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1.  Chest tube complications: How well are we training our residents? 
Canadian Journal of Surgery  2007;50(6):450-458.
Thoracic trauma is commonly treated with tube thoracostomy. The overall complication rate associated with this procedure is up to 30% among all operators. The primary purpose of this study was to define the incidence and risk factors for complications in chest tubes placed exclusively by resident physicians. The secondary objective was to outline the rate of complications occult to postinsertional supine anteroposterior (AP) chest radiographs (CXRs).
Over a 12-month period at a regional trauma centre, we retrospectively reviewed all severely injured trauma patients (injury severity score ≥ 12) who underwent tube thoracostomy (338/761 patients). Insertional, positional and infective complications were identified. Patients were assessed for complications on the basis of resident operator characteristics, patient demographics, associated injuries and outcomes. Thoracoabdominal CT scans and corresponding CXRs were also used to determine the rate of complications occult to postinsertional supine AP CXR.
Of the patients, 338 (44%,) had CXR and CT imaging. Out of 76 (22%) chest tubes placed by residents in 61 (18%) patients (99% of whom had blunt trauma injuries), there were 17 complications; 6 (35%) were insertional; 9 (53%) were positional and 2 (12%) were infective. Tube placement outside the trauma bay (p = 0.04) and nonsurgical resident operators (p = 0.03) were independently predictive of complications. The rates of complications according to training discipline were as follows: 7% general surgery, 13% internal and family medicine, 25% other surgical disciplines and 40% emergency medicine. Resident seniority, time of day and other factors were not predictive. Six of 11 (55%) positional and intraparenchymal lung tube placements were occult to postinsertional supine AP CXR.
Chest tubes placed by resident physicians are commonly associated with complications that are not identified by postinsertional AP CXR. Thoracic CT is the only way to reliably identify this morbidity. The differential rate of complications according to resident specialty suggests that residents in non–general surgical training programs may benefit from more structured instruction and closer supervision in tube thoracostomy.
PMCID: PMC2386217  PMID: 18053373
2.  The effect of a tuberculosis chest X-ray image reference set on non-expert reader performance 
European Radiology  2013;23(9):2459-2468.
In low-resource settings, limitations in diagnostic accuracy of chest X-rays (CXR) for pulmonary tuberculosis (PTB) relate partly to non-expert interpretation. We piloted a TB CXR Image Reference Set (TIRS) to improve non-expert performance in an operational setting in Malawi.
Nineteen doctors and clinical officers read 60 CXR of patients with suspected PTB, at baseline and using TIRS. Two officers also used the CXR Reading and Recording System (CRRS). Correct treatment decisions were assessed against a “gold standard” of mycobacterial culture and expert performance.
TIRS significantly increased overall non-expert sensitivity from 67.6 (SD 14.9) to 75.5 (SD 11.1, P = 0.013), approaching expert values of 84.2 (SD 5.2). Among doctors, correct decisions increased from 60.7 % (SD 7.9) to 67.1 % (SD 8.0, P = 0.054). Clinical officers increased in sensitivity from 68.0 % (SD 15) to 77.4 % (SD 10.7, P = 0.056), but decreased in specificity from 55.0 % (SD 23.9) to 40.8 % (SD 10.4, P = 0.049). Two officers made correct treatment decisions with TIRS in 62.7 %. CRRS training increased this to 67.8 %.
Use of a CXR image reference set increased correct decisions by doctors to treat PTB. This tool may provide a low-cost intervention improving non-expert performance, translating into improved clinical care. Further evaluation is warranted.
Key Points
• Tuberculosis treatment decisions are influenced by CXR findings, despite improved laboratory diagnostics.
• In low-resource settings, CXR interpretation is performed largely by non-experts.
• We piloted the effect of a simple reference training set of CXRs.
• Use of the reference set increased the number of correct treatment decisions. This effect was more marked for doctors than clinical officers.
• Further evaluation of this simple training tool is warranted.
Electronic supplementary material
The online version of this article (doi:10.1007/s00330-013-2840-z) contains supplementary material, which is available to authorized users.
PMCID: PMC3738845  PMID: 23652843
Radiography; Tuberculosis; Malawi; Sensitivity and Specificity; Teaching
3.  The role and performance of chest X-ray for the diagnosis of tuberculosis: A cost-effectiveness analysis in Nairobi, Kenya 
The objective of this study was to establish 1) the performance of chest X-ray (CXR) in all suspects of tuberculosis (TB), as well as smear-negative TB suspects and 2) to compare the cost-effectiveness of the routine diagnostic pathway using Ziehl-Neelsen (ZN) sputum microscopy followed by CXR if case of negative sputum result (ZN followed by CXR) with an alternative pathway using CXR as a screening tool (CXR followed by ZN).
From TB suspects attending a chest clinic in Nairobi, Kenya, three sputum specimens were examined for ZN and culture (Lowenstein Jensen). Culture was used as gold standard. From each suspect a CXR was made using a four point scoring system: i: no pathology, ii: pathology not consistent for TB, iii: pathology consistent for TB and iv: pathology highly consistent for TB. The combined score i + ii was labeled as "no TB" and the combined score iii + iv was labeled as "TB". Films were re-read by a reference radiologist. HIV test was performed on those who consented. Laboratory and CXR costs were used to compare for cost-effectiveness.
Of the 1,389 suspects enrolled, for 998 (72%) data on smear, culture and CXR was complete. 714 films were re-read, showing a 89% agreement (kappa value = 0.75 s.e.0.037) for the combined scores "TB" or "no-TB". The sensitivity/specificity of the CXR score "TB" among smear-negative suspects was 80%/67%. Using chest CXR as a screening tool in all suspects, sensitivity/specificity of the score "any pathology" was 92%, respectively 63%. The cost per correctly diagnosed case was for the routine process $8.72, compared to $9.27 using CXR as screening tool. When costs of treatment were included, CXR followed by ZN became more cost-effective.
The diagnostic pathway ZN followed by CXR was more cost-effective as compared to CXR followed by ZN. When cost of treatment was also considered CXR followed by ZN became more cost-effective. The low specificity of chest X-ray remains a subject of concern. Depending whether CXR was performed on all suspects or on smear-negative suspects only, 22%–45% of patients labeled as "TB" had a negative culture. The introduction of a well-defined scoring system, clinical conferences and a system of CXR quality control can contribute to improved diagnostic performance.
PMCID: PMC1326228  PMID: 16343340
4.  The clinical value of daily routine chest radiographs in a mixed medical–surgical intensive care unit is low 
Critical Care  2005;10(1):R11.
The clinical value of daily routine chest radiographs (CXRs) in critically ill patients is unknown. We conducted this study to evaluate how frequently unexpected predefined major abnormalities are identified with daily routine CXRs, and how often these findings lead to a change in care for intensive care unit (ICU) patients.
This was a prospective observational study conducted in a 28-bed, mixed medical–surgical ICU of a university hospital.
Over a 5-month period, 2,457 daily routine CXRs were done in 754 consecutive ICU patients. The majority of these CXRs did not reveal any new predefined major finding. In only 5.8% of daily routine CXRs (14.3% of patients) was one or more new and unexpected abnormality encountered, including large atelectases (24 times in 20 patients), large infiltrates (23 in 22), severe pulmonary congestion (29 in 25), severe pleural effusion (13 in 13), pneumothorax/pneumomediastinum (14 in 13), and malposition of the orotracheal tube (32 in 26). Fewer than half of the CXRs with a new and unexpected finding were ultimately clinically relevant; in only 2.2% of all daily routine CXRs (6.4% of patients) did these radiologic abnormalities result in a change to therapy. Subgroup analysis revealed no differences between medical and surgical patients with regard to the incidence of new and unexpected findings on daily routine CXRs and the effect of new and unexpected CXR findings on daily care.
In the ICU, daily routine CXRs seldom reveal unexpected, clinically relevant abnormalities, and they rarely prompt action. We propose that this diagnostic examination be abandoned in ICU patients.
PMCID: PMC1550788  PMID: 16420655
5.  Is a postintubation chest radiograph necessary in the emergency department? 
Postintubation chest X-rays (CXR) are standard practice in emergency department (ED) intubations. In the operating room, it is not usually a standard practice to confirm endotracheal tube placement with a CXR.
We seek to study the utility of postintubation CXR in ED patients.
This was a retrospective case series of 157 adult patients intubated in the ED of an urban academic hospital with an emergency medicine training program. Standardized chart review was performed by two emergency physicians (EP) using a structured data abstraction tool and final radiology attending reads of postintubation CXR to assess placement. Endotracheal tube placement was graded as satisfactory, too high, too low, or malpositioned in the esophagus. Descriptive statistics were used, and 95% confidence intervals (CI) were reported. Hospital Institutional Review Board approval was obtained.
A total of 157 patients were intubated in the ED during the study period: 127 (81%, 95% CI: 74–86) had adequate tube placement by CXR confirmation, 9 (6%, 95% CI: 3–11) endotracheal tubes were judged to be too high, and 20 (13%, 95% CI: 8–19) were judged to be too low with 10 (6.5%, 95% CI: 3–11) of these being right mainstem bronchus intubations. One patient (<1%, 95% CI:<0.0001–4) had a CXR confirming esophageal intubation.
ED intubations were judged to have “satisfactory” placement by CXR in 81% of patients. CXR is able to identify a small subset of patients that likely need immediate intervention based on their CXR. Until further studies refute the utility of postintubation CXR in ED intubations, they should remain a part of routine practice.
PMCID: PMC2840601  PMID: 20436895
Intubation; Chest X-ray; Emergency department
6.  Bone Suppression Increases the Visibility of Invasive Pulmonary Aspergillosis in Chest Radiographs 
PLoS ONE  2014;9(10):e108551.
Chest radiographs (CXR) are an important diagnostic tool for the detection of invasive pulmonary aspergillosis (IPA) in critically ill patients, but their diagnostic value is limited by a poor sensitivity. By using advanced image processing, the aim of this study was to increase the value of chest radiographs in the diagnostic work up of neutropenic patients who are suspected of IPA.
The frontal CXRs of 105 suspected cases of IPA were collected from four institutions. Radiographs could contain single or multiple sites of infection. CT was used as reference standard. Five radiologists and two residents participated in an observer study for the detection of IPA on CXRs with and without bone suppressed images (ClearRead BSI 3.2; Riverain Technologies). The evaluation was performed separately for the right and left lung, resulting in 78 diseased cases (or lungs) and 132 normal cases (or lungs). For each image, observers scored the likelihood of focal infectious lesions being present on a continuous scale (0–100). The area under the receiver operating characteristics curve (AUC) served as the performance measure. Sensitivity and specificity were calculated by considering only the lungs with a suspiciousness score of greater than 50 to be positive.
The average AUC for only CXRs was 0.815. Performance significantly increased, to 0.853, when evaluation was aided with BSI (p = 0.01). Sensitivity increased from 49% to 66% with BSI, while specificity decreased from 95% to 90%.
The detection of IPA in CXRs can be improved when their evaluation is aided by bone suppressed images. BSI improved the sensitivity of the CXR examination, outweighing a small loss in specificity.
PMCID: PMC4184785  PMID: 25279774
7.  Predictors of pulmonary involvement in patients with extra-pulmonary tuberculosis 
The aim of this study is to assess the value of chest radiographs (CXRs) and sputum examinations in detecting pulmonary involvement of tuberculosis (TB) in patients with extra-pulmonary tuberculosis (EPTB).
Materials and Methods:
A retrospective analysis was performed among 248 EPTB patients with culture-proven diagnosis of tuberculosis seen between January 2001 and December 2007 at a tertiary teaching hospital, Riyadh, Saudi Arabia. Demographics, clinical, laboratory and radiological findings were reviewed and assessed. This study was approved by the hospital ethics and research committee.
One hundred twenty five of 233 EPTB patients (53.6%) had abnormal CXR findings. There was a significant difference in the occurrence of positive sputum culture results between patients with abnormal CXR findings (30/57) and those with normal CXR findings (4/17) (P = 0.04). Of 17 HIV-negative/unknown HIV-status EPTB patients with normal CXR results, 4 patients (23.5%) had positive sputum culture results. Intrathoracic lymphadenopathy (P < 0.001), pleural TB (P < 0. 001) and disseminated TB (P = 0.004) were associated with an increased risk of abnormal CXR findings. Patients with cough (52.9%), weight loss (41.2%) and night sweats (26.5%) are more likely to have positive sputum culture results.
CXR findings are predictive of positive sputum culture results. However, the rate of normal CXR among EPTB patients with positive sputum culture results was relatively high. Therefore, respiratory specimen cultures should be obtained in TB suspects with a normal CXR to identify potentially infectious cases of TB.
PMCID: PMC3410185  PMID: 22870411
Predictors; pulmonary; extra-pulmonary tuberculosis; radiology
8.  A recommended method in order to interpret chest x-rays for diagnosing small size pneumothorax 
Pneumothorax can be a both progressive and life threatening disorder. In this survey we evaluated the diagnostic accuracy of a recommended method for the interpretation of chest X-Rays (CXRs) compared to the common method in diagnosis of iatrogenic Pneumothorax in an emergency department.
Materials and Methods:
We conducted a study on 100 CXRs (31 with the diagnosis of small size pneumothorax and 69 normal) of patients who have undergone the upper central venous catheterization. CXRs were interpreted by 5 Emergency Specialists (ESs) and 5 general practitioners (GPs) separately using the conventional and recommended method. Recommended method included a 90 degree rotation against the side of chateterization in addition to using a yellow shield as the background color. Presence of pneumothorax on the CXR was confirmed by a radiologist.
64.5% of the CXRs with pneumothorax were correctly diagnosed by GPs and 87.7% by ESs with reutine method and 83.2% and 97.4% by recommended method, respectively (P.value<0.001). 96.8% out of all CXRs were correctly diagnosed by GPs and 99.4% by ESs by conventional method and 97.9% by GP and 99.7% by ES was correctly diagnosed using recommended method(P.value<0.001). None of the underlying variables including sex, age, underlying diseases, the side of intervention did not affect on the diagnostic accuracy in either groups (P.value>0.05).
A significant raise was obtained in the diagnostic accuracy of CXR using the recommended method. This study can be a preliminary study to conduct further investigations in order to enhance the diagnostic accuracy of CXRs.
PMCID: PMC3665117  PMID: 23724383
Central venous catheterization; chest x-ray; diagnostic accuracy; iatrogenic pneumothorax; interpretation
9.  Association of Lung Function, Chest Radiographs and Clinical Features in Infants with Cystic Fibrosis 
The European respiratory journal  2013;42(6):10.1183/09031936.00138412.
The optimal strategy for monitoring cystic fibrosis (CF) lung disease in infancy remains unclear.
To describe longitudinal associations between infant pulmonary function tests (iPFTs), chest radiograph (CXR) scores and other characteristics.
CF patients ≤ 24 months old were enrolled in a 10-center study evaluating iPFTs 4 times over a year. CXRs ~1 year apart were scored with the Wisconsin and Brasfield systems. Associations of iPFT parameters with clinical characteristics were evaluated with mixed effects models.
The 100 participants contributed 246 acceptable flow/volume (FEV0.5, FEF75) and 303 acceptable functional residual capacity (FRC) measurements and 171 CXRs. Both Brasfield and Wisconsin CXR scores worsened significantly over the 1 year interval. Worse Wisconsin CXR scores and S. aureus were both associated with hyperinflation (significantly increased FRC) but not with diminished FEV0.5 or FEF75. Parent-reported cough was associated with significantly diminished FEF75 but not with hyperinflation.
In this infant cohort in whom we previously reported worsening in average lung function, CXR scores also worsened over a year. The significant associations detected between both Wisconsin CXR score and S. aureus and hyperinflation, as well as between cough and diminished flows, reinforce the ability of iPFTs and CXRs to detect early CF lung disease.
PMCID: PMC3795977  PMID: 23722613
cystic fibrosis; imaging; infants; lung function
10.  Pneumoperitoneum in peritoneal dialysis patients; one centre’s experience 
NDT Plus  2011;4(2):120-123.
The pneumoperitoneum (PP) on upright chest X-ray (CXR) usually indicates a perforated viscus. As peritoneal dialysis (PD) catheter provides an additional port of air entry into the peritoneal cavity, the incidence and clinical significance of PP in PD patients has been debated in the literature (a variable incidence from 4 to 34% has been reported in previous studies). With improvement in patient training and connecting devices of PD catheters, technique-related PP is quite rare. Following a recent patient with PP, we reviewed our 3-year data to evaluate the incidence and significance of this radiological sign in PD patients.
We reviewed all upright CXRs in our PD patients from 2006 to 2008, using an electronic radiology database. Over 3 years, we had a total of 156 patients on PD. We have reviewed a total 312 upright CXRs (mean 2 X-rays per patient), which were performed for various clinical reasons during this period.
Seven PD patients had 11 CXRs showing free air under the diaphragm (total incidence of PP 4% of PD population and 3% of CXR performed in PD patients). One patient had two episodes of PP with a total of four X-rays demonstrating free air. Two patients had surgical complications of PD catheter insertion and PP was diagnosed just after the insertion of PD catheter, both of them needed laparotomy. Five patients had incidental PP, which was possibly technique related. In four of these patients with incidental PP, no definite intervention was needed. However, one of these five patients was symptomatic. We established that the cause of PP was faulty technique. Aspiration of PP with a patient in the Trendelenburg position gave her immediate symptomatic relief. We also retrained her to prevent further episodes of PP.
This review demonstrates the quite low and falling incidence of PP (<4% in a prevalent PD population) most likely due to improvement in training and technique. The air should not enter the peritoneal cavity in normal properly performed exchanges. Air under the diaphragm in a PD patient requires appropriate evaluation to exclude visceral perforation. After that, patient technique of PD exchanges should be reviewed. However, if PP persists, aspiration of air can give symptomatic relief.
PMCID: PMC4421564  PMID: 25984130
pneumoaspiration; pneumoperitoneum
11.  Is routine chest radiography indicated following chest drain removal after cardiothoracic surgery? 
A best evidence topic was written according to a structured protocol. The question addressed was whether routine chest radiography is indicated following chest drain removal in patients undergoing cardiothoracic surgery. A total of 356 papers were found using the reported searches; of which, 6 represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were mean duration of drains left in situ, timing of drain removal, pathology detected on chest radiographs (CXRs), interventions following imaging and clinical assessment, complications in patients not undergoing routine CXRs and the cost saving of omitting routine CXRs. One large cohort study reported the detection of pathology in 79% of clinically indicated CXRs in comparison to 40% of routine CXRs (P = 0.005). Ninety-five per cent of the non-routine CXR cohort remained asymptomatic and required no intervention. One large observational study reported the detection of new pneumothoraces in 9.3% of patients, 70.3% of which were barely perceptible. Intervention following CXR was required in 0.25% and only one medium-sized pneumothorax would have been potentially missed without CXR. Another large observational study reported intervention following CXR in 1.9% and the presence of relevant clinical signs and symptoms to be a significant predictor of major intervention (P < 0.01). A smaller observational study reported no pathology detected or intervention following CXR in 98% and the cost saving of omitting a single CXR at £10 000 per annum. Another small observational study reported only 7% of CXRs to be clinically indicated with a false-positive rate of 100%, and a false-negative rate of 7% in CXRs not clinically indicated. The smallest study reported no complications in the non-CXR cohort and only one patient undergoing intervention in the routine CXR cohort. We conclude that there is evidence that routine post drain removal CXR provides no diagnostic or therapeutic advantage over clinically indicated CXR or simple clinical assessment. The best evidence studies reported the detection of pathology on routine CXR ranging from 2 to 40% compared with 79% in clinically indicated CXRs (P = 0.005). Whilst the rate of intervention following routine CXR was as high as 4% in the smallest study, clinical signs and symptoms suggestive of pathology were a significant predictor of major re-intervention (P < 0.01).
PMCID: PMC3352714  PMID: 22392935
Chest drain; Chest radiography
12.  A chest radiograph scoring system in patients with severe acute respiratory infection: a validation study 
BMC Medical Imaging  2015;15:61.
The 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.
We 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).
Agreement 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.
This 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.
PMCID: PMC4696329  PMID: 26714630
Influenza; Humans; Radiography; Thoracic; Respiratory tract infections; Validation studies
13.  Clinical significance of normal chest radiographs among HIV-seropositive patients with suspected tuberculosis in Uganda 
Respirology (Carlton, Vic.)  2011;16(5):836-841.
Background and objectives
The frequency, aetiologies, and outcomes of normal chest radiographs (CXRs) among HIV-seropositive patients with suspected pulmonary tuberculosis (TB) have been infrequently described.
Consecutive HIV-seropositive adults hospitalized for cough of ≥ 2 weeks duration at Mulago Hospital (Kampala, Uganda), between September 2007 and July 2008, were enrolled. Baseline CXRs were obtained on admission. Patients with sputum smears that were negative for acid-fast bacilli (AFB) were referred for bronchoscopy with bronchoalveolar lavage (BAL). BAL fluid was examined for mycobacteria, Pneumocystis jirovecii, and other fungi. Patients were followed for two months after enrolment.
Of the 334 patients, 54 (16%) had normal CXRs. These patients were younger (median age 30 vs. 34 years, P=0.002), had lower counts of CD4+ T lymphocytes (median 13 vs. 57 cells/μL, P<0.001), and were less likely to be smear positive for AFB (17% vs. 39%, P=0.002) than those with abnormal CXRs. Pulmonary TB was the most frequent diagnosis (44%) among those with normal CXRs, followed by unknown diagnoses, pulmonary aspergillosis, and pulmonary cryptococcosis. The frequency of normal CXRs was 12% among pulmonary TB patients. There was a trend towards increased two-month mortality among patients with normal CXRs compared to those with abnormal CXRs (40% vs. 29%, P=0.15).
Normal CXR findings were common among HIV-seropositive patients with suspected TB, especially those who were young, those with low CD4+ T cell counts, and those with sputum smears that were negative for AFB. Mortality was high among those with normal CXRs. Normal CXR findings should not preclude further diagnostic evaluation in this population.
PMCID: PMC3126910  PMID: 21518124
clinical epidemiology; critical care medicine; immunodeficiency; radiology and other imaging; tuberculosis
14.  Impact of a training course on the quality of chest radiography to diagnose pulmonary tuberculosis 
Public Health Action  2015;5(1):83-88.
Setting: Socio-economically underprivileged urban areas in the Philippines.
Objective: To assess the performance of radiological technicians (RTs) 3 years after their participation in a training course to improve the quality of chest X-ray (CXR) and to test a monitoring visit after the course.
Design: A cross-sectional and observational study including on-site monitoring of X-ray facilities in Manila and Quezon City and assessment of CXR films taken by 23 RTs who previously attended a training course in 2009 or 2010. The sum of the assessment scores for each of six assessment factors at four points, i.e., before and after the training course that had been previously analysed, and before and after the monitoring visits that were currently analysed, were compared.
Results: Two assessment sum scores, identification mark or patient positioning, did not show significant differences. However, assessment of density, contrast, sharpness and artefact significantly improved after the training course, and before and after the monitoring visit, compared with before the training. There were no significant differences in any of the assessment factors before and after the monitoring visits.
Conclusion: The training course appears to have had a long-term effect on maintaining CXR quality. The post-training monitoring visit did not significantly improve CXR quality.
PMCID: PMC4525364  PMID: 26400607
quality assurance; monitoring; urban; the Philippines
15.  Comparison of Radiological Findings of Chest X-Ray With Echocardiography in Determination of the Heart Size 
Heart size is an important and effective parameter in chest X-ray (CXR) interpretation. Studies indicate that, especially in middle-aged men, increased cardiothoracic ratio (CTR) is associated with ischemic heart disease (IHD) and increased rate of morbidity and mortality. The CXR is the most common imaging examination of the heart.
A good quality posterior-anterior (PA) chest radiograph is an important indicator of the cardiac size. Nowadays, CXR has given its place to more advanced approaches such as two-dimensional echocardiography. However, CXR is still more accessible and feasible for most of the physicians. This study was designed to compare the findings of CXR and echocardiography in determination of the heart size.
Patients and Methods:
This cross-sectional study was carried out from 2006 to 2007. A total of 197 patients entered the study. The cases had been undergone PA CXR and 2-D echocardiography maximum within two days.
Of participants, 24.9% had cardiomegaly according to the findings of CXR and 50.8% based on echocardiography. There was a statistically significant difference between the mean size of Right Ventricular End Diastolic Diameter in the patients with cardiothoracic ratio < 50% and ≥ 50% (P = 0.002) as well as Left Ventricular End Diastolic Diameter (P = 0.023). Also, a statistically significant difference was seen between echocardiography and CXR findings with regard to determination of the heart size (P = 0.003). Nonetheless, it is noteworthy that sensitivity and specificity of CXR findings in the diagnosis of cardiomegaly were 34%, and 84.5%, respectively.
CTR is the most common method of describing the heart size. Increased CTR in CXR is associated with poor prognosis, which is suggestive of importance and necessity of early diagnosis. Although CXR may not have the same diagnostic accuracy as echocardiography, its easy accessibility and high specificity in diagnosis of cardiomegaly is very helpful, which can play an important and a cost-benefit role, particularly in screening the enlarged heart size. Moreover, according to the statistics released by Medical Council of Iran, most of Iranian physicians are general practitioners and a few of them are cardiologist.
PMCID: PMC4341405  PMID: 25763274
Echocardiography; Thoracic Radiography; Enlarged Heart; Cardiomegaly
16.  Improving diagnostic accuracy in assessing pulmonary edema on bedside chest radiographs using a standardized scoring approach 
BMC Anesthesiology  2014;14:94.
To assess the value of a score-based system which allows standardized evaluation of pulmonary edema on bedside chest radiographs (CXRs) under routine clinical conditions.
Seven experienced readers assessed bedside CXRs of ten patients with an extravascular lung water (EVLW)-value of ≤ 8 mL/kg (range: 4–8 mL/kg; indicates no pulmonary edema) and a series of ten patients with an EVLW-value of ≥ 15 mL/kg (range: 15–21 mL/kg; = indicates a pulmonary edema) with and without customized software which would permit a standardized assessment of the various indications of pulmonary edema. The software provides a score that identifies patients with and without pulmonary edema. EVLW-values were measured instantly after bedside CXR imaging using a pulse contour cardiac output (PiCCO) system and served as a reference standard. The patients were non-traumatic and not treated with diuretics or dobutamine during bedside CXR imaging and the PiCCO measurements. Mean sensitivity, specificity, positive and negative predictive value, the percentage of overall agreement and the free-marginal multirater kappa value was calculated for both the standard and the standardized score-based approach. The net reclassification index was calculated for each reader as well as for all readers.
Evaluation of bedside CXRs by means of the score-based approach took longer (23 ± 12 seconds versus 7 ± 3 seconds without the use of the software) but improved radiologists’ sensitivity (from 57 to 77%), specificity (from 90 to 100%) and the free-marginal multirater kappa value (from 0.34 to 0.68). The positive predictive value was raised from 85 to 100% and the negative predictive value from 68 to 81%. A net reclassification index of 0.3 (all readers) demonstrates an improvement in prediction performance gained by the score-based approach. The percentage of overall agreement was 67% with the standard approach and 84% with the software-based approach.
The diagnostic accuracy of bedside CXRs to discriminate patients with elevated EVLW-values from those with a normal value can be improved with the use of a standardized score-based approach. The investigated system is freely available as a web-based application (accessible via:
PMCID: PMC4216356  PMID: 25364301
Bedside chest radiograph; Pulmonary edema; Scoring system; Extravascular lung water (EVLW); Web-based application
17.  Chest radiographic findings of pulmonary tuberculosis in severely immunocompromised patients with the human immunodeficiency virus 
The British Journal of Radiology  2012;85(1014):e130-e139.
We describe chest radiograph (CXR) findings in a population with a high prevalence of human immunodeficiency virus (HIV) and tuberculosis (TB) in order to identify radiological features associated with TB; to compare CXR features between HIV-seronegative and HIV-seropositive patients with TB; and to correlate CXR findings with CD4 T-cell count.
Consecutive adult patients admitted to a national referral hospital with a cough of duration of 2 weeks or longer underwent diagnostic evaluation for TB and other pneumonias, including sputum examination and mycobacterial culture, bronchoscopy and CXR. Two radiologists blindly reviewed CXRs using a standardised interpretation form.
Smear or culture-positive TB was diagnosed in 214 of 403 (53%) patients. Median CD4+ T-cell count was 50 cells mm–3 [interquartile range (IQR) 14–150]. TB patients were less likely than non-TB patients to have a normal CXR (12% vs 20%, p=0.04), and more likely than non-TB patients to have a diffuse pattern of opacities (75% vs 60%, p=0.003), reticulonodular opacities (45% vs 12%, p<0.001), nodules (14% vs 6%, p=0.008) or cavities (18% vs 7%, p=0.001). HIV-seronegative TB patients more often had consolidation (70% vs 42%, p=0.007) and cavities (48% vs 13%, p<0.001) than HIV-seropositive TB patients. TB patients with a CD4+ T-cell count of ≤50 cells mm–3 less often had consolidation (33% vs 54%, p=0.006) and more often had hilar lymphadenopathy (30% vs 16%, p=0.03) compared with patients with CD4 51–200 cells mm–3.
Although different CXR patterns can be seen in TB and non-TB pneumonias there is considerable overlap in features, especially among HIV-seropositive and severely immunosuppressed patients. Providing clinical and immunological information to the radiologist might improve the accuracy of radiographic diagnosis of TB.
PMCID: PMC3474111  PMID: 21976629
18.  High Discordance of Chest X-ray and CT for Detection of Pulmonary Opacities in ED Patients: Implications for Diagnosing Pneumonia 
To evaluate the diagnostic performance of chest x-ray (CXR) compared to computed tomography (CT) for detection of pulmonary opacities in adult emergency department (ED) patients.
We conducted an observational cross sectional study of adult patients presenting to 12 EDs in the United States from July 1, 2003 through November 30, 2006 who underwent both CXR and chest CT for routine clinical care. CXRs and CT scans performed on the same patient were matched. CXRs and CT scans were interpreted by attending radiologists and classified as containing pulmonary opacities if the final radiologist report noted opacity, infiltrate, consolidation, pneumonia, or bronchopneumonia. Using CT as a criterion standard, the diagnostic test characteristics of CXR to detect pulmonary opacities were calculated.
The study cohort included 3,423 patients. Shortness of breath, chest pain and cough were the most common complaints, with 96.1% of subjects reporting at least one of these symptoms. Pulmonary opacities were visualized on 309 (9.0%) CXRs and 191 (5.6 %) CT scans. CXR test characteristics for detection of pulmonary opacities included: sensitivity 43.5% (95% CI: 36.4%–50.8%); specificity 93.0% (95% CI: 92.1%–93.9%); positive predictive value 26.9% (95% CI: 22.1%–32.2%); and negative predictive value 96.5% (95% CI: 95.8%–97.1%).
In this multicenter cohort of adult ED patients with acute cardiopulmonary symptoms, CXR demonstrated poor sensitivity and positive predictive value for detecting pulmonary opacities. Reliance on CXR to identify pneumonia may lead to significant rates of misdiagnosis.
PMCID: PMC3556231  PMID: 23083885
chest x-ray; computed tomography; pneumonia; emergency department; diagnostic testing
19.  Role of Gist and PHOG Features in Computer-Aided Diagnosis of Tuberculosis without Segmentation 
PLoS ONE  2014;9(11):e112980.
Effective diagnosis of tuberculosis (TB) relies on accurate interpretation of radiological patterns found in a chest radiograph (CXR). Lack of skilled radiologists and other resources, especially in developing countries, hinders its efficient diagnosis. Computer-aided diagnosis (CAD) methods provide second opinion to the radiologists for their findings and thereby assist in better diagnosis of cancer and other diseases including TB. However, existing CAD methods for TB are based on the extraction of textural features from manually or semi-automatically segmented CXRs. These methods are prone to errors and cannot be implemented in X-ray machines for automated classification.
Gabor, Gist, histogram of oriented gradients (HOG), and pyramid histogram of oriented gradients (PHOG) features extracted from the whole image can be implemented into existing X-ray machines to discriminate between TB and non-TB CXRs in an automated manner. Localized features were extracted for the above methods using various parameters, such as frequency range, blocks and region of interest. The performance of these features was evaluated against textural features. Two digital CXR image datasets (8-bit DA and 14-bit DB) were used for evaluating the performance of these features.
Gist (accuracy 94.2% for DA, 86.0% for DB) and PHOG (accuracy 92.3% for DA, 92.0% for DB) features provided better results for both the datasets. These features were implemented to develop a MATLAB toolbox, TB-Xpredict, which is freely available for academic use at This toolbox provides both automated training and prediction modules and does not require expertise in image processing for operation.
Since the features used in TB-Xpredict do not require segmentation, the toolbox can easily be implemented in X-ray machines. This toolbox can effectively be used for the mass screening of TB in high-burden areas with improved efficiency.
PMCID: PMC4229306  PMID: 25390291
20.  Comparison of thermodilution measured extravascular lung water with chest radiographic assessment of pulmonary oedema in patients with acute lung injury 
Acute lung injury and the acute respiratory distress syndrome (ALI/ARDS) are characterized by pulmonary oedema, measured as extravascular lung water (EVLW). The chest radiograph (CXR) can potentially estimate the quantity of lung oedema while the transpulmonary thermodilution method measures the amount of EVLW. This study was designed to determine whether EVLW as estimated by a CXR score predicts EVLW measured by the thermodilution method and whether changes in EVLW by either approach predict mortality in ALI/ARDS.
Clinical data were collected within 48 hours of ALI/ARDS diagnosis and daily up to 14 days on 59 patients with ALI/ARDS. Two clinicians scored each CXR for the degree of pulmonary oedema, using a validated method. EVLW indexed to body weight was measured using the single indicator transpulmonary thermodilution technique.
The CXR score had a modest, positive correlation with the EVLWI measurements (r = 0.35, p < 0.001). There was a 1.6 ml/kg increase in EVLWI per 10-point increase in the CXR score (p < 0.001, 95% confidence interval 0.92-2.35). The sensitivity of a high CXR score for predicting a high EVLWI was 93%; similarly the negative predictive value was high at 94%; the specificity (51%) and positive predictive value (50%) were lower. The CXR scores did not predict mortality but the EVLW thermodilution did predict mortality.
EVLW measured by CXR was modestly correlated with thermodilution measured EVLW. Unlike CXR findings, transpulmonary thermodilution EVLWI measurements over time predicted mortality in patients with ALI/ARDS.
PMCID: PMC3846630  PMID: 23937970
Extravascular lung water; Chest radiograph; Acute lung injury; Acute respiratory distress syndrome
21.  A population-based cohort study of chest x-ray screening in smokers: lung cancer detection findings and follow-up 
BMC Cancer  2012;12:18.
Case-control studies of mass screening for lung cancer (LC) by chest x-rays (CXR) performed in the 1990s in scarcely defined Japanese target populations indicated significant mortality reductions, but these results are yet to be confirmed in western countries. To ascertain whether CXR screening decreases LC mortality at community level, we studied a clearly defined population-based cohort of smokers invited to screening. We present here the LC detection results and the 10-year survival rates.
The cohort of all smokers of > 10 pack-years resident in 50 communities of Varese, screening-eligible (n = 5,815), in July 1997 was invited to nonrandomized CXR screening. Self-selected participants (21% of cohort) underwent screening in addition to usual care; nonparticipants received usual care. The cohort was followed-up until December 2010. Kaplan-Meier LC-specific survival was estimated in participants, in nonparticipants, in the whole cohort, and in an uninvited, unscreened population (control group).
Over the initial 9.5 years of study, 67 LCs were diagnosed in screening participants (51% were screen-detected) and 178 in nonparticipants. The rates of stage I LC, resectability and 5-year survival were nearly twice as high in participants (32% stage I; 48% resected; 30.5% 5-year survival) as in nonparticipants (17% stage I; 27% resected; 13.5% 5-year survival). There were no bronchioloalveolar carcinomas among screen-detected cancers, and median volume doubling time of incidence screen-detected LCs was 80 days (range, 44-318), suggesting that screening overdiagnosis was minimal. The 10-year LC-specific survival was greater in screening participants than in nonparticipants (log-rank, p = 0.005), and greater in the whole cohort invited to screening than in the control group (log-rank, p = 0.001). This favourable long-term effect was independently related to CXR screening exposure.
In the setting of CXR screening offered to a population-based cohort of smokers, screening participants who were diagnosed with LC had more frequently early-stage resectable disease and significantly enhanced long-term LC survival. These results translated into enhanced 10-year LC survival, independently related to CXR screening exposure, in the entire population-based cohort. Whether increased long-term LC-specific survival in the cohort corresponds to mortality reduction remains to be evaluated.
Trial registration number
PMCID: PMC3315414  PMID: 22251777
Lung cancer; Chest x-ray screening; Population-based; Cohort study; volunteer effect; Survival; Community
22.  The Risk of Obstructive Lung Disease by Previous Pulmonary Tuberculosis in a Country with Intermediate Burden of Tuberculosis 
Journal of Korean Medical Science  2011;26(2):268-273.
We evaluated the effects of previous pulmonary tuberculosis (TB) on the risk of obstructive lung disease. We analyzed population-based, the Second Korea National Health and Nutrition Examination Survey 2001. Participants underwent chest X-rays (CXR) and spirometry, and qualified radiologists interpreted the presence of TB lesion independently. A total of 3,687 underwent acceptable spirometry and CXR. Two hundreds and ninty four subjects had evidence of previous TB on CXR with no subjects having evidence of active disease. Evidence of previous TB on CXR were independently associated with airflow obstruction (adjusted odds ratios [OR] = 2.56 [95% CI 1.84-3.56]) after adjustment for sex, age and smoking history. Previous TB was still a risk factor (adjusted OR = 3.13 [95% CI 1.86-5.29]) with exclusion of ever smokers or subjects with advanced lesion on CXR. Among never-smokers, the proportion of subjects with previous TB on CXR increased as obstructive lung disease became more severe. Previous TB is an independent risk factor for obstructive lung disease, even if the lesion is minimal and TB can be an important cause of obstructive lung disease in never-smokers. Effort on prevention and control of TB is crucial in reduction of obstructive lung disease, especially in countries with more than intermediate burden of TB.
PMCID: PMC3031013  PMID: 21286020
Tuberculosis; Lung Diseases, Obstructive
The Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial provides us an opportunity to describe interval lung cancers not detected by screening chest x-ray (CXR) compared to screen-detected cancers.
Participants were screened for lung cancer with CXR at baseline and annually for two (never smokers) or three (ever smokers) more years. Screen-detected cancers were those with a positive CXR and diagnosed within 12 months. Putative interval cancers were those with a negative CXR screen but with a diagnosis of lung cancer within 12 months. Potential interval cancers were re-reviewed to determine whether lung cancer was missed and probably present during the initial interpretation or whether the lesion was a “true interval” cancer.
77,445 participants were randomized to the intervention arm with 70,633 screened. Of 5,227 positive screens from any screening round, 299 resulted in screen-detected lung cancers; 151 had potential interval cancers with 127 CXR available for re-review. Cancer was probably present in 45/127 (35.4%) at time of screening; 82 (64.6%) were “true interval” cancers. Compared to screen-detected cancers, true interval cancers were more common among males, persons with <12 years education and those with a history of smoking. True interval lung cancers were more often small cell, 28.1% vs. 7.4%, and less often adenocarcinoma, 25.6% vs. 56.2% (p<0.001), more advanced stage IV (30.5% vs. 16.6%, p<0.02), and less likely to be in the right upper lobe, 17.1% vs. 36.1% (p<0.02).
True interval lung cancers differ from CXR-screen-detected cancers with regard to demographic variables, stage, cell type and location.
PMCID: PMC4232302  PMID: 25123333
lung cancer; PLCO Cancer Screening Trial; screening interval lung cancers; chest X-ray screen-detected lung cancers
24.  Comparing the Interpretation of Traumatic Chest X-Ray by Emergency Medicine Specialists and Radiologists 
Archives of Trauma Research  2014;3(4):e22189.
Discrepancy between X-ray readings of emergency physicians (EPs) versus radiologists was reported between 0.95% and 16.8% in different studies. The discordance was even higher when specific studies such as chest X-rays (CXR) were probed.
This prospective study was conducted to assess the discrepancies between emergency and radiology departments with respect to interpretation of the traumatic chest X-rays.
Patients and Methods:
This prospective study was conducted in Shohadaye Tajrish Hospital, Tehran, Iran, from March to April 2014. Based on Advanced Trauma Life Support (ATLS) guidelines, plain chest radiography (CXR) was ordered for all patients in two standard views of posterior-anterior and lateral. All CXRs were interpreted by a corresponding emergency medicine specialist and a radiologist blind to the clinical findings of the patients. Finally, the results of two interpretations were compared. Accuracy, sensitivity, specificity, and predictive values of traumatic CXR interpretation were calculated by EPs with 95% of confidence interval (CI).
The evaluation of EPs was identical to that of the radiologists in 89.5% of the cases. Ninety-eight percent (98%) indicated total agreement and 1.5 percent total disagreement.
There is a high agreement between EPs and radiologists in CXR interpretations in Shohadaye Tajrish Hospital. Thus, EPs can substitute radiologists in the emergency department. More improvements are recommended to achieve the standard level of agreement.
PMCID: PMC4329230  PMID: 25738133
Emergency Medicine; Advanced Trauma Life Support Care; Radiography, Thoracic; Radiographic Image Interpretation
25.  A Porcine Pneumothorax Model for Teaching Ultrasound Diagnostics 
Academic Emergency Medicine  2012;19(5):586-592.
Objectives: Ultrasound (US) is a sensitive diagnostic tool for detecting pneumothorax (PTX), but methods are needed to optimally teach this technique outside of direct patient care. In training and research settings, porcine PTX models are sometimes used, but the description of the PTX topography in these models is lacking. The study purpose was to define the distribution of air using the reference imaging standard computed tomography (CT), to see if pleural insufflation of air into a live anaesthetized pig truly imitates a PTX in an injured patient.
Methods: A unilateral catheter was inserted into one pleural cavity of each of 20 pigs, and 500 mL of air was insufflated. After a complete thoracic CT scan, the anterior, lateral, medial, basal, apical, and posterior components of the PTXs were compared. The amount of air in each location was quantified by measuring the distance from the lung edge to the chest wall (LE-CW). A supine anteroposterior chest radiograph (CXR) was taken from each model and interpreted by a senior radiologist, and the image results were compared to CT.
Results: All 20 hemithoraces with PTX were correctly identified by CT, while six remained occult after interpreting the CXRs. The PTXs were anterior (100%), lateral (95%), medial (80%), basal (60%), apical (45%), and posterior (15%). The major proportion of the insufflated 500-mL volume was found in the anterior, medial, and basal recesses.
Conclusions: The authors found the distribution of the intrathoracic air to be similar between a porcine model and that to be expected in human trauma patients, all having predominantly anterior PTX topographies. In a training facility, the model is easy to set up and can be scanned by the participants multiple times. To acquire the necessary skills to perform thoracic US examinations for PTX, the porcine models could be useful.
PMCID: PMC3502747  PMID: 22594363

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