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Objective To investigate the relationship between α1-antitrypsin deficiency (AATD), a disorder resulting in protease activity imbalances, and the risk of ascending aortic aneurysm. Methods In this single-center study, from August 1, 2018, to February 25, 2019, demographic data were retrospectively collated for patients with AATD-associated emphysema (AATD group) or non–AATD-associated emphysema (control group) with available high-resolution computed tomography scans. Mean ascending aortic diameter was compared between the groups, and the correlation of diameter with age was analyzed. Results Patients with AATD (n=51; mean AAT level, 20.3 mg/dL [to convert to μmol/L, multiply by 0.184]) were approximately 10 years younger than those in the control group (n=93; mean AAT level, 172.0 mg/dL), with a mean age of 55 vs 65 years. Overall and grouped by sex, the mean ascending aortic diameter in patients with AATD was not different from that in the control group (overall, 3.34 vs 3.37 cm; P=.68); however, ascending aortic diameter was significantly associated with age for patients in the AATD group (r=0.43; P=.0016), whereas no correlation was observed between age and aortic diameter in the control group (r=0.16; P=.11). Conclusion Results of this study suggest that there is a pathologic association between AATD and aortic distention and that AATD may increase the risk of ascending aortic aneurysm. These data provide a basis for the regular assessment of aortic diameter in patients with AATD as well as for the testing of patients with aortic distention or aneurysm for AATD.

Purpose We describe the presenting characteristics and hospital course of 11 novel coronavirus (COVID-19) patients who developed spontaneous subcutaneous emphysema (SE) with or without pneumomediastinum (SPM) in the absence of prior mechanical ventilation. Materials and methods A total of 11 non-intubated COVID-19 patients (8 male and 3 female, median age 61 years) developed SE and SPM between March 15 and April 30, 2020 at a multi-center urban health system in New York City. Demographics (age, gender, smoking status, comorbid conditions, and body-mass index), clinical variables (temperature, oxygen saturation, and symptoms), and laboratory values (white blood cell count, C-reactive protein, D-dimer, and peak interleukin-6) were collected. Chest radiography (CXR) and computed tomography (CT) were analyzed for SE, SPM, and pneumothorax by a board-certified cardiothoracic-fellowship trained radiologist. Results Eleven non-intubated patients developed SE, 36% (4/11) of whom had SE on their initial CXR. Concomitant SPM was apparent in 91% (10/11) of patients, and 45% (5/11) also developed pneumothorax. Patients developed SE on average 13.3 days (SD: 6.3) following symptom onset. No patients reported a history of smoking. The most common comorbidities included hypertension (6/11), diabetes mellitus (5/11), asthma (3/11), dyslipidemia (3/11), and renal disease (2/11). Four (36%) patients expired during hospitalization. Conclusion SE and SPM were observed in a cohort of 11 non-intubated COVID-19 patients without any known cause or history of invasive ventilation. Further investigation is required to elucidate the underlying mechanism in this patient population., Highlights • COVID-19 patients were observed to form subcutaneous air and pneumomediastinum in the absence of mechanical ventilation. • Patients in this cohort presented mainly with respiratory symptoms including mild hypoxia, but otherwise stable vital signs. • On initial presentation, all patients demonstrated abnormalities in inflammatory markers. • On initial presentation, all patients demonstrated abnormalities in inflammatory markers.

Background Chest radiography has not been validated for its prognostic utility in evaluating patients with coronavirus disease 2019 (COVID-19). Purpose To analyze the prognostic value of a chest radiograph severity scoring system for younger (nonelderly) patients with COVID-19 at initial presentation to the emergency department (ED); outcomes of interest included hospitalization, intubation, prolonged stay, sepsis, and death. Materials and Methods In this retrospective study, patients between the ages of 21 and 50 years who presented to the ED of an urban multicenter health system from March 10 to March 26, 2020, with COVID-19 confirmation on real-time reverse transcriptase polymerase chain reaction were identified. Each patient's ED chest radiograph was divided into six zones and examined for opacities by two cardiothoracic radiologists, and scores were collated into a total concordant lung zone severity score. Clinical and laboratory variables were collected. Multivariable logistic regression was used to evaluate the relationship between clinical parameters, chest radiograph scores, and patient outcomes. Results The study included 338 patients: 210 men (62%), with median age of 39 years (interquartile range, 31-45 years). After adjustment for demographics and comorbidities, independent predictors of hospital admission (n = 145, 43%) were chest radiograph severity score of 2 or more (odds ratio, 6.2; 95% confidence interval [CI]: 3.5, 11; P < .001) and obesity (odds ratio, 2.4 [95% CI: 1.1, 5.4] or morbid obesity). Among patients who were admitted, a chest radiograph score of 3 or more was an independent predictor of intubation (n = 28) (odds ratio, 4.7; 95% CI: 1.8, 13; P = .002) as was hospital site. No significant difference was found in primary outcomes across race and ethnicity or those with a history of tobacco use, asthma, or diabetes mellitus type II. Conclusion For patients aged 21-50 years with coronavirus disease 2019 presenting to the emergency department, a chest radiograph severity score was predictive of risk for hospital admission and intubation. © RSNA, 2020 Online supplemental material is available for this article.

Background Recent studies have demonstrated a complex interplay between comorbid cardiovascular disease, COVID-19 pathophysiology, and poor clinical outcomes. Coronary artery calcification (CAC) may therefore aid in risk stratification of COVID-19 patients. Methods Non-contrast chest CT studies on 180 COVID-19 patients ≥ age 21 admitted from March 1, 2020 to April 27, 2020 were retrospectively reviewed by two radiologists to determine CAC scores. Following feature selection, multivariable logistic regression was utilized to evaluate the relationship between CAC scores and patient outcomes. Results The presence of any identified CAC was associated with intubation (AOR: 3.6, CI: 1.4–9.6) and mortality (AOR: 3.2, CI: 1.4–7.9). Severe CAC was independently associated with intubation (AOR: 4.0, CI: 1.3–13) and mortality (AOR: 5.1, CI: 1.9–15). A greater CAC score (UOR: 1.2, CI: 1.02–1.3) and number of vessels with calcium (UOR: 1.3, CI: 1.02–1.6) was associated with mortality. Visualized coronary stent or coronary artery bypass graft surgery (CABG) had no statistically significant association with intubation (AOR: 1.9, CI: 0.4–7.7) or death (AOR: 3.4, CI: 1.0–12). Conclusion COVID-19 patients with any CAC were more likely to require intubation and die than those without CAC. Increasing CAC and number of affected arteries was associated with mortality. Severe CAC was associated with higher intubation risk. Prior CABG or stenting had no association with elevated intubation or death.

The main purpose of the study is to determine if the presence of a particular computed tomography (CT) imaging finding, a bursal lipohematoma, portends the presence of a concomitant rotator cuff tear (RCT) in patients with proximal humerus fractures by reviewing previous CTs. Three hundred eighty-six CT scans were retrospectively reviewed by two board-certified radiologists to determine the presence of a proximal humerus fracture and to assess for the presence of a subacromial/subdeltoid or subcoracoid bursal hematoma. The medical record including operative documentation was then examined in the patients with proximal humerus fractures, with or without a concomitant bursal lipohematoma. Of the surgically managed patients, four had an intraoperative diagnosis of RCT. The preoperative CT scans of all of these patients demonstrated a bursal lipohematoma. Additionally, a non-surgically managed patient with a subacromial/subdeltoid bursal lipohematoma on CT scan was found to have a RCT on subsequent MRI. Of note, a rotator cuff tear was not documented in operative reports of patients with CT scans that were not found to contain a bursal lipohematoma. Bursal lipohematoma is a potentially useful preoperative CT sign of full thickness rotator cuff tear in patients with proximal humerus fractures, providing the clinician with more information in the optimization of the management approach.

Background Chest radiography (CXR) often is performed in the acute setting to help understand the extent of respiratory disease in patients with COVID-19, but a clearly defined role for negative chest radiograph results in assessing patients has not been described. Research Question Is portable CXR an effective exclusionary test for future adverse clinical outcomes in patients suspected of having COVID-19? Study Design and Methods Charts of consecutive patients suspected of having COVID-19 at five EDs in New York City between March 19, 2020, and April 23, 2020, were reviewed. Patients were categorized based on absence of findings on initial CXR. The primary outcomes were hospital admission, mechanical ventilation, ARDS, and mortality. Results Three thousand two hundred forty-five adult patients, 474 (14.6%) with negative initial CXR results, were reviewed. Among all patients, negative initial CXR results were associated with a low probability of future adverse clinical outcomes, with negative likelihood ratios of 0.27 (95% CI, 0.23-0.31) for hospital admission, 0.24 (95% CI, 0.16-0.37) for mechanical ventilation, 0.19 (95% CI, 0.09-0.40) for ARDS, and 0.38 (95% CI, 0.29-0.51) for mortality. Among the subset of 955 patients younger than 65 years and with a duration of symptoms of at least 5 days, no patients with negative CXR results died, and the negative likelihood ratios were 0.17 (95% CI, 0.12-0.25) for hospital admission, 0.09 (95% CI, 0.02-0.36) for mechanical ventilation, and 0.09 (95% CI, 0.01-0.64) for ARDS. Interpretation Initial CXR in adult patients suspected of having COVID-19 is a strong exclusionary test for hospital admission, mechanical ventilation, ARDS, and mortality. The value of CXR as an exclusionary test for adverse clinical outcomes is highest among young adults, patients with few comorbidities, and those with a prolonged duration of symptoms.

“Just Accepted” papers have undergone full peer review and have been accepted for publication in Radiology: Artificial Intelligence. This article will undergo copyediting, layout, and proof review before it is published in its final version. Please note that during production of the final copyedited article, errors may be discovered which could affect the content. Purpose To train a deep learning classification algorithm to predict chest radiography severity scores and clinical outcomes in patients with coronavirus disease 2019 (COVID-19). Materials and Methods In this retrospective cohort study, we identified patients of ages of 21 to 50 who presented to the emergency department (ED) of a multicenter urban health system from March 10–26, 2020 with COVID-19 confirmation on real-time reverse transcription polymerase chain reaction. We collected the initial chest radiographs (CXRs), clinical variables, and outcomes including admission, intubation, and survival within 30 days (n = 338; median age 39; 210 men). Two fellowship-trained cardiothoracic radiologists examined CXRs for opacities and assigned a clinically validated severity score. We trained a deep learning algorithm to predict outcomes on a holdout test set composed of confirmed COVID-19 patients who presented from March 27–29, 2020 (n = 161; median age 60; 98 men) for both younger (ages 21–50; n = 51) and older (ages > 50; n = 110) populations. Bootstrapping methods computed confidence intervals. Results The model trained on the CXR severity score produced the following areas under the receiver operating characteristic (AUCs): 0.80 (0.73,0.88) for the CXR severity score, 0.76 (0.68,0.84) for admission, 0.66 (0.56,0.75) for intubation, and 0.59 (0.49,0.69) for death. The model trained on clinical variables produced the following AUCs 0.64 (0.55,0.73) for intubation and 0.59 (0.50,0.68) for death. Combining CXR and clinical variables increased AUC of intubation and death to 0.86 (0.79,0.96) and 0.82 (0.72,0.91), respectively. Conclusion The combination of imaging and clinical information improves outcome predictions.

Computed tomography (CT) scans are increasingly ordered in the emergent setting, for diagnosis of occult fractures and treatment planning of known fractures or fracture dislocations. Although having inferior soft tissue contrast resolution compared to magnetic resonance imaging (MRI), CT may provide important information regarding tendon pathology that is often under-recognized but may better serve patient outcomes, whether in or out of the operative setting. In this pictorial essay, we present CT cases which demonstrate some of the more commonly encountered tendon abnormalities in patients with acute trauma.