Incidence of Interstitial Lung Abnormalities: The MESA Lung Study.

The incidence of newly developed interstitial lung abnormalities (ILA) and fibrotic ILA have not been previously reported.Trained thoracic radiologists evaluated 13 944 cardiac CT scans for the presence of ILA in 6197 Multi-Ethnic Study of Atherosclerosis longitudinal cohort study participants >45 years of age from 2000 to 2012. 5% of the scans were re-read by the same or a different observer in a blinded fashion. After exclusion of participants with ILA at baseline, incidence rates and incidence rate ratios for ILA and fibrotic ILA were calculated.The intra-reader agreement of ILA was 92.0% (Gwet AC1=0.912, ICC=0.982) and the inter-reader agreement of ILA was 83.5% (Gwet AC1=0.814; ICC=0.969). Incidence of ILA and fibrotic ILA was estimated to be 13.1 cases/1000 person-years and 3.5/1000 person-years, respectively. In multivariable analyses, age (HR 1.06 (1.05, 1.08), p <0.001; HR 1.08 (1.06, 1.11), p <0.001), high attenuation area (HAA) at baseline (HR 1.05 (1.03, 1.07), p <0.001; HR 1.06 (1.02, 1.10), p=0.002), and the MUC5B promoter SNP (HR 1.73 (1.17, 2.56) p=0.01; HR 4.96 (2.68, 9.15), p <0.001) were associated with incident ILA and fibrotic ILA, respectively. Ever smoking (HR 2.31 (1.34, 3.96), p= 0.002) and an IPF polygenic risk score (HR 2.09 (1.61-2.71), p<0.001) were associated only with incident fibrotic ILA.Incident ILA and fibrotic ILA were estimated by review of cardiac imaging studies. These findings may lead to wider application of a screening tool for atherosclerosis to identify preclinical lung disease.

Radiologist Worklist Reprioritization Using Artificial Intelligence: Impact on Report Turnaround Times for CTPA Examinations Positive for Acute Pulmonary Embolism.

BACKGROUND. In patients with acute pulmonary embolism (PE), timely intervention (e.g., initiation of anticoagulation) is critical for optimizing clinical outcomes. OBJECTIVE. The purpose of this study was to evaluate the effect of artificial intelligence (AI)-based radiologist worklist reprioritization on report turnaround times for pulmonary CTA (CTPA) examinations positive for acute PE. METHODS. This retrospective single-center study included patients who underwent CTPA before (October 1, 2018-March 31, 2019 [pre-AI period]) and after (October 1, 2019-March 31, 2020 [post-AI period]) implementation of an AI tool that reprioritized CTPA examinations to the top of radiologists' reading worklists if acute PE was detected. EMR and dictation system timestamps were used to determine the wait time (time from examination completion to report initiation), read time (time from report initiation to report availability), and report turnaround time (sum of wait and read times) for the examinations. Times for reports positive for PE, with final radiology reports as reference, were compared between periods. RESULTS. The study included 2501 examinations of 2197 patients (1307 women, 890 men; mean age, 57.4 ± 17.0 [SD] years), including 1335 examinations from the pre-AI period and 1166 from the post-AI period. The frequency of acute PE, based on radiology reports, was 15.1% (201/1335) during the pre-AI period and 12.3% (144/1166) during the post-AI period. During the post-AI period, the AI tool reprioritized 12.7% (148/1166) of examinations. For PE-positive examinations, the post-AI period, compared with the pre-AI period, had significantly shorter mean report turnaround time (47.6 vs 59.9 minutes; mean difference, 12.3 minutes [95% CI, 0.6-26.0 minutes]) and mean wait time (21.4 vs 33.4 minutes; mean difference, 12.0 minutes [95% CI, 0.9-25.3 minutes]) but no significant difference in mean read time (26.3 vs 26.5 minutes; mean difference, 0.2 minutes [95% CI, -2.8 to 3.2 minutes]). During regular operational hours, wait time was significantly shorter in the post-AI than in the pre-AI period for routine-priority examinations (15.3 vs 43.7 minutes; mean difference, 28.4 minutes [95% CI, 2.2-64.7 minutes]) but not for stat- or urgent-priority examinations. CONCLUSION. AI-driven worklist reprioritization yielded reductions in report turnaround time and wait time for PE-positive CTPA examinations. CLINICAL IMPACT. By assisting radiologists in providing rapid diagnoses, the AI tool has potential for enabling earlier interventions for acute PE.

Impact of antigen identification on transplant free survival in interstitial lung disease.

INTRODUCTION: Antigen identification impacts diagnosis as well as prognosis in patients with hypersensitivity pneumonitis. An antigen may also be present in other etiologies of interstitial lung disease, however it is unknown whether identification impacts survival. METHODS: We evaluated a retrospective cohort in order to determine if antigen identification affects transplant free survival in patients with hypersensitivity pneumonitis, idiopathic pulmonary fibrosis, connective tissue disease interstitial lung disease, and interstitial pneumonia with autoimmune features. Only patients with definite or high probability of hypersensitivity pneumonitis by American Thoracic Society guidelines were included in the analysis. RESULTS: Transplant free survival was improved with antigen identification in patients with hypersensitivity pneumonitis but not in patients with idiopathic pulmonary fibrosis, connective tissue disease interstitial lung disease, and interstitial pneumonia with autoimmune features. CONCLUSION: Our study suggests that removal of identified antigen in interstitial lung diseases other than hypersensitivity pneumonitis may not be impactful. Additionally, it further suggests that definitive diagnosis of hypersensitivity pneumonitis with bronchoalveolar lavage and transbronchial biopsy may be beneficial prior to recommending antigen removal.

Impact of radiographic honeycombing on transplant free survival and efficacy of immunosuppression in fibrotic hypersensitivity pneumonitis.

BACKGROUND: The distinction between hypersensitivity pneumonitis (HP) and idiopathic pulmonary fibrosis (IPF) was thought to be important due to the difference in mortality between the conditions as well as the response to treatment. However, recent work suggests that the clinical diagnosis may matter less than certain radiographic features, namely usual interstitial pneumonia (UIP) pattern. The purpose of this study is to evaluate whether radiographic honeycombing is more predictive of transplant-free survival (TFS) than other clinical, radiographic, or histologic findings that distinguish HP from IPF in the current guidelines and to evaluate the impact of radiographic honeycombing on the efficacy of immunosuppression in fibrotic HP. METHODS: We retrospectively identified IPF and fibrotic HP patients evaluated between 2003 and 2019. Univariable and multivariable logistic regression was performed for patients with fibrotic HP and IPF to evaluate TFS. To assess the impact of treatment with immunosuppression on TFS in fibrotic HP, a cox proportional hazard model adjusted for known predictors of survival in HP including age, gender, and baseline pulmonary function testing results was constructed, and p-interaction for the presence of honeycombing on high resolution computed tomography and use of immunosuppression was calculated. RESULTS: Our cohort included 178 with IPF and 198 with fibrotic HP. In a multivariable analysis, the presence of honeycombing had a greater impact on the TFS than the diagnosis of HP vs. IPF. Among the criteria used in the HP diagnostic guidelines, only typical HP scan impacted survival in a multivariable model, while identification of antigen and surgical lung biopsy findings had no impact on survival. We identified a trend toward worse survival on immunosuppression in those with HP with radiographic honeycombing. CONCLUSION: Our data suggests that honeycombing and baseline pulmonary function testing have a greater impact on TFS than the clinical diagnosis of IPF vs. fibrotic HP and that radiographic honeycombing is a predictor of poor TFS in fibrotic HP. We suggest that invasive diagnostic testing including surgical lung biopsy may not be useful in predicting mortality in HP patients with honeycombing and may potentially increase risk of immunosuppression.

Detection of Incidental Pulmonary Embolism on Conventional Contrast-Enhanced Chest CT: Comparison of an Artificial Intelligence Algorithm and Clinical Reports.

BACKGROUND. Artificial intelligence (AI) algorithms have shown strong performance for detection of pulmonary embolism (PE) on CT examinations performed using a dedicated protocol for PE detection. AI performance is less well studied for detecting PE on examinations ordered for reasons other than suspected PE (i.e., incidental PE [iPE]). OBJECTIVE. The purpose of this study was to assess the diagnostic performance of an AI algorithm for detection of iPE on conventional contrast-enhanced chest CT examinations. METHODS. This retrospective study included 2555 patients (mean age, 53.2 ± 14.5 [SD] years; 1340 women, 1215 men) who underwent 3003 conventional contrast-enhanced chest CT examinations (i.e., not using pulmonary CTA protocols) between September 2019 and February 2020. A commercial AI algorithm was applied to the images to detect acute iPE. A vendor-supplied natural language processing (NLP) algorithm was applied to the clinical reports to identify examinations interpreted as positive for iPE. For all examinations that were positive by the AI-based image review or by NLP-based report review, a multireader adjudication process was implemented to establish a reference standard for iPE. Images were also reviewed to identify explanations of AI misclassifications. RESULTS. On the basis of the adjudication process, the frequency of iPE was 1.3% (40/3003). AI detected four iPEs missed by clinical reports, and clinical reports detected seven iPEs missed by AI. AI, compared with clinical reports, exhibited significantly lower PPV (86.8% vs 97.3%, p = .03) and specificity (99.8% vs 100.0%, p = .045). Differences in sensitivity (82.5% vs 90.0%, p = .37) and NPV (99.8% vs 99.9%, p = .36) were not significant. For AI, neither sensitivity nor specificity varied significantly in association with age, sex, patient status, or cancer-related clinical scenario (all p > .05). Explanations of false-positives by AI included metastatic lymph nodes and pulmonary venous filling defect, and explanations of false-negatives by AI included surgically altered anatomy and small-caliber subsegmental vessels. CONCLUSION. AI had high NPV and moderate PPV for iPE detection, detecting some iPEs missed by radiologists. CLINICAL IMPACT. Potential applications of the AI tool include serving as a second reader to help detect additional iPEs or as a worklist triage tool to allow earlier iPE detection and intervention. Various explanations of AI misclassifications may provide targets for model improvement.

Variables Associated With Response to Therapy in Patients With Interstitial Pneumonia With Autoimmune Features.

BACKGROUND/OBJECTIVE: We have limited knowledge regarding characteristics of patients with interstitial pneumonia with autoimmune features (IPAF) that are associated with response to immunosuppression. In this study, we used published IPAF criteria to characterize features associated with response to treatment. METHODS: We conducted a single-center medical records review study of 63 IPAF patients to evaluate for serological, clinical, and morphological characteristics that are associated with response to immunosuppression. Response was defined as % relative functional vital capacity decline of less than 10% and absence of death or lung transplant within the first year of continuous immunosuppressive therapy. Nonparametric measures of association and multivariate logistic regression were used to evaluate the relationship between baseline characteristics and immunosuppressive response. RESULTS: There was a trend of greater progression among men, ever smokers, those negative for antisynthetase antibodies, and those with usual interstitial pneumonia radiographic pattern, but no statistically significant relationship was found between baseline serological, clinical, or morphological features and response to immunosuppression. Patients on combination therapy with mycophenolate mofetil and prednisone had less disease progression (p = 0.018) than those on regimens that did not include both of these medications. CONCLUSIONS: In our cohort, baseline clinical assessment did not identify which patients with IPAF will respond to immunosuppressive therapy. Combination therapy with mycophenolate mofetil and prednisone was associated with lack of disease progression in our IPAF patients, including in IPAF-usual interstitial pneumonia. Further studies are needed to evaluate which IPAF patients would benefit from immunosuppressive therapy, antifibrotic therapy, or a combination of both.

Radiological approach to cavitary lung lesions.

Cavitary lesions in the lung are not an uncommon imaging encounter and carry a broad differential diagnosis that includes a wide range of pathological conditions from cancers, infections/inflammatory processes to traumatic and congenital lung abnormalities. In this review article, we describe a comprehensive approach for evaluation of cavitary lung lesions and discuss the differential diagnosis in the light of radiological findings.

Utility of Bronchoalveolar Lavage and Transbronchial Biopsy in Patients with Interstitial Lung Disease.

PURPOSE: Bronchoalveolar lavage and transbronchial biopsy can be a useful tool in the evaluation of interstitial lung disease (ILD), but patient selection for this procedure remains poorly defined. Determining clinical characteristics that help with patient selection for bronchoscopy may improve confidence of ILD classification while limiting potential adverse outcomes associated with surgical lung biopsy. The purpose of this study is to identify factors that were associated with change in multidisciplinary ILD diagnosis (MDD) before and after incorporation of BAL and TBBx data. METHODS: We conducted a retrospective cohort study of ILD patients at a single center who underwent bronchoscopy in the diagnostic workup of ILD. We performed sequential MDD both pre- and post-bronchoscopy to calculate the frequency of change in diagnosis after incorporating information from BAL and TBBx and identify features associated with change in diagnosis. RESULTS: 245 patients were included in the study. Bronchoscopy led to a change in diagnosis in 58 patients (23.7%). The addition of TBBx to BAL increased diagnostic yield from 21.8 to 34.1% (p = 0.027). Identification of antigen, HRCT scan inconsistent with UIP, and absence of a pre-bronchoscopy diagnosis of CTD-ILD or IPAF were associated with a change in diagnosis after bronchoscopy. CONCLUSION: Our study suggests clinical features that may assist with patient selection for bronchoscopy. We suggest bronchoscopy in patients with identified antigen or an HRCT that is consistent with a non-IPF diagnosis. Appropriate patient selection for bronchoscopy may improve ILD diagnostic confidence and avoid potential complications from more invasive and higher risk procedures.

Insult to Injury: Development of Alveolar Hemorrhage after Initiation of Extracorporeal Membrane Oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is associated with complications that are separate from the underlying diagnoses that require its use. One of the foremost complications of ECMO is a high incidence of bleeding, including alveolar hemorrhage (AH), which is believed to be due to both prophylactic anticoagulation and critical illness-induced systemic coagulopathy. However, akin to systemic inflammatory response syndrome after cardiopulmonary bypass, ECMO causes widespread systemic inflammation and acute lung injury, which likely further predisposes patients to AH. The burden of clinically significant AH among patients on ECMO for advanced lung disease remains unknown. PATIENTS AND METHODS: Charts of patients with advanced lung disease who required ECMO at a single institution were reviewed. The clinical course and variables of patients who developed AH and those who did not were compared. RESULTS: This report describes five patients who developed AH after initiation of venovenous ECMO for refractory hypoxemia. Clinical and laboratory variables did not predict the development or the prognosis of AH. Two of these patients with refractory hypoxemia and AH were treated with pulse-dose corticosteroids, with a dramatic response in one case. CONCLUSION: The acute decompensation of the patients and response to corticosteroids suggest AH was mediated by a systemic inflammatory process, as opposed to coagulopathy alone. Judicious use of steroids may be considered among select patients who develop AH without symptoms of systemic coagulopathy after initiation of ECMO. HOW TO CITE THIS ARTICLE: Williams S, Batra K, Mohanka M, Bollineni S, Kaza V, Torres F, et al. Insult to Injury: Development of Alveolar Hemorrhage after Initiation of Extracorporeal Membrane Oxygenation. Indian J Crit Care Med 2020;24(12):1201-1205.

Telomere length and genetic variant associations with interstitial lung disease progression and survival.

Leukocyte telomere length (LTL), MUC5B rs35705950 and TOLLIP rs5743890 have been associated with idiopathic pulmonary fibrosis (IPF).In this observational cohort study, we assessed the associations between these genomic markers and outcomes of survival and rate of disease progression in patients with interstitial pneumonia with autoimmune features (IPAF, n=250) and connective tissue disease-associated interstitial lung disease (CTD-ILD, n=248). IPF (n=499) was used as a comparator.The LTL of IPAF and CTD-ILD patients (mean age-adjusted log-transformed T/S of -0.05±0.29 and -0.04±0.25, respectively) is longer than that of IPF patients (-0.17±0.32). For IPAF patients, LTL <10th percentile is associated with faster lung function decline compared to LTL ≥10th percentile (-6.43% per year versus -0.86% per year; p<0.0001) and worse transplant-free survival (hazard ratio 2.97, 95% CI 1.70-5.20; p=0.00014). The MUC5B rs35705950 minor allele frequency (MAF) is greater for IPAF patients (23.2, 95% CI 18.8-28.2; p<0.0001) than controls and is associated with worse transplant-free IPAF survival (hazard ratio 1.92, 95% CI 1.18-3.13; p=0.0091). Rheumatoid arthritis (RA)-associated ILD (RA-ILD) has a shorter LTL than non-RA CTD-ILD (-0.14±0.27 versus -0.01±0.23; p=0.00055) and higher MUC5B MAF (34.6, 95% CI 24.4-46.3 versus 14.1, 95% CI 9.8-20.0; p=0.00025). Neither LTL nor MUC5B are associated with transplant-free CTD-ILD survival.LTL and MUC5B MAF have different associations with lung function progression and survival for IPAF and CTD-ILD.

Successful use of rituximab in granulomatosis with polyangiitis with aortic inflammation.

Large-vessel inflammation, although rare, has been increasingly recognised as a complication of granulomatosis with polyangiitis (GPA) in recent years. The presentation is highly variable, ranging from an incidental finding to aortic dissection and rupture. Treatment has predominately consisted of a combination of cyclophosphamide and high dose corticosteroids with surgical intervention when indicated. We present the case of a 34-year-old male diagnosed with GPA after presenting with sinus and eye inflammation and the ensuing investigation revealed large vessel involvement that remarkably improved after 6 months of treatment with the combination of rituximab infusions, methotrexate and corticosteroids.

Utility of Bronchoalveolar Lavage and Transbronchial Biopsy in Patients with Hypersensitivity Pneumonitis.

INTRODUCTION: Making the diagnosis of HP is challenging due to a lack of consensus criteria and variability of both pathologic and radiographic findings. The purpose of this retrospective study was to determine the diagnostic utility of the combination of BAL lymphocyte count and TBBX in patients with HP. METHODS: We conducted a retrospective cohort study of all patients with a MDD diagnosis of HP at a single center. RESULTS: 155 patients were included in the study. 49% of patients who underwent BAL had a lymphocyte count > 20, 42% had a lymphocyte count > 30, and 34% had lymphocyte count > 40%. The median BAL lymphocyte count was higher in inflammatory HP compared to fibrotic HP. The addition of TBBX to BAL significantly increased the diagnostic yield regardless of the BAL lymphocyte cutoff used. The yield of bronchoscopy with TBBX and BAL when a lymphocyte count > 40% was used as a cutoff was 52%. CONCLUSIONS: Our study suggests that the combination of TBBX with BAL significantly increases the likelihood that the procedure will provide adequate additional information to allow a confident MDD diagnosis of HP and may reduce the need for SLB in the diagnostic workup of HP.

Telomere-related lung fibrosis is diagnostically heterogeneous but uniformly progressive.

Heterozygous mutations in four telomere-related genes have been linked to pulmonary fibrosis, but little is known about similarities or differences of affected individuals.115 patients with mutations in telomerase reverse transcriptase (TERT) (n=75), telomerase RNA component (TERC) (n=7), regulator of telomere elongation helicase 1 (RTEL1) (n=14) and poly(A)-specific ribonuclease (PARN) (n=19) were identified and clinical data were analysed.Approximately one-half (46%) had a multidisciplinary diagnosis of idiopathic pulmonary fibrosis (IPF); others had unclassifiable lung fibrosis (20%), chronic hypersensitivity pneumonitis (12%), pleuroparenchymal fibroelastosis (10%), interstitial pneumonia with autoimmune features (7%), an idiopathic interstitial pneumonia (4%) and connective tissue disease-related interstitial fibrosis (3%). Discordant interstitial lung disease diagnoses were found in affected individuals from 80% of families. Patients with TERC mutations were diagnosed at an earlier age than those with PARN mutations (51±11 years versus 64±8 years; p=0.03) and had a higher incidence of haematological comorbidities. The mean rate of forced vital capacity decline was 300 mL·year-1 and the median time to death or transplant was 2.87 years. There was no significant difference in time to death or transplant for patients across gene mutation groups or for patients with a diagnosis of IPF versus a non-IPF diagnosis.Genetic mutations in telomere related genes lead to a variety of interstitial lung disease (ILD) diagnoses that are universally progressive.

Spectrum of suprascapular nerve lesions: normal and abnormal neuromuscular imaging appearances on 3-T MR neurography.

OBJECTIVE. In this article, we will review the normal anatomy and imaging features of various neuromuscular abnormalities related to suprascapular neuropathy. CONCLUSION. Suprascapular neuropathy can be difficult to distinguish from rotator cuff pathology, plexopathy, and radiculopathy. Electrodiagnostic studies are considered the reference standard for diagnosis; however, high-resolution 3-T MR neurography (MRN) can play an important role. MRN enables direct visualization of the nerve and simultaneous assessment of the cervical spine, brachial plexus, and rotator cuff.

Development of a novel labour monitoring tool: Improving labour care quality in the Indian setting.

Introduction: Efficient care by labour monitoring tools manages labour, identifies the abnormalities and avoids the fatalities. Various studies are being undertaken by the researchers to understand the limited use of these therapeutic tools. The present study aimed to develop a novel labour monitoring instrument after understanding the barriers and enablers of the currently used tools and using it in the health setting for improving clinical outcomes. Materials and Methods: Methodological research design was adopted to develop the novel tool. Item pool was generated by literature review, focus group discussions and retrospective observations of the partographs. Developed tool was evaluated by various experts by undergoing three rounds and was found to be reliable in terms of stability and equivalency. After undergoing pilot runs by researcher and nurses, tool was found to be feasible and understandable. The developed novel labour monitoring tool was used on 200 intranatal women. Results: Focus group discussions revealed various barriers in the current labour tools, such as lack of clarity, complexity, staff shortage, workload etc. Retrospective observation of filled partographs revealed the incomplete recording of the components of the partograph. The prepared first draft underwent rigorous review by the experts. The prepared novel tool, after being used on 200 intranatal women resulted in 90% of normal vaginal deliveries. Duration of 1st stage of labour was around 5 hours. Conclusion: A novel labour monitoring tool was developed after methodological approach resulting in adequate monitoring and improved labour outcomes.

ACR Appropriateness Criteria® Sepsis.

Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. A search for the underlying cause of infection typically includes radiological imaging as part of this investigation. This document focuses on thoracic and abdominopelvic causes of sepsis. In 2017, the global incidence of sepsis was estimated to be 48.9 million cases, with 11 million sepsis-related deaths (accounting for nearly 20% of all global deaths); therefore, understanding which imaging modalities and types of studies are acceptable or not acceptable is imperative. The 5 variants provided include the most commonly encountered scenarios in the setting of sepsis along with recommendations and data for each imaging study. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Imaging Features of Idiopathic Interstitial Lung Diseases.

Idiopathic interstitial pneumonias (IIPs) are a group of diffuse parenchymal lung diseases of unclear etiology and are distinguished from diffuse parenchymal lung diseases of known cause, such as connective tissue disease-related interstitial lung diseases or hypersensitivity pneumonitis by history, physical exam, imaging, serologic testing, and, when necessary, histopathology. The 2013 American Thoracic Society (ATS)/European Respiratory Society (ERS) guidelines are the most widely accepted classification of IIPs and include the following diagnoses: idiopathic pulmonary fibrosis, idiopathic nonspecific interstitial pneumonia, cryptogenic organizing pneumonia, acute interstitial pneumonia, idiopathic lymphocytic interstitial pneumonia, idiopathic pleuro-parenchymal fibroelastosis, respiratory bronchiolitis-interstitial lung disease, and desquamative interstitial pneumonia. The gold standard for diagnosis of IIP involves multidisciplinary discussion among pulmonologists, radiologists, and pathologists. The focus of this review will be to discuss the imaging features of the most common IIPs and the role of multidisciplinary discussion as the gold standard for diagnosis.