Airspace Consolidation Research Articles

The lung in systemic vasculitis: radiological patterns and differential diagnosis.

The respiratory system may be involved in all systemic vasculitides, although with a variable frequency. The aim of our review is to describe radiographic and high-resolution CT (HRCT) findings of pulmonary vasculitides and to correlate radiological findings with pathological results. Lung disease is a common feature of antineutrophil cytoplasmic autoantibody-associated small-vessel vasculitides, including granulomatosis with polyangiitis (Wegener's), eosinophilic granulomatosis with polyangiitis (Churg-Strauss) and microscopic polyangiitis. Pulmonary involvement is less frequent in immune-complex-mediated small-vessel vasculitides, such as Behçet's disease and Goodpasture's syndrome. Pulmonary involvement associated to large-vessel (gigantocellular arteritis and Takayasu's disease) or medium-vessel (nodose polyarteritis and Kawasaki's disease) vasculitides is extremely rare. The present review describes the main clinical and radiological features of pulmonary vasculitides with major purpose to correlate HRCT findings (solitary or multiple nodules, cavitary lesions, micronodules with centrilobular or peribronchial distribution, airspace consolidations, "crazy paving", tracheobronchial involvement, interstitial disease) with pathological results paying particular attention to the description of acute life-threatening manifestations. A thorough medical history, careful clinical examination and the knowledge of radiological patterns are mandatory for a correct and early diagnosis.

The clinical features of primary or metastatic malignancies presenting with multiple lung cavities

To evaluate the clinical, radiological and pathological features of primary or metastatic malignancies presenting with multiple lung cavities. A total of 38 cases met the inclusion criteria and had adequate imaging data for retrospective review between June 2006 and August 2013. There were 30 cases of primary lung cancer, and 8 cases of pulmonary metastasis including 6 gastrointestinal tract malignancies, 1 vulva malignancy and 1 scalp malignancy. There were 21 females and 17 males, with a median age of 63 years. Cough and expectoration were the most common clinical manifestations of primary lung cancer(22/30). There were 4 main types of lung cavities, including thick-walled cavities(n=12), circular cavities (n=24), thin-walled cavities or cystic cavities (n=11), cavities or multi-cystic changes within airspace consolidation or ground glass opacity(n=11). The cavitary lesions were often accompanied by pulmonary nodules, mass and ground glass opacity(32/38, 84%). The presence of internal soft-tissue septa in the cavity was commonly seen(17/38, 45%). The 4(th) type of cavity and presence of air-fluid levels were only found in lung adenocarcinoma, including 5 cases of mucinous adenocarcinoma. In both primary lung cancers and metastatic tumors, adenocarcinoma was the most common histological type (29/30 and 6/8, respectively). The other histological types included 1 case of lung squamous cell carcinoma, 1 vulva adenosquamous carcinoma and 1 scalp angiosarcoma. The possible mechanisms of cavity formation included necrosis, mucin-secretion air-containing cystic spaces in papillary tumors and the check-valve mechanism. Adenocarcinoma was the most common histological type in multiple cavitary primary lung cancers and metastatic tumors. These cavities showed varied radiological features and were easy to be misdiagnosed as benign cavitary lung diseases.

全身性強皮症による間質性肺炎の治療経過中に発症し肺炎類似の画像所見を呈した肺小細胞癌の1例

全身性強皮症による間質性肺炎の治療経過中に発症し肺炎類似の画像所見を呈した肺小細胞癌の1例

Pulmonary Legionellosis in Oncologic Patients: Findings on Chest CT.

The purpose of this study was to report the computed tomography (CT) findings of non-pneumophila Legionella pneumonia and to compare these CT findings to those caused by Legionella pneumophila in oncologic patients. Chest CT scans of 34 oncologic patients with culture-proven Legionella infection (16 L. pneumophila and 18 non-pneumophila Legionella) were retrospectively reviewed. Radiologic checkpoints included consolidation, ground-glass opacities, cavitation, nodules, tree-in-bud opacities, septal thickening, pleural effusions, and adenopathy, as well as the halo, reversed halo, and bulging fissure signs. The most common imaging feature of Legionella pneumonia was consolidation, seen in 94% of patients. Ground-glass opacities were the next most common abnormality. The halo sign was present in 26% of patients, in both immunocompetent and immunosuppressed hosts. Most features occurred with similar frequency between L. pneumophila and non-pneumophila Legionella. Findings in L. pneumophila pneumonia and non-pneumophila Legionella pneumonia are similar but nonspecific. Airspace consolidation is almost always present; the halo sign is not uncommon.

Computed tomography manifestation of acute exacerbation of chronic obstructive pulmonary disease: A pilot study.

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is an acute event characterized by the worsening of a patient's respiratory symptoms. To the best of our knowledge, few studies have investigated the computed tomography (CT) manifestation of AECOPD. Thus, the aim of the present study was to examine the CT manifestations during AECOPD. In total, 40 patients with AECOPD admitted to the emergency department were enrolled. CT images obtained at the time of exacerbation and at the 3-month follow-up were paired. Clinical characteristics and routine blood test results were also recorded. Airway dimensions and attenuation per patient were quantified from the 3rd to the 6th generation of four bronchi by Airway Inspector Slicer 2.8. The emphysema extent was also quantified and lung infiltration was detected, classified and measured. The CT images showed an increased wall area percentage (WA%) and increased mean and peak wall attenuation during the AECOPD; however, the extent of emphysema did not change significantly. In total, 60% of AECOPD patients presented with lung infiltration, compared with those at the follow-up CT scanning. The presence and extent of segmental distribution consolidation was correlated with the neutrophil percentage (N%), with a statistically significant difference observed. The total volume of lung parenchymal infiltration was correlated with the white blood cell (WBC) count and N%; however, no significant correlations were detected between the presence or extent of acinar shadow, air space consolidation with lobular distribution, ground-glass attenuation with lobular distribution, thickening of the interlobular septa and signs of infection (including the number of main symptoms, body temperature, WBC count and N%). The WA%, mean wall attenuation and peak wall attenuation increased during AECOPD, but the emphysema extent was unchanged. Lung infiltration existed frequently; however, only consolidation with segmental distribution appeared to be associated with bacterial infection.

Kikuchi-Fujimoto disease associated with community acquired pneumonia showing intrathoratic lymphadenopathy without cervical lesions.

IntroductionKikuchi-Fujimoto disease (KFD), or histiocytic necrotizing lymphadenitis, is a rare entity of unknown etiology in young adults that is typically characterized by cervical lymphadenopathy and persistent fever. The pathogenesis of KFD has been suggested to be an abnormal immune response, and infections or autoimmune diseases are considered to be involved in KFD. However, KFD associated with community acquired pneumonia (CAP) has not been reported.Case descriptionA 35-year-old male was admitted due to high fever, diffuse air-space consolidation in the right lung with ipsilateral pleural effusion and massive mediastinal and hilar lymphadenopathy without cervical lesions. On clinical suspicion of malignant lymphoma complicated with pneumonia, we performed a video-assisted thoracoscopic lymph node biopsy, and the diagnosis of KFD was established. Complete cure of the intrathoratic lesions was observed by administration of β-lactam antibiotics alone without steroid therapy.Discussion and evaluationPrevious large case series have identified no pathogenic relationship between KFD and pneumonia. The hilar adenopathy could have caused airway compression leading to pneumonia.ConclusionsKFD should be considered in the differential diagnosis of massive mediastinal and hilar lymphadenopathy, even when there are no superficial lesions. In addition, we need to bear in mind that unexpected disorders occasionally coexist with common diseases.

Migratory eosinophilic alveolitis caused by radiation therapy.

Although radiation pneumonitis is usually confined to irradiated areas, some studies have reported that radiation-induced lymphocytic alveolitis can also spread to the non-irradiated lung. However, there have been few reports of radiation-induced eosinophilic alveolitis. We report the case of a 27-year-old female with radiation pneumonitis, occurring 4 months after radiation therapy for cancer of the left breast. Clinical and radiological relapse followed withdrawal of corticosteroids. Examination of bronchoalveolar lavage (BAL) in patchy airspace consolidations revealed increased eosinophil counts. Finally, clinical and radiological signs resolved rapidly after reintroduction of corticosteroids. Eosinophilic alveolitis may be promoted by radiation therapy. In the present case report, possible mechanisms for radiation-induced eosinophilic alveolitis are also reviewed.

Community-acquired pneumonia: a correlative study between chest radiographic and HRCT findings.

To elucidate what kinds of lesions tend to be overlooked or misinterpreted and why they were overlooked or misinterpreted on chest radiographs in the diagnosis of community-acquired pneumonia (CAP) by comparing radiographic findings with HRCT findings. In 129 patients with CAP (107 bacterial and 22 atypical) and 105 healthy subjects, the chest radiographic findings were correlated with the HRCT findings. The diagnostic accuracy of each chest radiographic finding was evaluated by comparing it with the HRCT finding. The false negative rate of radiographic interpretation tended to be higher for nodules and thickening of the bronchial wall, especially in patients with atypical pneumonia. The most frequent reason for false negative interpretations of nodules and bronchial wall thickening was the overlapping of these findings with airspace consolidation or ground-glass opacity (GGO). Thin lesions were the most frequent reasons for the false negative interpretation of airspace consolidation and GGO. The chest radiographic interpretations of GGO and airspace consolidation were influenced by the thickness of lesions, and those of nodules and thickening of bronchial walls were influenced by coexisting GGO and airspace consolidation and may contribute to a misinterpretation of these lesions and an incorrect diagnosis of CAP.

Acute exacerbation of idiopathic pulmonary fibrosis: a clinical review.

Idiopathic pulmonary fibrosis (IPF) is a chronic and progressive fibrotic disease limited to the lung, with high variability in the course of disease from one patient to another. Patients with IPF may experience acute respiratory deteriorations; many of these acute declines are idiopathic and are termed acute exacerbations (AE) of IPF. In these cases, the exclusion of alternative causes of rapid deterioration, including heart failure, bilateral pneumonia or pulmonary embolism, is a challenging goal. AE may occur at any time during the course of IPF, although they are more common in patients with more progressive disease and gastroesophageal reflux. Surgical lung biopsy or even surgical procedures in organs other than the lungs may also trigger AE, mainly in rapidly progressive or advanced IPF. Current diagnostic criteria include the presence of new-onset ground glass opacities or airspace consolidation superimposed on an underlying usual interstitial pneumonia pattern seen on high-resolution computed tomography. The outcome is poor with a short-term mortality in excess of 50 % despite therapy. Currently, there is no treatment with demonstrated efficacy for AE-IPF: empirical high-dose corticosteroid therapy is generally used, with or without immunosuppressive agents, with limited evidence. On the other hand, there is hope that new treatments to slow down progression of IPF will translate into a reduction of AE-IPF’s occurrence. In conclusion, although significant progress in assessing disease severity in IPF has been made, AEs remain unpredictable and are associated with a high risk of death. Improvements in our understanding of the etiology, risk factors, clinical predictors and epidemiology are needed. It is the goal of clinical researchers in the field to provide respiratory physicians with evidence-based guidance to identify patients who may benefit from therapy for preventing or treating AE-IPF.

Thoracic imaging manifestations of mycobacterium avium-intracellulare complex infection in patients with acquired immunodeficiency syndrome

Objective To study the chest imaging manifestations of mycobacterium avium-intracellulare complex (MAC) infection in patients with acquired immunodeficiency syndrome(AIDS). Methods Thirty-one cases of proven AIDS and MAC infection were included in the study. Imaging findings and clinical data of the patients were retrospectively analyzed. Results All 31 patients underwent chest X-ray and/or chest CT examination, three patients were normal, 28 patients showed findings of lung infection. The chest CT imaging findings of MAC lung infection in AIDS patients were similar with pulmonary TB, including air space consolidation (21 cases) with three cases of large consolidation, bronchiectasis (18 cases), nodules (18 cases), miliary nodules (10 cases), cavities (10 cases), pleural effusion (10 cases), predominantly moderately enlarged mediastinal lymph nodes (15 cases), and enlarged hilus lymph nodes (7 cases). Conclusions The imaging manifestations of MAC infection in AIDS patients were varied and atypical. Air space consolidation,small nodules and bronchiectasis were the main CT manifestations of MAC pulmonary disease. Key words: Acquired immunodefieieney syndrome; Mycobacterium infections; Tomography, X-ray computed

Cavitary Lung Lesion in a Patient with Systemic Lupus Erythematosus: An Unusual Manifestation of Cytomegalovirus Pneumonia

Cytomegalovirus (CMV), a member of the human herpesvirus group, causes severe disease in immunocompromised patients. In particular, CMV pneumonia can be a life-threatening disease to patients taking immunosuppressive drugs. The radiographic manifestations of CMV are variable and may consist of reticular or reticulonodular patterns, ground-glass opacities, air-space consolidations, or mixed patterns. A cavitary lesion in pneumonia associated with CMV infection is extremely rare. Herein we report on a case of CMV pneumonia which presented with a cavitary lesion and was treated successfully in a systemic lupus erythematosus patient who was taking immunosuppressive drugs. (J Rheum Dis 2015;22:387-390)

Pleural fluid characteristics of pleuropulmonary paragonimiasis masquerading as pleural tuberculosis.

Background/AimsPleuropulmonary paragonimiasis produces no specific symptoms or radiologic findings, allowing for the possibility of misdiagnosis. We evaluated the specific clinical and pleural fluid features of pleuropulmonary paragonimiasis masquerading as pleural tuberculosis.MethodsWe retrospectively analyzed the clinical and radiologic characteristics of 20 patients diagnosed with pleuropulmonary paragonimiasis between 2001 and 2011.ResultsIn total, 17 patients presented with respiratory symptoms, including dyspnea (30%), hemoptysis (20%), cough (20%), and pleuritic chest pain (15%). Chest radiographs revealed intrapulmonary parenchymal lesions, including air-space consolidation (30%), nodular opacities (20%), cystic lesions (15%), ground-glass opacities (10%), and pneumothorax (5%). A pleural f luid examination revealed eosinophilia, low glucose levels, and high lactate dehydrogenase (LDH) levels in 87%, 76%, and 88% of the patients, respectively. These traits helped to distinguish pleuropulmonary paragonimiasis from other pleural diseases such as parapneumonic effusion, malignancy, and pleural tuberculosis.ConclusionsPleuropulmonary paragonimiasis is often initially misdiagnosed as other pleural diseases. Therefore, it is important to establish the correct diagnosis. In patients with unexplained pleural effusion living in paragonimiasis-endemic areas, pleural fluid obtained by thoracentesis should be examined to distinguish pleuropulmonary paragonimiasis. When marked eosinophilia, high LDH levels, and low glucose levels are identified in pleural fluid, physicians could consider a diagnosis of pleuropulmonary paragonimiasis.

Computed tomographic features of lymphangioleiomyomatosis: Evaluation in 138 patients

PurposeThe aim was to characterize the computed tomographic (CT) findings from Japanese patients with lymphangioleiomyomatosis (LAM). Materials and methodsCT scans of the chest, abdomen, and pelvis from 124 patients with sporadic LAM (S-LAM, mean age, 37.4 years) and 14 patients with tuberous sclerosis complex (TSC)-LAM (mean age, 35.6 years) were analyzed. ResultsPulmonary nodules (18.8%) and hepatic angiomyolipoma (AML, 24.3%) were more common in our patients than those in previous reports. Compared with TSC-LAM, S-LAM group had a higher frequency of pulmonary nodules (28.6% vs 32.3%, P<0.01) and lower frequencies of air-space consolidation (21.4% vs 2.4%, P<0.01), pneumothorax (28.6% vs 8.1%, P=0.02), pulmonary hilar lymphadenopathy (14.3% vs 0.8%, P<0.01), renal AML (85.7% vs 17.4%, P<0.01), hepatic AML (71.4% vs 17.4%, P<0.01), and retrocrural lymphadenopathy (14.3% vs 1.4%, P=0.04). Axial lymphatic abnormalities (i.e., thoracic duct dilatation, lymphadenopathy, and lymphangioleiomyoma) were most common in the pelvis and tended to decrease in incidence with increased distance from the pelvis. ConclusionThe incidence of some CT findings in Japanese patients differed from those in previous reports. Axial lymphatic abnormalities noted here suggest that the origin of LAM cells may be the pelvis.

Negative Mantoux test in a patient with definite pulmonary and ocular tuberculosis

The case is reported of a patient with pulmonary and ocular tuberculosis presenting with blurred vision in both eyes. A 27-year-old well-nourished male nursing-home resident with a previous history of traumatic intracerebral hemorrhage was brought to the ophthalmological clinic due to progressively blurred vision. His best-corrected visual acuity was 20/400 in the right eye with only light perception in the left eye. Fundus examinations revealed retinal segmental periphlebitis and hemorrhagic retinitis in the right eye and dense vitreous hemorrhage in the left eye. The Mantoux test was negative; however, the results of an interferon gamma release assay were positive. Ocular tuberculosis was suspected. Although he had never had any respiratory symptoms, his chest radiograph and computed tomography scan showed a multiple centrilobular glandular and ground-glass appearance with air-space consolidations and atelectasis in both lower lobes. Pulmonary tuberculosis was confirmed by a positive acid-fast stain of a bronchial alveolar lavage sample. A GEN-PROBE amplified Mycobacterium tuberculosis direct test of the vitreous fluids was also positive. Ocular tuberculosis was confirmed. After treatment for tuberculosis and vitrectomies, his final best-corrected visual acuity improved to 20/30 in the right eye and 20/200 in the left eye. Ocular tuberculosis is rarely reported as the primary presentation of systemic tuberculosis in young patients. A negative Mantoux test may lead to misdiagnosis and delayed treatment. Doctors should become more familiar with the manifestations of systemic tuberculosis and use advanced diagnostic tools in cases of clinical suspicion.

Pulmonary Tuberculosis Confirmed by Percutaneous Transthoracic Needle Biopsy: Analysis of CT Findings and Review of Correlations with Underlying Lung Disease.

Pulmonary tuberculosis (TB) can produce unusual radiographic findings. Further, negative sputum and bronchoscopic results are common. Early diagnosis is equally as significant as treatment in the reduction of morbidity and mortality associated with pulmonary TB. The aim of this study was to assess computed tomography (CT) findings of pulmonary TB, confirmed via percutaneous transthoracic needle biopsy (PTNB), and to correlate these findings with coexisting, underlying, lung diseases if present. Cross sectional study. We selected eighty-four patients who were diagnosed with pulmonary TB by way of PTNB. Initially, acid-fast bacilli smear test results from these patients were negative. CT findings were reviewed to detect the presence of parenchymal abnormalities as follows: nodule(s) (<3 cm in diameter), mass (any masses ≥3 cm), daughter nodules, air-space consolidation, cavitation, calcification, lymphadenopathy, mediastinal lymphadenopathy, and associated lung parenchymal disease. The CT findings of pulmonary TB confirmed by PTNB included nodules in 44 of 84 (52.4%) cases; 15 of these 44 cases (34.1%) had daughter nodules. The second most common finding was masses in 24 cases (28.6%), nine of which also had daughter nodules. 16 cases (19.0%) displayed nonsegmental consolidation. Of these 16 cases, four had coexisting usual interstitial pneumonia; four others had emphysema. Two patients with a mass had underlying pneumoconiosis. Nodules or a mass mimicking lung cancer were the most common findings on CT scans in patients with pulmonary TB, confirmed via PTNB. The second most common finding was airspace consolidation. Therefore, PNTB is useful for the accurate diagnosis of pulmonary TB in the following cases: airspace consolidation or mass associated with underlying usual interstitial pneumonia, emphysema mimicking lung malignancy or cases of bacterial pneumonia.

Primary pulmonary alveolar proteinosis: computed tomography features at diagnosis

Pulmonary alveolar proteinosis (PAP) is characterized by an abnormal accumulation of periodic acid-schiff-positive lipoproteinaceous material in the alveoli. Early diagnosis allows setting up of therapeutic lung lavages, which reduces the need for oxygen supplementation and weight gain. To provide a description of radiological features by CT at the onset of primary PAP in children. The clinical and radiological data of 24 patients, including 16 boys and 8 girls (median age: 12months), diagnosed with a primary form of PAP between April 1992 and May 2012 in a tertiary referral hospital, were retrospectively reviewed. CT images were examined for the presence of alveolar and interstitial elementary lesions. Correlation between clinical and radiological findings was assessed. The types of elementary lesions detected were: ground-glass opacities (n = 24), intralobular lines (n = 24), thickened interlobular septa (n = 22), thickened fissures (n = 21), airspace consolidation (n = 16), hyperinflation (n = 16), cystic lesions (n = 2) and micronodules (n = 1). A crazy-paving pattern was found in 92% of cases. Consolidation and hyperinflation were especially detected in younger children (median age, 8 months, P < 0.01). A density dependent gradient was found. The distribution of the lesions was symmetrical. There was no correlation between radiological and clinical data of severity of the disease. CT findings are suggestive of diagnosis of PAP in immunocompetent children with chronic respiratory failure.

Consolidation with a twisted appearance along the airways: A report of five cases of interstitial pneumonia

High-resolution CT showed areas of airspace consolidation with a twisted appearance of the airways, along with areas of peribronchial ground-glass attenuation and traction bronchiectasis, in five patients with interstitial pneumonia. These areas of airspace consolidation were termed "twisted consolidation" (TwC). The five patients included two patients receiving treatment for rheumatoid arthritis (RA), one patient with newly diagnosed RA, and one patient who subsequently showed RA. Three patients showed improvement after steroid administration. An association of TwC with RA is suspected, but further studies are necessary.

Imaging of Actinomycosis in Various Organs: A Comprehensive Review

Actinomycosis is a chronic suppurative bacterial infection caused by Actinomyces species. Actinomyces israelii is the organism most commonly found in human disease. Actinomycosis usually manifests with abscess formation, dense fibrosis, and draining sinuses. The disease is further characterized by the tendency to extensively spread beyond normal fascial and connective tissue planes. Actinomycosis occurs most commonly in the cervicofacial region (50%-65%), followed by the thoracic (15%-30%) and abdominopelvic (20%) regions, but rarely involves the central nervous system. Most cases of cervicofacial actinomycosis are odontogenic in origin. In the acute form, cervicofacial disease can manifest with soft-tissue swelling, a painful pyogenic abscess, or a mass lesion. In the subacute to chronic form, a painless indurated mass can spread to the skin, leading to draining sinus tracts. Thoracic manifestations include parenchymal, bronchiectatic, and endobronchial actinomycosis. At computed tomography, pulmonary actinomycosis usually appears as chronic segmental airspace consolidation containing necrotic low-attenuation areas with peripheral enhancement. Abdominopelvic actinomycosis preferentially involves the ileocecal region, ovary, and fallopian tube. The imaging findings favoring abdominopelvic actinomycosis include strong enhancement in the solid portion of the mass after contrast material administration, small rim-enhancing abscesses within the mass, and extensive inflammatory extensions. Actinomycosis in the central nervous system may produce brain abscess, meningitis, subdural empyema, actinomycetoma, and spinal and cranial epidural abscess. In general, actinomycosis responds well to antibiotic therapy, but long-term follow-up after treatment is needed because of frequent relapses.

A Patient With Progressive Dyspnea and Multiple Foci of Airspace Consolidation

A man in his mid-40s with known asthma presented to the ED 1 week after being discharged from inpatient care at UMass Memorial Medical Center. Ten days prior, he had presented to the hospital complaining of 3 days of progressive dyspnea; a painful, nonproductive cough; fevers; and headaches.

Clinical Presentation and Laboratory Findings of Mycoplasma pneumoniae Respiratory Infections in Children

Mycoplasma pneumoniae is a common cause of respiratory infections in children and adults, but the most severe presentations tend to be in older children and adolescents. The organism causes up to 30% of primary atypical pneumonia (PAP), but it is now recognized that these severe manifestations of infection represent only a small percentage of respiratory infections due to this species of bacteria. Typical incubation times until the development of symptoms are remarkably slow for a bacterial infection, usually between 2 and 3 weeks. The typical presentation includes flulike symptoms with cough, often with sore throat, headache, malaise, and fever. Symptoms, particularly cough, may be very prolonged despite appropriate antibiotic therapy, sometimes lasting up to 3 months. Cough, initially dry, may become productive of purulent sputum as the illness progresses. Examination of the throat may reveal some erythema but usually no exudates or associated lymphadenopathy. Auscultation of the chest in patients with PAP often demonstrates fine inspiratory rales, particularly at the lung bases, and occasionally expiratory wheezing. Chest films may show streaky unilateral or bibasilar infiltrates, peribronchial thickening, and not infrequently small pleural effusions. Computed tomographs of the chest are very likely to show peribronchial thickening and centrilobular nodules with a tree-in-bud pattern and patchy areas of airspace consolidation. Accurate diagnosis of M. pneumoniae infections is complicated by a current lack of rapid diagnostic techniques with appropriate sensitivity and specificity.