Bedside chest radiography: diagnostic efficacy

In order to evaluate the efficacy of bedside chest radiography, a prospective study was completed of 140 patients admitted to the surgical and medical intensive care units over a two-month period. A total of 1132 consecutive bedside radiographs was analyzed for malposition of tubes and lines and interval changes in the cardiopulmonary findings. The median number of bedside radiographs per patient was 0.7 per day. Endotracheal or tracheostomy tubes were present in 54% of all examinations; among these 12% were malpositioned. Central venous catheters were present in 47%; among these 9% were malpositioned. Interval changes regarding cardiopulmonary findings (pneumothorax, collapse, diffuse or focal infiltrate, effusion, and congestive heart failure) were present in 44% of the radiographs after the admission one. Overall there were new findings or changes affecting the patient's management present in 65% of the radiographs. The use of bedside radiography appeared to be appropriate.     

Image-intensifier photofluorography and conventional chest radiography: comparison of diagnostic efficacy

Photofluorography with a large image intensifier, which provides an image field of 40 x 40 cm, reduces both the radiation dose and the imaging costs in chest radiography as compared with the film-screen technique. The two techniques were evaluated in a clinical study of 135 patients with suspected chest abnormalities. Photofluorographs and film-screen chest radiographs were interpreted independently by three radiologists. The diagnoses were confirmed by CT, follow-up radiographs, and clinical records. Among the 135 patients, 75 had primary lung cancer, 39 had pulmonary nodules, 52 had hilar or mediastinal abnormalities, 17 had pleural fluid, and 45 had pneumonic or atelectatic changes. Twenty-three normal subjects were included. Differences in diagnostic accuracy, measured by sensitivity and specificity, were not statistically significant. A larger number of true-positive cases (65%) with peripheral lung nodules were found by photofluorography than by film-screen radiography (54%) (p less than .05). The results suggest that the diagnostic accuracy of chest images made by photofluorography is sufficient to warrant using it instead of the film-screen technique in routine chest radiography, especially to detect lung tumors and metastases.     

Routine chest radiography in a primary care setting

PURPOSE: To determine the frequency, diagnostic yield, outcomes, cost, and rate of false-positive results of routine chest radiography performed in asymptomatic patients in the primary care setting. MATERIALS AND METHODS: Radiography reports on all patients who underwent routine or screening posteroanterior and lateral chest radiography at a university-affiliated primary care clinic in 2001 were reviewed. Radiographic results were coded as normal or minor findings or as major abnormalities, such as pulmonary nodules, requiring further diagnostic evaluation. Outcomes of patients with major abnormalities were established by using chart reviews or reviewing additional radiographs. Costs were estimated by using 2002 Medicare reimbursement rates. The main measures assessed were frequency, costs, and rate of false-positive results of routine chest radiography. RESULTS: Of 3812 radiographs obtained at the primary care clinic, 1282 (34%) were ordered for routine or screening purposes by the referring physician. Nine hundred twenty-two radiographs were obtained in male patients and 360 were obtained in female patients; their mean and median age was 49 years (age range, 4-87 years). Fifteen chest radiographs showed major abnormalities. No patient younger than 40 years had a major abnormality. Fourteen of the 15 findings of major abnormalities proved to be false-positive. No disease requiring treatment was diagnosed as a result of radiographic findings. The total cost for follow-up radiography and computed tomography was US dollar 46,609.49. CONCLUSION: Routine chest radiography has low diagnostic yield in asymptomatic primary care patients.     

Maximizing the efficacy of chest radiography in the ICU.

In a prospective survey, we found that chest radiographs taken at the bedside in the intensive care unit had an appreciable impact on patient management, demonstrating new findings or changes 65% of the time. Monitoring devices can best be checked radiographically, and changes in cardiopulmonary status may be difficult to assess or confirm by other means. Consistent radiographic technique, availability of films to referring clinicians, and rapid reporting by radiologists serve to maximize the efficacy of bedside radiography.     

Sensitivity and value of digital CT scout radiography for detecting ureteral stones in patients with ureterolithiasis diagnosed on unenhanced CT.

OBJECTIVE: When unenhanced CT reveals ureterolithiasis, some patients will require baseline or follow-up conventional radiography to help guide clinical management. We sought to determine the sensitivity of routinely obtained scout radiographs for revealing stones to determine if the scout view can be used in place of baseline conventional radiography. MATERIALS AND METHODS: We retrospectively reviewed the CT scout radiographs in conjunction with axial CT images in a series of 215 consecutive patients in whom CT revealed a single ureteral stone. On the scout radiographs, stones were classified as definitely visible, definitely not visible, or indeterminate. In addition, a phantom was constructed using fragments of kidney stones to evaluate the effect of the digital scout kilovoltage settings on stone visualization. RESULTS: Forty-nine percent of stones were definitely visible on scout radiography, 47% were definitely not visible, and 4% were indeterminate. Four stones larger than 10 mm that were not visible on scout radiography were composed of uric acid (n = 2) or xanthine (n = 2). Scout radiographs of the phantom determined an optimal kilovoltage setting of 80-100 kVp to visualize stones less than 3 mm, whereas stones greater than or equal to 3 mm were visible at all kilovoltage settings. CONCLUSION: In our series, 49% of ureteral stones were visible on the often-overlooked routine CT scout radiograph. Imaging of phantoms showed that stone visualization can be optimized by using the lowest kilovoltage settings. Therefore, the CT scout view can be used as a baseline study in patients requiring follow-up radiography and for planning treatment of patients requiring lithotripsy or other intervention. Finally, large stones not visible on scout radiographs are likely composed of uric acid or xanthine.     

Thoracic CT scan in intensive care unit patients: information supplementary to thoracic radiography

PURPOSE: To assess the diagnostic value of thoracic CT-scans in comparison with conventional chest radiographs in ICU-patients. METHODS: Chest radiographs and corresponding thoracic CT-scans of 25 consecutive surgical ICU-patients were reviewed and interpreted independently by two radiologists. We analyzed the additional information provided by CT-scans and the diagnostic and therapeutic relevance of these findings. RESULTS: In 22 patients (88%), thoracic CT revealed 35 single additional findings, in comparison with the corresponding bedside radiographs. In 7 cases (28%), these findings (tube-malpositioning, mediastinitis, mediastinal abscess and pneumothorax) required modification of patient management. Of 7 patients with tube thoracostomy, 3 tubes were malpositioned, which was only depicted on CT-scans. In 10 of 21 cases (48%), pleural effusions could only be visualized by CT. 3 of 5 (60%) pneumothoraces were detected by CT-scans only. There were no significant complications during transport or CT-examination. CONCLUSION: Thoracic CT may provide significant information in addition to plain chest radiographs, particularly when specific problems or questions, referring to the management of ICU-patients, arise.     

心血管术后床旁胸片的临床应用评价

目的 :评价心血管术后床旁胸片的临床应用价值及限度。方法 :2 0 6例心血管术后病人 ,使用移动 X线机摄取床旁胸片 ,分析术后新出现的异常。结果 :上述床旁胸片新出现异常率高达 6 0 .7% (12 5 / 2 0 6 ) ,左侧居多占 35 .4% (73/ 2 0 6 )。其中最常见的依次为胸腔积液、肺不张和气胸 ,发生率分别为 36 .4%、2 7.7%和 9.2 %。结论 :床旁胸片是全面了解心血管术后病人胸肺异常的重要和有效的检查手段 ,但有一定限度     

Radiographic evaluation of endotracheal tube position.

A malpositioned endotracheal tube is a potential hazard to the intubated patient. Ideally, the tube tip should be 5+/-2 cm from the carina when the head and neck are in neutral position. In 92 of 100 patients studied, the carina overlay T5, T6, or T7 on portable radiographs. Therefore, even when the carina is not visible, it can be assumed that a tube tip positioned at the level of T3 or T4 is safe. The degree of neck flexion or extension at the time of radiography may be determined by evaluating the position of the mandible relative to the vertebral bodies.     

Efficacy of specimen radiography of clinically occult noncalcified breast lesions

Breast biopsy specimen radiography is required to ensure the accurate removal of clinically occult lesions discovered by mammography. Although used routinely for calcified lesions, it has not been widely accepted for those abnormalities that do not contain calcium. To determine the efficacy of film-screen specimen radiography for confirming the presence of clinically occult, noncalcified lesions, we undertook a prospective study of 104 specimen radiographs obtained after mammographically guided hookwire localization and planned excision of these lesions. Ninety-seven (93%) of the excised abnormalities were visualized on specimen mammograms. Malignancy was found in 22 (21%) of them. Thirty-five percent of the specimen radiographs showed better anatomic detail of the lesion, 48% showed the same detail, and 16% showed less detail than the original mammograms. Specimen radiographs failed to show the lesion in only seven cases. Five of the seven were true-negative specimen radiographs, making the efficacy rate 98%. Film-screen specimen radiography of clinically occult, noncalcified lesions is a highly effective procedure for correctly identifying the presence of a mammographic abnormality.     

Radiography of cervical spine injury in children: are flexion-extension radiographs useful for acute trauma?

OBJECTIVE: We assessed the role of cervical spine flexion-extension radiographs in the acute evaluation of pediatric trauma patients. MATERIAL AND METHODS: We performed a retrospective review of all pediatric trauma patients who underwent static cervical spine radiography followed by flexion-extension radiography during a 22-month period. We reviewed the mechanism of injury, physical examination findings, and patient age, and tabulated the results of initial and follow-up imaging studies. RESULTS: Two hundred forty seven children (age range, 1.6-18 years; mean age, 11.5 years) with a history of trauma underwent cervical spine radiography followed by flexion-extension radiography. Static cervical spine radiographs revealed normal findings in 224 patients (91%). Flexion-extension radiographs revealed normal findings for all patients with normal findings on cervical spine radiographs. Of 23 children (9%) with abnormal findings on static cervical spine radiographs, seven (30%) had congenital abnormalities visible on flexion-extension radiographs; 10 (43%) had traumatic injuries including fracture, subluxation, or soft-tissue swelling; two (9%) had instability; and six (26%) had questionable abnormalities that were noted on static cervical spine radiographs. In four patients (66%) with abnormal findings on static cervical spine radiographs, flexion-extension radiographs were helpful in ruling out abnormality. CONCLUSION: In children with a history of trauma and normal findings on static cervical spine radiographs, additional flexion-extension radiographs are of questionable use.     

Bone scintigraphy and radiography in the early recognition of diabetic osteopathy

Twenty-seven diabetic patients with clinical evidence of neuropathy were investigated by foot radiography, two-phase bone scintigraphy, biothesiometry and cardiovascular autonomic function testing. Typical signs of diabetic osteopathy on radiography were found in 10 subjects (37%), the degree of radiographic abnormality correlating with the severity of neurological impairment. Furthermore, all diabetics with evidence of severe neuropathy showed some evidence of osteopathy on foot radiographs. In all 10 cases of diabetic osteopathy diagnosed radiographically, abnormalities were shown on scintigraphy. In addition, five other patients showed scintigraphic abnormalities, without corresponding changes on radiography, and in this group the neurological impairment was less severe. Although confirmatory longitudinal studies are necessary, it seems likely that the earliest changes of diabetic neuropathic osteopathy may thus be recognized on bone scintigraphy, at a time when conventional radiographs are normal. This stage of diabetic osteopathy is associated with a lesser degree of neurological impairment.     

Central venous catheter motion: a pitfall in catheter localization on pediatric chest radiography

OBJECTIVE: We evaluated central venous catheter motion causing misinterpretation of catheter tip location in pediatric patients and in an experimental model. MATERIALS AND METHODS: After the recognition of clinically significant catheter motion in 12 randomly selected patients, we conducted a prospective 2-month study of chest radiographs in our pediatric care unit and neonatal emergency department. Serial radiographs were examined for change in catheter tip position ascribed to motion artifact. An in vitro model was developed to replicate clinical parameters. Experimentally, catheter movement and exposure time were analyzed and their impact on catheter localization was recorded. RESULTS: In the 12 randomly selected patients, radiographic assessment of central venous catheter tip localization on sequential radiographs caused minor to major misinterpretation of the position of the catheter tip and even total nonvisualization of the catheter. Ten (3.5%) of 352 prospectively interpreted pediatric emergency department radiographs showed similar findings. Catheter motion that caused blurring was reproduced in vitro using radiographic parameters typically used in a clinical setting. CONCLUSION: Catheter motion can cause problems in assessing catheter tip position on pediatric emergency department chest radiographs. We reproduced this phenomenon in an in vitro model. Catheter removal or change in position may be mimicked by this artifact, and patient management may be affected. In our study, catheter localization was affected by catheter motion and exposure time.     

Role of chest radiography after the insertion of a subclavian vein catheter for ambulatory chemotherapy.

OBJECTIVE: To determine the need for routine chest radiography after the insertion of a catheter via the subclavian vein for ambulatory chemotherapy. METHODS: The case notes of all patients who had undergone catheter insertion between 1994 and 1998 were reviewed retrospectively. RESULTS: Of 3844 cases, there were 52 (1.4%) complications detected on chest radiographs after catheter insertion, 46 of which were pneumothoraces; 15 of the 46 patients had a clinical risk factor at insertion (technical difficulty or symptoms), and 14 had a risk factor after insertion (respiratory symptoms and signs). For 22 (47.8%) pneumothoraces, there was no clinical risk factor identified; 3 of these patients required intercostal drain insertion. Other complications (n = 6) included catheter malposition and kinking, and chest radiography made an important contribution to management in at least 1 of these cases. CONCLUSION: In approximately 0.1% of cases of catheter insertion in the subclavian vein, chest radiography detected a clinically occult complication significant enough to require intervention.     

The utility of routine emergency department chest radiography in a population at high risk for tuberculosis

The purpose of this study was to determine the utility of performing routine screening chest radiography on all asymptomatic admissions from the emergency department in an urban population at high risk for contracting tuberculosis (TB). Chest radiographs were obtained on all asymptomatic patients admitted through the emergency department for drug detoxification or psychiatric illness at two urban hospitals in an area endemic for multidrug-resistant TB. The chest radiographs were interpreted prospectively by one of two radiologists, and the results were correlated with age, sex, and clinical outcome. A total of 481 chest radiographs were evaluated (407 men, 74 women; average age, 38 years). Of these, 436 (91%) were negative. Of the 45 with abnormalities, 35 (7%) were chronic, requiring no further work-up, whereas 10 (2%) had changes considered of immediate consequence. Of those with acute abnormalities, five patients presented with nodular densities, ranging from 5 mm to 3 cm in diameter; two patients had lobar infiltrates; and subsegmental atelectasis, congestive changes and an abnormal aortic contour were noted on one examination each. Of the six patients not lost to follow-up, five improved with medical therapy, and one was scheduled for surgical excision. The individuals with radiographic findings were significantly older than those with negative chest radiographs (47 years vs. 37 years). Only one patient had active TB; three others had chronic calcified granulomas. We conclude that routine chest radiography in young, asymptomatic individuals considered at high risk for contracting TB rarely detects significant pulmonary abnormalities or evidence of active TB.     

Improved control of image optical density with low-dose digital and conventional radiography in bedside imaging

The technical and diagnostic performance of simultaneously acquired low-dose (44% of standard dose) storage-phosphor digital radiographs (system resolution = 0.2 mm, 10 bits) were compared with those of standard-dose conventional bedside radiographs of the chest in 32 patients. The mean optical density (OD) of the lungs (800 measurements) was closer to the ideal density with digital radiography (1.45 OD +/- 0.20 [standard deviation] vs 1.75 OD +/- 0.53) and was less often outside the usable range (2.5% vs 42.5%). Receiver operating characteristic analysis for detection of simulated nodules and monitoring devices (nine readers, 4,608 observations) showed that digital radiography was superior to conventional radiography (P less than .05) for four of the nine readers and equivalent to conventional radiography for five readers. The authors concluded that digital radiography produces more consistent and ideal image density and performs at least as well as conventional radiography under phantom test conditions.     

Efficacy of daily bedside chest radiography as visualized by digital luminescence radiography

To determine the diagnostic impact of daily bedside chest radiography in comparison with digital luminescence technique (DLR; storage phosphor radiography) and conventional film screen radiography, a prospective randomized study was completed in 210 mechanically ventilated patients with a total of 420 analysed radiographs. The patients were allocated to two groups: 150 patients underwent DLR, and 60 patients underwent conventional film screen radiography. Radiological analysis was performed consensually and therapeutic efficacy was assessed by the clinicians. There was no statistical significant difference between the frequency of abnormal findings seen on DLR and conventional film screen radiography. In total, 448 abnormal findings were present in 249 of 300 DLR and 97 of 120 conventional film screen radiographs. The most common findings were signs of overhydration (41%), pleural effusion (31%), partial collapse of the lung (11%) and pneumothorax (2%). One hundred and twenty-three of 448 (27%) of these abnormal findings were thought to have a considerable impact on patient management. The high rate of abnormal findings with significant impact on patient management suggests that the use of daily bedside chest radiography may be reasonable.     

Are long bone radiographs necessary in neonates suspected of having congenital syphilis?

The frequency of appendicular bone abnormalities was prospectively evaluated in 93 newborns suspected of having congenital syphilis. The evaluation of each newborn included prenatal history, physical examination, serologic tests, and long bone radiography, which was performed during the first week after birth. In all patients, results of at least one serologic test for syphilis were positive or proof of syphilis was found at autopsy. In 75 patients (81%), the long bone radiographs were normal. The nonspecific finding of lucent metaphyseal bands was the most common abnormality on long bone radiographs; only five newborns had more specific changes of syphilis in the metaphyses and periosteal reaction. In view of the low frequency of relatively specific radiographic findings in the long bones, the authors recommend that long bone radiography not be a part of the routine evaluation of full-term newborns suspected of having congenital syphilis.     

Preoperative chest radiography: value as a baseline examination for comparison

An important use of the preoperative chest radiograph is as a baseline for comparison when complications occur after surgery. Many authors have commented on the value of preoperative chest radiography as a screening examination, but no statistics have been presented regarding its impact on postoperative management. In 369 consecutive general surgical patients, the need for a baseline chest radiograph was evaluated. In 65 patients undergoing chest radiography postoperatively, a preoperative baseline was essential in making an accurate interpretation in 33 (51%). The value of preoperative chest radiography proved to be twofold. Some minimal abnormalities on postoperative radiographs were demonstrated to be clearly new, necessitating treatment or further evaluation. Second, significant abnormalities detected on postoperative radiographs that may have otherwise been subjected to expensive evaluation were often shown to have been present preoperatively. In approximately 9% of patients the preoperative chest radiograph had a significant impact on postoperative management.     

CR床边胸部摄影吸收剂量的相关性研究

目的：评价CR床边胸部摄影对于患者的吸收剂量。方法：68例胸部X线摄影分别采用CR病房床边胸部摄影和DR在影像科进行胸部摄影两种不同的方式拍摄。CR床边胸部摄影采用68~76kVp进行前后位摄影。DR胸部摄影采用110~140kVp后前位进行摄影。用统计学方法对其X线吸收剂量进行评价。结果：在吸收剂量方面几种方法各不相同,CR床边胸部摄影与DR胸部摄影患者的随机吸收剂量无统计学差异。CR床边胸部摄影被检者与其邻近患者之间其吸收剂量有显著性差异。结论：DR胸部摄影患者的随机吸收剂量低于CR床边胸部摄影。     

Routine oblique radiography of the pediatric lumbar spine: is it necessary?

A series of 86 pediatric lumbar spine abnormalities was evaluated to determine the diagnostic benefit of radiography in oblique projection as compared to frontal-lateral projections alone. In only four patients was an abnormality apparent on the oblique view which had not already been demonstrated by the frontal-lateral series; each of these represented an isolated spondylolysis. Because the diagnostic yield was low at a patient cost of more than double the gonadal radiation dose, it is recommended that oblique views be eliminated in the routine radiography of the pediatric lumbar spine.