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

Fink, Adam; Levin, Terry L.; Blumfield, Einat; Nemerofsky, Sheri L.; Liszewski, Mark C.; George, Kandi; Nafday, Suhas; Shlomovich, Mark; Eddington, K. Allen; Myers, Eliza; Ushay, H. Michael

doi:10.1016/j.jacr.2017.12.007

Cited by 3 publications

(5 citation statements)

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“…Two studies reported a 7–46% rate of discrepancies in interpretation of radiographs (chest radiograph and abdominal x-ray) between PICU physicians and radiologists. Among discrepancies, 9–13% were found to be actionable and led to a change in management (17, 18). Common actionable discrepancies included failure to recognize line/tube malposition and misinterpretation of air space disease and atelectasis (17, 18).…”

Section: Resultsmentioning

confidence: 99%

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Diagnostic Errors in Pediatric Critical Care: A Systematic Review*

Cifra

Custer

Singh

et al. 2021

Pediatric Critical Care Medicine

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Studies on diagnostic error and the diagnostic process in pediatric critical care were included. Non-English studies with no translation, case reports/series, studies providing no information on diagnostic error, studies focused on non-PICU populations, and studies focused on a single condition/disease or a single diagnostic test/tool were excluded.DATA EXTRACTION: Data on research design, objectives, study sample, and results pertaining to the prevalence, impact, and factors associated with diagnostic error were abstracted from each study.DATA SYNTHESIS: Using independent tiered review, 396 abstracts were screened, and 17 studies (14 full-text, 3 abstracts) were ultimately included. Fifteen of 17 studies (88%) had an observational research design. Autopsy studies (autopsy rates were 20-47%) showed a 10-23% rate of missed major diagnoses; 5-16% of autopsy-discovered diagnostic errors had a potential adverse impact on survival and would have changed management. Retrospective record reviews reported varying rates of diagnostic error from 8% in a general PICU population to 12% among unexpected critical admissions and 21-25% of patients discussed at PICU morbidity and mortality conferences. Cardiovascular, infectious, congenital, and neurologic conditions were most commonly misdiagnosed. Systems factors (40-67%), cognitive factors (20-3%), and both systems and cognitive factors (40%) were associated with diagnostic error. Limited information was available on the impact of misdiagnosis.CONCLUSIONS: Knowledge of diagnostic errors in the PICU is limited. Future work to understand diagnostic errors should involve a balanced focus between studying the diagnosis of individual diseases and uncovering common system-and process-related determinants of diagnostic error.

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Section: Resultsmentioning

confidence: 99%

“…Among discrepancies, 9–13% were found to be actionable and led to a change in management (17, 18). Common actionable discrepancies included failure to recognize line/tube malposition and misinterpretation of air space disease and atelectasis (17, 18).…”

Section: Resultsmentioning

confidence: 99%

Diagnostic Errors in Pediatric Critical Care: A Systematic Review*

Cifra

Custer

Singh

et al. 2021

Pediatric Critical Care Medicine

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“…Mortality analysis focused on interpretations for 708 PARDS patients, while the inter-observer analysis was conducted on a smaller subgroup. Nevertheless, simultaneous interpretation of 702 radiographs represents one of the largest studies of inter-rater reliability in either adults or pediatrics [6][7][8][9][10]24], and the groups were similar (Table 2). Third, practitioners were blinded to clinical information.…”

Section: Discussionmentioning

confidence: 99%

“…The Pediatric Acute Lung Injury Consensus Conference (PALICC) definition for pediatric ARDS (PARDS) eliminated the requirement for bilateral radiographic findings, although evidence of new infiltrate(s) consistent with acute pulmonary parenchymal disease [4,5] is still required. Rationale for this change included: high inter-observer variability in the interpretation of bilateral infiltrates on chest X-ray (CXR) [6][7][8][9][10], low sensitivity of CXR for alveolar consolidation that often lags behind the degree of hypoxemia evidence that diffuse alveolar damage may neither be homogeneous nor bilateral [11], lack of evidence that bilateral infiltrates contribute to risk stratification in ARDS [12].…”

Section: Introductionmentioning

confidence: 99%

Prognostic relevance and inter-observer reliability of chest-imaging in pediatric ARDS: a pediatric acute respiratory distress incidence and epidemiology (PARDIE) study

et al. 2020

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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 PaO 2 /FiO 2 (PF) ratios (or SpO 2 /FiO 2 (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).

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“…[76][77][78][79][80] There has been a high degree of discrepancy in the interpretation of chest X-rays in diagnosing pneumonia between radiologists and neonatologists. 81,82 Computed tomography (CT) is a well-accepted gold standard for diagnosing pneumonia, but it is not a good firstline investigation in neonates because of high radiation exposure, issues with feasibility, and high costs. 83,84 Lung ultrasound is emerging as a good first-line, non-invasive bedside modality for diagnosis and monitoring.…”

Section: Diagnosis Of Pneumoniamentioning

confidence: 99%

Lung Ultrasound in Neonates: An Emerging Tool for Monitoring Critically Ill Infants

Maheshwari¹,

Suryawanshi²,

Paul³

et al. 2023

Newborn

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Context: Neonatal lung ultrasound is emerging as a useful clinical tool for the assessment of lung anatomy and management of various lung pathologies. In this review, we summarize normal lung ultrasound (LUS) findings and specific features of various lung morbidities. Evidence acquisition: A comprehensive literature search was conducted across multiple sources with relevant keywords with an additional filter of the age-group between 0 and 28 days. Findings: Apart from the description of normal newborn lungs, clinical and radiological features of a variety of lung pathologies were evaluated and incorporated in the review. Bedside LUS has evolved to be an important point-of-care imaging modality that can help in day-to-day clinical decision-making. It can be used in differentiating respiratory distress syndrome from transient tachypnea on the newborns, in the detection of pneumothorax, and in diagnosing pneumonia, pulmonary hemorrhage, and pleural effusion. Evidence supports the use of LUS scores to decide on the need for early rescue surfactant therapy with high sensitivity and specificity. Lung ultrasound scores obtained during the first 2 weeks after birth can help predict the likelihood of chronic lung disease/bronchopulmonary dysplasia. Once validated, it could be valuable for guiding early intervention and evaluation of new treatments. Conclusion: Neonatal lung ultrasound is emerging as a vital monitoring tool in critically ill infants with lung disease. It will be valuable in the early diagnosis, management, and prognosis of these patients.

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

Cited by 3 publications

References 10 publications

Diagnostic Errors in Pediatric Critical Care: A Systematic Review*

Diagnostic Errors in Pediatric Critical Care: A Systematic Review*

Prognostic relevance and inter-observer reliability of chest-imaging in pediatric ARDS: a pediatric acute respiratory distress incidence and epidemiology (PARDIE) study

Lung Ultrasound in Neonates: An Emerging Tool for Monitoring Critically Ill Infants

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