Fetal body MRI and its application to fetal and neonatal treatment: an illustrative review

This Review depicts the evolving role of MRI in the diagnosis and prognostication of anomalies of the fetal body, here including head and neck, thorax, abdomen and spine. A review of the current literature on the latest developments in antenatal imaging for diagnosis and prognostication of congenital anomalies is coupled with illustrative cases in true radiological planes with viewable three-dimensional video models that show the potential of post-acquisition reconstruction protocols. We discuss the benefits and limitations of fetal MRI, from anomaly detection, to classification and prognostication, and defines the role of imaging in the decision to proceed to fetal intervention, across the breadth of included conditions. We also consider the current capabilities of ultrasound and explore how MRI and ultrasound can complement each other in the future of fetal imaging.

Non-COVID Diseases during the Pandemic: Where Have All Other Emergencies Gone?

Background and objectives: the emergency department (ED) is frequently identified by patients as a possible solution for all healthcare problems, leading to a high rate of misuse of the ED, possibly causing overcrowding. The coronavirus disease 2019 (COVID-19) pandemic started in China; it then spread throughout Italy, with the first cases confirmed in Lombardy, Italy, in February 2020. This has totally changed the type of patients referred to EDs. The aim of this study was to analyze the reduction of ED admissions at a Second level urban teaching (Fondazione Policlinico Universitario Agostino Gemelli IRCCS) during the COVID-19 pandemic. Materials and Methods: in this retrospective observational cross-sectional study, we reviewed and compared clinical records of all the patients consecutively admitted to our ED over a 40-day period (21 February -31 March) in the last three years (2018-2019-2020). Mean age, sex, triage urgency level, day/night admission, main presentation symptom, and final diagnosis, according to different medical specialties, hospitalization, and discharge rate, were analyzed. Results: we analyzed 16,281 patient clinical records. The overall reduction in ED admissions in 2020 was 37.6% compared to 2019. In 2020, we observed an increase in triage urgency levels for ED admissions (the main presentation symptom was a fever). We noticed a significant drop in admissions for cardio-thoracic, gastroenterological, urological, otolaryngologic/ophthalmologic, and traumatological diseases. Acute neurological conditions registered only a slight, but significant, reduction. Oncology admissions were stable. Admissions for infectious diseases were 30% in 2020, compared to 5% and 6% in 2018 and 2019, respectively. In 2020, the hospitalization rate increased to 42.9% compared to 27.7%, and 26.4% in previous years. Conclusions: the drastic reduction of ED admissions during the pandemic may be associated with fear of the virus, suggesting that patients with serious illnesses did not go to the emergency room. Moreover, there was possible misuse of the ED in the previous year. In particular, worrisome data emerged regarding a drop in cardiology and neurology admissions. Those patients postponed medical attention, possibly with fatal consequences, just for fear of exposure to COVID-19, leading to unnecessary morbidity and mortality.

General thoracic surgery services across Asia during the 2020 COVID-19 pandemic

The COVID-19 pandemic of 2020 posed an historic challenge to healthcare systems around the world. Besides mounting a massive response to the viral outbreak, healthcare systems needed to consider provision of clinical services to other patients in need. Surgical services for patients with thoracic disease were maintained to different degrees across various regions of Asia, ranging from significant reductions to near-normal service. Key determinants of robust thoracic surgery service provision included: preexisting plans for an epidemic response, aggressive early action to "flatten the curve", ability to dedicate resources separately to COVID-19 and routine clinical services, prioritization of thoracic surgery, and the volume of COVID-19 cases in that region. The lessons learned can apply to other regions during this pandemic, and to the world, in preparation for the next one.

Perioperative implications of thoracic decortications: a retrospective cohort study

Purpose

An increasing number of thoracic decortications have been performed in Manitoba, from five in 2007 to 45 in 2014. The primary objective of this study was to define the epidemiology of decortications in Manitoba. The secondary objective was to compare patients who underwent decortication due to primary infectious vs non-infectious etiology with respect to their perioperative outcomes.

Methods

Data for this cohort study were extracted from consecutive charts of all adult patients who underwent a decortication in Manitoba from 2007-2014 inclusive.

Results

One hundred ninety-two patients underwent a decortication. The most frequent disease processes resulting in a decortication were pneumonia (60%), trauma (13%), malignancy (8%), and procedural complications (5%). The number of decortications due to complications of pneumonia rose at the greatest rate, from three cases in 2007 to 29 cases in 2014. Performing a decortication for an infectious vs a non-infectious etiology was associated with a higher rate of the composite postoperative outcome of myocardial infarction, acute kidney injury, need of vasopressors for > 12 hr, and mechanical ventilation for > 48 hr (44.4% vs 24.2%, respectively; relative risk, 1.83; 95% confidence interval, 1.1 to 2.9; P = 0.01).

Conclusion

There has been a ninefold increase in decortications over an eight-year period. Potential causes include an increase in the incidence of pneumonia, increased organism virulence, host changes, and changes in practice patterns. Patients undergoing decortication for infectious causes had an increased risk for adverse perioperative outcomes. Anesthesiologists need to be aware of the high perioperative morbidity of these patients and the potential need for postoperative admission to an intensive care unit.

People with dyslexia and heart, chest, skin, digestive, musculoskeletal, vision, learning, speech and mental disorders were more dissatisfied with neighbourhoods: Scottish Household Survey, 2007-2008

Rarely do we know the perception toward neighbourhoods in people specifically with health conditions. Therefore, the aim of the present study was to understand the perception toward neighbourhoods among adults with a series of the existing health conditions in a country-wide and population-based setting. Data were retrieved from and analysed in Scottish Household Survey, 2007-2008. Information on demographics, self-reported health conditions and perception toward neighbourhoods and the surrounding facilities was obtained by household interview. Analysis including chi-square test, t test and logistic regression modelling were performed. Of 19,150 Scottish adults (aged 16-80) included in the study cohort, 1079 (7.7 %) people were dissatisfied with their living areas; particularly for those who experienced harassment (15.4 %), did not recycle or with dyslexia, chest, digestive, mental and musculoskeletal problems. Twenty to forty per cent reported common neighbourhood problems including noise, rubbish, disputes, graffiti, harassment and drug misuse. People with heart or digestive problems were more dissatisfied with the existing parks and open space. People with arthritis, chest or hearing problems were more dissatisfied with the waste management condition. People with dyslexia were more dissatisfied with the existing public transportation. People with heart problems were more dissatisfied with the current street cleaning condition. People with hearing, vision, speech, learning problems or dyslexia were also more dissatisfied with sports and recreational facilities. People with heart, chest, skin, digestive, musculoskeletal, vision, learning, speech and mental disorders and dyslexia were more dissatisfied with their current neighbourhood environments. Upgrading neighbourhood planning to tackle social environment injustice and put pleasant life experience as priorty would be suggested. Graphical abstract interrelations of individual health and neighbourhood health.

Bacterial etiology of empyema thoracis and parapneumonic pleural effusion in Thai children aged less than 16 years

This study aimed to identify the bacterial etiology of empyema thoracis or parapneumonic pleural effusions in Thai children, with a focus on pneumococcus. This hospital-based, descriptive study included children aged < or = 16 years, diagnosed with empyema thoracis or parapneumonic pleural effusion, from whom a pleural fluid (PF) sample was taken between January 2008 and November 2009. PF and blood samples were cultured and PF samples were also tested by polymerase chain reaction (PCR) to assess whether evidence of an infection might be identified among culture-negative samples. Serotyping of Streptococcus pneumoniae-positive samples was performed by molecular techniques and Quellung reaction. In this study, 29 children with empyema thoracis and 42 children with parapneumonic pleural effusion were enrolled. Potentially pathogenic bacteria were cultured in 13/71 samples at local or central laboratories; the most common bacteria were Staphylococcus aureus (8 children) and S. pneumoniae (2 children). Molecular techniques detected one or more targeted respiratory pathogens in 18/71 PF samples. S. pneumoniae and Haemophilus influenzae were identified by PCR in 13 and 6 children, respectively; PCR for S. aureus was not performed. The pneumococcal serotypes identified were 1, 3, 5, 6A/B, 9A/V, 14, 15A, 19F and 23A. This study shows that among Thai children with empyema thoracis and parapneumonic pleural effusions, S. aureus and S. pneumoniae were the most common pathogens identified by culture and PCR, respectively. These findings confirmed that molecular techniques are more sensitive for identification of S. pneumoniae and H. influenzae and enhance detection of important bacterial causes of empyema.

Pattern of cardiothoracic surgical diseases in a new cardiothoracic surgery unit in Nigeria

BACKGROUND

Cardiothoracic surgical pathologies are available in all geographical regions of the world. Human and material resources are necessary for prompt diagnosis and proper treatment of these cases.

METHODOLOGY

Retrospective analysis of cardiothoracic surgical cases in the first five years of our new cardiothoracic surgery unit was done.

RESULTS

A total of 714 cases were seen during the study period with age range one month to 76 years with mean age of 37.12 +/- 11.24 and male female ratio of 2:1. The yearly admissions from 2007 to 2011 were 14%, 17%, 21%, 21% and 26% respectively. Cardiovascular diseases occurred in 22.30%, with 6% of children suffering from congenital heart defect and 6% of men suffering from acquired vascular disease. Surgical complications of pleuropulmonary tuberculosis occurred in 21.4% while thoracic trauma occurred in upto 21% of the patients. Aerodigestive tract foreign bodies were encountered in 10.1% of cases and Pyogenic diseases occurred in 8.68%. Oesophageal lesions were diagnosed in 6.4% of the patients, pulmonary tumours including primary and secondary tumours were found in 4.3% while nontraumatic chest wall pathologies which included chest wall tumours, congenital deformities and chronic osteomyelities accounted for 3.2%. Mediastinal pathologies occurred in 0.98% and in the remaining 1.5% rare diseases were diagnosed such as third degree heart block, pulmonary embolism and thoracic endometriosis syndrome.

CONCLUSION

This study shows that cardiothoracic surgical pathologies are common in our centre with predominance of thoracic pathologies, and therefore need to prioritize and ensure manpower development for treatment of all kinds of thoracic pathologies.

[Extra-cardiac findings on coronary computed Tomography scanning]

BACKGROUND

Multi-detector-row computed tomography (MDCT) has emerged as method for non-invasive imaging of the heart.

AIM

To investigate the frequency of the non cardiac findings in cardiac imaging with MDCT.

METHODS

A total of 191 patients underwent cardiac imaging with 64-slice MDCT over a period of 8 months. The detected abnormalities were classified in major (implying an immediate workup and treatment or at least a further investigation) and minor abnormalities.

RESULTS

Extra cardiac abnormalities were detected on 69 examinations (36 %). Major abnormalities were found in 17 % of the patients, and the minor abnormalities in 25,6 %. The scan revealed 4 cases of lung carcinomas, all at a still surgical stage.

CONCLUSION

There were a significant number of non cardiac findings in cardiac MDCT. To avoid missing clinically important findings, we should carefully evaluate all the organs included in the scan.

[Video-assisted thoracoscopic surgeries for thoracic diseases and trauma]

The experience of videothoracoscopic operations, performed for various diseases of the thoracic organs, was summarized. The reduction of the operation traumaticity, the complications rate, lethality, the patients rehabilitation duration permits to consider videothoracoscopic operations as the method of choice in many thoracic diseases and trauma.

[Pneumothorax in women and thoracic endometriosis]

Thoracic endometriosis has been considered a rare clinical condition but it is probably underestimated in the literature. Various clinical symptoms may occur but the most frequent are catamenial pneumothoraces. Four main clinical conditions may reveal thoracic endometriosis: catamenial pneumothorax, catamenial haemothorax, catamenial haemoptysis and endometrial nodules in the lung. Catamenial pneumothoraces are the most frequent manifestation, characterized, in the majority of the cases, by right side localization and diaphragmatic abnormalities (perforations and/or nodules). The resection of suspected areas of visceral or parietal pleural endometriosis, as well as partial resection of the diaphragm in the case of nodules and/or perforations, allows the histological diagnosis of endometriosis. Because of the high recurrence rate, treatment of catamenial pneumothoraces should combine surgery and hormonal therapy.

Thoracic endometriosis syndrome

Endometriosis is defined as the presence of endometrial glands and stroma outside the uterine cavity and is usually confined to the pelvis. Thoracic endometriosis syndrome (TES) is a rare disorder characterized by the presence of functioning endometrial tissue in the pleura, the lung parenchyma and the airways. TES may present with hemoptysis, due to the shedding of endometrial tissue in the bronchial tree, or spontaneous pneumothorax or hemothorax if the endometrial tissue is localized peripherally. Patients are of reproductive age, often nulliparous, with long-standing symptoms. The crucial issue for establishing the diagnosis is the cyclicity of the symptoms which occur along with the menstrual cycle. TES is virtually a diagnosis of exclusion, established on clinical grounds, since neither CT nor endoscopy are specific for TES. Treatment consists of gonadotropin-releasing hormone analogues, aiming to suppress the hypophyseal-gonadal axis, so as to ensure a regression of the endometrial implants. If medical treatment fails, surgical resection of the endometriomas is suggested, although relapse rate may be high.

Watson fundoplication in children: a comparative study with Nissen fundoplication

BACKGROUND

Nissen fundoplication is the gold standard antireflux procedure in children. In 1996, one pediatric surgeon adopted the anterior fundoplication described by Watson in 1991. This procedure is reported to achieve good reflux control while permitting burping, active vomiting, and reducing gas bloat. An audit project was undertaken to compare the clinical outcome of children undergoing Nissen and Watson fundoplication.

METHODS

The case notes of 144 children undergoing open fundoplication between February 1995 and February 2002 were reviewed retrospectively.

RESULTS

Results of 72 boys and 59 girls comprising 76 Nissen and 55 Watson fundoplications were assessed. In each group, one death occurred within 1 month of operation. Chest infections occurred in 6.6% (Nissen) and 1.8% (Watson), and wound infections in 2.6% and 1.8%, respectively. Dysphagia was recorded in 7.9% of Nissen and 1.8% of Watson fundoplications. Follow-up data were analyzed in 70 children with Nissen and 48 children with Watson fundoplication. When overall clinical outcome was assessed for those patients with a minimum follow-up of 1 year, 85.1% Nissen and 88.2% Watson were judged good/excellent; 14.9% Nissen and 11.8% Watson were judged poor/bad.

CONCLUSION

Watson fundoplication can safely be performed in children with comparable clinical outcome to Nissen fundoplication.

Nutritional depletion and its relationship to respiratory impairment in patients with chronic respiratory failure due to COPD or restrictive thoracic diseases

OBJECTIVE

While malnutrition, especially fat-free mass index (FFMI), is a predictor for mortality in chronic obstructive pulmonary disease (COPD), less information on prevalence and mechanisms is available in patients with chronic respiratory failure (CRF) due to restrictive thoracic diseases (RTD).

DESIGN AND SETTING

Cross-sectional study of patients consecutively admitted to an in-patient primary pulmonary centre.

SUBJECTS

One hundred and thirty-two patients (30% RTD; 70% COPD) with CRF and intermittent non-invasive positive pressure ventilation.

INTERVENTIONS

Malnutrition was quantified by bioelectrical impedance analysis or body mass index (BMI), and its relationship to laboratory, lung function, inspiratory muscle and blood gas parameters and 6-min walking distance (6-MWD) was assessed.

RESULTS

Malnutrition in terms of BMI<20 kg/m(2) occurred in 16.1% of patients with COPD but none of those with RTD. FFMI<17.4 (<15.0 in female patients) kg/m(2) was found in 35.4 and 30.7%, respectively. FFMI was correlated with airway obstruction (sR(aw), r = -0.50; FEV(1)/VC, r = -0.28; P< or = 0.01 each) and lung hyperinflation (intrathoracic gas volume, r = -0.41; total lung capacity (TLC), r = -0.50; P< or = 0.001 each) in COPD, and with lung restriction in RTD (TLC, r=0.40; P=0.011). Furthermore, malnourished patients showed a higher inspiratory load (P (0.1)) and reduced 6-MWD in both groups. In COPD, only hyperinflation and P (0.1) were independently related to FFMI.

CONCLUSIONS

Malnutrition as indicated by low FFMI was similarly prevalent in patients with CRF and COPD or RTD, but inadequately represented by BMI. The correlations between lung function impairments specific for the disease and FFMI emphasized the link between malnutrition and respiratory mechanical load irrespective of its aetiology.

Thoracic myelopathy in Japan: epidemiological retrospective study in Miyagi Prefecture during 15 years

Thoracic myelopathy is defined as spinal cord compression in the thoracic region, leading to sensory and motor dysfunctions in the trunk and lower extremities, and can be caused by various degenerative processes of the spine. Thoracic myelopathy is rare, and there are many unsolved problems including its epidemiological and clinical features. We have established a registration system of spinal surgeries, which covered almost all surgeries in Miyagi Prefecture, and enrolled the data of 265 patients with thoracic myelopathy from 1988 to 2002. The annual rate of surgery gradually increased and averaged 0.9 per 100,000 inhabitants, which was less than 1/10 of that for cervical myelopathy. About 20 patients with thoracic myelopathy are operated on in Miyagi Prefecture each year. It frequently develops in middle-aged males. About half of the cases were caused by ossification of the ligamentum flavum, followed by ossification of the posterior longitudinal ligament, intervertebral disc herniation and posterior spur. Patients usually noticed numbness or pain in the legs and the preoperative duration was long, averaging 2 years. Its symptomatic similarities to lumbar disorders might cause difficulty in making a correct diagnosis. Since thoracic myelopathy can markedly restrict the activities of daily life, even general physicians should recognize this entity.

Thoracic Endometriosis: Current Knowledge

Thoracic endometriosis syndrome includes four well-recognized clinical entities, namely catamenial pneumothorax, catamenial hemothorax, catamenial hemoptysis and lung nodules, as well as some exceptional presentations. The etiological mechanisms of this syndrome are not well understood, and different theories have been proposed. Controversies exist about optimal management, as experience has been drawn from case reports and small clinical series. Surgery, hormonal treatments and combined approaches have all been proposed, with variable results in terms of short and long term outcome.

Social equalization in youth: evidence from a cross-sectional British survey

BACKGROUND

A number of studies have suggested that social inequalities in health disappear or are attenuated in early adolescence possibly due to changing risk exposures. The present study examines social equalization in youth in a representative sample of British households with children aged 0-18 years.

METHODS

Secondary analysis of a cross-sectional survey of a representative sample of British households with children and youth with parent-reported less than good health, long-standing illness, and chest problems as outcomes.

RESULTS

Data were available on 15 756 children aged 0-18 years in 8541 households in the third sweep (2001) of the British government's Families and Children Study. Parent-rated health status, long-standing illness, and chest problems all showed social patterning among children who were 0-11 years of age. Among 12- to 14-year-olds, the social gradients in these outcomes noted in childhood associated with income, social class, and education were lost but inequalities in parent-rated health status and long-standing illness but not chest problems persisted associated with measures of household work status and wealth. Among 15- to 18-year-olds, income inequalities appeared to reassert themselves, particularly among girls, but gradients by maternal education noted among 0- to 11-year-olds were absent in both sexes. Inequalities persisted with measures of household worklessness and wealth.

CONCLUSIONS

In this cross-sectional study, the social equalization in youth was noted for some health outcomes and by some measures of socioeconomic status but not for others. Inequalities in parent-rated health status and long-standing illness persist among young people in workless households and those experiencing severe material hardship.

Tuberculosis of the chest

The relationship between tuberculosis and mankind has been known for many centuries, with the disease being one of the major causes of illness and death. During the early 1980s, there was a widespread belief that the disease was being controlled, but by the mid-1980s, the number of cases increased. This change in the epidemiological picture has several causes, of which the AIDS epidemic, the progression of poverty in developing countries, the increase in the number of elderly people with an altered immune status and the emergence of multidrug-resistant tuberculosis are the most important. Mainly due to this epidemiological change, the radiological patterns of the disease are also being altered, with the classical distinction between primary and postprimary disease fading and atypical presentations in groups with an altered immune response being increasingly reported. Therefore, the radiologist must be able not only to recognize the classical features of primary and postprimary tuberculosis but also to be familiar with the atypical patterns found in immuno-compromised and elderly patients, since an early diagnosis is generally associated with a greater therapeutic efficacy. Radiologists are, in this way, presented with a new challenge at the beginning of this millennium.

Ectopic thoracic kidney in a child with congenital diaphragmatic hernia

Thoracic ectopic kidney with partial or complete renal protrusion above the level of the diaphragma into the posterior mediastinum is the rarest form of all ectopic kidneys with an incidence of less than 1 per 10,000 cases. We present a newborn with right congenital diaphragmatic hernia associated with thoracic ectopic kidney. The diagnosis of ectopia was made prior to surgery. Gerota's fascia of kidney was used to close the diaphragmatic defect. Since this renal anomaly is usually asymptomatic, it does not require any specific treatment. However, a close examination of function and anatomy of the kidney prior to surgery of hernia is important and beneficial. We discuss the embryological context and the importance of renal scintigraphy in patients with ectopic kidney.

Role of thoracic surgery in patients suffering from Acquired Immune Deficiency Syndrome

BACKGROUND AND PURPOSE

To study the role of thoracic surgery in patients suffering from Acquired Immune Deficiency Syndrome (AIDS) in a South Bronx community with a high incidence of the disease.

METHODS

A retrospective analysis of medical records of patients who underwent thoracic surgery at Bronx-Lebanon hospital, New York, over a three year period between 1996-1998.

RESULTS

The thoracic surgeons at Bronx-Lebanon Hospital in New York operated upon a total of 210 patients. Of these, 39 were operated upon for AIDS-related illnesses, comprising 17% of the operative workload. The indications of surgery in these patients were variable, ranging from infections to tumours. Fifteen patients were operated on for pericardial effusion. Ten were operated on for empyema, which had failed to resolve with thoracostomy alone and necessitated decortication. Tumours also formed a significant portion of the surgical workload. Three patients had Kaposi's sarcoma of the lung and three had a primary lymphoma in the lung. The mortality rate was high (46%).

CONCLUSION

The data suggest that surgical intervention in AIDS-related chest diseases is unable to alter the course of the disease. Earlier detection and intervention of these complications may improve outcome in some patients.

Thoracic involvement in Behçet's disease and its correlation with multiple parameters

In Behçet's disease (BD), controversy has existed over the incidence of thoracic involvement, which may be a direct threat to the patient's life. The aim of this study is to evaluate the incidence of thoracic involvement in BD and its correlation with the number of diagnostic BD criteria of The International Study Group (ISG), gender, disease duration, and the presence of symptoms. Forty-two BD patients, who had consecutively applied to different clinics in Turgut Ozal Medical Center Research Hospital, were included in the study. They were either newly diagnosed or already under treatment. All patients were examined by standard chest roentgenogram, spirometry, and thorax CT. Perfusion scintigraphies were obtained in patients with thoracic involvement. Thoracic pathologic conditions were found in five patients (11.9%). All thoracic pathologic conditions appeared in patients with at least four diagnostic criteria (26 patients) of the ISG for BD. In this subgroup, the rate of thoracic involvement was 19.2%. Also, 25% of the patients with pulmonary symptoms (12 patients) had thoracic lesions. Gender and the duration of the disease did not correlate with thoracic involvement. Our findings suggest that the rate of thoracic involvement in BD is greater than is generally believed. An increased number of diagnostic BD criteria of the ISG may indicate other organ system involvement and an increased risk of thoracic pathosis. All BD patients with at least four diagnostic criteria or any pulmonary symptoms should be evaluated for thoracic involvement, which is a major menace to life and necessitates early intervention.

The current role of mediastinoscopy in the evaluation of thoracic disease

OBJECTIVE

Mediastinoscopy is a common procedure used for the diagnosis of thoracic disease and the staging of lung cancer. We sought to determine the current role of mediastinoscopy in the evaluation of thoracic disease.

METHODS

We conducted a retrospective review of all mediastinoscopies performed by members of our service between January 1988 and September 1998.

RESULTS

We performed mediastinoscopies on 2137 patients. A total of 1745 patients underwent mediastinoscopy for known or suspected lung cancer. In 422 of these procedures, N2 or N3 disease was identified; only 28 of these patients underwent resection. The remaining 1323 had no evidence of metastatic disease. In these patients 947 had lung cancer. Only 76 of the patients with lung cancer were found to have N2 disease at exploration. Among the 1323 patients with a negative mediastinoscopy result, 52 underwent resection of a nonbronchogenic malignancy, and 217 had resection of a benign lesion. A total of 392 patients underwent mediastinoscopy for the evaluation of mediastinal adenopathy in the absence of any identifiable pulmonary lesion. Of these, 161 had a nonbronchogenic malignancy, 209 had benign disease, and 25 had no diagnosis established; mediastinoscopy established a definitive diagnosis in 93.6% of patients. In the entire group of 2137 patients, there were 4 perioperative deaths and 12 complications. Only one death was directly attributed to mediastinoscopy. No deaths or complications occurred in patients undergoing mediastinoscopy for benign disease.

CONCLUSIONS

Mediastinoscopy is a highly effective and safe procedure. We believe that mediastinoscopy should currently be used routinely in the diagnosis and staging of thoracic diseases.

Thoracic CT in the intensive care unit: assessment of clinical usefulness

PURPOSE

To determine the clinical usefulness of thoracic computed tomography (CT) in patients in a general intensive care unit (ICU).

MATERIALS AND METHODS

Images obtained in 108 consecutive thoracic CT examinations and the associated bedside chest radiographs and medical records in 85 patients (55 men, 30 women; age range, 19-92 years) in the ICU of an institution were retrospectively reviewed. CT findings were compared with concurrent bedside chest radiographic findings. The clinical importance of each CT finding was determined by reviewing the clinical record.

RESULTS

Of the 232 chest radiographic findings, 199 (86%) were confirmed at CT; when disagreement about mild congestive heart failure was excluded, there was a 93% agreement (199 of 213 findings). However, only CT demonstrated 250 (52%) of the 482 total findings (232 + 250 findings). Although many of these new findings were not clinically important, 32 (30%) of the 108 CT examinations had at least one new clinically important finding. These important new findings most often were (a) abscesses or postoperative fluid collections in the mediastinum, chest wall, or retroperitoneum; (b) malignancies that were detected, staged, or evaluated; (c) unsuspected pneumonia; or (d) pleural effusions. The CT findings resulted in changes in clinical management in 24 (22%) of the 108 examinations.

CONCLUSION

CT of the thorax is clinically useful in selected situation in patients in ICUs.

Benign intrathoracic tumours. A population survey in northern Finland

Benign intrathoracic tumours are uncommon, but their occurrence in unselected populations is poorly defined. We reviewed all cases of suspected intrathoracic tumour in a population (440,000) in northern Finland during 1990 through 1992. Diagnostic investigations included fiberoptic bronchoscopy and computed tomography in all cases. Of the 653 intrathoracic tumours, 36 were benign. The male/female ratio in these 36 cases was 1.25; the mean age was 54 years. Twenty-three of the lesions were symptomless, found at health check or examination for other disease. Bronchoscopy did not confirm the diagnosis of any benign tumour. Thoracotomy was considered necessary in most cases and histologic diagnosis was therefore available in 24 (67%). Hamartoma was the most common benign lung tumour. This prospective study in an unselected population confirms previous findings in surgical series concerning benign intrathoracic tumours and their histology.

Analysis of status of surgery in thoracic tuberculosis

A retrospective analysis of the surgical procedure in 1655 patients in twenty years in a university hospital for thoracic tuberculosis revealed that the varieties of procedures were necessary in 2.2% cases only. They can be grouped as tubercular empyema with or without bronchopleural fistula in 1507 (91%), complicated pulmonary tuberculosis in 78 (4.7%), cold abscess in the chest wall with or without lymphadenitis in 54 (3.2%) and osteomyelitis of the ribs and sternum in 16 cases (0.9%). This is statistically significant with a confidence interval of 0.1248 to 0.2348. In tubercular empyema 222 procedures were performed of which 162 were minor procedures, intercostal drainage with irrigation: 89 cases, thoracostoma: 56 cases and continuous chest wall tube 17 cases and 60 were major procedures (decortication in 45 cases, thoracoplasty [modified] in 14 cases and muscle transfer in one case). All the above procedures were preceded by an intercostal drainage. In complicated pulmonary tuberculosis the operative procedures were as follows: lobectomy in 33 cases, pneumonectomy in 35 cases and thoracoplasty in 10 cases. Drainage of cold abscess with or without lymphnode resection was performed in 54 cases and in 16 cases of osteomyelitis of the ribs and sternum resection were necessary. All procedures were performed under the cover of antitubercular therapy and supportive treatment with the aim of resolution of process, obliteration of the empyema space, control of sepsis and improvement of activity performance. The morbidity was extensive and mortality was high in major procedures. Good results could be obtained in over 92% cases, and only 66.2% on major surgery cases.

Accuracy of diagnosis of subtle chest disease and subtle fractures with a teleradiology system

OBJECTIVE

This study compared conventional thoracic and skeletal radiographs with 12-bit digitized images of the same radiographs in terms of subjective image quality and accuracy of diagnosis of subtle disease.

MATERIALS AND METHODS

Thirty-six chest radiographs with normal findings, 48 chest radiographs with abnormal findings, 29 skeletal radiographs with normal findings, and 26 skeletal radiographs with abnormal findings were included in this study. The images were chosen for the subtlety of their findings (nodules, pneumothoraces, interstitial lung disease, fractures). Each set of images was laser-digitized and viewed independently by three radiologists at a teleradiology workstation with a 1280 x 1024 pixel matrix monitor equipped with an eight-bit-per-pixel gray-scale display. All images were viewed at maximum resolution. After review of the digitized images for image quality and for the presence of abnormalities, each radiologist analyzed the analog images in a similar way.

RESULTS

Sensitivities for detecting nodules, pneumothoraces, and interstitial lung disease on digitized chest radiographs were 58%, 75%, and 90%, respectively, compared with 62%, 79%, and 92%, respectively, on the original radiographs. Sensitivity for fracture detection on digitized bone radiographs was 87% compared with 88% on analog radiographs. None of these differences was statistically significant.

CONCLUSION

Digitization of radiographs for primary diagnosis by teleradiology results in a slight decrease in sensitivity for detection of subtle abnormalities, provided that the images are viewed at maximum resolution.

Intrathoracic lymphadenopathy in patients with empyema

PURPOSE

Our goal was to determine the prevalence of intrathoracic lymphadenopathy on chest CT in patients with empyema.

METHOD

We retrospectively identified 27 patients (14 men, 13 women, mean age 43 years) with nontuberculous empyema examined with chest CT. All scans were reviewed by two of three board-certified radiologists for the presence of intrathoracic lymphadenopathy (> or = 1 cm, short axis) in an American Thoracic Society (ATS) nodal station or the internal mammary region. Differences were resolved by consensus.

RESULTS

Thirteen (48%) patients with empyema had lymphadenopathy on chest CT. The mean number of enlarged lymph nodes for the patients with lymphadenopathy was 3.2 (SD +/-2.3, range 1-8). The mean size of the largest lymph node was 1.4 cm (range 1.0-2.5 cm). The lymphadenopathy was unilateral and ipsilateral to the empyema in seven (54%), bilateral in five (38%), and unilateral contralateral to the empyema in one. The distribution of lymphadenopathy according to ATS nodal stations was 4R (n = 8), 7 (n = 6), 10R (n = 5); n = 2 each 2R, 10L, 11L; and n = 1 each 11R, 2L, 4L, and 6. Four patients had internal mammary lymphadenopathy. Pleural fluid and smooth pleural thickening were present in each case. Four patients had follow-up CT after treatment. There was a decrease or resolution of the lymphadenopathy in each case.

CONCLUSION

Intrathoracic lymphadenopathy is a common CT finding in patients with empyema and occurred in 48% of this series. In patients with smooth pleural thickening and pleural effusion, intrathoracic lymphadenopathy should not be used as a criterion to differentiate empyema from malignant or tuberculous pleural effusion.

Thoracoscopic surgery in Brazil. An overview

The Video Assisted Thoracic Surgery (VATS) was introduced in Brazil in 1992 by Losso, Ghefter and Imaeda. Since its advent up to November 1994, 488 patients have been submitted to 497 VATS procedures in four Medical Centers of São Paulo city. The indications for the procedures were: lung diseases in 244 patients (50%), pleural disease in 155 patients (31.7%), thoracic traumas in 42 patients (8.6%), mediastinal diseases in 35 patients (7.1%), cardiovascular diseases in 7 patients (1.4%), chest wall diseases in 3 patients (0.6%) and esophageal diseases in 2 patients (0.4%). In the group of lung disease the most commonly used procedures were the lung biopsy in order to diagnose diffuse pulmonary disease and the indeterminate solitary nodule resection. Among the occurrences of pleural diseases, the most commonly used procedures were the pleurodesis with talc (talc poudrage) for the treatment of recurrent pleural effusion, the driven pleura biopsy and debridment or decortication of trapped lung in cases of pleural empyema. Concerning the mediastinal diseases, the pathology which was most frequently treated by VATS was the recurrent pericardic effusion through partial pericardiectomy. Among the patients presenting chest traumatic diseases, the VATS was used to explore thoracoabdominal penetrating injuries, to control bleeding, to remove clotted hemothorax, to suture diaphragm lesions and to remove intrapleural foreign bodies. Out of 497 procedures, there were 28 convertions to thoracotomy (5.7%) and two deaths occurred all over the cases. The complications, limitations and growth related to this method as well as a future overview of the VATS in Brazil will be presented.

Factors predisposing to median sternotomy complications. Deep vs superficial infection

STUDY OBJECTIVES

Median sternotomy infections are a serious complication of cardiac surgery. The purpose of this study was to determine the patient characteristics and operative variables that predict incidence of sternal infection, and possibly its severity.

DESIGN

Univariate and multivariate retrospective analysis comparing patient, operative, and post-operative data in patients with and without sternal infections.

SETTING

Cardiac surgery program of a 580-bed private hospital in Toledo, Ohio.

PATIENTS

We studied 2,317 consecutive (June 1991 to December 1994) patients undergoing cardiac surgery.

RESULTS

Forty-one sternal infections were documented. Of these, 21 (0.91%) were deep infections with mediastinal involvement and 20 (0.86%) were superficial. Two patients with deep infections died (2/41, 5%). Ten variables were associated with infection by univariate analysis (p < 0.05), and of these, five were independent predictors by multivariate logistic regression. These predictors were obesity (p < 0.001), insulin-dependent diabetes (p < 0.001), use of internal mammary artery grafts (p = 0.02), surgical reexploration of the mediastinum (p = 0.003), and postoperative transfusions (p = 0.01). Predictors of deep and superficial sternal infection did not differ. Length of hospitalization was substantially longer for patients with deep (32 +/- 21 days) vs superficial infection (13 +/- 10 days).

CONCLUSIONS

The present study confirms previous findings that obesity, insulin-dependent diabetes, and internal mammary artery grafting (especially bilaterally) increase the risk of sternal infection. In addition, chest surgical reexploration and blood transfusions were postoperative factors that predisposed patients with median sternotomy to infection. Unlike their associated morbidity and mortality, predictors of deep and superficial sternal infections are similar.

Accessory mammary tissue associated with congenital and hereditary nephrourinary malformations

BACKGROUND AND OBJECTIVES

The association between polythelia (supernumerary nipple) and kidney and urinary tract malformations (KUTM) is controversial. Some authors reported this association in newborns and infants. Case-control studies dealing with adult subjects are not found in the literature. The purpose of this study is to determine the frequency of the association between accessory mammary tissue (AMT) and congenital and hereditary nephrourinary defects in an adult population compared to a control group.

METHODS

The study was performed in 146 white patients (123 men, 23 women) with AMT out of 2645 subjects consecutively referred to us for physical examination. The following investigations were undertaken: ultrasonographic examination of the abdomen and the kidneys, ECG, echocardiogram, roentgenogram of the vertebral column, urinalysis, and other laboratory tests. A sex- and age-matched control group without any evidence of AMT or lateral displacement of the nipples underwent the same examinations.

RESULTS

Kidney and urinary tract malformations were detected in 11 patients with AMT (nine men, two women) and in one control. These data indicate a significantly higher frequency of KUTM in the AMT-affected patients compared to controls (7.53% vs. 0.68%, P < 0.001). A broad spectrum of KUTM was discovered in association with AMT: adult dominant polycystic kidney disease, unilateral renal agenesis, cystic renal dysplasia, familial renal cysts, and congenital stenosis of the pyeloureteral joint.

CONCLUSION

Accessory mammary tissue offers an important clue for congenital and hereditary anomalies of the kidneys and urinary collecting systems. Patients with AMT should, therefore, be extensively examined for the presence of occult nephrouropathies.

Bacterial and fungal infections after liver transplantation: an analysis of 284 patients

A prospective study of bacterial and fungal infections after liver transplantation in 284 adults was undertaken. One hundred seventy-five (62%) became infected; bacterial or fungal infections occurred in 159 (56%) and 36 (13%) patients, respectively. Gram-positive cocci, in particular Staphylococcus aureus and Enterococcus faecium, were the commonest bacterial pathogens, and bacteremia and wound infection were the most frequent bacterial infections. Acute rejection and prolonged admission were independent risk factors for bacterial infection; pretransplantation antibacterials had a protective effect. Fungal infection most frequently involved the urinary tract and chest; Candida albicans was the most common pathogen. Four independent variables predicted fungal infection: low pretransplantation hemoglobin, high pretransplantation bilirubin, return to surgery, and prolonged therapy with ciprofloxacin. Patients with acute liver failure were more prone to bacterial, but not fungal, infection. No associations were found between infections and duration of surgery. Bacterial, and to a lesser extent, fungal infections are important complications of liver transplantation. However, liver transplantation surgery per se may not be the major determinant of infection.

Thoracoscopy versus thoracotomy: indications and advantages

Although the diagnosis and treatment of intrathoracic diseases have been affected by the use of thoracoscopy, the indications and advantages of this procedure are poorly defined. To review the indications and results in a community practice, 52 consecutive cases of thoracoscopy were reviewed and the postoperative courses were compared to a control group of 43 simultaneous thoracotomies. Operative indications for thoracoscopy included investigation or treatment of a lung mass (n = 33), spontaneous pneumothorax (n = 10), mediastinal mass (n = 4), pleural effusion (n = 2), mesothelioma (n = 2), and a ruptured hemidiaphragm (n = 1). General endotracheal anesthesia was used in each case. Overall, thoracoscopy was successful in 40 cases (77%). Conversion to formal thoracotomy was required in 14 cases (27%) secondary to poor visualization or to aid in further dissection. Compared to thoracotomy, complication rates were less (7.6 vs 16.2%), hospital stay shorter (5.5 vs 8 days), ICU stay shorter (0 vs 2 days) and pleural drainage time less (2 vs 5 days) in the thoracoscopy group. In summary, 73% of the patients in this study who formerly would have undergone thoracotomy were successfully managed with thoracoscopy alone, with acceptable morbidity and mortality. These data define the indications, morbidity, and mortality of thoracoscopy and suggest that thoracoscopy may emerge as the procedure of choice in the diagnosis and management of many thoracic diseases.

One hundred and sixty-three consecutive video thoracoscopic procedures: the Hong Kong experience

Video-assisted thoracoscopy (VAT) offers a new approach to the diagnosis and treatment of many thoracic conditions. From September 1992 to August 1993, a total of 163 VAT procedures were successfully performed on 108 patients (87 male, 21 female; age range from 12 to 77) which consisted of 42 bleb eliminations and 64 mechanical pleurodesis for spontaneous pneumothorax, 11 wedge resections for pulmonary nodules, three wedge biopsies for diffuse pulmonary infiltrate, four thoracic sympathectomies, resections of two mediastinal masses, three pericardial windows, 10 guided pleural biopsies for undiagnosed effusions, six guided drainage of empyema and haemothorax, 16 staging of intrathoracic tumours and two explorations for penetrating thoracic trauma. There was no procedure-related mortality. Complications included one recurrence for spontaneous pneumothorax, one re-exploration for bleeding (also by VAT approach), one wound infection, and six persistent air leaks for more than 10 days. The median duration of postoperative chest tube drainage was 2 days and the median hospital stay was 4 days. It was concluded that VAT is a safe and effective approach in thoracic surgery and with further refinement in instrumentation even more procedures will be technically feasible. The long-term results of VAT are being awaited in order to define its true merits in thoracic surgery.

Chest illness in infancy and chronic respiratory disease in later life: an analysis by month of birth

BACKGROUND

Cohorts born at different times of year differ in their risk of exposure to seasonal respiratory infections in early life, but are likely to have similar socioeconomic status and lifestyle thereafter.

METHODS

We investigated the long-term consequences of acute chest illness in infancy for later development of chronic respiratory disease by analysing variations by month of birth in hospital admissions for respiratory illness (total n = 49,866), chronic respiratory symptoms and ventilatory function among British school children (n = 11,482) and middle-aged adults (total n = 55,829).

RESULTS

Admission for bronchiolitis in the first year of life was three times more common for infants born September to November (autumn) than those born March to May, yet people born in the autumn experienced fewer respiratory symptoms and had better ventilatory function. In two surveys of middle-aged men, forced expiratory volume in one second/forced ventilatory capacity (FEV1/FVC) was significantly (P = 0.025) higher among autumn births. Hospital admissions for chronic bronchitis/emphysema and pneumonia varied little with season of birth. Admissions for asthma were significantly (P < 0.05) more common among children and young adults born in the autumn.

CONCLUSIONS

These findings do not support the hypothesis of a causal link between chest illness in infancy and the later development of chronic bronchitis and emphysema. The variation in asthma admissions with month of birth deserves further investigation.

[Usefulness of preoperative chest radiography in elective surgery]

OBJECTIVES

To study the prevalence of abnormalities in preoperative chest X-rays taken of patients undergoing elective surgery; to determine radiological abnormalities not expected based on the patient's case history and their influence on treatment; and to identify patients with high risk of presenting abnormal radiographs.

PATIENTS AND METHODS

This retrospective study included 2,146 consecutive patients entering the hospital over a period of one year for non-cardiopulmonary surgery requiring anesthesia. Two physicians reviewed the radiodiagnostic reports on routine preoperative chest X-rays requested by surgeons. The reviewers classified the results as normal, expected abnormal and unexpected abnormal based on concordance or not between the patient's case history and the radiologist's report.

RESULTS

Of the original 2,146 patients, 160 (7.4%) were excluded from the study because of incomplete case histories and/or physical exams. X-rays were taken of 1,880 (94.6%) of the 1,986 patients remaining in the study. Abnormalities were found in 508 (27%), most often in men, patients over 45, those classified as ASA III-V and those with a history of cardiovascular or lung disease, or smokers of more than 20 cigarettes/day. In 254 (13.5%), the abnormalities were not expected based on the patient's history; the physician's attitude changed toward 11 of these (4.3%), 5 of whom had cancer. Unexpected abnormalities were detected in 2 patients (0.8%) during physical examination and the real index of unexpected attitude changes based on case history and physical examination was 9 (3.5%). A new treatment based on unexpected radiological abnormalities was chosen for only 2 (0.8%) patients. The prevalence of unexpected radiological abnormalities was higher in men, in those over 45 years old and in those classified as ASA III-V.

CONCLUSIONS

The prevalence of unexpected abnormalities in routine preoperative chest X-rays taken before non-cardiothoracic elective surgery is high, but the influence of their detection on patient management is minimal. The results of our study suggest that X-rays should be recommended for patients over 45; those with a history of cardiovascular or lung disease, or of cancer; smokers of more than 20 cigarettes/day; those classified as ASA III-V; and those with incomplete case histories or physical examinations.

A fifteen-year wound surveillance study after coronary artery bypass

Wound infections after coronary artery bypass operations have been continuously monitored at the Minneapolis Veterans Affairs Hospital for 15 years. All patients were followed up for 30 days. From 1977 to 1991, 2,402 coronary artery bypass operations were performed, and wound infections developed in 125 (5%) patients. There were 71 (3%) chest infections of which 33 (1.4%) were major and 38 (1.6%) superficial. Greater than 94% of these grew only a single organism, of which 74% were Staphylococcus species. There were 63 (2.6%) leg wound infections. More than 50% of these grew multiple organisms, of which 68% were enteric in origin. Nine (0.4%) patients had simultaneous chest and leg infections. Wound infections were diagnosed an average of 15.3 +/- 6.7 (range, 4 to 30) days postoperatively, with 50% occurring after discharge from the hospital. Of 14 variables evaluated by multivariate logistic regression analysis, only steroids (p = 0.005) and diabetes (p = 0.003) were identified as independent risk factors for wound infections. Patients taking steroids or with diabetes tended to have chest infections, whereas obese patients tended to have more leg infections (p = 0.08). During an interval in the surveillance program, a trend toward increasing infections was identified and successfully reversed.

Thoracic lesions: diagnosis by ultrasound-guided biopsy

We reviewed the results of US-guided fine-needle biopsies of peripheral pulmonary, pleural, mediastinal and chest wall lesions in 200 patients. Sufficient material for cytological analysis was obtained in 95%, 92%, 96% and 100%, respectively. Sensitivity was 88%, 94%, 96%, 100% and specificity 89%, 100% and 100%, respectively. The ratio of false-negative results was 7%. A cutting needle biopsy was additionally performed in 24 patients. All but two of the histological samples (92%) were adequate for diagnostic purposes and a correct diagnosis was established in 86% (19/22) of these. 8 patients (4%) with pleural or pulmonary targets had minor complications (5 pneumothorax, 3 haemoptysis), which did not require treatment. Cutting needle biopsies and biopsy of mediastinal lesions proved safe. Due to the many advantages US may be considered for guidance in peripheral larger-sized pulmonary lesions, particularly those abutting the pleura, and also in pleural, thoracic wall and mediastinal masses.

[Thoracic actinomycosis]

BACKGROUND

Thoracic actinomycosis is an rare disease in our medium. This fact, together with the variability of its forms of presentation and the difficulty in isolating its etiologic agent, make its diagnosis, particularly difficult.

METHODS

A series of 8 cases diagnosed in the years 1988, 1989 and 1990 in two centers (Hospital de Bellvitge-Prínceps d'Espanya and Hospital de l'Esperança) is described with evaluation of the clinical and analytical data and the therapy applied.

RESULTS

Species were only identified in 3 cases with Actinomyces israelii in two and Actinomyces odontolyticus in the third. The proven association with Mycobacterium tuberculosis, the presence of distant septic metastasis and eosinophilic pleuritis as forms of presentation are of note. Medical treatment was penicillin or derivatives in all the cases except one which was treated with diagnostic/therapeutic segmentectomy.

CONCLUSIONS

It is concluded that when any subacute involvement of the thoracic and/or pleuropulmonary wall specific cultures should be carried out to discard eventual thoracic actinomycosis.

Thoracoscopic surgery: the Belgian experience

Despite the already wide experience with video-assisted techniques in laparoscopic surgery, video-assisted thoracic surgery only recently came to be developed. This is clearly seen in a survey reflecting the experience among Belgian surgeons. A majority of the surgeons (63%) had limited experience (1 to 5 interventions), and only 28.5% had fairly considerable (between 11 and 20 interventions) or considerable (more than 20 interventions) experience. The majority of interventions performed were the treatment of pneumothorax, lung biopsies, wedge resections, and intrathoracic staging procedures, accounting for 209 (70%) of the 296 interventions collected in this survey. The remaining interventions display a wide variety of different thoracic procedures including lobectomy (4) and esophagectomy (20) for carcinoma. The overall technical success rate was 91% in this survey. Our own experience with 71 interventions or attempts reflects the same evolution with an overall technical success rate in 85% (60 patients). Pneumothorax was the most frequently performed intervention (35 patients), with a technical success rate of 94.5% (32 patients). Recurrences requiring further treatment occurred in 5 of the 32 patients (14.3%). All recurrences occurred before endostaplers were available, after which there were no failures in 12 consecutive cases. Other procedures successfully performed were lung biopsy/wedge resection (6), lung cancer staging procedures (3), lobectomy (1), hemothorax (3), chest wall neurinoma (2), sympathectomy (5), dorsal mediastinal neurinoma (1), thymectomy (1), esophagectomy (3), benign esophageal tumor enucleation (2), and Belsey Mark IV antireflux procedure (1). Furthermore, special emphasis was given to the development of video-assisted mediastinoscopy, which greatly facilitates teaching and interpreting this operation. Endoscopic myotomy using endostaplers was performed in 2 patients with Zenker's diverticulum. From our experience, however, it becomes clear that thoracoscopic approaches do not always result in a distinct benefit for the patient, as these procedures are more time consuming and usually require one-lung ventilation (probably the cause of the only fatal outcome in this series: a lung biopsy in an 85-year-old patient). In conclusion, video-assisted thoracic and thoracoscopic surgery is a new surgical modality offering new perspectives. However, careful patient selection and the same expertise as in open procedures are essential in determining the final outcome of each procedure.

[The use of thoracic radiography in a third-level-care pediatric hospital]

OBJECTIVES

1. To describe the frequency in which the thorax radiography is requested in a third-level pediatric hospital, 2. To identify the frequency of detected abnormalities in such a study by the radiology service, 3. To describe the frequency and the characteristics form the information considered as useful in a clinical way, not only in the radiography application but in the radiologic report and the clinical file as well, 4. To identify the frequency in which the thorax radiography result is associated with diagnosis changes and/or therapeutic ones. DESIGN OF THE INVESTIGATION: Descriptive survey.

STUDY UNITS

371 thorax X-rays completed during December 1990 and January 1991.

PRIMARY RESULTS

The thorax radiographies were 32% of the entire radiological study during the survey; 335 of the latter ones (90%) were requested for inpatients. The hospital services which had the highest request for such a study were the Intensive Care Unit (n = 149, 40%) and Medical Pediatrics (n = 116, 31%). The most frequent diagnosis leading to the application was pneumonia (n = 55, 15%) and solid neoplasia (n = 51, 14%). Three-hundred forty eight of the applications had diagnostic impression given by the physician in charge(94%); whereas only 127 (34%) mentioned clinical data. The radiology report was attached to the file in 162 (44%) of the cases. It was found that form the patients who had a radiology report and the thorax radiography as an initial study (n = 95), 48 (50%) suffered from abnormalities. The results of the study were transcribed in the file in 58 cases (16%); the physician's interpretation was written down in 229 cases (62%) and in 84 studies (23%) there was no reference to the results of the study (P < 0.0001). Changes in the therapeutic plan of 93 cases (50%) were identified from the studies with official report by the radiologist, other radiology studies were requested in 65 of the patients (35%), after the interpretation of such study.

CONCLUSIONS

Abnormalities in 50% were identified from the total thorax radiographies requested as the patient entered. The study application mentioned as a whole (94%) the diagnostic impression which led to the application, but only in 127 cases (34%) were supporting clinical data written down. The radiology report was attached to the file in less than half the cases (44%). In 63% of the cases the supporting reason of the study was written down whereas in 23% there was no reference to the result at all.

[Extra-pulmonary thoracic hydatid cyst (Pneumology and radiology services of the Military Hospital of Tunis)]

The authors report, in a retrospective study 11 cases of thoracic extra-pulmonary hydatic cyst observed during 4 years of pneumopathology practice. They stress the rarity of this localization and the variability of the clinical data. Chest X-Ray was found no specific whereas, computed tomography led often to the right diagnosis and helped in some cases a puncture of the hydatic cyst.

How useful are routine chest x-rays of preoperative patients at risk for postoperative chest disease?

The authors studied the value of routine chest x-rays in the management of patients admitted for vascular surgery, a population likely to have comorbid chest disease. Patient records from 341 admissions were reviewed to determine the relationship between chest x-ray results and postoperative chest complications. Patients who had major abnormalities had a 40% postoperative complication rate, compared with 9% for those with normal x-rays; but only 13% of the complications occurred in patients with major abnormalities. Nine patients had x-ray findings that led to clinical action: three with potentially beneficial management changes (congestive heart failure in 2, fibrosis in 1) and six with potentially detrimental clinical action (false diagnosis of tuberculosis in 2, false diagnosis of nodules in 2, falsely normal chest x-ray in 2). None of 50 surgical cancellations occurred as a result of an abnormal x-ray. All the beneficial effects attributable to preoperative chest x-rays accrued to patients who had clinical evidence of chest disease. The authors conclude that routine chest x-rays were not helpful in improving patient outcomes. They recommend ordering preoperative chest x-rays based on clinical indications so that the likelihood of false positives and false negatives and their associated detrimental effects can be minimized.

[Study of 58 intrathoracic complications in 166 accidental or iatrogenic esophageal injuries]

In 58 patients among 166 cases of esophageal trauma who developed an intrathoracic complication, the cases are studied of 26 esophageal instrumental perforations, 10 vomiting or effort ruptures, 14 ingestions of foreign bodies (observed in a surgical unit), 5 corrosions by acids or alkalis and 3 esophageal injuries after closed chest trauma. Some complications occurred or were recognized after a delay of 1 to 16 days. In 22 cases treated after the second day, 9 patients survived and in 18 cases treated after 4 days, 6 patients nevertheless survived. The outcome is difficult to assess initially but hope must be entertained even in the most severe cases. The discussion focuses on symptoms and signs, modes of clinical presentation and the different types of fistulas (4 intramural, 31 esophago-mediastinal, 15 esophago-pleural, 5 esophago-tracheal, 1 esophago-aortic, 1 esophago-pericardial). Treatment varies with the delay in diagnosis and is often complex. In cases requiring reoperation the mortality is very high.

Acute central chest pain in the elderly. A review of 296 consecutive hospital admissions during 1976 with particular reference to the possible role of beta-adrenergic blocking agents in inducing substernal pain

Two hundred and ninety-six patients were admitted to geriatric medical beds in Cardiff in 1976 with acute central chest pain. One hundred and eighty-six (63 per cent) had a confirmed acute myocardial infarction. Of the 37 per cent without evidence of cardiac infarction, 32 per cent were on beta-blocking drugs. The possible role of adrenergic blocking agents in producing acute central chest pain is discussed.