Rapid detection of traumatic effusion using surgeon-performed ultrasonography

BACKGROUND: In the injured patient, rapid assessment of the thorax can yield critical information for patient management and triage. OBJECTIVES: The objectives of this prospective study were (1) to determine if experienced surgeon sonographers could successfully use a focused thoracic ultrasonographic examination to detect traumatic effusion, and (2) to compare the accuracy and efficiency of ultrasonography with supine portable chest radiography. METHODS: Surgeon-sonographers performed thoracic ultrasonographic examinations on patients with blunt and penetrating torso injuries during the Advanced Trauma Life Support secondary survey. All patients also underwent portable chest radiography. Performance times for ultrasonography and chest radiography were recorded. Comparisons were made of the performance times and accuracy of both tests in detecting traumatic effusion. RESULTS: In 360 patients, there were 40 effusions, 39 of which were detected by ultrasonography and 37 of which were detected by chest radiography. The 97.5% sensitivity and 99.7% specificity observed for thoracic ultrasonography were similar to the 92.5% sensitivity and 99.7% specificity for portable chest radiography. Performance time for ultrasonography was significantly faster than that for chest radiography (1.30 +/- 0.08 vs. 14.18 +/- 0.91 minutes, p < 0.0001). CONCLUSION: Surgeons can accurately perform and interpret a focused thoracic ultrasonographic examination to detect traumatic effusion. Surgeon-performed thoracic ultrasonography is as accurate but is significantly faster than supine portable chest radiography for the detection of traumatic effusion.     

Evaluation of patients with sleep apnea after tracheotomy

OBJECTIVE: To determine the effect of tracheotomy on polysomnographic and arterial blood gas data in patients with obstructive sleep apnea (OSA). DESIGN: A retrospective study of all patients who underwent tracheotomy and were studied polysomnographically at the Johns Hopkins Sleep Disorders Center, Baltimore, Md, since 1981. SETTING: A regional sleep disorders center. PATIENTS: Twenty-eight patients (8 women and 20 men), aged 22 through 77 years. Patients were categorized into 2 groups on the basis of whether they had already undergone tracheotomy before polysomnography. Group 1 patients all had a polysomnographic diagnosis of OSA before tracheotomy. They were further subdivided on the basis of whether cardiopulmonary decompensation had been absent (group 1a, n=10) or present (group 1b, n=13). Group 2 patients (n=5) had undergone tracheotomy to treat upper airway obstruction that developed after non-apnea-related upper aerodigestive tract surgeries. INTERVENTION: Tracheotomy. MAIN OUTCOME MEASURES: Nocturnal non-rapid eye movement, apnea-hypopnea index, percentage oxyhemoglobin saturation, and arterial blood gas data. RESULTS: Patients with OSA underwent tracheotomy as definitive treatment for the apnea (n=15), to prevent postoperative upper airway compromise after uvulopalatopharyngoplasty (n=7), and to treat upper airway compromise after non-apnea-related upper aerodigestive tract surgeries (n=6). Tracheotomy alleviated apnea in all 10 patients with uncomplicated sleep apnea (group 1a). For patients with OSA complicated by cardiopulmonary decompensation (group 1b), tracheotomy improved but did not eliminate sleep apnea in 7 of the 13 patients, despite overall improvement in arterial blood gas values. For patients whose sleep apnea had not been diagnosed polysomnographically before tracheotomy (group 2), tracheotomy was still required to treat OSA that had previously not been recognized. CONCLUSIONS: Tracheotomy effectively treated patients with uncomplicated OSA, but was much less effective in treating patients with OSA and cardiopulmonary decompensation. In patients who underwent tracheotomy in conjunction with other upper aerodigestive tract surgeries, concomitant obstructive sleep apnea often required continued use of a tracheotomy to maintain upper airway patency.     

Fatal bronchiolitis obliterans in a patient with juvenile rheumatoid arthritis receiving chrysotherapy

Bronchiolitis obliterans has been described in adults with rheumatoid arthritis, particularly in association with D-penicillamine treatment, but to our knowledge has not been reported in juvenile rheumatoid arthritis (JRA). We describe a 12-year-old girl with JRA who developed bronchiolitis obliterans after a 6-month course of intramuscular gold. She presented with severe obstructive airway disease (FEV1, 17% predicted) unresponsive to bronchodilators, without obvious pathology on chest radiograph. Despite aggressive immunosuppressive therapy and eventual lung transplantation, she died 3 1/2 years after her initial diagnosis of JRA. Although rare, bronchiolitis obliterans must be considered in the differential diagnosis of respiratory distress in children with JRA.     

Hepatitis C virus RNA in peripheral blood mononuclear cells: relation with response to interferon treatment

The aim of our study was to compare the short-term efficacy of three different chest physiotherapy (CPT) regimens (PD, postural drainage; PEP, positive expiratory pressure physiotherapy; HFCC, high-frequency chest compression physiotherapy) on patients with cystic fibrosis (CF) hospitalized for an acute pulmonary exacerbation. Sixteen patients with CF, 8 males, 8 females, aged 15-27 years (mean, 20.3 +/- 4), met the inclusion criteria: 1) age over 14 years; 2) mild or moderate airway obstruction; 3) sputum volume > 30 mL/day; 4) being proficient in PD and PEP CPT. Patients at admission had (mean +/- SD) forced volume in 1 second (FEV1) 52.2 +/- 21.9 percent predicted; Shwachman-Kulczycki clinical score 65.1 +/- 11 points; Chrispin-Norman chest radiography score 18.6 +/- 4.3 points. The three CPT regimens and a control-treatment (CONT) were administered in a random sequence, each patient receiving each treatment twice a day (in 50 minute sessions) for 2 consecutive days. During CONT and for 30 minutes after each session only spontaneous coughing was allowed. Wet and dry weight of sputum were recorded during the 50-minute sessions and 30 minutes afterward. Lung function was measured before and 30 minutes after each session. For each treatment a score was given by the patient for efficacy, and by both the patient and the physiotherapist for tolerance. Wet and dry weights of sputum collected during the sessions were greater for all CPT regimens than for CONT (P < 0.001, P < 0.0001). No significant differences between the three CPT regimens for both wet and dry weights were found when the number of coughs was taken into account.(ABSTRACT TRUNCATED AT 250 WORDS)     

The utility of chest radiography in the follow-up of pneumonia

AIM: We conducted this study to determine whether chest radiography was clinically useful in the follow-up of uncomplicated pneumonia affecting children aged between 6 weeks and 15 years. METHOD: We examined the case records of all 78 paediatric admissions for pneumonia to our hospital over one year. Thirteen children were excluded on account of age or other complicating factors. RESULTS: Of the 65 study cases, the mean age was 3.5 years (range 0.4-13 years). On admission 51 (79%) had cough, 53 (82%) fever, 53 (82%) tachypnoea and 50 (77%) had abnormal chest signs. Elevation of C reactive protein was recorded in 43 (66%) cases and leukocytosis in 42 (65%). All children received initial chest radiographs which showed unilobular/lobar changes in 34 (53%), bilobar changes in 19 (29%) and diffuse abnormalities in 7 (11%). Forty-one patients were followed up both clinically and radiologically, usually (31 cases) between four and six weeks after discharge. Thirty-seven children had no abnormal symptoms or signs and had normal chest radiographs. The remaining four had symptoms and signs, their radiographs showed either slight resolution or no change from the admission films. CONCLUSION: In cases of uncomplicated pneumonia, follow-up chest radiography should be deferred until at least four weeks after discharge and is not indicated if symptoms and signs are absent.     

Value of routine pre-operative chest X-ray in patients over the age of 40 years

The overall usefulness of routine chest X-ray, its cost benefit ratio and effect on anaesthetic management in patients over the age of 40 years was assessed. Four hundred and seventy-seven consecutive patients undergoing elective non-cardiopulmonary surgery with no cardiopulmonary diseases, having a routine preoperative chest x-ray were selected at the Aga Khan University Hospital, Karachi. Twenty five (5.2%) were excluded from the study as their chest x-ray were not available at the time of surgery. Twenty eight (8.3%) below and 33 (28.7%) above 60 years of age had abnormalities in chest x-ray but the difference in cardiac abnormalities in two age groups was insignificant. The frequency of lung field abnormalities increased with age from 3.2% in less than 60 to 15.6% in patients above 60 years of age. The difference in frequency of occurrence of lung field abnormalities was statistically significant in case of lung abnormalities. Only one case required change in anaesthetic management based on routine preoperative chest x-ray. Our study showed that the incidence of significant lung field abnormalities increased in patients aged 60 years and above with no history of chronic obstructive airway disease. We recommend routine preoperative chest x-ray be carried out only in patients over the age of 60 years.     

Effects of extrinsic positive end-expiratory pressure on mechanically ventilated patients with chronic obstructive pulmonary disease and dynamic hyperinflation

OBJECTIVE: To examine the circulatory and respiratory effects of extrinsic positive end-expiratory pressure (PEEPe) in patients with chronic obstructive pulmonary disease (COPD) and dynamic hyperinflation during controlled mechanical ventilation. DESIGN: Different levels of PEEPe were applied randomly in mechanically ventilated patients with COPD and dynamic hyperinflation. SETTING: Respiratory Intensive Care Unit of a University Hospital. PATIENTS: 9 patients with acute respiratory failure and dynamic hyperinflation due to acute exacerbation of COPD. INTERVENTIONS: PEEPe 35%, 58% and 86% of intrinsic PEEP (PEEPi) were applied. MEASUREMENTS AND RESULTS: Using flow-directed pulmonary artery catheters hemodynamic measurements were obtained, while simultaneously lung volumes, airflows and airway pressures were recorded. In order to estimate alveolar pressures (Palv), rapid airway occlusions during passive expiration were also performed. At no level of PEEPe were significant changes in cardiac output, gas exchange variables, dead space, airways inflation resistances and respiratory system static end-inspiratory compliance observed. At high level of PEEPe central venous, mean pulmonary arterial and pulmonary capillary wedge pressures were increased significantly. All but one patient were flow-limited during passive expiration. PEEPe 86% of PEEPi caused a significant increase in end-expiratory lung volume and total PEEP. Iso-volume pressure-flow curves showed volume-dependence expiratory flow limitation in 2 patients, while in 8 patients volume-dependence of critical driving pressure (Palv-mouth pressure) that decreased flows was also observed. CONCLUSIONS: The effects of PEEPe on iso-volume flow and hence on lung mechanics and hemodynamics, depend on many factors, such as airways resistances, lung volumes and airway characteristics, making the patient response to PEEPe unpredictable.     

Orofacial pain with vascular-type features

BACKGROUND: Whether cardiologists or internists use discretionary tests differently for noncritical cardiological presentation is unclear. OBJECTIVE: To explore differences in decision making for 3 common scenarios. METHODS: We asked 318 cardiologists and 598 internists to manage scenario patients presenting with (1) uncomplicated syncope, (2) nonanginal chest pain, and (3) nonspecific electrocardiographic changes. Participants also estimated baseline clinical risk for each scenario and answered questions on uncertainty, malpractice concerns, and cost consciousness. We used chi 2 analysis, analysis of variance, and t tests to compare management choice and test ordering. Response rate was 50%. RESULTS: Initial management choices (ie, admit or discharge, allow or delay surgery) were similar but subsequent testing differed substantially. For a 50-year-old woman with uncomplicated syncope, cardiologists more often recommended cardiological tests such as exercise treadmill tests (37% vs 18%, 95% confidence interval [CI] for difference: 10%-28%) and signal-averaged electrocardiograms (13% vs 4%, 95% CI for difference: 3%-15%) but less often requested neurological tests (29% vs 37%, 95% CI for difference: -17% to 1%). For a 42-year-old man with nonanginal chest pain, cardiologists more frequently ordered exercise tests (70% vs 51%, 95% CI for difference: 10%-28%). For a 53-year-old woman with nonspecific electrocardiographic changes, equal proportions of cardiologists and internists ordered exercise tests (56%) but cardiologists recommended thallium studies more often (73% vs 47%, 95% CI for difference: 10%-36%). For all scenarios, average charges for diagnostic evaluations by cardiologists and internists were similar. CONCLUSIONS: In 3 noncritical cardiology scenarios, discretionary test use by cardiologists and internists differed substantially, although this was not reflected in dollar resources. Internists tended toward a broader diagnostic evaluation while cardiologists tended to focus on cardiological tests. The potential effect on clinical outcomes is unknown.     

Diffuse airway narrowing from carcinoma metastatic to the bronchial submucosa: identification by chest CT

The differential diagnosis of dyspnea in patients with prior malignancy and nondiagnostic chest radiographs is broad. We report a case of breast carcinoma diffusely metastatic to the bronchial submucosa presenting as obstructive airway disease. Chest radiographs failed to suggest metastatic disease as the cause of dyspnea. CT, however, revealed the unusual finding of diffusely thickened and narrowed airways. Carcinoma confined to airway submucosa was identified using bronchial biopsy. We suggest that diffuse airway narrowing from submucosal metastasis can be demonstrated by CT and should be added to the differential diagnosis of dyspnea in cancer patients with nondiagnostic chest radiographs and evidence of airflow obstruction.     

Occlusion pressure responses in asthma and chronic obstructive pulmonary disease

During CO2 rebreathing we measured ventilation and the pressure generated during the first 0.1 sec of inspiratory effort against a closed airway (P 0.1) in 12 asthmatics during acute exacerbation, 10 normal subjects, and 10 patients with chronic obstructive pulmonary disease. In normal subjects, the ventilatory responst to CO2 correlated with the P 0.1 response measured as delta In P 0.1. Patients with chronic obstructive pulmonary disease showed depressed responses to CO2 in terms of both ventilation and deltaIn P0.1. However, P 0.1 values in the patients with chronic obstructive pulmonary disease were greater than those of the normal subjects when they were compared at an alveolar PCO2 of 60 mm Hg. Asthmatics' responses to CO2 were similar to those of patients with chronic obstructive pulmonary disease. When measured at an alveolar PCO2 of 60 mm Hg, asthmatics' P 0.1 values were greater than those of both normal subjects and patients with chronic obstructive pulmonary disease. As the asthmatics' airway obstruction decreased so did their P 0.1. The asthmatics, and to a lesser extent the patients with chronic obstructive pulmonary disease, demonstrated increased inspiratory muscle activity that could not be explained on the basis of chemical drive or alterations in functional residual capacity. In the case of the asthmatics it was possible that the increased inspiratory muscle activity was a response to airway obstruction.     

Likelihood of malignancy in a solitary pulmonary nodule: comparison of Bayesian analysis and results of FDG-PET scan

OBJECTIVE: To compare the probability of cancer in a solitary pulmonary nodule using standard criteria with Bayesian analysis and result of 2-[F-18] fluoro-2-deoxy-D-glucose-positron emission tomographic (FDG-PET) scan. SETTING: A university hospital and a teaching Veteran Affairs Medical Center. METHODS: Retrospective analysis of 52 patients who had undergone both CT scan of the chest and a FDG-PET scan for evaluation of a solitary pulmonary nodule. FDG-PET scan was classified as abnormal or normal. Utilizing Bayesian analysis, the probability of cancer using "standard criteria" available in the literature, based on patient's age, history of previous malignancy, smoking history, size and edge of nodule, and presence or absence of calcification were calculated and compared to the probability of cancer based on an abnormal or normal FDG-PET scan. Histologic study of the nodules was the gold standard. RESULTS: The likelihood ratios for malignancy in a solitary pulmonary nodule with an abnormal FDG-PET scan was 7.11 (95% confidence interval [CI], 6.36 to 7.96), suggesting a high probability for malignancy, and 0.06 (95% CI, 0.05 to 0.07) when the PET scan was normal, suggesting a high probability for benign nodule. FDG-PET scan as a single test alone was more accurate than the standard criteria and standard criteria plus PET scan in correctly classifying nodules as malignant or benign. CONCLUSION: FDG-PET scan as a single test was a better predictor of malignancy in solitary pulmonary nodules than the standard criteria using Bayesian analysis. FDG-PET scan can be a useful adjunct test in the evaluation of solitary pulmonary nodules.     

Chest X-ray changes in air space disease are associated with parameters of mechanical ventilation in ICU patients

To assess relationships between parameters of mechanical ventilation (MV) and portable chest X-ray (CXR) measurements of lung length (LL) and severity of air space disease, a prospective, randomized, blinded comparison of 102 adults in a university hospital was performed. Each patient received two portable, supine CXRs on different MV breaths within 5 min of one another. Ventilator parameters were recorded. All 204 CXRs were randomly assorted and read independently by three radiologists. Air space disease was considered more severe with pressure support ventilation (PSV) breaths than with intermittent mandatory ventilation (IMV) breaths (p = 0.0003), and its extent correlated inversely with static compliance (p = 0.0001, r = -0.40). Among patients having CXRs on both IMV and PSV breaths, 15 of 67 (22%) had their overall degree of air space disease read differently by one category (mild, moderate, or severe). Increases in LL between the two CXRs were associated with increasing peak (p = 0.0038) or mean (p = 0.0065) airway pressure, tidal volume (VT) (p = 0.022), and VT per kilogram (p = 0.006). We conclude that lung volume changes during MV, typically not noted nor controlled for during portable chest radiography, may substantially alter the interpretation of air space disease and LL. Physicians monitoring intensive care unit (ICU) patients with daily CXRs should be aware of the variables influencing interpretation of portable CXRs of ICU patients.     

Hodgkin disease and non-Hodgkin lymphoma: plain chest radiographs and chest computed tomography of thoracic involvement in previously untreated patients

PURPOSE: To provide further information about the presentation of thoracic involvement in Hodgkin disease and non-Hodgkin lymphoma and to compare chest radiography with chest CT findings. MATERIALS AND METHODS: We reviewed the chest radiographs and the CT images of 100 Hodgkin and 100 non-Hodgkin patients, all of them untreated. Our data were compared with those of literature series: the latest study comparing the different patterns of Hodgkin and non-Hodgkin disease appeared in 1976 and it compared chest radiography with conventional tomography, not with CT. RESULTS: Intrathoracic involvement (75% vs 48%) and adenopathy (74% vs 28%) were more frequent in Hodgkin than in non-Hodgkin lymphoma. Ninety-nine per cent of the patients with intrathoracic involvement (74/75) had nodal disease. Paratracheal/prevascular nodes were most frequently involved, namely in 72/74 Hodgkin (97%) and in 27/28 non-Hodgkin patients (96%). The lung parenchyma was more often involved in non-Hodgkin (24%) than in Hodgkin (8%) patients; it was associated with mediastinal/hilar adenopathy in all Hodgkin and in 10/24 (42%) non-Hodgkin cases. Parenchymal involvement was demonstrated with chest radiography in 7/8 Hodgkin (88%) and in 13/24 non-Hodgkin patients (54%). Chest radiography showed paratracheal/prevascular adenopathy more often in Hodgkin (54/72, 75%) than in non-Hodgkin (15/27, 56%) cases. Subcarinal and internal mammary adenopathy was poorly depicted with plain films, while hilar adenopathy was generally identified with both CT and chest radiography. Chest radiography usually missed posterior mediastinal and anterior diaphragmatic adenopathy. CONCLUSIONS: The differences in the presentation of Hodgkin vs non-Hodgkin disease are not sufficiently distinctive to permit radiographic differentiation of the two conditions, but some patterns are helpful. Recognizing the frequency of thoracic involvement and that of the additional CT findings in Hodgkin and non-Hodgkin patients makes a sound basis for lymphoma imaging.     

Follow-up of asbestosis patients and predictors for radiographic progression

OBJECTIVE: We followed a group of 85 Finnish asbestosis patients radiographically for an average of 6.5 (range 2-10) years to examine the progression of the disease and to assess possible explanations for the progression. METHODS: The examinations included full-size chest radiographs and a blood specimen analysis. The radiographs were classified according to the 1980 International Labor Office (ILO) classification. Progression was accepted if the second or third radiography was estimated (in a side-by-side comparison) to have more profusion of small opacities qualitatively than the first, even if the radiographs were classified into the same profusion category. RESULTS: In all, 38% of the patients showed progression during the follow-up period. The average progression of small opacities ranged from ILO 1/1 to ILO 2/2 (0.4 minor ILO categories/year). The asbestosis was progressive more often among the sprayers than among the insulators and asbestos factory workers [cross-tabulation, odds ratio (OR) 5.0, 95% confidence interval (95% CI) 1.2-20]. In the logistic regression model the ILO classification category at the beginning of the follow-up (OR 1.54; 95% CI 0.96-2.47), the fibronectin (OR 1.01; 95% CI 1.00-1.01) and angiotensin-converting enzyme (ACE; OR 1.10; 95% CI 1.00-1.20) levels, and the erythrocyte sedimentation rate (ESR; OR 1.05; 95% CI 1.00-1.10) were statistically associated with the radiographic progression of small opacities. Abnormalities of the pleura were found to progress more often among the patients with progressive parenchymal opacities. CONCLUSION: For the progression of small-opacity profusion the significant predictors in the logistic regression model were the ILO profusion category at the beginning of the follow-up period, the fibronectin level, the ACE value, and the ESR. The model correctly classified 94% of the patients with progression and 65% of those without progression. The differences in the mean values recorded for the biomarkers between the progressors and nonprogressors, however, were small and may therefore not be of any importance to the clinician.     

High-resolution CT of the lung: determination of the usefulness of CT scans obtained with the patient prone based on plain radiographic findings

OBJECTIVE: We assessed the usefulness of chest radiographs for predicting whether high-resolution CT scans obtained with the patient prone would be valuable in assessing suspected diffuse lung disease. MATERIALS AND METHODS: In 100 consecutive patients undergoing high-resolution CT, findings on plain chest radiographs were classified as normal, possibly abnormal, or abnormal. CT scans obtained with the patient supine were assessed for the presence and distribution of lung abnormalities without knowledge of the plain radiographic classification. A second review of the CT scans was done with equal numbers of scans obtained with the patient prone and with the patient supine. The usefulness of the CT scans obtained with the patient prone for detecting lung disease was determined and related to the plain radiographic classifications. RESULTS: High-resolution CT scans obtained with patients prone were helpful in excluding or confirming posterior lung abnormalities in 10 (28%) of 36 patients who had normal findings on chest radiographs, five (28%) of 18 patients who had possibly abnormal findings on chest radiographs, and only two (4%) of 46 patients who had abnormal findings on chest radiographs. The proportion of patients who benefited from high-resolution CT scans obtained with the patient prone was significantly lower among the patients with abnormal findings on chest radiographs than among the patients with normal (p = .008) or possibly abnormal (p = .02) findings on chest radiographs. The two patients with abnormal findings on radiographs in whom CT scans obtained with the patient prone were helpful had minimal radiographic abnormalities. CONCLUSION: In patients with suspected diffuse lung disease, obtaining high-resolution CT scans with the patient prone may be useful when chest radiographs show normal findings, possibly abnormal findings, or minimal abnormalities indicative of diffuse lung disease. However, such scans are of little value in patients whose radiographs show abnormalities indicative of diffuse lung disease.     

Risk factors associated with chronic hepatitis C virus infection: limited frequency of an unidentified source of transmission

Acute hypoxaemia is a life-threatening emergency. Diagnosis of the exact aetiology maybe complicated by the presence of pre-existing lung conditions. A case report is presented of a non-intubated patient with a pre-existing lung tumour who developed sudden profound hypoxaemia 3 days after emergency abdominal surgery. Definitive aetiological diagnosis was delayed due to chest X-ray features suggestive of compression and erosion of tumour tissue into the airway. Emergency computerised tomography (CT) imaging however revealed mucous plugging leading to massive atelectasis as the main aetiology.     

Management of gallstones in pregnancy

BACKGROUND: Biliary disease during pregnancy is rare and the management of cholecystitis during pregnancy is controversial. Cholecystectomy in the pregnant patient has generally been avoided because of the reported high incidence of associated fetal loss. Recent developments relating to diagnostic and anaesthetic management have altered the overall approach to symptomatic biliary tract disease in pregnant patients. METHODS: The literature was reviewed using Medline searches for cholelithiasis in pregnancy, to include pathophysiology, diagnosis and management. RESULTS AND CONCLUSION: Surgery should be performed only for complicated non-resolving biliary tract disease during pregnancy as in over 90 per cent of patients the acute process will resolve with conservative management. For patients requiring operative intervention, laparoscopic cholecystectomy has emerged as a safe and effective method of treatment.     

Serum trypsinogen-2 in the prediction of outcome in acute necrotizing pancreatitis

BACKGROUND: The accuracy of serum trypsinogen-2 in predicting the severity of acute necrotizing pancreatitis (ANP) was prospectively evaluated in 52 consecutive patients. METHODS: A new sensitive immunofluorometric assay was used for serum trypsinogen-2, RESULTS: Mean values during the first 24 h were 42.1 micrograms/l in control patients, 1435 micrograms/l in uncomplicated cases, and 4090 micrograms/l in complicated or fatal cases. There was a significant difference in serum trypsinogen-2 values between patients with uncomplicated and complicated disease (p = 0.002) already on admission. When a cutoff level of 1000 micrograms/l was used, patients with uncomplicated ANP were differentiated from patients with complicated ANP with a sensitivity of 91% and with a specificity of 71%. CONCLUSIONS: The immunofluorometric assay of serum trypsinogen-2 is a sensitive and specific method for prediction of the severity of the disease in necrotizing pancreatitis.     

Digital radiography in paediatrics: radiation dose considerations and magnitude of possible dose reduction

The purpose of this study was to evaluate the radiation doses received by paediatric patients examined using a digital radiography unit, and to compare these doses with those received from conventional screen-film systems. In this way, guidelines could be drawn up concerning the magnitude of possible dose reductions achievable using digital radiography. The study was undertaken on approximately 900 patients undergoing abdomen, chest, pelvis and skull examinations. Patients were categorized into the following age groups: 0-1 month, 1-12 months, 1-5 years, 5-10 years and 10-15 years. Approximately half were X-rayed using a Fuji computed radiography system and half using a conventional screen-film system. Entrance surface dose was calculated from the recorded exposure parameters and measured X-ray tube outputs. Dose-area product was recorded directly. Image quality was assessed clinically using criteria recommended by a working group of the Commission of the European Communities. Apart from chest examinations, it was found possible to reduce doses by about 40% on average, by using a computed radiography system instead of a 600 speed screen-film combination. There was no significant difference in the dose for chest examinations. Satisfactory image quality can therefore be achieved by using computed radiography as a 1000 speed system for abdomen, pelvis and skull examinations, and as a 600 speed system for chests. Since very few departments appear to use screen-film systems of speeds greater than 400, then, for most departments, the use of computed radiography would result in dose reductions of at least 60%, or 33% for chests.