Spare children unnecessary X-rays, say doctors in Mater Dei medical audit

Nearly three out of four X-rays performed at the Mater Dei Hospital’s emergency department for ankle injuries could have been performed unnecessarily, as no fracture was found, an audit published in the Malta Medical School Gazette shows.

Out of the 323 patients for whom their physician requested an ankle or ankle-foot X-ray at the Mater Dei A&E between September and December 2015, 76.4% did not have any fractures.

The authors recommended the implementation of a standard protocol of care for ankle injuries based on the Ottawa Ankle Rules.

This protocol states that an X-ray is required only in patients who have an acute knee injury with one or more of the following conditions: when the patient is over 55, when there is tenderness at head of fibula, when there is isolated tenderness of patella, when patient is unable to flex the knee more than 90°, and when the patient is unable to bear weight both immediately and in the emergency department.

The study warns that the use of ionising radiation found in X-rays, even if in small doses, may predispose to an increased risk of developing a malignant tumour.

The authors said physicians tend to use X-rays in order to confirm their diagnosis especially when they need to rule out the presence  of a fracture.

The study concludes that the use of guidelines can reduce inappropriate radiography usage, through appropriately filled-in request forms to establish better communication between the physician and the radiologist.

Sarah Cuschieri from the Anatomy Department, Stephan Grech from the Royal National Orthopaedic hospital in London and occupational therapist Janice Abela authored the study.

Chest X-rays on infants can be avoided

Another study also found that 53 out of 81 chest X-rays performed on children reporting symptoms of bronchiolitis could have been avoided.

The study cites “parental requests and anxiety” as one of the main reasons for an over-reliance on X-rays in the treatment of this disease.

Bronchiolitis is the most common disease of the lower respiratory tract during the first year of life and one of the most common medical emergencies in infancy.

Pediatricians Sarah Anne Caruana Galizia, Veronica Said Pullicino and Cecil Vella warned that chest X-rays should not be taken indiscriminately as they carry a small but significant exposure to radiation and are rarely useful in the diagnosis.

A single chest X-ray film contains the equivalent of three days of natural background radiation.

All patients aged less than six months attending the Pediatric A&E between January to April 2016 and October 2016 to February 2017, with bronchiolitis, were included in the audit.

Of the 148 infants included in this study 81 (54.7%) had a chest X-ray performed. Only 28 (34.6%) of the chest X-rays were indicated according to the guidelines issued National Institute for Health and Care Excellence (NICE) of the United Kingdom and the American Academy of Pediatrics (AAP).

Chest X-rays may be useful in detecting pneumonia. But 82.7% of the chest X-rays performed for infants presenting symptoms of bronchiolitis, were reported as normal or as showing peribronchial cuffing.

Six cases where X-rays were conducted despite not fulfilling criteria established in international guidelines, showed signs of “consolidation” associated with pneumonia, thus leading to the administration of antibiotics.

The NICE guidelines on bronchiolitis warn that findings on chest X-rays may “mimic pneumonia” and lead to the unnecessary use of antibiotics, thus increasing antimicrobial resistance, without improving outcomes.

These guidelines include specific indicators on when to perform chest X-rays. These include fever over 39°C, signs of airway complications and fever in infants aged less than three months.

The study concludes that adherence to these guidelines may help to decrease unnecessary radiation exposure and its adverse effects, reduce the financial burden of bronchiolitis on the health services and avoid unnecessary administration of antibiotics and the subsequent development of antibiotic resistance.