title: A chest radiograph scoring system in patients with severe acute respiratory infection: a validation study.
abstract: BACKGROUND
  The term severe acute respiratory infection (SARI) encompasses a heterogeneous group of respiratory illnesses. Grading the severity of SARI is currently reliant on indirect disease severity measures such as respiratory and heart rate, and the need for oxygen or intensive care. With the lungs being the primary organ system involved in SARI, chest radiographs (CXRs) are potentially useful for describing disease severity. Our objective was to develop and validate a SARI CXR severity scoring system.
  
  
  METHODS
  We completed validation within an active SARI surveillance project, with SARI defined using the World Health Organization case definition of an acute respiratory infection with a history of fever, or measured fever of ≥ 38 °C; and cough; and with onset within the last 10 days; and requiring hospital admission. We randomly selected 250 SARI cases. Admission CXR findings were categorized as: 1 = normal; 2 = patchy atelectasis and/or hyperinflation and/or bronchial wall thickening; 3 = focal consolidation; 4 = multifocal consolidation; and 5 = diffuse alveolar changes. Initially, four radiologists scored CXRs independently. Subsequently, a pediatrician, physician, two residents, two medical students, and a research nurse independently scored CXR reports. Inter-observer reliability was determined using a weighted Kappa (κ) for comparisons between radiologists; radiologists and clinicians; and clinicians. Agreement was defined as moderate (κ > 0.4-0.6), good (κ > 0.6-0.8) and very good (κ > 0.8-1.0).
  
  
  RESULTS
  Agreement between the two pediatric radiologists was very good (κ = 0.83, 95% CI 0.65-1.00) and between the two adult radiologists was good (κ = 0.75, 95% CI 0.57-0. 93). Agreement of the clinicians with the radiologists was moderate-to-good (pediatrician:κ = 0.65; pediatric resident:κ = 0.69; physician:κ = 0.68; resident:κ = 0.67; research nurse:κ = 0.49, medical students: κ = 0.53 and κ = 0.56). Agreement between clinicians was good-to-very good (pediatrician vs. physician:κ = 0.85; vs. pediatric resident:κ = 0.81; vs. medicine resident:κ = 0.76; vs. research nurse:κ = 0.75; vs. medical students:κ = 0.63 and 0.66). Following review of discrepant CXR report scores by clinician pairs, κ values for radiologist-clinician agreement ranged from 0.59 to 0.70 and for clinician-clinician agreement from 0.97 to 0.99.
  
  
  CONCLUSIONS
  This five-point CXR scoring tool, suitable for use in poorly- and well-resourced settings and by clinicians of varying experience levels, reliably describes SARI severity. The resulting numerical data enables epidemiological comparisons of SARI severity between different countries and settings.
authors.affiliation: Starship Children's Hospital, Auckland, New Zealand.
authors.forename: Emma
authors.initials: E
authors.lastname: Taylor
authors.affiliation: The SHIVERS study, Auckland and Wellington, New Zealand.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Haven
authors.affiliation: Children's Research Centre, Starship Children's Hospital, Auckland, New Zealand.
authors.forename: Peter
authors.initials: P
authors.lastname: Reed
authors.affiliation: The SHIVERS study, Auckland and Wellington, New Zealand.|Institute of Environmental Science and Research, Wellington, New Zealand.
authors.forename: Ange
authors.initials: A
authors.lastname: Bissielo
authors.affiliation: Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand.
authors.forename: Dave
authors.initials: D
authors.lastname: Harvey
authors.affiliation: The SHIVERS study, Auckland and Wellington, New Zealand.|Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand.
authors.forename: Colin
authors.initials: C
authors.lastname: McArthur
authors.affiliation: University of Auckland, Auckland, New Zealand.
authors.forename: Cameron
authors.initials: C
authors.lastname: Bringans
authors.affiliation: University of Auckland, Auckland, New Zealand.
authors.forename: Simone
authors.initials: S
authors.lastname: Freundlich
authors.affiliation: Infectious Diseases, Auckland City Hospital, Auckland, New Zealand.
authors.forename: R Joan H
authors.initials: RJ
authors.lastname: Ingram
authors.affiliation: Radiology, Starship Children's Hospital, Auckland, New Zealand.
authors.forename: David
authors.initials: D
authors.lastname: Perry
authors.affiliation: Radiology, Starship Children's Hospital, Auckland, New Zealand.
authors.forename: Francessa
authors.initials: F
authors.lastname: Wilson
authors.affiliation: Radiology, Auckland City Hospital, Auckland, New Zealand.
authors.forename: David
authors.initials: D
authors.lastname: Milne
authors.affiliation: Radiology, Auckland City Hospital, Auckland, New Zealand.
authors.forename: Lucy
authors.initials: L
authors.lastname: Modahl
authors.affiliation: The SHIVERS study, Auckland and Wellington, New Zealand.|Infectious Diseases, Auckland City Hospital, Auckland, New Zealand.
authors.forename: Q Sue
authors.initials: QS
authors.lastname: Huang
authors.affiliation: Centers for Disease Control and Prevention (CDC), Atlanta, USA.
authors.forename: Diane
authors.initials: D
authors.lastname: Gross
authors.affiliation: Centers for Disease Control and Prevention (CDC), Atlanta, USA.
authors.forename: Marc-Alain
authors.initials: MA
authors.lastname: Widdowson
authors.affiliation: Starship Children's Hospital, Auckland, New Zealand. cc.grant@auckland.ac.nz.|The SHIVERS study, Auckland and Wellington, New Zealand. cc.grant@auckland.ac.nz.|University of Auckland, Auckland, New Zealand. cc.grant@auckland.ac.nz.|Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Wellesley Street, Auckland, 1142, New Zealand. cc.grant@auckland.ac.nz.
authors.forename: Cameron C
authors.initials: CC
authors.lastname: Grant
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D013902:Radiography, Thoracic / Q000592:standards*; D012141:Respiratory Tract Infections / Q000000981:diagnostic imaging*; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index