Biomedical subjects
Publications and source records attributed to D M Hansell.
Histological examination of a lung removed at transplantation revealed multiple peripheral tumourlets and microcarcinoids in close association with bronchioles causing an obliterative bronchiolitis. This was an unexpected finding but explained the progressive airflow limitation which characterised the patient's clinical course.
Bronchiectasis is characterized by chronic inflammation in one or more bronchi, but the extent of inflammation is difficult to monitor. The concentration of nitric oxide (NO) in exhaled air is increased in asthmatic patients, possibly as a result of the chronic inflammatory process. We have measured exhaled NO in patients with documented bronchiectasis and investigated whether the concentration of exhaled NO is related to the extent of disease as defined by computed tomography (CT) and lung function. In 20 patients with bronchiectasis who were not taking inhaled steroids, the peak concentration of NO in exhaled air, measured by a modified chemiluminescence analyzer, was significantly elevated (285 +/- 49.0 ppb) as compared with values for 79 normal subjects (89 +/- 2.7 ppb, p < 0.01) and 19 patients with bronchiectasis treated with inhaled steroids (88 +/- 13.4 ppb, p < 0.01). Thin-section CT was used to quantify the extent of bronchiectasis in the 19 patients. There was a significant correlation between the CT score and FEV1 (r = 0.73, p < 0.01). In patients not treated with inhaled steroids there was a significant relationship between CT score and peak exhaled NO (r = 0.81, n = 12, p < 0.02), but this was not the case for patients treated with regular inhaled steroids (n = 7). We conclude that untreated bronchiectasis is associated with an increase in exhaled NO, and that this is correlated with disease severity, whereas patients treated with inhaled steroids have levels of exhaled NO within the normal range.(ABSTRACT TRUNCATED AT 250 WORDS)
A 34 year old women was admitted to the hospital with a 9 year history of intermittent haemoptysis associated with increasing breathlessness. A working diagnosis of lymphangioleiomyomatosis was made, based on clinical, radiological and histological findings. Three years later, the patient was admitted to hospital with worsening haemoptysis, which rapidly progressed and resulted in death from massive pulmonary haemorrhage. Postmortem examination and histology revealed findings consistent with multiple mesenchymal cystic hamartomas of the lungs. This is a rare condition which has previously been described as having a good prognosis. This case is the first fatality resulting directly from the disease to be reported.
OBJECTIVE: The purpose of this study was to determine whether the pattern and distribution of bronchiectasis shown on CT scans can be used to discriminate between idiopathic cases and those with an identifiable cause. MATERIALS AND METHODS: The CT scans of 168 patients with chronic purulent sputum production and who were suspected of having bronchiectasis were analyzed (117 patients with idiopathic bronchiectasis, 15 with allergic bronchopulmonary aspergillosis, 15 with hypogammaglobulinemia, 15 with impaired mucociliary clearance, and seven with cystic fibrosis diagnosed in adult life). The scans were analyzed in random order by two observers. The extent, site, type, and lobar distribution of bronchiectasis and the severity of bronchial dilatation and bronchial wall thickening were scored. The frequency of these features in the known-cause groups was compared with that in the idiopathic group to identify any significant differences. RESULTS: Compared with idiopathic bronchiectasis, no significant lobar predominance was seen in any of the known-cause groups, apart from a higher frequency of lower lobe involvement in the patients with syndromes of impaired mucociliary clearance (p < .02). The bronchiectasis of allergic bronchopulmonary aspergillosis and adult cystic fibrosis was more often widespread (five or six lobes involved (p < .001 and p < .01, respectively) than idiopathic bronchiectasis. Central bronchiectasis was more common in allergic bronchopulmonary aspergillosis (p < .005), although the sensitivity when this was used as a diagnostic feature was only 37%. In all groups, cylindrical bronchiectasis was the most common type, with varicose and cystic bronchiectasis occurring more frequently in allergic bronchopulmonary aspergillosis (p < .01). On multiple regression analysis, allergic bronchopulmonary aspergillosis and adult cystic fibrosis showed more extensive disease than idiopathic bronchiectasis (p < .0005 and p < .001, respectively), independent of other CT features. In hypogammaglobulinemia, dilatation of the bronchial lumen was less than in idiopathic bronchiectasis (p < .02) independent of disease extent and bronchial wall thickness. CONCLUSION: Although differences in distribution and morphology of bronchiectasis may be seen on CT scans in groups of patients with bronchiectasis of different causes, CT findings applied to individual patients are of limited value in discriminating between idiopathic bronchiectasis and bronchiectasis of various known causes.
In fibrosing alveolitis the pattern type on thin section computed tomography (CT) predicts histological appearances at open lung biopsy and the likelihood of response to treatment. To test the level of inter- and intra-observer variability on CT and chest radiography (CXR), the pattern type and extent of disease were assessed by four observers (two experienced, two inexperienced). A total of 126 CT examinations and 108 concurrent postero-anterior chest radiographs were scored on two occasions, at least 8 weeks apart. A confidence rating was assigned to each observation. Three out of four observers agreed on pattern type in 81% of cases on CT compared with 54% on CXR (kappa coefficient 0.48 and 0.16 for CT and CXR, respectively). Inter-observer variability in categorizing pattern type on CT was lowest in patients with the highest confidence scores (kappa = 0.63). Confident observations were associated with extensive or moderately extensive disease (P < 0.001), and with a predominantly reticular pattern (P < 0.0001). Intra-observer variability for pattern type on CT was less for the experienced observers (kappa = 0.78 and 0.70) than for the inexperienced group (kappa = 0.50 and 0.37). Inter-observer variability for extent of disease was significantly less on CT than on CXR (standard deviations 7.8% and 9.2% respectively, P < 0.001). This study shows that observer variability using a clinical grading system is lower with CT than with chest radiography in fibrosing alveolitis.
BACKGROUND: Radiological estimates of hyperinflation are used in several clinical and radiographic scoring systems for cystic fibrosis, but it is not known if these estimates of hyperinflation are related to measured total lung capacity. METHODS: Comparison was made of independent clinical estimates of hyperinflation from chest radiographs with objective plethysmographic and radiographic measurements of total lung capacity in 25 children with cystic fibrosis. RESULTS: There was good agreement between plethysmographic and radiographic measurements. Clinical estimation correctly predicted the extremes of hyperinflation, but grading was no more than 50% accurate in all other groups. CONCLUSION: The degree of hyperinflation cannot be estimated by inspecting chest radiographs in many children with cystic fibrosis. This does not invalidate the scoring systems, but suggests that a better term than "hyperinflation" should be sought.
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PURPOSE: To characterize areas of decreased attenuation on expiratory computed tomographic (CT) scans in patients with bronchiectasis. MATERIALS AND METHODS: CT scans were obtained at full inspiration and end expiration in 70 patients with chronic purulent sputum production. Inspiratory scans were scored at a lobar level for the extent of bronchiectasis, and inspiratory and expiratory scans were scored for the presence and extent of areas of decreased attenuation. Total lobar observations were analyzed (n = 840). RESULTS: Bronchiectasis was identified in 434 of 840 lobar observations. The total decreased attenuation score was related to extent of bronchiectasis (r = .49; P < .001), independent of functional indexes. Negative correlations were found between forced expiratory volume in 1 second (FEV1) and total decreased attenuation score (P < .002) and FEV1 to forced vital capacity ratio (P < .004) but not with indexes of gas transfer. CONCLUSION: Areas of decreased attenuation on expiratory CT scans are common in severe bronchiectasis. Such areas in lobes without overt bronchiectasis suggest that small airways disease may precede the development of bronchiectasis.
Fibrosing alveolitis associated with systemic sclerosis (FASSc) is considered to be histologically and radiologically indistinguishable from lone cryptogenic fibrosing alveolitis (CFA). To date, the natural history of the two diseases has not been compared directly in large groups of patients followed at a single institution. We evaluated the survival of 205 patients with CFA and 68 patients with FASSc. Deaths during the follow-up period were reported in 142 patients with CFA (70%) and in 11 patients with FASSc (16%). Unadjusted survival from the onset of dyspnea was less in CFA than in FASSc (odds ratio, 3.3; p < 0.001); this difference persisted after adjustment for age of onset of dyspnea and smoking history. Survival from presentation was less in CFA (odds ratio approximately 3.3) after adjustment for age of presentation, smoking history, and initial pulmonary function indices. These differences persisted when analysis was confined to patients with histologic confirmation of fibrosing alveolitis and after adjustment for treatment. In patients undergoing computed tomography (CT) of the lungs, survival was less in CFA after adjustment for extent of abnormal lung on CT and CT pattern of disease (odds ratio, 3.9; p < 0.001). These findings indicate that despite their histologic and radiologic similarities, lone CFA and FASSc have different courses.
Fibrosing alveolitis in systemic sclerosis is histologically identical to lone cryptogenic fibrosing alveolitis (CFA) (idiopathic pulmonary fibrosis). The inflammatory cell content of bronchoalveolar lavage (BAL) samples has been used as a guide to prognosis and treatment in CFA. In this study, the relationship was explored between BAL findings and the extent and pattern of disease within the lavaged lobe, as judged by thin-section computed tomography (CT), in systemic sclerosis. Thirty-eight nonsmoking patients were studied; none had been treated with corticosteroids or immunosuppressive agents, and 11 had no evidence of fibrosing alveolitis on CT. BAL neutrophils were markedly increased in association with extensive disease on CT compared with less extensive disease (p < 0.001) and normal appearances (p < 0.001); the extent of a reticular pattern on CT (denoting fibrosis) correlated with the neutrophil percentage count (p < 0.005) and total neutrophil count/ml (p < 0.01). BAL eosinophils were increased in less extensive as well as in extensive disease when compared with lobes with a normal CT appearance (p < 0.01); eosinophil percentage counts but not total eosinophil counts/ml correlated with the extent of a ground-glass pattern on CT (through to denote inflammation) (p < 0.05). These findings indicate that in systemic sclerosis a BAL neutrophilia is generally associated with extensive fibrotic disease, whereas a BAL eosinophilia is often seen in less advanced disease, particularly when CT appearances suggest lung inflammation.
Cyclosporin was used successfully in a patient with severe pulmonary sarcoidosis, a poor response and unacceptable side-effects from corticosteroid therapy. Computed tomography (CT) scanning initially suggested reversible disease, and subsequently detected improvement earlier than other indices of disease activity. This information was critical in the decision to commence and to continue cyclosporin. The literature on the use of cyclosporin in sarcoidosis is reviewed.
Objective measurement of bronchial damage in patients with bronchiectasis is needed to identify progressive disease. This study evaluates the inter- and intraobserver variation in computed tomography (CT) measurements of bronchial wall circumference and examines the precision with which CT measurements of the bronchi can be repeated in patients with bronchiectasis. Twelve patients were scanned and the circumferences of 61 subsegmental bronchi were measured independently on two occasions, by three observers, using a tracing facility on the CT console. To determine the accuracy with which previously acquired sections could be repeated, five patients were scanned on two separate occasions. The mean bronchial circumference measured by the three observers was 16.1 +/- 8.3 mm. The standard deviations of differences between first and second measurements of bronchial circumference for the three observers (intraobserver variability) were: 0.60 mm, 0.67 mm and 0.40 mm. The standard deviation of readings for interobserver variability was 0.71 mm. The standard deviations of differences (and coefficients of variation) for measurements of bronchial circumference following rescanning were: 1.82 mm, 1.40 mm and 1.74 mm (9.9%, 7.6% and 9.3%, respectively). The reproducibility of measurements of wall circumference, between and within observers and between examinations, indicates that such measurements may be clinically useful in demonstrating the progression of bronchiectasis.
STUDY OBJECTIVES: To identify serial changes in the appearances of the lungs on computed tomography (CT) in patients with established adult respiratory distress syndrome (ARDS). Second, to evaluate any relationship between the extent of morphologic abnormalities on CT anatomic and physiologic derangement using a numeric score of the severity of lung injury. DESIGN: Retrospective, descriptive. SETTING: Adult intensive care unit, Department of Radiology, and outpatient department of a national tertiary referral center. PATIENTS: Eight patients meeting diagnostic criteria for ARDS able to tolerate CT scanning during the acute phase of their illness and who survived to be reevaluated during convalescence. INTERVENTIONS: Mechanical ventilatory support. Conventional intensive care support of other failed systems a appropriate. MEASUREMENTS AND RESULTS: Thin-section CT scans of the lungs categorized as to extent (calculated percent volume of abnormal lung), distribution, and dominant disease pattern. Concurrent lung injury score (LIS) was recorded at the time of the CT during the acute phase of illness (mean, 26 days; range, 3 to 48 days after precipitating event) and at follow-up (96; 17 to 187 days). On initial CT scans, disease patterns included ground-glass opacification (8/8), parenchymal distortion (8/8), multifocal areas of consolidation (6/8), reticular opacities (6/8), and linear opacities (5/8). On follow-up scans, there was clearing of consolidation in all patients, but ground-glass opacification persisted in four of eight patients. The reticular pattern persisted unchanged in five of eight patients, became more extensive in two of eight, and developed in one. A reticular pattern was most pronounced in areas that had been densely consolidated previously. Evidence of parenchymal distortion, present on the initial scan in all patients, persisted in six of eight patients. Computed tomographic features suggestive of emphysema developed in one patient. The LIS revealed moderate to severe ARDS in all patients initially; this decreased to a mild or zero LIS at follow-up. Overall, there was 76.9% +/- 5.3% abnormal lung on the initial CT scan and 34.5 +/- 9.3% on the follow-up CT scan. There was a significant correlation between the extent of abnormalities on CT and LIS (r = 0.75, p < 0.01). CONCLUSIONS: The CT appearances of patients with ARDS who survive are variable and relate to the pattern of disease in the acute phase. Furthermore, the extent of CT abnormalities correlates strongly with LIS in both the acute phase and at follow-up.
The aim of this study was to compare the performance of digital frontal radiographs vs digital lateral shoot-through radiographs for the diagnosis of pneumothoraces in supine patients. A total of 146 pairs of radiographs were performed on 32 ventilated patients on the Intensive Care Unit. Each radiograph was independently assessed by three observers for the presence or absence of a pneumothorax. A degree of confidence was assigned to each observation and an image quality score was given to each radiograph. At least two out of three observers positively diagnosed a pneumothorax in 13/146 (8.9%) of the frontal radiographs compared to 43/146 (29.4%) of the lateral radiographs (P < 0.0001), but suboptimal images were obtained more often with lateral shoot-through radiographs than with frontal radiographs. We conclude that digital lateral shoot-through radiographs are significantly more sensitive than digital frontal radiographs for the diagnosis of pneumothoraces in supine patients.
The utility of computed tomography (CT) is well established in patients with chronic interstitial lung disease. There are currently no descriptions of the CT appearances of diffuse pulmonary haemorrhage. The CT findings of six patients with diffuse pulmonary haemorrhage are presented. Pathological correlation from open lung biopsies in two of these patients provided a pathological basis for the CT appearances. All six patients had diffuse nodular opacities with no zonal predominance. The nodules were of uniform size in any single patient but varied (1-3 mm diam.) between patients. Patchy areas of 'ground-glass' opacification of the lung parenchyma due to recent haemorrhage was associated with apparent prominence of the segmental bronchi and obscured the background nodularity. The CT findings were similar in all six patients and, although not pathognomonic, awareness of the CT features described should raise the possibility of the diagnosis.
Small pulmonary nodules of soft tissue density are often found during computed tomography for the staging of lung cancer, but CT cannot reliably distinguish benign from malignant uncalcified pulmonary nodules. The purpose of this study was to assess the significance of pulmonary nodules discovered on staging CT. 551 patients with lung cancer who had a staging CT and who were considered operable were studied. Eighty-eight patients (16%) were found to have small non-calcified pulmonary nodules. Adequate follow-up was possible in 25 patients who had a total of 36 nodules. Twenty-five nodules (70%) were subsequently confirmed to be benign, four (11%) were malignant and the nature of seven (19%) could not be determined. The high prevalence of benign nodules in this population should be taken into account when staging lung cancer.
In order to characterize the appearances of bronchiolitis obliterans on high-resolution CT (HRCT) and to relate the extent of HRCT abnormalities to pulmonary function tests, the HRCT scans of 18 patients with bronchiolitis obliterans were examined by two independent observers. The underlying causes for the development of bronchiolitis obliterans were penicillamine therapy (n = 5), previous infection (n = 4), graft-vs-host disease (n = 3), and miscellaneous causes (n = 6). Abnormal HRCT findings were present in all cases. The commonest HRCT abnormalities consisted of patchy areas of decreased parenchymal attenuation (n = 15), subsegmental (n = 12) and segmental (n = 6) bronchial dilatation and centrilobular branching structures (n = 5). There was no significant correlation between the extent of abnormalities and the static lung volumes or the impairment in gas transfer (all P values > 0.05). The only significant correlation was between the number of segments with subsegmental bronchial dilatation and the forced expiratory volume in one second (Wilcoxon r = 0.61, P < 0.01). We conclude that the great majority of patients with bronchiolitis obliterans have HRCT abnormalities. However, there is poor correlation between the extent of abnormalities on HRCT and functional impairment.
BACKGROUND: Open lung biopsy is often performed to confirm the diagnosis in patients with suspected fibrosing alveolitis. The superior sensitivity and specificity of high resolution computed tomography (CT) over chest radiography in various diffuse lung diseases suggest that the characteristic appearance of fibrosing alveolitis on high resolution CT might render biopsy confirmation unnecessary. METHODS: The chest radiographs and high resolution CT scans of 86 patients (41 with fibrosing alveolitis and 45 with various other diffuse lung diseases) were examined individually and independently by two observers. No clinical information was given and the observers gave a level of confidence when the diagnosis was thought to be fibrosing alveolitis. RESULTS: The observers correctly and confidently discriminated between fibrosing alveolitis and other diffuse lung diseases on high resolution CT with an accuracy of 88% and on chest radiography with an accuracy of 76%. The false negative rate for fibrosing alveolitis diminished from 29% on chest radiography to 11% on high resolution CT. The false positive rate on chest radiography was 19% and on high resolution CT 13%; the false positive diagnoses on CT were the result of a few conditions (extrinsic allergic alveolitis, sarcoidosis, cryptogenic organising pneumonia, and pulmonary eosinophilia) which mimicked some of the CT features of fibrosing alveolitis. The superficial similarity of the CT patterns of these conditions are discussed. CONCLUSIONS: High resolution CT is superior to chest radiography in establishing the diagnosis of fibrosing alveolitis and the typical CT appearances are virtually pathognomonic. The diagnostic advantages of CT over chest radiography should further reduce the need for open lung biopsy in this condition.