P Grenier

Abnormalities of the airways and lung parenchyma in asthmatics: CT observations in 50 patients and inter- and intraobserver variability

The purpose of the study was to evaluate the CT abnormalities of airways and lung parenchyma in asthmatic patients and to assess inter- and intraobserver variability for these abnormalities. The CT scans of 50 asthmatic patients and 10 healthy volunteers were assessed independently by four independent chest radiologist who were masked with respect to the clinical information. Bronchiectasis involving mostly subsegmental and distal bronchi was noted in 28.5% of the asthmatic subjects and none of the non-asthmatics. Bronchial wall thickening, small centrilobular opacities and decreased lung attenuation were observed in 82%, 21% and 31% of asthmatic patients respectively, compared with 7%, 5% and 7% of healthy subjects. The intra- and inter-observer agreements for these four CT abnormalities were measured by the kappa statistic and ranged from 0.60 to 0.79 and from 0.40 to 0.60, respectively. It os concluded that asthmatic patients may exhibit bronchial wall thickening, bronchiectasis and morphological abnormalities suggestive of distal airways disease that can be assessed on CT scans with a clinically acceptable observer variability.

Long-term Outcomes of Pandemic 2009 Influenza A(H1N1)-Associated Severe ARDS

BACKGROUND No data on long-term outcomes of survivors of 2009 influenza A(H1N1) (A[H1N1])-associated ARDS are available. The objective of this study was to compare the 1-year outcomes of survivors of A(H1N1)-associated ARDS, according to use or no use of extracorporeal lung assist (ECLA), using its need as an ARDS severity surrogate. METHODS Survivors of ARDS (12 with ECLA use vs 25 without, corresponding to 75% and 54% of the eligible patients for each group, respectively) selected from the Réseau Européen de Ventilation Artificielle (REVA) registry had previously been healthy, with only pregnancy and/or moderate obesity (BMI ≤ 35 kg/m²) as known risk factors for A(H1N1) infection. Lung function and morphology, health-related quality of life (HRQoL), and psychologic impairment were evaluated. RESULTS At 1 year post-ICU discharge for the ECLA and no-ECLA groups, respectively, 50% and 40% reported significant exertion dyspnea, 83% and 64% had returned to work, and 75% and 64% had decreased diffusion capacity across the blood-gas barrier, despite their near-normal and similar lung function test results. For both groups, exercise test results showed diminished but comparable exercise capacities, with similar alveolar-arterial oxygen gradients at peak exercise, and CT scans showed minor abnormal findings. HRQoL assessed by the 36-Item Short-Form Health Survey was poorer for both groups than for a sex- and age-matched general population group, but without between-group differences. ECLA and no-ECLA group patients, respectively, had symptoms of anxiety (50% and 56%) and depression (28% and 28%) and were at risk for posttraumatic stress disorder (41% and 44%). CONCLUSIONS One year post-ICU discharge, a majority of survivors of A(H1N1)-associated ARDS had minor lung disabilities with diminished diffusion capacities across the blood-gas barrier, and most had psychologic impairment and poorer HRQoL than a sex- and age-matched general population group. ECLA and no-ECLA group patients had comparable outcomes. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01271842; URL: www.clinicaltrials.gov

Cost-effectiveness modeling of colorectal cancer: Computed tomography colonography vs colonoscopy or fecal occult blood tests

OBJECTIVES To assess the cost-effectiveness of three colorectal-cancer (CRC) screening strategies in France: fecal-occult-blood tests (FOBT), computed-tomography-colonography (CTC) and optical-colonoscopy (OC). METHODS Ten-year simulation modeling was used to assess a virtual asymptomatic, average-risk population 50-74 years old. Negative OC was repeated 10 years later, and OC positive for advanced or non-advanced adenoma 3 or 5 years later, respectively. FOBT was repeated biennially. Negative CTC was repeated 5 years later. Positive CTC and FOBT led to triennial OC. Total cost and CRC rate after 10 years for each screening strategy and 0-100% adherence rates with 10% increments were computed. Transition probabilities were programmed using distribution ranges to account for uncertainty parameters. Direct medical costs were estimated using the French national health insurance prices. Probabilistic sensitivity analyses used 5000 Monte Carlo simulations generating model outcomes and standard deviations. RESULTS For a given adherence rate, CTC screening was always the most effective but not the most cost-effective. FOBT was the least effective but most cost-effective strategy. OC was of intermediate efficacy and the least cost-effective strategy. Without screening, treatment of 123 CRC per 10,000 individuals would cost €3,444,000. For 60% adherence, the respective costs of preventing and treating, respectively 49 and 74 FOBT-detected, 73 and 50 CTC-detected and 63 and 60 OC-detected CRC would be €2,810,000, €6,450,000 and €9,340,000. CONCLUSION Simulation modeling helped to identify what would be the most effective (CTC) and cost-effective screening (FOBT) strategy in the setting of mass CRC screening in France.

New morphologic approach to the classification of anomalies of the aortic arch

The purpose of this article is to simplify the description of congenital anomalies of the aortic arch by developing a new classification system. Nine selected cases were retrospectively analyzed with the current classification and the new classification. We found that single anomalies of position or caliber were easy to classify. When complex anomalies were present classification was difficult, because only one aspect of the anomaly gives undue emphasis to that feature. We conclude that a system that details each anomaly on the basis of its abnormality of position and caliber, with reference to the normal situation, is an improvement. This new classification includes all of the potential aortic anomalies and facilitates their analysis. It appears to be a logical system that recognizes that congenital aortic malformations are a continuous spectrum from those anomalies purely of position to those purely of caliber.

Diffuse parenchymal lung diseases: 3D automated detection in MDCT

Characterization and quantification of diffuse parenchymal lung disease (DPLD) severity using MDCT, mainly in interstitial lung diseases and emphysema, is an important issue in clinical research for the evaluation of new therapies. This paper develops a 3D automated approach for detection and diagnosis of DPLDs (emphysema, fibrosis, honeycombing, ground glass). The proposed methodology combines multi-resolution image decomposition based on 3D morphological filtering, and graph-based classification for a full characterization of the parenchymal tissue. The very promising results obtained on a small patient database are good premises for a near implementation and validation of the proposed approach in clinical routine.

3D vector flow guided segmentation of airway wall in MSCT

This paper develops a 3D automated approach for airway wall segmentation and quantification inMSCT based on a patient-specific deformable model. The model is explicitly defined as a triangular surface mesh at the level of the airway lumen segmented from the MSCT data. The model evolves according to simplified Lagrangian dynamics, where the deformation force field is defined by a case-specific generalized gradient vector flow. Such force formulation allows locally adaptive time step integration and prevents model self-intersections. The evaluations performed on simulated and clinical MSCT data have shown a good agreement with the radiologist expertise and underlined a higher potential of the proposed 3D approach for the study of airway remodeling versus 2D cross-section techniques.

Volumetric Quantification of Airway Wall in CT via Collision-Free Active Surface Model: Application to Asthma Assessment

Emerging idea in asthma phenotyping, incorporating local morphometric information on the airway wall thickness would be able to better account for the process of airway remodeling as indicator of pathology or therapeutic impact. It is thus important that such information be provided uniformly along the airway tree, not on a sparse (cross-section) sampling basis. The volumetric segmentation of the airway wall from CT data is the issue addressed in this paper by exploiting a patient-specific surface active model. An original aspect taken into account in the proposed deformable model is the management of auto-collisions for this complex morphology. The analysis of several solutions ended up with the design of a motion vector field specific to the patient geometry to guide the deformation. The segmentation result, presented as two embedded inner/outer surfaces of the wall, allows the quantification of the tissue thickness based on a locally-defined measure sensitive to even small surface irregularities. The method is validated with respect to several ground truth simulations of pulmonary CT data with different airway geometries and acquisition protocols showing accuracy within the CT resolution range. Results from an ongoing clinical study on moderate and severe asthma are presented and discussed.

Relationship of spirometric, body plethysmographic, and diffusing capacity parameters to emphysema scores derived from CT scans:

Phenotyping of chronic obstructive pulmonary disease (COPD) with computed tomography (CT) is used to distinguish between emphysema- and airway-dominated type. The phenotype is reflected in correlations with lung function measures. Among these, the relative value of body plethysmography has not been quantified. We addressed this question using CT scans retrospectively collected from clinical routine in a large COPD cohort. Three hundred and thirty five patients with baseline data of the German COPD cohort COPD and Systemic Consequences-Comorbidities Network were included. CT scans were primarily evaluated using a qualitative binary emphysema score. The binary score was positive for emphysema in 52.5% of patients, and there were significant differences between the positive/negative groups regarding forced expiratory volume in 1 second (FEV1), FEV1/forced vital capacity (FVC), intrathoracic gas volume (ITGV), residual volume (RV), specific airway resistance (sRaw), transfer coefficient (KCO), transfer factor for carbon monoxide (TLCO), age, pack-years, and body mass index (BMI). Stepwise discriminant analyses revealed the combination of FEV1/FVC, RV, sRaw, and KCO to be significantly related to the binary emphysema score. The additional positive predictive value of body plethysmography, however, was only slightly higher than that of the conventional combination of spirometry and diffusing capacity, which if taken alone also achieved high predictive values, in contrast to body plethysmography. The additional information on the presence of CT-diagnosed emphysema as conferred by body plethysmography appeared to be minor compared to the well-known combination of spirometry and CO diffusing capacity.