 12 chest radiographs developed by the ARDS Definition Task Force (“the panel”) before and after training. Radiographic diagnoses by the panel were classified into the consistent (n = 4), equivocal (n = 4), and inconsistent (n = 4) categories and were used as a reference. The 1.5-hour training course attended by all 286 intensivists included introduction of the diagnostic rationale, and a subsequent in-depth discussion to reach consensus for all 12 radiographs.ResultsOverall diagnostic accuracy, which was defined as the percentage of chest radiographs that were interpreted correctly, improved but remained poor after training (42.0 ± 14.8% before training vs. 55.3 ± 23.4% after training, p < 0.001). Diagnostic sensitivity and specificity improved after training for all diagnostic categories (p < 0.001), with the exception of specificity for the equivocal category (p = 0.883). Diagnostic accuracy was higher for the consistent category than for the inconsistent and equivocal categories (p < 0.001). Comparisons of pre-training and post-training results revealed that inter-rater agreement was poor and did not improve after training, as assessed by overall agreement (0.450 ± 0.406 vs. 0.461 ± 0.575, p = 0.792), Fleiss’s kappa (0.133 ± 0.575 vs. 0.178 ± 0.710, p = 0.405), and intraclass correlation coefficient (ICC; 0.219 vs. 0.276, p = 0.470).ConclusionsThe radiographic diagnostic accuracy and inter-rater agreement were poor when the Berlin radiographic definition was used, and were not significantly improved by the training set of chest radiographs developed by the ARDS Definition Task Force.Trial registrationThe study was registered at ClinicalTrials.gov (registration number NCT01704066) on 6 October 2012.

Measuring performance in the interpretation of chest radiographs: a pilot study

To develop a system to assess the image interpretation performance of radiologists in identifying signs of malignancy on chest radiographs. A test set of 30 chest radiographs was chosen by an experienced radiologist consisting of 11 normal and 19 abnormal cases. The malignant cases all had biopsy-proven pathology; the normal and benign cases all had at least 2 years of imaging follow-up. Fourteen radiologists with a range of experiences were recruited. Participants individually read the test set displayed on a standard reporting workstation, with their findings entered directly into a laptop running specially designed reporting software. For each case, relevant clinical information was given and the reader was asked to mark any perceived abnormality and rate their level of suspicion on a five-point scale (normal, benign, indeterminate, suspicious, or malignant). On completion, participants were given instant feedback with performance parameters including sensitivity and specificity automatically calculated. An opportunity was then given to review the cases together with an expert opinion and pathology. The time each participant took to complete the test was recorded. Six consultant radiologists who took part showed significantly better performance as determined by receiver operating characteristic (ROC) analysis compared to eight specialist registrars (area under the ROC curve [AUC]=0.9297 and 0.7648 respectively, p=0.003). There was a significant correlation with years of experience in the interpretation of chest radiographs and performance on the test set (r=0.573, p=0.032). Consultant radiologists completed the test significantly more quickly that the specialist registrars: mean time 19.65 minutes compared to 26.51 minutes (p=0.033). It is possible to use a test set to measure individual differences in the interpretation of chest radiographs. This has the potential to be a useful tool in performance testing.