Abnormal CXR Research Articles

No Role for Routine Chest Radiography in Stage I Seminoma Surveillance

BackgroundAfter orchidectomy, the standard management options available for stage I seminoma are surveillance, adjuvant radiotherapy, or adjuvant chemotherapy. The optimal follow-up protocol for surveillance is yet to be determined but includes frequent chest radiography (CXR) and computed tomography (CT) scan of the abdomen and pelvis (CT-AP). ObjectiveThe purpose of this study was to identify the modality that first detected relapse and to assess the value of the CXR in this setting. Design, setting, and participantsFive hundred twenty-seven patients with histologically confirmed stage I testicular seminoma were managed with surveillance at our institution between 1982 and 2005. Routine CXRs were performed with each CT-AP and were done every 4–6 mo for 7 yr and annually thereafter. The median follow-up was 72 mo (range: 1–193). MeasurementsMeasurements included the 5-yr relapse rate, overall survival, and disease-free survival to determine the modality that first detected relapse disease. Results and limitationsThe 5-yr actuarial relapse rate for the 527 patients was 14%. The 5-yr disease-free survival and overall survival were 85.7% and 98.6%, respectively. Seventy-three patients (97.3%) had an abnormal CT-AP and a normal CXR at relapse. One patient (1.3%) had an abnormal CT-AP with pulmonary metastasis on CXR and CT chest scan, and one patient (1.3%) had a biopsy-proven inguinal node metastasis with a normal CXR. No patient had a normal CT-AP or physical examination with an abnormal CXR at relapse. This is a single-center retrospective study based on a relatively small number of relapses and may be subject to bias. Confirmation of these results from other studies would be useful for wider clinical applicability. ConclusionsAll except one relapse were detected by CT-AP with no relapses detected on CXR alone; therefore, CXR may be omitted as routine imaging in surveillance protocols.

Observations on environmental asbestos exposure in a high risk area

Environmental asbestos exposure is causally associated with various pulmonary pathologies. In Turkey, one of the most important sources of asbestos exposure is dust originating from the walls of homes whitewashed with white stucco. The main asbestos types implicated are tremolite and, to a lesser extent, chrysotile. This study investigated the presence and effect of environmental asbestos exposure in a small village in Isparta, Turkey. Samples of asbestos mine ore, whitewashed plaster from the interior walls of the houses and whitesoil from the outside walls of the houses were analysed. Chest radiographs of 132 villagers aged 30 years and over and living in the village during the study were obtained. Verbal histories from the relatives of people who had died from lung cancer or mesothelioma and hospital records contributed 13 cases to the study population, giving a total of 145 cases under study. Chrysotile fibres were found in the old asbestos mine sample, and zeolite in the whitesoil sample from the outside walls. Abnormal CXR were found in 19 subjects (14. 4%), the most common being pleural calcifications and/or pleural plaques (n = 14, 10.6%). A further five subjects with pleural calcifications and/or pleural plaques were identified from verbal autopsy and hospital records. Malignant pleural mesothelioma was present in one living subject and four of the deaths. A possible familial clustering of lung cancer and malignant mesothelioma was noted. While tremolite asbestos is the asbestos found in most white soil in Turkey, in this village chrysotile asbestos was found in the white soil. Familial clustering may indicate genetic susceptibility or increased environmental exposure in some families.

Pulmonary hydatid disease diagnosed by bronchoscopy: A report of three cases

Pulmonary hydatid disease is an important clinical problem where echinococcal infection is endemic. Bronchoscopy is unnecessary in patients with pulmonary hydatid disease who present with a typical clinical picture and radiological appearance. However, it may be performed when a tumour is suspected or when the radiological picture is atypical. This case report presents three patients with pulmonary hydatid disease diagnosed by bronchoscopy. All patients were male, aged between 24 and 30 years, presented with pulmonary symptoms and had an abnormal CXR. Bronchoscopy showed whitish membraneous material in all three patients and biopsy confirmed the diagnosis of hydatid disease. Cystectomy was performed in two patients and right pneumonectomy was performed in the third because of pulmonary artery involvement. Bronchoscopy may be valuable in the diagnosis of pulmonary hydatid cyst disease in patients with atypical clinical and radiological presentations.

Pyogenic Liver Abscess Associated with Septic Pulmonary Embolism

Septic pulmonary embolism (SPE) is one of the metastatic foci of pyogenic liver abscess. The purpose of this study was to investigate the clinical presentations of, and management options for patients with pyogenic liver abscess complicated with SPE. A retrospective chart review was conducted from January 1, 1999 to December 31, 2005 inclusively, in a medical center in northern Taiwan. We collected and analyzed the clinical presentations, diagnostic modalities, treatment programs and prognoses for all pyogenic liver abscess patients with SPE. The association between liver abscess affected with the complication of SPE and diabetes mellitus was significant. There were 9 patients who had pyogenic liver abscess with SPE. Abnormal chest radiograph (CXR) findings with multiple ill-defined peripheral round densities were noted in all patients. Seven patients were diabetic, fever occurred in 5 patients, respiratory symptoms were noted in 6 patients, and abdominal pain occurred in 3 patients. Endophthalmitis coexisted in 3 patients, meningitis in 1 patient, and necrotizing fasciitis in 2 patients. Microbiological studies revealed Klebsiella pneumoniae in 9 patients. Computed tomography (CT) demonstrated metastatic nodules in both lung lobes, some of which featured cavitation, in all 9 patients. Three patients soon advanced to acute respiratory failure, and later died due to acute respiratory distress syndrome and/or septic shock. The remaining 6 patients survived without complication during their hospital course. There is diagnostic value in performing a chest CT scan in diabetic patients who have liver abscess plus abnormal CXR findings with multiple ill-defined peripheral round densities, in order to detect SPE, which has a relatively poor outcome in patients with liver abscess.

Unexpected Pulmonary Involvement in Extrapulmonary Tuberculosis Patients

This study aimed to assess the utility of sputum examinations and chest radiographs (CXRs) in patients with extrapulmonary tuberculosis (XPTB) to detect pulmonary involvement of tuberculosis (TB). We studied 72 XPTB patients who were managed through the TB Program, King County, WA, from January 2003 through November 2004. The two most common sites of XPTB were the lymph nodes (36 [50%]) and pleura (12 [17%]). Thirty-five of 72 XPTB patients (49%) had abnormal CXR findings. Sputum was not obtained from 15 patients despite sputum induction. Of the 57 patients from whom sputum was collected, 30 (53%) had abnormal CXR findings, 5 (9%) had sputum smears that were positive for acid-fast bacilli, and 12 (21%) had sputum cultures that were positive for Mycobacterium tuberculosis. Weight loss was significantly associated with positive sputum culture findings in a multivariate analysis (odds ratio, 4.3; 95% confidence interval, 1.01 to 18.72; p = 0.049). There was no significant difference in the occurrence of positive sputum culture results between patients with abnormal CXR findings and those with normal CXR findings (7 of 30 patients [23%] vs 5 of 27 patients [19%], respectively; p = 0.656). Of 24 HIV-negative XPTB patients with normal CXR findings, 2 patients (8%) had positive sputum culture findings. CXR results did not reliably differentiate XPTB patients with and without positive sputum culture findings. Some XPTB patients had positive sputum culture results despite normal CXR findings and negative HIV status. Weight loss in XPTB patients was associated with positive sputum culture results. Sputum examinations in XPTB patients, regardless of the CXR results, may identify potentially infectious cases of TB.

Pulmonary coccidioidomycosis found in healthy Japanese individuals

Coccidioidomycosis is endemic in the south-western USA. This study described the clinicopathological features of pulmonary coccidioidomycosis found in otherwise healthy Japanese individuals. Four male patients with pulmonary coccidioidomycosis were assessed by clinical examination, serology, PCR assay, high-resolution computed tomography and histopathological findings. All patients had returned to Japan from the USA and all presented with an abnormal CXR during routine assessment; two of the patients were symptomatic. High-resolution computed tomography showed a well-defined homogenous nodule or mass adjacent to the pleura. All patients underwent surgical wedge resection. Histopathological examination revealed encapsulated caseating epithelioid cell granulomas containing spherules and endospores. Serum IgG antibody was negative in all patients, but PCR assay using DNA from resected specimens demonstrated the presence of coccidioides-specific DNA. Pulmonary coccidioidomycosis is very rare in Japan, but it can be found incidentally during routine evaluation. The main high-resolution computed tomography findings are a well-defined homogenous nodule adjacent to the pleura, reflecting the histological feature of encapsulated granulomas. PCR assay is useful for confirming the presence of coccidioides.

Engraftment Syndrome Is Common in Patients with POEMS Syndrome Undergoing PBSCT.

Background: POEMS syndrome is a devastating syndrome, characterized by peripheral neuropathy, organomegaly, endocrinopathy, monoclonal plasma cells, skin changes, papilledema, volume overload, sclerotic bone lesions, thrombocytosis, & high VEGF. We noted an unexpectedly high transplant related morbidity, which we have since postulated to be ES.Methods: 30 patients with POEMS were treated with PBSCT at Mayo Clinic Rochester. We retrospectively studied outcomes, with an emphasis on treatment related morbidity. Two definitions of ES were used: Spitzer (BMT 2001) and Maiolino (BMT 2003).Results: Two-thirds were male. Median age was 48, range 20–70. Time from first symptoms and diagnosis was 26 and 4 months, respectively. To mobilize stem cells, CTX/G-CSF was used in 5 & G-CSF in the remainder. Conditioning was Mel200 (n=19), Mel140 (n=10), and BEAM (n=1). Post-transplant 15 had GM-CSF begun day+6. Only 10% remained outpatient, and median time to discharge from hospital was transplant day 17 (range 0–175). Factors predicting for later dismissal included age (p=0.04), abnormal CXR 7 to 17 days post transplant (p<0.0001), & bolus corticosteroids (CS) beyond day 12 post-transplant (p=0.006). Ninety-three percent had fever, although only 9 had bacteremia. Eight satisfied criteria for ES according to Spitzer and 14 according to Maiolino. Another 3 patients received steroid bolus days 8, 12, and 11 for presumed ES but did not meet criteria because of delayed ANC recovery (days 16, 18, and 20, respectively). Of the 5 patients requiring endotracheal intubation, 3 satisfied Maiolino's criteria for ES. Although these 3 received bolus CS during their course, administration was delayed at 18, 14, and 18 days. The patient whose CS bolus antedated intubation only received prednisone 30 mg/day. In toto, fourteen patients received bolus CS (daily doses between 20 and 1200 mg prednisone equivalents) commencing day 8 to 59. Those 7 patients who received CS before day 13 did better than the 7 who received them day 13 or later (Table).Conclusions: It is essential to recognize that nearly 50% of patients satisfied formal criteria for ES as defined by Maiolino. In these patients ES may run a self-limited course or lead to catastrophe.No Steroid (n=16)Steroid ≤ D12 (n=7)Steroid > D12 (n=7)PES M / S, n*5 / 24 / 45 / 2NAWt change, %0.6 (−.4.2–6.7)6.7 (3.6–27.2)11.2 (–2.1–23.2)0.005Rash, %2771430.13Diarrhea, %7386860.71Tmax, C39 (37.8–41)40.1 (39–41.1)38.9 (38.7–40.8)0.081st fever, day10 (6–15)8 (7–9)12 (8–146)0.007Abn CXR1, %1371710.03Ventilator, %014710.004First WBC, day12 (8–21)14 (12–14)14 (12–17)0.03ANC500, day15 (12–29)16 (14–115)18 (15–45)0.08PLT20, day12 (8–41)20 (11–115)24 (9–170)0.05PLT50, day15 (11–192)32 (16–115)56 (13–551)0.03RBCs, units3 (2–8)6 (4–31)11 (6–64)0.0008PLTS, aph. units2 (1–9)9 (4–51)18 (4–60)0.0004Hosp dsm, day15 (13–36)21 (15–69)41 (16–175)0.009*Engraftment syndrome according to definition of Maiolino (M) or of Spitzer (S).

Clinician vs mathematical statistical models: which is better at predicting an abnormal chest radiograph finding in injured patients?

Objective The purpose of this study was to determine if statistical models for prediction of chest injuries would outperform the clinician's (MD) ability to identify injured patients at risk for a thoracic injury diagnosed by chest radiograph (CXR). Design A prospective observational study was done during a 12-month period. Setting The study was conducted in a level I trauma center. Patients Injured patients meeting trauma team activation criteria were enrolled to the study. Interventions Physical examination findings by a clinician were interpreted and CXR was performed. Outcome measures The accuracy of 2 mathematical models is compared against the accuracy of clinician's clinical judgment in predicting an injury by CXR. Two newly constructed multivariate models, binary logistic regression (LR) and classification and regression tree (CaRT) analysis, are compared to previously published data of clinician clinical assessment of probability of thoracic injury identified by CXR. Results Data for 757 patients were analyzed. Classification and regression tree analysis developed a stepwise decision tree to determine which signs/symptoms were indicative of an abnormal CXR finding. The sensitivity (CaRT, 36.6%; LR, 36.3%; MD, 58.7%), specificity (CaRT, 98.3%; LR, 98.2%; MD, 96.4%), and error rates (CaRT, 0.93; LR, 0.94; MD, 0.82) show that the mathematical decision aids are less sensitive and risk more misclassification compared to clinician judgment in predicting an injury by CXR. Conclusion Clinician judgment was superior to mathematical decision aids for predicting an abnormal CXR finding in injured patients with chest trauma.

211: Correlates of fatigue in advanced heart failure patients

211: Correlates of fatigue in advanced heart failure patients

Leptospirosis and its pulmonary complications

The aim of this study was to assess the incidence and factors associated with pulmonary complications of leptospirosis. In a retrospective study, patients with a definite diagnosis of leptospirosis following a 6-week period of severe flooding in Hadyai city, Thailand, were reviewed. Pulmonary complications of leptospirosis were defined as the occurrence of respiratory symptoms and an abnormal CXR. The clinical and laboratory test results for patients with and without pulmonary complications were compared. Among the 157 patients with leptospirosis, eight patients had pulmonary complications. Three patients had acute renal failure (ARF) and pulmonary oedema. One patient had ARF and adult respiratory distress syndrome (ARDS). Two patients had ARF, congestive heart failure and pulmonary oedema. One patient had congestive heart failure and pulmonary oedema. One patient had only ARF. Factors associated with pulmonary complications were delayed antibiotic treatment and thrombocytopenia (platelet count < 100 x 10(9)/L). Three patients developed adult respiratory distress syndrome and one died from respiratory failure. Pulmonary complications and death occur in a low percentage of patients with leptospirosis. Delayed antibiotic treatment and thrombocytopenia are risk factors for the development of pulmonary involvement in leptospirosis.

The 1-Year Impact of Severe Acute Respiratory Syndrome on Pulmonary Function, Exercise Capacity, and Quality of Life in a Cohort of Survivors

ObjectiveTo examine pulmonary function, exercise capacity, and health-related quality of life (HRQoL) among severe acute respiratory syndrome (SARS) survivors.MethodsWe evaluated survivors with confirmed SARS at the Prince of Wales Hospital, Hong Kong, at 3, 6, and 12 months after symptom onset. Our assessment included: lung volume (total lung capacity [TLC], vital capacity, residual volume, functional residual capacity), spirometry (FVC, FEV1), diffusing capacity of the lung for carbon monoxide (Dlco), inspiratory and expiratory respiratory muscle strength, 6-min walk distance (6MWD), chest radiographs (CXRs), and HRQoL by Medical Outcomes Study 36-Item Short-Form General Health Survey questionnaire.ResultsNinety-seven patients completed the serial assessments. There were 39 male and 58 female patients, and 63 patients (70%) were health-care workers (mean age, 36.9 years [SD, 9.5 years]; body mass index, 23.7 kg/m2 [SD, 4.0 kg/m2]). At 1 year, 27 patients (27.8%) had abnormal CXR findings. Four patients (4.1%), 5 patients (5.2%), and 23 patients (23.7%) had FVC, TLC, and Dlco values < 80% of predicted values, respectively. The 6MWD at 12 months was 511.0 m (SD, 89.8 m), which was higher than at 3 months (mean difference, 47.0 m; 95% confidence interval [CI], 31.8 to 62.1 m; p < 0.01) but not different from 6 months (mean difference, 9.7 m; 95% CI, − 4.4 to 23.8 m; p = 0.18). The 6MWD was lower than that for normal control subjects of the same age groups, and there was impairment of HRQoL at 12 months. Patients who required ICU admission (n = 31) showed higher CXR scores (1.6 [SD, 3.1]; vs 0.4 [SD, 1.1]; p = 0.04) and lower percentage of predicted FVC, TLC, and Dlco than those who did not, but there were no differences in 6MWD and health status.ConclusionSignificant impairment in Dlco was noted in 23.7% of survivors 1 year after illness onset. Exercise capacity and health status of SARS survivors were remarkably lower than those of a normal population.

Non‐cardiogenic pulmonary oedema induced by salazosulfapyridine

A 25-year-old woman received oral salazosulfapyridine, 4 g/day, for treatment of ulcerative colitis. At 10 days later, she presented with fever and respiratory symptoms. Based on physical, laboratory and radiological findings, bacterial pneumonia and non-cardiogenic pulmonary oedema was suspected. Salazosulfapyridine was immediately halted and antibiotic therapy started. Two days later, her symptoms and abnormal findings had improved rapidly. Bacteriological studies were negative. Salazosulfapyridine-induced non-cardiogenic pulmonary oedema was diagnosed. Non-cardiogenic pulmonary oedema should be considered as one of several salazosulfapyridine- induced pulmonary diseases in patients who are receiving salazosulfapyridine and who develop respiratory symptoms and an abnormal CXR.

Pulmonary Hypertension in Sickle Cell Disease: A Common Complication for Both Adults and Children.

Pulmonary hypertension (PHT) is a risk factor for death in adults with sickle cell disease (SCD). Although occurring in >30% of adult patients, routine screening is not yet standard of care, and many patients are undiagnosed and untreated. Little is known on the prevalence of PHT in the pediatric population. A retrospective chart review was performed on 362 patients to evaluate screening practices and prevalence of PHT in both adults and children with SCD. Thirty percent (n=110) were < 18 years old, and gender was equally distributed. This review identified 96 patients with PHT (TRjet ≥2.5 m/sec by echo), suggesting a prevalence of 26.5%. However, since only 57% were screened by echo, this prevalence is grossly underestimated. Many echos documenting a TRjet ≥2.5 m/sec were interpreted by a cardiologist as NOT having PHT, likely because abnormal PAP in SCD are lower than in primary PHT. Of patients screened by echo, 46% had PHT (75 SS, 13 SC, 8 Sb-thal). Only 51% were identified by a clinician as having PHT, and only 4% were receiving treatment (chronic transfusion). Fifteen children had PHT. While 11 carried the diagnosis, none were on therapy. There was no difference in the percentage of adults vs. children screened by echo, however 56% of adults screened had PHT compared to 25% of children screened. Patients screened by echo were more likely to be male, homozygous for SS and were generally a sicker population. Patients found to have PHT were older (r=0.22, p<0.0001), and had a higher incidence of asthma, VOC episodes, gallbladder and renal disease, hepatitis C, smoking, alcohol and/or drug abuse, >LFTs, >creatinine, and more were on oxygen and/or hydroxyurea therapy compared to those without PHT. Surprisingly, history of ACS and splenectomy was similar in both groups. Comparing adults to children with PHT, more men than women were affected among adults (however more men were screened), while gender was equally distributed among children. Age of children with PHT ranged from 7–17 years (mean 12.6±3 years). Children were more likely to be homozygous for SS (14/15), carry the diagnosis of PHT, have a history of ACS (93% vs. 52%), and a higher incidence of sepsis (40% vs. 14%) than their adult counterparts. However they had fewer complications overall; renal and liver disease was rare, and less were transfused. Compared to children who do not have PHT, kids with PHT are more likely to have a history of ACS (93% vs. 63%), an abnormal CXR (87% vs. 57%), asthma (33% vs. 15%), >VOC events (60% vs. 39%), history of sepsis (40% vs. 9%), but less stroke (7% vs. 17%) and less transfusions including chronic transfusion (27% vs. 50%). It is possible that early transfusion secondary to a CNS event is protective against the development of PHT in children. Stepwise logistical regression modeling included renal disease, chronic transfusion, liver disease and alcohol use as significant risk factors for PHT (ROC = 0.82). Current mortality rate is 2% for patients without PHT vs. 8% for the PHT group (p=0.03). In conclusion, PHT is a common complication in SCD that affects both adults and children. The diagnosis is often missed, even with echo evidence of PHT. In this population 96% were untreated. Children with PHT have a different profile of complications than adults with PHT, suggesting alternate mechanisms of disease pathogenesis in children. Since PHT is associated with high mortality and morbidity, universal screening by echo and increased awareness is essential to identify patients at risk, and new therapies are critically needed.

Effective Containment of Human Respiratory Syncytial Virus Infections in a Bone Marrow Transplantation Program Resulting from the Combined Implementation of Molecular Epidemiology, Infection Control, and Early Treatment Strategies.

Although the precise incidence, epidemiology, and impact of human respiratory syncytial virus (HRSV) infection may differ greatly from center to center, there is little debate about the potential for associated morbidity and mortality. We report our approach to infection control and clinical management to reduce the clinical impact of HRSV in our BMT population. An outbreak on our BMT unit was identified in the Winter of 2000–2001. RT-PCR and nucleotide (nt) sequencing of a 270 nt variable region of the HRSV G gene of 6 cases and 12 unrelated community controls was performed. Of the 6 cases, 4 were identified as group A (genotype GA2) and 2 were identified as group B (genotype GB3). Sequences of the GA2 hospital cluster cases were identical as were the 2 hospital case GB3 isolates and the hospital case sequences differed from their respective community controls. These data suggested that there were 2 separate introductions of virus from the community followed by nosocomial spread within the outpatient facility and we were able to direct our infection control efforts and treatment strategies accordingly. An educational campaign was implemented for staff and patients emphasizing the importance of early identification and isolation of patients with HRSV. All patients with either upper (URTI) or lower respiratory tract infection (LRTI) symptoms were isolated and a nasopharyngeal swab for HRSV direct detection and CXR were performed. Post-transplantation, patients with an URTI and a positive swab for HRSV received aerosolized ribavirin (1-beta-D-ribofuranosyl-1,2,4-triazole-3-carboxamide, 6g per day) and 1.5g per kg bodyweight per day of an intravenous immunoglobulin preparation (IVIg) for 3 days. Patients with a positive NP swab and an abnormal CXR or a requirement for supplemental oxygen also received IVIg and ribavirin; however, the treatment was continued until patients no longer required oxygen supplementation. Overall, 3 patients had received autologous and 19 had received allogeneic grafts (14 nonmyeloablative, 5 myeloablative). Steroid administration was not a risk factor for disease. Since the sentinel outbreak, there was a significant decrease in the case attack rates per 10,000 patient days (0.30, 0.27, 0.15, and <0.10, per season, respectively) despite no annual decrease in the number of total cases at our institution during the same time period. Similarly, the median time to diagnosis decreased (6.0, 5.0, and 2.5 days, respectively). In the sentinel outbreak, 4 of the 9 HRSV patients, either presented or progressed to LRTI without intervention. Since the institution of our current strategies, only 3 of the 15 HRSV patients presented with LRTI; no patients progressed from upper to lower tract disease. Our findings demonstrate: (1) HRSV sequence analysis is a useful epidemiologic tool in identifying breeches in infection control measures and (2) the highly cost-effective strategy of educational materials for staff and patients was associated with a reduction in the time to diagnosis/treatment and a lower incidence of LRTI. Moreover, treatment of URTI with a truncated course of ribavirin paired with IVIg was associated with a reduction in the overall incidence of infection and appeared to prevent the progression of URTI to LRTI.

Pulmonary Hypertension: A Common Complication in Thalassemia.

Pulmonary hypertension (PHT) is a complication that is associated with high mortality rate. It is increasingly recognized in thalassemia intermedia (TI) as a leading factor in heart failure and death. Undetected PHT has been reported in 60–75% of patients. Data on PHT and thalassemia major is limited. However, these patients have many risk factors for PHT, including splenectomy, red cell phosphatidylserine exposure, coagulation abnormalities and iron overload. Since chronic hemolysis continues despite transfusion, these patients are also at risk for hemolysis-associated PHT. This is a recently described syndrome where free hemoglobin scavenges nitrous oxide and catalyzes the formation of reactive oxygen species. The purpose of this study is to determine the prevalence of PHT in transfused thalassemia patients and its risk factors. We compared the echocardiogram of 28 patients with their transfusion history, iron stores, chest x-ray, age, hemoglobin level, splenectomy status and cardiac function.The prevalence of PHT in this population was 57%. Sixteen of the 28 patients had a tricuspid regurgitant jet velocity ≥2.5 m/s, indicating PHT. 5 patients had a jet velocity ≥ 2.9 m/s suggestive of moderate PHT. Patients with PHT were more likely to be older (29±10 vs. 24±7 years without PHT, r=0.52, p=0.01) and male (56%). 41% of the female patients undergoing echocardiogram exam had PHT, while 82% of the men screened had PHT (p=0.03). PHT was also inversely related to ferritin level (r=−0.46, p=0.02). A history of an abnormal CXR occurred more frequently in the PHT group (38% vs. 8%, p=0.08), but did not reach statistical significance. However, there was no difference in hemoglobin level, creatinine, splenectomy rate (63% vs. 58%) or abnormal cardiac function between patients with PHT vs. those without PHT.Two of the 16 patients with PHT have initiated therapy with hypertransfusion or sildenafil. An intermittently transfused 25-year-old female patient lowered the tricuspid jet velocity from 3.2 to 2.4 m/s following hypertransfusion program. The second patient, a 44-year-old chronically transfused female, lowered her tricuspid jet velocity from 3 to 2.3 m/s within one month of sildenafil therapy.In conclusion, PHT is a common complication in transfused thalassemia patients that is under recognized and under treated. In contrast to other complications, adequate chelation and low iron stores are not protective. Since secondary PHT is associated with a high mortality and morbidity, annual screening with echocardiogram for all thalassemia patients is recommended. Early identification of PHT and its risk factors may prevent the irreversible cardiomyopathy that may develop. Prospective studies evaluating therapies, including hypertransfusion, sildenafil and arginine are needed.

Is routine chest radiography necessary for the initial evaluation of fever in neutropenic children with cancer?

The yield of routine chest radiography (CXR) as part of the initial management of febrile neutropenic pediatric oncology patients is questionable. We retrospectively analyzed the clinical records of neutropenic (absolute neutrophil count < or = 0.5 x 10(9)/L) children with cancer, admitted with oral temperature > or = 38 degrees C to our institution, between January 2001 and October 2002. Following admission, patients received tobramycin plus (piperacillin or ticarcillin-clavulanic acid). Admission routine CXRs were reviewed. Clinical and radiological features were compared with the discharge diagnosis. Age, underlying disease, and the presence of pulmonary symptoms or signs were studied as possible predictors of CXR findings related to pneumonia. In total, 88 patients experienced 170 episodes of fever. A routine admission CXR was obtained for 157 of the episodes. Radiologists found 20 (12.7%) abnormal CXR (6 with a segmental or lobar consolidation considered as a pneumonia). In addition, two patients with abnormal admission CXR developed lobar consolidation on a repeat film, later in their hospital course. There were no differences in age and type of underlying disease between children with or without pneumonia. Respiratory symptoms were initially present in 58 cases. Seven (12%) had pneumonia. Among the 99 asymptomatic cases only one (1%) patient had a pneumonia (P = 0.0041). This child had a positive blood culture for P. aeruginosa at the time of admission. None of the children had initial therapy modified on the basis of radiologic findings. In this study, pneumonia is an unusual cause of fever (5%), especially in the absence of respiratory signs or symptoms (1%). Admission CXR should be reserved for the neutropenic pediatric oncology patient presenting with fever and abnormal respiratory findings.

The imaging implications of implementing the BTS guidelines for management of acute PE

The BTS has recently published new guidelines for the investigation of suspected pulmonary embolus (PE). The management pathway requires a reliable assessment with all patients of low or intermediate clinical probability having a D-dimer assay. If the D-dimer is negative, no further investigation for PE is recommended. For patients with a high clinical probability or a positive D-dimer assay, imaging is recommended with a preference for CTPA, particularly if the CXR is abnormal. We performed a retrospective review of the 859 V/Q studies over a 12 month period from August 2002 to July 2003 to evaluate the clinical outcome of the patient's study and to determine whether other imaging was performed. Seventeen per cent of these studies had an abnormal CXR. Overall, 41.8% of the studies were normal, with the following probabilities for acute PE: low 37.6%, intermediate 5.6%, and high 15%. Further imaging was performed in 96 patients (11.1%), 22 patients with an intermediate V/Q scan had a CTPA with 9 being positive and 15 negative. Given that the radiation and financial burden of V/Q and CTPA are 1.2 mSv and £380 vs 4.2 mSv and £120, respectively, we conclude that it is justifiable to use the V/Q as the gatekeeper in PE imaging reserving CTPA for intermediate V/Q results.

The effect of referrer education on ventilation perfusion imaging referral patterns

Background: Ventilation perfusion (VQ) imaging for suspected pulmonary embolism (PE) is more likely to be diagnostically useful in the presence of a clear chest radiograph (CXR). An audit was performed to determine the effect of education of referrers on the referral patterns in this respect. Method: VQ scan reports before and after referrer education, in the form of a letter and oral presentation, were assessed: 49 reports before and 43 after. The contemporary CXR was assessed in isolation and defined as either normal, minimally abnormal or grossly abnormal. The final VQ scan result was correlated with the CXR category. Results: Before the education, 12% of CXRs were grossly abnormal whereas after this it fell to 2%. In the grossly abnormal CXR subgroup the indeterminate rate for the associated VQ scan was 100% in both time periods. Overall indeterminate rates for these periods were 28% and 22%. Conclusion: The decrease from 12% grossly abnormal CXRs to 2% is likely to be due to successful education of the referrers. Pre-assessment of the CXR by the nuclear medicine department before deciding on which specialist investigation to choose would probably further decrease the indeterminate rate for VQ scanning.

Reducing the risk of methotrexate pneumonitis in rheumatoid arthritis.

has been associated with an increased risk of MTX pneumonitis in these studies [6–11]. Meta-analytic methods were used to pool the odds ratio for MTX pneumonitis in the presence of pre-existing lung disease. The summarized data from these six studies are in Table 1. Although these studies varied in their design and definition of pre-existing lung disease, all suggested that it predisposed to MTX pneumonitis (pooled odds ratio of 7.5, 95% confidence interval CI 3.6–15.8). Pre-existing lung disease was seen in 48% of 69 patients who developed MTX pneumonitis. By comparison, only 7.4% of 1769 patients without pneumonitis had evidence of prior lung disease. Kremer and Alarcon et al. [9, 14] described the single largest series of MTX pneumonitis (29 cases) in a retrospective case– control study of RA patients. Pre-existing lung disease, old age and previous use of DMARDs were identified as risk factors for pneumonitis after MTX. Ohosone [11] came to a similar conclusion. Age and previous DMARD use have not been identified as a risk in other studies [6–8, 10]. In a multicentre study [10] of 1162 patients with RA treated with MTX in northeast England, 27 probable cases of pneumonitis were identified, of which 10 met the Searles and McKendry criteria [25] for pneumonitis. Pre-existing pulmonary fibrosis was present in five of these 10 cases of pneumonitis. Our experience in a prospective study [6] of 120 patients with RA treated with MTX identified three cases of pneumonitis. Abnormal lung function tests (less than 70% of the value predicted for age and sex) were found to confer added risk of pneumonitis. A low forced expiratory volume in 1 s (FEV1) and vital capacity (VC) carried a relative risk of 3.2 and a low transfer factor for carbon monoxide (TLCO) carried a relative risk of 10, whereas an abnormal CXR carried a relative risk of 3.3. Golden et al. [7] reported a relative risk of 4 for patients with interstitial infiltrates on CXR.

Significance of Abnormal Chest Radiograph Findings in Patients With HIV-1 Infection Without Respiratory Symptoms

Patients with HIV-1 infection or AIDS may present with abnormal chest radiograph (CXR) findings in the absence of symptoms specific to the lung. The objective was to determine the spectrum of disease and the diagnostic modalities employed in these patients. From 1996 to 1998, we identified patients with HIV-1 infection presenting to the Bellevue Hospital Chest Service with abnormal CXR findings, and absence of specific pulmonary symptoms. Charts were reviewed for presence of constitutional symptoms, CD4 lymphocyte count, use of Pneumocystis carinii pneumonia (PCP) prophylaxis, eventual diagnosis, and all diagnostic modalities employed. CXR findings were classified according to their predominant abnormalities: nodules, infiltrates, cavity, mass, adenopathy, or effusion. Forty-four patients were eligible for inclusion. Eight-six percent of patients had a CD4 lymphocyte count < 200 cells/microL, and 57% were receiving PCP prophylaxis. Nodular disease was the most common radiographic abnormality (57%), followed by adenopathy (17%). A definitive diagnosis was obtained in 86% of the patients. The most common diagnosis was tuberculosis (26%), followed by nontuberculous mycobacteria (NTM; 23%) and Kaposi sarcoma (12%). No patients had PCP or bacterial pneumonia. Sixty-two percent of patients required an invasive modality to establish a diagnosis. Only 18% of patients with tuberculosis (2 of 11 patients) received diagnoses by sputum analysis. Patients with HIV-1 infection, abnormal CXR findings, and lack of pulmonary symptoms have a high incidence of infectious disorders, especially pulmonary tuberculosis and infection due to NTM. The high prevalence of treatable and potentially communicable disorders warrants an aggressive diagnostic approach in these patients.