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Huang J, Neill L, Wittbrodt M, Melnick D, Klug M, Thompson M, Bailitz J, Loftus T, Malik S, Phull A, Weston V, Heller JA, Etemadi M. Generative Artificial Intelligence for Chest Radiograph Interpretation in the Emergency Department. JAMA Netw Open 2023; 6:e2336100. [PMID: 37796505 PMCID: PMC10556963 DOI: 10.1001/jamanetworkopen.2023.36100] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/21/2023] [Indexed: 10/06/2023] Open
Abstract
Importance Multimodal generative artificial intelligence (AI) methodologies have the potential to optimize emergency department care by producing draft radiology reports from input images. Objective To evaluate the accuracy and quality of AI-generated chest radiograph interpretations in the emergency department setting. Design, Setting, and Participants This was a retrospective diagnostic study of 500 randomly sampled emergency department encounters at a tertiary care institution including chest radiographs interpreted by both a teleradiology service and on-site attending radiologist from January 2022 to January 2023. An AI interpretation was generated for each radiograph. The 3 radiograph interpretations were each rated in duplicate by 6 emergency department physicians using a 5-point Likert scale. Main Outcomes and Measures The primary outcome was any difference in Likert scores between radiologist, AI, and teleradiology reports, using a cumulative link mixed model. Secondary analyses compared the probability of each report type containing no clinically significant discrepancy with further stratification by finding presence, using a logistic mixed-effects model. Physician comments on discrepancies were recorded. Results A total of 500 ED studies were included from 500 unique patients with a mean (SD) age of 53.3 (21.6) years; 282 patients (56.4%) were female. There was a significant association of report type with ratings, with post hoc tests revealing significantly greater scores for AI (mean [SE] score, 3.22 [0.34]; P < .001) and radiologist (mean [SE] score, 3.34 [0.34]; P < .001) reports compared with teleradiology (mean [SE] score, 2.74 [0.34]) reports. AI and radiologist reports were not significantly different. On secondary analysis, there was no difference in the probability of no clinically significant discrepancy between the 3 report types. Further stratification of reports by presence of cardiomegaly, pulmonary edema, pleural effusion, infiltrate, pneumothorax, and support devices also yielded no difference in the probability of containing no clinically significant discrepancy between the report types. Conclusions and Relevance In a representative sample of emergency department chest radiographs, results suggest that the generative AI model produced reports of similar clinical accuracy and textual quality to radiologist reports while providing higher textual quality than teleradiologist reports. Implementation of the model in the clinical workflow could enable timely alerts to life-threatening pathology while aiding imaging interpretation and documentation.
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Affiliation(s)
- Jonathan Huang
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, Illinois
| | - Luke Neill
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Matthew Wittbrodt
- Research & Development, Northwestern Medicine Information Services, Chicago, Illinois
| | - David Melnick
- Research & Development, Northwestern Medicine Information Services, Chicago, Illinois
| | - Matthew Klug
- Research & Development, Northwestern Medicine Information Services, Chicago, Illinois
| | - Michael Thompson
- Research & Development, Northwestern Medicine Information Services, Chicago, Illinois
| | - John Bailitz
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Timothy Loftus
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sanjeev Malik
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Amit Phull
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Victoria Weston
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - J. Alex Heller
- Research & Development, Northwestern Medicine Information Services, Chicago, Illinois
| | - Mozziyar Etemadi
- Research & Development, Northwestern Medicine Information Services, Chicago, Illinois
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, Illinois
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Marais J, Venkatakrishna SSB, Calle-Toro JS, Goussard P, Eber E, Andronikou S. Patient rotation chest X-rays and the consequences of misinterpretation in paediatric radiology. Paediatr Respir Rev 2023; 47:41-50. [PMID: 37244797 DOI: 10.1016/j.prrv.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 05/05/2023] [Indexed: 05/29/2023]
Abstract
PURPOSE We aimed to demonstrate the consequences of rotation on neonatal chest radiographs and how it affects diagnosis. In addition, we demonstrate methods for determining the presence and direction of rotation. BACKGROUND Patient rotation is common in chest X-rays of neonates. Rotation is present in over half of chest X-rays from the ICU, contributed to by unwillingness of technologists to reposition new-borns for fear of dislodging lines and tubes. There are six main effects of rotation on supine paediatric chest X-rays: 1) unilateral hyperlucency of the side that the patient is rotated towards; 2) the side 'up' appears larger; 3) apparent deviation of the cardiomediastinal shadow in the direction that the chest is rotated towards; 4) apparent cardiomegaly; 5) distorted cardio-mediastinal configuration; and 6) reversed position of the tips of the umbilical artery and vein catheters with rotation to the left. These effects can cause diagnostic errors due to misinterpretation, including air-trapping, atelectasis, cardiomegaly, and pleural effusions, or disease may be masked. We demonstrate the methods of evaluating rotation with examples, including a 3D model of the bony thorax as a guide. In addition, multiple examples of the effects of rotation are provided including examples where disease was misinterpreted, underestimated or masked. CONCLUSION Rotation is often unavoidable in neonatal chest X-rays, especially in the ICU. It is therefore important for physicians to recognise rotation and its effects, and to be aware that it can mimic or mask disease.
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Affiliation(s)
- Jani Marais
- Faircape Health Tokai Estate, Cape Town, South Africa.
| | | | - Juan S Calle-Toro
- Department of Radiology, University of Texas Health Science Center at San Antonio - UT Health San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229, USA.
| | - Pierre Goussard
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa.
| | - Ernst Eber
- Division of Paediatric Pulmonology and Allergology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.
| | - Savvas Andronikou
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; University of Pennsylvania, Philadelphia, USA
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Elsingergy MM, Naidoo J, Baker G, Zar HJ, Lucas S, Andronikou S. Comparison of chest radiograph findings in ambulatory and hospitalized children with pulmonary tuberculosis. Pediatr Radiol 2023; 53:1765-1772. [PMID: 37423915 DOI: 10.1007/s00247-023-05707-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND The diagnosis of childhood tuberculosis (TB) is, in many instances, solely reliant on chest radiographs (CXRs), as they are often the only diagnostic tool available, especially in TB-endemic areas. Accuracy and reliability of CXRs for detecting TB lymphadenopathy may vary between groups depending on severity of presentation and presence of parenchymal disease, which may obscure visualization. OBJECTIVE To compare CXR findings in ambulatory versus hospitalized children with laboratory confirmed pulmonary TB versus other lower respiratory tract infections (LRTI) and test inter-rater agreement for these findings. MATERIALS AND METHODS Retrospective review, by two pediatric radiologists, of CXRs performed on children < 12 years old referred for evaluation of LRTI with clinical suspicion of pulmonary TB in inpatient and outpatient settings. Each radiologist commented on imaging findings of parenchymal changes, lymphadenopathy, airway compression and pleural effusion. Frequency of imaging findings was compared between patients based on location and diagnosis and inter-rater agreement was determined. Accuracy of radiographic diagnosis was compared to laboratory testing which served as the gold standard. RESULTS The number of enrolled patients was 181 (54% males); 69 (38%) were ambulatory and 112 (62%) were hospitalized. Of those enrolled, 87 (48%) were confirmed to have pulmonary TB, while 94 (52%) were other LRTI controls. Lymphadenopathy and airway compression were more common in TB patients than other LRTI controls, regardless of patient location. Parenchymal changes and pleural effusion were more common in hospitalized than ambulatory patients, regardless of patient diagnosis. Agreement for parenchymal changes was higher in the hospitalized group (kappa [κ] = 0.75), while agreement for lymphadenopathy (κ = 0.65) and airway compression (κ = 0.68) was higher in the ambulatory group. The specificity of CXRs for TB diagnosis (> 75%) was higher than the sensitivity (< 50%) for both ambulatory and hospitalized groups. CONCLUSION Higher frequency of parenchymal changes among hospitalized children may conceal specific imaging findings of TB such as lymphadenopathy, contributing to the poor reliability of CXRs. Despite this, the high specificity of CXRs shown in our results is encouraging for continued use of radiographs for TB diagnosis in both settings.
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Affiliation(s)
- Mohamed M Elsingergy
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
| | - Jaishree Naidoo
- Department of Radiology, University of Witwatersrand, Johannesburg, South Africa
| | - Gregory Baker
- Department of Radiology, University of Witwatersrand, Johannesburg, South Africa
| | - Heather J Zar
- Department of Pediatrics & Child Health, Red Cross Children's Hospital, and SA-MRC Unit On Child & Adolescent Health University of Cape Town, Cape Town, South Africa
| | - Susan Lucas
- Department of Radiology, University of Witwatersrand, Johannesburg, South Africa
| | - Savvas Andronikou
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Arias-Garzón D, Tabares-Soto R, Bernal-Salcedo J, Ruz GA. Biases associated with database structure for COVID-19 detection in X-ray images. Sci Rep 2023; 13:3477. [PMID: 36859430 PMCID: PMC9975856 DOI: 10.1038/s41598-023-30174-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 02/17/2023] [Indexed: 03/03/2023] Open
Abstract
Several artificial intelligence algorithms have been developed for COVID-19-related topics. One that has been common is the COVID-19 diagnosis using chest X-rays, where the eagerness to obtain early results has triggered the construction of a series of datasets where bias management has not been thorough from the point of view of patient information, capture conditions, class imbalance, and careless mixtures of multiple datasets. This paper analyses 19 datasets of COVID-19 chest X-ray images, identifying potential biases. Moreover, computational experiments were conducted using one of the most popular datasets in this domain, which obtains a 96.19% of classification accuracy on the complete dataset. Nevertheless, when evaluated with the ethical tool Aequitas, it fails on all the metrics. Ethical tools enhanced with some distribution and image quality considerations are the keys to developing or choosing a dataset with fewer bias issues. We aim to provide broad research on dataset problems, tools, and suggestions for future dataset developments and COVID-19 applications using chest X-ray images.
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Affiliation(s)
- Daniel Arias-Garzón
- Departamento de Electrónica y Automatización, Universidad Autónoma de Manizales, Manizales, 170001, Colombia
| | - Reinel Tabares-Soto
- Departamento de Electrónica y Automatización, Universidad Autónoma de Manizales, Manizales, 170001, Colombia
- Facultad de Ingeniería y Ciencias, Universidad Adolfo Ibáñez, 7941169, Santiago, Chile
- Departamento de Sistemas e Informática, Universidad de Caldas, Manizales, 170001, Colombia
| | - Joshua Bernal-Salcedo
- Departamento de Electrónica y Automatización, Universidad Autónoma de Manizales, Manizales, 170001, Colombia
| | - Gonzalo A Ruz
- Facultad de Ingeniería y Ciencias, Universidad Adolfo Ibáñez, 7941169, Santiago, Chile.
- Center of Applied Ecology and Sustainability (CAPES), 8331150, Santiago, Chile.
- Data Observatory Foundation, 7941169, Santiago, Chile.
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Tsitsiou Y, Rajkumar L, Hlabangana LT, Naidoo J, Clark LM, Zar HJ, Andronikou S. Quality assurance of paediatric lateral chest radiographs. J Med Imaging Radiat Sci 2022; 53:623-632. [PMID: 36070968 DOI: 10.1016/j.jmir.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/10/2022] [Accepted: 08/11/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Lateral chest radiographs aid in paediatric clinical practice in countries where the diagnosis of primary pulmonary tuberculosis (PTB) still relies heavily on the chest radiograph. This study aimed to create a validated quality assurance (QA) tool investigating the diagnostic performance of this projection by applying this to a database of lateral chest radiographs in children with suspected PTB. METHOD The QA tool was built to include a compilation of criteria from the different sources, accompanied by graphic representations and objective measurements where appropriate. Each defined criterion (radiographic error) was evaluated by implementing the QA tool on 300 radiographs, scored by three readers. The sample was subjected to two separate sets of data analysis, based on averages, and on majority decision methodology. RESULTS The QA tool was based on existing published criteria, as well as under-collimation and under-inspiration, two de novo criteria. For the total 900 reads, errors were categorized as patient-related in 681 (75.7%) and radiographer-related in 421 (46.8%) and 122 (13.6%) had no errors. The average number of errors per radiograph ranged from 0.9 to 4.7 errors out of the 11 quality factors reviewed. When considering the majority decision, the median errors per radiograph was 1 (IQR 1-2) (range 0-5). Inter-rater agreement varied for different criteria. CONCLUSION A novel QA tool for evaluating lateral chest radiographs was developed which requires further efforts of refinement regarding criteria such as exposure, field of view: under-collimation, and motion artifact, which remain subjective. The designed QA tool will allow comparison of radiograph quality before and after interventions. Furthermore, the tool can be used in tackling childhood PTB in low- and middle-income countries (LMICs) since the hallmark of the disease is lymphadenopathy, which is often depicted best on lateral chest radiographs.
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Affiliation(s)
- Yvonne Tsitsiou
- Faculty of Medicine, Imperial College London, London, United Kingdom; Department of Radiology, Charing Cross Hospital, Imperial NHS Trust, Fulham Palace Rd, London W6 8RF, UK.
| | - Leisha Rajkumar
- Department of Radiology, Faculty of Medicine, Helen Joseph Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Heather J Zar
- Unit on Child and Adolescent Health, South African Medical Research Council, Cape Town, South Africa; Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Savvas Andronikou
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatric Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Otero HJ, Elsingergy MM, Back SJ. Magnetic resonance urography: a practical approach to preparation, protocol and interpretation. Pediatr Radiol 2022:10.1007/s00247-022-05511-7. [PMID: 36149476 DOI: 10.1007/s00247-022-05511-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/15/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
Magnetic resonance urography (MRU) is an important MRI application that provides noninvasive comprehensive morphological and functional evaluation of the kidneys and urinary tract. It can be used to assess congenital anomalies of the kidney and urinary tract, which often present as urinary tract dilation. In children, MRU allows for high tissue contrast and high spatial resolution without requiring ionizing radiation. Magnetic resonance urography requires patient preparation in the form of pre-examination intravenous hydration, placement of a urinary catheter, and the administration of diuretics at the time of the exam. The imaging protocol is based on T2-weighted images for anatomical assessment and dynamic post-contrast images for functional evaluation. These images are then used to generate quantitative and graphic results including contrast transit and excretion time as well as to calculate differential renal function. This review focuses on a simple approach to pediatric MRU acquisition and interpretation based on clinical cases and the authors' experience.
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Affiliation(s)
- Hansel J Otero
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Mohamed M Elsingergy
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Susan J Back
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Elsingergy M, Kidd M, Hlabangana LT, Andronikou S. Response to the letter to the editor re: Inter-rater reliability in quality assurance (QA) of pediatric chest X-rays. J Med Imaging Radiat Sci 2021; 52:659-660. [PMID: 34602374 DOI: 10.1016/j.jmir.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Mohamed Elsingergy
- The Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Martin Kidd
- Centre for Statistical Consultation, University of Stellenbosch, Stellenbosch, South Africa
| | - Linda Tebogo Hlabangana
- University of the Witwatersrand School of Clinical Medicine, Faculty of Health Sciences, Johannesburg, South Africa
| | - Savvas Andronikou
- The Children's Hospital of Philadelphia, Philadelphia, PA, United States; University of Pennsylvania, Philadelphia, PA, United States
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Sabour S. Quality assurance (QA) of pediatric chest X-rays: Methodological issues on inter-rater reliability. J Med Imaging Radiat Sci 2021; 52:657-658. [PMID: 34583908 DOI: 10.1016/j.jmir.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 09/10/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Siamak Sabour
- Department of Clinical Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, I.R. Iran; Safety Promotions and Injury Prevention Research Centre, Shahid Beheshti University of Medical Sciences, Tehran, I.R. Iran.
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