Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Apr 2014
ReviewRheumatoid arthritis and lung disease: from mechanisms to a practical approach.
Rheumatoid arthritis (RA) is a common chronic systemic autoimmune disease characterized by joint inflammation and, in a proportion of patients, extra-articular manifestations (EAM). Lung disease, either as an EAM of the disease, related to the drug therapy for RA, or related to comorbid conditions, is the second commonest cause of mortality. All areas of the lung including the pleura, airways, parenchyma, and vasculature may be involved, with interstitial and pleural disease and infection being the most common problems. ⋯ Citrullination of proteins in the lung, frequently thought to be incited by smoking, and the subsequent development of ACPA appear to play an important role in the development of lung and possibly joint disease. The biologic and nonbiological disease modifying antirheumatic drugs (DMARDs) have had a substantial impact on morbidity and mortality from RA, and although there multiple reports of drug-related lung toxicity and possible exacerbation of underlying ILD, overall these reactions are rare and should only preclude the use of DMARDs in a minority of patients. Common scenarios facing pulmonologists and rheumatologists are addressed using the current best evidence; these include screening the new patient; monitoring and choosing RA treatment in the presence of subclinical disease; treating deteriorating ILD; and establishing a diagnosis in a patient with an acute respiratory presentation.
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Pulmonary hypertension is defined as a resting mean pulmonary arterial pressure of 25 mm Hg or more determined at right heart catheterization. The challenges for imaging in patients with suspected PH are fivefold: the imaging modality should have a high diagnostic accuracy with regard to the presence of PH; it should be able to characterize the underlying disease, and allow for quantification of its extent by measuring pulmonary hemodynamics. Finally, it should provide prognostic information, and can be used for monitoring of therapy. ⋯ MR imaging is the reference standard for assessment of cardiac structure and function and allows for physiologic assessment of the pulmonary vasculature. New developments show that with MR techniques, an estimation of hemodynamic parameters such as mean pulmonary arterial pressure and pulmonary vascular resistance will be possible. Actually, CT and MR imaging should be considered as complementary investigations providing comprehensive information in patients with pulmonary hypertension.
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Lung cancer is the leading cause of cancer death worldwide and accounts for more deaths than breast, prostate, colon, and pancreatic cancers combined. A distinct minority (15%) of lung cancers are diagnosed at an early stage; 5-year survival (all lung cancers) approximates 15%. Randomized, controlled trials in the 1960s and 1970s found that chest radiographic screening did not confer a survival benefit for high-risk patients. ⋯ Who should be screened and how often? What is the appropriate workup when lesions are noted in asymptomatic individuals? What is the risk of cumulative radiation exposure from repetitive low-dose CT scans? What is the responsibility of health care personnel to evaluate nonpulmonary issues detected by CT (e.g., coronary calcifications). In this review, we address these and other questions that arise. Further, implementation of screening programs may be logistically difficult, require additional personnel and computer software, and will incur significant health care costs.
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Semin Respir Crit Care Med · Feb 2014
ReviewIntegrated cardiothoracic imaging with computed tomography.
The respiratory and the cardiovascular systems are intimately connected. Because of the high degree of morphological and functional interaction, pathophysiological processes in one compartment are likely to induce adaptive changes in the other. ⋯ Up-to-date advanced imaging strategies allow for a combined assessment of the cardiopulmonary unit. Besides improved techniques of electrocardiogram (ECG)-synchronization for obtaining both morphological and functional information, latest advances of dual-source CT (DSCT) have shown great promise for even more comprehensive integrated cardiothoracic imaging.