Chest x-ray has low sensitivity to detect silicosis in artificial stone benchtop industry workers.

BACKGROUND AND OBJECTIVE: Chest x-ray (CXR) remains a core component of health monitoring guidelines for workers at risk of exposure to crystalline silica. There has however been a lack of evidence regarding the sensitivity of CXR to detect silicosis in artificial stone benchtop industry workers. METHODS: Paired CXR and high-resolution computed tomography (HRCT) images were acquired from 110 artificial stone benchtop industry workers. Blinded to the clinical diagnosis, each CXR and HRCT was independently read by two thoracic radiologists from a panel of seven, in accordance with International Labour Office (ILO) methodology for CXR and International Classification of HRCT for Occupational and Environmental Respiratory Diseases. Accuracy of screening positive (ILO major category 1, 2 or 3) and negative (ILO major category 0) CXRs were compared with identification of radiological features of silicosis on HRCT. RESULTS: CXR was positive for silicosis in 27/110 (24.5%) workers and HRCT in 40/110 (36.4%). Of the 83 with a negative CXR (ILO category 0), 15 (18.1%) had silicosis on HRCT. All 11 workers with ILO category 2 or 3 CXRs had silicosis on HRCT. In 99 workers ILO category 0 or 1 CXRs, the sensitivity of screening positive CXR compared to silicosis identified by HRCT was 48% (95%CI 29-68) and specificity 97% (90-100). CONCLUSION: Compared to HRCT, sensitivity of CXR was low but specificity was high. Reliance on CXR for health monitoring would provide false reassurance for many workers, delay management and underestimate the prevalence of silicosis in the artificial stone benchtop industry.

Structured Reporting in Radiology: what do radiologists think and does RANZCR have a role in implementation.

INTRODUCTION: The Royal Australian and New Zealand College of Radiologists (RANZCR) established a working group to explore how the college should engage with the future development of structured radiology reporting in our region, particularly in the context of a broader move to digital healthcare. Phase 1 of the project surveyed college members and affiliated interest groups about how they are using structured reporting currently and might like it to evolve. METHODS: Member and interest group questionnaires were based on previously published studies and posted to the Survey Monkey platform. Responses were analysed descriptively. RESULTS: There were 114 members and 58 affiliated group responses. There is clearest support for RANZCR developing guidelines around structured report quality, for improvements in report content, particularly tailoring to clinical context and study parameters, and for improved integration of structured reporting and RIS/PACS systems. CONCLUSIONS: Phase 2 of the structured reporting working group project will aim to develop guidelines for structured report quality and processes through which RANZCR can implement them.

Nebulised sargramostim in pulmonary alveolar proteinosis.

Five patients, comprising nine treatment courses of sargramostim use in pulmonary alveolar proteinosis, are described. The prevailing standard of treatment, whole lung lavage (WLL), is highly invasive, resource intensive and carries some procedural risk. Nebulised recombinant human GM-CSF (sargramostim) offers a pharmacological treatment option, allowing patients to be treated at home, possessing potential advantages in patient experience and wider health resourcing. The majority of reported patients described subjective improvement in symptoms along with radiographical improvement, although this did not translate into significant improvement in pulmonary function testing. Drug scarcity and high drug cost remain potential barriers to accessing this treatment, and so careful patient selection and treatment outcome assessment remain as challenging needs. Incorporating the routine assessment of validated patient symptom scores with objective physiological measures will allow prediction of response to treatment and help guide management. This report describes the largest published experience of sargramostim use in Australia.

New RANZCR clinical radiology written report guidelines.

The Royal Australian and New Zealand College of Radiologists (RANZCR) Radiology Written Report Guideline was first issued in 2011. A survey-based consultation of clinical radiology members of the college in 2015 found that the vast majority of 235 respondents supported all components of the guideline. Since the original guideline was developed, considerable new research has been published about radiology reporting, particularly regarding structured/template reports. In 2016/17 a RANZCR working group used the consultation results, stakeholder feedback and recent research to develop revised guidelines. This article outlines the consultation survey results and guideline revision process as well as some of the supporting evidence from the literature.

Adjuvant lung resection in the management of nontuberculous mycobacterial lung infection: A retrospective matched cohort study.

BACKGROUND AND OBJECTIVES: Lung resection in patients with nontuberculous mycobacterial pulmonary disease (NTM-PD) is considered when medical therapy alone fails to provide long term control. Data regarding comparative and long-term outcomes are limited. We aimed to review indications and outcomes of adjuvant lung resection for NTM-PD compared with controls. METHODS: We retrospectively studied 27 surgically treated patients, matched 1:1 for age, sex, NTM species, and radiologic pattern of disease, with control patients treated exclusively with antibiotics. RESULTS: In the surgical group, the median (IQR) age was 55 (49-61) years and 74.1% were female. Eighteen patients had Mycobacterium avium complex, and 9 had M. xenopi. Operations included 8 pneumonectomies, 20 lobectomies, one segmentectomy and one lobectomy plus segmentectomy. Post-surgical complications occurred in 6 patients (20%), including 2 acute respiratory distress syndrome, 1 bronchopleural fistula, 1 pericardial tamponade, and 2 empyema. Complications were more common among patients operated upon for progressive disease despite medical therapy (OR 10, p = 0.025). Of 24 matched pairs followed for ≥1 year, sustained culture conversion was observed in 21 (87.5%) patients in the surgical group and in 11 (45.8%) patients in the non-surgical group (RR 2.36, 95%CI 1.37-4.03, p = 0.002). Median (IQR) percentage of follow-up time on antibiotics was 14% (0-100%) in the surgical group and 83% (10.8%-100%) in the non-surgical group (p = 0.195) during a median (IQR) follow-up of 16 (2-36) months. CONCLUSIONS: NTM-PD patients who underwent adjuvant lung resection experienced significant morbidity and more frequently achieved sputum culture conversion. Long term antibiotic requirements may have been reduced.

Utility of transthoracic needle biopsy after lung transplantation.

The purpose of this study was to assess the diagnostic yield and complications of CT-guided transthoracic needle biopsy (TTNB) after lung transplantation. A database search identified all TTNB performed in lung transplant patients over a 14-year period. Forty-two biopsies in transplant patients (transplant group) were identified and matched to the next biopsy performed in native lungs by the same operator (nontransplant group) as a control. Primary outcomes recorded were diagnosis, diagnostic yield, pneumothorax requiring intervention, and symptomatic pulmonary hemorrhage. Biopsy outcomes were classified as diagnostic, not specifically diagnostic, and nondiagnostic. Patients in the transplant group were younger (P < .002). Emphysema along the biopsy trajectory was more commonly seen in the nontransplant group (P < .0006). Needle gauge, size of lesion, pleural punctures, lesion depth, and number of passes were not significantly different. Diagnostic yield was 71% in the transplant group and 91% in the nontransplant group. There were 20 of 42 (48%) malignant nodules in the transplant group compared to 31 of 44 (70%) nodules in the nontransplant group (P = .05). There were no complications in the transplant group. The nontransplant group had two pneumothoraces requiring intervention. TTNB after lung transplant is safe with a moderate diagnostic yield. Nonmalignant lesions are more common after lung transplantation.

Protective Capnothorax During Transthoracic Needle Biopsy.

PURPOSE: Transthoracic needle biopsy (TTNB) is an established procedure in the management of pulmonary nodules. The most common complications are directly related to crossing the lung or visceral pleura during the biopsy. In this study, we describe the use of carbon dioxide instead of room air to create a protective "capnothorax" during TTNB. MATERIALS AND METHODS: Five patients underwent creation of a capnothorax during TTNB. Parameters recorded were location and size of target, distance from pleura, length of procedure, volume of carbon dioxide, periprocedural complications and biopsy result. RESULTS: Induction of capnothorax was successful in all cases. In two patients, a continuous infusion of carbon dioxide was required to maintain an adequate volume of intrapleural gas. In two patients, the carbon dioxide resolved spontaneously and in the remaining patients it was aspirated at the end of the procedure. All biopsies were diagnostic with no periprocedural or postprocedural complications. CONCLUSION: This study suggests that protective iatrogenic capnothorax is a safe and effective technique during TTNB. The intrinsic properties and availability of carbon dioxide make it an attractive alternative to room air.

Agreement and mortality prediction in high-resolution CT of diffuse fibrotic lung disease.

INTRODUCTION: The prognosis of diffuse fibrotic lung disease (DFLD) is known to be variable, but there is a paucity of literature on prognostic markers independent of precise clinical diagnosis. This study aimed to assess the mortality prediction of three high-resolution computed tomography (HRCT) scores in a heterogeneous population of patients with DFLD. A large radiologist and physician reader group was used to determine agreement among readers of varying background in applying these scores. METHODS: Institutional review board approval was obtained. Informed consent was waived for this retrospective study. Eighty HRCTs in 68 patients with DFLD (35 men, mean age 72.9 years) were evaluated retrospectively by 18 readers. Readers included thoracic and general radiologists, respiratory physicians and radiology trainees. Features scored were honeycombing, extent of disease and traction bronchiectasis. Demographics, diagnosis and pulmonary function data were collected. Patients were categorised as having either idiopathic pulmonary fibrosis, fibrosis relating to connective tissue disease, 'miscellaneous' DFLD or 'undefined', where no single entity was felt entirely or confidently to explain the pulmonary disease. Agreement was assessed using the kappa statistic. Associations with mortality were analysed using the Cox marginal model. RESULTS: Agreement was better for honeycombing (kappa = 0.44) and disease extent (kappa = 0.47) than traction bronchiectasis (kappa = 0.24). Honeycombing presence (P < 0.0005) and disease extent >30% (P = 0.002) predicted increased mortality independent of clinical diagnosis. Traction bronchiectasis was non-predictive. Clinical diagnosis was not an independent predictor, but age was independently associated with mortality (P = 0.004). Pulmonary function data were only available for 43 patients, but in a limited subanalysis, the diffusion capacity of carbon monoxide was independently predictive of increased mortality (P = 0.005). CONCLUSIONS: The presence of honeycombing and a greater extent of fibrotic lung disease predict increased mortality independent of clinical diagnosis. Our large, mixed-expertise reader group shows moderate interobserver agreement, comparable with agreement values for these scores in the literature.