Restricting Daily Chest Radiography in the Intensive Care Unit: Implementing Evidence-Based Medicine to Decrease Utilizationt

Navigating challenges in radiography research: radiographers' perspectives in Saudi Arabia

Introduction

Radiography is a crucial healthcare specialty that requires ongoing research to advance imaging technologies and techniques. Despite this, radiographers are faced with obstacles such as time constraints, lack of resources, and the need for training on new technologies, which can discourage their research involvement. This study aims to provide a more representative understanding of the radiography research culture in Saudi Arabia, building upon previous studies.

Methods

Following the approval of an ethics committee at Taibah University (2024/173/302 DRD), a cross-sectional survey was conducted from January to March 2024 among registered radiographers in Saudi Arabia. An online questionnaire was distributed via social media platforms using a snowball sampling strategy to reach a diverse group of radiographers across different regions and institutions. Participants provided informed consent before completing the questionnaire. The questionnaire, originally in English, was translated into Arabic and validated by two bilingual academics. It included sections on demographics, previous research experience, barriers to research involvement, factors encouraging research engagement, and self-assessment of research competencies. Descriptive statistics and Cronbach's alpha were used to analyze the data.

Results

A total of 105 radiographers participated in the study, with 41% having prior research involvement. Among those engaged, the most common activity was data collection (65%), followed by preparation of scientific articles (49%). Challenges such as the lack of a research-focused culture (48%), insufficient awareness of opportunities (36%), and time constraints (34%) were prominent barriers to research participation. Encouraging factors included the need for research training (63%), support from research groups (51%), and allocated research time (50%). Respondents assessed their research skills, with confidence varied across skills, with 50% feeling capable of initiating research and 51% of participating, yet a significant proportion expressed uncertainties, especially in statistical knowledge and research methodology.

Conclusion

Most of the surveyed radiographers did not engage in research. However, there is a substantial interest in enhancing research involvement, with training, collaborative groups, and organizational support identified as key factors encouraging participation. The findings suggest that addressing these barriers can foster a more robust research culture, leading to improved diagnostic practices.

Improving sustainability and mitigating the environmental impacts of anaesthesia and surgery: a narrative review

Climate change, environmental degradation, and biodiversity loss are adversely affecting human health and exacerbating existing inequities, intensifying pressures on already strained health systems. Paradoxically, healthcare is a high-polluting industry, responsible for 4.6% of global greenhouse gas emissions and a similar proportion of air pollutants. Perioperative services are among the most resource-intensive healthcare services and are responsible for some unique pollutants. Opportunities exist to mitigate pollution throughout the entire continuum of perioperative care, including those that occur upstream of the operating room in the process of patient selection and optimisation, delivery of anaesthesia and surgery, and the postoperative recovery period. Within a patient-centred, holistic approach, clinicians can advocate for healthy public policies that modify the determinants of surgical illness, can engage in shared decision-making to ensure appropriate clinical decisions, and can be stewards of healthcare resources. Innovation and collaboration are required to redesign clinical care pathways and processes, optimise logistical systems, and address facility emissions. The results will extend beyond the reduction of public health damages from healthcare pollution to the provision of higher value, higher quality, patient-centred care.

Lung ultrasound and supine chest X-ray use in modern adult intensive care: mapping 30 years of advancement (1993-2023)

In critically ill patients with acute respiratory failure, thoracic images are essential for evaluating the nature, extent and progression of the disease, and for clinical management decisions. For this purpose, computed tomography (CT) is the gold standard. However, transporting patients to the radiology suite and exposure to ionized radiation limit its use. Furthermore, a CT scan is a static diagnostic exam for the thorax, not allowing, for example, appreciation of "lung sliding". Its use is also unsuitable when it is necessary to adapt or decide to modify mechanical ventilation parameters at the bedside in real-time. Therefore, chest X-ray and lung ultrasound are today's contenders for shared second place on the podium to acquire a thoracic image, with their specific strengths and limitations. Finally, electrical impedance tomography (EIT) could soon have a role, however, its assessment is outside the scope of this review. Thus, we aim to carry out the following points: (1) analyze the advancement in knowledge of lung ultrasound use and the related main protocols adopted in intensive care units (ICUs) over the latest 30 years, reporting the principal publications along the way, (2) discuss how and when lung ultrasound should be used in a modern ICU and (3) illustrate the possible future development of LUS.

Utility of the serial portable chest x-ray for the diagnosis and quantification of COVID-19 patients

Objective

To determine the role of the serial portable chest X-ray in the diagnosis and quantification of patients with confirmed COVID-19 admitted to a tertiary care hospital.

Methods

A retrospective study was conducted at Dow Institute of Radiology, Dow University of Health Sciences. Confirmed positive cases of COVID-19 from November 2020 to January 2021 were retrospectively studied. Patients' demographics and clinical characteristics, chest X-ray findings, and outcomes were retrieved through electronic medical records. Baseline and final follow-up chest X-rays findings were compared by using chest X-ray severity score. Multivariable logistic regression was used to evaluate the relationship between patients' characteristics and patient outcomes.

Results

The study included 329 patients with a mean age of 56.43 ± 13.10 years (range 16-85 years). Peripheral consolidation and ground glass opacities (89.4%) were the most common X-ray findings followed by bilateral lung involvement (79.0%) and perihilar consolidation/ground glass opacities (69.9%). Among the patients who were admitted, 61.4% were discharged, 49.5% had prolonged length of stay ≥10 days, and 37.7% died. After adjustment of all patients' characteristics, the multivariate model showed no significant difference in chest X-ray severity score in relation to the patient's outcome. Patients who were admitted to the intensive care unit, and received oxygen support, bilevel positive airway pressure, and a ventilator were significantly associated with the outcome of being discharged, prolonged hospital stay, and death.

Conclusion

Peripheral consolidation and ground glass opacities were the most common chest X-ray findings in admitted COVID-19 patients. No significant difference in chest X-ray severity score was noted in the primary outcome of being discharged, prolonged hospital stay, and death. There is no requirement for daily chest X-rays in hospitalized patients until required in the condition of worsening symptoms or significant intervention such as endotracheal intubation.

A Nomogram for Early Diagnosis of Community-Acquired Pneumonia Based on Bronchoalveolar Lavage Fluid Metabolomics

Purpose

There is a high disease burden associated with community-acquired pneumonia (CAP) around the world. A timely and correct diagnosis of CAP can facilitate early treatment and prevent illness progression. The present study aimed to find some novel biomarkers of CAP by metabolic analysis and construct a nomogram model for precise diagnosis and individualized treatment of CAP patients.

Patients and Methods

42 CAP patients and 20 controls were enrolled in this study. The metabolic profiles of bronchoalveolar lavage fluid (BALF) samples were identified by untargeted LC-MS/MS analysis. With a VIP score ≥ 1 in OPLS-DA analysis and P < 0.05, the significantly dysregulated metabolites were estimated as potential biomarkers of CAP, which were further included in the construction of the diagnostic prediction model along with laboratory inflammatory indexes via stepwise backward regression analysis. Discrimination, calibration, and clinical applicability of the nomogram were evaluated by the C-index, the calibration curve, and the decision curve analysis (DCA) estimated by bootstrap resampling.

Results

The metabolic profiles differed obviously between CAP patients and healthy controls, as shown by PCA and OPLS-DA plots. Seven metabolites significantly dysregulated in CAP were established: dimethyl disulfide, oleic acid (d5), N-acetyl-a-neuraminic acid, pyrimidine, choline, LPC (12:0/0:0) and PA (20:4/2:0). Multivariate logistic regression revealed that the expression levels of PA (20:4/2:0), N-acetyl-a-neuraminic acid, and CRP were associated with CAP. After being validated by bootstrap resampling, this model showed satisfactory diagnostic performance.

Conclusion

A novel nomogram prediction model containing metabolic potential biomarkers in BALF that was developed for the early diagnosis of CAP offers insights into the pathogenesis and host response in CAP.

The value of case reports in diagnostic radiography

OBJECTIVE

- This paper sought to explore the value of case reports in diagnostic radiography with regards to current usage, relevance to evidence-based radiography, and educational benefits.

KEY FINDINGS

Case reports are short accounts of novel pathologies, trauma or treatment with a critical review of relevant literature. Examples within diagnostic radiography include the appearances of COVID-19 alongside examination-level scenarios involving image artefacts, equipment failure and patient incidents in radiology. With greatest risk of bias and lowest generalisability, they are considered as low-quality evidence with generally poor citation rates. Despite this, there are examples of significant discoveries or developments initiated with case reports with important patient care implications. Furthermore, they offer educational development for both reader and author alike. Whereas the former learns about an unusual clinical scenario, the latter develops scholarly writing skills, reflective practice and may generate further, more complex, research. Radiography-specific case reports could capture the diverse imaging skills and technological expertise currently under-represented in traditional case reports. Potential avenues for cases are broad and may include any imaging modality where patient care or safety of other persons may illicit a teaching point. This encapsulates all stages of the imaging process, before, during and after patient interaction.

CONCLUSION

Despite being low-quality evidence, case reports contribute to evidence-based radiography, add to the knowledge base, and foster a research culture. However, this is contingent upon rigorous peer-review and adherence to ethical treatment of patient data.

IMPLICATIONS FOR PRACTICE

With the drive to increase research engagement and output at all levels in radiography (student to consultant), case reports may act as a realistic grass-root activity for a burdened workforce with limited time and resources.

Imaging in the Intensive Care Unit

Radiology plays an important role in the management of the most seriously ill patients in the hospital. Over the years, continued advances in imaging technology have contributed to an improvement in patient care. However, even with such advances, the portable chest radiograph (CXR) remains one of the most commonly requested radiographic examinations. While they provide valuable information, CXRs remain relatively insensitive at revealing abnormalities and are often nonspecific. Chest computed tomography (CT) can display findings that are occult on CXR and is particularly useful at identifying and characterizing pleural effusions, detecting barotrauma including small pneumothoraces, distinguishing pneumonia from atelectasis, and revealing unsuspected or additional abnormalities which could result in increased morbidity and mortality if left untreated. CT pulmonary angiography is the modality of choice in the evaluation of pulmonary emboli which can complicate the hospital course of the ICU patient. This article will provide guidance for interpretation of CXR and thoracic CT images, discuss some of the invasive devices routinely used, and review the radiologic manifestations of common pathologic disease states encountered in ICU patients. In addition, imaging findings and complications of more specific clinical scenarios in which the incidence has increased in the ICU setting, such as patients who are immunocompromised, have interstitial lung disease, or COVID-19, will also be discussed. Communication between the radiologist and intensivist, particularly on complicated cases, is important to help increase diagnostic accuracy and leads to an improvement in the management of the most critically ill patients.

Reducing thoracic and lumbar radiographs in an urban emergency department through a clinical champion led quality improvement intervention

Background

Low back pain is a common emergency department (ED) complaint that does not always necessitate imaging. Unnecessary imaging drives medical overuse with potential to harm patients. Quality improvement (QI) interventions have shown to be an effective solution. The purpose of this QI intervention was to increase the percentage of appropriately ordered radiographs for low back pain while reducing the absolute number.

Methods

A multi-component intervention led by a clinician champion including staff education, patient education, electronic medical record modification, audit and peer-feedback, and clinical decision support tools was implemented at an urban public hospital Emergency Department. In addition to the total number ordered, Choosing Wisely and American College of Radiology recommendations were used to assess appropriateness of all ED thoracic and lumbar conventional radiographs by chart review over eight months.

Results

The percent of appropriately ordered radiographs increased from 5.8 to 53.9% and the monthly number of radiographs ordered decreased from 86 to 47 over the eight-month initiative. There were no compensatory increases in thoracic or lumbar computed tomography (CT) scans during this time frame.

Conclusion

A multi-component QI intervention led by a clinician champion is an effective way to reduce the overutilization of thoracic and lumbar radiographs in an urban public hospital emergency department.

Diagnostic Modalities in Critical Care: Point-of-Care Approach

The concept of intensive care units (ICU) has existed for almost 70 years, with outstanding development progress in the last decades. Multidisciplinary care of critically ill patients has become an integral part of every modern health care system, ensuing improved care and reduced mortality. Early recognition of severe medical and surgical illnesses, advanced prehospital care and organized immediate care in trauma centres led to a rise of ICU patients. Due to the underlying disease and its need for complex mechanical support for monitoring and treatment, it is often necessary to facilitate bed-side diagnostics. Immediate diagnostics are essential for a successful treatment of life threatening conditions, early recognition of complications and good quality of care. Management of ICU patients is incomprehensible without continuous and sophisticated monitoring, bedside ultrasonography, diverse radiologic diagnostics, blood gas analysis, coagulation and blood management, laboratory and other point-of-care (POC) diagnostic modalities. Moreover, in the time of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, particular attention is given to the POC diagnostic techniques due to additional concerns related to the risk of infection transmission, patient and healthcare workers safety and potential adverse events due to patient relocation. This review summarizes the most actual information on possible diagnostic modalities in critical care, with a special focus on the importance of point-of-care approach in the laboratory monitoring and imaging procedures.

Narrowing the Gap: Imaging Disparities in Radiology

It may seem unlikely that the field of radiology perpetuates disparities in health care, as most radiologists never interact directly with patients, and racial bias is not an obvious factor when interpreting images. However, a closer look reveals that imaging plays an important role in the propagation of disparities. For example, many advanced and resource-intensive imaging modalities, such as MRI and PET/CT, are generally less available in the hospitals frequented by people of color, and when they are available, access is impeded due to longer travel and wait times. Furthermore, their images may be of lower quality, and their interpretations may be more error prone. The aggregate effect of these imaging acquisition and interpretation disparities in conjunction with social factors is insufficiently recognized as part of the wide variation in disease outcomes seen between races in America. Understanding the nature of disparities in radiology is important to effectively deploy the resources and expertise necessary to mitigate disparities through diversity and inclusion efforts, research, and advocacy. In this article, the authors discuss disparities in access to imaging, examine their causes, and propose solutions aimed at addressing these disparities.