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Accuracy of Ultra-Low-Dose-CT of the Chest Compared to Plain Film in an Unfiltered Emergency Department Patient Cohort (UP-Chest)

Primary Purpose

Chest Pain, Cough, Thoracic Diseases

Status
Completed
Phase
Not Applicable
Locations
Austria
Study Type
Interventional
Intervention
ULDCT
Sponsored by
Medical University of Vienna
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional diagnostic trial for Chest Pain

Eligibility Criteria

18 Years - 92 Years (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  • all patients who are assigned to a clinically indicated chest X-ray by the emergency department of Vienna General Hospital
  • ability to provide informed consent
  • informed consent after detailed patient briefing

Exclusion Criteria:

  • the emergency departments assessment of a critical clinical condition oppose an examination with both modalities (ULDCT of the chest, chest X-ray)
  • assigned to chest X-ray as follow-up
  • women with positive ß-HCG-test

Sites / Locations

  • Vienna General Hospital - Medical University of Vienna

Arms of the Study

Arm 1

Arm 2

Arm Type

Other

Other

Arm Label

Reporting order: Plain Film - ULDCT

Reporting order: ULDCT - Plain Film

Arm Description

The plain film of half the participants (randomized) will be submitted for reporting by a radiologist as a first imaging method. After finishing this report, the same radiologist will assess the ULDCT of this participant. In this second report, the findings of both examinations will be summarized, and a second report will be filed. Emergency physicians will first receive the report for the plain film of the chest and will be asked for the diagnosis and its probability. Next, the report for ULDCT will be presented to them. Again, diagnosis and probabilities will be documented.

For half the participants (randomized) radiologists will first receive the data from ULDCT of the chest and write a report. Subsequently, they will receive the data from the plain film of the chest and may expand their report (explicitly separated). Emergency physicians will first receive the report for the ULDCT of the chest and will be asked for probabilities of the nine most frequent diagnoses in chest-imaging plus "other". Next, they will be presented with the report for the plain film and will again be asked to give an estimation of the probabilities for the same diagnoses as before.

Outcomes

Primary Outcome Measures

Accuracy of ultra-low-dose-CT of the chest and plain film of the chest
Initial radiologic diagnostic accuracy of both methods will be assessed by analyzing the number of reports that are changed after the images of the second modality become available to the radiologist in Arm 1 compared to Arm 2. In a final approach, the diagnostic accuracy will be analyzed by retrospectively comparing all reports with the gold standard, which will be built from all available patient data at the end of the study, including all follow-up imaging studies and laboratory tests.

Secondary Outcome Measures

Sensitivity and Specificity of ULDCT and plain film
Comparison between the two arms "ULDCT - Plain Film" and "Plain Film - ULDCT"
Frequency of change in radiological diagnosis
Comparison between the two arms "ULDCT - Plain Film" and "Plain Film - ULDCT"
Frequency of change in emergency physician's diagnosis
Comparison between the two arms "ULDCT - Plain Film" and "Plain Film - ULDCT"
Frequency of change in (planned) therapeutic course of action by emergency physician
Comparison between the two arms "ULDCT - Plain Film" and "Plain Film - ULDCT"
Frequency of accidental diagnosis in ULDCT and plain film
Comparison between the two arms "ULDCT - Plain Film" and "Plain Film - ULDCT"
Frequency of additional diagnostic imaging needed
Comparison between the two arms "ULDCT - Plain Film" and "Plain Film - ULDCT"
Frequency of unclear reports in ULDCT and plain film
Comparison between the two arms "ULDCT - Plain Film" and "Plain Film - ULDCT"
Diagnostic confidence in ULDCT and plain film by radiologist
Comparison between the two arms "ULDCT - Plain Film" and "Plain Film - ULDCT"
Diagnostic confidence in ULDCT and plain film by emergency physician
Comparison between the two arms "ULDCT - Plain Film" and "Plain Film - ULDCT"

Full Information

First Posted
April 17, 2019
Last Updated
December 18, 2019
Sponsor
Medical University of Vienna
Collaborators
Siemens AG
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1. Study Identification

Unique Protocol Identification Number
NCT03922516
Brief Title
Accuracy of Ultra-Low-Dose-CT of the Chest Compared to Plain Film in an Unfiltered Emergency Department Patient Cohort
Acronym
UP-Chest
Official Title
Accuracy of Ultra-Low-Dose-CT (ULDCT) of the Chest Compared to Plain Film in an Unfiltered Emergency Department Patient Cohort
Study Type
Interventional

2. Study Status

Record Verification Date
December 2019
Overall Recruitment Status
Completed
Study Start Date
May 2, 2019 (Actual)
Primary Completion Date
November 26, 2019 (Actual)
Study Completion Date
November 26, 2019 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Principal Investigator
Name of the Sponsor
Medical University of Vienna
Collaborators
Siemens AG

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
No

5. Study Description

Brief Summary
This trial compares the accuracy provided by plain film as well as ultra-low-dose-computed-tomography (ULDCT) of the chest. It also aims to analyze differences in diagnostic confidence and therapeutic consequence offered by these two imaging modalities.
Detailed Description
For nearly a century, chest X-ray (plain film, projectional radiography) has been the established primary imaging modality for patients with acute chest pain, suspected pneumonia, and / or acute dyspnoea in the diagnostic pathway of emergency departments, although the sensitivity and specificity of this X-ray technique are moderate. The widespread availability and use of chest X-ray is due to the low acquisition and operating costs for projectional radiography equipment, the short examination time, and the very low radiation exposure. In addition, projectional radiography of the chest often serves as a guide for further, more sensitive, diagnostical procedures. However, these advantages are partially offset by the disadvantages inherent to projectional methods: anatomical structures may superpose or mask pathological structures. As a result, some areas of the lung may be obscured, and assessment may therefore be limited. Whereas computed tomography was reserved for certain clinical questions over the last few decades, and, in most cases, served as a second imaging approach after plain film radiography, it has increasingly evolved as a primary imaging modality for several indications (e.g., suspicion of pulmonary embolism, highly suspected aortic dissection). This rise of computed tomography was due not only to its significant advantage of no superposition, but also partly driven by the marked reduction in radiation dose needed without sacrificing image quality. This was driven by the development of new detectors, modulation of tube current and voltage, as well as iterative reconstruction techniques. As a result, recent computed tomography scanners currently offer not only a more precise visualization of differences in tissue-attenuation and the significant advantage of the absence of artefacts due to superposition, but also allow for imaging with a considerably reduced radiation dosage compared to older scanners. Therefore, computed tomography may now be utilized as screening method in specific indications that carry an increased risk of certain pathologies (e.g., in long-time smokers). The introduction of the latest generation of computed tomography devices about three years ago allowed for an even further reduction in dose by filtering out low-energy photons using a tin filter, which offers the possibility of a reduction in radiation dose by another 50 % or more for established CT indications. For specific indications (e.g., lung nodules in follow-up), the radiation dose may even be reduced to a tenth or one-hundredth of a standard-dose CT (SDCT). The current reference dose-length-product (DLP) in Germany for thoracic standard-dose CT (SDCT) is ~350 mGycm (effective dose ~6 mSv) and, for thoracic low-dose-CT (LDCT / HR-CT), ~100 mGycm (effective dose ~1.7 mSv). However, the latest devices (third-generation dual-energy CT) provide the opportunity to considerably reduce the reference dose of thoracic low-dose CT. In the current literature, these scans are referred to as Ultra-Low-Dose-CT (ULDCT) and are usually associated with a radiation dosage of 0.14 to 0.5 mSv. For this dose range, no standardized reference values have been published as yet. The limiting factors of ULDCT are quantum noise, loss of spatial resolution, and other image artefacts. Therefore, careful selection of appropriate CT protocols and dosage is mandatory in order to achieve sufficient image quality to answer the respective diagnostic question. Several papers have been published on the subject of ULDCT, which are dedicated to the comparison of ULDCT with LDCT and/or SDCT. These papers conclude that this technology may be used with sufficient sensitivity and specificity for indications such as dyspnea, emphysema, or lung nodules. Due to the potential to reduce the radiation dose to less than 1/30 of a standard-dose CT while still providing acceptable image quality with the latest generation of devices, ULDCT of the chest is emerging as an interesting alternative to conventional chest X-ray. To the best of the authors' knowledge, there are currently no studies comparing and evaluating ultra-low-dose-CT as a primary imaging alternative to chest X-ray in emergency department patients. This study aims to compare ULDCT and plain film of the chest with regard to their accuracy in an unfiltered patient cohort of an emergency department. For this purpose, the investigator's ULDCT protocol will use the lowest possible dose at which image quality is diagnostically sufficient (approximately 0.2 mSv effective dose). This corresponds to less than 1/30 of the radiation dose of a standard-dose CT of the chest and to only about 2.5 times the dose of a chest X-ray in two views. This dose is equal to less than a month of natural background radiation in Austria and less than the radiation exposure on an intercontinental flight. In addition to the accuracy of ULDCT of the chest compared to plain film of the chest, this trial also aims to analyze the clinical relevance of both methods by assessing the respective impact on final diagnosis, as well as possible changes in therapy.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Chest Pain, Cough, Thoracic Diseases, Lung Diseases

7. Study Design

Primary Purpose
Diagnostic
Study Phase
Not Applicable
Interventional Study Model
Parallel Assignment
Masking
None (Open Label)
Allocation
Randomized
Enrollment
295 (Actual)

8. Arms, Groups, and Interventions

Arm Title
Reporting order: Plain Film - ULDCT
Arm Type
Other
Arm Description
The plain film of half the participants (randomized) will be submitted for reporting by a radiologist as a first imaging method. After finishing this report, the same radiologist will assess the ULDCT of this participant. In this second report, the findings of both examinations will be summarized, and a second report will be filed. Emergency physicians will first receive the report for the plain film of the chest and will be asked for the diagnosis and its probability. Next, the report for ULDCT will be presented to them. Again, diagnosis and probabilities will be documented.
Arm Title
Reporting order: ULDCT - Plain Film
Arm Type
Other
Arm Description
For half the participants (randomized) radiologists will first receive the data from ULDCT of the chest and write a report. Subsequently, they will receive the data from the plain film of the chest and may expand their report (explicitly separated). Emergency physicians will first receive the report for the ULDCT of the chest and will be asked for probabilities of the nine most frequent diagnoses in chest-imaging plus "other". Next, they will be presented with the report for the plain film and will again be asked to give an estimation of the probabilities for the same diagnoses as before.
Intervention Type
Diagnostic Test
Intervention Name(s)
ULDCT
Intervention Description
Ultra-Low-Dose-CT (ULDCT) of the chest using tin filters with third-generation dual-energy CT devices. The projected dose used will be approximately 0.2 mSv per ULDCT of the chest.
Primary Outcome Measure Information:
Title
Accuracy of ultra-low-dose-CT of the chest and plain film of the chest
Description
Initial radiologic diagnostic accuracy of both methods will be assessed by analyzing the number of reports that are changed after the images of the second modality become available to the radiologist in Arm 1 compared to Arm 2. In a final approach, the diagnostic accuracy will be analyzed by retrospectively comparing all reports with the gold standard, which will be built from all available patient data at the end of the study, including all follow-up imaging studies and laboratory tests.
Time Frame
1 year
Secondary Outcome Measure Information:
Title
Sensitivity and Specificity of ULDCT and plain film
Description
Comparison between the two arms "ULDCT - Plain Film" and "Plain Film - ULDCT"
Time Frame
1 year
Title
Frequency of change in radiological diagnosis
Description
Comparison between the two arms "ULDCT - Plain Film" and "Plain Film - ULDCT"
Time Frame
1 year
Title
Frequency of change in emergency physician's diagnosis
Description
Comparison between the two arms "ULDCT - Plain Film" and "Plain Film - ULDCT"
Time Frame
1 year
Title
Frequency of change in (planned) therapeutic course of action by emergency physician
Description
Comparison between the two arms "ULDCT - Plain Film" and "Plain Film - ULDCT"
Time Frame
1 year
Title
Frequency of accidental diagnosis in ULDCT and plain film
Description
Comparison between the two arms "ULDCT - Plain Film" and "Plain Film - ULDCT"
Time Frame
1 year
Title
Frequency of additional diagnostic imaging needed
Description
Comparison between the two arms "ULDCT - Plain Film" and "Plain Film - ULDCT"
Time Frame
1 year
Title
Frequency of unclear reports in ULDCT and plain film
Description
Comparison between the two arms "ULDCT - Plain Film" and "Plain Film - ULDCT"
Time Frame
1 year
Title
Diagnostic confidence in ULDCT and plain film by radiologist
Description
Comparison between the two arms "ULDCT - Plain Film" and "Plain Film - ULDCT"
Time Frame
1 year
Title
Diagnostic confidence in ULDCT and plain film by emergency physician
Description
Comparison between the two arms "ULDCT - Plain Film" and "Plain Film - ULDCT"
Time Frame
1 year

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Maximum Age & Unit of Time
92 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: all patients who are assigned to a clinically indicated chest X-ray by the emergency department of Vienna General Hospital ability to provide informed consent informed consent after detailed patient briefing Exclusion Criteria: the emergency departments assessment of a critical clinical condition oppose an examination with both modalities (ULDCT of the chest, chest X-ray) assigned to chest X-ray as follow-up women with positive ß-HCG-test
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Helmut Ringl, MD
Organizational Affiliation
Medical University of Vienna
Official's Role
Principal Investigator
Facility Information:
Facility Name
Vienna General Hospital - Medical University of Vienna
City
Vienna
ZIP/Postal Code
1090
Country
Austria

12. IPD Sharing Statement

Plan to Share IPD
No
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Accuracy of Ultra-Low-Dose-CT of the Chest Compared to Plain Film in an Unfiltered Emergency Department Patient Cohort

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