Clinical relevance of the routine daily chest X-Ray in the surgical intensive care unit

CDC_Net: multi-classification convolutional neural network model for detection of COVID-19, pneumothorax, pneumonia, lung Cancer, and tuberculosis using chest X-rays

Coronavirus (COVID-19) has adversely harmed the healthcare system and economy throughout the world. COVID-19 has similar symptoms as other chest disorders such as lung cancer (LC), pneumothorax, tuberculosis (TB), and pneumonia, which might mislead the clinical professionals in detecting a new variant of flu called coronavirus. This motivates us to design a model to classify multi-chest infections. A chest x-ray is the most ubiquitous disease diagnosis process in medical practice. As a result, chest x-ray examinations are the primary diagnostic tool for all of these chest infections. For the sake of saving human lives, paramedics and researchers are working tirelessly to establish a precise and reliable method for diagnosing the disease COVID-19 at an early stage. However, COVID-19's medical diagnosis is exceedingly idiosyncratic and varied. A multi-classification method based on the deep learning (DL) model is developed and tested in this work to automatically classify the COVID-19, LC, pneumothorax, TB, and pneumonia from chest x-ray images. COVID-19 and other chest tract disorders are diagnosed using a convolutional neural network (CNN) model called CDC Net that incorporates residual network thoughts and dilated convolution. For this study, we used this model in conjunction with publically available benchmark data to identify these diseases. For the first time, a single deep learning model has been used to diagnose five different chest ailments. In terms of classification accuracy, recall, precision, and f1-score, we compared the proposed model to three CNN-based pre-trained models, such as Vgg-19, ResNet-50, and inception v3. An AUC of 0.9953 was attained by the CDC Net when it came to identifying various chest diseases (with an accuracy of 99.39%, a recall of 98.13%, and a precision of 99.42%). Moreover, CNN-based pre-trained models Vgg-19, ResNet-50, and inception v3 achieved accuracy in classifying multi-chest diseases are 95.61%, 96.15%, and 95.16%, respectively. Using chest x-rays, the proposed model was found to be highly accurate in diagnosing chest diseases. Based on our testing data set, the proposed model shows significant performance as compared to its competitor methods. Statistical analyses of the datasets using McNemar's, and ANOVA tests also showed the robustness of the proposed model.

Exploring the Necessity of Routine Daily Chest X-rays for Mechanically Ventilated Patients in the Pediatric Intensive Care Unit: An Integrative Review

PROBLEM

In the PICU of a university teaching hospital, daily chest X-rays (CXR) are performed on all intubated and non-invasive ventilation-assisted patients, even when the patient is stable with no changes in clinical status. Inconsistent practice was identified with PICUs globally. This review aims to address the risk-benefit balance of clinical value, outcomes, cost, and radiation exposure when performing routine daily CXRs in the PICU.

ELIGIBILITY CRITERIA

CINAHL, Medline, and Embase (Ovid) were searched for relevant articles within the last ten years (2009 to 2019). Articles involving routine daily CXR on adult patients were included due to limited pediatric research.

SAMPLE

18 articles were included in this review which evaluated the necessity of routine daily CXR protocol in the ICU setting and the risks of radiation exposure (pediatric n = 5, adult n = 10, both n = 3).

RESULTS

When comparing the routine daily to on-demand CXR ordering protocols, there was no difference noted in clinical outcomes including mortality, complications, length of stay in hospital or ICU, and number of ventilator days. The on-demand CXR protocol decreased the number of CXRs per patient, which thereby decreased radiation exposure for patients, decreasing their risk of potential toxicity and malignancy.

CONCLUSION

Routine daily CXR protocols are no longer recommended due to lack of clinical value, similar outcomes, increased cost, and since it places patients at risk for undue radiation exposure.

IMPLICATIONS

Further studies should evaluate clinical and physical exam findings that would trigger ordering a CXR in order to optimize their diagnostic value in the pediatric setting.

Safety and efficacy of routine diagnostic test reduction interventions in patients admitted to the intensive care unit: A systematic review and meta-analysis

Reducing unnecessary routine diagnostic testing has been identified as a strategy to curb wasteful healthcare. However, the safety and efficacy of targeted diagnostic testing strategies are uncertain. The aim of this study was to systematically review interventions designed to reduce pathology and chest radiograph testing in patients admitted to the intensive care unit (ICU). A predetermined protocol and search strategy included OVID MEDLINE, OVID EMBASE and the Cochrane Central Register of Controlled Trials from inception until 20 November 2019. Eligible publications included interventional studies of patients admitted to an ICU. There were no language restrictions. The primary outcomes were in-hospital mortality and test reduction. Key secondary outcomes included ICU mortality, length of stay, costs and adverse events. This systematic review analysed 26 studies (with more than 44,00 patients) reporting an intervention to reduce one or more diagnostic tests. No studies were at low risk of bias. In-hospital mortality, reported in seven studies, was not significantly different in the post-implementation group (829 of 9815 patients, 8.4%) compared with the pre-intervention group (1007 of 9848 patients, 10.2%), (relative risk 0.89, 95% confidence intervals 0.79 to 1.01, P = 0.06, I² 39%). Of the 18 studies reporting a difference in testing rates, all reported a decrease associated with targeted testing (range 6%-72%), with 14 (82%) studies reporting >20% reduction in one or more tests. Studies of ICU targeted test interventions are generally of low quality. The majority report substantial decreases in testing without evidence of a significant difference in hospital mortality.

Trends in Use of Daily Chest Radiographs Among US Adults Receiving Mechanical Ventilation

IMPORTANCE

Guidelines from December 2011 recommended against obtaining daily chest radiographs (CXRs) for patients requiring mechanical ventilation (MV). Daily CXR use for patients receiving MV in US hospitals is unknown and, if high, may represent an opportunity to reduce low-value care and unnecessary radiation.

OBJECTIVES

To determine frequency of daily CXR use for US patients receiving MV, assess variability across hospitals, and evaluate whether use has decreased over time.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of hospitalized adults (aged ≥18 years) receiving MV for 3 days or longer. Mechanical ventilation was defined by having an International Classification of Diseases, Ninth Revision, Clinical Modification code of 96.7x and an MV charge on more than 1 hospital day. Hospital discharges in the Premier Perspectives database were examined from July 1, 2008, to December 31, 2014. Data analysis was conducted from July 28, 2017, to December 13, 2017.

EXPOSURES

Hospital discharge date (quarter of the year) and hospital in which patients received MV.

MAIN OUTCOMES AND MEASURES

The outcome was daily CXR use (up to 7 days) during MV. We used standard statistics to describe CXR use, multilevel multivariable regression modeling with adjusted median odds ratio (OR) to evaluate variability by hospital, and multivariable piecewise regression (breakpoint: fourth quarter of 2011) with adjusted OR to evaluate time trends and response to guideline recommendations.

RESULTS

The primary cohort included 512 518 patients receiving MV (mean [SD] age, 63.0 [16.1] years; 46% female) in 416 hospitals, of whom 321 093 (63%) received daily CXRs. Wide variability was seen across hospitals; hospitals performed daily CXRs on a median of 66% of patients (interquartile range, 50%-77%; full range, 12%-97%). The adjusted median OR was 2.43 (95% CI, 2.29-2.59), suggesting the same patient had 2.43-fold higher odds of receiving a daily CXR if admitted to a higher- vs lower-use hospital; the odds of receiving daily CXRs were unchanged through quarter 3 of 2011 (adjusted OR, 1.00; 95% CI, 0.99-1.01), after which there was a 3% relative reduction in the odds of daily CXR use per quarter (adjusted OR, 0.97; 95% CI, 0.96-0.98).

CONCLUSIONS AND RELEVANCE

Three-fifths of US patients receiving MV also received daily CXRs from 2008 to 2014, although use declined slowly after new guidelines were published. The hospital at which a patient received care was associated with the odds of daily CXR receipt.

Single intervention for a reduction in portable chest radiography (pCXR) in cardiovascular and surgical/trauma ICUs and associated outcomes

PURPOSE

Studies suggest that "on-demand" radiography is equivalent to daily routine with regard to adverse events. In these studies, provider behavior is controlled. Pragmatic implementation has not been studied.

MATERIALS AND METHODS

This was a quasi-experimental, pre-post intervention study. Medical directors of two intervention ICUs requested pCXRs be ordered on an on-demand basis at one time point, without controlling or monitoring behavior or providing follow-up.

RESULTS

A total of 11,994 patient days over 18months were included. Combined characteristics: Age: 56.7, 66% male, 96% survival, APACHE II 14 (IQR: 11-19), mechanical ventilation (MV) (occurrences)/patient admission: mean 0.7 (SD: 0.6; range: 0-5), duration (hours) of MV: 21.7 (IQR: 9.8-81.4) and ICU LOS (days): 2.8 (IQR: 1.8-5.6). Average pCXR rate/patient/day before was 0.93 (95% CI: 0.89-0.96), and 0.73 (95% CI: 0.69-0.77) after. Controlling for severity, daily pCXR rate decreased by 21.7% (p<0.001), then increased by about 3%/month (p=0.044). There was no change in APACHE II, mortality, and occurrences or duration of MV, unplanned re-intubations, ICU LOS.

CONCLUSIONS

In critically ill adults, pCXR reduction can be achieved in cardiothoracic and trauma/surgical patients with a pragmatic intervention, without adversely affecting patient care, outside a controlled study.