Biomedical subjects
Publications and source records attributed to B Strickland.
Twenty-one patients with established cystic fibrosis were examined using high-resolution, narrow-section computed tomography. The bronchiectasis of cystic fibrosis is described and is shown to be characteristic in many respects. Computed tomography was found to be more accurate than standard radiography in locating the disease process and demonstrated pleural involvement which was not apparent on chest radiographs.
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The cause of the reduced lung volume in the 'shrinking lung' syndrome of systemic lupus erythematosus (SLE) was investigated in 12 patients with the condition. Nine patients described persistent episodes of pleuritic chest pain. Narrow section (3 mm) computed tomography of the thorax revealed no interstitial fibrosis or significant pleural disease. Assessment of diaphragmatic function using manoeuvres more reliable than the maximal occluded efforts previously used alone to assess respiratory muscle strength, showed that diaphragm strength was unequivocally normal in nine of 12 patients. In three, maximum transdiaphragmatic pressure was moderately reduced, but phrenic nerve stimulation demonstrated that this was due to incomplete activation of the diaphragm during a maximal voluntary effort, rather than to a primary abnormality of the diaphragm. Results of maximum lung recoil pressures and dynamic compliance, and analysis of the 12-s maximum voluntary ventilation, suggested a restriction in chest-wall expansion, although it was not possible to identify the underlying cause of this on the basis of our results. We conclude that the 'shrinking lung' syndrome of SLE is not explained by a primary abnormality of the diaphragm.
The place of computed tomography (CT) scanning in the detection of pulmonary nodules is now well established. Due to the increasing spatial resolution of CT and shorter scan times, patients with diffuse lung disease can now be examined more effectively. Narrow section CT demonstrates the morphological detail of some diffuse lung diseases at an earlier stage than conventional radiography.
Fibrosing alveolitis was studied by high definition, narrow section computed tomography (CT) in 50 patients, 30 of whom were suffering from systemic sclerosis and 20 from cryptogenic fibrosing alveolitis (CFA). Apart from changes in the mid and lower zones, abnormalities were also observed anteriorly in the upper lobes and in the pleura. Scanning in the prone position was important in seeking evidence of minimal pathological change. In systemic sclerosis CT was 24% more accurate than high kilovoltage radiography in demonstrating minimal evidence of fibrosing alveolitis; this had a characteristic distribution as a peripheral crescent of high attenuation in the lower lobes before any changes were visible on standard radiographs. The CT appearances in CFA were also characteristic, particularly when the disease appeared to be early or limited. We believe that high definition CT may be of value in suggesting the diagnosis of CFA in patients with non-specific abnormalities on the chest radiograph.
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Whenever fibrosing alveolitis is suspected a computed tomographic (CT) scan should be carried out using a high definition narrow section technique. Pulmonary involvement in cryptogenic fibrosing alveolitis and scleroderma may be demonstrated by CT before it is apparent clinically or by standard radiography. CT may be the most accurate and practical imaging technique in the follow-up of these cases and for indicating the optimal site for biopsy.
Narrow section (3 mm width slices every 10 mm) computed tomography on an Elscint 2002 scanner and plain chest radiography were performed in 10 patients with allergic bronchopulmonary aspergillosis. No patient was experiencing an acute exacerbation. The investigations were reported separately and in random order. Bronchiectasis was reported in 31 of 60 lobes on computed tomography compared with only 15 on plain chest radiographs. Computed tomography was also more sensitive for proximal bronchiectasis detected in 16 lobes compared with only in 10 on plain chest radiographs. Serial computed tomography may allow earlier identification of progression of lung damage in patients with allergic bronchopulmonary aspergillosis and so help in planning treatment.
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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.
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.
The authors describe the computed tomographic (CT) appearances of aspergilloma in 26 patients. With narrow (3-mm) sections, a bone algorithm, and wide window settings, CT scans enabled accurate identification of both the forming aspergilloma as well as the mature fungus ball in 25 cases. The diagnostic accuracy of CT was confirmed histologically in nine cases. The radiologic concept of the aspergilloma as a solid mass partially surrounded by a crescent of air is no longer tenable as the only definite criterion for diagnosis. In cases in which this classic appearance is seen on CT scans, mobility is easily demonstrated with use of prone and supine positions. In other cases, the aspergilloma appears as an irregular spongework containing air spaces and filling the cavity, obliterating the air crescent sign. The fungus ball is therefore fixed and immobile. Forming aspergillomas can also be identified by the fungal strands that fall into the cavity lumen, trapping air and initiating the sponge-work appearance. The CT appearance in patients with positive precipitins is characteristic and allows earlier diagnosis than does conventional tomography.
Diffuse lung disease is often a difficult clinical and radiographic problem to resolve. Standard computed tomography (CT) techniques are often unhelpful. By combining practical physiological criteria with narrow section CT a protocol has been developed which yields more accurate information and is now the standard method of CT investigation of diffuse lung disease in our department.
Computed tomography and lung function tests were performed on 43 patients who had evidence on the chest radiograph suggesting bullous emphysema. After computed tomography scan two groups of patients could be identified. Twenty patients had generalised emphysema, which was locally worse in the area of the suspected bulla; and 23 had well defined bullae, which were potentially operable. Results of lung function tests did not distinguish between the two groups. The volume and ventilation of the true bullae were measured by computed tomography and this confirmed that most of them did not contribute to ventilation (residual volume (RV)/total capacity (TLC) bulla = 89% (SD 10%). The patients with true bullae were considered suitable for surgery but only 12 had an operation. All the patients who underwent surgery survived and had a symptomatic improvement, which was accompanied by objective increases in spirometric volumes and by reductions in static lung volumes; there were no improvements in carbon monoxide transfer or blood gas tensions. It is concluded that computed tomography used alone can identify bullae that are amen-able to surgery and can measure their volume and ventilation. The surgical removal of such clearly identified bullae is safe and associated with symptomatic and functional improvement even when the preoperative FEV1 is less than 1 litre. This improvement is likely to be a consequence of reduction in lung volume and may not necessarily be associated with relief of compressed peribullous lung or the removal of dead space.
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Haemoptysis is a symptom which demands prompt and efficient investigation. It is important to appreciate the merits and limitations of the various investigative procedures available so that they may be employed in the most logical and economical manner.
Patients are people as well as potential problems. Increasing our awareness of patients' lifestyle preferences, as well as developing more productive ways to interact with them, can promote growth along with recovery. The very least it can do is to facilitate working with patients and reduce the negative impact of stress of conflict in a very demanding profession.
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