Farhad Arjomand

The utility of routine admission chest X-ray films on patient care.

BACKGROUND Routine chest X-rays are the most widely obtained radiological studies during hospital admissions. In this study, we evaluated the utility of routine admission chest X-rays on patient care in patients admitted to The Brooklyn Hospital center. METHODS We included consecutive patients admitted to the medical floors during a 4-month period who had a chest X-ray done on admission. The medical records of patients who had chest X-ray on admission were reviewed to identify any impact of chest X-ray on patient care during the course of hospitalization. RESULTS Chest X-ray was noted to be done in 229 patients on admission. Chest X-rays of 100 (43.6%) patients were deemed medically necessary because of the presenting complaints which included cough (15.2%), fever (13.1%), dyspnea (6.1%), hemoptysis (1.7%), and combined symptoms (7.4%). Routine chest X-rays were done in 129 (56.3%) patients to rule out occult findings in the absence of any symptoms. Chest X-ray abnormalities were noted in 56 of 129 (43.4%) patients. In 51 of 56 patients, abnormalities were chronic, stable and previously known and did not contribute to patient care. In only 5 of 129 (3.87%) patients, there were findings which necessitated a change in patient care. CONCLUSION We conclude that routine chest films rarely reveal clinically unsuspected findings. The overall impact on patient care based on these findings is small when compared to the risks associated with repeated exposure to radiation. We recommend that routine chest X-ray films should not be ordered solely because of hospital admission.

Acute lung injury following transcatheter hepatic arterial chemoembolization of doxorubicin-loaded LC beads in a patient with hepatocellular carcinoma

Transcatheter arterial chemoembolization (TACE) currently is being used as an effective palliative therapy for unresectable cancers especially hepatocelluar carcinoma (HCC). Accidental lipiodol embolism to the lungs is a rare but potentially fatal complication of TACE. This procedure involves injection of drug-eluting microspheres (LC Bead) loaded with doxorubicin, followed by embolization with embozene microspheres until stasis is evident, being used in advanced HCC. We report a patient with inoperable HCC with underlying Hepatitis C and liver cirrhosis, who developed acute lung injury following targeted chemoembolization of selective feeding hepatic artery with LC beads loaded with doxorubicin. Acute lung injury as a complication of unintended lung chemoembolization with doxorubicin has not been previously reported in the literature. Interventional radiologists screen patients for potential hepatic A-V shunt and take appropriate precautions to prevent unintended pulmonary embolization. These include appropriate selection of LC bead particle size especially in patients who are embolized with radiation pellets. This report highlights the need for a screening total body scintigraphy after injection of radionuclide Tc-99 MAA in the feeding hepatic artery to identify patients with hepatic A-V shunt. In such patients, appropriate size selection of LC bead particles is critical to prevent unintended pulmonary chemoembolization and acute lung injury. Other measures include careful patient selection, low dose of chemotherapy, and transient selective hepatic vein balloon occlusion.

Primary pulmonary mucosa-associated lymphoid tissue lymphoma in a patient with acquired immune deficiency syndrome

Non-Hodgkin lymphoma usually arises from lymphoid or nodal tissue, and can occasionally involve other sites. Extra-nodal marginal-zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) is uncommon and constitutes around 8% of all non-Hodgkin lymphomas. Most MALT lymphomas are of

Dyspnoea in a patient with unilateral lung agenesis

A 28-year-old woman presented with sudden onset dyspnoea, left-sided chest pain and dry cough for 3 days. She was a non-smoker. Her blood pressure was 90/60 mm Hg; respiratory rate, 20 breaths/min; finger pulse oximetry, 95% on 10 L/min; supplemental oxygen via non-rebreather mask and heart rate, 100 bpm. On chest auscultation, air entry was absent bilaterally. Initial chest X-ray showed ‘bilateral’ pneumothoraces, left more than right (figure 1). Tube thoracotomy was performed on the left pleural space, with complete resolution of left pneumothorax and partial resolution of right pneumothorax. Contrast-enhanced CT of chest revealed anterior …

A 23-year old male with cough, fever and blood-streaked sputum

A 23-year-old male presented with a history of 2 weeks of cough with blood-tinged sputum, fever, chills and 10-lbs weight loss. Prior to this, he denied any complaint and had no known medical or surgical history. He emigrated 3 years ago to the United States from Mexico, smoked five cigarettes per day on average for the past 5 years and drank alcohol socially. Vitals at presentation were: BP 105/60, HR 125, RR 19, T 99.6 O2Sat 96% on room air. Examination revealed decreased air entry with dullness to percussion on the right lower lung zone. Lab results were: Hb/Hct: 6.5/20, MCV: 62, PPD (–). Initial chest X-ray is shown in Figure 1 and the patient was started on antibiotics for pneumonia. With no improvement in symptoms, and a worsening chest X-ray finding on day 3 of antibiotics, computed tomography (CT) chest was carried out (Fig. 2).