Original Article 1 An Analysis of One Thousand Chest Radiographs at a Secondary Care Center Abdus Salam,* Ghulam Sabir Iqbal,** Muhammad Usman Ahmed*** From *Department of Radiology, POF Hospital, and **Departments of Surgery and ***Otolaryngology, Wah Medical College Wah Cantt Correspondence: Lt Col Abdus Salam, Classified Radiologist, Department of Radiology, POF Hospital Wah Cantt. Received: August 17, 2007 Accepted: May 24, 2008 ABSTRACT Objective: To find the workload of radiology department consisting of chest x-ray, clinical notes writing trends, and, percentage of radiographs showing abnormalities, Material and Methods: One Thousand Chest X-Rays were studied at the department of radiology, CMH Murree from April 2002 to August 2002. Results: Chest x-ray made up 28% of the workload. Three major symptoms of patients were cough (7%), Fever (6%) and chest pain (5%). Only 9.2% films had significant findings. Pulmonary Tuberculosis (2.1%) cardiomegaly (2.1%) consolidation (1.4%) and pleural effusion (.8%) were the major radiological findings. Conclusion: X-ray chest constitutes the major bulk of radiographic workload at our institution and Tuberculosis was the commonest radiological finding. (Rawal Med J 2008;33:150-154). Key Words: Chest X-ray, clinical information, radiation protection, tuberculosis. INTRODUCTION The plain chest film is the most frequently requested radiological examination. 1 It accounts for 5% of all radiological examinations in UK. 2 In USA, 1.4 Billion dollars are spent on chest x-ray every year. 3 Chest x-ray remain an important tool in depicting diseases of lungs using PA view, AP, lateral supine and occasionally apical views. 4 From radiation hazard point of view effective dose equivalent of chest x-ray is very safe (0.02 milli Sievert). It is equal to 3 days natural back ground radiations. Except hand or foot all other x-rays impart far greater effective radiation dose than chest x-ray. 5 This study was designed to find out the workload of radiology department made by chest x-ray, clinical notes writing trends of referring physicians, awareness of radiation protection procedures, percentage of radiographs showing abnormalities, wet film load, and
2 percentage of indoor/outdoor patients advised chest x-ray in a secondary care center. The result of the study will help the policy makers in developing regulatory and practice guidelines for judicial use of x-ray chest to make it cost effective. PATIENTS AND METHODS One Thousand Chest X-Rays were studied at the department of radiology CMH Murree. The study was started on First April 2002 and ended on 14 th August 2002. Patient of all ages and gender were included, both indoor and outdoor. For x-rays, 300 mas general purpose x-ray machine was used with ward radiography by 20 mas mobile x-ray unit. Manual developing was done in all the cases. Age, gender and clinical information provided on the request form were noted. A record of radiographic views advised and referring OPD / Ward was kept. All the films were examined to determine the repeat film rate and radiological findings. RESULTS Out of 15162 patients attended in OPDs only 5% were advised chest x-ray. The ratio was much higher (20%) in case of indoor patients i.e. 276 out of 1400 inpatients were advised chest x-ray. Total radiological investigations during the study were 3550 and chest x-ray made up 28% of the workload. Age of patients ranged from new born to 105 years with marked male preponderance. (M:F 6.7:1). Clinical information was provided in 50% of the cases (Table 1). Three major symptoms of patients were cough (7%), fever (6%) and chest pain (5%).
3 Table 1. Symptoms provided on requests of study subjects. Clinical Information available 502 No Clinical Information available 498 Cough 70 Fever 60 Chest Pain 52 Pre-employment 32- All Normal Annual medical check up/deputation 08 All Normal GA Fitness 10 All Normal In 97.8% of cases PA view was advised (Table 2). Repeat film rate was 0.6%. Majority (75.1%) of the chest x-rays were normal (Table3). All the cases of pre-employment/annual medical checkup and GA fitness were normal. Fifteen percent x-rays were taken away by the patients without report as wet film. Only 9.2% x-rays had significant findings. Pulmonary Tuberculosis (2.1%) Cardiomegaly (2.1%) consolidation (1.4%) and pleural effusion (.8%) were the major abnormal radiological findings. Out of 130 female patients only one was advised to be x-rayed with abdominal shield. DISCUSSION A trained radiologist may overlook 20-30% of significant abnormality on a chest film 1 and pickup rate is improved by providing clinical information on request form. The radiologist must develop a routine, which ensures that all areas of the radiographs are scrutinized. This study has disproved the assumption that 100% admitted patients and every second patient reporting in OPD is sent for x-ray. In our study, most of these patients were having cough, fever or chest pain.
4 Table 2. Radiographic views advised for the study subjects. PA View 977 Portable 12 Supine 07 Lateral 01 Abdomen Shield for Pregnancy 01 AP for ribs 01 PA for ribs 01 Total 1000 In this study, 12 patients needed ward radiography. Usually the junior most inexperienced technician is sent for this. To get good quality x-ray the most experienced radiographer should be earmarked for ward radiography. Fifteen percent x-rays were taken away without report. These wet films are usually seen in emergency room under suboptimal viewing conditions. Homogeneous light of proper brightness and color with dim room lights improve pickup rate. 6 Repeat rate should not exceed 2 %. 7 In our study, it was 0.6% which is ideal. Table 3. Radiological findings in study subjects.
5 Normal X-ray 759 Wet films 149 Cardiomegaly 21 Tuberculosis 21 Pneumonia 14 Pleural Effusion 08 Cervical Ribs 04 Rib anomalies 04 Goitre 04 Bronchiectasis 02 Chiladitis Syndrome 02 CABG 02 Kartagener Syndrome 01 Transposition of Great Arteries 01 Tracheostomy 01 Mediastinal widening 01 Diaphragm hump 01 Pulmonary Edema 01 T-10 Hemivertebra 01 Lung Abscess 01 Miliary Tuberculosis 01 Pneumonothorax 01 Total Abnormal radiographs 92 In this study, 75% radiographs were normal. Pre employment medical, annual medical and GA fitness cases had 100% normal radiographs. These results are in conformity with earlier studies done in Saudi Arabia, UK and USA which showed that there was no rationale for routine chest radiograph in apparently healthy individuals. 3 Hospital staff in regular contact with patients with tuberculosis (TB) or who handle tuberculous material is at high risk. 8 It is advisable to perform chest radiography annually for staff at high risk in hospital laboratories. For those working in normal risk area, periodic chest radiography is unnecessary. 9 Hospitals should evolve guidlines in this regard and in UK, such guidelines have reduced chest x-ray referrals to 30%. 3
6 Plain chest film has its own limitations. Small pulmonary emboli without infarction, bronchiectasis and obstructive airway disease may be associated with normal chest film. Similarly, miliary shadows, small metastases and early interstitial disease may fail to appear as visible abnormality on a plain film. 1 Tuberculosis continues to be a common health problem in underdeveloped and developing countries. 10,11 Pakistan is included in the 16 countries where lack of progress is threatening global TB control efforts. 12 The diagnosis of TB is based on clinical presentation, radiological and laboratory findings. 13,14 In this study, there were 21 cases of Pulmonary TB, 8 cases of pleural effusion and one case of miliary T.B. Only one out of 130 females was advised abdominal shield reflecting low level of radiation hazards awareness. Ideally, the referring physician should check the menstrual history and withhold x-ray examination request if there is any question about the necessity of the examination. 7 In conclusion, x-ray chest constituted bulk of radiographic workload.and TB was the commonest radiological finding. Optimum usefulness of radiographs increases when hospital investigation protocol is followed and clinical information are provided. Enforcement of radiation protection procedures is vital especially in women of reproductive age group. REFERENCES 1. Sutton D. A textbook of Radiology and Imaging. 5 th ed. Edinburg: Churchill livingstone; 1992. 289-292,315, 422-425. 2. Royal College of Radiologist Working Party. A multicentre audit of hospital referral for radiological investigation in England and Wales. BMJ 1991;303:809-12. 3. Al-Damegh S, Ghani HA, EI-Khwsky F, Kalantan K, Al-Taweel A. Evaluation of pre-entrance chest radiography in students and employees of a Saudi University. JCPSP 2002;12:65-467.
7 4. Bryan GJ. Diagnostic Radiography. 3 rd ed. Edinburg. Churchill livingstone; 1979. 19,180-188. 5. Chapman S, Nakiely R. A guide to Radiological Procedures. 3 rd ed.london. Bailliere Tindall; 1993. 402. 6. Swallow RA. Clark s Positioning in Radiography. 11 th ed.london. William Heinmann Medical Books Ltd; 1986. pp17,278-290,336,337. 7. Buchong SC. Radiologic Science for Technologist. 5 th ed. St. Louis. Mosby. Year Book, Inc; 1993. 437 607-615. 8. John HH, Leitch AG, McNicol MW, Skinner C. Control and prevention of tuberculosis in Britain: an update code of practice, BMJ 1990; 300:995-9. 9. Gatley MS. Tuberculosis in Britain (correspondence). BMJ 1990; 300: 1339. 10. Khan D. Radiological evaluation of ileocecal tuberculosis. JCPS 1999;9:307-310. 11. Almani SA, Memon NM, Qureshi AF. Drug-resistant tuberculosis in Sind. JCPSP 2000;12:136-139. 12. Khadim MK, Sarfraz J, Masud TI. Factors affecting tuberculosis control: decisionmaking at the household level. JCPSP 2003;13:697-700. 13. Sohail S. Socio-economic and diagnostic aspects of tuberculosis in Pakistan. JCPSP 2003;13:677-678. 14. Butt T, Ahmed RN, Kazmi SY, Afzal RK, Mehmood A. An update on the diagnosis of tuberculosis. JCPSP 2003;13:728-734.
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