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1 OCCUPATIONAL SAFETY AND HEALTH SERIES No. 22 (Rev. 2000) GUIDELINES FOR THE USE OF THE ILO INTERNATIONAL CLASSIFICATION OF RADIOGRAPHS OF PNEUMOCONIOSES Revised edition 2000 INTERNATIONAL LABOUR OFFICE GENEVA
2 Copyright International Labour Organization 2002 First published 2002 Publications of the International Labour Office enjoy copyright under Protocol 2 of the Universal Copy r i g h t Convention. Nevertheless, short excerpts from them may be reproduced without authorization, on condition that the source is indicated. For rights of reproduction or translation, application should be made to the Publications Bureau (Rights and Permissions), International Labour Office, CH-1211 Geneva 22, Switzerland. The International Labour Office welcomes such applications. Libraries, institutions and other users registered in the United Kingdom with the Copyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP [Fax (+44) (0) ; in the United States with the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA [Fax (+1) (978) ; or in other countries with associated Reproduction Rights Orga n i z a t i o n s, may make photocopies in accordance with the licences issued to them for this purpose. ILO Guidelines for the use of the ILO International Classification of Radiographs of Pneumoconioses 2000 edition Geneva, International Labour Office, 2002 (Occupational Safety and Health Series, No. 22 (rev. 2000)) Pneumoconiosis, medical examination, standardization ISBN ISSN ILO Cataloguing in Publication Data The designations employed in ILO publications, which are in conformity with United Nations practice, and the presentation of material therein do not imply the expression of any opinion whatsoever on the part of the International Labour Office concerning the legal status of any country, area or territory or of its authorities, or concerning the delimitation of its frontiers. The responsibility for opinions expressed in signed articles, studies and other contributions rests solely with their authors, and publication does not constitute an endorsement by the International Labour Office of the opinions expressed in them. Reference to names of firms and commercial products and processes does not imply their endorsement by the International Labour Office, and any failure to mention a particular firm, commercial product or process is not a sign of disapproval. ILO publications can be obtained through major booksellers or ILO local offices in many countries, or direct from ILO Publications, International Labour Office, CH-1211 Geneva 22, Switzerland. Catalogues or lists of new publications are available free of charge from the above address or by Photocomposed in Switzerland Printed in Switzerland BRI ART
3 Contents Foreword 1. Introduction 1 2. General instructions 2 3. Specific instructions for use of the Complete Classification Technical quality Parenchymal abnormalities Pleural abnormalities Symbols Comments 9 4. Specific instructions for the use of the Abbreviated Classification Using the ILO Classification Appendices 14 A. A note on technical quality for chest radiographs of dust-exposed workers 15 B. Reading sheets 17 C. Description of standard radiographs 23 D. Diagrams 31 E. Summary of details of the ILO (2000) International Classification of Radiographs of Pneumoconioses 35 F. Participants in ILO-convened meetings leading to the revised (2000) edition of the Classification 39 vii v
5 Foreword Over the last seven decades the International Labour Office (ILO) has promoted discussion and published a series of guidelines on how to classify chest radiographs of persons with pneumoconioses. The goals have been to standardize classification methods and facilitate international comparisons of data on pneumoconioses, epidemiological investigations and research reports. This revised edition of the ILO s International Classification of Radiographs of Pneumoconioses is a further effort towards these objective s. Based on the principles that governed the development of earlier editions of the Classification (those of 1950, 1958, 1968, 1971 and 1980), it refers to radiological appearances seen in all types of pneumoconioses. The description of the scheme in this revision of the G u i d e l i n e s is more concise than prev i o u s l y. Some ambiguities in earlier editions have been c l a r i fied further, and the conventions for classifying pleural abnormalities have been r evised. The changes are based on a comprehensive rev i ew of experience in using the preceding (1980) edition of the Classification. The ILO initiated the rev i ew process in November 1989 at a meeting of 11 experts from seven countries. Participants were asked to advise on the kind of changes to the scheme that might be desirable, and to reconsider the suitability of the standard radiographs that accompanied the 1980 edition. Some parts of the Guidelines were identified as requiring revision, but the importance of continuity in the Classification was reemphasized. With this in mind, it was agreed that the set of standard radiographs that were distributed with the 1980 edition should be retained, although it was recognized that the technical quality of many of them was inferior to that available with modern equipment and techniques. Participants in the meeting also suggested that the number of radiographs included in the complete set of standards (22) might be usefully reduced by reproducing critical parts from some of them onto quadrant sections of full-size radiographs. It wa s agreed, how eve r, that it was necessary to verify that such a reform would not, in itself, result in a change in the way that radiographs of persons exposed to dust were classified. A controlled trial was therefore arranged by the ILO and the Division of Respiratory Disease Studies of the United States National Institute for Occupational Safety and Health (NIOSH). This invo l ved 40 physicians, working at specialized clinical and research centres in ten countries (see Appendix F). Results from the trial showed that the proposed modification to the ILO standard radiographs, involving reproduction of sections from 15 of the ILO (1980) standards onto five new q u a d r a n t radiographs, would not increase variability between readers, and might improve the reproducibility of small-opacity profusion classification in some respects, but could also reduce slightly the frequency with which some readers identify large opacities. Use of the standards containing the quadrant radiographs was associated with an increase in the frequency with which some readers described the shapes of the small opacities that they saw as predominantly irreg u l a r, rather than rounded. It wa s vii
6 GUIDELINES FOR THE USE OF RADIOGRAPHS OF PNEUMOCONIOSES concluded, however, that the effects found were unlikely to be distinguishable from interand intra-reader variability in most occupational health survey situations. 1 In October 1997 more than 200 participants in the Ninth International Conference on Occupational Respiratory Diseases in Kyoto, Japan, attended an ILO-convened Working Group on the Classification. That meeting recommended further work on the development of quadrant or sectional composite radiographs and improved techniques for standard radiograph reproduction prior to the introduction of revised standard radiographs. A smaller group of experts attending the same conference then considered in detail a draft revised text of the Guidelines to the Classification. Discussion of this draft continued at a further meeting in March 1998 at the offices of the American College of Radiology (AC R ) in Reston, Virginia, and was concluded on 26 October 2000 at the ILO Branch Office in Washington, DC. Participants in the latter meeting also compared two types of new copies of several sets of ILO (1980) standard radiographs, of sectional quadrant radiographs that had been used in the international trial, and of a newly prepared composite radiograph illustrating pleural abnormalities. The new copies that were under review were produced from earlier copies, both by standard film copying methods and by improved techniques from digitized versions of the earlier copies. The experts preferred the copies made from the digitized versions, and they recommended the use of this technology and the associated reproduction process for producing future copies of ILO standard radiographs. The individuals who attended the various ILO-convened meetings concerned with the revision of the Classification are listed in Appendix F. The ILO (2000) International Classification of Radiographs of Pneumoconioses is accompanied by two sets of standard radiographs, as described in Appendix C. Both sets are available from the ILO. The first ( Complete ) Set consists of 22 radiographs. Twenty of them are new copies from digitized full-size standard radiographs distributed prev i o u s l y with the 1980 edition of the ILO Classification. A further radiograph illustrates u/u-sized i r r egular opacities. Three quadrants of this radiograph reproduce the sections of the composite radiograph that was used in 1980 to depict increasing profusion of u/u-sized i r r egular opacities; the fourth quadrant illustrates subcategory 0/0. A new composite radiograph is provided to illustrate pleural abnormalities. The Q u a d Set consists of 14 radiographs. Nine of them are the most commonly used standards from the Complete Set. The other five reproduce (quadrant) sections of the remaining radiographs in the Complete Set. The development of this revised (2000) edition of the Guidelines for the Use of the ILO International Classification of Radiographs of Pneumoconioses has been made possible by virtue of intensive and sustained activity on the part of many individuals and o rganizations. Some of them are named in Appendix F. Others, too numerous to list, p r ovided valuable comments and suggestions in writing and by contributing to discussions at various scientific meetings, including four ILO international conferences on pneumoconioses and occupational lung diseases (Bochum, Germany, 1983; Pittsburgh, Pennsylvania, 1987; Prague, 1992; and Kyoto, 1997). The ILO wishes to express its sincere thanks to all concerned, and to acknowledge gratefully the active assistance from the Committee on Pneumoconiosis (previously the Task Force on Pneumoconiosis) of the A m e r i c a n College of Radiology (ACR), the United States National Institute for Occupational Safety and Health (NIOSH), the Rosai Hospital for Silicosis in Japan, the WHO Collaborating 1 A trial of additional composite standard radiographs for use with the ILO International Classification of Radiog raphs of Pneumoconioses, NIOSH Report No. HETA , July 1997, available from National Technical Information Service (NTIS), 5825 Port Royal Road, Springfield, Vi rginia 2216, United States. A shorter report has been published: New composite ( Quadrant ) standard films for classifying radiographs of pneumoconioses, in Industrial Health, Vol. 36, No. 4, Oct. 1998, pp viii
7 FOREWORD Centre for Radiological Education in Sweden, the Finnish Institute of Occupational Health, the German Committee for Diagnostic Radiology of Occupational and Environmental Diseases, and the Institute for Occupational and Social Medicine of the University o f Cologne. Continuing use of the ILO International Classification of Radiographs of Pneumoconioses will contribute further to the protection of the health of workers in dusty occupations. ix
9 1 Introduction Scope of the Classification The Classification provides a means for describing and recording systematically the radiographic abnormalities in the chest provoked by the inhalation of dusts. It is used to describe radiographic abnormalities that occur in any type of pneumoconiosis and is designed for classifying only the appearances seen on postero-anterior chest radiographs. Other views and imaging techniques may be required for clinical assessment of individuals, but the ILO International Classification has not been designed to code such findings. Object of the Classification The object of the Classification is to codify the radiographic abnormalities of the pneumoconioses in a simple, reproducible manner. The Classification neither defi n e s pathological entities nor takes into account working capacity. It does not imply legal defi n- itions of pneumoconioses for compensation purposes and does not set or imply a level at which compensation is payable. Uses of the Classification The Classification is used internationally for epidemiological research, for screening and surveillance of those in dusty occupations, and for clinical purposes. Use of the scheme may lead to better international comparability of data concerning the pneumoconioses. Standard radiographs and written definitions The Classification consists of a set of standard radiographs and this text, with the accompanying footnotes. These footnotes are intended to reduce ambiguity and are based on experience with earlier editions of the ILO Classification. In some parts of the scheme, the standard radiographs take precedence over the written definitions. The text makes it clear when this is so. 1
10 2 General instructions No radiographic features are pathognomonic of dust exposure. Some radiographic features that are unrelated to inhaled dust may mimic those caused by dust. Readers may differ about the interpretation of such appearances. In epidemiological studies, therefore, the study protocol will usually require that all appearances described in these Guidelines and seen on the standard radiographs are to be classified. Symbols must always be used and appropriate Comments must be reported. 1 When the Classification is used for some clinical purposes, the protocol may require that medical readers classify only those appearances which the reader believes or suspects to be pneumoconiotic in origin. Symbols must always be used and appropriate Comments must be reported. 1 1 See sections 3.4 and
11 3 Specific instructions for use of the Complete Classification 3.1. Technical quality 2, 3 Four grades of technical quality are used: 1. Good. 2. Acceptable, with no technical defect likely to impair classification of the radiograph for pneumoconiosis. 3. Acceptable, with some technical defect but still adequate for classifi c a t i o n purposes. 4. Unacceptable for classification purposes. defects. If technical quality is not grade 1, a Comment must be made about the technical 3.2. Parenchymal abnormalities Parenchymal abnormalities include both small opacities and large opacities. Small opacities Small opacities are described by p rofusion, affected zones of the lung, shape ( rounded or irreg u l a r ) and s i z e. The order of identifying and recording the presence or absence of these findings while classifying a radiograph is left to the reader s preference. Profusion The profusion of small opacities refers to the concentration of small opacities in a ffected zones of the lung. The category of profusion is based on comparisons with the standard radiographs. For profusion the written descriptions are a guide, but the standard 2 Appendix A emphasizes the importance of good radiographic quality for the interpretation of chest radiographs. It is essential to produce radiographs that show clearly both the parenchyma and the pleural characteristics. For clinical purposes, special views or techniques may also be required. When it is not possible to replace a grade 3 radiograph by a better one, more details about technical defects should be recorded. 3 The standard radiographs are not to be considered in determining technical quality of the subject radiographs. The standard radiographs were chosen to demonstrate the radiographic features of the pneumoconioses, rather than to demonstrate technical quality. 3
12 GUIDELINES FOR THE USE OF RADIOGRAPHS OF PNEUMOCONIOSES radiographs take precedence. Four categories are defined by the standard radiographs. Profusion is classified into one of 12 ordered subcategories, which are represented symbolically as follows. 4 Increasing profusion of small opacities Categories Subcategories 0/ 0/0 0/1 1/0 1/1 1/2 2/1 2/2 2/3 3/2 3/3 3/+ Category 0 refers to the absence of small opacities or the presence of small opacities that are less profuse than category 1. C l a s s i fication of a radiograph using the 12-subcategory scale is performed as follows. The appropriate category is chosen by comparing a subject radiograph with standard radiographs that define the levels of profusion characteristic of the centrally placed s u b c a t egories (0 / 0, 1 / 1, 2 / 2, 3 / 3) within these categories. The category is recorded by writing the corresponding symbol followed by an oblique stroke, i.e. 0/, 1/, 2/, 3/. If no altern a t ive category was seriously considered, the radiograph is classified into the central subcategory, i.e. 0/0, 1/1, 2/2, 3/3. For example, a radiograph that shows profusion which is considered to be similar to that shown on a subcategory 2 / 2 standard radiograph, i.e. neither category 1 nor 3 was seriously considered as an alternative, would be classified as 2 / 2. How eve r, subcategory 2 / 1 refers to a radiograph with profusion of small opacities judged to be similar in appearance to that depicted on a subcategory 2/2 standard radiograph, but category 1 was seriously considered as an alternative before deciding to classify it as category 2. The standard radiographs provide examples of appearances classifiable as subcategory 0/0. Subcategory 0/0 refers to radiographs where there are no small opacities, or if a few are thought to be present, they are not sufficiently definite or numerous for category 1 to have been seriously considered as an alternative. Subcategory 0 / 1 is used for radiographs classified as category 0 after having seriously considered category 1 as an alternative. Subcategory 1/0 is used for radiographs classified as category 1 after having seriously considered category 0 as an alternative. If the absence of small opacities is particularly obvious, then the radiograph is classified as subcategory 0/. A radiograph showing profusion much greater than that depicted on a subcategory 3/3 standard radiograph is classified as subcategory 3/+. 4 The 12 subcategories refer only to the profusion of small opacities. Profusion, including references to subcategories 0/ or 0/0 when appropriate, must always be recorded, irrespective of any other abnormalities that may be present. Conve r s e l y, when other abnormalities are seen, their presence must also be recorded, irrespective of whether any small opacities are present. The subcategories are arbitrary divisions of an underlying continuum of increasing profusion of small opacities. Those divisions are defined by the standard radiographs, together with the instructions for their use. The validity of the classification procedure to represent this continuum has been demonstrated in studies of relationships between results obtained by using the ILO Classification and (a) indices of cumulative exposures to various dusts; (b) the dust content of coalminers lungs post mortem; (c) mortality of asbestos wo r kers and coalminers; and (d) pathological appearances of coalminers lungs post mortem. 4
13 INSTRUCTIONS FOR USE OF THE COMPLETE CLASSIFICATION Affected zones The zones in which the opacities are seen are recorded. Each lung field is div i d e d into three zones (upper, middle, lower) by horizontal lines drawn at approximately onethird and two-thirds of the vertical distance between the lung apices and the domes of the diaphragm. The overall profusion of small opacities is determined by considering the profusion as a whole over affected zones of the lungs. When there is a marked (three subcategories or more) difference in profusion in different zones of the lungs, then the zone or zones showing the marked lesser degree of profusion is/are ignored for the purpose of classifying the overall profusion. 5 Shape and size For shape and size, the written definitions are a guide, and the standard radiographs take precedence. The shape and size of small opacities are recorded. Two kinds of shape are recognized: rounded and irregular. In each case, three sizes are differentiated. For small rounded opacities, the three size ranges are denoted by the letters p, q and r, and are defined by the appearances of the small opacities on the corresponding standard radiographs. These illustrate: p-opacities with diameters up to about 1.5 mm; q-opacities with diameters exceeding about 1.5 mm and up to about 3 mm; r-opacities with diameters exceeding about 3 mm and up to about 10 mm. The three size ranges of small irregular opacities are denoted by the letters s, t and u, and are defined by the appearances of the small opacities on the corresponding standard radiographs. These illustrate: s-opacities with widths up to about 1.5 mm; t-opacities with widths exceeding about 1.5 mm and up to about 3 mm; u-opacities with widths exceeding about 3 mm and up to about 10 mm. 5 A marked (three subcategories or more) difference in profusion in different zones of the lung is present when there are two or more subcategories of profusion between the zone (or zones) of the lowest profusion and the zone (or zones) of the highest profusion. For example, if a subject radiograph displays zones with profusion levels 1 / 1, 1 / 2, 2 / 1 and 2 / 2, the overall profusion is determined by ignoring the zone with profusion leve l 1/1, since two or more subcategories (1/2, 2/1) are between that zone and the zone of the highest profusion (2/2). The overall profusion, therefore, is determined by considering only the affected zones showing profusion levels 1/2, 2/1 and 2/2, since there is only one subcategory of profusion (2/1) between profusion levels 1/2 and 2/2. Example 1 Only one intervening subcategory between the zones of lowest (1/2) and highest (2/2) profusion; use all three to determine overall profusion. 1/1 1/2 2/1 2/2 There are two intervening subcategories between the zones of lowest (1/1) and highest (2/2) profusion; ignore 1/1 to determine overall profusion. Example 2 Only one intervening subcategory between the zones of lowest (2/1) and highest (2/3) profusion; use all three to determine overall profusion. 1/1 1/2 2/1 2/2 2/3 There are three intervening subcategories between the zones of lowest (1/1) and highest (2/3) profusion; ignore 1 / 1 and 1 / 2; use 2 / 1, 2 / 2, 2 / 3 to determine overall profusion since there is only one subcategory between 2 / 1 and 2/3. All zones in which opacities are seen are recorded, irrespective of whether some are later ignored in determining overall profusion. 5
14 GUIDELINES FOR THE USE OF RADIOGRAPHS OF PNEUMOCONIOSES Two letters must be used to record shape and size. Thus, if the reader considers that all, or virtually all, opacities seen are of one shape and size, then this is noted by recording the letter twice, separated by an oblique stroke (for example q/q). If, however, significant numbers of another shape or size are seen, then this is recorded by writing a different letter after the oblique stroke (for example q/t); q/t would mean that the predominant small opacities are rounded and of size q, but that there are significant numbers of small irregular opacities present of size t. In this way, any combination of small opacities may be recorded. 6 When small opacities of different shapes and/or size are seen, the letter for the predominant shape and size (primary) is recorded before the oblique stroke, while the letter for the less frequently occurring shape and size (secondary) is recorded after the oblique stroke. Large opacities A large opacity is defined as an opacity having the longest dimension exceeding 10 mm. Categories of large opacities are defined below. These definitions take precedence over the examples of large opacities illustrated on standard radiographs. Category A One large opacity having the longest dimension up to about 50 mm, or several large opacities with the sum of their longest dimensions not exceeding about 50 mm. Category B One large opacity having the longest dimension exceeding 50 mm but not exceeding the equivalent area of the right upper zone, or several large opacities with the sum of their longest dimensions exceeding 50 mm but not exceeding the equivalent area of the right upper zone. Category C One large opacity which exceeds the equivalent area of the right upper zone, or several large opacities which, when combined, exceed the equivalent area of the right upper zone Pleural abnormalities Pleural abnormalities are divided into pleural plaques (localized pleural thickening), costophrenic angle obliteration and diffuse pleural thickening. Pleural plaques (localized pleural thickening) Pleural plaques represent localized pleural thickening, generally of the parietal pleura. Pleural plaques may be seen on the diaphragm, on the chest wall (in-profile or fa c e - on), and at other sites. At times, they are recognized only by their calcification. Pleural plaques are recorded as absent or present. If present on the chest wall, they are recorded as in-profile or face-on, and separately for the right and left sides. A minimum width of about 3 mm is required for an in-profile plaque to be recorded as present. 7, 8 6 See Appendix E for possible combinations. 7 The measurement of width is made from the innermost margin of the rib to the innermost sharp margin of the plaque at the pleural-parenchymal boundary. 8 If more detailed measurement of width is required for a particular study, three categories may be used: a about 3 mm up to about 5 mm; b about 5 mm up to about 10 mm; c over about 10 mm. 6
15 INSTRUCTIONS FOR USE OF THE COMPLETE CLASSIFICATION Site, calcification and extent of pleural plaques are recorded separately for the right and for the left side of the chest. The written guidelines describing these features take precedence over the examples provided on the standard radiograph. Site The sites (locations) of pleural plaques include chest wall, diaphragm and other sites. Other sites include the mediastinal pleura in the para-spinal or para-cardiac locations. The presence or absence of pleural plaques is recorded for all sites, and separately for the right and for the left sides. Calcification Radiographic images of pleural plaques may include recognizable areas of calcification. The presence or absence of calcification is recorded for all plaques, and separately for the right and for the left sides. When calcification is seen, a plaque is also recorded as present at that site. Extent Extent is not recorded for plaques on the diaphragm or at other sites. It is recorded only for plaques along the chest wall, and is combined for both in-profile and face-on varieties. Extent is defined in terms of the total length of involvement with respect to the projection of the lateral chest wall (from the apex to the costophrenic angle) on the postero anterior chest radiograph: 1 = total length up to one-quarter of the projection of the lateral chest wall; 2 = total length exceeding one-quarter and up to one-half of the projection of the lateral chest wall; 3 = total length exceeding one-half of the projection of the lateral chest wall. Costophrenic angle obliteration Costophrenic angle obliteration is recorded as either present or absent, separately for the right and for the left side. The lower limit for recording costophrenic angle obliteration is defined by the standard radiograph showing profusion subcategory 1/1 t/t. If the pleural thickening extends up the lateral chest wall from the obliterated costophrenic angle, the thickening should be classified as diffuse pleural thickening. Costophrenic angle obliteration may occur without diffuse pleural thickening. Diffuse pleural thickening Diffuse pleural thickening historically has referred to thickening of the visceral pleura. The radiological distinction between parietal and visceral pleural thickening is not always possible on a postero anterior radiograph. For the purpose of the ILO (2000) Classification, diffuse pleural thicke n i n g extending up the lateral chest wall is recorded only in the presence of, and in continuity with, an obliterated costophrenic angle. Diffuse pleural thickening is recorded as absent or present along the chest wall. If present, it is recorded as in-profile or face-on, and separately for the right and the left side. Its extent is recorded in the same manner as for pleural plaques. A minimum width of about 3 mm is required for in-profile diffuse pleural 7
16 GUIDELINES FOR THE USE OF RADIOGRAPHS OF PNEUMOCONIOSES thickening to be recorded as present. If detailed measurement of its width is required for a particular study, see the comment provided in footnote 8. C a l c i fication and extent of diffuse pleural thickening on the chest wall are recorded separately for the right and for the left side (see guidelines for pleural plaques). The pleura may often be seen at the apex of the lung and should not be recorded as part of diffuse pleural thickening of the chest wall Symbols Symbols to record radiographic features of importance are listed below. T h e i r use is relevant because they describe additional features related to dust exposure and other aetiologies. Use of these symbols is obligatory. 9 Some of the symbols imply interpretations, rather than just descriptions, of what is seen on the radiograph. A postero anterior chest radiograph on its own may not be sufficient to justify defi n i t ive interpretation; therefore, each of the following definitions of symbols assumes an introductory qualifying word or phrase such as changes indicative of, or opacities suggestive of, or suspect. The symbols are: aa atherosclerotic aorta at significant apical pleural thickening (see Appendix D) ax coalescence of small opacities 10 bu bulla(e) ca cancer: thoracic malignancies excluding mesothelioma cg calcified non-pneumoconiotic nodules (e.g. granuloma) or nodes cn calcification in small pneumoconiotic opacities co abnormality of cardiac size or shape cp cor pulmonale cv cavity di marked distortion of an intrathoracic structure ef pleural effusion em emphysema es eggshell calcification of hilar or mediastinal lymph nodes fr fractured rib(s) (acute or healed) hi enlargement of non-calcified hilar or mediastinal lymph nodes ho honeycomb lung id ill-defined diaphragm border 11 ih ill-defined heart border 12 kl septal (Kerley) lines me mesothelioma 9 Inclusion of this information in statistical analyses of results may help to explain otherwise inexplicable variation between readers in their classifications of the same radiographs. 1 0 The symbol a x represents coalescence of small opacities with margins of the small opacities remaining visible, whereas a large opacity demonstrates a homogeneous opaque appearance.the symbol a x (coalescence of small opacities) may be recorded either in the presence or in the absence of large opacities. 11 The symbol id (ill-defined diaphragm border) should be recorded only if more than one-third of one hemidiaphragm is affected. 12 The symbol ih (ill-defined heart border) should be recorded only if the length of the heart border affected, whether on the right or on the left side, is more than one-third of the length of the left heart border. 8
17 INSTRUCTIONS FOR USE OF THE COMPLETE CLASSIFICATION pa plate atelectasis pb parenchymal bands 13 pi pleural thickening of an interlobar fissure 14 px pneumothorax ra rounded atelectasis rp rheumatoid pneumoconiosis 15 tb tuberculosis 16 od other disease or significant abnormality Comments If the technical quality of the radiograph is not recorded as 1 (good), then a Comment on why this is so should be made at that time, before proceeding with the classification. Comments are also required if the symbol od (other disease) is recorded, and to identify any part of the reading of a chest radiograph which is believed by a reader to be probably or certainly not dust related. Comments should also be recorded to provide other relevant information. 13 Significant parenchymal fibrotic strands in continuity with the pleura. 14 Illustrated on the 3/3 s/s standard radiograph. 15 Illustrated on the 1/1 p/p standard radiograph. 1 6 The symbol t b should be used for either suspect active or suspect inactive tuberculosis. The symbol tb should not be used for the calcified granuloma of tuberculosis or other granulomatous processes, e.g. histoplasmosis. Such appearances should be recorded as cg. 17 If the symbol od is used, then an explanatory Comment must be made. 9
18 4 Specific instructions for the use of the Abbreviated Classification The A b b r eviated Classification, described below, is a simplified version of the Complete Classification and includes its major components. Technical quality The recording of the technical quality of the radiograph is the same as for the Complete Classification (see section 3.1). Small opacities Profusion is determined by comparison with standard radiographs and recorded as one of the categories: 0, 1, 2 or 3 (see section 3.2). Shape and size are determined by comparison with standard radiographs. T h e predominant shape and size are recorded using only one of the following letters: p, q, r, s, t or u (see section 3.2). Large opacities L a rge opacities are recorded as size A, B or C, in the same way as for the Complete Classification (see section 3.2). Pleural abnormalities All types of pleural thickening are recorded by the letters PT. All types of pleural calcifications are recorded by the letters PC. 10
19 INSTRUCTIONS FOR USE OF THE ABBREVIATED CLASSIFICATION Symbols Symbols are recorded as for the Complete Classification (see section 3.4). Comments Comments are recorded as for the Complete Classification (see section 3.5). 11
20 5 Using the ILO Classification E fficient use of the ILO Classification requires good viewing and recording conditions. The following recommendations are particularly important for epidemiological studies. Viewing The illuminated boxes for viewing the radiographs to be classified and the standard radiographs must be close enough for the observer to see opacities only 1 mm in d i a m e t e r, that is, a distance of about 250 mm. It is also essential to view the entire radiograph. The observer should be seated comfortably. The minimum number of viewing spaces is two, allowing comparisons between the subject radiograph and the standard radiographs. How eve r, it is recommended that three viewing spaces be used, so that the subject radiograph can be placed between the appropriate standard radiographs to assess profusion. It is important to make it easy to select and put up the standard radiographs for comparison, which is mandatory. The viewing surfaces must be clean and the intensity of illumination should be uniform over all surfaces. The general illumination in the room should be low, without direct daylight. The room should be quiet, comfortable and free from distractions. Epidemiological reading protocols When classifying radiographs for epidemiological purposes, it is essential that the reader does not consider any other information about the individuals being studied. Awareness of supplementary details specific to individuals can introduce bias into results. If the epidemiological objective is to make comparisons between two or more groups, then the radiographs from all groups should be mixed and presented to the reader in random order. Failure to observe these principles may invalidate conclusions from the study. Recording Recording of results should be standardized and systematic. It is important to m a ke provision for recording explicitly the presence or absence of all features to be evaluated for a particular study. Clerical help for recording results is valuable when 12
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text:
The most important thing you can do to promote your newborn's good health is free. Breast milk is a powerhouse of nutrition for your new baby and will save you money. No need to buy formula. Another money saver is lower medical bills as most breast fed babies get sick less frequently and less seriously than formula fed infants. Less ear infections and respiratory infections make a happier baby and mother.
Containing all the right vitamins and minerals your infant needs, breast milk is truly a superstar. Scientists keep trying to create the perfect synthetic replica of human breast milk for infants, and keep falling short. There are hundreds of compounds that support brain growth, digestion and the immune system while others fight infections that science simply cannot copy. And in the search for creating these scientific replications scientists are continually learning just how perfect breast milk is for babies.
Some of the long term benefits of breast feeding your baby include a reduced risk of obesity, allergies, asthma and some forms of childhood cancer. Studies are even proving that breast fed babies tend to be smarter than infants fed with formula.
Surprisingly breast feeding is also beneficial for the mother. Breast feeding releases hormones that help the mother's uterus shrink back to normal size while also curbing blood loss after delivery. Another advantage of breast feeding is the burning of calories. Not only are you shedding baby weight faster, but you are creating a very special bond with your child. One of the long term advantages includes a lower risk for premenopausal breast cancer. Benefits begin to show within three to six months of breast feeding and will gradually increase when breast feeding is continued.
With the importance of breast feeding on an infant's life it's surprising that "globally less than 40% of infants under six months of age are exclusively breastfed." (World Health Organization)
About Naturally Earth Friendly
Naturally Earth Friendly was born out of a love for everything healthy and good for our bodies and planet. This includes tips to adjust our everyday lives, environmentally conscious efforts we can make and smarter natural products that help make a difference. It's possible to head towards a more sustainable future and we can do it together.

subset: commoncrawl


text:
Warren S87 motor yacht sold by Denison Yacht Sales
by Malcolm MacLean
David Johnson at Denison Yacht Sales sends news that he's closed on the sale of his central listing, a 2009-build 26.5m Warren S87 motor yacht, representing both buyer and seller.
Says David: 'This four stateroom Warren S87 is as good as new since it has never been sold before to a private party. The MTU 10V2000 M93 engines only have 245 dealer demo hours on them and the manufacturer's warranty was activated upon completion of the sale.'
Warren S87 yacht pictures and specifications
The Warren S87 was asking €2.78 million. For more information contact:
Denison Yacht Sales
David Johnson
E: email@example.com
W: www.denisonyachtsales.com
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text:
— "Buzz is nice," he added at Big Ten Media Days. "… But now we have to go out and actually show it on the floor." Given the early practice schedule and ostensible willingness to recover from last year's season-ending nine-game losing streak, Collins' team looks prepared to face real competition again. Despite his efforts to build the program hype, Collins is an "old-school" coach focused on results.
— Collins has proved expert at pitching his players and their skillsets. Asked about Sanjay Lumpkin, he called the redshirt freshman a potential starter and "glue guy"—outing him as one of NU's best defenders. If Lumpkin can prove that, he'll likely work his way into the starting lineup. They need defensive toughness in Collins' first year.
— Everyone's asking about Alex Olah, the exciting sophomore center who averaged who averaged 6.1 points per game last season, but shot under 42 percent. Collins continues to praise Olah, who owns a signature hook shot and gained critical experience against elite competition. To take the next step, Collins said, Olah will need to be even more physical.
— Collins wants to build a team of slashers—guys who aren't simply content with chucking from the three-point line. He's comfortable shooting threes–given that his team has some perimeter threats–but would hate for that to define his team. He labeled Drew Crawford, Jershon Cobb and others as "hybrid multi-faceted players" who can score from anywhere—even the post.
— "I want my players to always know that I'm in the fight with them," Collins said. Though he's generally "outward" with his emotions, Collins expects to balance his calmness and his fire to keep his team in check. It seems as though he's more excited than anyone for this season to begin; it's his first opportunity in a new and exciting role.
Jordan Bernfield contributed reporting.


text:
A Thin, Dark LineEmma Elliot
When Cormac O'Malley—Dogwood, Ohio's former outcast and a man just released after spending fifteen years in prison—returns and shows up on her doorstep, librarian Eloise Carmichael hires him as a handyman despite her family's warnings and her own misgivings. Inexplicably drawn to Cormac, Eloise begins to form a tentative friendship with the tortured, aloof man and unknowingly becomes ensnared in his quest for vengeance.
When a body is found at the library, suspicions center on Cormac, and Eloise finds herself in the role of his defender, pitted against the most powerful men in town. As the threats against Cormac escalate, Eloise becomes obsessed with the mysteries surrounding a murder that took place fifteen years ago and begins the task of delving into the past in hopes of discovering the source of the present danger.
As the body count rises and family secrets are brought to light, Eloise and Cormac are forced to realize that the only hope for redemption—and love—lies in each other. But when doubt is cast on Cormac's innocence and her very life is threatened, the one man Eloise isn't certain she can trust is the only one who can save her.
Praise for A Thin, Dark Line
The characters felt like people I could know, warm, welcoming, quirky at times and loving...I haven't felt so strongly the need to cheer for a male fictional character in a long time...In this story, there are good guys and bad guys, and guys who should be good but aren't, and some who don't do good things but you understand why....When it was over, I was fully and deeply satisfied, even as I wanted more of it, just a few more pages of time to spend with characters I had come to love.
Sherry Gnomes
This was great writing by Emma Elliot. She meticulously built her characters and plot, taking her time to draw you into their lives. I loved Cormac, and Eloise is a strong character with strong convictions--the only thing she didn't have the strength to fight was her feelings for Cormac.
Cindy McDonald, Amazon
What a nice surprise A Thin, Dark Line turned out to be! I'm always wary of debut novels, but this debut reads like the work of a veteran author. It was an incredible, emotional, riveting romantic suspense novel that I finished in one sitting.
Crista, Goodreads
A Thin, Dark Line is a debut novel, but you won't realize that when reading it. The prose is flowing effortlessly, the characters are well developed, the touches of humour well blended with the more serious and dark parts of the story. Because essentially, A Thin, Dark Line is a dark story: a story about how cruel people can be, taking advantage of others when in need, about how hard life can be to a small boy, about how difficult it can be to fit in when you're not willing to conform with society's rules or blend with the crowd.
Fani "avid reader", Amazon
The author's voice is captivating and I felt transported straight into her world right from the first paragraphs. It's hard to believe that this is a debut novel and I'm looking forward to more books by Emma Elliott.
Becs, Goodreads
A Thin, Dark Line is tightly wound suspense reminiscent of the best of Alfred Hitchcock. A part of the genius of Alfred Hitchcock is that he hinted at things and let the imaginations of his audience do the rest. It's something you don't see these days and I didn't even realize how much I missed it until I read this little gem.
Ian, Goodreads
It's very hard to believe this is a debut novel. Emma Elliot has given us a very well written and believable story with a cast of characters that feel more like old friends instead of people on a page.
KatLynee, Goodreads
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Is Prince Against Artists Covering His Music?
\ Some of us get excited when our favorite artists cover songs from legends. Who could forget Alicia Keys' powerful rendition of Prince's "How Come U Don't Call Me Anymore" or Chaka Khan's hugely popular cover of Prince's "I Feel For You"? Despite numerous artists putting their own spin on Prince's great music, he wants it to come to an end...
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It's a week away from Christmas, and if you're like me, you're scrambling to get last minute gifts shipped to your house. Because nobody wants to go to the maul mall this close to December 25th. You have a party to go to tomorrow, but haven't had time to make a proper hostess gift or to do regular holiday baking. What do you do?
You cheat. That's what you do.
Take something store bought and spruce it up well enough to pass off as homemade. Then sit back and enjoy while everyone raves about how delicious your cookies are.
What if I told you the platter in the picture above only took about 40 minutes to make from start to finish? …and it only took that long because I mixed peanut butter icing by hand.
You can use any For this platter, I used Biscoff cookies, Lorna Doone shortbread and a small pack of pre-made double chocolate cookies. If your local grocery has a good selection of fresh cookies, look for unadorned sugar cookies or macaroons. If I could have found one, I would have used one of the assortment packs of shortbread cookies in order to have more variety in shape and size.
The easiest thing to do is just melt some chocolate chips in the microwave (15 to 30 second intervals, stirring in between to avoid scorching) and then just swipe the chocolate over the top of the cookie with the back of a spoon. Sprinkles are always a welcome addition.
If you want to get fancy, use a fork to drizzle the chocolate on top instead.
I've also been going a little crazy with that basic powdered sugar icing recipe used in the cut-out sugar cookies and lemon clove cookies. I adjusted the ingredients a bit to make a Peanut Butter icing recipe to coat the store-bought double chocolate cookies that was dry enough for stacking.
Peanut Butter Icing
- 1 Cup powdered sugar
- 2 tsp milk
- 1 tsp light corn syrup
- 2 tbsp peanut butter
- Place milk and peanut butter in a bowl. Mix in small amounts of powdered sugar until icing consistency is reached. The mixture should be thick.
- Mix in corn syrup until thoroughly combined.
You can also use a handheld mixer or small food processor to make the process go faster, but I usually just mix everything with a fork or small whisk. Next time, I might just use Biscoff cookie butter instead of peanut butter. Mmmmm…… The possibilities are endless!
What cookie would you use with peanut butter icing?
Would you ever create a cheater's cookie platter?
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