[Diagnostic problems in reading chest radiographies of elderly patients at admission. Personal experience]. / Problemi diagnostici nella lettura degli esami radiologici del torace di accoglimento nell'anziano. Esperienza personale.

PURPOSE: More chest radiographs are presently performed in the elderly, especially the hospitalized ones. Reading these images is difficult because of the involutions in the thoracic cage, heart and lungs and the scars or calcifications from different abnormal causes. In the elderly, bronchogenic carcinoma may present as an occasional "coin" lesion and therefore such a finding may be an important diagnostic problem and require some expensive and dangerous examinations next. We investigated the relative frequency of questionable abnormal findings in the daily reading of the chest radiographs of elderly patients, the relative importance of the radiologist's experience and of the examination execution technique; the relative costs were also evaluated. MATERIAL AND METHODS: Four radiologists, two of them more experienced (FS, PT), read the consecutive chest radiographs of 811 elderly patients (273 men, 538 women) hospitalized May to December, 1997. Four hundred and ten of them were 65-75 years old and 401 over 75 (particularly, 28 were over 90). Five hundred and sixty-five chest radiographs were made with the AMBER technique and 246 with frontal views only. T-MAT G RA Kodak high-contrast films with Kodak Lanex green-transmitting intensifying screens were used in all cases. CT scans were made with conventional (CT Sytec 3000, GE) or spiral (X Vision, Toshiba) scanners. RESULTS: Seven hundred and fifty-seven radiographs were considered adequate (93%) and 54 inadequate (7%) for diagnosis (25 in patients 65-75 years old, 25 in patients 75-80 and 4 in patients over 90). Thirty-eight of these 54 inadequate radiographs had been made with the AMBER technique and 16 with frontal views only. The more experienced radiologists read 27 (11%) and 19 (10%) of them and the less experienced ones read 4 (2%) and 4 (3%), respectively. The next examinations were other projections and/or radioscopy (4 cases), conventional tomography (7 cases), CT (43 cases), and US (2 cases). "Coin" lesions were the major cause of questionable diagnosis, especially in posterior (10 cases) and peripheral (7 cases) regions, where the differential diagnosis was with vertebral osteophytosis and small rib crowding, respectively. CONCLUSIONS: More skilled radiologists have more doubts reading the chest radiographs of elderly patients. But the next examinations will likely balance the needless ones after an initial misdiagnosis. The chest of elderly patients remains a complex and very little known subject and the reader's experience plays an important role. The examination execution technique must be as accurate as possible in both optimal and suboptimal settings.

[The radiological exam of the chest in the elderly. Technical and methodological considerations]. / L'esame radiologico del torace nell'anziano. Considerazioni tecniche e metodologiche.

PURPOSE: We investigated the capabilities of chest radiography in the elderly considering that the examination must meet the main clinical indications of this population and that it is necessary in the elderly because the correct clinical assessment is often difficult or impossible. MATERIALS AND METHODS: We reviewed the chest radiographs of 756 consecutive elderly patients admitted to our hospital from September 1 to October 31, 1996. If possible, chest radiographs were performed with the AMBER technique (156 patients, 20.7%); 240 patients (31.7%) underwent conventional radiography and the others frontal projections only (360 patients, 47.6%). T-MAT G RA Kodak high contrast films with Kodak Lanex green transmitting intensifying screens were used in all cases. The AMBER examinations of 48/156 patients with hemodynamic clinical indications were repeated with conventional frontal projections. Radiographic reports were made separately by different radiologists who considered especially the diagnostic accuracy of every examination in determining the venous overload of pulmonary circulation. RESULTS: Hemodynamic studies are the most frequent clinical indication of chest radiography in elderly patients (228/756 patients in our series, 30.2%); moreover, even if careful cardiac and pulmonary circulation studies are very important in these patients, only 52.4% of all radiographs could be made in two orthogonal projections. The blurred appearance of vascular landmarks indicating increased extravascular fluid is better depicted by conventional radiography (59.7% of cases) than by AMBER (40.3%). CONCLUSIONS: We conclude that the reduced pulmonary contrast obtained with the so-called "hard X-ray" technique poorly depicts the blurred appearance of pulmonary vessels in pulmonary venous overload. Moreover, "hard X-ray" techniques can be only sporadically used because elderly patients are often in very critical conditions, which prevents this type of examination.