A validation of register-derived diagnoses of interstitial lung disease in patients with inflammatory arthritis: data from the NOR-DMARD study.

OBJECTIVE: There is a lack of knowledge concerning the validity of the interstitial lung disease (ILD) diagnoses used in epidemiological studies on rheumatic diseases. This paper seeks to verify register-derived ILD diagnoses using chest computed tomography (CT) and medical records as a gold standard. METHOD: The Norwegian Anti-Rheumatic Drug Register (NOR-DMARD) is a multicentre prospective observational study of patients with inflammatory arthritis who start treatment with disease-modifying anti-rheumatic drugs. NOR-DMARD is linked to the Norwegian Patient Registry (NPR) and Cause of Death Registry. We searched registers for ILD coded by ICD-10 J84 or J99 among patients with rheumatoid arthritis, psoriatic arthritis, or spondyloarthritis. We extracted chest CT reports and medical records from participating hospitals. Two expert thoracic radiologists scored examinations to confirm the ILD diagnosis. We also searched medical records to find justifications for the diagnosis following multidisciplinary evaluations. We calculated the positive predictive values (PPVs) for ILD across subsets. RESULTS: We identified 71 cases with an ILD diagnosis. CT examinations were available in 65/71 patients (91.5%), of whom ILD was confirmed on CT in 29/65 (44.6%). In a further 10 patients, medical records confirmed the diagnosis, giving a total of 39/71 verified cases. The PPV of a register-derived ILD diagnosis was thus 54.9%. In a subset of patients who had received an ILD code at two or more time-points and had a CT scan taken within a relevant period, the PPV was 72.2%. CONCLUSION: The validity of register-based diagnoses of ILD must be carefully considered in epidemiological studies.

An investigation into the variability of radiographers assessing body composition prior to CT contrast media administration.

INTRODUCTION: To evaluate and report the variability of radiographers in determining a patient's body type and using this to determine contrast media (CM) volumes for chest computed tomography (CT). METHODS: This prospective study recruited 50 patients undergoing chest CT examinations. Three radiographers independently used two methods to determine patient body type and consequently CM volume. In Method 1, subjective evaluation of body type together with patient weight determined CM volume. In Method 2, patient weight along with additional criteria applied by the radiographer determined CM volume. Both the determination of body type and CM volumes were compared in terms of agreement and variability between radiographers, and between methods. RESULTS: Fleiss' kappa was lower (0.583) for Method 1 when compared to Method 2 (0.926) indicating stronger agreement in the radiographer determination of body type for Method 2. Median (IQR) CM volume was 95.0 mL (85.0-110.0) for Method 1, compared to 92.5 mL (85.0-100.0) for method 2 (P < 0.001). CONCLUSION: Method 2 provided greater agreement in determination of body type, and reduction of CM volumes compared to Method 1. IMPLICATIONS FOR PRACTICE: Determining body type as part of a CT CM strategy can be subjective and enhanced methods are required to ensure that the most appropriate CM volumes are reliably used.

Chest abnormalities in juvenile-onset mixed connective tissue disease: assessment with high-resolution computed tomography and pulmonary function tests.

BACKGROUND: Mixed connective tissue disease (MCTD) is associated with several chest manifestations. Only a few studies have focused on chest manifestations in juvenile-onset MCTD (jMCTD), and the true prevalence of pulmonary abnormalities on high-resolution computed tomography (HRCT) in these patients is unknown. PURPOSE: To investigate the occurrence of pulmonary abnormalities in jMCTD with particular reference to interstitial lung disease (ILD), and to evaluate a possible association between pulmonary findings and disease-related variables. MATERIAL AND METHODS: Twenty-four childhood-onset MCTD patients with median disease duration of 10.5 years (range 1-21 years) were investigated in a cross-sectional study by means of HRCT, pulmonary function tests (PFT), and clinical assessment. RESULTS: Discrete ILD was identified in six patients (25%). Median extent of ILD was 2.0%, and all except one of the patients had very mild disease in which 5% or less of the parenchyma was affected. The CT features of fibrosis were mainly microcystic and fine intralobular. The most frequently abnormal PFT was carbon monoxide uptake from the lung, which was abnormal in 33% of the patients. PFT and disease duration were not significantly associated with HRCT findings of ILD. CONCLUSION: The prevalence of ILD in childhood-onset MCTD patients was lower than previously believed. In most of the patients with ILD, the findings were subtle and without clinical correlation. The results suggest a low extent of ILD in childhood-onset MCTD, even after long-term disease duration.

Computed tomography enhancement characteristics of lymphomatous lymph nodes of the neck.

OBJECTIVES: The objective of this study was to investigate prospectively CT contrast medium enhancement curves of lymphomatous lymph nodes of the neck. MATERIALS AND METHODS: Eleven patients with biopsy-proven lymphoma had their enlarged cervical lymph nodes examined with dynamic CT and compared with a control group. RESULTS: The mean contrast medium enhancement of the lymphomatous nodes was significantly lower than that of the control group in the time interval from 40 s to 180 s after injection. DISCUSSION: The enhancement pattern previously suggested from studies of retroperitoneal lymph nodes was confirmed in this prospective study of cervical nodes.

Pulmonary involvement in patients with childhood-onset systemic lupus erythematosus.

OBJECTIVE: Pulmonary involvement is a common finding in adults with systemic lupus erythematosus (SLE). The aim of this study was to investigate the frequency of pulmonary abnormalities in patients with childhood-onset SLE, with particular reference to interstitial lung disease (ILD), and to examine any association between pulmonary abnormalities and other disease-related variables. METHODS: A cohort of 60 Norwegian patients with childhood-onset SLE was examined in a cross-sectional study by high-resolution computed chest tomography (HRCT) and pulmonary function tests (PFT). Median disease duration was 11.2 years. Disease activity, cumulative organ damage and immunological markers were also assessed. RESULTS: Five patients (8%) had abnormal HRCT findings, including micronodules in four patients and bronchiectasis in one. None of the patients had radiographic evidence of ILD. PFT results were impaired in 37% of the patients, the most frequent pulmonary dysfunction was reduced carbon monoxide diffusing capacity (26%). HRCT findings, disease activity or serology did not correlate with PFTs. Reduced diffusion capacity was associated with smoking (p-value < 0.05). CONCLUSION: Lung function was moderately impaired, while the frequency of pulmonary parenchymal involvement was low. There was no radiographic evidence of ILD, which is an unexpected finding given the high frequencies reported in adult SLE patients assessed with HRCT. The results suggests that PFT values are often abnormal, but these are infrequently associated with development of ILD or other substantial parenchymal alterations in childhood-onset SLE, and do not require further HRCT investigation in asymptomatic patients.

Multicenter evaluation of a new laser guidance system for computed tomography intervention.

PURPOSE: To measure the accuracy of laser-guided punctures and to evaluate the usefulness of the developed laser-guided system. MATERIAL AND METHODS: The study included 67 patients referred for computed-tomography-guided puncture. The majority of the punctured lesions were located in the chest (28 patients) or abdomen (19 patients). The mean diameter of the lesion was 3.1 cm, and the mean path length was 6.8 cm. The laser guide was movable along a horizontal or vertical rail and not physically connected to the CT unit. The angle of insertion was entered manually into the display of the unit by the interventional radiologist. A prospective multicenter trial was carried out. RESULTS: A mean of 1.1 needle passes were necessary to reach the target, and in 55 (84.6%) of the patients the target was reached on the first needle pass. The mean deviation of the needle from the preselected angle was 1.8 degrees. The mean targeting time (from the initial localizing scan until the needle was in the target) was 15.6 min. In every case, both the usefulness and the ease of use of the laser guidance system were subjectively evaluated on a 5-point scale; the mean usefulness score was 4.5, while the mean ease of use score was 4.7. CONCLUSION: Different users at four different centers found the laser guidance system useful and easy to use. A high level of accuracy of the puncture angle was obtained in most cases.

Conventional sinus radiography compared with CT in the diagnosis of acute sinusitis.

OBJECTIVES: To evaluate the value of plain film radiography in a prospective investigation of patients with clinical suspicion of acute sinusitis, using standard CT as a gold standard. METHODS: 47 consecutive patients were examined. Each patient underwent conventional X-ray and standard dose CT examinations on the same day. The sensitivity and specificity of the plain film examination were calculated. RESULTS: The specificity of the plain film examination was high, but the sensitivity was low except for the maxillary sinus (sensitivity 80%). Thus, for maxillary sinusitis, plain film examination was reasonably accurate. A negative finding in the other sinuses could not be relied upon. CONCLUSIONS: The sensitivity of plain film radiography for detecting sinus opacifications was unacceptably low for the ethmoid, frontal and sphenoid sinuses. The specificity was high.

A new low-dose CT examination compared with standard-dose CT in the diagnosis of acute sinusitis.

A low-dose CT of the paranasal sinuses was designed with few, thin sections, non-uniform intersection gaps, low milliampere settings and avoidance of direct radiation to the eye lens. The low-dose CT was prospectively compared with standard-dose CT in patients with suspicion of acute sinusitis. Forty-seven patients were examined with low-dose CT immediately after standard-dose CT. The effective dose and the lens dose were calculated and compared. Using standard-dose CT as a gold standard the sensitivity and specificity of low-dose CT was calculated for each sinus group. The effective dose and the lens dose of the low-dose CT were reduced to, respectively, 3 and 2% of the standard-dose CT. The diagnostic yield of the low-dose CT with regard to acute sinusitis was good with a high specificity (> or =96%) for all sinus groups. The sensitivity was also high (> or =95%) except for the frontal sinus where the sensitivity was 83%. Low-dose CT offers considerable dose reduction and should be the standard for imaging patients with suspected acute inflammatory paranasal disease.

CT appearances of unilateral cleft palate 20 years after bone graft surgery.

PURPOSE: To describe CT appearances in patients with unilateral cleft lip and palate (CLP) 20 years after bone graft surgery. MATERIAL AND METHODS: Eighteen consecutive patients with unilateral CLP were examined. All patients had been treated with primary closure, both in infancy and early childhood, supplemented with bone grafting at the age of around 10 years. The CT examination of the upper jaw included a dental CT program. The CT appearances of the cleft side were compared with those of the untreated non-cleft side. RESULTS: Abnormal CT appearances included skew nasal aperture (n=17), nasal septal deviation (n=17), low floor of nasal aperture (n=15) at or towards the cleft side, and deviation of anterior nasal spine towards the non-cleft side (n=18). The posterior part of the bone cleft was visible in all patients, and the dental arch was V-shaped in 8. CONCLUSION: Although adherence to the present treatment protocol is considered to give satisfactory functional and cosmetic results, certain abnormalities persist. A knowledge of these is a prerequisite for a complete and final evaluation of the surgical and orthodontic regimen.

[Resection of malignant tumors involving the anterior cranial fossa]. / Reseksjon av maligne svulster med relasjon til fremre skallgrop.

BACKGROUND: The craniofacial approach has greatly facilitated resections of tumours involving the base of the anterior cranial fossa when compared to either the transcranial or transfacial approach alone. MATERIAL AND METHODS: This approach was used in 11 patients with malignant tumours localized to the ethmoid sinus, orbit and bone or soft tissue of the base of the anterior part of the skull. By combining a low frontal or frontolateral craniotomy with resection of the facial skull, en bloc resections were accomplished. A frontogaleal periostal flap or a muscle flap from the temporal muscle was used to replace resected bone and to seal the skull base. RESULTS: There were no peri- or postoperative deaths. One patient died due to local recurrence, one patient is alive with residual tumour six years after surgery, and one is reoperated due to local recurrence. In addition one patient developed recurrence of a previously treated tumour of the maxillary sinus. Two patients developed meningitis and one pneumocephalus postoperatively. One patient has partial loss of vision and two patients underwent dacryocystorhinostomy due to epiphora. INTERPRETATION: The planning and execution of this type of surgery requires close interaction in an interdisciplinary team, in particular between neurosurgeon and head and neck surgeon.

CT of the oral vestibule with distended cheeks.

PURPOSE: To evaluate patient compliance in CT examination of the oral vestibule with distended, blown-up cheeks and to determine how often such images provided additional information when disease processes in this area were suspected. MATERIAL AND METHODS: Fifty-four patients were examined with CT of the oral vestibule with distended cheeks and 16 of them had diseases where oral vestibule affection was considered possible. RESULTS: Fifty-three of 54 patients were able to perform cheek distension. Of 16 patients with possible disease involvement of the oral vestibule, additional information was thus obtained in 11 patients. CONCLUSION: When lesions involving the oral vestibule or adjacent regions are suspected, CT examination with distended cheeks is recommended as a routine procedure. The oral vestibule separates the teeth and gingiva from the buccal mucosa of the lips and cheek. On CT images of the oral region, the buccal and gingival mucosa are not separated and thus difficult to define. Problems may arise in deciding whether or not a limited tumorous or infectious lesion of the gingiva also involves the buccal region and vice-versa. We observed that images with distended, blown-up cheeks could be useful in this respect, as the air separated the gingival from the buccomasseteric region and allowed a determination of buccal distensibility. The purpose of the present report was to establish how well the patients could co-operate in performing the CT examination with distended cheeks, and how often such images provided additional information in patients with disease processes which might affect the oral vestibule.

[High-resolution computer tomography of the lungs]. / Høyoppløsningscomputertomografi av lungene.

High-resolution CT (HRCT) is a technique developed over the last decade. It optimises spatial resolution and provides details similar to those obtainable from gross pathologic specimens. HRCT of the lungs provides an accurate assessment of the pattern and distribution of many disease processes that in the conventional chest radiograph are occult or non-specific. HRCT is an established technique and the method of choice for evaluating a variety of pulmonary diseases. In this review we describe the modifications in CT technique that are instrumental in obtaining HRCT, and we also give examples of normal and pathologic findings in general.

[CT combined with arterial portography. A sensitive method for evaluation of liver tumors]. / CT kombinert med arteriell portografi. En sensitiv metode for evaluering av leversvulster.

During the period 1994-95, 22 patients were examined with CT during arterial portography for evaluation of hepatic tumours. The majority, 20 patients, had metastases from colon cancer. All patients were candidates for liver resection. In the series of patients described here, this process detected additional lesions in four more of the patients than found with any other imaging techniques. This supports that CT during arterial portography is the most sensitive method for detecting small malignant hepatic tumours, and for localizing them in relation to liver segments and major vascular structures. Optimal results are obtained in the absence of diffuse parenchymal disease and portal hypertension. Non-tumourous perfusion defects limit the accuracy of this technique, but such defects have characteristic locations and appearance. In difficult cases the technique should be correlated with ultrasonography and MR.

[Fulminant fasciitis in the head and neck region]. / Fulminant fasciitt i hode- og halsregionen.

Deep interstitial infections of the head and neck are potentially life-threatening conditions because of the double threat of upper airway obstruction and production of bacterial toxins, which may result in spread of infection, sepsis and multiorgan failure. At an early stage the symptoms are rather diffuse. It is of critical importance however, to make an early diagnosis if a fatal outcome is to be prevented. We describe a patient with infection caused by group F streptococci, (Streptococcus anginosus or milleri), and discuss the diagnosis and treatment.

[Synovial chondromatosis]. / Synovial kondromatose.

Synovial chondromatosis is a rare monarticular condition in which cartilaginous masses are formed by metaplasia of the synovial membrane. These masses may calcify and ossify. The disease most commonly affects the knee, and the symptoms include pain, swelling, locking and palpable loose bodies. Although the clinical features are usually non-specific, the roentgenograms often provide important diagnostic information. Synovial chondromatosis is rarely a difficult diagnostic problem, but should not be confused with other disorders that give rise to loose bodies, such as degenerative joint disease and osteochondritis dissecans. Two cases are described and synovial chondromatosis is discussed in some detail, including radiological features and treatment.

[Salivary gland ultrasonography]. / Ultralydundersøkelse av spyttkjertlene.

Many pathologic conditions of the salivary gland are diagnosed clinically. Until a few years ago, supplementary radiographic methods have only included plain film radiography and sialography. Both methods vary in usefulness, and the indications are controversial. During the last two decades other imaging methods, both radiographic and non-radiographic, have been used, and have provided clinically useful information. Probably the most useful of these is ultrasonography. Because the salivary glands are superficial structures they lend themselves well to ultrasonographic evaluation. Although sialography should still be the method of choice for some conditions, ultrasonography alone will often give the correct diagnosis. The purpose of this article is to describe the role of sonography for imaging pathologic conditions of the salivary glands.