[Show abstract][Hide abstract] ABSTRACT: A 28-year-old woman was incidentally found to have a large right apical mass (figure 1) on a chest radiograph. She denied having any respiratory symptoms but had noted asymmetric flushing of her face following strenuous exercise (figure 2). On closer questioning she also described hypohydrosis affecting the right side of her face.
[Show abstract][Hide abstract] ABSTRACT: To evaluate the computed tomographic (CT) predictors of a clinically significant yield from microbiological tests in patients with a tree-in-bud pattern.
CT examinations in 53 patients (male=34; mean age=52.9±17.3 y) with a tree-in-bud pattern in whom a diagnostic test (sputum analysis, bronchoalveolar lavage or nasopharyngeal aspirates) had been performed within 2 weeks were identified. The following CT patterns were independently quantified by 2 thoracic radiologists: tree-in-bud, bronchiectasis, bronchial wall thickening, consolidation, ground-glass opacification, and nodules. The presence of cavitation (in nodules and/or consolidation) was recorded. Patient charts were reviewed for the presence of a clinically significant positive microbiological result.
A clinically significant causal organism was present in 25/53 (47%) patients. The median extent of a tree-in-bud pattern was 5 [range=1 to 16 (maximum range=0 to 18)], and cavitation was present in 14/53 (26%) patients (cavitating nodules=8, cavitation in consolidation=3, and cavitation in consolidation and nodules=3). There was no independent linkage between the extent of a tree-in-bud pattern and the identification of a clinically significant organism. The microbiological yield was significantly higher if there was coexistent cavitation in nodules or consolidation [11/14 (79%) vs. 14/39 (39%); P=0.005]. On stepwise logistic regression, the only CT predictor of a clinically significant microbiological yield was cavitation on CT (odds ratio=9.7; 95% confidence interval=1.9, 49.9; P<0.01); the extent of a tree-in-bud pattern, concurrent use of antibiotics, age, and sex were not independently linked to a significant microbiological yield.
A specific clinically significant microbiological diagnosis was obtained in approximately 50% of patients with a tree-in-bud pattern. The microbiological yield rises strikingly when a tree-in-bud pattern coexists with cavitation (in nodules or consolidation) but is not predicted by ancillary CT signs or clinical parameters.
Journal of thoracic imaging 02/2014; DOI:10.1097/RTI.0000000000000078 · 1.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Abstract Rationale - Lung clearance index (LCI) is a more sensitive measure of lung function than spirometry in cystic fibrosis (CF) and correlates well with abnormalities in high resolution computed tomography (HRCT) scanning. We hypothesised LCI would be equally sensitive to lung disease in primary ciliary dyskinesia (PCD). Objectives - To test the relationships between LCI, spirometry and HRCT in PCD and to compare them to the established relationships in CF. Methods -Cross sectional study of 127 patients with CF and 33 patients with PCD, all of whom had spirometry and LCI, of which a subset of 21 of each had HRCT performed. HRCT was scored for individual features and these features compared with physiological parameters. Measurements and main results - Unlike in CF, and contrary to our hypothesis, there was no correlation between spirometry and LCI in PCD, and no correlation between HRCT features and LCI or spirometry in PCD. Conclusions - We show for the first time that HRCT, spirometry and LCI have different relationships in different airway diseases, and that LCI does not appear to be a sensitive test of airway disease in advanced PCD. We hypothesise that this results from dissimilarities between the components of large and small airway disease in CF and PCD. These differences may in part lead to the different prognosis in these two neutrophilic airway diseases. Abstract word count: 220 Keywords: spirometry, HRCT, LCI.
American Journal of Respiratory and Critical Care Medicine 07/2013; 188(5). DOI:10.1164/rccm.201304-0800OC · 11.99 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Pulmonary embolism (PE) is frequently cited as a common primary cause of unilateral pleural effusion, but in clinical practice appears to be uncommon. Objectives: In order to evaluate this observation, CT pulmonary angiography (CTPA) was performed in consecutive patients presenting to a single centre with a new uninvestigated unilateral pleural effusion and no clear cause and was supplemented by delayed-phase thoracic CT, optimized for visualization of the pleura. Methods: All patients underwent standard clinical assessment and pleural investigations in line with recent national guidelines and were followed up for a minimum of 1 year or until histological/microbiological diagnosis. Results: One hundred and fifty patients were recruited, and of these, 141 had a CTPA. PEs were detected in 9/141 (6.4%) patients, and of these, 8/9 were subsequently diagnosed with pleural malignancy. In only 1 case was PE clinically suspected and in no case was PE the primary cause of effusion; 9.8% (8/82) of patients who were ultimately diagnosed with pleural malignancy had PE at presentation. Conclusions: This study indicates that PE is a frequent concomitant finding in patients with malignant effusions but uncommon as a primary cause of unilateral effusion. In addition, it highlights the known difficulty of clinical diagnosis of PE in the context of malignancy. In view of this, we recommend that CTPA combined with pleural-phase thoracic CT should be considered at presentation when investigating patients with suspected malignant pleural effusion.
[Show abstract][Hide abstract] ABSTRACT: Rheumatoid arthritis is a relatively common multisystem disease associated with significant mortality and morbidity. Thoracic disease, both pleural and pulmonary, is a frequent extra-articular manifestation of rheumatoid arthritis and responsible for approximately 20% of rheumatoid-associated mortality. Rheumatoid disease and its associated therapies can affect all compartments of the lung inciting a range of stereotyped pathological responses and it is not infrequent for multiple disease entities to co-exist. In some instances, development of pulmonary complications may precede typical rheumatological presentation of the disease and be the first indication of an underlying connective tissue disease. The spectrum of thoracic disease related to rheumatoid arthritis is reviewed.
[Show abstract][Hide abstract] ABSTRACT: Advances in our understanding of lung adenocarcinoma have led to the recently revised classification of lung adenocarcinoma. This replaces the term bronchoalveolar carcinoma and introduces the concept of preinvasive, minimally invasive, and frankly invasive lesions to the classification. Although more work is required to validate these concepts, it is likely that they will be incorporated into the next World Health Organization and TNM classifications. We illustrate the likely radiographic appearance of lesions in the new classification, highlight salient features to watch for on follow-up, and offer guidance on their management.
[Show abstract][Hide abstract] ABSTRACT: Pulmonary hypertension (PH) is associated with increased mortality in fibrotic idiopathic interstitial pneumonia (IIP). We hypothesize that baseline K(CO) (diffusing capacity of carbon monoxide/alveolar volume) and 6-month decline in K(CO) reflect PH, thus predicting mortality in IIP.
All IIP referrals (2004-2007) were identified (n = 269). 192 had pulmonary function at 6 months. Fifty-two (27%) died during follow-up (median 22.5 months). Outcome was evaluated for early (1 year from 6-month pulmonary function) and overall mortality. A vascular index best predicting mortality was identified (using baseline and 6-month decline in K(CO) ) and evaluated against PH at echocardiography.
Baseline and 6-month decline in K(CO) were associated with early and overall mortality. A positive vascular index (baseline K(CO) % ≤ 50% and/or ≥15% decline in K(CO) at 6 months; n = 40) was strongly predictive of early and overall mortality. Neither a diagnosis of idiopathic pulmonary fibrosis nor PH predicted early death when incorporated into this model. In patients without baseline PH, with follow-up echocardiography (n = 60), a positive vascular index was associated with PH at follow-up.
A vascular index comprised of baseline and 6-month decline in K(CO) strongly predicted increased mortality and development of PH on echocardiography. In, K(CO) may be an important marker for pulmonary vascular disease and its associated mortality.
[Show abstract][Hide abstract] ABSTRACT: The study aims were to identify CT features that predict outcome of fibrotic idiopathic interstitial pneumonia (IIP) when information from lung biopsy data is unavailable.
HRCTs of 146 consecutive patients presenting with fibrotic IIP were studied. Visual estimates were made of the extent of abnormal lung and proportional contribution of fine and coarse reticulation, microcystic (cysts ≤4 mm) and macrocystic honeycombing. A score for severity of traction bronchiectasis was also assigned. Using death as our primary outcome measure, variables were analysed using the Cox proportional hazards model.
CT features predictive of a worse outcome were coarse reticulation, microcystic and macrocystic honeycombing, as well as overall extent of lung abnormality (p < 0.001). Importantly, increased severity of traction bronchiectasis, corrected for extent of parenchymal abnormality, was predictive of poor prognosis regardless of the background pattern of abnormal lung (HR = 1.04, CI = 1.03-1.06, p < 0.001). On bivariate Cox analysis microcystic honeycombing was a more powerful determinant of a poor prognosis than macrocystic honeycombing.
In fibrotic IIPs we have shown that increasingly severe traction bronchiectasis is indicative of higher mortality irrespective of the HRCT pattern and extent of disease. Extent of microcystic honeycombing is a more powerful determinant of outcome than macrocystic honeycombing.
European Radiology 03/2011; 21(8):1586-93. DOI:10.1007/s00330-011-2098-2 · 4.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The widespread use of multidetector computed tomography for imaging of the chest has lead to a significant increase in the number of incidentally detected pulmonary nodules. The significance of these nodules is often uncertain and further investigations may be required. This article will review the spectrum of imaging appearances of small pulmonary nodules, and highlight the few features that allow confident characterization of a nodule as benign or malignant; current guidelines for the management of incidentally detected nodules will also be discussed.
[Show abstract][Hide abstract] ABSTRACT: Lung cancer is the most common cause of cancer-related death in the UK. Despite aggressive primary prevention measures and improved medical care, the 5-year survival rate is less than 10% for patients in the UK who present with symptoms. The possibility of CT screening for lung cancer provides some hope of reducing mortality. However, the case for screening remains unproven. This article explores the issues surrounding lung cancer screening in the context of historical studies, trials in progress and tentative plans for a UK CT lung cancer screening trial.
The British journal of radiology 08/2009; 82(979):529-31. DOI:10.1259/bjr/17503608 · 2.02 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine whether delayed-phase liver imaging using a destructive imaging mode is able to provide similar information to phase-inversion imaging regarding detection and conspicuity of liver metastases.
Patients with a known primary malignancy with suspected liver metastases were recruited. Ultrasound was performed at baseline, and up to 5 min after the administration of Sonazoid, using phase-inversion imaging at both low and high mechanical indices (MI) and at 10-15 min using destructive imaging. One of four doses of Sonazoid was used: 0.008, 0.08, 0.12, and 0.36 microl/kg of body weight. Two observers documented lesion number and conspicuity subjectively, and divided the patients into group A (no lesions), group B (one to seven lesions), and group C(I-III) (more than eight lesions, subdivided with increasing lesion number) depending on the number of lesions and categories I-IV based on lesion conspicuity. These parameters were compared with contrast-enhanced computed tomography (CECT) as the reference standard.
Sixteen patients were examined (six women, 10 men), mean age 67.3 years (range 48-83 years). Based on CECT imaging, the division was as follows: group A n=1, group B n=8, group C(I)n=1, group C(II)n=4, group C(III)n=2. The accuracy of baseline ultrasound versus CECT was 75% (in 12 of the 16 patients the group concurred) and the accuracy for contrast-enhanced ultrasound (CEUS) versus CECT was 93.8% (15/16). There was a significant improvement in lesion conspicuity for both low (p=0.0029) and high MI phase-inversion (p=0.0004) and destructive (p=0.0015) CEUS imaging in comparison with baseline ultrasound. Artefact was noted at higher doses of Sonazoid; and no side effects were recorded.
Following a single, intravenous injection of Sonazoid, the properties of this microbubble allow for a and robust examination of the liver using two different techniques with comparable results.