Search

Background/Objective \ud Patients classified as interstitial pneumonia with autoimmune features (IPAF) have interstitial lung disease (ILD) and features of autoimmunity but do not fulfill criteria for connective tissue diseases (CTDs). Our goal was to identify patients classifiable as IPAF, CTD-ILD, and idiopathic pulmonary fibrosis (IPF) from a preexisting pulmonary cohort and evaluate the prognosis of patients with IPAF.\ud \ud Methods \ud We reviewed the medical records of 456 patients from a single-center pulmonary ILD cohort whose diagnoses were previously established by a multidisciplinary panel that did not include rheumatologists. We reclassified patients as IPAF, CTD-ILD, or IPF. We compared transplant-free survival using Kaplan-Meier methods and identified prognostic factors using Cox models.\ud \ud Results \ud We identified 60 patients with IPAF, 113 with CTD-ILD, and 126 with IPF. Transplant-free survival of IPAF was not statistically significantly different from that of CTD-ILD or IPF. Among IPAF patients, male sex (hazard ratio, 4.58 [1.77–11.87]) was independently associated with worse transplant-free survival. During follow-up, only 10% of IPAF patients were diagnosed with CTD-ILD, most commonly antisynthetase syndrome.\ud \ud Conclusion \ud Despite similar clinical characteristics, most patients with IPAF did not progress to CTD-ILD; those who did often developed antisynthetase syndrome, highlighting the critical importance of comprehensive myositis autoantibody testing in this population. As in other types of ILD, male sex may portend a worse prognosis in IPAF. The routine engagement of rheumatologists in the multidisciplinary evaluation of ILD will help ensure the accurate classification of these patients and help clarify prognostic factors.

Diagnosis of diffuse parenchymal lung diseases (DPLD) on high resolution CT (HRCT) is difficult for non-expert radiologists due to varied presentation for any single disease and overlap in presentation between diseases.To evaluate whether a pattern-based training algorithm can improve the ability of non-experts to diagnosis of DPLD.Five experts (cardiothoracic-trained radiologists), and 25 non-experts (non-cardiothoracic-trained radiologists, radiology residents, and pulmonologists) were each assigned a semi-random subset of cases from a compiled database of DPLD HRCTs. Each reader was asked to create a top three differential for each case. The non-experts were then given a pattern-based training algorithm for identifying DPLDs. Following training, the non-experts were again asked to create a top three differential for each case that they had previously evaluated. Accuracy between groups was compared using Chi-Square analysis.A total of 400 and 1450 studies were read by experts and non-experts, respectively. Experts correctly placed the diagnosis as the first item on the differential versus having the correct diagnosis as one of their top three diagnoses at an overall rate of 48 and 64.3%, respectively. Pre-training, non-experts achieved a correct diagnosis/top three of 32.5 and 49.7%, respectively. Post-training, non-experts demonstrated a correct diagnosis/top three of 41.2 and 65%, a statistically significant increase (p0.0001). In addition, post training, there was no difference between non-experts and experts in placing the correct diagnosis within their top three differential.The diagnosis of DPLDs by HRCT imaging alone is relatively poor. However, use of a pattern-based teaching algorithm can improve non-expert interpretation and enable non-experts to include the correct diagnosis within their differential diagnoses at a rate comparable to expert cardiothoracic trained radiologists.

BACKGROUND:\ud Idiopathic pulmonary fibrosis (IPF), a progressive disease with an unknown pathogenesis, may be due in part to an abnormal response to injurious stimuli by alveolar epithelial cells. Air pollution and particulate inhalation of matter evoke a wide variety of pulmonary and systemic inflammatory diseases. We therefore hypothesized that increased average ambient particulate matter (PM) concentrations would be associated with an accelerated rate of decline in FVC in IPF.\ud \ud METHODS:\ud We identified a cohort of subjects seen at a single university referral center from 2007 to 2013. Average concentrations of particulate matter < 10 and < 2.5 μg/m3 (PM10 and PM2.5, respectively) were assigned to each patient based on geocoded residential addresses. A linear multivariable mixed-effects model determined the association between the rate of decline in FVC and average PM concentration, controlling for baseline FVC at first measurement and other covariates.\ud \ud RESULTS:\ud One hundred thirty-five subjects were included in the final analysis after exclusion of subjects missing repeated spirometry measurements and those for whom exposure data were not available. There was a significant association between PM10 levels and the rate of decline in FVC during the study period, with each μg/m3 increase in PM10 corresponding with an additional 46 cc/y decline in FVC (P = .008).\ud \ud CONCLUSIONS:\ud Ambient air pollution, as measured by average PM10 concentration, is associated with an increase in the rate of decline of FVC in IPF, suggesting a potential mechanistic role for air pollution in the progression of disease.

Background\ud Despite the relationship between idiopathic pulmonary fibrosis (IPF) and advancing age, little is known about the epidemiology of interstitial lung disease (ILD) in the elderly. We describe the diagnoses, clinical characteristics, and outcomes of patients who were elderly at the time of ILD diagnosis.\ud \ud Methods\ud Among subjects from a prospective cohort study of ILD, elderly was defined as age ≥ 70 years. Diagnoses were derived from a multidisciplinary review. Differences between elderly and nonelderly groups were determined using the χ2 test and analysis of variance.\ud \ud Results\ud Of the 327 subjects enrolled, 80 (24%) were elderly. The majority of elderly subjects were white men. The most common diagnoses were unclassifiable ILD (45%), IPF (34%), connective tissue disease (CTD)-ILD (11%), and hypersensitivity pneumonitis (8%). Most elderly subjects (74%) with unclassifiable ILD had an imaging pattern inconsistent with usual interstitial pneumonia (UIP). There were no significant differences in pulmonary function or 3-year mortality between nonelderly and elderly subjects combined or in a subgroup analysis of those with IPF.\ud \ud Conclusions\ud Although IPF was the single most common diagnosis, the majority of elderly subjects had non-IPF ILD. Our findings highlight the need for every patient with new-onset ILD, regardless of age, to be surveyed for exposures and findings of CTD. Unclassifiable ILD was common among the elderly, but for most, the radiographic pattern was inconsistent with UIP. Although the effect of ILD may be more pronounced in the elderly due to reduced global functionality, ILD was not more severe or aggressive in this group.

Interstitial lung disease (ILD) is common among patients with both classic dermatomyositis (DM) and clinically amyopathic dermatomyositis (CADM), patients with classic skin manifestations without weakness. ILD prognosis is thought to be worse in patients with CADM, but this observation may be due primarily to an increased frequency of rapidly-progressive ILD. This article is protected by copyright. All rights reserved.

Background CT scan measures of emphysema and airway disease have been correlated with lung function in cohorts of subjects with a range of COPD severity. The contribution of CT scan-assessed airway disease to objective measures of lung function and respiratory symptoms such as dyspnea in severe emphysema is less clear. Methods Using data from 338 subjects in the National Emphysema Treatment Trial (NETT) Genetics Ancillary Study, densitometric measures of emphysema using a threshold of −950 Hounsfield units (%LAA-950) and airway wall phenotypes of the wall thickness (WT) and the square root of wall area (SRWA) of a 10-mm luminal perimeter airway were calculated for each subject. Linear regression analysis was performed for outcome variables FEV 1 and percent predicted value of FEV 1 with CT scan measures of emphysema and airway disease. Results In univariate analysis, there were significant negative correlations between %LAA-950 and both the WT ( r = −0.28, p = 0.0001) and SRWA ( r = −0.19, p = 0.0008). Airway wall thickness was weakly but significantly correlated with postbronchodilator FEV 1 % predicted (R = −0.12, p = 0.02). Multivariate analysis showed significant associations between either WT or SRWA (β = −5.2, p = 0.009; β = −2.6, p = 0.008, respectively) and %LAA-950 (β = −10.6, p = 0.03) with the postbronchodilator FEV 1 % predicted. Male subjects exhibited significantly thicker airway wall phenotypes (p = 0.007 for WT and p = 0.0006 for SRWA). Conclusions Airway disease and emphysema detected by CT scanning are inversely related in patients with severe COPD. Airway wall phenotypes were influenced by gender and associated with lung function in subjects with severe emphysema.

Mucormycosis is an opportunistic, angioinvasive fungal infection characteristically affecting individuals with diabetes mellitus, chronic renal failure, and hematologic malignancies. In most cases it is a rapidly progressive infection with an 80% overall mortality. Radiographic manifestations are usually nonspecific focal consolidation or masses. The air crescent sign is a rare manifestation of angioinvasive fungi and indicates either aspergillosis or mucormycosis.

Aspergillus causes a variety of pulmonary diseases. For the most part, they can be divided into three groups: mycetoma, invasive aspergillosis, and allergic forms of aspergillosis. The mycetoma form of aspergillosis has no effective treatment other than surgery, which is reserved for the severely symptomatic patient, usually with massive hemoptysis. Invasive aspergillosis is a dangerous pulmonary infection seen in patients who are generally severely immunocompromised. It is treated with amphotericin B and success in treatment of this form of aspergillosis is limited. Two of the allergic forms of Aspergillus infection, allergic bronchopulmonary aspergillosis and bronchocentric granulomatosis, are treated with steroids. The third allergic type of reaction, hypersensitivity lung, is best treated by removal of the patient from exposure to the antigen. Although these are the characteristic forms of aspergillosis, there is occasional overlap of the different types of aspergillosis.

Objective To evaluate the clinical and radiographic features of pulmonary aspergillosis as they present in AIDS patients; in particular, to determine similarities and differences between Aspergillus infection in patients with AIDS vs those without AIDS. Subjects and Methods Six new cases of confirmed or probable pulmonary aspergillosis were discovered during a search of hospital records. These are reviewed with 30 previously reported cases with special attention to radiographic appearance of disease and how radiographic appearance influences clinical outcome. Results Symptoms of pulmonary aspergillosis in AIDS were nonspecific, most often including fever, cough, and dyspnea, and less commonly, chest pain or hemoptysis. Major risk factors for the development of pulmonary aspergillosis in patients with AIDS were steroid administration and neutropenia. Neutropenia was often a complication of therapies for AIDS, in particular, ganciclovir and zidovudine. Radiographic appearance of disease could be divided into three general categories. One third of the patients (13/36) presented with cavitary upper lobe disease resembling noninvasive or chronic necrotizing aspergillosis. Fatal hemoptysis occurred in 42 percent of patients with this form of disease. Twenty-two percent (8/36) of the cases presented as a nondescript focal alveolar opacity similar to invasive aspergillosis. In several patients, the focal infiltrate remained stable for several months, a feature that is unusual for aspergillosis in non-AIDS patients. The air crescent sign was present in none of the 36 reported cases. Patients with only focal disease had the best prognosis of patients with pulmonary aspergillosis. Bilateral alveolar or interstitial disease similar to invasive aspergillosis was present in 23 percent (9/36) of the patients. Bilateral disease appears to be a marker for disseminated infection and was associated with a high mortality due to aspergillosis. Two new forms of bronchial aspergillosis (5/36 cases) have been described previously. These patients presented with either obstructing fungal casts or bronchial pseudomembranes demonstrated bronchoscopically. In some patients with the bronchial forms of aspergillosis, transient alveolar opacities were seen on chest radiographs. These opacities may represent regions of atelectasis due to airway obstruction. One patient who had bilateral pneumothoraces without parenchymal opacities did not correspond to any of the three previously mentioned categories. Mortality due to aspergillosis was greater than 50 percent among AIDS patients. Death was subsequent to fatal hemoptysis or widespread pulmonary or systemic infection. Conclusion Unlike other risk groups that tend to contract only one form of pulmonary aspergillosis, AIDS patients can develop the whole spectrum of aspergillosis-related pulmonary disorders, including chronic cavitary, invasive, and bronchial forms of aspergillosis. Clinical symptoms are nonspecific and major risk factors include neutropenia, which is often a side effect of various therapies for AIDS, and steroid administration. Patients with the chronic cavitary form of disease have an unusually high mortality due to fatal hemoptysis. Patients with bilateral pulmonary infiltrates and aspergillosis have a high mortality due to disseminated infection.

Recurrent spontaneous pneumothorax is a disorder often managed by thoracic surgeons. Most etiologies are benign in nature; however, there are several syndromes that are associated with potentially fatal pulmonary or systemic manifestations. One such example is Birt-Hogg-Dube syndrome, a rare inheritable syndrome characterized by papular skin lesions involving the scalp, head, face and neck; pulmonary cysts; and a propensity to develop renal carcinoma. In our report, we describe a patient, who was diagnosed with Birt-Hogg-Dube syndrome after presenting with a history of recurrent spontaneous pneumothorax, and a family history of spontaneous pneumothorax and renal cell carcinoma. This case is of particular interest to the cardiothoracic surgery community as the patient described as well as several of his family members were managed by multiple thoracic surgeons, who did not appreciate the diagnosis.

In summary, there are a wide range of pulmonary manifestations seen in asbestos-exposed individuals from pleural and parenchymal fibrosis to pleural and parenchymal malignancy. The chest roentgenogram has assumed an important role in the detection and surveillance of asbestos-related pleural and parenchymal changes.

Rationale and Objectives. To determine whether observer performance in the localization of tubes and catheters on computed radiography (CR) chest images can be improved by using an automatic image-processing algorithm. Methods. Comparisons were made of CR hard-copy, CR soft-copy, and CR enhanced soft-copy images obtained with an image-processing algorithm. The enhanced images used gray-level optimization and nonlinear unsharp masking to emphasize the edges of the devices. Chest radiologists (n = 4), general radiologists (n = 4); and interns (n = 6) read 45 images that contained endotracheal tubes, pulmonary artery catheters, and central venous catheters. Results. Chest radiologists had the smallest mean interobserver localization variability (4 mm), followed by general radiologists (6 mm) and interns (8 mm). Localization variability was greatest for hard-copy images and least for enhanced soft-copy images. Conclusion. Use of an automatic imaging-processing algorithm reduced localization variability and enabled the medical interns to perform at approximately the same level as the chest radiologists.

A staging system, based upon the experience of 1215 patients, was published by the American Joint Committee Task Force on Soft Tissue Sarcoma in 1977. A subset of these patients, 594, was selected to study recurrence-free survival time. The authors found 331 patients with a recurrence within 5 years (100 local only, 123 metastatic only, and 108 local + metastatic); median months to recurrence was 9.7. Within 5 years, recurrence was clearly associated with mortality: among the 331 patients who experienced a recurrence, 245 died, whereas only 31 died among the 263 who had no recurrence. To further evaluate the utility of the published staging system, a multivariate analysis of five factors was carried out for 297 of the 594 patients (patients with unknown information for any one of these factors were excluded). Factors in addition to grade that exerted a significant influence on recurrence were: direct extension, symptoms, and location of tumor when survival was measured to the first of any recurrence, and tumor size, measuring survival to the first metastatic recurrence. It is therefore recommended that these factors be taken into account in staging this disease. Estimates of probable recurrence-free survival time based upon the multivariate model (Weibull) are also presented.

The hemodynamic and respiratory effects of unilateral pneumothorax were studied during positive-pressure mechanical ventilation in five sheep. The sheep were anesthetized, intubated, and placed on mechanical ventilation with positive end-expiratory pressure (5 cm H2O). After baseline studies, including chest roentgenograms, were taken, increments of air were injected into the right pleural cavity. Measurements were repeated at pneumothoraces of 500, 1,000, and 1,500 ml. There was a steady fall in cardiac output (p

A major criterion for the selection of patients with gallstones for treatment with chenodeoxycholic acid is the radiographic demonstration of lucent gallstones. In this study, we sought to evaluate the degree of selectivity of that criterion for distinguishing patients with cholesterol stones from those with pigment stones and to define the determinants of stone lucency or opaqueness. Of 92 lucent stones, 14% were pigment stones; and of 18 of opaque stones, 33% were cholesterol. Thus, the criterion of stone lucency allows inclusion of a significant number of subjects (14%) with lucent pigment stones, which may account for about one-half of the reported 33% incidence of treatment failures with chenodeoxycholic acid. Conversely, of patients with opaque stones, the one-third with cholesterol stones would be excluded from chenodeoxycholic acid treatment. Calcium is the major metal of both types of stones. However, opaque stones contain 6 times more calcium than lucent stones, which accounts for the difference in radiographic appearance.

from the casting molds. After many years of use it became evident that the interior of the pipe was affected by certain types of water. As early as 100 years ago a recommendation made to the French Academy of Sciences states that this difficulty could be cured by the use of a cement lining. Not long after this, bituminous coatings were introduced and soon came into common use, probably because of the simplicity with which they could be applied, as well as their low cost. In the United States, most of the cast-iron pipe sold for water works service after about 1860 was provided with a hot-dip bituminous coating, usually a molten coal-tar pitch. In those systems where the water was relatively hard and slightly alkaline the bituminous coating was generally satisfactory. Where soft or acid waters were encountered, however, problems frequently arose, such as the water's becoming red or rusty and a gradual reduction of the flow rate through the pipe.

1. A review of the plain roentgenograms of 68 patients with acute, irreversible mesenteric infarction revealed "specific" roentgenologic signs of ischemic mucosal edema in 41 (60 per cent); intramural air was present in 11 (15 per cent). This is a considerably higher incidence than has previously been reported. Four ischemic mucosal patterns were distinguished.2. The incidence of "specific" roentgenologic signs was directly related to the extent of mesenteric infarction.3. "Pseudo-obstruction" of the small bowel was the most common nonspecific roentgenologic sign and was present in onehalf of all patients.4. Emergency upper gastrointestinal examination is of value in identifying the earliest changes of ischemia. Preoperatively the "leading edge" of the common, massive infarction is demonstrated. Postoperatively the viability of the residual bowel segment can be further evaluated.

Retroperitoneal fibrosis presents with a clinical and roentgenographic spectrum involving the ureters, inferior vena cava, iliac vein and rectum.The clinical and roentgenographic aspects of this spectrum are discussed and illustrated.The medial deviation of tapered obstructed ureters in the lower lumbar region is described as a "classic sign" of retroperitoneal fibrosis. A comparison statistical analysis of the position of the ureters relative to the lower lumbar spine and sacrum was done comparing 21 cases of retroperitoneal fibrosis with 60 normal cases. This analysis is shown and the lack of significant difference between the 2 groups is demonstrated.

Two patients with sickle cell disease presented with joint pain and early x-ray evidence of articular cartilage loss. Both later developed increasingly destructive arthritis with chronic synovitis identified in synovial biopsies. One patient developed demonstrable aseptic necrosis. Destructive arthropathy is much less common than the frequent transient effusions in sickle cell disease.

A categorical approach to eosinophilic lung disease is discussed.Using the clinical and roentgenographic information, the numerous causes of this syndrome can be separated into 5 groups: 1. simple pulmonary eosinophilia; 2. prolonged pulmonary eosinophilia; 3. tropical eosinophilia; 4. asthma associated with pulmonary eosinophilia; and 5. polyarteritis nodosa and its variants.Fifteen illustrative cases are presented.

The roentgenologic investigation of sinus tracts and fistulae is reviewed.Emphasis is placed upon the use of a small polyethylene catheter in demonstrating the extent of a fistula or sinus tract.