Fleischner Society Guideline Recommendations for Incidentally Detected Pulmonary Nodules and the Probability of Lung Cancer

PurposeThe Fleischner Society aims to limit further evaluations of incidentally detected pulmonary nodules when the probability of lung cancer is <1% and to pursue further evaluations when the probability of lung cancer is ≥1%. To evaluate the internal consistency of guideline goals and recommendations, the authors evaluated stratum-specific recommendations and 2-year probabilities of lung cancer.MethodsA retrospective cohort study (2005-2015) was conducted of individuals enrolled in one of two integrated health systems with solid nodules incidentally detected on CT. The 2017 Fleischner Society guidelines were used to define strata on the basis of smoking status and nodule size and number. Lung cancer diagnoses within 2 years of nodule detection were ascertained using cancer registry data. Confidence interval (CI) inspection was used to determine if stratum-specific probabilities of lung cancer were different than 1%.ResultsAmong 5,444 individuals with incidentally detected lung nodules (median age, 66 years; 54% women; 57% smoked; median nodule size, 5.5 mm; 55% with multiple nodules), 214 (3.9%; 95% CI, 3.4%-4.5%) were diagnosed with lung cancer within 2 years. For 7 of 12 strata (58%), 2,765 patients (51%), and 194 lung cancer cases (91%), there was alignment between Fleischner Society goals and recommendations. Alignment was indeterminate for 5 strata (42%), 2,679 patients (49%), and 20 lung cancer cases (9%) because CIs for the probability of lung cancer spanned 1%.ConclusionsFleischner Society guideline goals and recommendations align at least half the time. It is uncertain whether alignment of guideline goals and recommendations occurs more often.     

Liquid-Crystal Display Monitors and Cathode-Ray Tube Monitors: A Comparison of Observer Performance in the Detection of Small Solitary Pulmonary Nodules

Objective

To compare observer performance using liquid-crystal display (LCD) and cathode-ray tube (CRT) monitors in the interpretation of soft-copy chest radiographs for the detection of small solitary pulmonary nodules.

Materials and Methods

By reviewing our Medical Center''s radiologic information system, the eight radiologists participating in this study (three board-certified and five resident) retrospectively collected 40 chest radiographs showing a solitary noncalcified pulmonary nodule approximately 1 cm in diameter, and 40 normal chest radiographs. All were obtained using a storage-phosphor system, and CT scans of the same patients served as the gold standard for the presence of a pulmonary nodule. Digital images were displayed on both high-resolution LCD and CRT monitors. The readers were requested to rank each image using a five-point scale (1 = definitely negative, 3 = equivocal or indeterminate, 5 = definitely positive), and the data were interpreted using receiver operating characteristic (ROC) analysis.

Results

The mean area under the ROC curve was 0.8901±0.0259 for the LCD session, and 0.8716±0.0266 for the CRT session (p > 0.05). The reading time for the LCD session was not significantly different from that for the CRT session (37.12 and 41.46 minutes, respectively; p = 0.889).

Conclusion

For detecting small solitary pulmonary nodules, an LCD monitor and a CRT monitor are comparable.     

Best Reporting Practices for Multipart CT Scans: A Pilot Evaluation and Construction of the Optimal Analysis Methodology

PurposeCommunication failure between radiologists and referring physicians contributes to a substantial portion of medical errors. With a rising number of complex imaging orders and subspecialization among radiologists, the best method of reporting those results has yet to be evaluated. The aim of this study was to create, validate, and pilot a survey to reveal best practices for communication of radiologic findings, specifically addressing multipart CT scans of the chest, abdomen, and pelvis.MethodsA survey consisting of Likert-type and narrative response items was created, tested, and validated. It was then administered to physicians of five specialties (including radiology) at an urban quaternary care academic center and an affiliated community hospital.ResultsThe pilot survey results revealed that there was a small preference among both radiologists and referring physicians to have a single radiologist read in a single report for a multipart CT scan, rather than multiple subspecialist radiologists and reports. The findings were supported by narrative response explanations as well and demonstrate the importance of a rapid, clear, and cohesive image interpretation, despite the growing trend of radiology subspecialization. The results of the survey also confirmed its validity through an assessment with Messick’s five sources of validity evidence.ConclusionsThe survey’s validity indicates its generalizability to a future national survey to physicians of multiple specialties to further identify the preference of physicians on reporting of complex radiologic studies, in the setting of increased radiologic subspecialization.     

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AimThis clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.MethodsA comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered.StructureChest pain is a frequent cause for emergency department visits in the United States. The “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain” provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.