Effects of intravenous urokinase versus alteplase on total pulmonary resistance in acute massive pulmonary embolism: a European multicenter double-blind trial. The European Cooperative Study Group for Pulmonary Embolism.

Twelve centers participated in a double-blind study in which 63 patients with angiographically documented acute massive pulmonary embolism were randomly assigned to treatment with either urokinase (4,400 U/kg as an intravenous bolus infusion, then 4,400 U/kg per h over 12 h; n = 29) or alteplase (10 mg as an intravenous bolus infusion, then 90 mg over 2 h) followed by heparin (n = 34). The primary objective was to compare the resolution of pulmonary embolism as judged by the change in total pulmonary resistance over the initial 2 h. Further objectives were to evaluate the changes in total pulmonary resistance over the next 10 h and the degree of angiographic resolution at 12 to 18 h. At 2 h, total pulmonary resistance decreased by 18 +/- 22% in the urokinase group and by 36 +/- 17% in the alteplase group (p = 0.0009). Continuous monitoring of pulmonary artery mean pressure, cardiac index and total pulmonary resistance revealed that these variables improved faster in the alteplase group, with consistently significant intergroup differences from 30 min up to 3 to 4 h. After 12 h, the decrease in total pulmonary resistance was 53 +/- 19% in the urokinase group compared with 48 +/- 17% in the alteplase group and the reduction in the angiographic severity score was 30 +/- 25% compared with 24 +/- 18%, respectively, with no significant intergroup differences. Bleeding was equally frequent in the two treatment groups, except that more urokinase-treated patients experienced hematomas at puncture sites.

Advanced multiple beam equalization radiography (AMBER) in the detection of diffuse lung disease.

To evaluate the effects of scanning equalization radiography (SER) on the detection of diffuse lung disease a clinical comparison between an Advanced Multiple Beam Equalization Radiography (AMBER) unit and conventional chest radiography was performed. Even though the overall detection of focal pulmonary lesions with the AMBER unit has been shown to be significantly higher than with conventional radiography because of the improved demonstration of the costophrenic and retrocardiac regions, the utility of AMBER in the demonstration of diffuse lung disease has not been established. Twenty-one patients with diffuse lung disease (fibrosing alveolitis or sarcoidosis) and six patients with no pulmonary disease had high kVp frontal and lateral chest radiographs on both an AMBER unit and a conventional chest stand. The pooled results of five observers using Receiver Operating Characteristic (ROC) analysis indicate that there is a slight improvement but no statistically significant difference in observer performance between AMBER (Area under the ROC curve AZ = 0.934) and conventional radiography (AZ = 0.868) in the task of detecting diffuse lung disease.

Silicosis in a Himalayan village population: role of environmental dust.

The Himalayan villages of Chuchot Shamma and Stok were surveyed because silicosis had been suspected from the radiographs of some of the inhabitants. The villages are agricultural, and Chuchot is exposed to frequent dust storms. Chest radiographs of villagers aged 50-62 were assessed blind by two independent observers using ILO criteria. In Chuchot five of seven men and all of the nine women examined showed varying grades of silicosis, compared with three of 13 men and seven of 11 women in Stok, which lies 300 metres higher and is exposed to fewer dust storms. The difference in prevalence of silicosis between the two villages was significant, as was the differences between men and women. Three patients from the village adjoining Chuchot were later found to have radiological evidence of progressive massive fibrosis. A necropsy on a man in a neighbouring village in the Indus valley showed classical silicosis in a hilar lymph node. Chemical analysis of the inorganic dust in the lung showed that 54.4% was elemental silicon [corrected]. This was similar to the silicon [corrected] content of dust samples collected from houses in Chuchot, which included particles of respirable size. X-ray microanalysis showed that quartz formed 16-21% of the inorganic lung dust. This study suggests that silicosis is common among the older inhabitants of these Himalayan villages. The dust exposure is clearly environmental and not industrial. Further studies are needed to define the extent and severity of silicosis in this community and to examine possible preventive measures.

Clinical correlates of angiographically diagnosed idiopathic pulmonary hypertension.

During 1970-87 43 patients with unexplained pulmonary hypertension (mean pulmonary arterial pressure greater than 25 mm Hg) were admitted to the Brompton Hospital and classified by angiographic criteria as having either symmetrical peripheral pulmonary artery pruning (thought to represent primary plexogenic pulmonary arteriopathy), n = 21, or asymmetrical pulmonary arterial occlusions (thought to represent chronic thromboembolic disease), n = 22. Patients with symmetrical pulmonary arteriopathy had significantly higher mean pulmonary arterial pressures (67 mm Hg) at the time of presentation than those with asymmetrical pulmonary arteriopathy (49 mm Hg). Clinical distinction between these two groups was impossible. Survival from the time of diagnosis was similarly poor in the two groups (26 weeks and 38 weeks) and did not correlate with any of the haemodynamic measurements. The difficulties in making distinctions between these conditions are discussed.

Relapsing polychondritis.

Relapsing polychondritis is a progressive multisystem disorder that predominantly affects cartilage, producing an inflammatory reaction. We present case histories from four patients having mainly respiratory symptoms in whom we measured the coronal diameters of the trachea and compared them with the tracheal measurements from radiographs of patients with no respiratory symptoms. The results showed that the disease produced diffuse narrowing of the main airway in all four patients. Early detection of tracheal narrowing is important, as patients presenting with respiratory tract disease have a worse prognosis than those who develop it later in the course of their illness. Other features of the disease are also discussed with reference to the cases presented.

Cryptogenic bilateral fibrosing pleuritis.

We describe four patients with bilateral pleural effusions progressing to diffuse pleural thickening for which we have been unable to find any evidence of an infective, embolic or occupational aetiology. In order to avoid confusion with diffuse pleural thickening attributable to asbestos-related disease, the term cryptogenic bilateral fibrosing pleuritis is suggested. The patients differed from those with pleural shadowing due to asbestos in that none of them gave a history of asbestos exposure, all were ill, presented with chest pain which was not always pleuritic in character, and had dyspnoea, cough or malaise. They had pleural effusions of variable size, pleural shadowing radiographically and raised sedimentation rates. Computed tomography revealed bilateral extensive pleural thickening in all cases. All four were HLA B44 positive. Histology showed that in all cases the pleura was thickened by fibrous tissue. Both layers were affected and the pleural space was often obliterated. Otherwise the pleural surface was covered by organizing fibrin. Focal collections of lymphocytes were often present when the fibrous tissue abutted on the subpleural fat. No asbestos bodies were seen in any of the cases and in one patient electron microscopic fibre counts showed no excess of asbestos. Pleural decortication was successful in three patients. In one of these, contralateral disease was successfully controlled with corticosteroids, but the fourth patient has not improved on corticosteroids.

Role of computed tomography in diagnosis of bronchiectasis.

Bronchograms and computed tomograms were performed in 27 patients who presented consecutively for bronchography with chronic sputum production. The films were reported separately by three consultant radiologists, who had been asked to give a diagnostic interpretation of the films for each bronchopulmonary segment. The reporting of bronchiectasis on computed tomograms was compared with that on bronchograms. The sensitivity and specificity of computed tomography at segmental level compared with bronchography was 66% and 92%, respectively. We conclude that computed tomography alone is not yet suitable for accurate characterisation and localisation of disease in patients in whom surgery is contemplated. Computed tomography may be useful in patients in whom bronchography is contraindicated and for monitoring progression of disease after initial combined computed tomography and bronchography.

Interpretation of bronchograms and chest radiographs in patients with chronic sputum production.

Bronchograms and plain chest radiographs of 27 patients with chronic sputum production were reported separately in random order and independently by two pulmonary radiologists to establish the diagnostic rate of each investigation and to assess interobserver variation. Both radiologists agreed on the presence of bronchiectasis on bronchography in 19 of 27 (70%) patients and in 94 of 448 (21%) bronchopulmonary segments. One radiologist only interpreted the films as showing bronchiectasis in a further two (7%) patients and 26 (6%) segments. There was more disagreement about the presence or absence of individual bronchographic abnormalities. Two main groups of patients with bronchiectasis were identified by bronchography: 11 with bronchiectasis alone and eight with bronchiectasis and bronchographic features suggestive of "chronic bronchitis". There was no clinical difference between these two groups. Plain chest radiographs were insensitive, being diagnostic (both radiologists agreeing) of bronchiectasis in only nine of 19 (47%) patients with definite bronchiectasis on bronchography.

Mortality in cases of asbestosis diagnosed by a pneumoconiosis medical panel.

One hundred and fifty five male cases of asbestosis certified by the London Pneumoconiosis Medical Panel during 1968-74 were followed up during 1978-9, 4-11 (mean 7.5) years after certification. Fifty nine patients had died, 23 (39%) from lung cancer, 6 (10%) from mesothelioma, and 11 (19%) from other respiratory causes. The number of observed deaths was 2.25 times greater than expected and 7.4 times greater than expected for lung cancer. Adenocarcinoma was the commonest histological type but other cell types were also increased. Finger clubbing (p less than 0.01) and percentage of predicted FEV1 (p less than 0.01) were of value in predicting death, but increasing profusion of small opacities greater than 1/0 (ILO/U-C international classification of radiographs of pneumoconiosis, 1971), duration of exposure to asbestos, time from first exposure to asbestos, and percentage of predicted vital capacity and transfer factor did not predict death.

Significance of finger clubbing in asbestosis.

The prognostic significance of finger clubbing in asbestosis has been assessed in 167 cases certified by the London Pneumoconiosis Medical Panel from 1968 to 1974. Finger clubbing developed early in the clinical course of the disease and was associated with a lower gas transfer, a higher mortality and a greater likelihood of progression in intrapulmonary fibrosis than was found among cases without finger clubbing. Finger clubbing was not associated with heavier asbestos exposure. Its presence appears to be associated with a more severe form of disease.

Subpulmonary pleural effusions in children after cardiac surgery.

Postoperative chest radiographs on 100 children who had undergone cardiac operations were evaluated to determine the frequency of subpulmonary effusions after surgery. Of the 83 patients in whom adequate erect postoperative radiographs were available, 9 (11%) had effusions confirmed by lateral decubitus radiographs. On the frontal chest x ray film, the evidence of an effusion was an increase in distance between the diaphragm and air in the gastric fundus, or an apparent elevation of the right hemidiaphragm. None of the patients examined echocardiographically had associated pericardial effusions. When a subpulmonary effusion was detected diuretic treatment was started or continued. None of the patients had radiographic evidence of residual fluid when they were seen two weeks after their discharge from hospital.

Allergic broncho-pulmonary aspergillosis: the radiological appearance during long-term follow-up.

The radiographs of 100 patients with allergic bronchopulmonary aspergillosis were examined to assess the type and distribution of abnormalities seen during long-term follow-up. Lobar shrinkage occurred almost exclusively in the upper zones but other abnormalities were distributed throughout both lungs. Bronchial wall thickening was the commonest lesion observed and was usually a permanent finding. Consolidation was commonest in the perihilar regions, persisted for up to 20 weeks when transient and was a permanent finding in 10 patients. Dilated bronchi were noted to change in calibre with exacerbations and remissions of the condition. Episodes of transient collapse were segmental, lobar or involved a whole lung. Permanent collapse was always segmental. Massive shadowing, band shadows and 'gloved fingers' were seen less frequently than expected and cavitation was rare. In some patients the chest radiograph was normal between exacerbations of the disease.

Radiographic abnormalities of the duodenum in cystic fibrosis.

Radiologically demonstrable abnormalities of the duodenum are common in cystic fibrosis and are most prevalent in the second part of the duodenum. Out of 14 upper gastrointestinal barium studies performed on patients with cystic fibrosis over a period of 10 years, radiographic abnormalities of the duodenum were found in 12, an incidence of 86%. The abnormalities consisted of thickened mucosal folds, nodular indentations and effacement of the normal mucosal pattern. A duodenal stricture that was radiologically similar to a carcinoma presented as pyloric obstruction in one patient and this resolved on medical treatment. We conclude that barium studies in patients with cystic fibrosis may uncover unsuspected abnormalities of the duodenum, that these form part of the syndrome and that invasive treatment is not indicated.