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Background Minimal aortic injury (MAI), a subtype of acute traumatic aortic injury, is being increasingly recognized with better imaging techniques. Given conservative management, the role of follow-up imaging albeit important yet has to be defined. Methods All trauma chest computed tomography angiographies (CTAs) at our center between January 2012 and January 2019 were retrospectively reviewed for presence of MAI. MAIs were generally reimaged at 24 to 72 hours and then at a 7- and 30-day interval. Follow-up CTAs were reviewed for stability, progression, or resolution of MAI, along with assessment of injury severity scores (ISS) and concomitant injuries, respectively. Results A total of 17,569 chest CTAs were performed over this period. Incidence of MAI on the initial chest CTA was 113 (0.65%), with 105 patients receiving follow-up CTAs. The first, second, third, and fourth follow-up CTAs were performed at a median of 2, 10, 28, and 261 days, respectively. Forty five (42.9%), 22 (21%), 5 (4.8%), and 1 (1%) of the MAIs were resolved by first, second, third, and fourth follow-up CTAs. Altogether, 21 patients showed stability (mean ISS of 16.6), and 11 demonstrated improvement (mean ISS 25.8) of MAIs. Eight patients had no follow-up CTA (mean ISS 21). No progression to higher-grade injury was observed. Advancing age decreased the odds of MAI resolution on follow-up. A possible trend (p-value 0.22) between increasing ISS and time to resolution of MAIs was noted. Conclusion In our series of acute traumatic MAIs diagnosed on CTA imaging, there was no progression of injuries with conservative management, questioning the necessity of sequential follow-up imaging.

The US Preventive Services Task Force has recommended lung cancer screening (LCS) with low-dose CT (LDCT) in high-risk individuals since 2013. Because LDCT encompasses the lower neck, chest, and upper abdomen, many incidental findings (IFs) are detected. The authors created a quick reference guide to describe common IFs in LCS to assist LCS program navigators and ordering providers in managing the care continuum in LCS.The ACR IF white papers were reviewed for findings on LDCT that were age appropriate for LCS. A draft guide was created on the basis of recommendations in the IF white papers, the medical literature, and input from subspecialty content experts. The draft was piloted with LCS program navigators recruited through contacts by the ACR LCS Steering Committee. The navigators completed a survey on overall usefulness, clarity, adequacy of content, and user experience with the guide.Seven anatomic regions including 15 discrete organs with 45 management recommendations were identified as relevant to the age of individuals eligible for LCS. The draft was piloted by 49 LCS program navigators from 32 facilities. The guide was rated as useful and clear by 95% of users. No unexpected or adverse experiences were reported in using the guide. On the basis of feedback, relevant sections were reviewed and edited.The ACR Lung Cancer Screening CT Incidental Findings Quick Reference Guide outlines the common IFs in LCS and can serve as an easy-to-use resource for ordering providers and LCS program navigators to help guide management.

Background An ever-increasing number of studies have reported an increased incidence of spontaneous pulmonary barotrauma such as pneumothorax, pneumomediastinum, and subcutaneous emphysema in patients with COVID-19. We conducted this systematic review and meta-analysis to assess the value and significance of the available data. Methods A thorough systematic search was conducted to identify studies of barotrauma in hospitalized patients with COVID-19. Data analysis of case reports was done using a statistical package for the social sciences (SPSS) version 22, and meta-analysis was performed using CMA-3. Results We identified a total of 4488 studies after thorough database searching.118 case reports and series, and 15 observational studies were included in the qualitative analysis. Fifteen studies were included in the quantitative analysis. The observational studies reported barotrauma in 4.2% (2.4–7.3%) among hospitalized patients; 15.6% (11–21.8%) among critically ill patients; and 18.4% (13–25.3%) in patients receiving invasive mechanical ventilation, showing a linear relationship of barotrauma with the severity of the disease. In addition, barotrauma was associated with a longer length of hospital stay, more extended ICU stay, and higher in-hospital mortality. Also, a slightly higher odds of barotrauma was seen in COVID-19 ARDS compared with non-COVID-19 ARDS. Conclusion COVID-19 pneumonia is associated with a higher incidence of barotrauma. It presents unique challenges for invasive and non-invasive ventilation management. Further studies are required to unravel the underlying pathophysiology and develop safer management strategies.

Risk stratification of COVID‐19 patients is essential for pandemic management. Changes in the cell fitness marker, hFwe‐Lose, can precede the host immune response to infection, potentially making such a biomarker an earlier triage tool. Here, we evaluate whether hFwe‐Lose gene expression can outperform conventional methods in predicting outcomes (e.g., death and hospitalization) in COVID‐19 patients. We performed a post‐mortem examination of infected lung tissue in deceased COVID‐19 patients to determine hFwe‐Lose’s biological role in acute lung injury. We then performed an observational study (n = 283) to evaluate whether hFwe‐Lose expression (in nasopharyngeal samples) could accurately predict hospitalization or death in COVID‐19 patients. In COVID‐19 patients with acute lung injury, hFwe‐Lose is highly expressed in the lower respiratory tract and is co‐localized to areas of cell death. In patients presenting in the early phase of COVID‐19 illness, hFwe‐Lose expression accurately predicts subsequent hospitalization or death with positive predictive values of 87.8–100% and a negative predictive value of 64.1–93.2%. hFwe‐Lose outperforms conventional inflammatory biomarkers and patient age and comorbidities, with an area under the receiver operating characteristic curve (AUROC) 0.93–0.97 in predicting hospitalization/death. Specifically, this is significantly higher than the prognostic value of combining biomarkers (serum ferritin, D‐dimer, C‐reactive protein, and neutrophil–lymphocyte ratio), patient age and comorbidities (AUROC of 0.67–0.92). The cell fitness marker, hFwe‐Lose, accurately predicts outcomes in COVID‐19 patients. This finding demonstrates how tissue fitness pathways dictate the response to infection and disease and their utility in managing the current COVID‐19 pandemic., A post‐mortem examination of COVID‐19 infected lung tissues and an observational study were performed in order to evaluate whether expression of cell fitness marker hFwe‐Lose in patient's nasopharyngeal swabs could predict hospitalization or death from COVID‐19.

ACR RADPEER® is the leading method of radiologic peer review in the United States. The program has evolved since its inception in 2002 and was most recently updated in 2016. In 2018, a survey was sent to RADPEER participants to gauge the current state of the program and explore opportunities for continued improvement. A total of 26 questions were included, and more than 300 practices responded. In this report, the ACR RADPEER Committee authors summarize the survey results and discuss opportunities for future iterations of the RADPEER program.

The ACR's RADPEER program is currently the leading method for peer review in the United States. To date, more than 18,000 radiologists and more than 1,100 groups participate in the program. The ABR accepted RADPEER as a practice quality improvement in 2009, which can be applied toward maintenance of certification; there are currently over 2,200 practice quality improvement participants. There have been ongoing deliberations regarding the utility of RADPEER, its goals, and its scoring system since the preceding 2009 white paper. This white paper reviews the history and evolution of RADPEER and eRADPEER, the 2016 ACR Peer Review Committee's discussions, the updated recommended scoring system and lexicon for RADPEER, and updates to eRADPEER including the study type, age, and discrepancy classifications. The central goal of RADPEER to aid in nonpunitive peer learning is discussed.

The purposes of this article are to review the treatment options for late-stage biventricular heart failure, discuss the clinical indications for total artificial heart (TAH) implantation, illustrate the expected imaging findings after uncomplicated TAH implantation, and highlight the radiologic findings of common and uncommon complications associated with TAH implantation through case examples.TAH implantation is an effective therapeutic option for the treatment of patients with end-stage biventricular heart failure. The duration of implantation varies depending on a particular patient's medical condition and the eventual availability of a human heart for orthotopic transplantation. TAH recipients often undergo imaging with conventional radiography, CT, or both for the assessment of device-related issues, many of which are life-threatening and require emergency management. As the clinical use of the TAH increases and becomes more commonplace, it is imperative that radiologists interpreting imaging studies recognize both the expected and the unexpected imaging findings that affect patient care.

Aim To determine the absorbed radiation dose to the female breast during chest computed tomography (CT), and whether a custom-designed breast shield can reduce that dose. Materials and methods Bilateral breast phantoms were combined with an anthropomorphic torso phantom. Each breast phantom contained 20 thermoluminescent dosimeter (TLD) cavities. Eight cavities were used per phantom. Absorbed radiation was measured using TLD 100s. Three-stacked TLDs comprised a set. Three sets of three TLDs were positioned at eight designated locations and three depths (surface; 1 cm; 4 cm). One set of three TLDs was positioned at eight additional designations, 1 cm deep. Each breast was divided anatomically into quadrants. In total, 32 TLD sets/96 TLDs were deployed. The breast–torso phantom was consecutively imaged using a 16-detector array CT machine. Subsequently, 32 new TLD sets were similarly placed, the phantom re-imaged in a likewise manner, but with the application of a tungsten–antimony composite breast shield. TLD readings were averaged and calculated. Results Average absorbed radiation doses for unshielded right and left breast phantoms ranged from 13.83–19.36 mGy, and 14–20.47 mGy, respectively. The absorbed dose in the shielded right and left breast was reduced to 6.64–8.12 mGy, and 6.7–8.03 mGy, respectively. Average absorbed radiation doses based on the depth for the unshielded breasts ranged from 15.4–18.3 mGy. Shielding reduced this dose to 7–7.9 mGy. Unshielded absorbed radiation doses based on anatomic quadrants ranged from 17.5–18.9 mGy. Shielding reduced this dose to 7–7.5 mGy. Conclusions The average absorbed radiation dose to the unshielded female breast phantom is approximately 14–20 mGy. An externally applied shield can reduce this absorbed dose by 56–61%.

Lung cancer is the leading cause of cancer death in the United States and worldwide. However, among the top 4 deadliest cancers, lung cancer is the only one not subject to routine screening. Optimism for an effective lung cancer-screening examination soared after the release of the National Lung Screening Trial results in November 2011. Since then, nearly 40 major medical societies and organizations have endorsed low-dose computed tomography (LDCT) screening. In December 2013, the United States Preventive Services Task Force also endorsed LDCT. However, the momentum for LDCT screening slowed in April 2014 when the Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) panel concluded that there was not enough evidence to justify the annual use of LDCT scans for the detection of early lung cancer. This article briefly reviews the epidemiology of lung cancer, the National Lung Screening Trial study results, and the growing national endorsement of LDCT from a variety of key stakeholder organizations. We subsequently analyze and offer our evidence-based counterpoints to the major assumptions underlying the MEDCAC decision.

The purpose of this study was to show that helical CT could be used at our center in lieu of routine aortography to examine patients who have had serious blunt chest trauma. We also wanted to assess the potential savings of using CT to avoid unnecessary aortography.The institutional review board approved the parallel imaging-CT immediately followed by aortography-of patients presenting with blunt chest trauma between August 1997 and August 1998. To screen patients for potential aortic injuries, we performed parallel imaging on 142 patients, and these patients comprised our patient population. CT examinations of the patients were reviewed for signs of injury by radiologists who were unaware of each other's interpretations and the aortographic results. Findings of CT examinations were classified as negative, positive, or inconclusive for injury. Aortography was performed immediately after CT. The technical and professional fees for both transcatheter aortography and helical CT were also compared.Our combined kappa value for all CT interpretations was 0.714. The aortographic sensitivity and negative predictive value were both 100%. Likewise, the sensitivity and negative predictive value of CT were 100%. The total costs of performing aortography were estimated at approximately $402,900, whereas those for performing helical CT were estimated at $202,800.Helical CT has a sensitivity and negative predictive value equivalent to that of aortography. Using CT to eliminate the possibility of mediastinal hematoma and to evaluate the cause of an abnormal aortic contour in a trauma patient allows us to use aortography more selectively. Avoiding the performance of unnecessary aortography will expedite patient care and reduce costs. We report the results of our experience with CT and how our center successfully made this transition in the initial examination of patients with serious thoracic trauma.

Most centers continue to use conventional chest radiography as the principal screening modality for the detection of mediastinal hemorrhage and potential injury to the aorta or great vessels after blunt decelerating trauma. Of the many radiographic signs proposed to suggest potential injury, the mos

The first case of postpneumonectomy cardiac herniation was described in 1948. Despite advances in surgical technique and patient care, this very rare, potential surgical catastrophe may still be seen today. We present a similar case to that of the original description, but furthermore accentuated by an additional unsuspected surgical complication. This case involves a 59-year-old African-American man initially treated with radical pneumonectomy to resect an invasive T3 squamous cell lung cancer. After surgical resection, the patient developed both clinical and radiographic manifestations of cardiac herniation. Primary suture repair of the pericardial sac led to subsequent cardiac tamponade necessitating correction with Prolene mesh.

Objective Case reviews and retrospective analyses have raised the possibility of an increased frequency of primary lung carcinoma in HIV- and AIDS-infected patients. Conclusions have often been controversial and conflicting. We conducted a population-based epidemiologic study to assess the incidence of lung neoplasms in an HIV/AIDS cohort. Materials and methods The Texas Department of Health generated descriptive data on lung neoplasms in HIV-AIDS patients whose conditions were diagnosed between 1990 and 1995. The cancer registry matched against all patients whose conditions were diagnosed during the same time interval. Relative risk was measured through standardized incidence ratios of lung neoplasms in the HIV-AIDS population as compared with that of the US population. Results The HIV-AIDS data file included 26,181 cases. A total of 76 lung cancer cases were identified, of which 36 (47.4%) were primary lung cancers. All major histologies were represented. The observed (36)/expected (5.6) ratio (standard incidence ratio) for primary lung cancer compared to the US population was 6.5 (4.5 to 8.9, 95% confidence interval). Conclusions Our data indicate a 6.5-fold increased incidence of primary lung cancer in HIV- and AIDS-infected patients. We present the results of our study, a review of the work of other investigators, and address a potentially even greater public health problem in the HIV/AIDS population than previously realized.

A 44-year-old African-American male presented to the emergency department with progressive left-sided anterior chest pain of 1-month duration, which was rated six out of 10 in intensity. Associated symptoms included nocturnal dry cough and tenderness to touch. The patient's symptoms were relieved with ibuprofen.

The purpose of this study was to quantify the absorbed radiation dose received by the adult female breast during coronary CT angiography (CTA) and to evaluate the effectiveness of various dose reduction strategies.An adult female thoracic anthropomorphic phantom was scanned using eight different clinical coronary CTA protocols that varied in detector configuration (320 × 0.5 mm or 64 × 0.5 mm), x-ray tube activation (full R-R, 65% R-R, or 70-80% R-R), use of tube current modulation, and use of breast shields. Direct dosimetry measurements were performed using Gafchromic film to determine the absorbed breast dose.Retrospective helical data acquisition using a 64-detector array and a full cardiac cycle without dose modulation or breast shielding is associated with an average absorbed breast dose of 82.9 mGy. Optimization of coronary CTA technique using a 320-detector array and a 70-80% cardiac phase reduces the absorbed breast dose by 78.9% to 17.5 mGy, whereas breast shields used in isolation reduces breast dose by up to 46.8%.The implementation of clinically validated coronary CTA protocols using large-area detector acquisition and prospective ECG gating with limited x-ray tube activation results in substantial breast dose savings of up to 78.9% and should be used whenever possible in combination with bismuth breast shields to achieve further dose reduction.

47-year-old woman was referred for evaluation of dyspnea and recurrent bilateral pneumothoraces, with the last episode requiring left apical resection and talc pleurodesis. The pathology from this procedure revealed only a scarred bleb lining. Dyspnea was described as insidious and gradually progressive since onset 5 years earlier. The medical history was notable for emphysema. The findings of a review of systems was otherwise negative, as was the family history. A social history revealed a 10 pack-year history of smoking with current use being described as sporadic. The physical examination findings were unremarkable with the exceptions of pulse oximetry values of 82% while breathing room air and a well-healed thoracotomy scar. The data available at the time of referral included normal serum chemistry levels, CBC, and 1-antitrypsin levels, along with pulmonary function test (PFT) results that revealed an FEV1 74% of predicted, FVC 97% of predicted, and FEV1/FVC ratio 62% of predicted. The diffusing capacity of the lung for carbon monoxide (Dlco) was also 27% of predicted.

ObjectiveChest imaging remains one of the most complicated sub-specialties of diagnostic radiology. The successful interpretation of thoracic imaging studies requires the recognition and understanding of the radiologic signs that are characteristic of many complex disease processes.ConclusionThe educational objectives for this case-based self-assessment module are for the participant to exercise, self-assess, and improve his or her understanding of important thoracic radiologic signs that are useful in establishing the diagnosis of particular diseases of the chest.

A case of a 35-year-old woman with acute circumferential type B aortic dissection is presented. A review of the literature demonstrated that circumferential aortic dissection is limited to a small number of case reports and a small case series of type A lesions. This is the first report of a circumferential type B dissection. The case highlights the need to fully evaluate patients with acute aortic dissection and illustrates the unique data provided by transesophageal echocardiography and helical computed tomographic angiography.

The objective of our study was to estimate the effective radiation dose to the female breast during CT pulmonary angiography compared with other routine diagnostic imaging techniques.We retrospectively reviewed the demographic data of patients who underwent CT pulmonary angiography between May 2000 and December 2002, the diagnostic yield of those studies, and the estimated effective radiation dose to the breast incurred during CT. The estimated effective radiation dose was calculated using the ImPACT CT (Impact Performance Assessment of CT) dosimetry calculator and the CT dose index (CTDI) and was compared with the average glandular dose for two-view screening mammography.During the study period, 1,325 CT pulmonary angiograms were obtained. Sixty percent (797) of the scans were obtained on female patients. The mean age of scanned females was 52.5 years (range, 15-93 years). Of the studies performed in females, 401 (50.31%) were negative, 151 (18.95%) were nondiagnostic, and 245 (30.74%) were positive for pulmonary thromboembolism. The calculated effective minimum dose to the breast of an average 60-kg woman during CT was 2.0 rad (20 mGy) per breast compared with an average glandular dose of 0.300 rad (3 mGy) for standard two-view screening mammography.CT pulmonary angiography delivers a minimum radiation dose of 2.0 rad (20 mGy) to the breasts of an average-sized woman. This greatly exceeds the American College of Radiology recommendation ofor = 0.300 rad (3 mGy) or less for standard two-view mammography. The potential latent carcinogenic effects of such radiation exposure at this time remain unknown. We encourage the judicious use of CT pulmonary angiography and lower doses and nonionizing radiation alternatives when appropriate.

Hermansky-Pudlak Syndrome (HPS) is a rare, inheritable disorder characterized by the classic triad of oculo-cutaneous albinism, platelet dysfunction, and ceroid deposition. An associated complication is pulmonary fibrosis with progressive restrictive lung disease. This report discusses the lung involvement often seen in this condition correlated with radiography, computed tomography, high-resolution computed tomography, and the underlying pathology, by means of two such afflicted siblings. The elder died of respiratory failure while awaiting lung transplantation. The younger sibling is currently undergoing evaluation for transplantation.

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A patient with a continuous-flow left ventricular assist device experienced debilitating lightheadedness after initiation of an oral vasodilator. On examination, a loud systolic crescendo-decrescendo murmur was heard over the

The association of abdominal aortic injury with transverse fractures of the lumbar spine is not well recognized. Three cases are presented with description of a mechanism common to both injuries that may explain this association — that of distraction and hyperflexion, such as occurs in seat-belt injuries. Whenever a transverse lumbar spine fracture following such a mechanism of injury is recognized, the co-existence of an injury to the abdominal aorta should be excluded by aortography if there is any doubt concerning the integrity of the peripheral pulses. This is best performed prior to laparotomy for any associated intraperitoneal injuries. Repeated clinical examination may detect deterioration in those cases with initially normal pulses. Ultimately, detection of the aortic injury rests on a high index of suspicion.