Routine chest X-ray on hospital admission: does it contribute to diagnosis or treatment?

BACKGROUND: In many hospitals a routine chest X-ray is performed on admission. There are, however, scant data regarding its usefulness in contemporary patient populations. METHODS: We studied consecutive patients admitted during a 2 month period to a single department of medicine, where hospital policy mandates performing an admission CXR. Two senior clinicians not involved in the care of these patients assessed the discharge summaries for a clinical indication to perform CXR on admission, as well as its contribution to patient management (major positive, major negative, minor positive, or no contribution). RESULTS: There were 675 patients whose mean age was 64.5 +/- 17.2 years. In 19.6% (130 cases) CXR was not performed. Of the 545 CXRs done, 260 (48%) were normal. In only 128 (23.5%) did the admission CXR make a major positive contribution to diagnosis or treatment. In 61 (11.2%) it provided a minor positive contribution and in 153 (28.1%) a major negative contribution. In 184 patients (33.8%) the CXR did not affect either diagnosis or management. It made a major positive contribution to management in patients for whom there was an indication for performing the X-ray (odds ratio 10.3, P < 0.0005) and in those with a relevant finding on physical examination (OR 1.63, P = 0.110). For the 329 patients who had neither a clinical indication for performing a CXR nor an abnormal chest examination the admission CXR contributed to patient management in only 12 cases (3.6%). CONCLUSIONS: A routine admission CXR has a significant impact on patient management only in those patients in whom there are relevant findings on physical examination or a clear clinical indication for performing the test. There is no need to routinely order CXR on admission to hospital.

Strongyloides hyperinfection in Ethiopian immigrants in Israel.

We report four cases of Strongyloides hyperinfection among Ethiopian immigrants, of which three were fatal. Many immigrants from countries in which Strongyloides is endemic settle in developed countries. A high index of suspicion will lead to earlier diagnosis and treatment of this disease. Testing for Strongyloides infestation in this susceptible population by enzyme-linked immunosorbent assay serology, stool testing or duodenal aspiration may prevent the fatal complications of hyperinfection.

Splenic embolus: 13 cases from a single medical department.

BACKGROUND: Despite the spleen having a very rich blood supply, there is a paucity of reports of splenic emboli. OBJECTIVES: To investigate the incidence of splenic emboli treated in a single general internal medicine department over the last 3 years. METHODS: We examined the records of a 35 bed internal medicine department in a hospital in the center of Israel. RESULTS: Over a period of 3 years 13 patients admitted to one internal medicine department developed acute abdominal pain and areas of hypoperfusion in the spleen on contrast computed tomography imaging. The patients were treated with anticoagulants, their course was benign and there were no long-term sequelae. CONCLUSIONS: Embolus to the spleen is not rare in an internal medicine department. Diagnosis can be easily made by contrast CT scanning, and treatment with anticoagulants results in a good prognosis.

A cost-effective method for reducing the volume of laboratory tests in a university-associated teaching hospital.

BACKGROUND: Laboratory tests comprise a significant portion of hospital expenditure. Attempts to reduce their use have had mixed results. OBJECTIVE: To investigate the effect of an intervention based on a simple form-based system for ordering laboratory tests by physicians, on both use of laboratory resources and diagnostic accuracy. DESIGN: At Kaplan Medical Center in Rehovot , Israel , there are 4 similar Internal Medicine departments. In one department (C), the new system was initiated, whereas in the other 3 departments (A, B and D), the traditional method of ordering blood tests was continued. The intervention used was a requirement for tests to be specifically requested by residents following unbundling of test panels, with hands-on supervision by a senior physician. In addition, the residents attended a series of lectures on the economic implications of laboratory testing. The intervention study lasted for 3 years. MEASUREMENTS: Total number of tests performed in each department, number of tests per admission and total cost of each test at Medicare reimbursement prices. RESULTS: The number of tests per admission prior to the intervention was 1.91 +/- 0.89; it decreased for each of the next 3 years: 0.76 +/- 0.61, 0.80 +/- 0.62 and 0.78 +/- 0.63 respectively. There was a total decrease of 97,365 tests during the 3-year period, saving 1,914,149 dollars. There was no difference in the readmission rate or in the number of diagnoses of conditions based primarily on blood tests such as hypokalemia or hyponatremia, between department C and the other departments. CONCLUSIONS: The intervention developed here produced significant and sustained reduction of financial savings in the number of laboratory tests ordered, without negatively impacting diagnostic capability or patient care.

Acute renal embolism. Forty-four cases of renal infarction in patients with atrial fibrillation.

Acute renal embolus is rarely reported in the medical literature; thus, accurate data regarding presentation, laboratory tests, diagnostic techniques, and treatment are lacking. To better define this condition, we examined the medical records of all patients admitted to Kaplan Medical Center and Sheba Medical Center in central Israel from 1984 to 2002 who had a diagnosis of renal infarction and atrial fibrillation. We noted demographic, clinical, and laboratory parameters; method of diagnosis; treatment received; and patient outcome. We identified 44 cases of renal embolus: 23 females and 21 males, with an average age of 69.5 +/- 12.6 years. Thirty (68%) patients had abdominal pain, and 6 (14%) had a previous embolic event. Nine patients were being treated with warfarin on admission, 6 (66%) of whom had an international normalized ratio (INR) < 1.8. Hematuria was present in 21/39 (54%), and 41 (93%) patients had a serum lactate dehydrogenase (LDH) level > 400 U/dL. The mean LDH was 1100 +/- 985 U/dL. Diagnostic techniques included renal isotope scan, which was abnormal in 36/37 cases (97%); contrast-enhanced computed tomography (CT) scan, which was diagnostic in 12/15 cases (80%); and ultrasound, which was positive in only 3/27 cases (11%). Angiography was positive in 10/10 cases (100%). Twenty-three (61%) of 38 patients had normal renal function on follow-up. The 30-day mortality was 11.4%. Renal embolus was diagnosed mainly in patients aged more than 60 years, some of whom had a previous embolic event. Most of those receiving anticoagulant therapy had a subtherapeutic INR. Abdominal pain was common, as well as hematuria and an elevated LDH. These patients are at risk of subsequent embolic events to other organs. The most sensitive diagnostic technique in this population is a renal isotope scan, but contrast-enhanced CT scan requires further assessment.

Hemochromatosis mutations are not linked to dilated cardiomyopathy in Israeli patients.

AIMS: Hemochromatosis is a condition in which iron loading impairs the function of many organs, including the heart. Congestive heart failure with left ventricular dilatation is commonly found in patients with hemochromatosis. Two missense mutations (C282Y and H63D) have been shown to be responsible for the majority of cases of hemochromatosis. METHODS AND RESULTS: We examined 156 patients with congestive heart failure due to dilated cardiomyopathy. Details were recorded of clinical and echocardiographic parameters. DNA was extracted from peripheral blood and checked for the presence of the C282Y and H63D mutations by a commercially available single nucleotide primer extension assay. A control group of 98 healthy blood donors was also checked for the presence of these mutations. Of the 157 patients, 42 (26.75%) had at least one mutation. Five (3.65%) were homozygotic for the H63D mutation and 37 (23.6%) were heterozygotic for the H63D mutation. The C282Y mutation was not present. In a control population of 98 healthy blood donors, 27 (27.6%) were heterozygous for the H63D population and none had the C282Y mutation (no significant difference between the patients with cardiomyopathy and the healthy blood donors, chi(2) test 0.754). There was a non-significant trend to a difference in the prevalence of homozygotic H63D between the cardiomyopathy patients and the healthy blood donors (3.18% vs. 0%, P=0.076, chi(2) test). There was no statistically significant difference between the cardiomyopathy patients with and without the mutations in terms of age, gender, hemoglobin, iron, transferrin, ferritin, presence of diabetes mellitus, hypertension and previous coronary artery bypass grafting. CONCLUSION: In our population of patients with dilated cardiomyopathy, there was no evidence for hemochromatosis being an important etiology.