Viswanath Vasudevan

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

BACKGROUNDnRoutine 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.nnnMETHODSnWe 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.nnnRESULTSnChest 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.nnnCONCLUSIONnWe 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.

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 3u2005days. She was a non-smoker. Her blood pressure was 90/60u2005mmu2005Hg; respiratory rate, 20u2005breaths/min; finger pulse oximetry, 95% on 10u2005L/min; supplemental oxygen via non-rebreather mask and heart rate, 100u2005bpm. 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 …

Diffuse interstitial lung infiltrates in a smoker with human immunodeficiency virus infection

Pulmonary Langerhans cell histiocytosis is a rare interstitial lung disease characteristically affecting middle-aged smokers. It has unpredictable clinical course and may be associated with malignant neoplasms. Opportunistic lung infections are frequently considered when patients with Human immunodeficiency virus (HIV) infection present with respiratory symptoms and an abnormal chest X-ray. Though fiberoptic bronchoscopy with bronchoalveolar lavage is diagnostic for infectious etiologies, surgical lung biopsies are preferred to diagnose noninfectious lung diseases and to help guide appropriate therapy. In the present study, we report a case of progressive bilateral lung infiltrates in a smoker with HIV infection which presented a diagnostic dilemma in view of coexistent HIV infection. Analysis of clinical symptomatology aided by surgical lung biopsy helped in diagnosis.