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Contains fulltext : 220761.pdf (Publisher’s version ) (Open Access) Rationale: The decades-long progression of chronic obstructive pulmonary disease (COPD) renders identifying different trajectories of disease progression challenging.Objectives: To identify subtypes of patients with COPD with distinct longitudinal progression patterns using a novel machine-learning tool called "Subtype and Stage Inference" (SuStaIn) and to evaluate the utility of SuStaIn for patient stratification in COPD.Methods: We applied SuStaIn to cross-sectional computed tomography imaging markers in 3,698 Global Initiative for Chronic Obstructive Lung Disease (GOLD) 1-4 patients and 3,479 controls from the COPDGene (COPD Genetic Epidemiology) study to identify subtypes of patients with COPD. We confirmed the identified subtypes and progression patterns using ECLIPSE (Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints) data. We assessed the utility of SuStaIn for patient stratification by comparing SuStaIn subtypes and stages at baseline with longitudinal follow-up data.Measurements and Main Results: We identified two trajectories of disease progression in COPD: a "Tissue-->Airway" subtype (n = 2,354, 70.4%), in which small airway dysfunction and emphysema precede large airway wall abnormalities, and an "Airway-->Tissue" subtype (n = 988, 29.6%), in which large airway wall abnormalities precede emphysema and small airway dysfunction. Subtypes were reproducible in ECLIPSE. Baseline stage in both subtypes correlated with future FEV1/FVC decline (r = -0.16 [P < 0.001] in the Tissue-->Airway group; r = -0.14 [P = 0.011] in the Airway-->Tissue group). SuStaIn placed 30% of smokers with normal lung function at elevated stages, suggesting imaging changes consistent with early COPD. Individuals with early changes were 2.5 times more likely to meet COPD diagnostic criteria at follow-up.Conclusions: We demonstrate two distinct patterns of disease progression in COPD using SuStaIn, likely representing different endotypes. One third of healthy smokers have detectable imaging changes, suggesting a new biomarker of "early COPD."

Rationale and Objectives We evaluated the role of automated quantitative computed tomography (CT) scan interpretation algorithm in detecting interstitial lung disease (ILD) and/or emphysema in a sample of elderly subjects with mild lung disease. We hypothesized that the quantification and distributions of CT attenuation values on lung CT, over a subset of Hounsfield units (HUs) range (−1000 HU, 0 HU), can differentiate early or mild disease from normal lung. Materials and Methods We compared the results of quantitative spiral rapid end-exhalation (functional residual capacity, FRC) and end-inhalation (total lung capacity, TLC) CT scan analyses of 52 subjects with radiographic evidence of mild fibrotic lung disease to the results of 17 normal subjects. Several CT value distributions were explored, including (1) that from the peripheral lung taken at TLC (with peels at 15 or 65 mm), (2) the ratio of (1) to that from the core of lung, and (3) the ratio of (2) to its FRC counterpart. We developed a fused-lasso logistic regression model that can automatically identify sub-intervals of −1000 HU and 0 HU over which a CT value distribution provides optimal discrimination between abnormal and normal scans. Results The fused-lasso logistic regression model based on (2) with 15-mm peel identified the relative frequency of CT values of over −1000 HU and −900 and those over −450 HU and −200 HU as a means of discriminating abnormal versus normal lung, resulting in a zero out-sample false-positive rate, and 15% false-negative rate of that was lowered to 12% by pooling information. Conclusions We demonstrated the potential usefulness of this novel quantitative imaging analysis method in discriminating ILD and/or emphysema from normal lungs.

Two decades have passed since the publication of laboratory studies of satisfaction of search (SOS) in chest radiography. Those studies were performed using film. The current investigation tests for SOS effects in computed radiography of the chest.Sixty-four chest computed radiographs half demonstrating various "test" abnormalities were read twice by 20 radiologists, once with and once without the addition of a simulated pulmonary nodule. Receiver-operating characteristic detection accuracy and decision thresholds were analyzed to study the effects of adding the nodule on detecting the test abnormalities. Results of previous studies were reanalyzed using similar modern techniques.In the present study, adding nodules did not influence detection accuracy for the other abnormalities (P = .93), but did induce a reluctance to report them (P.001). Adding nodules did not affect inspection time (P = .58) so the reluctance to report was not associated with reduced search. Reanalysis revealed a similar decision threshold shift that had not been recognized in the early studies of SOS in chest radiography (P.01) in addition to reduced detection accuracy (P.01).The nature of SOS in chest radiography has changed, but it is not clear why.SOS may be changing as a function of changes in radiology education and practice.

Rationale and Objectives We tested whether satisfaction of search (SOS) effects that occur in computed tomography (CT) examination of the chest on detection of native abnormalities are produced by the addition of simulated pulmonary nodules. Materials and Methods Two experiments were conducted. In the first experiment, 70 CT examinations, half that demonstrated diverse, subtle abnormalities and half that demonstrated no native lesions, were read by 18 radiology residents and fellows under two experimental conditions: presented with and without pulmonary nodules. In a second experiment, many of the examinations were replaced to include more salient native abnormalities. This set was read by 14 additional radiology residents and fellows. In both experiments, detection of the natural abnormalities was studied. Receiver operating characteristic (ROC) curve areas for each reader-treatment combination were estimated using empirical and proper ROC models. Additional analyses focused on decision thresholds and visual search time on abnormality-free CT slice ranges. Institutional review board approval and informed consent from 32 participants were obtained. Results Observers more often missed diverse native abnormalities when pulmonary nodules were added, but also made fewer false-positive responses. There was no change in ROC area, but decision criteria grew more conservative. The SOS effect on decision thresholds was accompanied by a reduction in search time on abnormality-free CT slice ranges. Conclusion The SOS effect in CT examination of the chest is similar to that found in contrast examination of the abdomen, involving induced visual neglect.

The value of quantitative CT (QCT) to identify chronic obstructive pulmonary disease (COPD) phenotypes is increasingly appreciated. The authors hypothesised that QCT-defined emphysema and airway abnormalities relate to St George's Respiratory Questionnaire (SGRQ) and Body-Mass Index, Airflow Obstruction, Dyspnea and Exercise Capacity Index (BODE).1200 COPDGene subjects meeting Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria for COPD with QCT analysis were included. Total lung emphysema was measured using the density mask technique with a -950 Hounsfield unit threshold. An automated programme measured mean wall thickness (WT), wall area percentage (WA%) and 10 mm lumenal perimeter (pi10) in six segmental bronchi. Separate multivariate analyses examined the relative influence of airway measures and emphysema on SGRQ and BODE.In separate models predicting SGRQ score, a 1 unit SD increase in each airway measure predicted higher SGRQ scores (for WT, 1.90 points higher, p=0.002; for WA%, 1.52 points higher, p=0.02; for pi10, 2.83 points higher p0.001). The comparable increase in SGRQ for a 1 unit SD increase in emphysema percentage in these models was relatively weaker, significant only in the pi10 model (for emphysema percentage, 1.45 points higher, p=0.01). In separate models predicting BODE, a 1 unit SD increase in each airway measure predicted higher BODE scores (for WT, 1.07-fold increase, p0.001; for WA%, 1.20-fold increase, p0.001; for pi10, 1.16-fold increase, p0.001). In these models, emphysema more strongly influenced BODE (range 1.24-1.26-fold increase, p0.001).Emphysema and airway disease both relate to clinically important parameters. The relative influence of airway disease is greater for SGRQ; the relative influence of emphysema is greater for BODE.

Background Cigarette smoking is a major risk factor for chronic obstructive pulmonary disease (COPD) and COPD severity. Previous genome-wide association studies (GWAS) have identified numerous single nucleotide polymorphisms (SNPs) associated with the number of cigarettes smoked per day (CPD) and a dopamine beta-hydroxylase (DBH) locus associated with smoking cessation in multiple populations. Objective To identify SNPs associated with lifetime average and current CPD, age at smoking initiation, and smoking cessation in patients with COPD. Methods GWAS were conducted in four independent cohorts encompassing 3441 ever-smoking patients with COPD (Global Initiative for Obstructive Lung Disease stage II or higher). Untyped SNPs were imputed using the HapMap (phase II) panel. Results from all cohorts were meta-analysed. Results Several SNPs near the HLA region on chromosome 6p21 and in an intergenic region on chromosome 2q21 showed associations with age at smoking initiation, both with the lowest p=2x10(-7). No SNPs were associated with lifetime average CPD, current CPD or smoking cessation with p

Rationale and Objectives Evaluate the role of two-dimensional echocardiography and electrocardiographically (ECG)-gated contrast-enhanced multislice computed tomographic (MSCT) cardiac imaging to assess cardiac anatomy, specifically pulmonary venous anatomy and left atrial thrombus, in a selected group of patients before catheter-based atrial fibrillation ablation. Materials and Methods Left atrial anatomy and associated findings in 34 consecutive patients scheduled for electrophysiologic testing who underwent both echocardiography and ECG-gated 16-slice MSCT cardiac imaging were retrospectively compared. Results from two-dimensional transthoracic echocardiography (TTE), cardiac MSCT, electrophysiologic study (EPS), and transesophageal echocardiography (TEE) (when performed) were taken from the official medical record without prior knowledge of this study when interpretation was rendered for clinical use. Electronic record review included: presence of left atrial thrombus (defined as constant filling defect on at least two echocardiographic views or filling defect on computed tomography) and location, pulmonary venous anatomy, and other cardiac, mediastinal, or pulmonary abnormalities. Results Left atrial thrombus was identified by cardiac MSCT alone in five patients (15%). Pulmonary venous variants were identified with cardiac MSCT in two patients (6%). Both MSCT and echocardiography were normal in 17 subjects (79%). Echocardiography was better at identifying associated valvular abnormalities that were seen in 10 patients (29%). Cardiac MSCT angiography alone identified other cardiac and noncardiac abnormalities, including suspicious pulmonary malignancy, mediastinal adenopathy, and coronary stenosis in 15 patients (44%). Conclusions Echocardiography and cardiac MSCT angiography often provide complimentary findings during the preprocedural evaluation for patients with atrial fibrillation requiring ablation. Cardiac MSCT may provide significant additional information about the left atrium, mediastinum, coronary circulation, and visualized lung fields. Based on this study, we would advise that patients considered for radiofrequency ablation for uncontrolled right atrial fibrillation have both echocardiography and ECG-gated contrast-enhanced cardiac MSCT performed as part of the preprocedure evaluation.

Rationale and Objectives We sought to assess the performance of a real-time interactive pulmonary nodule analysis system for evaluation of chest digital radiographic (DR) images in a routine clinical environment. Materials and Methods A real-time interactive pulmonary nodule analysis system for chest DR image softcopy reading (IQQA-Chest; EDDA Technology, Princeton Junction, NJ) was used in daily practice with a Picture Archiving and Communication System in a National Cancer Institute−designated cancer teaching hospital. Patients referred for follow-up of known cancer underwent digital chest radiography. Posteroanterior and lateral DR images were first read by resident radiologists along with experienced chest radiologists using a Picture Archiving and Communication System work station. The computer-assisted detection (CAD) program was subsequently applied to the posteroanterior DR images, and changes (if any) in diagnosis were recorded. For reference standard, a follow-up chest radiograph at least 6 months following the initial examination or a follow-up computed tomographic scan of the chest within 3 months was used to establish diagnostic accuracy. Results Of 324 DR examinations, follow-up imaging according to our parameters was available for 214 patients (67%). Lung nodules were found and subsequently confirmed in 35 patients (10%) without CAD. Using CAD, nodules were found and subsequently confirmed in 51 patients (15%), improving sensitivity from 63.8% (95% confidence interval [CI], 0.49%−0.76%) to 92.7% (95% CI, 0.82%−0.98%) ( P Conclusions This study suggests that the interpretation of chest radiographs for lung nodules can be improved using an automated CAD nodule detection system. This improvement in reader performance comes with a minimal number of false-positive interpretations.

The aim of this study was to assess mediastinal lymphatic drainage patterns from each pulmonary lobe using computed tomographic (CT) observations of calcified primary complex pulmonary histoplasmosis.We assessed 400 CT studies of patients with primary complex histoplasmosis consisting of a single lobe pulmonary lesion and mediastinal nodal disease. We assessed the distribution of mediastinal nodal involvement depending on pulmonary lobes for the total number of involved nodes, the number with single-station involvement (which suggests the initial site of involvement), and the number with skip involvement which suggests direct drainage to the mediastinum.The most commonly involved mediastinal nodal stations from the right upper lobe, left upper lobe, and left lower lobe were the right lower paratracheal node (97%, 74/76), the subaortic node (72%, 49/68), and the left pulmonary ligament node (61%, 66/108), respectively. These nodes were the most common site of skip involvement in each lobe. In the right lower lobe and middle lobe, the subcarinal node was most commonly involved: 62% (65/105) and 81% (35/43), respectively. By contrast, skip involvement was uncommon in the drainage to this node.Our data show a predictable pattern of lobar lymphatic drainage to the mediastinum. This may have implications on the minimal N2 disease of non-small-cell lung cancer.

This article reviews the pathological classification of cardiac and pericardial neoplasms, the incidence of the various tumor types, and the role of CT and MRI, including their major differences and clinical impact on patient management.

Although a checklist has been recommended for preventing satisfaction of search (SOS) errors, a previous research study did not demonstrate that benefit. However, observers in that study had to turn away from the image display to use the checklist. The current study tested a vocalized checklist to avoid this constraint.A total of 64 chest computed radiographs, half containing various "test" abnormalities, were read twice by 20 radiologists, once with and once without the addition of a simulated pulmonary nodule. Readers used a vocalized checklist-directing search. Receiver operating characteristic (ROC) detection accuracy and decision thresholds were analyzed to study the effects of adding the nodule on detecting the test abnormalities.Adding nodules induced a substantial reluctance to report the other abnormalities (P 0.001), as had been the case in the most recent study of the SOS effect in radiography.The vocalized checklist did not reduce nor eliminate the SOS effect on readiness to report further abnormalities. Although useful for organizing search and reporting, particularly among students, a vocalized checklist does not prevent SOS effects.

Rationale and Objectives Image perception studies have been difficult to perform using clinical images because of the problems associated with obtaining proven abnormalities and appropriate normal controls. The objective of this research was to develop and evaluate interactive software that allows the seamless removal, archiving and insertion of abnormal areas from computed tomography (CT) lung image sets for use in image perception research. Materials and Methods The software tools for removing, archiving, and adding lesions are described in detail. The efficacy of the software to remove abnormal areas of lung CT studies was evaluated by having radiologists select the one altered image from a display of four. The software for adding lesions was evaluated by having radiologists classify displayed CT slices with lesions as real or artificial along with their confidence level. Results Observers could not reliably detect when images had been altered by the software. In the lesion-removal experiment, the observers correctly identified the altered display in only 15.8 ± 2.8 of 56 sets. In the lesion-add experiment, the observers correctly identified the artificially placed lesions in 38.2 ± 3.9 of 77 sets. The frequency distribution of the correct responses did not differ from that expected from chance selection. Conclusions The results from both of these experiments demonstrate that radiologists could not distinguish between original and altered images. We conclude that this software can be used with volumetric CT lung images for creating normal control and target data sets for medical image perception research.

The measurement of parameters relating to the assessment of cardiac function and morphology are critically important prognostic determinates in patients with known or suspected cardiac disease, such as coronary artery disease and myocardial infarction. Similarly, the measurement of indices, such as ejection fraction and myocardial mass, are key in assessing the efficacy of therapy in patients with valvular, coronary artery and intrinsic myocardial diseases. Electron-beam computed tomography has been proven to be a reliable and accurate modality for measuring a host of parameters relating to cardiac function. This article reviews the unique technologic design of the electron-beam computed tomography scanner and specifically addresses how this technology has enabled electron-beam computed tomography to become the gold standard for the quantification of cardiac function.

To compare coronary artery calcium scores from a multi-detector row helical computed tomographic (CT) scanner with those from an electron-beam CT scanner, with emphasis on subjects with calcium scores less than 400.Seventy-eight asymptomatic subjects (37 women, 41 men; age range, 39-78 years; mean age, 54.2 years) underwent multi-detector row CT and electron-beam CT. Volume and Agatston scores were calculated with a workstation. Statistical analyses included assessment of association between calcium scores from two scanners, calculation of percent absolute difference to assess score variability between scanners, equivalence analysis, construction of Bland-Altman plots to assess agreement between scores, and assessment of changes in score grouping and risk criteria based on score differences between scanners.Electron-beam CT calcium scores were higher than multi-detector row CT scores. Linear association between calcium scores obtained from paired scans was significant (r = 0.96-0.99, P.001). Mean percent absolute differences were 67.9% and 65.0% for volume and Agatston scores, respectively (48.6% and 46.3% for corresponding natural log-transformed scores). In subjects with a score of 11 or greater, mean percent absolute differences between electron-beam CT and multi-detector row CT scores ranged from 15% to 30% (10% for natural log-transformed calcium scores). With a 20% equivalence limit, calcium scores from the two scanners were statistically equivalent (P.05). Score grouping would have been subject to change in 12 (11 increased and one decreased; six with scores of 11 or greater), and possible risk management decisions would have been subject to change in eight (16%) of 51 subjects who underwent electron-beam CT versus multi-detector row CT scanning.Multi-detector row CT appears to be comparable to electron-beam CT for coronary calcification screening, except in subjects with a calcium score less than 11.

As an unequivocal biomarker for arteriosclerosis, the presence of coronary calcium serves as a qualitative reflection of the severity of coronary artery disease (CAD). Greater calcium burdens correlate with more advanced disease, a higher likelihood of coronary stenoses, and a higher risk for coronary heart disease (CHD). Empirically, the quantification of coronary calcium not only provides an accurate reflection of disease severity, but also has great potential as a screening tool for CHD. Computed tomography (CT) has been shown to be capable of providing accurate, noninvasive measurements of coronary calcification. Evidence shows that calcium measurements by CT correlate well with histological plaque analyses, and that calcium burdens accurately reflect disease severity and can be used to assess individual risk for CHD. The purpose of this review article is to examine the accumulated evidence that has attempted to validate CT as a diagnostic tool for CAD and as a screening exam for CHD. J. Magn. Reson. Imaging 2004;19:720–733. © 2004 Wiley-Liss, Inc.

The value of a coronary artery disease prediction algorithm, the Framingham risk score (score), for detecting coronary artery calcium (CAC) was examined in 385 men and 472 women, aged 29 to 43 years. Scores were compared in subjects with and without CAC and were also used to predict presence of CAC. Receiver-operating characteristic curves were computed to compare different prediction models. The score model was compared with age only, natural logarithm of body mass index (lnBMI) only, and score plus lnBMI models. CAC was detected in 30% of men and 16% of women. The mean score was significantly higher in men and women with CAC. For every 2-point increase in the score, the odds of CAC increased by 30% in women and 20% in men. Significant associations between CAC status and risk factors were observed for age in women, and high- density lipoprotein cholesterol and blood pressure in men and women. The area under the receiver-operating characteristic curve for the score was 0.67 and 0.57 for women and men, respectively. When lnBMI was added to the score model, the area increased to 0.76 in women (lnBMI p0.0001, score p0.005). For men, the area increased from 0.57 to 0.67, and the score was no longer significant (p0.60) in the model with lnBMI (p0.0001). Score predicts CAC in asymptomatic young adults. Inclusion of lnBMI in the score model adds significantly to the prediction of CAC in women and men. The lnBMI model has a greater predictive value than the score in this young population.

SUMMARY The primary goal of performing cross-sectional imaging of the chest in the radiologic evaluation of lung cancer is to obtain information about the character and magnitude of the neoplasm. Patient prognosis and therapy decisions depend directly on identifying the size and full extent of the tumor. The ideal imaging modality therefore should provide reliable information that can be used to assist in accurately staging the malignancy. Traditionally, CT scanning has been used exclusively as part of the preoperative evaluation of primary lung carcinomas. Recent advances in CT scanning technology have greatly improved image acquisition times and image quality and consequently have enhanced the role of CT imaging in the evaluation of bronchogenic carcinomas. Single-breath CT acquisitions of the chest can now be accomplished in a matter of seconds. These rapid acquisitions improve image quality by decreasing respiratory motion, while enhancing patient compliance and throughput. Clearly, CT scanning has matured into an efficient and accurate diagnostic tool to stage primary lung malignancies noninvasively. In its present state of development, MR imaging has one distinct disadvantage that makes it significantly less attractive as a routine lung cancer examination, namely the inability to produce images of the lung that are high in spatial resolution. Also, the sensitivity and specificity of MR imaging, which are similar to those of CT scanning in identifying mediastinal and hilar metastases, offer no clinical advantages. Longer image acquisition times and time constraints force most MR imaging examinations to be abbreviated and limited in coverage. As a result, the necessary exclusion of important anatomic areas routinely visualized by CT scanning may limit the diagnostic power of MR imaging. Finally, MR imaging requires greater physician supervision than CT scanning to direct imaging and to maintain examination quality and thoroughness. Although MR imaging can contribute significantly to the radiologic evaluation of patients with lung cancer, its role is somewhat limited, and it is most useful as a complement to CT scanning. The additional versatility offered by pulse sequences that take advantage of the intrinsic relaxation of tissues greatly facilitates identification of tumor, particularly when local invasion is present. By virtue of the short T1 value of fat, MR imaging may improve the detection of mediastinal disease, particularly in cases in which the sensitivity of CT scanning cannot be optimized because of allergies to contrast or renal insufficiency. MR imaging is superior to CT scanning in demonstrating musculoskeletal anatomy and the neurovascular structures of the neck and mediastinum. Although MR imaging has a potential usefulness in the radiographic evaluation of lung carcinoma, technical shortcomings relegate this modality to a role that is primarily complementary to CT scanning. With time, technological improvements will undoubtedly redefine the role of MR imaging in the radiographic evaluation and staging of bronchogenic carcinomas.

Background. To determine the relative utility of positron emission tomography (PET), computed tomography (CT), and magnetic resonance imaging with Combidex (MRI-C) in the non-invasive staging of non-small cell lung cancer (NSCLC) mediastinal lymph nodes (MLN), we compared the three tests’ individual performance with surgical mediastinal sampling. In contrast to prior studies, cytology was not used. Methods. The MLN were evaluated using PET and CT in 64 NSCLC patients. MRI-C was performed in 9 of these patients. MLN with a PET standard uptake value greater than or equal to 2.5, or greater than 1 cm in the short axis by CT or lack of MRI-C signal change were considered positive for metastatic disease. All MLN were sampled and subjected to standard pathologic analysis. PET, CT, and MRI-C scans were interpreted blinded to the histopathological results. Sensitivity, specificity, and accuracy for each scan type to appropriately stage MLN was determined using pathologic results as the standard. Results. Thirty patients had stage I disease, 8 stage II, 9 stage IIIA, 7 stage IIIB, and 10 stage IV. Two-hundredand-thirty MLN were sampled. Sixteen patients had metastatic mediastinal disease. Compared to the pathological results, PET, CT, and MRI-C had a sensitivity, specificity, and accuracy of 70%, 86%, 84%; 65%, 79%, 76%; 86%, 82%, and 83%, respectively. PET and MRI-C were statistically more accurate than CT (p < 0.001). In cases where PET and CT did not identify MLN involvement with NSCLC, 8% (2/25) were pathologically positive. Conclusions. PET and MRI-C are statistically more accurate than CT. However, the differences are small and may not be clinically relevant. No technique was sensitive or specific enough to change the current recommendation to perform mediastinoscopy for MLN staging in NSCLC.

The purpose of this study was to evaluate the clinical efficacy of ultrasmall superparamagnetic iron oxide particles as a magnetic resonance (MR) contrast agent in differentiating metastatic from benign lymph nodes. Eighteen patients with primary lung malignancy and suspected regional lymph node metastases underwent MR imaging before and after Combidex® infusion in a multi-institutional study. All MR sequences were interpreted by one or more board-certified radiologists experienced in imaging thoracic malignancy. Each patient was evaluated for the number and location of lymph nodes, homogeneity of nodal signal, and possible change of MR signal post contrast. All patients underwent resection or sampling of the MR-identified lymph node(s) 1–35 day(s) post contrast MR imaging. In all, 27 lymph nodes or nodal groups were available for histopathologic correlation. Combidex had a sensitivity of 92% and a specificity of 80% in identifying pathologically confirmed metastatic mediastinal lymph nodes. Based on our preliminary data, Combidex MR imaging may provide additional functional information useful in the staging of mediastinal lymph nodes. J. Magn. Reson. Imaging 1999;10:468–473. © 1999 Wiley-Liss, Inc.

Coronary artery calcification is a marker for atherosclerotic disease. The calcifications frequently occur early in the disease process and often before the development of luminal narrowing or cardiac events. Electron beam CT has a high accuracy in detecting calcifications, and thus has prognostic value in predicting luminal narrowing and future cardiac events.

Coronary artery disease affects millions of Americans annually. In evaluating coronary artery disease, it is important to develop diagnostic methodology that can screen patients before the onset of symptoms or cardiac events and, in addition, evaluate the functional aspects of coronary artery disease, including any residual effects on the heart after events have occurred. Electron beam computed tomography allows the identification of coronary calcium, which is a marker for coronary atherosclerotic disease, and also allows the quantification of cardiac function, which may be altered from coronary atherosclerosis or the occurrence of a cardiac event. Thus, electron beam computed tomographic imaging is having a major impact on the diagnosis and follow-up on coronary artery disease.

Aim: To define the utility of the frontal chest radiograph in the assessment of chest drain position. Patients and Methods: Fifty-six frontal chest radiographs in 45 patients with 61 chest drains (18 anterior, 9 interlobar, and 34 posterior position) were reviewed retrospectively to determine radiographic characteristics Results: Eighty-nine percent of the anterior drains demonstrated a curved appearance at the insertion site, while 50% of posterior drains and all interlobar drains were straight at the insertion site. A curved intrapleural drain was a common finding when positioned anteriorly and posteriorly (67% and 59%, respectively). Interlobar drains were often straight throughout their course (89%). The tips of interlobar drains were usually positioned at the hilum (89%). Conclusion: Results suggest that interlobar positioning can be suspected on the frontal chest radiograph. A curving chest drain with straight appearance at the insertion site was indicative of a posterior location.

Pulmonary aspergillosis represents a common, potentially lethal opportunistic infection that has four unique forms: allergic bronchopulmonary aspergillosis (ABPA), aspergilloma, and invasive and semi-invasive aspergillosis. In individuals who are at risk, pulmonary aspergillosis is characterized by a spectrum of clinical and radiographic findings that are intrinsically related to the status of the immune system or the presence of structural lung disease. ABPA, occurring almost exclusively in asthma patients, is characterized radiographically by fleeting pulmonary alveolar opacities caused by deposition of immune complexes and inflammatory cells within the lung parenchyma. Mucus plugging and bronchial wall thickening can be expected in time. Aspergilloma, occurring in patients with structural lung disease, typically appears radiographically as a focal intracavitary mass and is characterized initially by an increase in the wall thickness of a preexisting cavity or cyst. Invasive aspergillosis, which occurs primarily in profoundly immunocompromised patients, may exhibit nonspecific patchy nodular opacities or lobar-type air-space disease in cases with vascular invasion. Computed tomography may reveal a halo or ground-glass attenuation and is more accurate in the detection of early disease. Cavitation often develops with time and typically results in the air crescent sign. Semi-invasive aspergillosis is radiographically similar to the invasive form but differs in clinical course, being associated with mild immunosuppression or chronic illness and typically progressing over the course of months rather than weeks.

A reliable imaging technique is needed for follow-up of patients with temporal and facial osteomyelitis. Clinical outcome in 20 patients with suspected osteomyelitis of the temporal/mastoid, calvarium, and mandible facial bones was evaluated with 30 combined In-WBC/Tc-99m MDP bone single photon emission computed tomographic (SPECT) scans and 27 computed tomographic scans. Simultaneous dual-tracer 25-minute SPECT scans were acquired 18 to 20 hours after radiotracer injection by use of a three-detector system. Diagnosis of the 20 patients (age range, 3 to 74 years) included 8 with facial osteomyelitis, 6 with malignant otitis externa, 3 with mandibular osteomyelitis, and 3 with calvarial osteomyelitis. Diagnosis was confirmed by biopsy/culture results in 18 patients and by endoscopic and clinical evaluation in 2 patients with initial negative scans. Of the 30 In-WBC/MDP scans, 15 were true-positive, 13 true-negative, 1 false-negative, and 1 equivocal. Of a total of 27 CT scans, 9 were true-positive, 5 false-negative, and 1 equivocal in patients with biopsy-proven osteomyelitis. Three computed tomographic scans were false-positive and 1 was equivocal in patients without osteomyelitis, because of concurrent postoperative bone abnormalities. Additionally, 8 computed tomographic scans were true-negative. These results suggest that dual In-WBC/Tc-99m MDP bone SPECT scintigraphy provides an accurate imaging modality for diagnosis and follow-up of temporal and facial osteomyelitis when existing clinical or postoperative bone changes make it difficult to detect active osteomyelitis by computed tomographic scan.

This study assessed whether subtle fractures are mised in multitrauma patients because other fractures are detected. Sixty-five simulated trauma patients were each depicted in series of radiographs that were assembled from radiographs of several actual patients. The radiographs were selected to look like they belonged to a single patient. Forty-six cases included a radiograph showing a subtle fracture (which we called the “target”). In one experimental condition, none of the other radiographs in the patient’s series contained a fracture. In a second experimental condition, a radiograph containing an additional fracture (called the “distracter”) was substituted for a radiograph that had no fracture in the first experimental condition. The accuracy of detecting the target fractures was significantly reduced for cases in which the distracter fracture was reported. Awareness of the nature of this type of miss may lead to realistic strategies to avoid it.

The authors previously demonstrated the feasibility of graph-searching-based automated edge detection in cardiac magnetic resonance (MR) imaging. To further assess the clinical utility of this method, unselected images from 11 consecutive subjects undergoing clinically indicated (except for one healthy volunteer) short-axis spin-echo MR imaging were analyzed. A total of 142 images from the 11 subjects, encompassing the left ventricle from apex to outflow tract, were analyzed. The computer algorithm correctly identified complete endocardial and epicardial contours in 121 of 142 images (85%). Correlations between observer-traced and computer-derived epicardial areas for all images were good (r = .71 for epicardium, r = .83 for endocardium); they improved for a subset of higher-quality images (r = .82 for epicardium, r = .92 for endocardium). The authors conclude that the current data further support the usefulness of computer digital image processing in geometric analysis of cardiac MR image data.

The millisecond image acquisition time characteristic of the ultrafast computed tomography (UFCT) scanner makes it an ideal modality for evaluating patients with suspected vascular lesions of the thoracic aorta. Unlike conventional CT, the UFCT electron beam technology produces images with excellent resolution, minimal respiratory artifact, and superior vascular enhancement. This report discusses the (1) basic characteristics of the UFCT scanner as they relate to the imaging of the thoracic aorta, (2) UFCT appearances of uncomplicated and complicated aneurysms and dissections, (3) appropriate CT protocols used in the work-up of suspected thoracic aortic disease, and (4) strengths and weaknesses of other imaging modalities compared with UFCT.

The ability to insert abnormalities in clinical tomographic images makes image perception studies with medical images practical. We describe a new insertion technique and its experimental validati on that uses complementary image masks to select an abnormality from a library and place it at a desired location. The me thod was validated using a 4-alternative forced-choice experiment. For each case, four quadrants were simultaneously displayed consisting of 5 consecutive frames of a chest CT with a pulmonary nodule. One quadrant was unaltered, while the other 3 had the nodule from the unaltered quadrant artificially inserted. 26 different sets were generated and repeated with order scrambling for a total of 52 cases. The cases were viewed by radiology staff and resi dents who ranked each quadrant by realistic appearance. On average, the observers were able to co rrectly identify the unaltered quadrant in 42% of cases, and identify the unaltered quadrant both times it appeared in 25% of cases. Consensus, defined by a majority of readers, correctly identified the unaltered quadrant in only 29% of 52 cases. For repeats, the consensus observer successfully identified the unaltered quadrant only once. We conclude that the insertion method can be used to reliably place abnormalities in perception experiments. Keywords: Abnormality insertion, medical image perception, tomographic studies 1. INTRODUCTION Perception studies with actual medical images are difficult becau se of the lack of control of the images and because of the lack of truth data. Clinically normal images may contain a number of benign entities that could act as distractors and otherwise desirable target abnormalities may not be located in suitable locations. As a result, the collection of usable clinical cases for perception research is time cons uming and often requires making compromises. To circumvent these problems, we have developed software that allows the manipulation of images to remove or introduce

Computer-aided diagnosis (CAD) has been developed to ensure that the radiologist considers suspect focal opacities that may represent cancer in chest radiography. Although CAD was not developed to counteract the satisfaction of search (SOS) effect, it may be an effective intervention to do so. The objective of this study is to determine whether an idealized CAD can reduce SOS effects in chest radiography.Fifty-seven chest radiographs, half of which demonstrated diverse, native abnormalities were read twice by 16 observers, once with and once without the addition of a simulated pulmonary nodule. Simulated CAD prompts were provided during the interpretation, which unerringly pointed to the added simulated nodule. Area under the ROC curve for detecting the native abnormalities was estimated for each observer in each treatment condition. In addition to testing for the SOS effect in the presence of CAD prompts, results were compared to those of a previous SOS study.Significantly more nodules were reported in the SOS with CAD experiment than in the original SOS experiment (49 versus 43, P.01). An SOS effect was found even when CAD prompts were provided; ROC areas for detecting native abnormalities were reduced with added nodules [0.68 versus 0.65, P (one-tailed).05]. Comparison of the current experiment with CAD and the previous SOS experiments failed to show a significant difference of the magnitude of the SOS effect (P = .52). The threshold for reporting was more conservative with CAD prompts than in SOS studies (P = .052).Our results indicate that the CAD prompts, even those that always point to their target lesion without false-positive error, fail to counteract SOS in chest radiography. The stricter decision thresholds with CAD prompts may indicate less visual search for native abnormalities.

Delineation of the interlobar fissures on multiplanar reconstruction (MPR) images is useful to assess masses at the fissures for invasion into adjacent lobes. We performed this study to determine the appropriate MDCT protocol to visualize the interlobar fissures on sagittal MPR images.For the phantom studies, radiographic film was used to replicate the interlobar fissures. For the clinical studies, we obtained MDCT scans of 130 patients with normal interlobar fissures. Visualization of the interlobar fissures on sagittal MPR was assessed using the following scanning parameters: scan collimations of 0.5, 1, 2, and 3 mm with helical pitches of 1 and 1.5 for the phantom studies; and scan collimations of 0.5, 1, 2, and 3 mm with a helical pitch of 1.5 and a scan collimation of 2 mm with a helical pitch of 1 for the clinical studies.To visualize fissures as a sharp line, a 0.5- or 1-mm collimation was required for the major fissure and 0.5 mm for the minor fissure in the phantom studies. In the clinical studies, 0.5-mm-collimation MPR images depicted interlobar fissures as a sharp line in all cases. Fissures on MPR images using 1-, 2-, and 3-mm collimations appeared as a sharp line in 77.5-95.0%, 0-43.3%, and 0% of cases, respectively.Volume data obtained using a 1-mm collimation are required to visualize all the interlobar fissures as a sharp line on sagittal MPR images except the minor fissure and superior portion of the right major fissure, for which a 0.5-mm collimation is required.

Invasive coronary angiography is considered to be the gold standard for diagnosis and follow-up of coronary artery aneurysms, thrombosis and stenosis in patients with Kawasaki Disease. However, the availability of multi-detector CT coronary angiography provides a viable alternative as a non-invasive imaging modality for sequential follow-up of patients with Kawasaki disease. High quality multidetector CT angiography images of coronary arterial anatomy can be obtained after adequate heart rate control using beta blockers.

Image perception studies of medical images provide important information about how radiologists interpret images and insights for reducing reading errors. In the past, perception studies have been difficult to perform using clinical imaging studies because of the problems associated with obtaining images demonstrating proven abnormalities and appropriate normal control images. We developed and evaluated interactive software that allows the seamless removal of abnormal areas from CT lung image sets. We have also developed interactive software for capturing lung lesions in a database where they can be added to lung CT studies. The efficacy of the software to remove abnormal areas of lung CT studies was evaluated psychophysically by having radiologists select the one altered image from a display of four. The software for adding lesions was evaluated by having radiologists classify displayed CT slices with lesions as real or artificial scaled to 3 levels of confidence. The results of these experiments demonstrated that the radiologist had difficulty in distinguishing the raw clinical images from those that had been altered. We conclude that this software can be used to create experimental normal control and "proven" lesion data sets for volumetric CT of the lung fields. We also note that this software can be easily adapted to work with other tissue besides lung and that it can be adapted to other digital imaging modalities.

Coronary artery disease (CAD) is the number one killer of adults in the United States, claiming one-half million deaths annually. Early detection and prevention strategies clearly remain a top priority for health care providers in order to reduce the high mortality rate of heart disease. As an unequivocal reflection of arteriosclerosis, coronary arterial calcium (CAC) may provide a means to qualitatively assess the overall disease severity and likewise serve as a means to assess risk for CHD. It is known that patients with heavy calcium burdens have more advanced CAD, a concomitantly a higher likelihood of coronary stenoses, and a concomitant higher risk for acute cardiac events. Computed tomography has been shown to be an accurate, non-invasive method to quantify coronary calcification burden in patients. Evidence shows that calcium measurements by CT correlate well with histological plaque analyses, and that CAC measurements accurately reflect disease severity and can be useful to assess individual risk for CHD. The purpose of this article is to summarize the currently available evidence that has attempted to validate CAC screening as a screening exam and risk predictor for coronary heart disease.

To determine whether differences in body mass index (BMI) and image section levels representing the proximal through the distal sections of the heart are associated with attenuation differences in images of calcium phantoms scanned during computed tomographic (CT) imaging of study subjects.Mean attenuation values for three calcium phantoms (each with a different calcium hydroxyapatite concentration), as measured at each of four different image section levels, were obtained for 691 participants in the Muscatine CT Vascular Calcium Study. The subjects were grouped according to sex-specific BMI quartiles, and the degree of attenuation in each phantom was investigated as a function of image section level and BMI quartile. Spearman rank order correlation coefficients and one-, two-, and three-factor repeated-measures analysis of variance were used to examine the association between section level and BMI and the mean phantom attenuations.Attenuation was, for the most part, significantly associated with both section level (P.005) and BMI quartile (P.0025-.05). The degree of attenuation tended to decrease in images obtained at the more distal cardiac levels and to increase with increasing BMI quartile.Differences in attenuation related to BMI and image section level appear to have a significant effect on current calcium scoring methods.

We report a case of group F streptococcal pericarditis, the source of which was found to be an esophagomediastinal fistula arising from a midesophageal diverticulum. The patient presented subacutely and had no preexisting symptoms of esophageal disease. Antibiotic therapy, surgical drainage, pericardiectomy, and esophageal myotomy led to a successful outcome.

Coronary arterial calcification has unequivocally been shown to be a marker of atherosclerosis. To date, much research interest has been generated regarding the quantification of coronary calcification by electron beam computed tomography, and how best to use such measurements to identify and predict those at greatest risk for an adverse cardiac event. This article represents an attempt to provide an objective review of the literature regarding the potential role electron beam computed tomography (EBCT) has as an accurate and cost effective screening modality for coronary arterial disease, as well as a predictor for coronary heart disease.

Rationale and Objectives. Real-time computed tomography (CT) has the potential to expedite and improve CT-guided needle biopsies by allowing cross-sectional images to be viewed in real time as a needle is advanced toward the target lesion. A major concern about this procedure is the scattered and leaked radiation to which the operator is exposed. This study was undertaken to determine the exposure rates around a CT scanner during CT-guided needle biopsies and to identify the areas of greatest personnel exposure. Materials and Methods. Pig and human cadavers were used to simulate patients undergoing a CT-guided needle biopsy. Various anatomic biopsy sites were used. The radiologist's exposure was assessed by timing the procedure and measuring the exposure rates around the CT scanner with an ionization-chamber survey meter. Ion-chamber measurements multiplied by the time the radiologist spent performing several mock biopsies were compared with film dosimeter results. Doses to the hands, wrists, and whole body were measured with ring, wrist, body, and collar film dosimeters. Results. The average time required to perform a single biopsy was about 1 minute. The dose to the radiologist performing the simulated biopsies was calculated to be 123 mR, 68 mR, 14 mR, and less than 0.5 mR to the fingers, wrist, collar, and body, respectively, as calculated from ionization-chamber and time measurements. These exposure rates correlate well with the film dosimeter readings accumulated during the mock procedures. Conclusion. The dose received by the radiologist performing a CT-guided biopsy was comparable to that of other interventional procedures. In addition, operating from the head of the machine (ie, distal to the bed) appeared to markedly reduce personnel exposure, due to the shielding in the gantry of the CT scanner used in the study.

Rationale and Objectives. The authors sought to determine whether the lateral chest radiograph is helpful in identifying left lower lobe pneumonia among inexperienced readers. Materials and Methods. The authors selected all patients who presented to a family practice training program with radiologic and clinical evidence of left lower lobe pneumonia ( n = 65). They then selected an equal number of patients in whom chest radiographs were taken to “rule out pneumonia” and were found to be normal. Eight 1st-year family practice residents were asked to read the radiographs before and after a didactic session that emphasized lateral chest radiograph interpretation. The radiographs were presented under two viewing conditions: posteroanterior (PA) only versus PA and lateral. Receiver operating characteristic (ROC) curve methods were used to compare the effect of both the didactic session and the viewing condition on diagnostic accuracy. Results. There were no significant differences in performance before and after the didactic session and no differences between the two viewing conditions. After including only abnormal radiographs that demonstrated the “spine sign” (an apparent increased opacification of the lower vertebral bodies on the lateral view), the residents performed better when presented with both PA and lateral radiographs than when presented with the PA radiograph only (area under ROC curve, .8158 vs .7418, respectively; P = .024). Conclusion. In patients with left lower lobe pneumonia whose radiographs demonstrated the spine sign, diagnostic accuracy improved when the lateral chest radiograph was viewed.

Objectives In three experiments, we studied the detection of multiple abnormality types using the satisfaction of search (SOS) paradigm, the provision of a computer-aided detection (CAD) of pulmonary nodules and a focused nodule detection task. Methods 51 chest CT examinations (24 that demonstrated subtle pulmonary nodules and 27 that demonstrated no pulmonary nodules) were read by 15 radiology residents and fellows under two experimental conditions: (1) when there were no other abnormalities present except test abnormalities in the exams (non-SOS condition), and (2) when other abnormalities were present in the exams (SOS condition). Trials from the two conditions were intermixed. Readers were invited to return for two sessions: one in which the SOS condition was repeated with a simulated CAD; another in which only the non-SOS condition was presented. Detection accuracy was measured using receiver operating characteristic (ROC) analysis. Results An SOS effect (reduced detection accuracy for the test nodules in the presence of the diverse added abnormalities) was not found. Average accuracy was much higher when the CAD prompt was provided, without cost in the detection of the added abnormalities. Accuracy for detecting nodules appearing without intermixed SOS trials was also substantially improved. Conclusions CT interpretation was highly task dependent. Nodule detection was poor in the general search task. Therefore, CAD may offer a greater performance improvement than demonstrated in experiments assessing CAD using focused search. The absence of SOS may be due to limited nodule detection even without other abnormalities. Advances in knowledge CAD prompts of nodules increase the detection accuracy of nodules and decrease the time to detection-without impairing the detection accuracy-of non-nodule abnormalities.

The purpose of this study was to develop a valid, reliable and accurate system of measurement of abdominal aortic aneurysms, using volumetric analysis of x-ray computed tomographic data. This study evaluates illustrative cases, and compares measurements of AAA phantoms, using standard 2D versus volumetric methods. To validate the volumetric analysis, four phantom aneurysms were constructed in a range of diameters (4.5 - 7.0 cm) which presents the greatest management challenge to the clinician. These phantoms were imaged using a Toshiba Xpress SX helical CT. Separate scans were obtained at conventional (10 mm X 10 mm) and thin slice (5 mm X 5 mm) collimations. The thin slices were reconstructed at 2 mm intervals. Data from each of the 96 scans were interpreted using a standard 2D approach, then analyzed using task-oriented volumetric software. We evaluate patient assessments, and compare greatest outer diameters of phantoms, by standard versus volumetric methods. Qualitative differences between solutions based on standard versus volumetric analysis of illustrative patient cases are substantial. Expert radiologists' standard measurements of phantom aneurysms are highly reliable (r2 equals 0.901 - 0.958; p < 0.001), but biased toward significant overestimation of aneurysm diameters in the range of clinical interest. For the same phantoms, volumetric analysis was both more reliable (r2 equals 0.986 - 0.996; p < 0.001), and more accurate, with no significant bias in the range of interest. Volumetric analysis promotes selection of more valid management strategies, by providing vital information not otherwise available, and allowing more reliable and accurate assessment of abdominal aortic aneurysms. It is particularly valuable in the presence of aortic tortuosity, vessel eccentricity, and uncertain involvement of critical vessels.© (1996) COPYRIGHT SPIE--The International Society for Optical Engineering. Downloading of the abstract is permitted for personal use only.

Objectives. This study was designed to estimate the prevalence of coronary artery calcification in young adult men and women and to examine the association between the presence of coronary artery calcification and coronary risk factors measured in childhood and young adult life. Background. Electron beam computed tomography is a sensitive, noninvasive method for detecting coronary artery calcification, a marker of the atherosclerotic process. Coronary artery calcification is associated with coronary risk factors in older adults. Methods. Subjects (197 men, 187 women) had coronary risk factors measured in childhood (mean age 15 years) and twice during young adult life (mean ages 27 and 33 years). Each underwent an electron beam computed tomographic study at their second young adult examination. Results. The prevalence of coronary artery calcification was 31% in men and 10% in women. Increased body size, increased blood pressure and decreased high density lipoprotein (HDL) cholesterol levels were the coronary risk factors that showed the strongest association with coronary artery calcification. Significant odds ratios for coronary artery calcification, using standardized risk factor measurements at a mean age of 33 years in men and women, respectively, were 6.4 and 13.6 for the highest decile of body mass index, 6.4 and 6.4 for the highest decile of systolic blood pressure and 4.3 and 4.7 for the lowest decile of HDL cholesterol. Conclusions. Coronary artery calcification is more prevalent in men in this young adult population. Coronary risk factors measured in children and young adults are associated with the early development of coronary artery calcification. Increased body mass index measured during childhood and young adult life and increased blood pressure and decreased HDL cholesterol levels measured during young adult life are associated with the presence of coronary artery calcification in young adults.

We present here our initial findings regarding the utility of functional x-ray CT imaging in determining the presence of pulmonary emboli. Recently, x-ray CT has been reported to be a promising technique in detecting pulmonary emboli through direct visualization of the clot as a filling defect of the reconstructed vascular lumen with CT scanning occurring during i.v. contrast drip. To determine whether functional imaging via the dynamic mode of electron beam CT might add to the sensitivity and specificity of pulmonary emboli diagnosis through the visualization of pulmonary parenchymal blood flow and its associated temporal parameters, we scanned 32 pigs and report here our findings on 17 pigs evaluated to date. Findings to date show that the evaluation of flow deficits detected via electron beam CT with a small 2-3 sec. bolus contrast injection has the potential to provide improvement in embolus detection over visual inspection of this section CT/continuous infusion contrast where the viewer is looking for unenhanced regions in the pulmonary arteries.

Rationale and objectives Ultrafast computed tomography (UFCT) has proven useful, but is of limited practical application in the diagnosis of central pulmonary embolism; however, its ability to detect more peripheral emboli has not been established. In this study, the use of contrast-enhanced UFCT images for the detection of autologous peripheral pulmonary emboli in the pig is evaluated. Methods A single autologous embolus measuring 0.7 x 1.5 cm was introduced into the superior vena cava of eight pigs. Contiguous, 3-mm axial UFCT images from the lung apex to the base were obtained before and after the introduction of the embolus. After scanning, the pigs were killed, and the thorax was removed intact and was frozen in a dry ice-alcohol mixture. Later, the thorax was sliced at 10-mm thicknesses, and the locations of the emboli were determined by a pulmonary pathologist blinded to the imaging results. Concomitantly, the locations of the emboli were determined by consensus of three chest radiologists blinded to the autopsy results. Results In 6 of 8 animals with emboli, the embolus location correlated exactly with the autopsy findings. In one, the embolus was on the same side, but 1.6 cm further distal. In the other, a marking suture was identified, but no clot was identified on the pathologic or UFCT examination. In the eight animals scanned before the introduction of the embolus, no embolus was found. Interobserver agreement was 100%. Conclusions Ultrafast computed tomography has the potential to detect autologous emboli in second- to fourth-division pulmonary vessels. Further studies are needed to determine if in vivo emboli can be similarly visualized.

Pulmonary Embolism After Sequential Use of Recombinant Factor VIIa and Activated Prothrombin Complex Concentrate in a Factor VIII Inhibitor Patient