A pilot study evaluating the “STATSCAN” digital X-ray machine in paediatric polytrauma

A comparison of computed tomography, X-ray and Lodox® scans in assessing pediatric skull fractures using piglets

Skull fractures are common in children both due to abuse and accidental incidences. The accurate detection of these fractures may therefore be critical. The aim of this study was to investigate the reliability of CT, X-ray, and Lodox^® scans, the latter which has not previously been evaluated and is commonly employed in South Africa, in detecting the number, location and type of pediatric skull fractures. Blunt force trauma was inflicted with a mallet on ten piglet skulls, which were CT, X-ray, and Lodox^® scanned and then macerated. The number, location, and type of skull fractures visible using each imaging modality, and on the cleaned skulls, were recorded. Sensitivities and specificities of each method were calculated. For fracture number and location, CTs had a sensitivity of 47.3%, X-rays 22.4% and Lodox^® 23.3%. For fracture type, sensitivities were 46.1%, 16.6%, and 17.8% for CT, X-ray, and Lodox^® , respectively. Specificities were high (92.5%-100%) which reduces the risk of incorrectly diagnosing fractures. However, low sensitivities increase the risk of failing to identify fractures and possible victims of abuse. Osteological analysis should preferably be the method of choice when evaluating pediatric skull trauma, and CTs should be used when osteological analysis is not feasible. If CT scanners are not available, X-rays and Lodox^® may have to be used. In these cases, additional radiographic views of the skull are imperative and may increase the sensitivity of these methods, although they are not recommended to detect exact pediatric skull fracture number, location, and type.

An audit of the polytrauma fracture detection rate of clinicians evaluating lodox statscan bodygrams in two South African public sector trauma units

BACKGROUND

Increasing global demand for specialized radiological investigations has resulted in delayed or non-reporting of plain trauma radiographs by radiologists. This is particularly true in resource-limited environments, where referring clinicians rely largely on their own radiographic interpretation. A wide accuracy range has been documented for non-radiologist reporting of conventional trauma radiographs. The Lodox Statscan whole-body digital X-ray machine is a relatively new technology that poses unique interpretive challenges. The fracture detection rate of trauma clinicians utilizing this modality has not been determined.

OBJECTIVE

An audit of the polytrauma fracture detection rate of clinicians evaluating Lodox Statscan bodygrams in two South African public-sector Trauma Units.

METHODS

A retrospective descriptive study of imaging data of Cape Town Level 1-equivalent public-sector Trauma Units during March-April 2015. Statscan bodygrams acquired for adult polytrauma triage were reviewed and correlated with follow-up imaging and patient records. Missed fractures were stratified by body part, mechanism of injury and ventilatory support. The fracture detection rate was determined with 95% confidence. The Generalised Fischer Exact Test assessed any association between the fracture site and failure of detection. Specialist orthopaedic review assessed the potential need for surgical management of missed fractures.

RESULTS

227 patients (male = 193, 85%; mean age: 33 years) were included; 195 fractures were demonstrated on the whole-body triage projections. Lower limb fractures predominated (n = 66, 34%). The fracture detection rate was 89% (95% CI = 86-93%), with the site of fracture associated with failure of detection (p = 0.01). Twelve of 21 undetected fractures (57%) involved the elbow or shoulder girdle. All elbow fractures (n = 3, 100%), more than half the shoulder girdle fractures (9/13,69%) and 12% (15/123) of extremity fractures were undetected. One missed fracture (1/21,4.7%) unequivocally required surgical management, while a further 7 (7/21, 33.3%) could potentially have benefitted from surgery, depending on follow-up imaging findings.

CONCLUSION

This is the first analysis of the accuracy of bodygram polytrauma fracture detection by clinicians. Particular review of the shoulder girdle, elbow and extremities for subtle fractures, in addition to standardized limb positioning, are recommended for improved diagnostic accuracy in this setting. These findings can inform clinician training courses in this domain.

Identification of ureteral stones at reduced radiation exposure: a pilot study comparing conventional versus digital low-dosage linear slot scanning (Lodox®) radiography

PURPOSE

Digital low-dosage, linear slot scanning radiography (Lodox^®) is an imaging modality that can emit down to one-tenth the radiation of conventional X-ray systems. We prospectively evaluated Lodox^® as a diagnostic imaging modality in patients with ureterolithiasis.

METHODS

Conventional kidney-ureter-bladder (KUB) X-ray and Lodox^® were performed in 41 patients presenting with acute flank pain due to unilateral ureteral stone confirmed by computed tomography. KUB X-ray and Lodox^® images were then reviewed by four blinded readers (urology expert/resident, radiology expert/resident). Identification rates were compared using Pearson's Chi square test. The impact of different parameters on stone identification by Lodox^® was evaluated using logistic regression and generalized linear mixed models. Inter-reader agreement was tested using Cohen's kappa coefficient.

RESULTS

Median stone size was 5 mm (range 2-12), median stone density was 800 HU (range 200-1500). The identification rates of the urology expert were 68% for KUB X-ray and 90% for Lodox^® (p = 0.014), and for all four readers 61% for KUB X-ray and 62% for Lodox^® (p = 0.8). Radiation exposure for KUB X-ray and Lodox^® was 0.45 mSv (SD ± 0.64) and 0.027 mSv (SD ± 0.038), respectively. Multivariable analyses showed an association between stone identification by Lodox^® and stone size (p < 0.001), stone density (p = 0.005), lower body mass index (p = 0.005), and reader (p < 0.001).

CONCLUSIONS

The high identification rates and low radiation doses of Lodox^® make it a promising imaging modality for the diagnosis of ureteral stones. Further validation in larger cohorts, including performance evaluation for renal stones, is warranted.

TRIAL REGISTRATION

http://www.controlled-trails.com/ISRCTN12915426.

Use of a full-body digital X-ray imaging system in acute medical emergencies: a systematic review

BACKGROUND

To evaluate the available evidence for the clinical effectiveness and biohazard safety of a full-body digital X-ray imaging system (Lodox) in acute medical emergencies.

METHODS

Electronic databases (including PubMed, Embase and the Cochrane Library; up to January 2014) and reference lists of articles were searched. The quality of the included studies was determined, and a narrative assessment was undertaken.

RESULTS

A total of 256 articles were reviewed. Fifteen clinical studies and eight case series met the eligibility criteria. All 23 studies reporting use of a full-body X-ray imaging system in acute medical emergencies on Lodox. Based on figures in six studies comprising various evaluation methods, image quality of Lodox was mostly comparable to that of conventional X-rays and the radiation dose was considerably lower. Lodox demonstrated a sensitivity ranging from 62% to 73%, and a specificity ranging from 99% to 100% compared with CT for the evaluation of emergency patients with polytrauma, which is similar to that of conventional X-rays. Examination time using Lodox ranged from 3.5  to 13.9 min compared with 8 to 25.7 min using conventional X-rays. However, there was no evidence it significantly shortened resuscitation time or emergency department length of stay. Publication bias might have occurred; some published studies might have been influenced by conflicts of interest.

CONCLUSIONS

The Lodox machine is capable of rapidly scanning the entire body and offers an equivalent diagnostic assessment tool compared with conventional X-rays. It seems to have the potential to reduce cumulative radiation dosage for emergency patients compared with conventional X-rays. Application of Lodox might be helpful to reduce resource use and simplify care in lower-resourced areas.

Full-body x-ray imaging to facilitate triage: a potential aid in high-volume emergency departments

The levels of traumatic injury seen in South African emergency departments (EDs) are epidemic. This is coupled with a severe lack of resources and adequately trained emergency staff. The Lodox Statscan (LS) is an X-ray scanner capable of producing rapid, low-dose, and full-body X-ray images. In this paper, a new trauma protocol-the Johannesburg trauma protocol-that implements LS scanning on entry to the ED as a triage tool is reported. A case study illustrating the use of LS to triage 63 patients in a single Saturday shift at a level 1 Trauma Centre is also presented. Because of the ability to rapidly and safely provide X-ray imaging information to support clinical decision making, the LS could be a useful tool to aid in resource allocation to improve treatment of the high levels of trauma patients that present to South African EDs daily.

Interactive segmentation of airways from chest X-ray images using active shape models

Classification of airway shapes in chest X-ray images may be useful in computer-aided detection of lymphadenopathy associated with pediatric tuberculosis. This paper presents an interactive approach for airway segmentation from chest X-ray images that may be used in an airway shape classification algorithm. A local normalization filter is applied as a preprocessing step to enhance the visibility of the airways. Segmentation is then performed with the aid of active shape models (ASMs), which are warped to a set of manually defined control points on the image to be segmented, using an affine transformation. Two shape models are built, one of which consists of points on the airway edges only and the other consists of points on the airway edges as well as points on the ribs. The ASMs are built from a set of manually segmented images. The Hausdorff distance is used to compute the accuracy of the segmentations with reference to a manual segmentation.

A review of full-body radiography in nontraumatic emergency medicine

This paper reports on the application of full-body radiography to nontraumatic emergency situations. The Lodox Statscan is an X-ray machine capable of imaging the entire body in 13 seconds using linear slit scanning radiography (LSSR). Nontraumatic emergency applications in ventriculoperitoneal (VP) shunt visualisation, emergency room arteriography (ERA), detection of foreign bodies, and paediatric emergency imaging are presented. Reports show that the fast, full-body, and low-dose scanning capabilities of the Lodox system make it well suited to these applications, with the same or better image quality, faster processing times, and lower dose to patients. In particular, the large format scans allowing visualisation of a greater area of anatomy make it well suited to VP shunt monitoring, ERA, and the detection of foreign bodies. Whilst more studies are required, it can be concluded that the Lodox Statscan has the potential for widespread use in these and other nontraumatic emergency radiology applications.

How reliable and safe is full-body low-dose radiography (LODOX Statscan) in detecting foreign bodies ingested by adults?

OBJECTIVE

Foreign body ingestion is common and potentially lethal. This study evaluates the use of low-dose Statscans (LODOX) in emergency departments.

DESIGN

This comparative cross-sectional study retrospectively assessed 28289 digital chest x-rays and 2301 LODOX scans performed between 2006 and 2010 at a tertiary emergency centre. The radiographic appearance, image quality and location of ingested foreign bodies were evaluated in standard digital chest and LODOX radiography. The mean irradiation (μSv) and cumulative mean radiation dose per patient with the ingested foreign body were calculated according to literature-based data, together with the sensitivity and specificity for each modality.

RESULTS

A total of 62 foreign bodies were detected in 39 patients, of whom 19 were investigated with LODOX and 20 with conventional digital chest radiography. Thirty-three foreign bodies were located in the two upper abdominal quadrants, 21 in the lower quadrants-which are not visible on conventional digital chest radiography-seven in the oesophagus and one in the bronchial system. The sensitivity and specificity of digital chest radiography were 44.4% and 94.1%, respectively, and for the LODOX Statscan 90% and 100%, respectively. The calculated mean radiation dose for LODOX investigations was 184 μS, compared with 524 μS for digital chest radiography.

CONCLUSIONS

LODOX Statscan is superior to digital chest radiography in the diagnostic work-up of ingested foreign bodies because it makes it possible to enlarge the field of view to the entire body, has higher sensitivity and specificity, and reduces the radiation dose by 65%.

Full-body radiography (LODOX Statscan) in trauma and emergency medicine: a report from the first European installation site

Lodox Statscan is a whole-body, skeletal and soft-tissue, low-dose X-ray scanner with digital enhancement and enlargement capabilities. Ten years ago it was introduced as a screening device for the examination of trauma patients. Its incorporation into the Emergency Room enabled anterior-posterior and lateral thoraco-abdominal studies to be performed in 3—5 min with only about one-third of the radiation required for conventional radiography. Since its approval by the Food and Drug Administration in the USA, several trauma centres have incorporated this technology into their Advanced Trauma Life Support protocols. This review provides an overview of the system, and reports on the authors’ own experience with the system and that of others over the past 10 years, based on a literature search for all review articles, original articles, conference proceedings, case reports and short reports related to the Lodox Statscan device.

Detection of chest trauma with whole-body low-dose linear slit digital radiography: a multireader study

OBJECTIVE

The objective of our study was to compare the performance of low-dose linear slit digital radiography (DR) with computed radiography (CR) for the detection of trauma sequelae in the chest including rib fractures, pneumothorax, and lung contusion.

MATERIALS AND METHODS

Eighty trauma victims (62 males, 18 females; mean age, 51.5 years) with a total of 612 rib fractures and 80 consecutive patients without rib fractures (59 males, 21 females; mean age, 39.5 years) were retrospectively analyzed. All patients had undergone whole-body linear slit DR and consecutive chest CT, and 87 patients underwent follow-up CR of the chest within 24 hours of DR and CT. Four blinded readers assessed image quality, rib fracture localization with diagnostic confidence, and the presence of pneumothorax and lung contusion on linear slit DR and CR images. Sensitivity for rib fractures and image quality were compared using the Wilcoxon's test. For the detection of pneumothorax and lung contusion, the difference in the areas under the receiver operating characteristic curves were calculated.

RESULTS

The rate of correctly identified rib fractures was higher (true-positive findings per image, 2.55 vs 2.21, respectively; p = 0.02), the rate of missed fractures was lower (false-negative findings per image, 4.98 vs 6.19; p = 0.02), and the diagnostic confidence was greater (2.03 vs 1.73 on a 3-point scale; p = 0.01) with linear slit DR than with CR, respectively. Image quality and performance for detecting pneumothorax and lung contusion with both techniques were not statistically different (p = 0.22, 0.85, and 0.55, respectively).

CONCLUSION

Linear slit DR is a reliable substitute for CR in the initial evaluation of chest trauma, with better sensitivity for detecting rib fractures and similar performance in assessing pneumothorax and lung contusion.

Detection of urinary stones at reduced radiation exposure: a phantom study comparing computed radiography and a low-dose digital radiography linear slit scanning system

OBJECTIVE

In this experimental study we assessed the diagnostic performance of digital linear slit scanning radiography compared with computed radiography (CR) for the detection of urinary calculi in an anthropomorphic phantom imitating patients weighing approximately 58-88 kg.

CONCLUSION

Compared with CR, linear slit scanning radiography is superior for the detection of urinary stones and may be used for pretreatment localization and follow-up at a lower patient exposure.

The use of the Statscan digital X-ray unit in paediatric polytrauma

We present a 3-year review of clinical paediatric experience with the Statscan (Lodox Systems, Johannesburg, South Africa), a low-dose, digital, whole-body, slit-scanning X-ray machine. While focusing on the role of the unit in paediatric polytrauma, insight into its applications in other paediatric settings is provided.