Chest X-ray Results Research Articles

Limited Utility of Routine Chest X-Ray (CXR) in Initial Evaluation of Febrile Neutropenia in Patients with Haematological Diseases Undergoing Chemotherapy

BackgroundInitial investigations for patients presenting to health services with febrile neutropenia (FN) aim to identify the infective source. Routine CXR is recommended by several international guidelines as a component of this assessment. However, in the era of rapid delivery of empirical broad-spectrum antibiotics, the evidence supporting use of CXR in detecting chest infection in asymptomatic patients and its role in directing management are lacking. While CXRs are considered relatively inexpensive, accessible and low-risk, they still contribute to the overall healthcare bill, expose patients to ionising radiation and may involve moving immunocompromised patients from a filtered 'clean air' environment. The aim of this study was to evaluate the use of CXR in haematology patients undergoing immunosuppressive therapy who presented for management of FN.Methods:A retrospective single-centre analysis of patients with haematological diseases undergoing chemotherapy admitted to a large cancer centre with FN over a 5 year period. FN was defined as fever and a neutrophil count below the lower limit of normal (<1.5 x 109/L). Eligible patients were aged ≥16years with a confirmed diagnosis of a haematological disease who had received chemotherapy within the preceding 2 months. Protocolised investigations of newly diagnosed FN included full blood count, biochemistry, blood cultures, urine culture together with the prompt administration of piperacillin-tazobactam (4.5g) IV. CXRs were recommended but not mandated. Further antibiotic management and investigation were guided by results and clinical assessment. Patients were identified from electronic hospital records and baseline demographics, initial assessment, pre-existing lung conditions, investigation and treatment details and outcomes were collated. CXR were reviewed by an independent radiologist and results were recorded together with overall management decisions. Univariate analysis was used to determine any variables with a significant association with an abnormal CXR.Results:Between January 2011 & December 2015, 427 FN episodes were identified in321patients with a median age 58 years (range 17-90); 56% were male; 98% had an underlying diagnosis of leukemia, lymphoma or myeloma. CXR was performed in 322 episodes (75%); 137 standard PA, 182 AP, 3 unknown (of these, 163 were portable). Twenty-seven CXRs (8%) demonstrated evidence of infection, 285 (89%) were normal and 10 (3%) were indeterminate. Only 4/182 (2%) of CXRs in patients with no reported respiratory symptoms or signs had evidence of infection; in those with reported respiratory symptoms/signs, 23/130 (18%) CXRs were consistent with chest infection. The presence of ≥1 respiratory symptom/sign was associated with an increased chance of an abnormal CXR (odds ratio 17.19; p=0.007, 95%CI:2.16-136.41). Only 5/322 (1.6%) of CXR results caused a change in antibiotic management, all 5 in patients with respiratory symptoms or signs.Conclusion:In FN patients undergoing chemotherapy for haematological conditions, CXR rarely detected chest infection or changed management in asymptomatic patients. CXR in our institution is no longer part of routine assessment of FN in the absence of clinical respiratory features in patients with haematological conditions. DisclosuresHawkes:Merck Serono: Research Funding; BMS: Other: travel expenses, Research Funding; Takeda: Other: travel expenses.

Radiographie de thorax et bronchiolite aiguë : des indications en diminution ?

A management protocol for infants hospitalized for acute bronchiolitis, established after the study conducted in our unit in 2012, recommends a chest X-ray when the clinical course is unusual or if a differential diagnosis is suspected. The goal of this study was to evaluate professional practices after the introduction of this new management protocol. Retrospective descriptive study in two pediatric units from October 2013to March 2015, including infants (0-23months) hospitalized for their first episode of acute bronchiolitis without any underlying chronic condition. Overall, 599infants were included (median age, 3.7months, 54% boys). Nearly six out of ten (n=355, 59.3%) had at least one chest radiograph (38.5% fewer than in 2012). It was abnormal in 96.3% of cases, revealing distension and/or bronchial wall thickening (56.7%), focal opacity (23.5%), or atelectasis (19.5%). An X-ray was performed out of the recommendations in 42.5% of cases. The chest X-ray result led to management changes in 52infantswith prescription of antibiotics for pneumonia (86.5%) and allowed the diagnosis of heart disease in one case (0.2%). Management of acute bronchiolitis (X-ray and antibiotics) was statistically different between the two pediatric units. This protocol led to a significant decrease in the number of chest X-rays. However, many are still performed out of the recommendations, resulting in an increase of antibiotic use for pneumonia. The decrease in use of chest X-rays in acute bronchiolitis for hospitalized infants was significant but remains insufficient.

Evaluation and Management of the Nursing Home Resident With Respiratory Symptoms and an Equivocal Chest X-Ray Report

ObjectivesPneumonia is a leading cause of morbidity and mortality in nursing home (NH) residents. Chest x-ray evidence is considered a key diagnostic criterion for pneumonia by the Infectious Disease Society of America (IDSA) diagnostic guidelines, the modified McGeer diagnostic criteria, and the Loeb criteria for initiating antibiotics; however, x-ray interpretation is often equivocal. We conducted chart audits of patients in NHs who had chest x-rays for new respiratory symptoms to determine the degree of ambiguity in the radiology reports and their relationship to antibiotic prescription decisions. DesignCross-sectional study. SettingThirty-one NHs in North Carolina. ParticipantsTwo hundred twenty-six NH residents who had a chest x-ray. MethodsMedical charts were abstracted to record (1) the patient's clinical presentation when a chest x-ray was ordered, (2) the verbatim report of the chest x-ray, and (3) the patient's course during the subsequent 7 days. To standardize the radiologist reports, a seven-category coding system was developed, which was further aggregated into three groups based on the radiologist's description of the likelihood of pneumonia. ResultsOf the 226 chest x-rays, 118 (52%) identified a very low likelihood of pneumonia, 67 (30%) indicated that pneumonia was present or highly likely, and the remaining 41 (18%) used a variety of terms to describe uncertainty regarding the presence of pneumonia. NH medical providers tended to treat ambiguous chest x-ray reports similarly to positive x-ray reports, prescribing antibiotic therapy to 71% of patients with ambiguous reports and 78% of positive reports. Also notable is that 40 (34%) of the 118 patients with a very low likelihood of pneumonia based on chest x-ray results were prescribed antibiotics, the majority of whom failed to meet criteria for a clinical diagnosis of pneumonia or chronic obstructive pulmonary disease exacerbation. ConclusionThe moderate rate of ambiguous x-ray interpretations in NH residents is likely a combination of the poor quality of portable x-rays, a high prevalence of chronic lung conditions, and conservative (ie, cautious) decision making by radiologists whose interpretation is based on little clinical information and a suboptimal quality film. As a result, data suggest that chest x-rays obtained in NHs may unnecessarily encourage antibiotic prescribing because a majority of readings are ambiguous or show a low likelihood of pneumonia, yet more than half of the patients are still treated. From an antibiotic stewardship standpoint, the apparent solution is to more closely rely on clinical signs and symptoms for diagnosis of pneumonia and to place less emphasis on the role of the chest x-ray given the high number of unclear readings.

Subcutaneous sarcoidosis: a clinical analysis of nine patients.

Subcutaneous sarcoidosis is the specific subset of cutaneous sarcoidosis frequently associated with systemic disease. However, the disease activity, severity, and prognosis have not yet been elucidated due to the limited number of reported cases. The purpose of this study was to identify the clinical, laboratory, and prognostic differences between subcutaneous sarcoidosis and other type of cutaneous sarcoidosis. All patients with sarcoidosis diagnosed histopathologically from 2000 to 2012 at our institution were enrolled. The clinical, laboratory, chest X-ray, and pulmonary function test results were retrospectively evaluated in the patients with cutaneous sarcoidosis. In the 130 patients with sarcoidosis, cutaneous sarcoidosis was diagnosed in 37 patients (28.4%), and 9 (6.9%) of these patients had subcutaneous sarcoidosis. The serum levels of soluble interleukin-2 receptor (sIL-2R) were significantly elevated in the group of patients with subcutaneous sarcoidosis in comparison to the patients with other types of cutaneous sarcoidosis, whereas there was no significant difference in the severity score between the two groups. Following a 2-year observation period, three patients were in remission, five patients demonstrated stable disease, and one patient had progressive disease. Subcutaneous sarcoidosis may be associated with the disease activity, although it was not found to be associated with the disease severity and it was not a predictive factor for the prognosis. Furthermore, the prevalence of subcutaneous sarcoidosis may be higher than that in previously reported series.

WODONERCZE O NIEJASNEJ ETIOLOGII PRZEBIEGAJĄCE Z OBJAWAMI „OSTREGO BRZUCHA” – OPIS PRZYPADKU

We report a case of a patient whose clinical status and results of a plain chest X-ray showed digestive tract perforation, but in whom the true cause of the disease appeared to be hydronephrosis, probably caused by a tumour of the pyelo-ureteral junction. The course of the diagnostic process and causes of the false diagnosis and unnecessary laparotomy are discussed. The usefulness of computed tomography scanning with contrast in the detection of clinically unlcear abdominal disorders (i.e. radiologically "silent" perforation) is emphasised.

Outbreak of acute febrile respiratory illness caused by human adenovirus B P14H11F14 in a military training camp in Shandong China.

This study reports an outbreak of acute febrile respiratory illness caused by human adenovirus B [P14H11F14] in a military training center in China between May and June 2014. In total, 164 military personnel were affected, and two patients were admitted into the intensive care unit of the military regional central hospital. A HAdV-B [P14H11F14] virus was confirmed as the etiological pathogen of this acute outbreak of febrile respiratory illness based on clinical manifestations, epidemiological characteristics, specific molecular detection results, phylogenetic analysis, and serological assays. The virus was isolated by the rhabdomyosarcoma cell culture method, and the complete sequences of the E1A, penton base, hexon, and fiber genes were determined and deposited in the GenBank database. Phylogenetic and sequence homology analyses indicated that the isolated strain is most closely related to some HAdV-55 strains from mainland China. However, this strain appeared to be less virulent than former HAdV-55 strains. According to the chest X-ray results of 31 affected patients, there was no radiological evidence of pneumonia. The most frequent symptoms in these patients were sore throat (95.12 %, 156/164) and tonsillitis (93.29 %, 153/164). During the course of the outbreak, incorrect response measures and some potential risk factors, such as fire training and marching training, may have exacerbated the spread of the infection. This outbreak illustrates the urgent need to improve the epidemiological and etiological surveillance of HAdV infections and to improve the ability of doctors and health officials in basic units of the Chinese army to respond effectively to febrile respiratory illness.

Isolated sarcoidosis of accessory spleen in the greater omentum: A case report.

Sarcoidosis is a multisystemic disease of unknown origin characterized by the formation of non-caseating granulomas. Thoracic involvement is the most common presentation; however, sarcoidosis can involve almost any other organ. To the best of our knowledge there have been only 10 cases of splenic sarcoidosis reported in the English literature, with no reports of sarcoidosis of an accessory spleen. The present study reports a case of isolated sarcoidosis of an accessory spleen in the greater omentum, which was identified postoperatively in a 44-year-old female. Chest X-ray results were normal. Gastric endoscopy demonstrated an ulcer in the antrum, which was confirmed to be a signet-ring cell carcinoma via biopsy. Computed tomography of the abdomen revealed mild thickening of the posterior antrum, and a mass in the inferior pole of the left kidney. Intraoperatively, no masses were detected in the liver and spleen. Moreover, no enlarged lymph nodes were detected in the abdominal cavity, pelvic cavity, mesenteric and para-aorta. Following a radical distal gastrectomy and left radical nephrectomy, postoperative pathology demonstrated signet-ring cell carcinoma in the antrum, left renal clear cell cancer and a red lesion measuring 0.5×0.5 cm in the greater omentum, which was similar to the spleen in the splenic cavity and was regarded as an accessory spleen. Following exclusion of fungi and acid-fast bacilli as causative agents, sarcoidosis of the accessory spleen in the greater omentum was confirmed. The patient recovered uneventfully and was discharged on day 8 postoperation. The patient remained alive after two-year follow-up without sarcoidosis and malignant tumor recurrence. The present case demonstrated that, intraoperatively, comprehensive exploration should be conducted to exclude the accessory spleen, which may also suffer from sarcoidosis.

Abnormal Admission Chest X-Ray and MEWS as ICU Outcome Predictors in a Sub-Saharan Tertiary Hospital: A Prospective Observational Study.

Background. Critical care in Uganda is a neglected speciality and deemed costly with limited funding/prioritization. We studied admission X-ray and MEWS as mortality predictors of ICU patients requiring mechanical ventilation. Materials and Methods. We did a cross-sectional study in Mulago Hospital ICU and 87 patients for mechanical ventilation were recruited with mortality as the outcome of interest. Chest X-ray results were the main independent variable and MEWS was also gotten for all patients. Results. We recruited 87 patients; most were males (60.92%), aged between 16 and 45 years (59.77%), and most admissions for mechanical ventilation were from the Trauma Unit (30.77%). Forty-one (47.13%) of the 87 patients died and of these 34 (53.13%) had an abnormal CXR with an insignificant IRR = 1.75 (0.90–3.38) (p = 0.062). Patients with MEWS ≥ 5 (p values = 0.018) and/or having an abnormal superior mediastinum (p values = 0.013) showed a positive association with mortality while having a MEWS ≥ 5 had an incidence risk ratio = 3.29 (1.00–12.02) (p = 0.018). MEWS was a good predictor of mortality (predictive value = 0.6739). Conclusion. Trauma (31%) caused most ICU admissions, having an abnormal admission chest X-rays positively associated with mortality and a high MEWS was also a good predictor of mortality.

THE COURSE OF PYELONEPHRITIS IN CHILDREN AND ADOLESCENTS INFECTED IN THE PAST AND UNINFECTED WITH MYCOBACTERIUM TUBERCULOSIS

Objective: to evaluate the course of pyelonephritis in children and adolescents infected since the past years and uninfected with Mycobacterium tuberculosis. The study included 50 patients aged 3 to 17 years with acute and chronic pyelonephritis. Clinical, laboratory, instrumental, and functional examinations were used, by obligatorily verifying the uropathogenic etiological factor. The investigators identified contacts with tuberculosis patients and analyzed the results of BCG vaccination, Mantoux test, and, if indicated, chest X-ray, and urine test for Mycobacterium tuberculosis by flotation and culture methods. Among the 50 children with pyelonephritis, 24 patients were diagnosed with Mycobacterium tuberculosis infection since the previous years (more than 1 year); one had the early stage of primary tuberculosis infection. Among the 25 infected children, one patient was detected to have intrathoracic lymph node tuberculosis in the calcification phase (no evidence of activity). Conclusion. One-half of the children with pyelonephritis were found to have Mycobacterium tuberculosis infection; of them, one-half of the cases were identified to have contacted a patient with tuberculosis and the signs of its activity, as shown by a tuberculin test and Diaskintest®. The findings give grounds to consider children with pyelonephritis to be at risk for renal tuberculosis.

Evaluation of Chest X-ray and Thoracic Computed Tomography in Patients with Suspected Tuberculosis.

To investigate if there is any correlation between positive findings detected by posterior-anterior (PA) chest radiograph and thoracic computerized tomography (CT) in cases with suspected lung tuberculosis (TB) due to positive tuberculin skin test (TST) results. This is a retrospective evaluation of the medical files of patients who visited the Department of Pediatrics, Istanbul University, Istanbul Faculty of Medicine from 2006, through 2011 as outpatients and had positive TST (>15mm) results. A total of 326 patients were included in the study; 45.7% (n=149) were girls, and the mean age was 9.0±4.1 y (range: 1-17 y). In total, 14.4% (n=47) had TB findings, all of which were in the form of hilar lymphadenopathy. Among the 47 cases with TB findings in PA chest X-ray, 45 (95.7%) also had findings in thoracic CT. Only 2 (4.3%) patients had normal thoracic CT results although their PA chest X-ray results were positive. Evaluation for pulmonary TB in children with positive isolated TSTs should be made primarily with PA chest X-ray. A routine thoracic CT scan is not necessary for asymptomatic patients with only hilar lymphadenopathy findings in PA chest radiographs.

Interest of chest X-ray in tailoring the diagnostic strategy in patients with suspected pulmonary embolism.

Current diagnostic strategies for pulmonary embolism rely on the sequential use of noninvasive diagnostic tests including ventilation-perfusion (V/Q) scan and computed tomography pulmonary angiography (CTPA). V/Q scan remains criticized because of a high proportion of nondiagnostic test results, especially when the chest X-ray (CXR) is abnormal. The present study assesses whether CXR results have an impact on the conclusiveness of a noninvasive diagnostic strategy of pulmonary embolism based on the combination of pretest probability, compression ultrasonography, V/Q scan, and CTPA. Patients suspected of having pulmonary embolism were managed according to a validated diagnostic strategy. All patients underwent a CXR within 24 h of the suspicion of pulmonary embolism. CXR results were correlated to strategy conclusiveness, as assessed by the rate of required CTPA as per the diagnostic algorithm. Two hundred and twenty-three patients were retrospectively analyzed. CXRs were considered as normal in 108 (48%) patients and abnormal in 115 (52%) patients. According to the diagnostic algorithm, a CTPA was required to reach a diagnostic conclusion in 11 (10%) patients of the normal CXR group, and in 14 (12%) patients of the abnormal CXR group (P > 0.05). In this study, the presence of CXR abnormalities did not have an impact on the conclusiveness of a diagnostic strategy of pulmonary embolism based on V/Q scan. CXR abnormalities should likely not be regarded as a contraindication to the use of V/Q scan in patients with suspected pulmonary embolism.

Enlarged Right Atrium Falsely Interpreted as a Mediastinal Mass: A Case Report

Right atrial dilation due to left heart disease is a common complication among adults. The present review aimed to describe a case of massively dilated right atrium in a female patient presenting with valvular heart disease and no atrial fibrillation. The results of chest X-ray revealed a large opacity filling the lower right hemithorax, falsely interpreted as a mediastinal mass. During the transesophageal echocardiography, severe enlargement of the right atrium was detected, and open mitral and tricuspid valve replacements were performed successfully.

PTH-087 Pre-screening tests for biological therapy: is clinical acumen enough?

Introduction Historically most Inflammatory Bowel Disease (IBD) patients on biological therapy have not been routinely screened for HIV, HBV, HCV, VZV immunity and TB at Northampton General Hospital. Our aim was to discover if any complication developed in patients who had not been screened according to the ECCO Guidelines for prevention of opportunistic infections. Method We reviewed retrospectively all IBD patients who received biological treatment over a period of six months (1 st April 2013–4 th November 2013). Previous blood tests and chest x-ray results were reviewed and patients invited to undertake any outstanding blood investigations. Clinical follow up notes were reviewed. Results 92 patients received a biologic in the six month period. Less than 20% had prior virology testing. Subsequently, all virology tests were negative (HIVx70, HBV x69, HCVx67). All patients tested for VZV had immunity. All chest x-rays were normal. The most notable finding was the result of the TB test as detailed in Figure 2 below. The clinical significance of this finding will be discussed later. A total of 67 patients were tested; 65 with the T-spot TB and 2 with Quantiferon-TB Gold, (the latter test was performed at a different hospital). Of these, only 16 patients (17%) were tested prior to commencement of treatment. A further 52 were tested during the audit. Of these, at the time of writing, three patients have an indeterminate T-spot TB result, two patients need retesting as their samples were unable to be processed and three patients were found to have a reactive T-spot TB test. The patients with a reactive T-spot TB test were all Caucasians and asymptomatic. They then had a chest x-ray performed, all of which showed no evidence of active TB. They have subsequently been referred to the Consultant TB Specialist for further review. Conclusion Routinely pre-screening patients for infections in accordance with ECCO guidelines at an early stage after their IBD diagnosis seems to be a reasonable precaution and will be our practice from now on. Given the reassuring findings from our retrospective testing, it seems unlikely that there is much to be gained by screening all low risk IBD patients who have already been exposed to immunosuppressants. Disclosure of interest None Declared. References Rahier JF, et al . (2014) Kenane J, et al Lawrance IC, et al Esteve M, et al Miyake Y, et al

Usefulness of the C-Reactive Protein in Predicting the Need for Antibiotics Among Febrile Inpatients with Sickle Cell Disease

Objective: To determine whether the C-reactive protein (CRP) can help identify which febrile patients with sickle cell disease (SCD) require antibiotic therapy. Patients and Methods: We performed a chart review of patients with SCD (including S-S, S-C, and S-Thal) admitted to the hospital with fever (temperature >38.3 o C 38.9 o C ≥2 years of age) over a thirty-month period (July 2009 - December 2011). Data extracted included temperature, age, high sensitivity CRP value, chest x-ray and culture results, and the underlying cause of fever, categorized as bacterial (antibiotics necessary) or non-bacterial (antibiotics not necessary). The Mann-Whitney U-test was then used to compare the median CRP levels of patients requiring antibiotics versus those whose illnesses did not require antibiotic treatment. Results: Fifty-four febrile patients with SCD were admitted to the hospital. Nineteen had final diagnoses that required antibiotic treatment and their median CRPs were significantly higher than the thirty-five who had diagnoses that did not meet the requirements for antibiotic treatment (100.9 mg/L vs 17.3 mg/L, p 39 mg/L. Conclusion: The current data indicate that among febrile patients with SCD, the CRP may help differentiate bacterial infections which require antibiotic treatment from other diseases for which antibiotics are not necessary. Our data suggests that there may be a level of CRP below which a bacterial etiology is unlikely.

A neurofeedback-based intervention to reduce post-operative pain in lung cancer patients: study protocol for a randomized controlled trial.

BackgroundThoracic surgery appears to be the treatment of choice for many lung cancers. Nevertheless, depending on the type of surgery, the chest area may be painful for several weeks to months after surgery. This painful state has multiple physical and psychological implications, including respiratory failure, inability to clear secretions by coughing, and even anxiety and depression that have negative effects on recovery.ObjectiveThe aim of this study is to evaluate the effect of a neurofeedback-based intervention on controlling acute post-surgery pain and improving long-term recovery in patients who undergo thoracotomy for lung resection for non-small cell lung cancer (NSCLC) at an academic oncologic hospital.MethodsThis study will be based on a 2-parallel group randomized controlled trial design, intervention versus usual care, with multiple in-hospital assessments and 2 clinical, radiological, and quality of life follow-ups. Participants will be randomized to either the intervention group receiving a neurofeedback-based relaxation training and usual care, or to a control group receiving only usual care. Pain intensity is the primary outcome and will be assessed using the Numeric Pain Rating Scale (NRS) in the days following the operation. Secondary outcomes will include the effect of the intervention on hospital utilization for pain crisis, daily opioid consumption, anxiety, patient engagement, blood test and chest x-ray results, and long-term clinical, radiological, and quality of life evaluations. Outcome measures will be repeatedly taken during hospitalization, while follow-up assessments will coincide with the follow-up visits. Pain intensity will be assessed by mixed model repeated analysis. Effect sizes will be calculated as mean group differences with standard deviations.ResultsWe expect to have results for this study before the end of 2016.ConclusionsThe proposed innovative, neurofeedback- and relaxation-based approach to support post-surgery pain management could lead to significant improvements in patient short and long-term outcomes.

Prevalence of large and occult pneumothoraces in patients with severe blunt trauma upon hospital admission: experience of 526 cases in a French level 1 trauma center

BackgroundOccult pneumothoraces (PTXs), which are not visible on chest x-ray, may progress to tension PTX. The aim of study was to establish the prevalence of large occult PTXs upon admission of patients with severe blunt trauma, according to prehospital mechanical ventilation. MethodsPatients with severe trauma consecutively admitted to our institution for 5 years were retrospectively analyzed. All patients with blunt thoracic trauma who had undergone computed tomographic (CT) within the first hour of hospitalization were included. Mechanical ventilation was considered as early if it was introduced in the prehospital period or on arrival at the hospital. Occult PTXs were defined as PTXs not visible on chest x-ray. All PTXs were measured on CT scan (largest thickness and vertical dimension). Large occult PTXs were defined by a largest thickness of 30 mm or more. ResultsOf the 526 patients studied, 395 (75%) were male, mean age was 37.9 years, mean Injury Severity Score was 22.2, and 247 (47%) received early mechanical ventilation. Of 429 diagnosed PTXs, 296 (69%) were occult. The proportion of occult PTXs classified as large was 11% (95% confidence interval, 8%-15%). The overall prevalence of large occult PTXs was 6% (95% confidence interval, 4%-8%). Both CT measurements and proportion of large occult PTXs were found statistically comparable in patients with or without mechanical ventilation. ConclusionsSix percent of studied patients with severe trauma had a large and occult PTX as soon as admission despite a normal chest x-ray result. The observed sizes and rates of occult PTX were comparable regardless of the initiation of early mechanical ventilation.

Nontuberculous Mycobacterium, Myobacterium and Mixed Pulmonary Infections: A Case Report

In the 1980’s, nontuberculous myobacteria (NTM) was recognized as the common cause of disseminated infection in patients who were severely immunocompromised. In Thailand, a study was reported where almost half of the disseminated NTM infections in HIV negative cases were related to farming. NTM contaminated soil and water lead to tissue invasion and cause disease. In recent years, Bangkok Hospital Medical Center has observed a constant rise of patients diagnosed with NTM with or without accompanying disease or infection. Diagnosing NTM has been made easier with the availability and aid of endobronchial ultrasound (EBUS) in collecting specimens for culture and to indicate sensitivity. OBJECTIVES: To illustrate 10 different cases and management of NTM. MATERIALS AND METHODS: From 2012-2014, data from NTM positive patients from culture and sensitivity results were collected. RESULTS: 10 HIV negative cases of NTM were identified by bronchoscopy, endobronchial ultrasonogram guided sheath (EBUS-GS) and sputum culture. The age ranged from 41 to 89 years old with a mean of 64 years. There were eight females (80%), most were menopausal (87.5%) and two males (20%). Underlying conditions included diabetes mellitus (30%), coexisting Tuberculosis (50%) and 10% with lung cancer. All suffered from respiratory symptoms such as fever, dyspnea, sputum production and abnormal chest x-ray and chest CT scan results. All were identified by using EBUS (70%) or sputum culture (20%) or bronchoscopy (10%). Bacteria recorded were myobacterium avium complex (MAC) (30%), myobacterium intracellulare complex (MIC) (10%) and 60% were unidentified specific NTM bacteria. All responded well to Macrolide and Quinolone treatment. Specimens obtained from EBUS are highly reliable with the right laboratory setting to identify specific types of NTM.

Spontaneous All Three Electrocardiographic Patterns in Same patient with Brugada Syndrome

Brugada Syndrome (BS) was described as a clinical entity in 1992. The diagnosis is made by ECG and is defined by the presence of an atypical right bundle branch block pattern with a characteristic cove-shaped ST elevation in leads V1 to V3, in the absence of obvious structural heart disease, electrolyte disturbances or ischaemia [1]. This condition is genetically transmitted as an autosomal dominant syndrome with incomplete penetrance. The ECG changes of BS are dynamic, transient [2] and can vary spontaneously which also makes it difficult to assess its exact incidence. Three subtypes have been recognised, based on different ECG features. A 59-year-old male presented to the ED after an episode of palpitations that began 60 minutes earlier. He was resuscitated outside for ventricular tachycardia, referred to our hospital in view of Electrocardiographic changes. He had no prior medical problems and was not on any medications. The electrocardiogram (ECG) showed subtle downsloping ST-segment elevation in leads V1,to V3 suggestive diagnostic of Brugada syndrome (Figure 1). Results of laboratory investigations and chest x-ray were normal. Later next day patients ECG showed type II pattern of BS (Figure 2) followed by type III ECG pattern (Figure 3) spontaneously .This case is an example demonstrating the dynamic ECG changes of all three subtypes in a single individual spontaneously.

Neurogenic Shock Immediately following Posterior Lumbar Interbody Fusion: Report of Two Cases

Study Design Case report. Objective To present two cases of neurogenic shock that occurred immediately following posterior lumbar interbody fusion (PLIF) and that appeared to have been caused by the vasovagal reflex after dural injury and incarceration of the cauda equina. Case Report We present two cases of neurogenic shock that occurred immediately following PLIF. One patient had bradycardia, and the other developed cardiac arrest just after closing the surgical incision and opening the drainage tube. Cardiopulmonary resuscitation was performed immediately, and the patients recovered successfully, but they showed severe motor loss after awakening. The results of laboratory data, chest X-ray, electrocardiogram, computed tomography, and echocardiography ruled out pulmonary embolism, hemorrhagic shock, and cardiogenic shock. Although the reasons for the postoperative shock were obscure, reoperation was performed to explore the cause of paralysis. At reoperation, a cerebrospinal fluid collection and the incarceration of multiple cauda equina rootlets through a small dural tear were observed. The incarcerated cauda equina rootlets were reduced, and the dural defect was closed. In both cases, the reoperation was uneventful. From the intraoperative findings at reoperation, it was thought that the pathology was neurogenic shock via the vasovagal reflex. Conclusion Incarceration of multiple cauda equina rootlets following the accidental dural tear by suction drainage caused a sudden decrease of cerebrospinal fluid pressure and traction of the cauda equina, which may have led to the vasovagal reflex.

Usefulness of initial diagnostic tests carried out in the emergency department for blunt trauma.

To evaluate the usefulness of the initial diagnostic tests carried out in blunt trauma patients in our emergency department. Blunt trauma patients admitted between October 2009 and October 2011 were retrospectively reviewed. A scoring system was developed (0 to 28 points) to differentiate between potential major trauma patients and physiologically stable patients. Patients were classified into three groups: Group I (minor trauma), revised trauma score normal and our score 0-14; Group II (potential major trauma), revised trauma score normal and our score 15-28; Group III (major trauma), revised trauma score low. The proportions of patients with positive initial diagnostic test results (blood tests, X-rays, and computed tomography) were determined in each group. The study included 1,291 patients (Group I, 1,019; Group II, 85; Group III, 187). Blood tests and X-rays were carried out frequently in all groups, but positive results were infrequent in Group I. Comparisons using Pearson's χ2-test showed significant differences in the proportions of patients with positive blood test, X-ray, and computed tomography results among the three groups. The proportions of patients with positive blood test and chest X-ray results were significantly lower in Group II than in Group III, but there were no significant differences in the proportions of patients with other positive results between these two groups. In physiologically stable blunt trauma patients, diagnostic tests should be selected only after careful patient evaluation. To achieve this, standardized criteria for the identification of minor trauma patients should be established.