Rheumatoid interstitial lung disease in Canterbury, Aotearoa New Zealand - A retrospective cohort study.

BACKGROUND: Rheumatoid arthritis associated interstitial lung disease (RA-ILD), is an important extra-articular manifestation of rheumatoid arthritis (RA). The frequency, risk factors, and prognosis of RA-ILD are incompletely understood. AIMS: To determine the prevalence and incidence, clinical characteristics and risk factors for development, and outcomes of persons with RA-ILD in the population of the Canterbury District Health Board (CDHB) catchment area. METHODS: Individuals aged ≥ 18 years with RA, resident in the CDHB catchment area between 1 January 2006 and 31 December 2008 (Period One), and 1 January 2011 to 31 December 2013 (Period Two) were identified by medical record review and followed until 30 June 2019. Individuals with RA-ILD as defined by pre-specified criteria were identified. The association between demographic and clinical characteristics and RA-ILD development and mortality was examined using Cox-proportional hazards models. RESULTS: The prevalence of RA-ILD per 100,000 was 10.97 (95 % CI 7.53,14.42) for Period One, and 14.74 (95 % CI 10.84,18.63) for Period Two. Among individuals evaluated for risk factors for RA-ILD development, the estimated cumulative incidence of ILD at 10 years was 4.47 % (95 % CI 3.14, 6.14). After adjusting for age, rheumatoid factor positivity (HR 3.73, 95 % CI, 1.32,10.56), extra-articular manifestations other than RA-ILD (HR 4.48, 95 % CI 2.36,8.48), and subcutaneous rheumatoid nodules (HR 4.66, 95 % CI 2.34, 9.26) were associated with increased risk of developing RA-ILD. The standardised mortality ratio for RA-ILD was 3.90 (95 % CI 2.55,5.72) compared to the general population. Extent of ILD on CT chest was associated with mortality (HR for >20% vs. < 20 % 4.47, 95 % CI 1.67,11.96). CONCLUSIONS: Clinically evident RA-ILD occurred in approximately 5 % of individuals with RA. Mortality was increased almost fourfold compared to the general population. Radiologic extent was the most important prognostic factor.

Etiologic Investigation of Patients Diagnosed with Bacteriologically Unconfirmed Tuberculosis in Tanzania.

Globally, half of patients with pulmonary tuberculosis (PTB) are diagnosed clinically without bacteriologic confirmation. In clinically diagnosed PTB patients, we assessed both the proportion in whom PTB could be bacteriologically confirmed by reference standard diagnostic tests and the prevalence of diseases that mimic PTB. We recruited adult patients beginning treatment of bacteriologically unconfirmed PTB in Moshi, Tanzania, in 2019. We performed mycobacterial smear, Xpert MTB/RIF Ultra, and mycobacterial culture, fungal culture, and bacterial culture on two induced sputum samples: fungal serology and computed tomography chest scans. We followed participants for 2 months after enrollment. We enrolled 36 (63%) of 57 patients with bacteriologically unconfirmed PTB. The median (interquartile range) age was 55 (44-67) years. Six (17%) were HIV infected. We bacteriologically confirmed PTB in 2 (6%). We identified pneumonia in 11 of 23 (48%), bronchiectasis in 8 of 23 (35%), interstitial lung disease in 5 of 23 (22%), pleural collections in 5 of 23 (22%), lung malignancy in 1 of 23 (4%), and chronic pulmonary aspergillosis in 1 of 35 (3%). After 2 months, 4 (11%) were dead, 21 (58%) had persistent symptoms, 6 (17%) had recovered, and 5 (14%) were uncontactable. PTB could be bacteriologically confirmed in few patients with clinically diagnosed PTB and clinical outcomes were poor, suggesting that many did not have the disease. We identified a high prevalence of diseases other than tuberculosis that might be responsible for symptoms.

Rheumatoid interstitial lung disease in Canterbury New Zealand: prevalence, risk factors and long-term outcomes-protocol for a population-based retrospective study.

INTRODUCTION: Rheumatoid arthritis (RA) affects approximately 0.5%-1% of the general population. Clinically significant interstitial lung diseases (ILD) develops in just under 10% of people with RA, and subclinical disease is more common. Little is known about RA-ILD in New Zealand (NZ), or the number of persons with RA in Canterbury, NZ. This study aims to determine: (1) incidence and prevalence of RA, (2) incidence and prevalence of RA-ILD, (3) clinical characteristics and risk factors for the development of RA-ILD, (4) long-term outcomes of RA-ILD, in the population resident within the Canterbury District Health Board (CDHB) catchment area. METHODS AND ANALYSIS: Persons aged 18 years of age and older, and resident in the region covered by the CDHB with RA as well as RA-ILD will be identified by retrospective review of medical records. Prevalent as well as incident cases of RA between 1 January 2006 and 31 December 2008 and between 1 January 2011 and 31 December 2013 will be identified, and followed until 30 June 2019. Existing as well as incident cases of RA-ILD during this time will be identified. The association between the development of ILD and clinical characteristics and environmental exposures will be examined using Cox-proportional hazard models. Kaplan-Meier methods will be used to estimate survival rates for patients with RA-ILD. Mortality for people with RA and RA-ILD will also be compared with the general population of the CDHB. ETHICS AND DISSEMINATION: Data will be obtained by retrospective review of medical records. Deidentified patient data will be stored in a secure online database. Data on individual patients will not be released, and all results will only be published in aggregate. Ethical approval has been obtained from the University of Otago Human Research Ethics Committee (REF HD18/079). Results will be published in peer-reviewed medical journals and presented at conferences. TRIAL REGISTRATION NUMBER: ACTRN12619001310156; Pre-results.

Effect of adjunctive single high-dose vitamin D3 on outcome of community-acquired pneumonia in hospitalised adults: The VIDCAPS randomised controlled trial.

Low vitamin D status is associated with increased risk of pneumonia, greater disease severity and poorer outcome. However, no trials have examined the effect of adjunctive vitamin D therapy on outcomes in adults with community-acquired pneumonia (CAP). We conducted a randomised, double-blind, placebo-controlled trial examining the effects of adjunctive vitamin D in adults hospitalised with CAP. Participants were randomised to either a single oral dose of 200,000 IU vitamin D3 or placebo. The primary outcome was the complete resolution of chest radiograph infiltrate at 6 weeks post-study treatment. Secondary outcomes included length of hospital stay, intensive care admission and return to normal activity. Only participants who completed the study or died within the 6 week period were included in the analysis (n = 60 vitamin D, n = 57 placebo). Adjunctive vitamin D did not have any effect on the primary outcome (OR 0.78, 95% CI 0.31 to 1.86, p = 0.548). However, there was evidence it increased the complete resolution of pneumonia in participants with baseline vitamin D levels <25 nmol/L (OR 17.0, 95% CI 1.40-549.45, P = 0.043), but this did not reach statistical significance using exact methods (OR 13.0, 95%CI 0.7-960.4, P = 0.083). There were no significant effects for any secondary outcome.

Pseudotumours and IgG4-related disease: a case report.

We report a case of a patient presenting with abdominal pain, weight loss and CT imaging showing mass lesions in the chest and abdomen associated with lymphadenopathy. He was diagnosed as having IgG4-related disease and responded well to steroid treatment.

Pulmonary hamartomas: CT pixel analysis for fat attenuation using radiologic-pathologic correlation.

INTRODUCTION: To assess the accuracy of CT pixel analysis for fat attenuation in pulmonary hamartomas. METHODS: Retrospective review identified 32 patients in three separate groups; pathologically proven hamartoma (n = 11), hamartoma diagnosed on imaging (n = 9) and a control group (n = 14) of pathology-proven non-hamartomatous smoothly marginated solitary pulmonary nodules. All lesions were assessed using: visual assessment for fat, pixel analysis of the inner 2/3rds and mean attenuation of the entire lesion, using an internal reference for fat. Fat percentages on CT and at histology were compared. RESULTS: Visual assessment for macroscopic fat was the most reliable method for diagnosing pulmonary hamartoma. Combining percentage of fat-attenuation pixels in the inner 2/3rds of the lesion improved specificity to 100%. Mean attenuation or pixel analysis in isolation were not helpful in lesional characterization. CONCLUSION: Combining percentage fat-attenuating pixels in the inner 2/3rds with visual assessment for macroscopic fat improves specificity for diagnosing pulmonary hamartomas.

The use of the radiographic appearance of the azygos vein to assess volume status in trauma patients.

BACKGROUND: The assessment of hypovolemia in victims of trauma is a critical aspect of resuscitation and care in the initial presentation of a patient. This study attempted to validate the use of the appearance of the azygos vein (AV) on initial chest radiographs as a parameter that may add to this initial assessment. METHODS: The design involved a blinded independent assessment of serial chest radiographs from consecutive trauma cases from January 21, 2008, until September 13, 2008, by a trained Radiologist and a Trauma Team Leader (TTL) and then comparing this assessment to mean arterial pressure (MAP) and heart rate estimates of volume status in serial severe trauma patients. This is an insensitive but specific measure of volume status. RESULTS: In this population with high prevalence of hypovolemia, the presence of an AV ≤ 0.5 cm yielded a sensitivity of 4.9% and 9.8% for the TTL and Radiologist, respectively, in patients with a mean arterial pressure <70 and heart rate >100. The specificity was 98.8% and 91.6%, which translates into a positive likelihood ratio of 4.08 and 1.17 for the TTL and Radiologist, respectively. The Kappa score for agreement between the two readers was 0.4. CONCLUSION: When a small AV can be seen by the TTL, it may be a useful adjunct to the assessment of volume status.

Reexpansion pulmonary edema: computed tomography findings in 22 patients.

PURPOSE: To determine the computed tomography (CT) imaging features of reexpansion pulmonary edema. MATERIALS AND METHODS: A retrospective review was performed of 22 consecutive patients with clinical and radiologic features consistent with reexpansion pulmonary edema (14 male, 8 female; mean age, 56±22.8 y; range, 19 to 82 y) and with available CT scan images within 3 days of drainage of pleural effusion or pneumothorax. The CT images were reviewed by 2 chest radiologists with consensus for the presence, extent, and distribution of ground-glass opacities, septal thickening, consolidation, presence of persistent areas of atelectasis, vascular caliber, linear opacities, residual midline shift, and trapped lung. RESULTS: CT findings included ipsilateral ground-glass opacities (n=21, 95%), smooth septal thickening (n=17, 77%), consolidation (n=14, 68%), and persistent foci of atelectasis (n=19, 86%). Less commonly seen features included air-bronchograms (n=6, 27%) and nodules (n=5, 23%) [centrilobular, n=4 (18%); random, n=1 (4.5%)]. Contralateral abnormalities were seen in 8 cases (36%) and included ground-glass opacities in 6 patients, interlobular septal thickening in 3 patients (13.6%), and consolidation in 3 patients. CONCLUSIONS: The most common CT findings of reexpansion pulmonary edema include ipsilateral ground-glass opacities, septal thickening, foci of consolidation, and areas of atelectasis.

Single coronary artery from the right aortic sinus of Valsalva with anomalous prepulmonic course of the left coronary artery.

Cardiac computed tomography allows for improved, noninvasive and accurate visualization of coronary artery anomalies. The case of a single coronary artery with origin from a single ostium in the right sinus of Valsalva with an anomalous course of the left coronary artery anterior to the pulmonary trunk is presented. The unusual distal reconstitution of a normal anatomical course at the junction of the mid and distal left anterior descending artery with occlusion of the proximal circumflex artery has not, to the authors' knowledge, been previously described.

Fibrosing mediastinitis: successful stenting of the pulmonary artery.

Fibrosing mediastinitis is a rare benign condition, which can cause compression of the pulmonary or systemic vessels, tracheobronchial tree, coronary arteries or esophagus, leading to disabling clinical symptoms and even death. The case of a 26-year-old woman who presented with dyspnea is described. She was found to have 80% stenosis of the right pulmonary artery secondary to fibrosing mediastinitis. The stenosis was managed successfully with an endovascular Palmaz-Schatz stent, and the patient remains symptom-free 10 years later.

Necrotizing granuloma of the lung: imaging characteristics and imaging-guided diagnosis.

OBJECTIVE: The purpose of this study was to assess CT findings and the sensitivities of imaging-guided fine-needle aspiration (FNA) biopsy and core needle biopsy in the diagnosis of necrotizing granuloma of the lung. CONCLUSIONS: The CT characteristics of necrotizing granuloma are indistinguishable from those of malignant tumors; tissue diagnosis therefore is necessary. Core needle biopsy is a sensitive method for diagnosing necrotizing granuloma of the lung, but FNA biopsy is insufficient for diagnosis.