Confident Diagnosis Research Articles

Mature ovarian teratoma in a newborn: A case report

Mature cystic ovarian teratomas, also called dermoid cysts, are one of the most frequent ovarian tumors and are suggested when a fat-containing cystic tumor is identified on imaging. Knowledge of the imaging features of these tumors allows for a confident diagnosis to be made in most cases. Treatment is usually based on surgical resection, which is preferably carried out by laparoscopic way.

Clinical Investigation of a Rapid Non-invasive Multispectral Imaging Device Utilizing an Artificial Intelligence Algorithm for Improved Burn Assessment.

Currently, the incorrect judgment of burn depth remains common even among experienced surgeons. Contributing to this problem are change in burn appearance throughout the first week requiring periodic evaluation until a confident diagnosis can be made. To overcome these issues, we investigated the feasibility of an artificial intelligence algorithm trained with multispectral images of burn injuries to predict burn depth rapidly and accurately, including burns of indeterminate depth. In a feasibility study, 406 multispectral images of burns were collected within 72 hours of injury and then serially for up to 7 days. Simultaneously, the subject's clinician indicated whether the burn was of indeterminate depth. The final depth of burned regions within images were agreed upon by a panel of burn practitioners using biopsies and 21-day healing assessments as reference standards. We compared three convolutional neural network architectures and an ensemble in their capability to automatically highlight areas of nonhealing burn regions within images. The top algorithm was the ensemble with 81% sensitivity, 100% specificity, and 97% positive predictive value (PPV). Its sensitivity and PPV were found to increase in a sigmoid shape during the first week postburn, with the inflection point at day 2.5. Additionally, when burns were labeled as indeterminate, the algorithm's sensitivity, specificity, PPV, and negative predictive value were: 70%, 100%, 97%, and 100%. These results suggest multispectral imaging combined with artificial intelligence is feasible for detecting nonhealing burn tissue and could play an important role in aiding the earlier diagnosis of indeterminate burns.

The role of hair follicle counts and ratios in the histopathological assessment of androgenic alopecia, alopecia areata and telogen effluvium: does counting ‘count’?

The histopathological assessment of scalp biopsies for the diagnosis of alopecia is most commonly undertaken in specialist centers. Occasionally, pathologists encounter such specimens outside a specialist setting or at a low frequency, which makes a confident diagnosis difficult. A methodical approach is essential to identify and interpret the histopathological findings, and one of the diagnostic tools is the use of follicular counts and ratios. This method is particularly emphasized in the context of non-scarring alopecia and, furthermore, for the identification of alopecias with overlapping features. We raised the question as to what is the role of follicular hair counts and ratios in the differential diagnosis of non-scarring alopecia with overlapping features, and sought the answer in our literature review. The English literature on the histopathological assessment of horizontal scalp biopsies taken for the evaluation of non-scarring alopecia, focusing on hair folliclecounting as a diagnostic tool, with particular emphasis on androgenetic alopecia, alopecia areata, and telogen effluvium, was reviewed. Follicular counts and ratios are a helpful diagnostic tool. However, these need to be coupled with the morphological features specific for each alopecia subtype to render a confident diagnosis.

Bacterial Infections Associated with Immunosuppressive Agents Commonly Used in Patients with Interstitial Lung Diseases.

There are about 200 different types of interstitial lung disease (ILD), and a crucial initial step in the assessment of a patient with suspected ILD is achieving an appropriate diagnosis. Some ILDs respond to immunosuppressive agents, while immunosuppression can be detrimental in others, hence treatment is based on the most confident diagnosis with consideration of a patient's risk factors. Immunosuppressive medications have the potential to result in substantial, and perhaps life-threatening, bacterial infections to a patient. However, data on the risk of bacterial infections from immunosuppressive treatment specifically in patients with interstitial lung disease is lacking. We hereby review the immunosuppressive treatments used in ILD patients excluding sarcoidosis, highlight their risk of bacterial infections, and discuss the potential mechanisms that contribute to the increased risk of infections.

Comparative Analysis of Interstitial Lung Diseases on Chest Radiographs and HRCT

Introduction: Interstitial lung diseases are a diverse group of diseases which affect the lung interstium and share similar clinical and radiological manifestations. Although there are several interstitial lung diseases, only a few handful of about 10-12 account for more than 90% of them. Hence, proper knowledge and understanding of these common entities is pertinent in diagnosing them and in including them in the differential diagnosis. Aims and Objectives: The study aims to diagnose study and compare Interstitial Lung Diseases using HRCT and Chest X-Ray by using a prospective and observational study model. Results: HRCT showed statistically significant difference in diagnosis of Interstitial Lung Disease as compared to Chest X-Ray as p value was significant in 4 out of 6 assessed parameters. Hence, CT scan was found essential in evaluation of Interstitial Lung Diseases. Conclusion: High resolution computed tomography (HRCT) chest scans are essential to the diagnostic work-up since each ILD form is characterized by a specific pattern of abnormalities and a confident diagnosis can often be arrived at by HRCT alone or in correlation with the clinical symptoms.

Mass Spectrometry-Based Untargeted Approaches to Reveal Diagnostic Signatures of Male Infertility in Seminal Plasma: A New Laboratory Perspective for the Clinical Management of Infertility?

Male infertility has been recognized as a global health problem. Semen analysis, although considered the golden standard, may not provide a confident male infertility diagnosis alone. Hence, there is the urgent request for an innovative and reliable platform to detect biomarkers of infertility. The rapid expansion of mass spectrometry (MS) technology in the field of the 'omics' disciplines, has incredibly proved the great potential of MS-based diagnostic tests to revolutionize the future of pathology, microbiology and laboratory medicine. Despite the increasing success in the microbiology area, MS-biomarkers of male infertility currently remain a proteomic challenge. In order to address this issue, this review encompasses proteomics investigations by untargeted approaches with a special focus on experimental designs and strategies (bottom-up and top-down) for seminal fluid proteome profiling. The studies reported here witness the efforts of the scientific community to address these investigations aimed at the discovery of MS-biomarkers of male infertility. Proteomics untargeted approaches, depending on the study design, might provide a great plethora of biomarkers not only for a male infertility diagnosis, but also to address a new MS-biomarkers classification of infertility subtypes. From the early detection to the evaluation of infertility grade, new MS-derived biomarkers might also predict long-term outcomes and clinical management of infertility.

Beyond the abdominal and pelvic cavity: abdominal wall and spinal "Aunt Minnies".

Abdominal wall and spinal soft tissue findings are frequently encountered on CT or MR imaging of the abdomen and pelvis. Many of these entities have specific imaging findings, for which a definitive diagnosis can be made without the need for further work up. These abdominal wall and spinal findings may be diagnostically challenging for sub-specialized abdominal radiologists who are unfamiliar with their appearance and appropriate management. This review article describes and illustrates pathognomonic or characteristic abdominal wall and spinal pathologies, which reside outside the abdominopelvic cavity. The cases selected all have findings that allow a confident diagnosis without further imaging or intervention. The cases presented include myonecrosis, intramuscular abscess, myositis, iliopsoas bursitis, Morel-Lavallée lesion, hydrocele of canal of Nuck, Klippel Trenaunay Weber syndrome, neurofibroma with target sign, perineural cysts, filum terminale lipoma, calvarial bone flap, transverse rectus abdominis muscle (TRAM) flap, liposuction, and hidradenitis suppurativa, among others. Although not all-encompassing, this paper will help abdominal radiologists to accurately diagnose a variety of abdominal and pelvic extra-cavitary soft tissue pathologies by identifying key radiologic findings.

The Role of CT Imaging in Characterization of Small Renal Masses.

Small renal masses (SRM) are increasingly detected incidentally during imaging. They vary widely in histology and aggressiveness, and include benign renal tumors and renal cell carcinomas that can be either indolent or aggressive. Imaging plays a key role in the characterization of these small renal masses. While a confident diagnosis can be made in many cases, some renal masses are indeterminate at imaging and can present as diagnostic dilemmas for both the radiologists and the referring clinicians. This review focuses on CT characterization of small renal masses, perhaps helping us understand small renal masses. The following aspects were considered for the review: (a) assessing the presence of fat, (b) assessing the enhancement, (c) differentiating renal tumor subtype, and (d) identifying valuable CT signs.

Detection of anomalous aortic origin of a coronary artery (AAOCA) by echocardiogram: When does computed tomographic angiography add value?

Background and objectiveThere is limited literature comparing TTE and CCTA in children with suspected AAOCA. To determine the distribution of various coronary anomalies comparing TTE and CCTA data, and define the added value advanced imaging brings in clinical decision-making. Materials and methodsRetrospective review of data was obtained in patients aged 0–18 years who underwent TTE and CCTA for suspected AAOCA. Patient demographics, CCTA and TTE findings, and interventions performed were recorded. Results100 consecutive patients were included (60% male), mean age 11 years (7 days-18 years old). In 93 patients, CCTA detected 94 anomalous coronaries. Definitive coronary abnormality was reported on TTE in 77 patients; 76 of which were confirmed by CCTA, 1 patient was found to have a normal variant. Suspected anomalous origin was reported in 16 patients on TTE, 13 of which were abnormal on CCTA. The coronary origin was not seen on TTE in 6 patients; of these, 3 had AAOCA on CCTA and 3 had hypoplastic RCA with left dominant system. Only 1 patient who had a normal TTE was found to have AAOCA on CCTA.CCTA was better than TTE in defining ostial characteristics and the course of the anomalous coronary artery, and detecting myocardial bridge. ConclusionsCCTA adds value in diagnosing AAOCA when the coronary origins are not well assessed or suspected anomalous origin is suggested on TTE. In addition, when a confident definitive diagnosis of AAOCA is reported on TTE, CCTA demonstrates better performance in determining additional features of AAOCA.

Classification regularized dimensionality reduction improves ultrasound thyroid nodule diagnostic accuracy and inter-observer consistency

ProblemConvolutional Neural Networks (CNNs) for medical image analysis usually only output a probability value, providing no further information about the original image or inter-relationships between different images. Dimensionality Reduction Techniques (DRTs) are used for visualization of high dimensional medical image data, but they are not intended for discriminative classification analysis. AimWe develop an interactive phenotype distribution field visualization system for medical images to accurately reflect the pathological characteristics of lesions and their similarity to assist radiologists in diagnosis and medical research. MethodsWe propose a novel method, Classification Regularized Uniform Manifold Approximation and Projection (UMAP) referred as CReUMAP, combining the advantages of CNN and DRT, to project the extracted feature vector fused with the malignant probability predicted by a CNN to a two-dimensional space, and then apply a spatial segmentation classifier trained on 2614 ultrasound images for prediction of thyroid nodule malignancy and guidance to radiologists. ResultsThe CReUMAP embedding correlates well with the TI-RADS categories of thyroid nodules. The parametric version that embeds external test dataset of 303 images in presence of the training data with known pathological diagnosis improves the benign and malignant nodule diagnostic accuracy (p-value = 0.016) and confidence (p-value = 1.902 × 10−6) of eight radiologists of different experience levels significantly as well as their inter-observer agreements (kappa≥0.75). CReUMAP achieve 90.8% accuracy, 92.1% sensitivity and 88.6% specificity in test set. ConclusionCReUMAP embedding is well correlated with the pathological diagnosis of thyroid nodules, and helps radiologists achieve more accurate, confident and consistent diagnosis. It allows a medical center to generate its locally adapted embedding using an already-trained classification model in an updateable manner on an ever-growing local database as long as the extracted feature vectors and predicted diagnostic probabilities of the correspondent classification model can be outputted.

Ultrasound compression elastography: possibilities for early diagnosing in case of dystrophic lesions of the long dorsal sacroiliac ligament with low back pain

Objective. Evaluate the possibility of using ultrasound compression elastography for detecting early dystrophic changes in the long dorsal sacroiliac ligaments in case of pain in the lower backMaterials. To achieve this goal, we compared the data of compression elastography of the long dorsal sacroiliac ligament in 36 patients aged 46.0 years [23; 54] with lower back pain (experimental group) and 30 patients aged 36.5 years [29; 48] without lower back pain (control group).Results. The results of the evaluation of diagnostic significance of ultrasound compression elastography were as follows: AUC ‒ 0.81 (95% CI (0.63; 0.93)), p=0.0001; Juden index ‒ 0.64, sensitivity ‒ 90% (95% CI (0.69; 0.99)), p=0.0001; specificity ‒ 74% (95% CI (0.56; 0.99)), p=0.0001.Conclusion. Compression elastography enables to detect areas of long dorsal sacroiliac ligament structure disorganization in cases where standard B-mode can’t reveal changes in the structure of this ligament. For the long dorsal sacroiliac ligament, ultrasound compression elastography has comparable sensitivity (90%) to shear wave elastography, but lower specificity (74%) and prognostic value (81%), allowing a fairly confident diagnosis of early degenerative changes in the long dorsal sacroiliac ligament.

Luminal and Extraluminal Factors in Normal and Pathological Appendix- A Cadaveric Study from Central Kerala, India

Introduction: Appendicitis is the most common clinical entity among the acute abdominal emergencies. Variations in the position of appendix along with degree of inflammation makes the clinical presentation of the condition notoriously inconsistent. Anatomical knowledge about the organ is thereby mandatory for the clinical assessment and to make a confident diagnosis. Obstructive causes have been found to be responsible in 50-80% cases of acute appendicitis. The way in which the inflammatory process proceeds, still remains a topic of debate. Aim: To study the luminal and extraluminal factors in both normal and pathological appendices. Materials and Methods: This was a cross-sectional descriptive study on gross morphological parameters like frequency of various positions, blood supply of appendix, length of appendix and mesoappendix, gross luminal content conducted on 50 normal and 53 pathological appendices collected from the Departments of Forensic Medicine, Anatomy and Pathology in the Government Medical College, Kottayam, Kerala, India, for a period of one year from April 2013-March 2014. Data entered in the excel sheet was further analysed using Statistical Package for Social Sciences (SPSS) software. Continuous variables were summarised as mean and Standard Deviation (SD) and the significance between their mean variables were analysed using t-test. Results: The most common age group presenting with appendicitis was 15-30 years with male incidence more than female. Appendices were supplied by single artery in 64% and by dual arteries in 36% samples. The average length of normal appendix was 7.8±2.33 cm and pathological appendix was 6.05±1.83 cm. Total 34 (77%) of normal appendices and 9 (81.81%) of pathological appendices showed shortening in length of mesoappendix from the tip of appendix. Common positions in normal and pathological appendices were retrocaecal and pelvic respectively. The most common complication presented in this study was perforation (n=7). Appendices were fixed in 16 (32%) of normal and 12 (22.6%) of pathological appendices. Fixity and complication were commonly associated with retrocaecal position. Conclusion: Appendicitis was more common among the younger age groups. The positions of appendix had no role in initiating the appendicitis. But fixity in particular position played an important role in late presentation thereby favouring complications.

Histological evaluation of PAXgene tissue fixation in Barrett’s esophagus and esophageal adenocarcinoma diagnostics

The dysplasia grading of Barrett’s esophagus (BE), based on the histomorphological assessment of formalin-fixed, paraffin-embedded (FFPE) tissue, suffers from high interobserver variability leading to an unsatisfactory prediction of cancer risk. Thus, pre-analytic preservation of biological molecules, which could improve risk prediction in BE enabling molecular and genetic analysis, is needed. We aimed to evaluate such a molecular pre-analytic fixation tool, PAXgene-fixed paraffin-embedded (PFPE) biopsies, and their suitability for histomorphological BE diagnostics in comparison to FFPE. In a ring trial, 9 GI pathologists evaluated 116 digital BE slides of non-dysplastic BE (NDBE), low-grade dysplasia (LGD), high-grade dysplasia (HGD), and esophageal adenocarcinomas (EAC) using virtual microscopy. Overall quality, cytological and histomorphological parameters, dysplasia criteria, and diagnosis were analyzed. PFPE showed better preservation of nuclear details as chromatin and nucleoli, whereas overall quality and histomorphologic parameters as visibility of basal lamina, goblet cells, and presence of artifacts were scored as equal to FFPE. The interobserver reproducibility with regard to the diagnosis was best for NDBE and EAC (κF = 0.72–0.75) and poor for LGD and HGD (κF = 0.13–0.3) in both. In conclusion, our data suggest that PFPE allows equally confident histomorphological diagnosis of BE and EAC, introducing a novel tool for molecular analysis and parallel histomorphological evaluation.

Pathology of neoadjuvant therapy and immunotherapy testing for breast cancer.

Neoadjuvant chemotherapy (NACT) has become the standard of care for high-risk breast cancer, including triple-negative (TNBC) and HER2-positive disease. As a result, handling and reporting of breast specimens post-NACT is part of routine practice, and it is important for pathologists to recognise the changes in tumour cells, tumour-associated stroma and background breast tissue induced by NACT. Familiarity with characteristic stromal features enables identification of the pre-treatment tumour site and allows confident diagnosis of pathological complete response (pCR) which is important for decisions concerning adjuvant therapy. Neoadjuvant endocrine therapy (NAET) is used less frequently than NACT; however, the SARS-COVID-19 pandemic has changed practice, with increased use as bridging therapy if surgery is delayed. NAET also induces characteristic changes in the tumour and stroma. Changes in the tumour microenvironment following NACT and NAET are also described. Immunotherapy is approved for use in advanced TNBC, and there are several trials exploring its role in early TNBC in the neoadjuvant setting. The current biomarker to determine eligibility for treatment with immune checkpoint inhibitors is programmed death ligand-1 (PD-L1) immunohistochemistry; however, this is complicated by lack of standardisation with different drugs linked to tests using different antibodies with different scoring systems. The situation in the neoadjuvant setting is further complicated by improved pCR rates for PD-L1-positive tumours in both immune therapy and placebo arms. Alternative biomarkers are urgently needed to identify which patients will derive benefit from immunotherapy and key candidates are discussed.

High-Resolution Computed Tomography of Nonfibrotic Interstitial Lung Disease.

Nonfibrotic interstitial lung diseases include a heterogeneous group of conditions that can result in various patterns of lung involvement. When approaching the computed tomographic (CT) scan of a patient with a suspected or known interstitial lung disease, the use of the appropriate radiological terms and a systematic, structured approach to the interpretation of the imaging findings are essential to reach a confident diagnosis or to limit the list of differentials to few possibilities. The large number of conditions that cause nonfibrotic interstitial lung diseases prevents a thorough discussion of all these entities. Therefore, this article will focus on the most common chronic lung diseases that can cause these CT findings. A pattern-based approach is used, with a discussion of nodular pattern, consolidation, crazy paving, ground-glass opacities, septal thickening, and calcifications. The different clinical conditions will be described based on their predominant pattern, with particular attention to findings that can help in the differential diagnosis.

INNV-23. MANAGING CENTRAL NERVOUS SYSTEM MANIFESTATIONS OF CHRONIC GRAFT VERSUS HOST DISEASE FOLLOWING HEMATOPOIETIC STEM CELL TRANSPLANTATION: A CASE REPORT

Abstract Central nervous system (CNS) manifestation of chronic graft versus host disease (cGVHD) is a rare, difficult to diagnose phenomenon that can follow allogeneic hematopoietic stem cell transplantation (HSCT). CNS-cGVHD typically onsets 2-31 months post-transplant, involves diffuse infiltration of inflammatory cells, demyelination, and cerebral vasculitis, and is associated with an extremely poor prognosis. We present a case of a 37-year-old man who developed seizures, myopathy, bilateral upper and lower extremity weakness, confusion, and irritability almost 2 years after HSCT for acute myeloid leukemia (AML). CNS-cGVHD diagnosis was confidently determined via magnetic resonance imaging (MRI) demonstrating enhanced focal white matter lesions, cerebrospinal fluid (CSF) studies demonstrating elevated globulin (12.7 mg/dL; normal range: 0-6 mg/dL) and elevated immunoglobulin G (IgG) synthesis rate (13.9 mg/d; normal range: ≤ 8 mg/d), and a right brain biopsy demonstrating encephalitis, perivascular inflammation, microglial activation, and gliosis with predominately intramural and perivascular CD3+ T-cells, CD4+ and CD8+ cells. Complete resolution of neurological symptoms, including seizures, was achieved with a combination of steroids, ibrutinib, intravenous immunoglobulin (IVIG), and anti-seizure medications. Improvements to CNS-cGVHD was further indicated by normalized MRI studies without abnormal enhancements and improved CSF studies with reduction in globulin levels (11.3 mg/dL) and complete normalization of IgG synthesis rate (≤ 0 mg/d). It is imperative that CNS-cGVHD be considered in patients that present with neurological signs post-transplant. An early, confident diagnosis generates prompt intervention and as demonstrated, can lead to complete resolution of neurological symptoms.

Spectrum of opportunistic fungal lung co-infections in COVID-19: What the radiologist needs to know

Fungal lung co-infections associated with COVID-19 may occur in severely ill patients or those with underlying co-morbidities, and immunosuppression. The most common invasive fungal infections are caused by aspergillosis, mucormycosis, pneumocystis, cryptococcus, and candida. Radiologists integrate the clinical disease features with the CT pattern-based approach and play a crucial role in identifying these co-infections in COVID-19 to assist clinicians to make a confident diagnosis, initiate treatment and prevent complications.

Impact of cardiac resynchronisation therapy in patients with cardiac sarcoidosis

Abstract Background Implantation of a device is usually required in cardiac sarcoidosis (CS) patients presenting with advanced conduction abnormalities or ventricular arrhythmias. A cardiac resynchronisation therapy (CRT) device is often chosen in patients with concomitant left ventricular systolic impairment. The role of CRT in CS is not well established. Purpose To describe the cohort of CS patients with CRT device in situ in our hospital focusing on the short-term effect in serial echocardiography and long-term outcomes on morbidity and mortality. Methods All consecutive CS patients with a CRT device in situ were identified in our CS database (2005–2022). A confident CS diagnosis was provided after review of all relevant clinical and imaging baseline data in our CS multi-disciplinary meeting and a consensus decision for CRT-D implantation was made based on international guidelines. All patients were followed up for at least 6 months with serial echocardiography. Serial data regarding symptoms, rhythm disturbance and echocardiographic parameters were obtained and comparisons were performed using Wilcoxon signed rank test. Results A total of 51 CS patients with CRT-D were identified (mean age: 57±10 years old). Patients were male predominant (64.7%) and Caucasian in origin (86.2%). Extra-cardiac sarcoidosis was confirmed histologically in 33 (64.7%) patients. The prevalence of smoking, diabetes, hypertension and ischaemic heart disease was 27.5%, 21.6%, 49.0% and 7.8% respectively. At the time of device implantation or during follow-up, 43 (84.3%) patients were found to have active cardiac sarcoidosis on cardiac PET. Post CRT implantation there was a significant difference in LV ejection fraction (35.9±15.0% vs 42.2±14.1%, p<0.001), LV end-systolic diameter (4.90±1.46 cm vs 4.62±1.32 cm, p=0.012) and LV end-diastolic diameter (5.99±1.18 cm vs 5.66±1.06 cm, p<0.001). No significant changes were observed in the right ventricular function (p=0.09) and severity of mitral regurgitation (p=0.40). There was one patient who experienced acute heart failure decompensation admission within six months of CRT-D implantation. The New York Heart Association (NYHA) class improved in 26 patients (51.0%), worsened in 4 (7.8%) patients and remained the same in 21 (41.2%) patients at 6 months post CRT-implantation. During the mean follow up of 47.6 months, the composite end-point of death and cardiac transplantation was reached in 9 (17.6%) patients (8 deaths and 1 cardiac transplantation). 5 patients had major complications including a large haematoma, a small atrio-septal defect, haemothorax, device associated endocarditis and lead fracture. Minor wound infections were seen in 3 patients and 4 patients received inappropriate shock or anti-tachycardia pacing. Conclusions CRT in cardiac sarcoidosis patients is associated with short-term improvement in LV remodelling and functional status but over a four year follow up, morbidity and mortality are common. Funding Acknowledgement Type of funding sources: None.

Spectrum of imaging findings in hyperplastic cholecystosis and potential mimics.

Adenomyomatosis and cholesterolosis of the gallbladder, collectively termed hyperplastic cholecystosis, are commonly encountered incidental findings on imaging studies performed for a variety of indications including biliary colic or nonspecific abdominal pain. These pathologies are rarely the source of symptoms, generally considered benign and do not require further work-up. However, their imaging characteristics can overlap with more sinister conditions that should not be missed. In this review, the imaging findings of adenomyomatosis and cholesterolosis will be reviewed followed by other gallbladder pathologies that might mimic these conditions radiologically. Important differentiating factors will be discussed that can aid the radiologist in making a more confident imaging diagnosis.

POSITIVE ENVISIA GENOMIC CLASSIFIER RESULT PREDICTS CLINICAL PROGRESSION IN FIBROTIC INTERSTITIAL LUNG DISEASE

POSITIVE ENVISIA GENOMIC CLASSIFIER RESULT PREDICTS CLINICAL PROGRESSION IN FIBROTIC INTERSTITIAL LUNG DISEASE