Management of interstitial lung disease in patients with autoimmune disease-related interstitial lung disease.

Interstitial lung disease (ILD) is a common manifestation of systemic autoimmune diseases. A proportion of patients with autoimmune disease associated-ILDs develop progressive pulmonary fibrosis. Regular monitoring of patients with pulmonary fibrosis is recommended to enable prompt detection of progression and initiation or escalation of therapy if needed. However, there is no established algorithm for the treatment of autoimmune disease associated-ILDs. In this article, we present three case studies that demonstrate the challenges in the diagnosis and management of patients with autoimmune disease associated-ILDs and the importance of taking a multidisciplinary approach to their care.

Spontaneous Closure of a Coronary Artery Bypass Graft Pseudoaneurysm Embedded in a Mediastinal Hematoma.

Coronary artery bypass graft (CABG) pseudoaneurysms are a rare but often unrecognized clinical entity. They are prone to rupture and hemodynamic compromise and should therefore be on the differential in the appropriate patient. We present a case of a gentleman with a recent CABG surgery who presented with acute onset dyspnea and a large pleural effusion. Imaging revealed a saphenous vein graft pseudoaneurysm embedded in a mediastinal hematoma. Four weeks later, prior to planned stenting, the pseudoaneurysm had spontaneously closed. This case highlights an unusual acute presentation of a CABG pseudoaneurysm and a multidisciplinary approach to its management.

Centrilobular emphysema and coronary artery calcification: mediation analysis in the SPIROMICS cohort.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is associated with a two-to-five fold increase in the risk of coronary artery disease independent of shared risk factors. This association is hypothesized to be mediated by systemic inflammation but this link has not been established. METHODS: We included 300 participants enrolled in the SPIROMICS cohort, 75 each of lifetime non-smokers, smokers without airflow obstruction, mild-moderate COPD, and severe-very severe COPD. We quantified emphysema and airway disease on computed tomography, characterized visual emphysema subtypes (centrilobular and paraseptal) and airway disease, and used the Weston visual score to quantify coronary artery calcification (CAC). We used the Sobel test to determine whether markers of systemic inflammation mediated a link between spirometric and radiographic features of COPD and CAC. RESULTS: FEV1/FVC but not quantitative emphysema or airway wall thickening was associated with CAC (p = 0.036), after adjustment for demographics, diabetes mellitus, hypertension, statin use, and CT scanner type. To explain this discordance, we examined visual subtypes of emphysema and airway disease, and found that centrilobular emphysema but not paraseptal emphysema or bronchial thickening was independently associated with CAC (p = 0.019). MMP3, VCAM1, CXCL5 and CXCL9 mediated 8, 8, 7 and 16% of the association between FEV1/FVC and CAC, respectively. Similar biomarkers partially mediated the association between centrilobular emphysema and CAC. CONCLUSIONS: The association between airflow obstruction and coronary calcification is driven primarily by the centrilobular subtype of emphysema, and is linked through bioactive molecules implicated in the pathogenesis of atherosclerosis. TRIAL REGISTRATION: ClinicalTrials.gov: Identifier: NCT01969344 .

Interval lung cancer after a negative CT screening examination: CT findings and outcomes in National Lung Screening Trial participants.

OBJECTIVES: This study retrospectively analyses the screening CT examinations and outcomes of the National Lung Screening Trial (NLST) participants who had interval lung cancer diagnosed within 1 year after a negative CT screen and before the next annual screen. METHODS: The screening CTs of all 44 participants diagnosed with interval lung cancer (cases) were matched with negative CT screens of participants who did not develop lung cancer (controls). A majority consensus process was used to classify each CT screen as positive or negative according to the NLST criteria and to estimate the likelihood that any abnormalities detected retrospectively were due to lung cancer. RESULTS: By retrospective review, 40/44 cases (91%) and 17/44 controls (39%) met the NLST criteria for a positive screen (P < 0.001). Cases had higher estimated likelihood of lung cancer (P < 0.001). Abnormalities included pulmonary nodules ≥4 mm (n = 16), mediastinal (n = 8) and hilar (n = 6) masses, and bronchial lesions (n = 6). Cancers were stage III or IV at diagnosis in 32/44 cases (73%); 37/44 patients (84%) died of lung cancer, compared to 225/649 (35%) for all screen-detected cancers (P < 0.0001). CONCLUSION: Most cases met the NLST criteria for a positive screen. Awareness of missed abnormalities and interpretation errors may aid lung cancer identification in CT screening. KEY POINTS: • Lung cancer within a year of a negative CT screen was rare. • Abnormalities likely due to lung cancer were identified retrospectively in most patients. • Awareness of error types may help identify lung cancer sooner.

Rheumatoid arthritis-associated autoantibodies and subclinical interstitial lung disease: the Multi-Ethnic Study of Atherosclerosis.

BACKGROUND: Adults with interstitial lung disease (ILD) often have serologic evidence of autoimmunity of uncertain significance without overt autoimmune disease. We examined associations of rheumatoid arthritis (RA)-associated antibodies with subclinical ILD in community-dwelling adults. METHODS: We measured serum rheumatoid factor (RF) and anticyclic citrullinated peptide antibody (anti-CCP) and high attenuation areas (HAAs; CT attenuation values between -600 and -250 Hounsfield units) on cardiac CT in 6736 community-dwelling US adults enrolled in the Multi-Ethnic Study of Atherosclerosis. We measured interstitial lung abnormalities (ILAs) in 2907 full-lung CTs at 9.5-year median follow-up. We used generalised linear and additive models to examine associations between autoantibodies and both HAA and ILA, and tested for effect modification by smoking. RESULTS: In adjusted models, HAA increased by 0.49% (95% CI 0.11% to 0.86%) per doubling of RF IgM and by 0.95% (95% CI 0.50% to 1.40%) per RF IgA doubling. ILA prevalence increased by 11% (95% CI 3% to 20%) per RF IgA doubling. Smoking modified the associations of both RF IgM and anti-CCP with both HAA and ILA (interaction p values varied from 0.01 to 0.09). Among ever smokers, HAA increased by 0.81% (95% CI 0.33% to 1.30%) and ILA prevalence increased by 14% (95% CI 5% to 24%,) per RF IgM doubling; and HAA increased by 1.31% (95% CI 0.45% to 2.18%) and ILA prevalence increased by 13% (95% CI 2% to 24%) per anti-CCP doubling. Among never smokers, no meaningful associations were detected. CONCLUSIONS: RA-related autoimmunity is associated with both quantitative and qualitative subclinical ILD phenotypes on CT, particularly among ever smokers.

High attenuation areas on chest computed tomography in community-dwelling adults: the MESA study.

Evidence suggests that lung injury, inflammation and extracellular matrix remodelling precede lung fibrosis in interstitial lung disease (ILD). We examined whether a quantitative measure of increased lung attenuation on computed tomography (CT) detects lung injury, inflammation and extracellular matrix remodelling in community-dwelling adults sampled without regard to respiratory symptoms or smoking.We measured high attenuation areas (HAA; percentage of lung voxels between -600 and -250 Hounsfield Units) on cardiac CT scans of adults enrolled in the Multi-Ethnic Study of Atherosclerosis.HAA was associated with higher serum matrix metalloproteinase-7 (mean adjusted difference 6.3% per HAA doubling, 95% CI 1.3-11.5), higher interleukin-6 (mean adjusted difference 8.8%, 95% CI 4.8-13.0), lower forced vital capacity (FVC) (mean adjusted difference -82 mL, 95% CI -119--44), lower 6-min walk distance (mean adjusted difference -40 m, 95% CI -1--80), higher odds of interstitial lung abnormalities at 9.5 years (adjusted OR 1.95, 95% CI 1.43-2.65), and higher all cause-mortality rate over 12.2 years (HR 1.58, 95% CI 1.39-1.79).High attenuation areas are associated with biomarkers of inflammation and extracellular matrix remodelling, reduced lung function, interstitial lung abnormalities, and a higher risk of death among community-dwelling adults.

Improved identification of sternal injuries with multidetector computed tomography (MDCT): sagittal reconstructions.

Chest computed tomography is acquired in the axial plane, but sternal injuries may be missed on axial images. This study hypothesized that sagittal sternal reconstruction images improve detection of sternal injury and radiologist's confidence in diagnosis compared to axial images. Five radiologists independently reviewed first axial images and on a different day sagittal images of a retrospective set of trauma cases recording presence/absence of a sternal injury and/or adjacent hematoma. The reviewer's confidence in the presence/absence of a sternal injury was assessed on a 5-point scale. Sagittal reconstructions generally yielded higher interreader agreement and confidence indices on statistical analysis.

Visual scoring of coronary artery calcification in lung cancer screening computed tomography: association with all-cause and cardiovascular mortality risk.

OBJECTIVE: Current and former smokers are at an increased risk for lung cancer and cardiovascular disease (CVD). We investigated two methods of visual scoring of coronary artery calcium on lung cancer screening computed tomography (CT) to predict cardiovascular and all-cause mortality. PARTICIPANTS AND METHODS: Cases were 1000 participants, age 55-74 years, enrolled in the National Lung Screening Trial CT arm who died during the study. An equal number of participants alive at the end of the study (controls) were matched in terms of sex, CT scanner vendor, and model, and 5-year age and smoking pack-years group. Coronary calcium was measured visually by three readers using two semiquantitative scoring schemes. Conditional logistic regression was used to analyze the association between the presence and the extent of coronary calcium and all-cause and cardiovascular mortality, stratified on matching criteria. RESULTS: Cases and controls were well matched for age (64±6 vs. 64±5, P=0.95) and mean pack-years smoking (61±24 vs. 62±24, P=1.0). Cases were significantly more likely to have coronary calcium than controls (85 vs. 77%, P<0.001). Having any calcium was associated with an increased risk for CVD mortality using either visual scoring method (odds ratio 3.4, 95% confidence interval 2.0-5.6, P<0.001, and odds ratio 3.3, 95% confidence interval 2.0-5.6, P<0.001). CONCLUSION: Visual scoring of coronary calcium predicts all-cause and CVD mortality in National Lung Screening Trial participants, independent of current versus former smoking status. Visual coronary calcium scoring in low-dose CT scans helps identify individuals at high risk for mortality who may benefit from further CVD prevention.

Pictorial review of the role of multidetector computed tomography imaging in the postoperative evaluation of congenital heart disease.

Echocardiography and cardiac magnetic resonance imaging are the methods of choice for preoperative and postoperative assessments of most congenital heart diseases. However, multidetector computed tomographic angiography of the chest is a complementary imaging technique especially in postoperative evaluations. To accurately interpret those computed tomography examinations, an appropriate study protocol, knowledge of the details of surgical procedures, and their complications are essential. In this pictorial review, we discuss our computed tomography technique with a number of illustrative cases with varied postoperative appearances and complications after some of the commonly performed surgical procedures.

Determinants of arterial stiffness in COPD.

BACKGROUND: Cardiovascular morbidity and mortality is high in patients with chronic obstructive pulmonary disease (COPD) and arterial stiffness is a potentially modifiable risk factor with added predictive value beyond that obtained from traditional risk factors. Arterial stiffness has been the target of pharmacologic and exercise interventions in patients with COPD, but the effects appear limited to those patients with more significant elevations in arterial stiffness. We aimed to identify predictors of increased arterial stiffness in a cohort with moderate to severe COPD. METHODS: Aortic pulse wave velocity (aPWV) was measured in subjects with moderate to severe COPD enrolled in a multicenter randomized controlled trial. Subjects were categorized into quartiles based on aPWV values and factors affecting high arterial stiffness were assessed. Multivariate models were created to identify independent predictors of high aPWV, and cardiovascular disease (CVD). RESULTS: 153 patients were included. Mean age was 63.2 (SD 8.2) years and mean FEV1 was 55.4 (SD 15.2) % predicted. Compared to the quartile with the lowest aPWV, subjects in the highest quartile were older, had higher systolic blood pressure (SBP), were more likely to be current smokers, and had greater burden of thoracic aortic calcification. On multivariate analyses, age (adjusted OR 1.14, 95%CI 1.05 to 1.25, p = 0.003) and SBP (adjusted OR 1.06, 95% CI 1.02 to 1.09, p = 0.001) were independent predictors of elevated aPWV. Body mass index, therapy with cholesterol lowering medications and coronary calcification were independent predictors of CVD. CONCLUSIONS: Elevated arterial stiffness in patients with COPD can be predicted using age, blood pressure and thoracic aortic calcification. This will help identify subjects for enrollment in clinical trials using aPWV for assessing the impact of COPD therapies on CV outcomes.

Pictorial review of multidetector CT imaging of the preoperative evaluation of congenital heart disease.

Sequential segmental approach is an efficient method for complete evaluation of complex congenital heart diseases (CHD). Although echocardiography is the imaging technique of choice, recent advances in computed tomography and cardiac magnetic resonance have given a new dimension to the traditional diagnostic assessment of CHD. CT has advantages of fast speed, higher spatial resolution, and simultaneous lung and airway visualization. The purpose of this pictorial review is to discuss the role of CT and emphasize its protocol and the segmental approach for comprehensive assessment of CHD.

Incidental discovery of an anterior mediastinal angiomyolipoma.

Angiomyolipomas are benign mesenchymal tumors consisting of blood vessels, smooth muscle, and fat. These noninvasive lesions characteristically manifest in renal tissue but may arise less frequently in extrarenal locations including the mediastinum. Only 8 cases of mediastinal angiomyolipomas have been reported in the literature, 3 of which were reported in the English literature, and only 2 of which were located in the anterior mediastinum. We report a surgically confirmed case of an anterior mediastinal angiomyolipoma incidentally discovered in an asymptomatic patient, in whom a screening breast magnetic resonance imaging revealed an incidental 5.7 cm anterior mediastinal mass. Further characterization with contrast-enhanced chest computed tomography confirmed a heterogeneously enhancing anterior mediastinal mass, suggestive of thymoma or lymphoma. The mass was resected and histopathologic evaluation revealed an angiomyolipoma.