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As a consequence&#44; the results of different studies are quite heterogeneous&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> We only found one study in the literature assessing these aspects and specifically focused on infants with AB&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The main objective of our study was to determine whether CXR is reliable enough to be used in our setting for diagnosis of AB&#44; exploring whether the medical speciality of the observer and the level of professional experience affected the degree of agreement with the reference radiologist&#46; As secondary objectives&#44; we aimed to describe the radiological findings in a sample of infants admitted to hospital with AB and assess the technical quality of the radiographs&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design and sample</span><p id="par0010" class="elsevierStylePara elsevierViewall">We conducted a cross-sectional&#44; observational and analytical study in a secondary level hospital &#40;Appendix <a class="elsevierStyleCrossRef" href="#sec0070">B</a>&#41; and included physicians that interpreted CXRs of infants with a diagnosis of AB&#46; The data collection was prospective between 2009 and 2017&#44; including infants aged 12 or fewer months admitted with AB &#40;based on the McConnochie criteria adjusted for age&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">12</span></a> and retrospective between 2006 and 2008&#44; by reviewing the health records of all infants aged 12 or fewer months&#44; and including those with a diagnosis of AB based on the International Classification of Diseases&#44; ninth revision &#40;ICD-9&#41;&#44; specifically with a documented diagnostic code of 466&#46;11 or 466&#46;19&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Observers</span><p id="par0015" class="elsevierStylePara elsevierViewall">The study involved a total of 12 observers&#58; 5 paediatricians &#40;P1&#44; P2&#44; P3&#44; P4 y P5&#41;&#44; 3 emergency doctors &#40;ED1&#44; ED2 and ED3&#41;&#44; 2 medical residents in the speciality of Family and Community Medicine &#40;R1&#44; R2 and R3&#41; and 1 paediatric radiologist &#40;PR&#41;&#46; With the aim of analysing the potential association between the amount of professional experience of the observing paediatricians and the degree of agreement with the radiologist that served as reference&#44; we classified their professional experience based on an arbitrary breakdown of the years of professional experience following completion of the residency&#58; less than 10 years &#40;low experience&#41;&#44; 10&#8211;19 years &#40;intermediate experience&#41; and 20 or more years &#40;high experience&#41;&#46; Based on this classification&#44; paediatricians P2 and P5 had the least experience&#44; P1 had intermediate experience and P3 and P4 were most experienced&#46; We considered the PR the reference in the interpretation of the CXR&#46; She was specifically trained on paediatric radiology during her residency and has been exclusively devoted to paediatric radiology in our hospital in the past 12 years&#46; All the included physicians that performed as observers gave their verbal consent to participate in the study&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Radiographs included in the study</span><p id="par0020" class="elsevierStylePara elsevierViewall">Out of a total of 281 infants&#44; 129 &#40;45&#46;9&#37;&#41; underwent at least one CXR&#46; A total of 140 CXRs were performed in this group&#44; either during the initial contact with the emergency department or during the hospital stay&#46; All of them were anteroposterior CXRs&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Variables under study</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Protocol for observation and interpretation of radiographs</span><p id="par0025" class="elsevierStylePara elsevierViewall">For the purpose of observation and interpretation&#44; each of the 140 CXRs was displayed in the same digital format and in a different order for each of the 12 observers&#46; We set up a computer in each of the departments where the collaborating observers were affiliated to&#46; To prevent the potential identification of the images and potential communication between observers&#44; we changed the sequence of the CXRs to be examined for each observer&#44; although all of them interpreted the same images&#46; During the period in which the X-ray films were available for interpretation&#44; the observers were not allowed to talk to each other or to access any other external source of information&#46; They were also denied access to the health records of the patients and all they knew about the patients was that they were infants with a diagnosis of AB&#46; The films were viewed on a 24-inch screen with 1920&#8239;&#215;&#8239;1080 full high-definition resolution&#46; Each observer had to assess each and every radiograph for the presence or absence of the following 10 radiographic signs&#58; hyperinflated lungs&#44; hilar enlargement&#44; perihilar or peribronchial infiltrates&#44; diffuse interstitial infiltrates&#44; subsegmental atelectasis&#44; pulmonary infiltrates or major atelectasis&#44; cardiomegaly&#44; pneumomediastinum&#44; pneumothorax and foreign body&#46; The presence of any of these radiographic signs did not exclude the others&#46; We considered the first 5 signs compatible with &#8220;simple or uncomplicated AB&#8221;&#46; We considered the presence of the sixth sign compatible with &#8220;complicated AB&#8221;&#44; and the remaining 4 signs suggestive of a &#8220;possible alternative diagnosis other than AB&#8221;&#46; When none of these 10 signs were present&#44; the radiograph was considered a &#8220;normal CXR&#8221;&#46; The categories we used to classify the CXRs taken in infants with AB do not constitute a validated approach but were established by consensus by the research team following the reading and analysis of similar studies in the previous literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;15</span></a> In addition&#44; the PR evaluated another 4 features that are indicative of the quality of the image&#58; inclusion of the entire ribcage in the image&#44; proper centring&#47;alignment of the image&#44; adequate hardness&#47;depth of penetration and adequate inspiration&#46; These features were agreed on by the research team after consulting the literature on the subject&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">16</span></a> All radiographic signs were documented as dichotomous variables with the possible values yes&#47;no&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0030" class="elsevierStylePara elsevierViewall">We have summarised the data as absolute frequencies and percentages with the corresponding 95&#37; confidence intervals &#40;CIs&#41;&#46; We assessed the agreement between 2 observers with the Cohen kappa<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">17&#44;18</span></a> and the agreement between 3 or more observers with the Fleiss kappa&#46; The latter is a generalization of the Cohen kappa that can be applied to multinomial data &#40;more than 2 categories&#41;&#44; ordinal data&#44; more than 2 observers&#44; incomplete designs and the combination of all of the above&#44; generalizations that involve more complex calculations but resulting in a statistic that is interpreted the same way&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">18&#44;19</span></a> The statistical analysis was performed with the software MATLAB 2018&#46; To interpret the kappa statistic &#40;&#8239;&#954;&#41; with a widely accepted approach&#44; we took as reference the standards of strength of agreement proposed by Landis and Koch&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">20</span></a> which have since been endorsed in the scientific literature&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">21</span></a> According to these standards&#44; kappa values of less than 0&#46;00 indicate poor agreement&#44; 0&#46;00&#8722;0&#46;20 slight agreement&#44; 0&#46;21&#8722;0&#46;40 fair agreement&#44; 0&#46;41&#8722;0&#46;60 moderate agreement&#44; 0&#46;61&#8722;0&#46;80 substantial agreement and 0&#46;81&#8211;1&#46;00 near perfect agreement&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Calculation of precision for the sample size</span><p id="par0035" class="elsevierStylePara elsevierViewall">Based on the article published by AB Cantor<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">22</span></a> and using the Epidat 4&#46;2 software&#44; we estimated the precision of the kappa statistics given the obtained sample size &#40;140 radiographs&#41;&#46; Assuming an expected value of 0&#46;4&#44; with a proportion of positives of 0&#46;8 in observer 1 and 0&#46;5 in observer 2&#44; with a 95&#37; level of confidence and a sample size of 140&#44; the precision of the obtained kappa coefficient would be 0&#46;903&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">At least 1 CXR was ordered in 129 of the 281 hospitalised infants &#40;45&#46;9&#37;&#41;&#46; One radiograph was ordered in 120 infants&#44; two in 7 infants and three in 2 infants&#46; A total of 140 CXRs were performed and included in the analysis&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarises the main characteristics of the sample under study&#46; When it came to the technical quality of the radiographs&#44; we found adequate inspiration in 96&#46;4&#37; &#40;95&#37; CI&#44; 94&#46;9&#8211;97&#46;8&#41;&#44; adequate penetration in 90&#46;7&#37; &#40;95&#37; CI&#44; 86&#46;5&#8211;94&#46;9&#41; and inclusion of the full ribcage in the image in 86&#46;4&#37; &#40;95&#37; CI&#44; 81&#46;1&#8211;91&#46;7&#41;&#46; However&#44; only 22&#46;1&#37; &#40;95&#37; CI&#44; 15&#46;0&#8211;29&#46;2&#41; were properly centred&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> presents the assessment of the presence or absence of the different radiographic signs made by the reference radiologist for the total sample of CXRs&#46; The PR found radiographic signs compatible with complicated AB in 8&#46;5&#37; of the images &#40;95&#37; CI&#44; 3&#46;7&#8211;13&#46;3&#41;&#46; There were signs compatible with alternative diagnoses other than AB in 2&#46;1&#37; of the radiographs &#40;95&#37; CI&#44; 0&#46;3&#8211;4&#46;6&#41;&#44; in 2 due to evidence of pneumothorax and in 1 due to indirect signs suggestive of the presence of a foreign body in the airway&#46; Lastly&#44; 92&#46;8&#37; &#40;95&#37; CI&#44; 89&#46;3&#8211;96&#46;3&#41; of the radiographs only featured signs compatible with simple or uncomplicated AB and 5&#46;7&#37; &#40;95&#37; CI&#44; 1&#46;7&#8211;9&#46;6&#41; were considered normal&#46; For most of the signs under study&#44; the strength of the agreement between the different providers was fair&#44; with kappa values ranging from 0&#46;20 to 0&#46;40&#44; as can be seen in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46; We only found slight agreement for the hyperinflation sign&#44; with kappa values ranging from 0&#46;00 to 0&#46;20&#46; Specifically&#44; we found a kappa of 0&#46;17 &#40;0&#46;15&#8722;0&#46;18&#41; for paediatricians&#44; a kappa of 0&#46;05 &#40;0&#46;02&#8722;0&#46;07&#41; for emergency physicians and a kappa of 0&#46;02 &#40;&#8804; 0&#46;00&#8722;0&#46;04&#41; for medical residents&#46; The strongest agreement corresponded to the foreign body sign&#44; with a kappa of 0&#46;32 &#40;0&#46;32&#8722;0&#46;32&#41; for paediatricians&#44; a kappa of 0&#46;34 &#40;0&#46;34&#8722;0&#46;34&#41; for emergency physicians and a kappa of 0&#46;32 &#40;0&#46;32&#8722;0&#46;33&#41; for medical residents &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; We also assessed the strength of agreement between each of the 11 observers &#40;5 paediatricians&#44; 3 emergency physicians and 3 medical residents&#41; and the PR&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> shows that all the paediatricians but one &#40;P5&#41; were in moderate agreement with the radiologist for most of the signs&#44; with kappa values between 0&#46;40 and 0&#46;60&#46; Nevertheless&#44; and while one of the most experienced paediatricians &#40;P3&#41; exhibited a strong agreement with the PR&#44; the next most experienced paediatrician &#40;P4&#41; ranked fourth when it came to the strength of agreement with the PR&#44; as P1 and P2 exhibited greater agreement with the radiologist&#46; Emergency physicians achieved kappa values that ranged from 0&#46;20 to 0&#46;40&#44; and 2 of the 3 medical residents exhibited weaker agreement compared to the emergency physicians&#44; with kappa values ranging from &#8211;0&#46;20 to 0&#46;20&#46; The kappa values for the remaining medical resident were comparable to the kappa values of the paediatricians&#46; Furthermore&#44; and overall&#44; all professionals exhibited lower agreement with the radiologist in the detection of radiographic signs of uncomplicated AB compared to other signs &#40;complicated AB&#44; other possible diagnoses and normal radiographic findings&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">In our study&#44; 77&#46;8&#37; of the CXRs were not properly centred in the opinion of the PR&#46; This is one of the basic characteristics used to assess the technical quality of the image&#44; and poor alignment is a frequent cause of false interpretations in paediatric chest radiographs&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">23</span></a> Our findings regarding the proportion of radiographs with signs compatible with complicated AB&#44; which was of 8&#46;5&#37; in our sample&#44; or suggestive of an alternative diagnosis&#44; which corresponded to 2&#46;1&#37; of the radiographs&#44; were similar to those of other authors&#46; Thus&#44; Schuh et al&#46; reported a proportion of radiographs compatible with complicated AB of 6&#46;9&#37; and a proportion suggestive of alternative diagnoses of 0&#46;7&#37; in a sample of 265 radiographs of patients with AB&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">24</span></a> A similar study in 140 patients found a percentage compatible with complicated AB of 16&#37; and a percentage compatible with other diagnoses of 0&#46;7&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">25</span></a> This already suggests that multiple CXRs and exposure of many infants with a clinical diagnosis of AB to radiation is required to identify signs that would change the diagnosis or the approach to treatment&#46; Studies that analyse interobserver agreement are quite heterogeneous not only in terms of the patients and disorders that they focus on&#44; but also in the radiographic signs chosen to assess the specialists interpreting the radiographs and their level of professional experience&#44; but also the methodology used&#44; for instance the comparison of only 2 observers or 3 or more observers at the same time&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">13&#44;14&#44;26&#44;27</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Under these circumstances&#44; studies yield highly heterogeneous results that are difficult to compare&#44; and some report considerable agreement between observeres<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;14</span></a> while others report moderate or fair levels of agreement with kappa values ranging from 0&#46;20 to 0&#46;60&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">13&#44;15&#44;27</span></a> similar to the levels that we found&#46; In our study&#44; when we analysed the agreement within each group of medical providers&#44; we found fair agreement with Fleiss kappa values within a narrow range from 0&#46;20 to 0&#46;40 for all signs but one&#44; as can be seen in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46; However&#44; we found greater variability in the strength of agreement&#44; with Cohen kappa values ranging from &#8211;0&#46;20 to 0&#46;60&#44; when we compared the agreement between each professional and the paediatric radiologist&#44; as can be seen in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46; Our findings were consistent with those of Lewinsky et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">15</span></a> as we found an association between the strength of the agreement with the reference and the speciality of the observer &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; with an overall stronger agreement in paediatricians compared emergency physicians and medical residents&#46; Other authors have suggested that the substantial interrater variability observed could be attributed to the different levels of clinical experience&#44;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">15&#44;27</span></a> so that more experienced observers would exhibit stronger agreement with the reference&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">15</span></a> However&#44; our findings do not support this hypothesis&#44; as the strength of agreement with the reference found in paediatric providers was not directly proportional to their level of clinical experience&#44; as one of the paediatricians with substantial experience &#40;P4&#41; exhibited a lower agreement compared to 3 of the 5 paediatricians in the study &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; There are limitations to our study&#44; such as the observers knowing from the outset that the radiographs that they would be interpreting corresponded to patients with AB&#46; Although this could have resulted in an increased agreement between observers&#44; this was not the case&#46; Furthermore&#44; our study focused on the reliability of this diagnostic test through the analysis of interobserver agreement&#44; and the information would have been more comprehensive if we had also analysed intraobserver agreement&#46; We also ought to highlight the fact that only one radiologist was used for reference&#44; although she was the only full-time paediatric radiologist in the hospital&#44; and therefore seemed the best possible choice for the purpose of the study&#46; There are also strengths to our study&#44; such as the homogeneous sample of patients&#44; all of them infants aged less than 12 months admitted to hospital with bronchiolitis&#44; and collection of data throughout 11 epidemic seasons&#46; We have found only one other study in the previous literature analysing the reliability of CXR exclusively in infants with AB&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In our study&#44; we found poor to fair interobserver agreement in the interpretation of CXR used for diagnosis of AB in infants&#46; We also described factors that may be related to the low reproducibility observed in our study&#44; such as the quality of the image&#44; the radiographic signs under assessment&#44; the medical speciality of the observer&#44; the clinical experience of the observer and the method used to assess interobserver agreement&#44; comparing 2 observers or 3 or more observers at a time&#46; Based on these findings&#44; CXR offers a low reliability as a diagnostic test in the assessment of infants with AB&#44; and therefore its routine use is not recommended&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">None of the researchers have any conflicts of interest to declare&#46; In addition&#44; none have received a grant or any other form of external funding to carry out this study&#46;</p></span></span>"
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    "fechaRecibido" => "2020-01-21"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Despite the recommendations of the current Clinical Practice Guidelines&#44; the chest x-ray continues to be a widely used diagnostic test in the assessment of infants with acute bronchiolitis &#40;AB&#41;&#46; However&#44; there have not been many studies that have assessed its reproducibility in these patients&#46; In the present study&#44; an evaluation is made on the radiographs&#44; describing their quality&#44; their radiological findings&#44; and provides new evidence on the agreement between observers&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Out of a total of 281 infants admitted due to acute bronchiolitis&#44; 140 chest x-rays were performed&#46; Twelve doctors from different specialities evaluated the presence or absence of 10 radiological signs previously agreed by consensus&#46; The level of agreement between 2 observers&#44; and in groups of 3 or more&#44; were analysed using the Cohen and Fleiss kappa index&#44; respectively&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Only 8&#46;5&#37; of the radiographs showed evidence of a complicated AB&#46; The between-observer agreement in groups of 3 or more was medium&#44; and with little variability &#40;kappa&#58; 0&#46;20&#8722;0&#46;40&#41;&#46; However&#44; between 2 observers&#44; specialists in radiology&#44; the variability was wider&#44; &#40;kappa&#58; &#8722;0&#46;20 to 0&#46;60&#41;&#46; This level of agreement was associated with factors including&#44; the sign to evaluate&#44; the medical specialty&#44; and level of professional experience&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">The low levels of agreement between observers and the wide variability&#44; makes the chest x-ray an unreliable diagnostic tool&#44; and is not recommended for the assessment of infants with AB&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">A pesar de las recomendaciones de las actuales Gu&#237;as de Pr&#225;ctica Cl&#237;nica&#44; la radiograf&#237;a de t&#243;rax sigue siendo una prueba diagn&#243;stica ampliamente utilizada en la evaluaci&#243;n de lactantes con bronquiolitis aguda&#46; No obstante&#44; su reproductibilidad en estos pacientes no ha sido muy estudiada&#46; En la presente investigaci&#243;n&#44; se eval&#250;an radiograf&#237;as describi&#233;ndose su calidad t&#233;cnica&#44; hallazgos radiol&#243;gicos en las mismas y se aportan nuevas evidencias sobre la concordancia entre observadores&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Sobre un total de 281 lactantes ingresados por bronquiolitis aguda&#44; 140 radiograf&#237;as de t&#243;rax fueron realizadas&#46; 12 m&#233;dicos de diferentes especialidades evaluaron la presencia o ausencia de 10 signos radiogr&#225;ficos previamente consensuados&#46; El nivel de concordancia entre 2 observadores y en grupos de 3 o m&#225;s&#44; fue estudiado mediante el &#237;ndice kappa de Cohen y de Fleiss respectivamente&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">&#218;nicamente en el 8&#44;5&#37; de las radiograf&#237;as se evidenciaron signos de BA complicada&#46; La concordancia entre observadores en grupos de 3 o m&#225;s fue mediana y con escasa variabilidad &#40;kappa&#58; 0&#44;20&#8722;0&#44;40&#41;&#44; sin embargo&#44; entre 2 observadores&#44; especialista con radi&#243;logo de referencia&#44; la variabilidad fue m&#225;s amplia&#44; &#40;kappa&#58; &#8722;0&#44;20 to 0&#44;60&#41;&#46; Este nivel de concordancia se relacionaba con factores tales como el signo a evaluar&#44; la especialidad m&#233;dica y el grado de experiencia profesional&#44; entre otros&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Los bajos niveles de concordancia entre observadores y su amplia variabilidad&#44; convierten a la radiograf&#237;a de t&#243;rax en una herramienta diagn&#243;stica poco fiable y no recomendable para la evaluaci&#243;n de lactantes con BA&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todo"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; Rius Peris JM&#44; Mara&#241;a P&#233;rez AI&#44; Valiente Armero A&#44; Mateo Sotos J&#44; Guardia Nieto L&#44; Mar&#237;a Torres A&#44; et al&#46; La radiograf&#237;a de t&#243;rax en la bronquiolitis aguda&#58; calidad t&#233;cnica&#44; hallazgos y evaluaci&#243;n de su fiabilidad&#46; An Pediatr &#40;Barc&#41;&#46; 2021&#59;94&#58;129&#8211;135&#46;</p>"
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      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0085" class="elsevierStylePara elsevierViewall">The following is Supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0070"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evaluation by the radiologist of the presence of the different radiographic signs&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Strength of agreement&#44; measured by means of the Fleiss kappa&#44; between observers grouped by professional category&#58; 5 paediatricians&#44; 3 emergency physicians and 3 medical residents&#46; The strength of agreement categories are shown in the horizontal axis&#46;</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">AB&#44; acute bronchiolitis&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Interobserver agreement measured with the Cohen kappa for 2 observers&#46; We compared each of the professionals &#40;5 paediatricians&#44; 3 emergency physicians and 3 medical residents&#41; with the paediatric radiologist that served as reference&#46;</p>"
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">ABX&#44; antibiotherapy&#59; CXR&#44; chest radiograph&#59; LOS&#44; length of stay&#59; PICU&#44; paediatric intensive care unit&#59; RSV&#44; respiratory syncytial virus&#59; SaO<span class="elsevierStyleInf">2</span>&#44; oxygen saturation&#46;</p>"
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                  \t\t\t\t">242 &#40;86&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Moroccan&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">129 &#40;45&#46;9&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">158 &#40;60&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                    0 => array:2 [
                      "titulo" => "Costs of hospitalization with respiratory syncytial virus illness among children aged &#60;5 years and the financial impact on households in Bangladesh&#44; 2010"
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                        0 => array:2 [
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                          "autores" => array:6 [
                            0 => "M&#46;U&#46; Bhuiyan"
                            1 => "S&#46;P&#46; Luby"
                            2 => "N&#46;I&#46; Alamgir"
                            3 => "N&#46; Homaira"
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        "texto" => "<p id="par0065" class="elsevierStylePara elsevierViewall">We thank the family medicine residents&#44; Juan Manuel S&#225;nchez&#44; Francisco Javier Cord&#243;n and Francisco Alonso&#44; the emergency department physicians&#44; Lu&#237;s Fern&#225;ndez&#44; Diana Moya and David Garc&#237;a&#44; and the physicians in the department of diagnostic radiology&#44; Lourdes Hern&#225;ndez and Daniel Soliva&#44; all of them affiliated to the Hospital Virgen de la Luz in Cuenca&#44; Spain&#44; for their voluntary and unpaid participation in the interpretation of the chest radiographs included in this study&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">We also thank our colleague in the department of information technology&#44; Mar&#237;a Victoria Carrasco&#44; for managing the blind interpretation of the radiographs by the different health care staff&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Last of all&#44; I thank Rosa Josefina Bertol&#237;n Bernades and our children&#44; Juanma and Pedro&#44; for the family time lost to the study&#44; which cannot ever be replaced&#46;</p>"
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Original Article
The chest x-ray in acute bronchiolitis: technical quality, findings, and an assessment of its reliability
La radiografía de tórax en la bronquiolitis aguda: calidad técnica, hallazgos y evaluación de su fiabilidad
Juan Manuel Rius Perisa,b,
Corresponding author
jmrius@sescam.jccm.es

Corresponding author.
, Ana Isabel Maraña Péreza,b, Ana Valiente Armeroa, Jorge Mateo Sotosa,b, Leonor Guardia Nietoa, Ana María Torresa,b, Elisa María Cueto Calvoa
a Hospital Virgen de la Luz, Cuenca, Spain
b Instituto de Tecnología, Universidad de Castilla-La Mancha, Cuenca, Spain
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    "titulo" => "The chest <span class="elsevierStyleSmallCaps">x</span>-ray in acute bronchiolitis&#58; technical quality&#44; findings&#44; and an assessment of its reliability"
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        "titulo" => "La radiograf&#237;a de t&#243;rax en la bronquiolitis aguda&#58; calidad t&#233;cnica&#44; hallazgos y evaluaci&#243;n de su fiabilidad"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Acute bronchiolitis &#40;AB&#41; is a disease that entails a substantial utilization of health care services and resources in each epidemic season&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> The plain chest radiograph &#40;CXR&#41; has been and continues to be a widely used diagnostic tool&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The most recent clinical practice guidelines and systematic reviews on AB recommend against using CXR in most of these patients<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;7</span></a> to avoid an increase in health care costs&#44; reduce waiting times in the emergency department and avoid unnecessary exposure to ionising radiation and irrational use of antibiotherapy&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In the past few years&#44; significant efforts have been made to adhere to these recommendations&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> A diagnostic test must offer an adequate validity&#44; safety&#44; reliability and precision to be recommended for use in clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The reliability and precision are determined by how reproducible the test is in different clinical contexts&#46; The reproducibility of diagnostic tests is assessed by means of interobserver agreement analyses&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Most of the previous studies on the reliability and precision of CXR in children have not focused on infants with AB&#44; but in patients with a broad age range &#40;infants and children&#41; with all sorts of lower respiratory tract infections&#46; In addition&#44; they mainly compared only 2 observers&#46; As a consequence&#44; the results of different studies are quite heterogeneous&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> We only found one study in the literature assessing these aspects and specifically focused on infants with AB&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The main objective of our study was to determine whether CXR is reliable enough to be used in our setting for diagnosis of AB&#44; exploring whether the medical speciality of the observer and the level of professional experience affected the degree of agreement with the reference radiologist&#46; As secondary objectives&#44; we aimed to describe the radiological findings in a sample of infants admitted to hospital with AB and assess the technical quality of the radiographs&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design and sample</span><p id="par0010" class="elsevierStylePara elsevierViewall">We conducted a cross-sectional&#44; observational and analytical study in a secondary level hospital &#40;Appendix <a class="elsevierStyleCrossRef" href="#sec0070">B</a>&#41; and included physicians that interpreted CXRs of infants with a diagnosis of AB&#46; The data collection was prospective between 2009 and 2017&#44; including infants aged 12 or fewer months admitted with AB &#40;based on the McConnochie criteria adjusted for age&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">12</span></a> and retrospective between 2006 and 2008&#44; by reviewing the health records of all infants aged 12 or fewer months&#44; and including those with a diagnosis of AB based on the International Classification of Diseases&#44; ninth revision &#40;ICD-9&#41;&#44; specifically with a documented diagnostic code of 466&#46;11 or 466&#46;19&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Observers</span><p id="par0015" class="elsevierStylePara elsevierViewall">The study involved a total of 12 observers&#58; 5 paediatricians &#40;P1&#44; P2&#44; P3&#44; P4 y P5&#41;&#44; 3 emergency doctors &#40;ED1&#44; ED2 and ED3&#41;&#44; 2 medical residents in the speciality of Family and Community Medicine &#40;R1&#44; R2 and R3&#41; and 1 paediatric radiologist &#40;PR&#41;&#46; With the aim of analysing the potential association between the amount of professional experience of the observing paediatricians and the degree of agreement with the radiologist that served as reference&#44; we classified their professional experience based on an arbitrary breakdown of the years of professional experience following completion of the residency&#58; less than 10 years &#40;low experience&#41;&#44; 10&#8211;19 years &#40;intermediate experience&#41; and 20 or more years &#40;high experience&#41;&#46; Based on this classification&#44; paediatricians P2 and P5 had the least experience&#44; P1 had intermediate experience and P3 and P4 were most experienced&#46; We considered the PR the reference in the interpretation of the CXR&#46; She was specifically trained on paediatric radiology during her residency and has been exclusively devoted to paediatric radiology in our hospital in the past 12 years&#46; All the included physicians that performed as observers gave their verbal consent to participate in the study&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Radiographs included in the study</span><p id="par0020" class="elsevierStylePara elsevierViewall">Out of a total of 281 infants&#44; 129 &#40;45&#46;9&#37;&#41; underwent at least one CXR&#46; A total of 140 CXRs were performed in this group&#44; either during the initial contact with the emergency department or during the hospital stay&#46; All of them were anteroposterior CXRs&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Variables under study</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Protocol for observation and interpretation of radiographs</span><p id="par0025" class="elsevierStylePara elsevierViewall">For the purpose of observation and interpretation&#44; each of the 140 CXRs was displayed in the same digital format and in a different order for each of the 12 observers&#46; We set up a computer in each of the departments where the collaborating observers were affiliated to&#46; To prevent the potential identification of the images and potential communication between observers&#44; we changed the sequence of the CXRs to be examined for each observer&#44; although all of them interpreted the same images&#46; During the period in which the X-ray films were available for interpretation&#44; the observers were not allowed to talk to each other or to access any other external source of information&#46; They were also denied access to the health records of the patients and all they knew about the patients was that they were infants with a diagnosis of AB&#46; The films were viewed on a 24-inch screen with 1920&#8239;&#215;&#8239;1080 full high-definition resolution&#46; Each observer had to assess each and every radiograph for the presence or absence of the following 10 radiographic signs&#58; hyperinflated lungs&#44; hilar enlargement&#44; perihilar or peribronchial infiltrates&#44; diffuse interstitial infiltrates&#44; subsegmental atelectasis&#44; pulmonary infiltrates or major atelectasis&#44; cardiomegaly&#44; pneumomediastinum&#44; pneumothorax and foreign body&#46; The presence of any of these radiographic signs did not exclude the others&#46; We considered the first 5 signs compatible with &#8220;simple or uncomplicated AB&#8221;&#46; We considered the presence of the sixth sign compatible with &#8220;complicated AB&#8221;&#44; and the remaining 4 signs suggestive of a &#8220;possible alternative diagnosis other than AB&#8221;&#46; When none of these 10 signs were present&#44; the radiograph was considered a &#8220;normal CXR&#8221;&#46; The categories we used to classify the CXRs taken in infants with AB do not constitute a validated approach but were established by consensus by the research team following the reading and analysis of similar studies in the previous literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;15</span></a> In addition&#44; the PR evaluated another 4 features that are indicative of the quality of the image&#58; inclusion of the entire ribcage in the image&#44; proper centring&#47;alignment of the image&#44; adequate hardness&#47;depth of penetration and adequate inspiration&#46; These features were agreed on by the research team after consulting the literature on the subject&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">16</span></a> All radiographic signs were documented as dichotomous variables with the possible values yes&#47;no&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0030" class="elsevierStylePara elsevierViewall">We have summarised the data as absolute frequencies and percentages with the corresponding 95&#37; confidence intervals &#40;CIs&#41;&#46; We assessed the agreement between 2 observers with the Cohen kappa<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">17&#44;18</span></a> and the agreement between 3 or more observers with the Fleiss kappa&#46; The latter is a generalization of the Cohen kappa that can be applied to multinomial data &#40;more than 2 categories&#41;&#44; ordinal data&#44; more than 2 observers&#44; incomplete designs and the combination of all of the above&#44; generalizations that involve more complex calculations but resulting in a statistic that is interpreted the same way&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">18&#44;19</span></a> The statistical analysis was performed with the software MATLAB 2018&#46; To interpret the kappa statistic &#40;&#8239;&#954;&#41; with a widely accepted approach&#44; we took as reference the standards of strength of agreement proposed by Landis and Koch&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">20</span></a> which have since been endorsed in the scientific literature&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">21</span></a> According to these standards&#44; kappa values of less than 0&#46;00 indicate poor agreement&#44; 0&#46;00&#8722;0&#46;20 slight agreement&#44; 0&#46;21&#8722;0&#46;40 fair agreement&#44; 0&#46;41&#8722;0&#46;60 moderate agreement&#44; 0&#46;61&#8722;0&#46;80 substantial agreement and 0&#46;81&#8211;1&#46;00 near perfect agreement&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Calculation of precision for the sample size</span><p id="par0035" class="elsevierStylePara elsevierViewall">Based on the article published by AB Cantor<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">22</span></a> and using the Epidat 4&#46;2 software&#44; we estimated the precision of the kappa statistics given the obtained sample size &#40;140 radiographs&#41;&#46; Assuming an expected value of 0&#46;4&#44; with a proportion of positives of 0&#46;8 in observer 1 and 0&#46;5 in observer 2&#44; with a 95&#37; level of confidence and a sample size of 140&#44; the precision of the obtained kappa coefficient would be 0&#46;903&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">At least 1 CXR was ordered in 129 of the 281 hospitalised infants &#40;45&#46;9&#37;&#41;&#46; One radiograph was ordered in 120 infants&#44; two in 7 infants and three in 2 infants&#46; A total of 140 CXRs were performed and included in the analysis&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarises the main characteristics of the sample under study&#46; When it came to the technical quality of the radiographs&#44; we found adequate inspiration in 96&#46;4&#37; &#40;95&#37; CI&#44; 94&#46;9&#8211;97&#46;8&#41;&#44; adequate penetration in 90&#46;7&#37; &#40;95&#37; CI&#44; 86&#46;5&#8211;94&#46;9&#41; and inclusion of the full ribcage in the image in 86&#46;4&#37; &#40;95&#37; CI&#44; 81&#46;1&#8211;91&#46;7&#41;&#46; However&#44; only 22&#46;1&#37; &#40;95&#37; CI&#44; 15&#46;0&#8211;29&#46;2&#41; were properly centred&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> presents the assessment of the presence or absence of the different radiographic signs made by the reference radiologist for the total sample of CXRs&#46; The PR found radiographic signs compatible with complicated AB in 8&#46;5&#37; of the images &#40;95&#37; CI&#44; 3&#46;7&#8211;13&#46;3&#41;&#46; There were signs compatible with alternative diagnoses other than AB in 2&#46;1&#37; of the radiographs &#40;95&#37; CI&#44; 0&#46;3&#8211;4&#46;6&#41;&#44; in 2 due to evidence of pneumothorax and in 1 due to indirect signs suggestive of the presence of a foreign body in the airway&#46; Lastly&#44; 92&#46;8&#37; &#40;95&#37; CI&#44; 89&#46;3&#8211;96&#46;3&#41; of the radiographs only featured signs compatible with simple or uncomplicated AB and 5&#46;7&#37; &#40;95&#37; CI&#44; 1&#46;7&#8211;9&#46;6&#41; were considered normal&#46; For most of the signs under study&#44; the strength of the agreement between the different providers was fair&#44; with kappa values ranging from 0&#46;20 to 0&#46;40&#44; as can be seen in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46; We only found slight agreement for the hyperinflation sign&#44; with kappa values ranging from 0&#46;00 to 0&#46;20&#46; Specifically&#44; we found a kappa of 0&#46;17 &#40;0&#46;15&#8722;0&#46;18&#41; for paediatricians&#44; a kappa of 0&#46;05 &#40;0&#46;02&#8722;0&#46;07&#41; for emergency physicians and a kappa of 0&#46;02 &#40;&#8804; 0&#46;00&#8722;0&#46;04&#41; for medical residents&#46; The strongest agreement corresponded to the foreign body sign&#44; with a kappa of 0&#46;32 &#40;0&#46;32&#8722;0&#46;32&#41; for paediatricians&#44; a kappa of 0&#46;34 &#40;0&#46;34&#8722;0&#46;34&#41; for emergency physicians and a kappa of 0&#46;32 &#40;0&#46;32&#8722;0&#46;33&#41; for medical residents &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; We also assessed the strength of agreement between each of the 11 observers &#40;5 paediatricians&#44; 3 emergency physicians and 3 medical residents&#41; and the PR&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> shows that all the paediatricians but one &#40;P5&#41; were in moderate agreement with the radiologist for most of the signs&#44; with kappa values between 0&#46;40 and 0&#46;60&#46; Nevertheless&#44; and while one of the most experienced paediatricians &#40;P3&#41; exhibited a strong agreement with the PR&#44; the next most experienced paediatrician &#40;P4&#41; ranked fourth when it came to the strength of agreement with the PR&#44; as P1 and P2 exhibited greater agreement with the radiologist&#46; Emergency physicians achieved kappa values that ranged from 0&#46;20 to 0&#46;40&#44; and 2 of the 3 medical residents exhibited weaker agreement compared to the emergency physicians&#44; with kappa values ranging from &#8211;0&#46;20 to 0&#46;20&#46; The kappa values for the remaining medical resident were comparable to the kappa values of the paediatricians&#46; Furthermore&#44; and overall&#44; all professionals exhibited lower agreement with the radiologist in the detection of radiographic signs of uncomplicated AB compared to other signs &#40;complicated AB&#44; other possible diagnoses and normal radiographic findings&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">In our study&#44; 77&#46;8&#37; of the CXRs were not properly centred in the opinion of the PR&#46; This is one of the basic characteristics used to assess the technical quality of the image&#44; and poor alignment is a frequent cause of false interpretations in paediatric chest radiographs&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">23</span></a> Our findings regarding the proportion of radiographs with signs compatible with complicated AB&#44; which was of 8&#46;5&#37; in our sample&#44; or suggestive of an alternative diagnosis&#44; which corresponded to 2&#46;1&#37; of the radiographs&#44; were similar to those of other authors&#46; Thus&#44; Schuh et al&#46; reported a proportion of radiographs compatible with complicated AB of 6&#46;9&#37; and a proportion suggestive of alternative diagnoses of 0&#46;7&#37; in a sample of 265 radiographs of patients with AB&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">24</span></a> A similar study in 140 patients found a percentage compatible with complicated AB of 16&#37; and a percentage compatible with other diagnoses of 0&#46;7&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">25</span></a> This already suggests that multiple CXRs and exposure of many infants with a clinical diagnosis of AB to radiation is required to identify signs that would change the diagnosis or the approach to treatment&#46; Studies that analyse interobserver agreement are quite heterogeneous not only in terms of the patients and disorders that they focus on&#44; but also in the radiographic signs chosen to assess the specialists interpreting the radiographs and their level of professional experience&#44; but also the methodology used&#44; for instance the comparison of only 2 observers or 3 or more observers at the same time&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">13&#44;14&#44;26&#44;27</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Under these circumstances&#44; studies yield highly heterogeneous results that are difficult to compare&#44; and some report considerable agreement between observeres<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;14</span></a> while others report moderate or fair levels of agreement with kappa values ranging from 0&#46;20 to 0&#46;60&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">13&#44;15&#44;27</span></a> similar to the levels that we found&#46; In our study&#44; when we analysed the agreement within each group of medical providers&#44; we found fair agreement with Fleiss kappa values within a narrow range from 0&#46;20 to 0&#46;40 for all signs but one&#44; as can be seen in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46; However&#44; we found greater variability in the strength of agreement&#44; with Cohen kappa values ranging from &#8211;0&#46;20 to 0&#46;60&#44; when we compared the agreement between each professional and the paediatric radiologist&#44; as can be seen in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46; Our findings were consistent with those of Lewinsky et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">15</span></a> as we found an association between the strength of the agreement with the reference and the speciality of the observer &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; with an overall stronger agreement in paediatricians compared emergency physicians and medical residents&#46; Other authors have suggested that the substantial interrater variability observed could be attributed to the different levels of clinical experience&#44;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">15&#44;27</span></a> so that more experienced observers would exhibit stronger agreement with the reference&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">15</span></a> However&#44; our findings do not support this hypothesis&#44; as the strength of agreement with the reference found in paediatric providers was not directly proportional to their level of clinical experience&#44; as one of the paediatricians with substantial experience &#40;P4&#41; exhibited a lower agreement compared to 3 of the 5 paediatricians in the study &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; There are limitations to our study&#44; such as the observers knowing from the outset that the radiographs that they would be interpreting corresponded to patients with AB&#46; Although this could have resulted in an increased agreement between observers&#44; this was not the case&#46; Furthermore&#44; our study focused on the reliability of this diagnostic test through the analysis of interobserver agreement&#44; and the information would have been more comprehensive if we had also analysed intraobserver agreement&#46; We also ought to highlight the fact that only one radiologist was used for reference&#44; although she was the only full-time paediatric radiologist in the hospital&#44; and therefore seemed the best possible choice for the purpose of the study&#46; There are also strengths to our study&#44; such as the homogeneous sample of patients&#44; all of them infants aged less than 12 months admitted to hospital with bronchiolitis&#44; and collection of data throughout 11 epidemic seasons&#46; We have found only one other study in the previous literature analysing the reliability of CXR exclusively in infants with AB&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In our study&#44; we found poor to fair interobserver agreement in the interpretation of CXR used for diagnosis of AB in infants&#46; We also described factors that may be related to the low reproducibility observed in our study&#44; such as the quality of the image&#44; the radiographic signs under assessment&#44; the medical speciality of the observer&#44; the clinical experience of the observer and the method used to assess interobserver agreement&#44; comparing 2 observers or 3 or more observers at a time&#46; Based on these findings&#44; CXR offers a low reliability as a diagnostic test in the assessment of infants with AB&#44; and therefore its routine use is not recommended&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">None of the researchers have any conflicts of interest to declare&#46; In addition&#44; none have received a grant or any other form of external funding to carry out this study&#46;</p></span></span>"
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    "fechaRecibido" => "2020-01-21"
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            0 => "Bronchiolitis"
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            2 => "Reproducibility"
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            0 => "Bronquiolitis"
            1 => "Radiograf&#237;a de t&#243;rax"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Despite the recommendations of the current Clinical Practice Guidelines&#44; the chest x-ray continues to be a widely used diagnostic test in the assessment of infants with acute bronchiolitis &#40;AB&#41;&#46; However&#44; there have not been many studies that have assessed its reproducibility in these patients&#46; In the present study&#44; an evaluation is made on the radiographs&#44; describing their quality&#44; their radiological findings&#44; and provides new evidence on the agreement between observers&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Out of a total of 281 infants admitted due to acute bronchiolitis&#44; 140 chest x-rays were performed&#46; Twelve doctors from different specialities evaluated the presence or absence of 10 radiological signs previously agreed by consensus&#46; The level of agreement between 2 observers&#44; and in groups of 3 or more&#44; were analysed using the Cohen and Fleiss kappa index&#44; respectively&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Only 8&#46;5&#37; of the radiographs showed evidence of a complicated AB&#46; The between-observer agreement in groups of 3 or more was medium&#44; and with little variability &#40;kappa&#58; 0&#46;20&#8722;0&#46;40&#41;&#46; However&#44; between 2 observers&#44; specialists in radiology&#44; the variability was wider&#44; &#40;kappa&#58; &#8722;0&#46;20 to 0&#46;60&#41;&#46; This level of agreement was associated with factors including&#44; the sign to evaluate&#44; the medical specialty&#44; and level of professional experience&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">The low levels of agreement between observers and the wide variability&#44; makes the chest x-ray an unreliable diagnostic tool&#44; and is not recommended for the assessment of infants with AB&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">A pesar de las recomendaciones de las actuales Gu&#237;as de Pr&#225;ctica Cl&#237;nica&#44; la radiograf&#237;a de t&#243;rax sigue siendo una prueba diagn&#243;stica ampliamente utilizada en la evaluaci&#243;n de lactantes con bronquiolitis aguda&#46; No obstante&#44; su reproductibilidad en estos pacientes no ha sido muy estudiada&#46; En la presente investigaci&#243;n&#44; se eval&#250;an radiograf&#237;as describi&#233;ndose su calidad t&#233;cnica&#44; hallazgos radiol&#243;gicos en las mismas y se aportan nuevas evidencias sobre la concordancia entre observadores&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Sobre un total de 281 lactantes ingresados por bronquiolitis aguda&#44; 140 radiograf&#237;as de t&#243;rax fueron realizadas&#46; 12 m&#233;dicos de diferentes especialidades evaluaron la presencia o ausencia de 10 signos radiogr&#225;ficos previamente consensuados&#46; El nivel de concordancia entre 2 observadores y en grupos de 3 o m&#225;s&#44; fue estudiado mediante el &#237;ndice kappa de Cohen y de Fleiss respectivamente&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">&#218;nicamente en el 8&#44;5&#37; de las radiograf&#237;as se evidenciaron signos de BA complicada&#46; La concordancia entre observadores en grupos de 3 o m&#225;s fue mediana y con escasa variabilidad &#40;kappa&#58; 0&#44;20&#8722;0&#44;40&#41;&#44; sin embargo&#44; entre 2 observadores&#44; especialista con radi&#243;logo de referencia&#44; la variabilidad fue m&#225;s amplia&#44; &#40;kappa&#58; &#8722;0&#44;20 to 0&#44;60&#41;&#46; Este nivel de concordancia se relacionaba con factores tales como el signo a evaluar&#44; la especialidad m&#233;dica y el grado de experiencia profesional&#44; entre otros&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Los bajos niveles de concordancia entre observadores y su amplia variabilidad&#44; convierten a la radiograf&#237;a de t&#243;rax en una herramienta diagn&#243;stica poco fiable y no recomendable para la evaluaci&#243;n de lactantes con BA&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; Rius Peris JM&#44; Mara&#241;a P&#233;rez AI&#44; Valiente Armero A&#44; Mateo Sotos J&#44; Guardia Nieto L&#44; Mar&#237;a Torres A&#44; et al&#46; La radiograf&#237;a de t&#243;rax en la bronquiolitis aguda&#58; calidad t&#233;cnica&#44; hallazgos y evaluaci&#243;n de su fiabilidad&#46; An Pediatr &#40;Barc&#41;&#46; 2021&#59;94&#58;129&#8211;135&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Strength of agreement&#44; measured by means of the Fleiss kappa&#44; between observers grouped by professional category&#58; 5 paediatricians&#44; 3 emergency physicians and 3 medical residents&#46; The strength of agreement categories are shown in the horizontal axis&#46;</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">AB&#44; acute bronchiolitis&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Interobserver agreement measured with the Cohen kappa for 2 observers&#46; We compared each of the professionals &#40;5 paediatricians&#44; 3 emergency physicians and 3 medical residents&#41; with the paediatric radiologist that served as reference&#46;</p>"
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        "titulo" => "Acknowledgments"
        "texto" => "<p id="par0065" class="elsevierStylePara elsevierViewall">We thank the family medicine residents&#44; Juan Manuel S&#225;nchez&#44; Francisco Javier Cord&#243;n and Francisco Alonso&#44; the emergency department physicians&#44; Lu&#237;s Fern&#225;ndez&#44; Diana Moya and David Garc&#237;a&#44; and the physicians in the department of diagnostic radiology&#44; Lourdes Hern&#225;ndez and Daniel Soliva&#44; all of them affiliated to the Hospital Virgen de la Luz in Cuenca&#44; Spain&#44; for their voluntary and unpaid participation in the interpretation of the chest radiographs included in this study&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">We also thank our colleague in the department of information technology&#44; Mar&#237;a Victoria Carrasco&#44; for managing the blind interpretation of the radiographs by the different health care staff&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Last of all&#44; I thank Rosa Josefina Bertol&#237;n Bernades and our children&#44; Juanma and Pedro&#44; for the family time lost to the study&#44; which cannot ever be replaced&#46;</p>"
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ISSN: 23412879
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