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Arruda Bergamaschi N, Huber L, Ludewig E, Böhler A, Gumpenberger M, Hittmair KM, Strohmayer C, Folkertsma R, Rowan C. Association between clinical history in the radiographic request and diagnostic accuracy of thorax radiographs in dogs: A retrospective case-control study. J Vet Intern Med 2023; 37:2453-2459. [PMID: 37845839 PMCID: PMC10658523 DOI: 10.1111/jvim.16899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 09/27/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND The effect of clinical history on the interpretation of radiographs has been widely researched in human medicine. There is, however, no data on this topic in veterinary medicine. HYPOTHESIS/OBJECTIVES Diagnostic accuracy would improve when history was supplied. ANIMALS Thirty client-owned dogs with abnormal findings on thoracic radiographs and confirmation of the disease, and 30 healthy client-owned controls were drawn retrospectively. METHODS Retrospective case-control study. Sixty radiographic studies of the thorax were randomized and interpreted by 6 radiologists; first, with no access to the clinical information; and a second time with access to all pertinent clinical information and signalment. RESULTS A significant increase in diagnostic accuracy was noted when clinical information was provided (64.4% without and 75.2% with clinical information; P = .002). There was no significant difference in agreement between radiologists when comparing no clinical information and with clinical information (Kappa 0.313 and 0.300, respectively). CONCLUSIONS AND CLINICAL IMPORTANCE The addition of pertinent clinical information to the radiographic request significantly improves the diagnostic accuracy of thorax radiographs of dogs and is recommended as standard practice.
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Affiliation(s)
| | - Lukas Huber
- University of Veterinary Medicine ViennaViennaAustria
| | | | | | | | | | | | | | - Conor Rowan
- University of Veterinary Medicine ViennaViennaAustria
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2
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Li D, Pehrson LM, Tøttrup L, Fraccaro M, Bonnevie R, Thrane J, Sørensen PJ, Rykkje A, Andersen TT, Steglich-Arnholm H, Stærk DMR, Borgwardt L, Hansen KL, Darkner S, Carlsen JF, Nielsen MB. Inter- and Intra-Observer Agreement When Using a Diagnostic Labeling Scheme for Annotating Findings on Chest X-rays-An Early Step in the Development of a Deep Learning-Based Decision Support System. Diagnostics (Basel) 2022; 12:diagnostics12123112. [PMID: 36553118 PMCID: PMC9776917 DOI: 10.3390/diagnostics12123112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/21/2022] [Accepted: 11/26/2022] [Indexed: 12/14/2022] Open
Abstract
Consistent annotation of data is a prerequisite for the successful training and testing of artificial intelligence-based decision support systems in radiology. This can be obtained by standardizing terminology when annotating diagnostic images. The purpose of this study was to evaluate the annotation consistency among radiologists when using a novel diagnostic labeling scheme for chest X-rays. Six radiologists with experience ranging from one to sixteen years, annotated a set of 100 fully anonymized chest X-rays. The blinded radiologists annotated on two separate occasions. Statistical analyses were done using Randolph's kappa and PABAK, and the proportions of specific agreements were calculated. Fair-to-excellent agreement was found for all labels among the annotators (Randolph's Kappa, 0.40-0.99). The PABAK ranged from 0.12 to 1 for the two-reader inter-rater agreement and 0.26 to 1 for the intra-rater agreement. Descriptive and broad labels achieved the highest proportion of positive agreement in both the inter- and intra-reader analyses. Annotating findings with specific, interpretive labels were found to be difficult for less experienced radiologists. Annotating images with descriptive labels may increase agreement between radiologists with different experience levels compared to annotation with interpretive labels.
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Affiliation(s)
- Dana Li
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2100 Copenhagen, Denmark
- Correspondence:
| | - Lea Marie Pehrson
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Computer Science, University of Copenhagen, 2100 Copenhagen, Denmark
| | | | | | | | | | - Peter Jagd Sørensen
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Alexander Rykkje
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Tobias Thostrup Andersen
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Henrik Steglich-Arnholm
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Dorte Marianne Rohde Stærk
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Lotte Borgwardt
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Kristoffer Lindskov Hansen
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Sune Darkner
- Department of Computer Science, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Jonathan Frederik Carlsen
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Michael Bachmann Nielsen
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2100 Copenhagen, Denmark
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3
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An Evaluation of the Quality of Plain Radiograph Interpretations by Radiology Trainees: A Single Institution Experience. Diagnostics (Basel) 2022; 12:diagnostics12081954. [PMID: 36010304 PMCID: PMC9406469 DOI: 10.3390/diagnostics12081954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/18/2022] [Accepted: 07/20/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: The primary communication between the radiologist and referrer is through the radiological report. However, there are incidents of misinterpretation during radiologist training. Therefore, the present study aimed to evaluate the accuracy level and incidence of interpretation errors for plain radiographs among radiology trainees at our institution. Materials and Methods: The present study retrospectively reviewed 508 reported plain radiographs for one year, and two radiologists subsequently evaluated these plain radiographs. The initial diagnosis by the trainee was compared with the radiologists’ evaluation, and the results were categorized as either ‘accurate’, ‘minor discrepancy’, or ‘major discrepancy’. The data were analyzed concerning the overall performance, year of trainee, anatomic area, patient age group, and radiograph type. A chi-square test was performed, with p < 0.05 indicating statistical significance. Results: The overall accuracy rate was 69%, with minor and major discrepancy rates of 21% and 10%, respectively. There was an insignificant increase in overall accuracy with increased years of training, despite a reduction to 58% accuracy among Year 3 trainees. The accuracy level increased between Year 1, Year 2 and Year 4 by 70%, 71% and 75%, respectively (p > 0.05). The accuracy rates for both the adult and pediatric age groups were not statistically significant. The mobile radiographs showed lower accuracy rate of reporting than the plain radiographs. Conclusion: The radiological trainee interpretations for plain radiographs had an average rating with low discrepancy rates. The Year 3 trainees had the lowest accuracy compared to the other trainee groups. However, the present study suggests the need for further research to determine if the current outcomes are outliers or are indicative of a real phenomenon.
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4
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Geanacopoulos AT, Lipsett SC, Hirsch AW, Monuteaux MC, Neuman MI. Impact of Viral Radiographic Features on Antibiotic Treatment for Pediatric Pneumonia. J Pediatric Infect Dis Soc 2022; 11:207-213. [PMID: 35020928 DOI: 10.1093/jpids/piab132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 12/14/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND/OBJECTIVES Chest radiograph (CXR) is routinely performed among children with suspected pneumonia, though it is not clear how specific radiographic findings impact antibiotic treatment for pneumonia. We evaluated the impact of viral radiographic features on antibiotic treatment among children undergoing pneumonia evaluation in the emergency department (ED). METHODS Children presenting to a pediatric ED who underwent a CXR for pneumonia evaluation were prospectively enrolled. Prior to CXR performance, physicians indicated their level of suspicion for pneumonia. The CXR report was reviewed to assess for the presence of viral features (peribronchial cuffing, perihilar markings, and interstitial infiltrate) as well as radiographic features suggestive of pneumonia (consolidation, infiltrate, and opacity). The relationship between viral radiographic features and antibiotic treatment was assessed based on the level of clinical suspicion for pneumonia prior to CXR. RESULTS Patients with normal CXRs (n = 400) and viral features alone (n = 370) were managed similarly, with 8.0% and 8.6% of patients receiving antibiotic treatment, respectively (P = .75). Compared with children with radiographic pneumonia (n = 174), patients with concurrent viral features and radiographic pneumonia (n = 177) were treated with antibiotics less frequently (86.2% vs 54.3%, P < .001). Among children with isolated viral features on CXR, antibiotic treatment rates were correlated with pre-CXR level of suspicion for pneumonia. CONCLUSIONS Among children with suspected pneumonia, the presence of viral features alone on CXR is not associated with increased rates of antibiotic use. Among children with radiographic pneumonia, the addition of viral features on CXR is associated with lower rates of antibiotic use, as compared to children with radiographic pneumonia alone.
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Affiliation(s)
- Alexandra T Geanacopoulos
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Susan C Lipsett
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alexander W Hirsch
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Michael C Monuteaux
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mark I Neuman
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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5
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Voigt GM, Thiele D, Wetzke M, Weidemann J, Parpatt PM, Welte T, Seidenberg J, Vogelberg C, Koster H, Rohde GGU, Härtel C, Hansen G, Kopp MV. Interobserver agreement in interpretation of chest radiographs for pediatric community acquired pneumonia: Findings of the pedCAPNETZ-cohort. Pediatr Pulmonol 2021; 56:2676-2685. [PMID: 34076967 DOI: 10.1002/ppul.25528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 05/08/2021] [Accepted: 05/09/2021] [Indexed: 11/09/2022]
Abstract
Although chest radiograph (CXR) is commonly used in diagnosing pediatric community acquired pneumonia (pCAP), limited data on interobserver agreement among radiologists exist. PedCAPNETZ is a prospective, observational, and multicenter study on pCAP. N = 233 CXR from patients with clinical diagnosis of pCAP were retrieved and n = 12 CXR without pathological findings were added. All CXR were interpreted by a radiologist at the site of recruitment and by two external, blinded pediatric radiologists. To evaluate interobserver agreement, the reporting of presence or absence of pCAP in CXR was analyzed, and prevalence and bias-adjusted kappa (PABAK) statistical testing was applied. Overall, n = 190 (82%) of CXR were confirmed as pCAP by two external pediatric radiologists. Compared with patients with pCAP negative CXR, patients with CXR-confirmed pCAP displayed higher C-reactive protein levels and a longer duration of symptoms before enrollment (p < .007). Further parameters, that is, age, respiratory rate, and oxygen saturation showed no significant difference. The interobserver agreement between the onsite radiologists and each of the two independent pediatric radiologists for the presence of pCAP was poor to fair (69%; PABAK = 0.39% and 76%; PABAK = 0.53, respectively). The concordance between the external radiologists was fair (81%; PABAK = 0.62). With regard to typical CXR findings for pCAP, chance corrected interrater agreement was highest for pleural effusions, infiltrates, and consolidations and lowest for interstitial patterns and peribronchial thickening. Our data show a poor interobserver agreement in the CXR-based diagnosis of pCAP and emphasized the need for harmonized interpretation standards.
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Affiliation(s)
- Gesche M Voigt
- Department of Pediatric Pneumology and Allergology, University Hospital Schleswig-Holstein, Lübeck, Germany.,Airway Research Center North (ARCN) Lübeck and Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH) Hannover, Member of the German Center for Lung Research (DZL), Germany
| | - Dominik Thiele
- Airway Research Center North (ARCN) Lübeck and Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH) Hannover, Member of the German Center for Lung Research (DZL), Germany.,University Medical Center Schleswig-Holstein, Institute of Medica, Biometry and Statistics, University of Lübeck, Lübeck, Germany
| | - Martin Wetzke
- Airway Research Center North (ARCN) Lübeck and Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH) Hannover, Member of the German Center for Lung Research (DZL), Germany.,Department of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Jürgen Weidemann
- Department of Pediatric Radiology and Imaging, Children's and Youth Hospital auf der Bult, Hannover, Germany
| | - Patricia-Maria Parpatt
- Department of Imaging and Interventional Radiology, University Hospital Oldenburg, Germany
| | - Tobias Welte
- Airway Research Center North (ARCN) Lübeck and Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH) Hannover, Member of the German Center for Lung Research (DZL), Germany.,Department of Pulmonary Medicine, German Centre for Lung Research, Hannover Medical School, Hannover, Germany.,Deptartment of Pulmonay Medicine, Hannover Medical School, Hannover, Germany, Hannover, Germany
| | - Jürgen Seidenberg
- Department of Pediatric Pneumology and Allergology, University Hospital, Oldenburg, Germany
| | - Christian Vogelberg
- Department of Pediatric Pneumology and Allergology, University Hospital, Dresden, Germany
| | - Holger Koster
- Department of Pediatric Pneumology and Allergology, University Hospital, Oldenburg, Germany
| | - Gernot G U Rohde
- Airway Research Center North (ARCN) Lübeck and Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH) Hannover, Member of the German Center for Lung Research (DZL), Germany.,Department of Respiratory Medicine, University Hospital Frankfurt, Germany
| | - Christoph Härtel
- Department of Pediatric Pneumology and Allergology, University Hospital Schleswig-Holstein, Lübeck, Germany.,Department of Pediatrics, University Hospital, Würzburg, Germany
| | - Gesine Hansen
- Airway Research Center North (ARCN) Lübeck and Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH) Hannover, Member of the German Center for Lung Research (DZL), Germany.,Department of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Matthias V Kopp
- Department of Pediatric Pneumology and Allergology, University Hospital Schleswig-Holstein, Lübeck, Germany.,Airway Research Center North (ARCN) Lübeck and Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH) Hannover, Member of the German Center for Lung Research (DZL), Germany.,Department of Pediatrics, Inselspital, University of Bern, Bern, Switzerland
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6
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Small L. The role of clinical history in the interpretation of chest radiographs. Radiography (Lond) 2020; 27:698-703. [PMID: 33158752 DOI: 10.1016/j.radi.2020.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 10/01/2020] [Accepted: 10/03/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This review will appraise the literature pertaining to the influences that clinical history has on the action of assessing the chest radiograph. KEY FINDINGS There remains conflicting evidence on the impact of clinical history on chest radiography. Some research suggests that clinical history has the potential to influence the reporter in a negative way by limiting their search strategy to a more focussed search. Image interpretation is more accurate when reporters are allowed to conduct a free search of the chest image, untainted by preconceived concepts. CONCLUSION Clinical history needs to be accessed appropriately to aid and not stifle accurate image interpretation. Reporters need to be aware of the potential bias clinical history can introduce to their reporting and develop strategies to alleviate this as much as possible. IMPLICATIONS FOR PRACTICE A greater understanding of the potential bias of clinical history on the process of image interpretation is required by all reporters. Reporters need to develop an approach and strategy when accessing clinical history. Novice reporters need to be educated regarding the impact of clinical history on their reporting.
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Affiliation(s)
- L Small
- University Hosiptals Birmingham, Imaging Department, Birmingham, B9 5SS, United Kingdom.
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7
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López-Fernández YM, Smith LS, Kohne JG, Weinman JP, Modesto-Alapont V, Reyes-Dominguez SB, Medina A, Piñeres-Olave BE, Mahieu N, Klein MJ, Flori HR, Jouvet P, Khemani RG. Prognostic relevance and inter-observer reliability of chest-imaging in pediatric ARDS: a pediatric acute respiratory distress incidence and epidemiology (PARDIE) study. Intensive Care Med 2020; 46:1382-1393. [PMID: 32451578 PMCID: PMC7246298 DOI: 10.1007/s00134-020-06074-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/27/2020] [Indexed: 11/29/2022]
Abstract
Purpose Definitions of acute respiratory distress syndrome (ARDS) include radiographic criteria, but there are concerns about reliability and prognostic relevance. This study aimed to evaluate the independent relationship between chest imaging and mortality and examine the inter-rater variability of interpretations of chest radiographs (CXR) in pediatric ARDS (PARDS). Methods Prospective, international observational study in children meeting Pediatric Acute Lung Injury Consensus Conference (PALICC) criteria for PARDS, which requires new infiltrate(s) consistent with pulmonary parenchymal disease, without mandating bilateral infiltrates. Mortality analysis focused on the entire cohort, whereas inter-observer variability used a subset of patients with blinded, simultaneous interpretation of CXRs by intensivists and radiologists. Results Bilateral infiltrates and four quadrants of alveolar consolidation were associated with mortality on a univariable basis, using CXRs from 708 patients with PARDS. For patients on either invasive (IMV) or non-invasive ventilation (NIV) with PaO2/FiO2 (PF) ratios (or SpO2/FiO2 (SF) ratio equivalent) > 100, neither bilateral infiltrates (OR 1.3 (95% CI 0.68, 2.5), p = 0.43), nor 4 quadrants of alveolar consolidation (OR 1.6 (0.85, 3), p = 0.14) were associated with mortality. For patients with PF ≤ 100, bilateral infiltrates (OR 3.6 (1.4, 9.4), p = 0.01) and four quadrants of consolidation (OR 2.0 (1.14, 3.5), p = 0.02) were associated with higher mortality. A subset of 702 CXRs from 233 patients had simultaneous interpretations. Interobserver agreement for bilateral infiltrates and quadrants was “slight” (kappa 0.31 and 0.33). Subgroup analysis showed agreement did not differ when stratified by PARDS severity but was slightly higher for children with chronic respiratory support (kappa 0.62), NIV at PARDS diagnosis (kappa 0.53), age > 10 years (kappa 0.43) and fluid balance > 40 ml/kg (kappa 0.48). Conclusion Bilateral infiltrates and quadrants of alveolar consolidation are associated with mortality only for those with PF ratio ≤ 100, although there is high- inter-rater variability in these chest-x ray parameters. Electronic supplementary material The online version of this article (10.1007/s00134-020-06074-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yolanda M López-Fernández
- Pediatric Intensive Care Unit, Department of Pediatrics, Biocruces Health Research Institute, Cruces University Hospital, Plaza Cruces 12, 48903, Barakaldo, Bizkaia, Basque Country, Spain.
| | - Lincoln S Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Joseph G Kohne
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan CS. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Jason P Weinman
- Department of Radiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | - Alberto Medina
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Byron E Piñeres-Olave
- Department of Pediatric Critical Care Medicine, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Natalie Mahieu
- Department of Radiology, Children's Hospital of Los Angeles, University of Southern California, Los Angeles, CA, USA.,Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Margaret J Klein
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Heidi R Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan CS. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Philippe Jouvet
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles, University of Southern California, Los Angeles, CA, USA
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8
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Geanacopoulos AT, Porter JJ, Monuteaux MC, Lipsett SC, Neuman MI. Trends in Chest Radiographs for Pneumonia in Emergency Departments. Pediatrics 2020; 145:peds.2019-2816. [PMID: 32079719 DOI: 10.1542/peds.2019-2816] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES National guidelines recommend against routine use of chest radiography (CXR) for community-acquired pneumonia (CAP) diagnosis in the pediatric emergency department (ED). Given that CXR is often used to exclude the diagnosis of CAP, a reduction in CXR use may result in overdiagnosis of CAP. We sought to evaluate trends in CXR use and assess the association between CXR performance and CAP diagnosis among children discharged from pediatric EDs. METHODS Children 3 months to 18 years of age discharged from 30 US EDs with (1) CAP or (2) fever or respiratory illness between 2008 and 2018 were included. Temporal trends in CXR use and rates of CAP diagnoses among patients with fever or respiratory illness were assessed. Correlation between hospital-level CXR use and CAP diagnosis rates were evaluated by using Spearman's correlation weighted by hospital volume. RESULTS CXR usage decreased from 86.6% to 80.4% (P < .001) for patients with CAP and from 30.4% to 18.6% (P < .001) for children with fever or respiratory illness over the 10-year study period. CAP diagnosis rates also declined from 7.8% to 5.9% (P < .001). Hospital-level CXR use was correlated with pneumonia diagnosis rates (correlation coefficient 0.58; P < .001). CONCLUSIONS Over the past decade, there has been a decline in CXR use in the ED among children with pneumonia and respiratory illnesses, with a decrease in pneumonia diagnoses over the same time period. Future studies are needed to assess the role of CXR in the evaluation of children with possible pneumonia in the ED setting.
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Affiliation(s)
- Alexandra T Geanacopoulos
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - John J Porter
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and.,Division of Emergency Medicine and
| | - Michael C Monuteaux
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Division of Emergency Medicine and
| | - Susan C Lipsett
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Division of Emergency Medicine and
| | - Mark I Neuman
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and .,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Division of Emergency Medicine and
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9
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Chest Radiography for Diagnosing Acute Respiratory Distress Syndrome-Fishing in the Dark? Crit Care Med 2019; 46:820-821. [PMID: 29652710 DOI: 10.1097/ccm.0000000000003041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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10
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Lockhart JJ, Satya-Murti S. Blinding or information control in diagnosis: could it reduce errors in clinical decision-making? ACTA ACUST UNITED AC 2018; 5:179-189. [PMID: 30231010 DOI: 10.1515/dx-2018-0030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 08/21/2018] [Indexed: 11/15/2022]
Abstract
Background Clinical medicine has long recognized the potential for cognitive bias in the development of new treatments, and in response developed a tradition of blinding both clinicians and patients to address this specific concern. Although cognitive biases have been shown to exist which impact the accuracy of clinical diagnosis, blinding the diagnostician to potentially misleading information has received little attention as a possible solution. Recently, within the forensic sciences, the control of contextual information (i.e. information apart from the objective test results) has been studied as a technique to reduce errors. We consider the applicability of this technique to clinical medicine. Content This article briefly describes the empirical research examining cognitive biases arising from context which impact clinical diagnosis. We then review the recent awakening of forensic sciences to the serious effects of misleading information. Comparing the approaches, we discuss whether blinding to contextual information might (and in what circumstances) reduce clinical errors. Summary and outlook Substantial research indicates contextual information plays a significant role in diagnostic error and conclusions across several medical specialties. The forensic sciences may provide a useful model for the control of potentially misleading information in diagnosis. A conceptual analog of the forensic blinding process (the "agnostic" first reading) may be applicable to diagnostic investigations such as imaging, microscopic tissue examinations and waveform recognition. An "agnostic" approach, where the first reading occurs with minimal clinical referral information, but is followed by incorporation of the clinical history and reinterpretation, has the potential to reduce errors.
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Affiliation(s)
- Joseph J Lockhart
- Consulting Psychologist, Forensic Services Division, Department of State Hospitals, State of California, Suite 410, Sacramento, CA 95814, USA
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11
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Lipsett SC, Monuteaux MC, Bachur RG, Finn N, Neuman MI. Negative Chest Radiography and Risk of Pneumonia. Pediatrics 2018; 142:peds.2018-0236. [PMID: 30154120 DOI: 10.1542/peds.2018-0236] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2018] [Indexed: 11/24/2022] Open
Abstract
UNLABELLED : media-1vid110.1542/5804413949001PEDS-VA_2018-0236Video Abstract BACKGROUND AND OBJECTIVES: The ability of the chest radiograph (CXR) to exclude the diagnosis of pneumonia in children is unclear. We sought to determine the negative predictive value of CXR in children with suspected pneumonia. METHODS Children 3 months to 18 years of age undergoing CXRs for suspected pneumonia in a tertiary-care pediatric emergency department (ED) were prospectively enrolled. Children currently receiving antibiotics and those with underlying chronic medical conditions were excluded. The primary outcome was defined as a physician-ascribed diagnosis of pneumonia independent of radiographic findings. CXR results were classified as positive, equivocal, or negative according to radiologist interpretation. Children with negative CXRs and without a clinical diagnosis of pneumonia were managed for 2 weeks after the ED visit. Children subsequently diagnosed with pneumonia during the follow-up period were considered to have had false-negative CXRs at the ED visit. RESULTS There were 683 children enrolled during the 2-year study period, with a median age of 3.1 years (interquartile range 1.4-5.9 years). There were 457 children (72.8%) with negative CXRs; 44 of these children (8.9%) were clinically diagnosed with pneumonia, and 42 (9.3%) were given antibiotics for other bacterial syndromes. Of the 411 children with negative CXRs who were managed without antibiotics, 5 were subsequently diagnosed with pneumonia within 2 weeks (negative predictive value of CXR 98.8%; 95% confidence interval 97.0%-99.6%). CONCLUSIONS A negative CXR excludes pneumonia in the majority of children. Children with negative CXRs and low clinical suspicion for pneumonia can be safely observed without antibiotic therapy.
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Affiliation(s)
- Susan C Lipsett
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Harvard University and
| | - Michael C Monuteaux
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Harvard University and
| | - Richard G Bachur
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Harvard University and
| | - Nicole Finn
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Mark I Neuman
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Harvard University and
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12
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Clark K, Lam L, Talley NJ, Watts G, Phillips JL, Byfieldt NJ, Currow DC. A pragmatic comparative study of palliative care clinician's reports of the degree of shadowing visible on plain abdominal radiographs. Support Care Cancer 2018; 26:3749-3754. [PMID: 29736868 DOI: 10.1007/s00520-018-4238-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 04/26/2018] [Indexed: 11/28/2022]
Abstract
The assessment of constipation symptoms is based on history and physical examination. However, the experience is highly subjective perhaps explaining why palliative medicine doctors continue to use plain abdominal radiographs as part of routine assessment of constipation. Previous studies have demonstrated poor agreement between clinicians with this work in palliative care, limited further by disparity of clinicians' experience and training. The aim of this work was to explore whether there was less variation in the assessments of faecal shadowing made by more experienced clinicians compared to their less experienced colleagues. This pragmatic study was conducted across six palliative care services in Sydney (NSW, Australia). Doctors of varying clinical experience were asked to independently report their opinions of the amount of shadowing seen on 10 plain abdominal radiographs all taken from cancer patients who self-identified themselves as constipated. There were 46 doctors of varying clinical experience who participated including qualified specialists, doctors in specialist training and lastly, doctors in their second- and third post-graduate years. Poor agreement was seen between the faecal shadowing scores allocated by doctors of similar experience and training (Fleiss's kappa (FK): RMO 0.05; registrar 0.06; specialist 0.11). Further, when the levels of agreement between groups were considered, no statistically significant differences were observed. Although the doctors did not agree on the appearance of the film, the majority felt they were able to extrapolate patients' experiences from the radiograph's appearance. As it remains challenging in palliative care to objectively assess and diagnose constipation by history and imaging, uniform and objective assessment and diagnostic criteria are required. It is likely that any agreed criteria will include a combination of imaging and history. The results suggest the use of radiographs alone to diagnose and assess constipation in palliative care represents low value care.
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Affiliation(s)
- Katherine Clark
- Northern Sydney Local Health District Cancer and Palliative Care Network, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW, 2065, Australia. .,The University of Sydney, Sydney, NSW, Australia.
| | - L Lam
- The University of Technology, Sydney, NSW, Australia
| | - N J Talley
- The University of Newcastle, Newcastle, NSW, Australia
| | - G Watts
- The University of Newcastle, Newcastle, NSW, Australia.,Calvary Mater Newcastle, Newcastle, NSW, Australia
| | - J L Phillips
- The University of Technology, Sydney, NSW, Australia
| | - N J Byfieldt
- Calvary Mater Newcastle, Newcastle, NSW, Australia
| | - D C Currow
- The University of Technology, Sydney, NSW, Australia
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13
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Affiliation(s)
- Joseph J Lockhart
- Forensic Services Division, California Department of State Hospitals, 1305 North "H" Street, #117, Lompoc, CA
| | - Saty Satya-Murti
- Health Policy Consultant, 2534 Knightbridge Drive, Santa Maria, CA
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14
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Florin TA, Carron H, Huang G, Shah SS, Ruddy R, Ambroggio L. Pneumonia in Children Presenting to the Emergency Department With an Asthma Exacerbation. JAMA Pediatr 2016; 170:803-5. [PMID: 27270612 PMCID: PMC5358794 DOI: 10.1001/jamapediatrics.2016.0310] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Todd A. Florin
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio2Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Hannah Carron
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Guixia Huang
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Samir S. Shah
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio4Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio5Division of Infectious Diseases, Cincinnati Children’s Hospital Medical
| | - Richard Ruddy
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio2Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Lilliam Ambroggio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio3Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio4Division of Hospital Medicine, Cincinnati Children’s Hospi
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15
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O'Grady KAF, Torzillo PJ, Frawley K, Chang AB. The radiological diagnosis of pneumonia in children. Pneumonia (Nathan) 2014; 5:38-51. [PMID: 31641573 PMCID: PMC5922330 DOI: 10.15172/pneu.2014.5/482] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 08/26/2014] [Indexed: 12/29/2022] Open
Abstract
Despite the importance of paediatric pneumonia as a cause of short and long-term morbidity and mortality worldwide, a reliable gold standard for its diagnosis remains elusive. The utility of clinical, microbiological and radiological diagnostic approaches varies widely within and between populations and is heavily dependent on the expertise and resources available in various settings. Here we review the role of radiology in the diagnosis of paediatric pneumonia. Chest radiographs (CXRs) are the most widely employed test, however, they are not indicated in ambulatory settings, cannot distinguish between viral and bacterial infections and have a limited role in the ongoing management of disease. A standardised definition of alveolar pneumonia on a CXR exists for epidemiological studies targeting bacterial pneumonias but it should not be extrapolated to clinical settings. Radiography, computed tomography and to a lesser extent ultrasonography and magnetic resonance imaging play an important role in complicated pneumonias but there are limitations that preclude their use as routine diagnostic tools. Large population-based studies are needed in different populations to address many of the knowledge gaps in the radiological diagnosis of pneumonia in children, however, the feasibility of such studies is an important barrier.
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Affiliation(s)
- Kerry-Ann F O'Grady
- 16Queensland Children's Medical Research Institute, Queensland University of Technology, Level 4, Foundation Building, Herston, Queensland Australia
| | - Paul J Torzillo
- 26Sydney Medical School, The University of Sydney, Camperdown, Sydney, Australia.,66Departments of Respiratory Medicine and Intensive Care Royal Prince Alfred Hospital, Camperdown, Sydney, Australia
| | - Kieran Frawley
- 36Department of Radiology, Royal Children's Hospital, Brisbane, Queensland Australia
| | - Anne B Chang
- 16Queensland Children's Medical Research Institute, Queensland University of Technology, Level 4, Foundation Building, Herston, Queensland Australia.,46Child Health Division, Menzies School of Health Research, Charles Darwin University, Tiwi, Northern Territory Australia.,56Queensland Children's Respiratory Centre, Royal Children's Hospital, Brisbane, Queensland Australia
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