Routine Chest X-ray Research Articles

Castleman Disease Masquerading as the Posterior Mediastinal Mass on 18F-Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography.

A 28-year-old female presented with an incidentally detected mediastinal mass, found on routine chest X-ray. 18F-fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) was advised to plan course of further management. FDG-PET/CT findings were suggestive of an FDG-avid soft-tissue mass in the left posterior mediastinum in paravertebral location with left pleural effusion. Overall, PET/CT scan findings favored the possibility of a nerve sheath tumor. However, histopathology along with immunohistochemistry confirmed the diagnosis of Castleman disease.

Impact of radiographer immediate reporting of chest x-rays from general practice on the lung cancer pathway (radioX)

Introduction Rapid and early diagnosis is are important factors in determining outcomes in lung cancer. The aim of this study was to investigate the impact of immediate reporting of chest X-rays from primary care by reporting radiographers on the time to diagnosis of lung cancer. Methods A 12 month, block randomised trial was conducted at a single centre in London, UK. Half of the sessions per week (5) were randomised to an immediate or routine chest X-ray (CXR) report by a reporting radiographer, with an immediate CT where indicated. Time taken to diagnosis of lung cancer or discharge from the lung cancer pathway was determined and Mann-Whitney test used. Results During this study 8,732 patients were recruited and a total of 9,137 CXRs were performed with 4,128 (45.1%) CXRs in the immediate radiographer reporting arm. A total of 49 lung cancers were diagnosed, 26 in the immediate arm. Time to diagnosis of lung cancer for patients in the immediate arm was a median of 21.5 days (mean 26.0) compared with 30 days (mean 41.6) in the routine CXR arm (p=0.012). For patients with a suspicious CXR, diagnosis of lung cancer was achieved in a median of 18 days (mean 24.3) compared with 32 days (mean 42.6) in the routine arm (p=0.0375). Conclusion At a single centre, immediate reporting of CXRs referred from primary care by radiographers reduced time to diagnosis of lung cancer by a median of 14 days where the CXR was suspicious and by a median of 8.5 days for all patients. This has significant implications for patient outcome and adherence to new cancer targets.

Assessment of quality of life before and after successful percutaneous transvenous mitral commissurotomy in patients with severe mitral stenosis.

Background:Rheumatic mitral stenosis (MS) is a significant cause of morbidity and mortality in India. Percutaneous transvenous mitral commissurotomy (PTMC) has become the procedure of choice for severe MS with pliable leaflets. Despite a wealth of literature on the technical aspects of PTMC, there is a dearth of literature addressing the impact of PTMC on the quality of life (QOL).Aim:The aim of the study is to assess the impact of PTMC on clinical status and QOL of patients with severe MS.Materials and Methods:Twenty-five consecutive patients with severe MS undergoing PTMC were included in the study with their informed consent. All patients were subjected to routine blood tests, electrocardiogram, chest X-ray, two-dimensional and color echocardiography, treadmill test (TMT), and World Health Organization (WHO) QOL scale. The echocardiography, TMT, and WHOQOL scale were repeated after the procedure.Results:The procedural success was 98%. The mean (range) mitral valve area preprocedure was 0.82 (0.59–0.92) cm2 and postprocedure was 1.61 (1.51–1.76) cm2. The difference was statistically significant (t = 5.02; P < 0.01). The mean (range) of TMT preprocedure was 4.05 (3.0–7.0) METS and postprocedure was 8.52 (6–12) METS. The difference was statistically significant (T = 3.08; P < 0.01). The mean (range) of QOL assessment pre- and post-procedure on physical domain was 8.83 (8.3–10.1) which increased to 11.11 (10–12.7); on social relationship domain from 9.17 (7.5–12.4) to 11.37 (9.4–12.0); on personal relationship from 11.6 (11–13) to 12.52 (12–13); on environment domain from 10.78 (10.2–11.7) to 11.56 (10.8–12); and on level of independence from 9.02 (8–10) to 12.29 (11.0–13.6). All the differences were statistically significant (Wilcoxon signed-rank test z = −4.376; −4.379; −4.234; −4.200; −4.375; respectively, all P < 0.001 highly significant).Conclusions:PTMC resulted in a significant improvement in the QOL of patients with severe MS. The significant improvement in QOL post-PTMC may be an indication for offering PTMC at an earlier stage to those patients whose QOL is severely compromised.

Comparison of Postoperative Analgesia Following Epidural Bupivacaine and Epidural Bupivacaine with Verapamil in Orthopaedic Lower Limb Surgeries

Comparison of Postoperative Analgesia Following Epidural Bupivacaine and Epidural Bupivacaine with Verapamil in Orthopaedic Lower Limb Surgeries

Bedside Lung Ultrasound for Postoperative Lung Conditions in Cardiothoracic Intensive Care Unit: Diagnostic Value and Comparison with Bedside Chest Roentgenogram.

Background:The postoperative settings in cardiothoracic intensive care unit (ICU) patients pose a certain risk with pulmonary dysfunction causing morbidity and mortality. Lung ultrasound (LUS) has a potential to supplant or replace Chest X-rays (CXR) in these subset of patients, who will require bed side pulmonary pathology diagnosis and interventions.Aims and Objectives:Aim of the study is to compare the diagnosis predicted from LUS to the diagnosis made from routine bedside CXR and to find the degree of agreement in diagnosis made by both modalities in different cardiopulmonary pathologies in ICUs.Materials and Methods:Prospective observational study involving 250 postoperative patients, admitted in cardio-thoracic and vascular ICU of a tertiary referral centre. LUS was done in the study patients after the scheduled CXR in the immediate postoperative period and postoperative day one. Findings of pulmonary pathologies by each imaging modality were independently interpreted by two different team of specialist investigators. The findings were evaluated for the degree of agreement between the two imaging modalities using Cohen's kappa statistical test.Results:CXR and LUS imaging showed substantial agreement in the diagnosing cardiopulmonary pathologies (κ = 0.652) in the immediate postoperative period as well as on the postoperative day one (κ = 0.740). For specific cardiopulmonary pathologies, the degree of agreement was moderate for pleural effusion (κ = 0.561), substantial for atelectasis (κ = 0.673) and interstitial edema (κ = 0.707) and perfect for pneumothorax (κ = 0.931).Conclusions:LUS can effectively replace CXR with reduction in radiation exposure in the immediate postoperative period and also in the follow up period. It can be used as a bedside diagnostic and monitoring tool in postoperative cardiothoracic and ICUs for diagnosing pneumothorax, pleural effusion, atelectasis and interstitial edema.

Clinical Utility of Routine Chest X-Rays During the Initial Stabilization of Trauma Patients.

The Advanced Trauma Life Support (ATLS) course encourages the use of chest x-ray (CXR) to identify injuries that may change clinical management during the initial stage of trauma resuscitations. Several studies have failed to show benefit for the routine use of CXR without a clinical indication, however. We sought to validate these findings by determining the incidence of clinically significant findings discovered on a portable single-view CXR during the initial stabilization of trauma patients at a Level 1 trauma center. Using our electronic medical record system, we searched for all of the patients who were brought in as a trauma activation that had a portable single-view CXR performed in the emergency department. We used a selected sampling of available subjects for inclusion into the study. We reviewed the staff radiologist reports for positive findings and reviewed the physician and nursing flow sheets for procedural interventions occurring after the CXR was performed but before leaving the resuscitation area. Subjects who were transferred from another facility, had a thoracic procedure performed before CXR or underwent computed tomography before CXRs were excluded. From 2011 through 2012, we found 2101 subjects who had a portable CXR performed in the emergency department. We reviewed the first 400 subjects' records, with 33 (8.3%) subjects having positive findings on CXR. Of those 33, 8 met inclusion criteria and the remainder met exclusion criteria. The most common findings were pneumothorax (n = 4), clavicle fracture (n = 3), and rib fracture (n = 2). No subjects received a procedural intervention before leaving the resuscitation bay to be transported to the operating room or the computed tomography suite. We observed a low incidence of abnormal findings on portable CXR during the initial stabilization of trauma patients, none of whom received an immediate procedural intervention. This dataset supports previously published reports that suggest that a more targeted approach to CXR use may reduce resource utilization.

Surveying the Literature

Surveying the Literature

Routine postnatal chest x-ray and intensive care admission are unnecessary for a majority of infants with congenital lung malformations

BackgroundPostnatal evaluation of prenatally identified congenital lung malformations (CLMs) often includes a chest x-ray (CXR) and neonatal intensive care unit (NICU) admission for observation. With current efforts aimed at prioritizing value and resource utilization, we sought to assess the utility of this practice in infants with known CLMs. We hypothesized that CXR and NICU admission are overused and could be deferred in the majority of cases. MethodsClinical and radiographic data for infants with CLM from 2007 to 2016 were reviewed with IRB approval. Regression models were developed for respiratory support (RS), symptoms within 30 days of discharge (Sx30), and abnormal CXR. Predictors included initial symptoms (IS), birth weight (BW), gestational age (GA), cyst-volume-ratio (CVR) and abnormal CXR. Odds ratios (ORs) and ROC curves were generated for significant predictors (p < 0.05). ResultsFifty-eight infants were identified. Eight were excluded because birth or surgery occurred outside of our institution. Another four were excluded for requiring immediate surgery, leaving forty-six for full analysis. All infants underwent initial CXR and NICU admission, and 22 (47.8%) had an abnormal CXR. Higher CVR (OR = 6.69, p = 0.024) and lower BW (OR = 0.27, p = 0.028) both increased the odds of an abnormal CXR. Applying optimal ROC cutoffs for CVR and BW would have safely eliminated 21 of 46 CXRs, increasing CXR sensitivity from 48% to 68%. For RS and Sx30, no variable, including abnormal CXR, significantly predicted outcomes. Twenty-seven infants (59%) had a NICU stay of <24 h and only three patients (6.8%) developed Sx30. ConclusionsBoth CXR and NICU admission appear to be overused in infants with CLM. CXR result did not predict need for respiratory support or symptoms following discharge, and thus may not aid in the initial evaluation or in the prediction of future care needs. Using CVR and birth weight can guide CXR use and optimize its sensitivity. Need for NICU admission could not be predicted, but a majority of infants spent <24 h in the NICU without intervention, suggesting that NICU admission was likely not needed for all infants in this setting. Level of evidenceStudy of diagnostic test, Level II evidence.

Clinicopathological Features and Survival Data of Localized Renal Masses in Young Adults

Purpose:Renal tumors are rarely seen in young adults. In this study, was aimed to report the data of 18-40 years old patients with Renal Cell Carcinoma (RCC) whom we operated.Material and Method:We retrospectively reviewed the data of patients between the ages of 18 and 40 years old patients who have renal masses. All patients were evaluated with chest X-ray, Computed tomography (CT) and/or MRI. Radical or partial nephrectomy was performed for clinical localized masses with malignancy suspicion. Clinicopathological features and survival data of all the patients were recorded. In the follow-up protocol routine blood tests, chest X-ray and abdominal CT were used.Results:A total of 42 patients, [22 (52.4%) male and 20 (47.6%) female], with a mean age of 34.48 (range 18 to 40) were included in the study. Of these, 32 (%76) had RCC and 10 (24%) had benign pathologies. Female patients had more benign pathology (35% vs 13.6%). The most commonly subtype of RCC (n = 22% 69) was clear cell RCC (cRCC), while the most common benign mass was oncocytoma (n = 4% 40). At the mean follow-up period of 42.34 months, overall survival rate was found to be 93.8%.Conclusion:Young adults with localized renal mass have benign pathology in a considerable rate. All of the malign masses in this population have low Furhman grade (1 or 2).

Moving Beyond Diagnostic Accuracy With Systematic Reviews and Meta-analyses.

Moving Beyond Diagnostic Accuracy With Systematic Reviews and Meta-analyses.

Computed tomography for suspected pulmonary embolism results in a large number of non-significant incidental findings and follow-up investigations

Computed tomographic pulmonary angiograms (CTPAs) are often ordered to evaluate pulmonary embolism (PE) in the emergency department (ED). The increase use of CTPA has led to an increase in incidental findings, often of low clinical significance. Our objectives were to (1) assess the prevalence and clinical significance of incidental findings identified in patients evaluated with CTPAs for PE in the ED, (2) evaluate follow-up investigations for these incidental findings, and (3) assess the utility of routine chest X-rays done prior to CTPA. This is a historical cohort study of adult patients, presenting to two tertiary care EDs from January-December 2015, evaluated with CTPA for possible PE. Two reviewers' extracted data from electronic CT records in a standardized fashion with inter-rater reliability reported using the kappa statistic. We measured the prevalence of PE and stratified non-PE findings according to alternative diagnoses and incidental findings. Data were reported as mean and standard deviation (SD). Univariate analyses were performed with t test for continuous variables. A total of 1708 studies were included (mean 62years (SD 16.7), 56.9% female). PE was found in 233 (13.6%) patients. A total of 223 (13.1%) patients had an incidental finding, the majority of which included pulmonary nodules (n = 83, 37.2%) and adenopathy (n = 26, 11.6%). Of the incidental findings, 197 (88.3%) were non-significant and led to no definitive diagnosis of cancer. In patients who underwent both CTPA and chest X-ray, X-ray reports revealed the same diagnosis in 77% of PE-negative patients without missing a clinically significant incidental finding. Incidental findings are as common as a diagnosis of PE in patients undergoing CTPA. They are rarely clinically significant. Chest radiograph remains a reasonable initial investigation as it can aid in identifying alternative diagnoses especially in the setting of a low pre-test probability for PE.

Profile of exudative pleural effusion in the region of Bhuj people

Background: Exudative pleural effusions are a common diagnostic problem in clinical practice, as the list of causes is quite exhaustive, although sometimes they can be inferred from the clinical picture. In the West the most common cause is Para pneumonic effusions followed by malignancy, while in India it is tubercular effusion followed by malignant effusion. Despite the availability of various tests, there is a need for defining the best diagnostic and cost-effective approach to quickly diagnose and treat exudative pleural effusions. The objectives are to conduct a clinical and etiological study of exudative pleural effusion, to evaluate biochemical profile, cytological profile and radiological profiles of exudative pleural effusion.Methods: Prospective study of 100 patients with exudative pleural effusions. The demographic data was expressed as mean±standard deviation. Comparison between groups was done by Chi-Square test and Fischer exact test for categorical variables and Kruskar-Wallis and Mann-Whitney tests for continuous variables.Results: There were 67 males and 33 females. The mean age was 41.6±15.74. The majority were tubercular in origin (67%),13%,8%,3%and 6% were malignant effusions, Synpneumonic effusion, pancreatic effusions and empyema respectively. Diagnosis was not established in 3% of effusions. Massive effusions were seen in 53.8% of malignant effusions and 33.3% of empyemas. Most effusions had a total cell count between 1000 to 5000 cells /mm3.Lymphocyte predominant effusions were seen in 84.6% and 89.6% of malignant and tubercular effusions. 61.5% of malignant effusions had a positive cytology. Tubercular effusion had a pleural fluid ADA more than 40 IU/L. 92.3% of malignant effusion had pleural fluid ADA less than 30IU.Conclusions: Pleural effusion is a commonly encountered in medical practice and in our country, the commonest cause is tuberculosis, as is evidenced from the present study. The initial step in evaluating case of pleural effusion is to establish the cause of pleural effusion which is done by a detailed history, clinical examination and investigations like a chest radiology and pleural fluid analysis. Even in the advanced diagnostic approaches, still detailed clinical history and examination of the patient of the patient is important to make a clinical diagnosis. All suspected cases of pleural effusion should undergo Sonography of the thorax along with routine chest x-ray. Fluid cytology should be done to confirm tuberculosis or to rule out malignancy, which guides the physician for further evaluation of the patient if required.

Epithelial-myoepithelial carcinoma of the lung: a case report

BackgroundPulmonary epithelial-myoepithelial carcinoma (P-EMC) is a rare subset of salivary gland-type tumors of the lung. Because of its rarity and unproven malignant potential, the optimal therapy for P-EMC has not been defined. Here, we report a typical case of P-EMC and a review of the literature to consider appropriate treatment.Case presentationA 54-year-old woman presented with an abnormal lung shadow on a routine chest X-ray. A chest computed tomography (CT) scan verified an 18-mm endobronchial nodule on the middle lobe. We performed a bronchoscopic biopsy, and the patient was diagnosed with P-EMC. After confirming the absence of tumors in the salivary glands, she underwent a right middle lobectomy along with hilar and mediastinal lymph node dissections. Currently, the patient is doing well, without any sign of recurrence 3 years after surgery.ConclusionsAlthough a majority of P-EMC cases, as in our case, behave indolently, several poor progression cases have been reported. For distinguishing the minor malignancy cases from others, histological findings such as myoepithelial anaplasia could be a predictive factor. Complete resection is needed to evaluate the whole tumor, because P-EMCs often show histological heterogeneity. Moreover, incomplete excision may be a poor prognostic factor. Although lobectomies as well as lymph node dissections, sleeve lobectomies, or pneumonectomies are routinely performed for complete resection, further investigation is required to establish the optimal treatment strategy.

Etiology and prognosis of children and adolescents with situational syncope

Objective To retrospectively analyze the etiology and prognosis of the children and adolescents with situational syncope in a single center. Methods There were 4 274 cases of children and adolescents [aged from 2 to 18 years old, the average age being (10.82 ± 3.13) years old], male 2 208 cases, female 2 066 cases with orthostatic intolerance syndromes, such as unexplained syncope or symptoms of presyncope, etc, who were treated at Children′s Syncope Outpatient Department or Inpatient Department in the Second Xiangya Hospital, Central South University from January 2000 to November 2017.All subjects underwent detailed history investigation, careful physical examinations, routine 12-lead electrocardiogram, Holter electrocardiogram(ECG), chest X-ray, echocardiography, electroencephalogram(EEG) and head computerized tomography(CT) or magnetic resonance imaging(MRI), blood biochemical examination (including fasting glucose, myocardial enzymes) and organic diseases in the heart, brain, blood vessels were excluded, but the cause of syncope was still not clear.The head-up tilt table test (HUTT) was performed after the patients or/and the families wrote the informed consent agreement. Results A total of 177 (4.14%) patients with situational syncope were diagnosed among 4 274 cases.Etiology included the abdominal musecle exercise (35.59%, 63/177 cases), urination (24.29%, 43/177 cases), bathing (9.60%, 17/177 cases), defecation (7.34%, 13/177 cases), singing (5.08%, 9/177 cases), rides (4.52%, 8/177 cases), blood-injection-injury phobia (3.95%, 7/177 cases), swallowing (3.39%, 6/177 cases), and hair-grooming (2.82%, 5/177 cases), syncope during acupuncture treatment (2.26%, 4/177 cases), and cough (1.13%, 2/177 cases). The common positions were upright position (84.18%, 149/177 cases), squatting to standing position (8.47%, 15/177 cases), sitting position (5.08%, 9/177 cases), and squatting position (2.26%, 4/177 cases). HUTT positive rate was 69.49% (123/177 cases), common type of hemodynamic were the vasodepressive type of vasovagal syncope (45.20%, 80/177 cases), mixed type of vasovagal syncope (19.77%, 35/177 cases), postural orthostatic tachycardia syndrome (3.39%, 6/177 cases) and the cardiac suppressive type of vasovagal syncope (1.13%, 2/177 cases). In 35 cases of situational syncope, the number of children and adolescents with syncope was significantly reduced by health education and upstanding training.By the first follow-up review, the cases were reduced from (2.69 ±1.81) times to (0.59 ± 0.96) times after healthy education of 2-16 weeks [(4.97±3.16) weeks]. By the second follow-up review, 3 out of 8 cases did not faint, 3 cases fainted 1 time, 1 case fainted 2 times, and 1 case fainted 4 times.The outcomes of the first reexamination of HUTT in 16 cases were negative, and other 3 cases were negative by twice visit. Conclusions The etiology of children and adolescents are flag-raising(abdominal muscle exercise), urination, bathing, defecation, singing, riding, blood-injection-injury phobia, swallowing, hair-grooming, syncope during acupuncture treatment and coughing.Healthy education is good for situational syncope. Key words: Situational syncope; Head-up tilt table test; Etiology; Healthy education; Prognosis; Child; Adolescent

Routine use of chest x-ray for low-risk patients undergoing a periodic health examination: a retrospective cohort study.

Many evidence-based recommendations advocate against the use of routine chest x-rays for asymptomatic, low-risk outpatients; however, it is unclear how regularly chest x-rays are ordered in primary care. Our study aims to describe the frequency of, and variation in, routine chest x-ray use in low-risk outpatients among primary care physicians. In this retrospective cohort study, Ontario residents aged 18 years and older with a periodic health examination (PHE) between Apr. 1, 2010, and Mar. 31, 2015, were identified via administrative claims data. Patients with a recent history (last 3 years) of any of the following were excluded: cardiac or pulmonary disease, high-risk comorbidity (e.g., diabetes), consultations/visits or procedures involving cardiac or pulmonary specialists, cancer and severe chest trauma. The primary outcome, a routine chest x-ray, was defined as at least 1 chest x-ray claim within 7 days after a PHE. While a routine chest x-ray followed only 2.42% of 2 847 508 PHEs, one-quarter of family physicians (499/2031) ordered chest x-rays for more than 5.0% of their PHEs (interquartile range 1.5%-5.0%) and accounted for 62.9% of all tests observed. Routine chest x-ray use declined by 2.0% per quarter (adjusted rate ratio 0.98, 95% confidence interval [CI] 0.97-0.98). Older age (45-64 yr v. 18-44 yr, adjusted odds ratio [OR] 1.82, 95% CI 1.78-1.86; ≥ 65 yr v. 18-44 yr, adjusted OR 2.48, 95% CI 2.39-2.58) and male sex of the patient (OR 2.19, 95% CI 2.14-2.24) and male sex of the provider (OR 1.55, 95% CI 1.51-1.59) were significantly associated with increased odds of a routine chest x-ray being ordered. It is relatively uncommon for a chest x-ray to be ordered as part of a PHE in Ontario; however, the substantial variation observed among physicians suggests potential for interventions targeted at the most frequent users.

Medical Decisions: Who Should Get to Decide?

Medical Decisions: Who Should Get to Decide?

Cost-effectiveness of preoperative chest X-rays in low-grade endometrial cancer and atypical endometrial hyperplasia

Objective: To determine the cost-effectiveness of obtaining routine preoperative chest X-rays in women with atypical endometrial hyperplasia or low-grade endometrial cancer.

Limited utility of routine chest X-ray in initial evaluation of neutropenic fever in patients with haematological diseases undergoing chemotherapy.

Routine chest X-ray (CXR) is recommended for neutropenic fever (NF) management however its role is relatively understudied in haematology patients. To investigate the utility of CXR in the diagnosis and management of patients with haematological conditions complicated by NF. Retrospective, single-centre analysis of haematology patients admitted with NF between January 2011 and December 2015. Baseline demographics, treatment details and outcomes were collected from electronic patient records. CXR underwent independent radiology review. Primary endpoints were a proportion of NF episodes in which CXR detected a probable chest infection in the absence of respiratory symptoms/signs and/or resulted in a change in antibiotic management. Four hundred and thirty-five episodes were identified; CXR was performed in 75% of patients (65% within 2 days of NF). In 4 of 164 (2.4%) asymptomatic patients, CXR was consistent with infection, in contrast to 19 of 119 (16%) patients with clinical signs of respiratory infection. Only 3 of 283 (1.1%) CXR resulted in a change to antibiotics. CXR consistent with infection was not associated with increased mortality or increased admission length, although there was an association with intensive care unit admission (odds ratios: 7.61, 95% confidence interval: 2.04-28.31). In haematology patients with NF, CXR rarely detected chest infection or changed management in patients with no respiratory symptoms or signs. CXR in our institution is no longer part of routine assessment of NF in the absence of these features.

(73) Examining the incidence of critical findings in intubated patients receiving routine daily chest x-rays in a pediatric intensive care unit

(73) Examining the incidence of critical findings in intubated patients receiving routine daily chest x-rays in a pediatric intensive care unit

(72) Examining the cost of the routine daily chest x-ray and identifying opportunities to limit redundancy in a pediatric ICU

(72) Examining the cost of the routine daily chest x-ray and identifying opportunities to limit redundancy in a pediatric ICU