Use Of Chest Radiography Research Articles

Prediction of Pneumonia in a Pediatric Emergency Department

To study the association between historical and physical examination findings and radiographic pneumonia in children who present with suspicion for pneumonia in the emergency department, and to develop a clinical decision rule for the use of chest radiography. We conducted a prospective cohort study in an urban pediatric emergency department of patients younger than 21 who had a chest radiograph performed for suspicion of pneumonia (n = 2574). Pneumonia was categorized into 2 groups on the basis of an attending radiologist interpretation of the chest radiograph: radiographic pneumonia (includes definite and equivocal cases of pneumonia) and definite pneumonia. We estimated a multivariate logistic regression model with pneumonia status as the dependent variable and the historical and physical examination findings as the independent variables. We also performed a recursive partitioning analysis. Sixteen percent of patients had radiographic pneumonia. History of chest pain, focal rales, duration of fever, and oximetry levels at triage were significant predictors of pneumonia. The presence of tachypnea, retractions, and grunting were not associated with pneumonia. Hypoxia (oxygen saturation ≤92%) was the strongest predictor of pneumonia (odds ratio: 3.6 [95% confidence interval (CI): 2.0-6.8]). Recursive partitioning analysis revealed that among subjects with O₂ saturation >92%, no history of fever, no focal decreased breath sounds, and no focal rales, the rate of radiographic pneumonia was 7.6% (95% CI: 5.3-10.0) and definite pneumonia was 2.9% (95% CI: 1.4-4.4). Historical and physical examination findings can be used to risk stratify children for risk of radiographic pneumonia.

Quel est l’intérêt de la radiographie du thorax dans le diagnostic d’une pneumonie de l’enfant en 2011 ?

According to the French national health authority guidelines, the diagnosis of childhood pneumonia is based on clinical suspicion and radiological confirmation. The chest radiography is an expensive procedure, and potentially deleterious by its radiating character. We have attempted to clarify its diagnostic value in community acquired pneumonia in children through a literature review using the Pubmed search engine with the following keywords: “pneumonia, child, radiograph”. Conclusion: The indication of chest radiography in severe pneumonia achieved unanimity among the various scientific societies. In contrast, in mild forms, tendency of the available data is to not recommend the routine use of chest radiography; further randomised and prospective studies are necessary to confirm this trend. Finally, because of the frequency of atypical presentations in children, chest radiography retains all its usefulness in the etiologic diagnosis of fever of unknown origin.

Variation in the Use of Chest Radiography for Pneumonia in Pediatric Emergency Departments

We sought to examine the utilization of chest radiography among children with pneumonia and other respiratory illnesses and to investigate interinstitution chest radiograph (CXR) utilization to identify if there is a relationship between CXR utilization and rate of pneumonia. This is a retrospective study of children evaluated in an emergency department at 25 institutions contributing information to the Pediatric Health Information System database from 2003 to 2008. The use of chest radiographs was determined for patients with a diagnosis of pneumonia, upper respiratory tract illness, wheeze, and fever. Over a 6-year period, pneumonia accounted for 2.1% of all visits to an emergency department. Comparing institutions, the proportion of children with a diagnosis of pneumonia who had a CXR obtained ranged from 38% to 88%. There was no observed association between CXR utilization rate and the proportion of patients with a diagnosis of pneumonia between institutions. There was also a wide variation in the use of CXR for other diagnoses (upper respiratory tract infection [range, 9%-36%], wheeze [14%-56%], fever [7%-41%]). Eighty-percent of children hospitalized with pneumonia had a radiograph obtained, compared with 76% of children with pneumonia discharged from the ED (P = 0.28). However, the rate of utilization of CXR for patients hospitalized with other diagnoses was higher than respective rates of CXR use for discharged patients (upper respiratory tract infection, 68% vs 16% [P < 0.001]; wheeze, 57% vs 23% [P < 0.001]; and fever, 45% vs 18% [P < 0.001]). The use of CXR varies widely among pediatric emergency departments but does not appear to influence the institution-specific rate of pneumonia.

Letter to the editor: Post-thoracocentesis chest radiograph – is it time for a change in practice?

The Editor, It appears to be common practice and almost customary for clinicians to request a chest radiograph following diagnostic or therapeutic thoracocentesis. Understandably, this is done to exclude complications that can occur as a result of the procedure; however, a critical look into this reveals a range of unresolved issues. Firstly, routine chest radiographs are usually requested to exclude the most likely complication following thoracocentesis i.e. pneumothorax. It had a 6% incidence following thoracocentesis in a recently published systematic review and meta-analysis [1] and an incidence of between 3% and 20% in a previous study [2]. 1.7% of all patients following thoracocentesis and 34.1% of those with demonstrated pneumothorax require chest tube insertion [1]. A retrospective audit conducted in our institution (Derriford Hospital, Plymouth, UK) yielded similar results whereby the incidence of post-thoracocentesis pneumothorax was 5% with none requiring tube drainage. The indication for a chest radiograph was to exclude pneumothorax in all cases (Table 1). Pneumothorax is a much feared complication; however, it does not occur in the majority of patients and, when it does occur, about two-thirds of patients will not require further intervention. Important factors that should be taken into consideration as possible predictors of pneumothorax include symptoms such as pleuritic chest pain, cough and shortness of breath during or after thoracocentesis, aspiration of air during the procedure and patients undergoing mechanical ventilation. Table 1 Results of a retrospective audit of post-thoracocentesis chest radiographs at Derriford Hospital, Plymouth, UK Secondly, thoracocentesis under ultrasound guidance has been shown to be associated with lower occurrence of pneumothorax and is identified as the “most important strategy to reduce pneumothorax rates” [1]. Although it is safer to perform thoracocentesis under image guidance, the feasibility and impact on service delivery cannot be ignored, leading to wider unresolved issues. If radiologists are expected to perform all ultrasound-guided thoracocentesis, the pros and cons need to be carefully thought through. Apart from lowering the occurrence of pneumothoraces, there is also the opportunity for trainee radiologists to acquire generic skills such as familiarity with ultrasound scanning and image interpretation applicable to a career in general or interventional radiology. However, it will increase the current workload and will probably require service expansion. The possibility of delay before a diagnosis is made has to be entertained if this becomes a planned procedure, which might not be acceptable, especially for urgent cases such as cases of suspected malignancy where prompt diagnosis is crucial. If non-radiologists embrace this to reduce pneumothorax rates, adequate training of the use of ultrasound guidance has to be taken more seriously. There are currently no clinical guidelines, which has led to varying practices across various institutions. Recognition of patients who will benefit from routine chest radiographs will not only avoid unnecessary exposure to radiation but also foster a more efficient and cost-effective use of limited resources. On balance, routine chest radiographs is clearly not indicated in all patients following diagnostic or therapeutic thoracocentesis. Results from various studies over the past decade do not support routine chest radiographs following all thoracocentesis [3-5]. Ultrasound-guided thoracocentesis is undoubtedly beneficial and needs to be incorporated into well designed clinical guidelines, which are long overdue to maintain efficient service provision.

Differential Effects of Zinc in Severe Pneumonia in Children

We read with great interest the article by Bansal et al. [1]. The authors had conducted a clinical trial and found that, zinc supplementation did not reduce recovery time and duration of hospital stay in children with severe acute lower respiratory tract infection (ALRTI). The study is well described, but there are few points that need comment. The authors describe that; zincmay bemore effective in the treatment of serious bacterial pneumonias, and not in viral pneumonias or bronchiolitis, which are predominantly viral illnesses. In their study, the percentage of children with wheezing was quite high (68.5%), and though they analyzed the outcome measures for wheezy and non-wheezy children separately, they did not find any significant difference in outcome. Actually, there is no published study examining the role of zinc in severe bacterial versus viral pneumonia. So, these are all speculations that zinc does not help children with pneumonia due to viral etiology (based on proportion of children with wheezing). If we look at the mechanism, how zinc might be beneficial in pneumonia, the following points need mention. Zinc deficiency enhances airway inflammation and cellular damage, whereas zinc supplementation might protect the lung from inflammatory states. Mechanisms for anti-inflammatory action of zinc in the respiratory tract include: blocking the binding of leucocytes to the endothelial cells via interaction between intercellular adhesion molecule (ICAM) -1 and leucocyte associated antigen-1 [2], inhibiting the release of preformed mediators from inflammatory cells, etc. So, the beneficial effects of zinc in severe pneumonia might depend upon the extent of inflammation and its resolution rate, as well as on the acute phase response mediated by the cytokines. Zinc also has potent antiviral action that includes: prevents the formation of viral capsid proteins (inhibiting in vitro replication of viruses) [3], prevents the virus from combining with the ICAM-1 (inhibiting viral entry into the cell), may induce the production of interferon (having non-specific antiviral actions) [4], inhibit human prostaglandin metabolism (thus decreasing inflammation). So, there is no reason for the differential effects of zinc in severe pneumonia according to the etiology. If this is proved, zinc may find its place in management of severe pneumonia as in acute diarrhea. We hope that, future trials should focus on this issue and try to compare the differential effects of zinc in severe bacterial and viral pneumonia. This might be difficult, but some suggestions include: use of chest radiograph in addition to clinical definition of pneumonia, designing the studies in a way to detect the difference in the subgroup of children without wheezing or totally excluding wheezing children, microbiological criteria (culture, PCR, antigen and/or antibody detection, etc), use of inflammatory markers (C reactive protein, procalcitonin), etc.

Pulmonary ultrasonography in the follow-up of respiratory distress syndrome on preterm newborns. Reduction of X-ray exposure

Purpose Respiratory distress syndrome (RDS) is the most common cause of respiratory failure in preterm neonates, whose lungs are often immature. The diagnosis and follow-up are based on clinical and radiographic findings. Due to the problem of air artifacts, ultrasonography (US) is not used routinely in the diagnosis of lung diseases. However, when the alveolar air content decreases, as it does in RDS, characteristic patterns appear that can be observed during US lung examinations. The aim of this study was to determine whether the use of chest radiographs in neonates with RDS could be reduced by the routine use of chest US for follow-up examinations. Materials and methods From April through September 2008, were enrolled all preterm newborns, with very low birth weight (VLBW), consecutive admitted in NICU with clinically and radiologically diagnosed RDS. We performed lung ultrasound examination in this patients. Video-taped US examinations were done every 8–12 h until clinical resolution of the disease was observed. Chest X-rays were performed only in unclear cases. We compared the number of chest radiographs obtained in the NICU during this period and during the preceding six months. Results 105 serial US lung examinations were performed in 21 preterm infant with clinically and radiologically diagnosed RDS. US lung examinations revealed “comet-tail” artifacts that were compact, diffuse, and symmetrically distributed throughout both lung fields. In 8 cases, the pleural line was also extensively thickened and irregular, and in 7 cases multiple subpleural hypoechoic areas indicative of lung consolidation were observed (mainly on posterior and lateral scans). The mean number of chest radiographs per infant performed in the NICU during the study period was significantly lower than that of the preceding six months (2.6 ± 1 versus 3.8 ± 1.5; p < 0.05). Conclusions Chest ultrasound is a valid alternative for the follow-up of VLBW infants with RDS, which can decrease the need for chest X-rays and reduce patient exposure to ionizing radiation.

Improved Detection of Subtle Lung Nodules by Use of Chest Radiographs With Bone Suppression Imaging: Receiver Operating Characteristic Analysis With and Without Localization

The purpose of this article is to evaluate radiologists' ability to detect subtle nodules by use of standard chest radiographs alone compared with bone suppression imaging used together with standard radiographs. The cases used in this observer study comprised radiographs of 72 patients with a subtle nodule and 79 patients without nodules taken from the Japanese Society of Radiological Technology nodule database. A new image-processing system was applied to the 151 radiographs to create corresponding bone suppression images. Two image reading sets were used with an independent test method. The first reading included half of the patients (a randomly selected subset A) showing only the standard image and the remaining half (subset B) showing the standard image plus bone suppression images. The second reading entailed the same subsets; however, subset A was accompanied by bone suppression images, whereas subset B was shown with only the standard image. The two image sets were read by three experienced radiologists, with an interval of more than 2 weeks between the sessions. Receiver operating characteristic (ROC) curves, with and without localization, were obtained to evaluate the observers' performance. The mean value of the area under the ROC curve for the three observers was significantly improved, from 0.840 with standard radiographs alone to 0.863 with additional bone suppression images (p = 0.01). The area under the localization ROC curve was also improved with bone suppression imaging. The use of bone suppression images improved radiologists' performance in the detection of subtle nodules on chest radiographs.

Pulmonary tuberculosis in infants less than one year old: implications for early diagnosis

Tuberculosis in older children has been well described; however, its description in infants is very limited. There are a few studies of infants with tuberculosis in the literature. In this study from February 2007 to May 2009, cases of infantile tuberculosis investigated retrospectively. Thirteen patients with pulmonary tuberculosis detected. Mean age of the patients was 168.8 days. The most frequent symptoms were cough in 10 (72.4%) patients, night sweating in five (35.7%) and fever in three (21.4%). Four patients didn't have any symptoms. Physical examinations were normal in 12 patients. Thorax computerized tomography studies of all of the patients were abnormal included the cases with normal chest radiographies. Antituberculosis treatment was well tolerated by all of the patients and all of them improved. Prevention of tuberculosis in infants rest upon the early detection and treatment of tuberculosis of the infant's household members. This study demonstrates that with high index of suspicion and the correct use of chest radiographs and thorax computerized tomography, the disease diagnosed early in infants. Early diagnosis and treatment may prevent dissemination and may reduce mortality, so pediatrician should alert for tuberculosis in infants.

Community-Acquired Pneumonia in Primary Care

Community-acquired pneumonia (CAP) is a common serious illness in childhood. It occurs in previously healthy children who acquired the infection outside of the hospital. The etiology and treatment for CAP in children and adults differ greatly. In diagnosing CAP in pediatrics, the practitioner must know the most likely age-specific causes of pneumonia. Understanding the likely etiology will assist in the treatment and management of this illness. Diagnosis is often based on the patient’s history, physical exam, age, immune status, and judicious use of chest radiographs and laboratory tests. This case study highlights one of the many presentations of CAP in pediatric primary care. It reviews diagnosis, treatment, management, and complications of this illness based on the current era of vaccinations.

170: Provider Perceptions Regarding Use of Chest Radiography In Adult Blunt Trauma Assessments

To determine 1) the reasons physicians order chest radiography (CXRs) in initial blunt trauma assessments; 2) what significant injuries they expect CXRs to reveal; and 3) whether physicians can accurately predict low-likelihood of injury on CXR. In this prospective, observational study at a level-1 trauma center, resident and attending physicians treating adult blunt trauma patients were surveyed regarding clinical decisionmaking prior to reviewing imaging. Patient inclusion criteria were 1) age > 14 years; 2) blunt trauma occurring within 24 hours of ED presentation; and 3) receipt of a CXR in the ED. Treating physicians were asked 1) the primary reason(s) for getting the CXR; 2) what, if any, injuries they expected the CXR to reveal; and 3) the likelihood of these injuries. Significant intrathoracic injury (SITI) was defined by expert panel as 2 or more rib fractures, sternal fracture, pulmonary contusion, pneumothorax, hemothorax, or aortic injury on official CXR readings. 484 patient encounters were analyzed; 65% of participating physicians were residents and 35% were attendings. The most common reasons for ordering CXRs were: “have enough concern of finding a significant injury” (54.5%), belief it is a “standard part of trauma workup” (21.5%), “other” reasons (19.9%), being taught to do so (2.6%) and malpractice concerns (1.6%). Residents were more likely to cite “standard trauma workup” than attendings (mean difference in proportions = 15.4%, p=<0.001). In 33% of encounters, physicians did not expect the CXR to reveal injuries. In the 67% of the encounters where providers expected to find a significant injury, broken ribs were most frequently expected (43.2%), followed by pneumothorax (20.3%), signs of aortic injury (8.8%), hemothorax (6.9%) and pulmonary contusion (6.5%). 16 (3.3%) patients had SITI on CXR. When providers estimated <10% likelihood of finding any significant injuries on CXR, 2.1% (95% CI: 1.0- 4.1%) of patients had SITI; when they predicted a 10-25% likelihood, 5.7% (1.2-15.7%) of patients had SITI and when they predicted a >25% likelihood, 9.1% (3.0-20.0%) had SITI. ED physicians order CXRs in blunt trauma patients primarily because they expect to find injuries and believe CXRs are part of a “standard” workup. In a third of cases, they do not expect the CXR to reveal a significant injury. When providers estimated low likelihood of SITI, the rate of SITI was very low, indicating a possible role for more selective CXR ordering.

Conferencia de Consenso sobre Bronquiolitis Aguda (III): diagnóstico en la bronquiolitis aguda. Revisión de la evidencia científica

A review of the evidence on the most commonly used diagnostic procedures in acute bronchiolitis is presented. Rapid diagnostic tests for respiratory syncytial virus infection are acceptably valid. These tests show a moderate to high sensitivity and a high specificity in relation to other reference tests. The tests most commonly used, due to their low complexity and rapid performance (enzyme immunoassay, immunochromatography and optical immunoassay techniques), have lower sensitivity than immunofluorescence. With these, a positive result is valid, but a negative result does not exclude the presence of infection with sufficient certainty. Respiratory specimens obtained by nasopharyngeal aspirate are the most valid for the identification of respiratory syncytial virus. The usefulness of chest radiography in the management of bronchiolitis has not been demonstrated. There is an unfavourable risk-benefit ratio due to the ionizing radiation exposure. There are no specific signs or symptoms to identify patients who will benefit from performing a chest radiograph. The measurement of oxygen saturation is useful in the initial assessment or in the monitoring of clinical changes of patients. Patients with AB have a very low risk of concurrent bacterial infection (particularly urinary tract infection), so the routine use of screening tests for bacterial infection is not useful. There are no clinical criteria with sufficient predictive capacity to select cases that would benefit from such tests.

Effect of Improving the Quality of Radiographic Interpretation on the Ability to Predict Pulmonary Tuberculosis Relapse

Chest radiographic findings are important for diagnosis and management of tuberculosis. The reliability of these findings is therefore of interest. We sought to describe interobserver reliability of chest radiographic findings in pulmonary tuberculosis, and to understand how the reliability of these findings might affect the utility of radiographic findings in predicting tuberculosis relapse. Three blinded readers independently reviewed chest radiographs from a randomly selected group of 10% of HIV-seronegative subjects participating in a tuberculosis treatment trial. The three readers then arrived at a fourth, consensus radiographic interpretation. A total of 241 films obtained from 99 patients were reviewed. Agreement among the independent readers was very good for the findings of bilateral disease (kappa = 0.71-0.86 among readers) and cavitation (kappa = 0.66-0.73). The original interpretation was reasonably sensitive and specific (compared to the consensus interpretation) for bilateral disease, but the sensitivity for cavity decreased from 81% for the 2-month film to 47% at end of treatment (P = 0.013). Substituting the consensus interpretation for the original interpretation increased the odds ratio for the association between cavitation on early chest radiograph and subsequent tuberculosis relapse from 4.97 to 8.97. Radiographic findings were reasonably reliable between independent reviewers and the original interpretations. The original investigators, who knew the patient's clinical course, were less likely to identify cavitation on the end of treatment chest radiograph. Improving the reliability of these findings could improve the utility of chest radiographs for predicting tuberculosis relapse.

Comparison of routine and on-demand prescription of chest radiographs in mechanically ventilated adults: a multicentre, cluster-randomised, two-period crossover study

Present guidelines recommend routine daily chest radiographs for mechanically ventilated patients in intensive care units. However, some units use an on-demand strategy, in which chest radiographs are done only if warranted by the patient's clinical status. By comparison between routine and on-demand strategies, we aimed to establish which strategy was more efficient and effective for optimum patient care. In a cluster-randomised, open-label crossover study, we randomly assigned 21 intensive care units at 18 hospitals in France to use a routine or an on-demand strategy for prescription of chest radiographs during the first of two treatment periods. Units used the alternative strategy in the second period. Each treatment period lasted for the time taken for enrolment and study of 20 consecutive patients per intensive care unit; patients were monitored until discharge from the unit or for up to 30 days' mechanical ventilation, whichever was first. Units enrolled 967 patients, but 118 were excluded because they had been receiving mechanical ventilation for less than 2 days. The primary outcome measure was the mean number of chest radiographs per patient-day of mechanical ventilation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00893672. 11 intensive care units were randomly allocated to use a routine strategy to order chest radiographs in the first treatment period, and 10 units to use an on-demand strategy. Overall, 424 patients had 4607 routine chest radiographs (mean per patient-day of mechanical ventilation 1.09, 95% CI 1.05-1.14), and 425 had 3148 on-demand chest radiographs (mean 0.75, 0.67-0.83), which corresponded to a reduction of 32% (95% CI 25-38) with the on-demand strategy (p<0.0001). Our results strongly support adoption of an on-demand strategy in preference to a routine strategy to decrease use of chest radiographs in mechanically ventilated patients without a reduction in patients' quality of care or safety. Assistance Publique-Hôpitaux de Paris (Direction Régionale de la Recherche Clinique Ile de France).

Clinical Predictors of Pneumonia Among Children With Wheezing

The goal was to identify factors associated with radiographically confirmed pneumonia among children with wheezing in the emergency department (ED) setting. A prospective cohort study was performed with children <or=21 years of age who were evaluated in the ED, were found to have wheezing on examination, and had chest radiography performed because of possible pneumonia. Historical features and examination findings were collected by treating physicians before knowledge of the chest radiograph results. Chest radiographs were read independently by 2 blinded radiologists. A total of 526 patients met the inclusion criteria; the median age was 1.9 years (interquartile range: 0.7-4.5 years), and 36% were hospitalized. A history of wheezing was present for 247 patients (47%). Twenty-six patients (4.9% [95% confidence interval [CI]: 3.3-7.3]) had radiographic pneumonia. History of fever at home (positive likelihood ratio [LR]: 1.39 [95% CI: 1.13-1.70]), history of abdominal pain (positive LR: 2.85 [95% CI: 1.08-7.54]), triage temperature of >or=38 degrees C (positive LR: 2.03 [95% CI: 1.34-3.07]), maximal temperature in the ED of >or=38 degrees C (positive LR: 1.92 [95% CI: 1.48-2.49]), and triage oxygen saturation of <92% (positive LR: 3.06 [95% CI: 1.15-8.16]) were associated with increased risk of pneumonia. Among afebrile children (temperature of <38 degrees C) with wheezing, the rate of pneumonia was very low (2.2% [95% CI: 1.0-4.7]). Radiographic pneumonia among children with wheezing is uncommon. Historical and clinical factors may be used to determine the need for chest radiography for wheezing children. The routine use of chest radiography for children with wheezing but without fever should be discouraged.

Value of preoperative staging of breast cancer patients using computed tomography to detect asymptomatic lung and liver metastasis

1105 Background: Preoperative clinical staging in breast cancer patients is important to determine the most appropriate treatment plans and to predict prognosis for individual patients. Identifying unexpected distant metastases in newly diagnosed breast cancer patients frequently alters initial treatment plans. Routine imaging studies to detect lung or liver metastasis is not indicated in patients with early and operable breast cancer. A recent study showed that routine use of chest radiograph and liver ultrasound does not provide much diagnostic benefit in early breast cancer patients. Methods: We aimed to investigate the value of preoperative computed tomography to detect asymptomatic liver and lung metastasis in breast cancer patients. We performed preoperative CT for 667 breast cancer patients to detect lung and liver metastasis among 1,636 primary breast cancer patients who had been diagnosed and treated between January 2006 and December 2007 at Seoul National University Hospital. Results: CT showed abnormal findings (suspicious of metastasis or indeterminate nodules) in 78 patients (10.5%). Among these, abnormal finding in 13 patients (1.7%) turned out to be true metastatic lesions. There was no CT-detected lung or liver metastasis in patients with T1 tumor and 4 metastases in patients with T2 tumor. There was no CT-detected lung or liver metastasis in patients with negative axillary lymph node metastasis. When patients were classified according to the AJCC staging, CT-detected true metastatic lesions were only present in stage III patients (13 out of 173 patients, 7.5%). The true metastatic lesions in lung or liver were all small sized nodules, ranging from 0.3cm to 1.2cm in largest diameters. In seven patients, the CT-detected metastatic lesions were less than 1cm which is in contrast with the previous studies. Conclusions: Our results demonstrated the lack of usefulness in performing routine CT exams to detect asymptomatic liver and lung metastasis in early breast cancer patients. Staging CT might be useful in stage III patients, since 13 (7.5%) patients were upstaged to stage IV by the use of CT. No significant financial relationships to disclose.

Chest Computed Tomography Screening in Colorectal Cancer Patients

We read with interest the article ‘‘Clinical usefulness of chest radiography in detection of pulmonary metastases after curative resection for colorectal cancer’’ that was published in the July 2007 issue of World Journal of Surgery [1]. In a retrospective analysis of patients after curative resection for colorectal cancer, the authors showed that the sensitivity of abdominal computed tomography (CT) with lower thorax images was superior to chest radiography for lung metastasis detection. They concluded that elevating the upper level of the scan during abdominal CT or performing chest CT could result in higher detection of lung metastases. As Lee et al. noted, reports evaluating CT versus radiography for detecting pulmonary metastases in the context of colorectal cancer have been few and somewhat inconsistent [2, 3]. In our center, we did a prospective study in a selected subset of 96 patients undergoing preoperative evaluation for liver metastases resection, 90% of which were from colorectal cancer, with intrapatient comparison of chest radiography and whole-chest CT for the detection of lung metastases. Neoplastic confirmation of lung lesions was done either by lung biopsy or evidence of growth on follow-up. Lung metastases were present in 13 patients (13.5%). Chest CT was more sensitive than radiography and alone prevented unnecessary liver surgery in three patients (3.1%) in whom chest radiography was normal. Four other chest CT-positive/chest radiography-negative patients were not operated on based on the nonresectability of liver lesions demonstrated by abdominal CT. In six patients, lung metastases were demonstrated by both chest CT and radiography. Incidental CT visualization of indeterminate small lung nodules (too small for characterization with biopsy or positron emission tomography) remains a potential drawback of routine chest CT for colorectal cancer in a small number of patients. Those patients require follow-up chest CT [4]. Since our prospective study, we have included chest CT in the preoperative evaluation of our patients for colorectal liver metastases resection. This is especially valuable with the wider indications of surgical resection of liver metastases allowed by the use of improved combination chemotherapy regimens [5].

National Study of Emergency Department Visits for Acute Exacerbation of Chronic Obstructive Pulmonary Disease, 1993–2005

Little is known about recent trends in U.S. emergency department (ED) visits for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) or about ED management of AECOPD. This study aimed to describe the epidemiology of ED visits for AECOPD and to evaluate concordance with guideline-recommended care. Data were obtained from National Hospital Ambulatory Medical Care Survey (NHAMCS). ED visits for AECOPD, during 1993 to 2005, were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Concordance with guideline recommendations was evaluated using process measures. Over the 13-year study period, there was an average annual 0.6 million ED visits for AECOPD, and the visit rates for AECOPD were consistently high (3.2 per 1,000 U.S. population; P(trend) = 0.13). The trends in the use of chest radiograph, pulse oximetry, or bronchodilator remained stable (all P(trend) > 0.5). By contrast, the use of systemic corticosteroids increased from 29% in 1993-1994 to 60% in 2005, antibiotics increased from 14% to 42%, and methylxanthines decreased from 15% to <1% (all P(trend) < 0.001). Multivariable analysis showed patients in the South (vs. the Northeast) were less likely to receive systemic corticosteroids (odds ratio [OR] = 0.6; 95% confidence interval [CI] = 0.4 to 0.9). The high burden of ED visits for AECOPD persisted. Overall concordance with guideline-recommended care for AECOPD was moderate, and some emergency treatments had improved over time.

Update on Screening for Lung Cancer

Prognosis of lung cancer is markedly improved when cancers are resected in early stages (particularly in stage I). Previous investigations failed to show benefit with use of chest radiographs or sputum cytologies to screen for lung cancer among high-risk populations. More recently, computed tomography (CT) has been used as a screening technique and appears to detect lung cancer at earlier stages (e.g., stage I) compared with usual clinical practice. However, whether screening CT reduces death from lung cancer has not been clarified. This review examines the problem presented by lung cancer, the issues presented by screening, and the results of past and recent studies of lung cancer screening.

Left displacement of the mediastinum determines the imbalance in the pulmonary vascular bed and lung volume in children with pectus excavatum

The purpose of this study was to determine the influence of morphologic alteration on lung function in children with pectus excavatum (PE) and to establish the usefulness of chest radiography to predict the imbalance of pulmonary perfusion and lung volume. Chest radiography, pulmonary perfusion scintigraphy, and computed tomography (CT) for calculation of each lung volume were performed in 38 children with PE. To assess the relationship between position change of the mediastinum and lung, the following indices were calculated: (1) vertebral index (VI); the severity of sternal depression on the lateral chest radiograph, (2) left displacement index (LDI); the ratio between the left border of the mediastinum and the left border of the thorax to the transverse thoracic dimension on posterioanterior chest radiography; (3) left-to-right count ratio for the lung scintigraphy (Ls/Rs), and (4) the left-to-right thorax volume ratio from the CT scan (Lv/Rv). Compared to children without PE, VI was significantly higher, and LDI was lower in patients with PE. Pulmonary perfusion scintigraphy and CT showed that left pulmonary perfusion and lung volume were significantly lower than in the right lung in PE. LDI showed a close correlation with Ls/Rs (R = 0.443, P = 0.005) and Lv/Rv (R = 0.703, P < 0.001). Left displacement of the mediastinum within the closed thoracic cavity directly imposes constraints on the left lung, resulting in reductions of perfusion and lung volume that likely determine the physiologic severity of lung function in PE. Posterioanterior chest radiography might be useful in predicting the severity of PE.

Comparison of practice patterns of hospitalists and community physicians in the care of patients with congestive heart failure

The objective of the present study was to compare the practice patterns of hospitalists and community physicians in the care of patients with congestive heart failure. The study was a retrospective chart review of 342 patients treated for congestive heart failure at a community-based teaching hospital. Use of established therapeutic modalities for congestive heart failure and utilization of resources by hospitalists and nonhospitalists were compared. Outcome measures were adjusted length of stay (LOS), costs per case, in-hospital mortality, acute renal failure rate, and readmission rate. The patients of hospitalist were more likely to receive ACE-I or ARB therapy within 24 hours of admission (86% vs. 72%; P = .003), intravenous diuretics (90% vs. 73%; P < .001), and social work consultation (48% vs. 29%; P < .001). They were less likely to have had serial chest radiographs (4% vs. 13%; P = .01) and multiple consultants (8% vs. 16%; P = .03). Hospitalists' patients with an illness whose severity was categorized as minor had a 40% reduction in LOS, those with a moderately severe illness had a 20% reduction, and those with an extremely severe illness had a 13% reduction (P = .002). Costs per case were reduced by $1000-$3100 across all severity categories (P < .001). Rates of acute renal failure and readmission were similar between the groups. Early use of ACE-I/ARB, aggressive approach to diuresis, greater involvement of social work services and decreased use of chest radiographs and medical consultants were identified as distinct practices of hospitalists in this medical center. These practices may have led to a shorter LOS and lower costs while preserving quality of care and possibly improving clinical outcomes.