Prone Chest Radiographs: Distinguishing Features and Identification of Support Devices.

PURPOSE: Prone position is known to improve acute lung injury, and chest radiographs are often necessary to monitor disease and confirm support device placement. However, there is a paucity of literature regarding radiographs obtained in this position. We evaluated prone radiographs for distinguishing features and ability to identify support devices. METHODS: Pairs of prone and supine radiographs obtained during the COVID-19 pandemic were assessed retrospectively. IRB approval and waiver of informed consent were obtained. Radiographs were assessed for imaging adequacy, distinguishing features, and support device identification (endotracheal tube, enteric tube, or central line). Radiographs were reviewed by ≥ 2 cardiothoracic radiologists. RESULTS: Radiographs from 81 patients (63yo ± 13, 30% women) were reviewed. Prone and supine radiographs were comparable for imaging the lung bases (81% vs. 90%, p = 0.35) and apices (93% vs. 94%, p = 1); prone radiographs more frequently had significant rotation (36% vs. 19%, p = 0.021). To identify prone technique, scapula tip located beyond the rib border was 89% sensitive (95%CI 80-95%) and 85% specific (76-92%), and a fundal stomach bubble was 44% sensitive (33-56%) and 90% specific (81-96%). For women, displaced breast shadow was 46% sensitive (26-67%) and 92% specific (73-99%). Prone and supine radiographs each identified > 99% of support devices. Prone exams trended toward increased rate of malpositioned device (12% vs. 6%, p = 0.07). CONCLUSION: Scapula position reliably distinguishes prone from supine position; fundal stomach bubble or displaced breast shadow is specific for prone position. Prone radiographs reliably identify line and tube position, which is particularly important as prone patients appear at increased risk for malpositioned devices.

Chest Radiograph and CT Findings in Patients Hospitalized with Breakthrough COVID-19.

PURPOSE: To characterize chest radiograph and CT imaging appearance in patients with breakthrough COVID-19 (defined as an illness occurring in patients that previously received a COVID-19 vaccination) in a hospital setting. MATERIALS AND METHODS: In this retrospective study, all patients admitted to the hospital between August 26 and September 8, 2021 with a positive SARS-CoV-2 reverse transcription polymerase chain reaction-confirmed infection who were fully vaccinated against COVID-19 were evaluated. Clinical, laboratory data, and outcomes were collected and assessed. All patients had chest imaging performed (either radiography, CT, or a combination of both). Chest radiographs and CTs were assessed and scored on admission and on follow up to determine the extent and type of pulmonary involvement. Descriptive statistics were used. RESULTS: Charts of 60 hospitalized patients that tested positive for SARS-CoV-2 were reviewed for a prior history of COVID-19 vaccination. Eight (13.3%) such patients were identified and included for analysis (mean age, 54 years; range 34-81 years; four women). Patients received either two doses of Pfizer-BioNTech (n = 6), two doses of Moderna (n = 1), or one dose of Johnson and Johnson (n = 1). Five (63%) patients were immunosuppressed at the time of presentation, and six (75%) reported respiratory symptoms. Most of the patients had normal radiographs (4 of 7; 57%). The most common chest CT findings were ground glass opacities (three of five), with mild to moderate severity scores (average, 51; range 8-88). Two patients required intensive care unit admission. However, no patients died and all were either discharged or were on room air without residual respiratory symptoms by the end of the study period. CONCLUSION: In hospitalized patients with COVID-19 breakthrough illness, normal to mild or moderately positive imaging findings were observed.©RSNA, 2021.

Cardiac MRI Findings of Myocarditis After COVID-19 mRNA Vaccination in Adolescents.

BACKGROUND. A possible association has been reported between COVID-19 messenger RNA (mRNA) vaccination and myocarditis. OBJECTIVE. The purpose of our study was to describe cardiac MRI findings in patients with myocarditis after COVID-19 mRNA vaccination. METHODS. This retrospective study included patients without known prior SARS-CoV-2 infection who underwent cardiac MRI between May 14, 2021, and June 14, 2021, for suspected myocarditis within 2 weeks of COVID-19 mRNA vaccination. Information regarding clinical presentation, hospital course, and events after hospital discharge were recorded. A cardiothoracic imaging fellow and cardiothoracic radiologist reviewed cardiac MRI examinations in consensus. Data were summarized descriptively. RESULTS. Of 52 patients without known prior SARS-CoV-2 infection who underwent cardiac MRI during the study period, five underwent MRI for suspected myocarditis after recent COVID-19 mRNA vaccination. All five patients were male patients ranging in age from 16 to 19 years (mean, 17.2 ± 1.0 [SD] years) who presented within 4 days of receiving the second dose of a COVID-19 mRNA vaccine. Troponin levels were elevated in all patients (mean peak troponin I value, 6.82 ± 4.13 ng/mL). Alternate possible causes of myocarditis were deemed clinically unlikely on the basis of medical history, physical examination findings, myocarditis viral panel, and toxicology screening. Cardiac MRI findings were consistent with myocarditis in all five patients on the basis of the Lake Louise criteria, including early gadolinium enhancement and late gadolinium enhancement (LGE) in all patients and corresponding myocardial edema in four patients. All five patients had a favorable hospital course and were discharged from the hospital in stable condition with improved or resolved symptoms after hospitalization (mean length of hospital stay, 4.8 days). Two patients underwent repeat cardiac MRI that showed persistent, although decreased, LGE. Three patients reported mild intermittent self-resolving chest pain after hospital discharge, and two patients had no recurrent symptoms after discharge. CONCLUSION. In this small case series, all patients with myocarditis after COVID-19 vaccination were male adolescents and had a favorable initial clinical course. All patients showed cardiac MRI findings typical of myocarditis from other causes. LGE persisted in two patients who underwent repeat MRI. These observations do not establish causality. CLINICAL IMPACT. Radiologists should be aware of a possible association of COVID-19 mRNA vaccination and myocarditis and recognize the role of cardiac MRI in the assessment of suspected myocarditis after COVID-19 vaccination.

Determinants of Chest X-Ray Sensitivity for COVID- 19: A Multi-Institutional Study in the United States.

PURPOSE: To evaluate the sensitivity, specificity, and severity of chest x-rays (CXR) and chest CTs over time in confirmed COVID-19+ and COVID-19- patients and to evaluate determinants of false negatives. METHODS: In a retrospective multi-institutional study, 254 RT-PCR verified COVID-19+ patients with at least one CXR or chest CT were compared with 254 age- and gender-matched COVID-19- controls. CXR severity, sensitivity, and specificity were determined with respect to time after onset of symptoms; sensitivity and specificity for chest CTs without time stratification. Performance of serial CXRs against CTs was determined by comparing area under the receiver operating characteristic curves (AUC). A multivariable logistic regression analysis was performed to assess factors related to false negative CXR. RESULTS: COVID-19+ CXR severity and sensitivity increased with time (from sensitivity of 55% at ≤2 days to 79% at >11 days; p<0.001 for trends of both severity and sensitivity) whereas CXR specificity decreased over time (from 83% to 70%, p=0.02). Serial CXR demonstrated increase in AUC (first CXR AUC=0.79, second CXR=0.87, p=0.02), and second CXR approached the accuracy of CT (AUC=0.92, p=0.11). COVID-19 sensitivity of first CXR, second CXR, and CT was 73%, 83%, and 88%, whereas specificity was 80%, 73%, and 77%, respectively. Normal and mild severity CXR findings were the largest factor behind false-negative CXRs (40% normal and 87% combined normal/mild). Young age and African-American ethnicity increased false negative rates. CONCLUSION: CXR sensitivity in COVID-19 detection increases with time, and serial CXRs of COVID-19+ patients has accuracy approaching that of chest CT.

Management of Lung Nodules and Lung Cancer Screening During the COVID-19 Pandemic: CHEST Expert Panel Report.

Background: The risks from potential exposure to coronavirus disease 2019 (COVID-19), and resource reallocation that has occurred to combat the pandemic, have altered the balance of benefits and harms that informed current (pre-COVID-19) guideline recommendations for lung cancer screening and lung nodule evaluation. Consensus statements were developed to guide clinicians managing lung cancer screening programs and patients with lung nodules during the COVID-19 pandemic. Materials and Methods: An expert panel of 24 members, including pulmonologists (n = 17), thoracic radiologists (n = 5), and thoracic surgeons (n = 2), was formed. The panel was provided with an overview of current evidence, summarized by recent guidelines related to lung cancer screening and lung nodule evaluation. The panel was convened by video teleconference to discuss and then vote on statements related to 12 common clinical scenarios. A predefined threshold of 70% of panel members voting agree or strongly agree was used to determine if there was a consensus for each statement. Items that may influence decisions were listed as notes to be considered for each scenario. Results: Twelve statements related to baseline and annual lung cancer screening (n = 2), surveillance of a previously detected lung nodule (n = 5), evaluation of intermediate and high-risk lung nodules (n = 4), and management of clinical stage I non-small cell lung cancer (n = 1) were developed and modified. All 12 statements were confirmed as consensus statements according to the voting results. The consensus statements provide guidance about situations in which it was believed to be appropriate to delay screening, defer surveillance imaging of lung nodules, and minimize nonurgent interventions during the evaluation of lung nodules and stage I non-small cell lung cancer. Conclusion: There was consensus that during the COVID-19 pandemic, it is appropriate to defer enrollment in lung cancer screening and modify the evaluation of lung nodules due to the added risks from potential exposure and the need for resource reallocation. There are multiple local, regional, and patient-related factors that should be considered when applying these statements to individual patient care.© 2020 RSNA; The American College of Chest Physicians, published by Elsevier Inc; and The American College of Radiology, published by Elsevier Inc.

Management of Lung Nodules and Lung Cancer Screening During the COVID-19 Pandemic: CHEST Expert Panel Report.

BACKGROUND: The risks from potential exposure to coronavirus disease 2019 (COVID-19), and resource reallocation that has occurred to combat the pandemic, have altered the balance of benefits and harms that informed current (pre-COVID-19) guideline recommendations for lung cancer screening and lung nodule evaluation. Consensus statements were developed to guide clinicians managing lung cancer screening programs and patients with lung nodules during the COVID-19 pandemic. METHODS: An expert panel of 24 members, including pulmonologists (n = 17), thoracic radiologists (n = 5), and thoracic surgeons (n = 2), was formed. The panel was provided with an overview of current evidence, summarized by recent guidelines related to lung cancer screening and lung nodule evaluation. The panel was convened by video teleconference to discuss and then vote on statements related to 12 common clinical scenarios. A predefined threshold of 70% of panel members voting agree or strongly agree was used to determine if there was a consensus for each statement. Items that may influence decisions were listed as notes to be considered for each scenario. RESULTS: Twelve statements related to baseline and annual lung cancer screening (n = 2), surveillance of a previously detected lung nodule (n = 5), evaluation of intermediate and high-risk lung nodules (n = 4), and management of clinical stage I non-small cell lung cancer (n = 1) were developed and modified. All 12 statements were confirmed as consensus statements according to the voting results. The consensus statements provide guidance about situations in which it was believed to be appropriate to delay screening, defer surveillance imaging of lung nodules, and minimize nonurgent interventions during the evaluation of lung nodules and stage I non-small cell lung cancer. CONCLUSIONS: There was consensus that during the COVID-19 pandemic, it is appropriate to defer enrollment in lung cancer screening and modify the evaluation of lung nodules due to the added risks from potential exposure and the need for resource reallocation. There are multiple local, regional, and patient-related factors that should be considered when applying these statements to individual patient care.

CT Scans Obtained for Nonpulmonary Indications: Associated Respiratory Findings of COVID-19.

Background Atypical manifestations of coronavirus disease 2019 (COVID-19) are being encountered as the pandemic unfolds, leading to non-chest CT scans that may uncover unsuspected pulmonary disease. Purpose To investigate patients with primary nonrespiratory symptoms who underwent CT of the abdomen or pelvis or CT of the cervical spine or neck with unsuspected findings highly suspicious for pulmonary COVID-19. Materials and Methods This retrospective study from March 10, 2020, to April 6, 2020, involved three institutions, two in a region considered a hot spot (area of high prevalence) for COVID-19. Patients without known COVID-19 were included who presented to the emergency department (ED) with primary nonrespiratory (gastrointestinal or neurologic) symptoms, had lung parenchymal findings suspicious for COVID-19 at non-chest CT but not concurrent chest CT, and underwent COVID-19 testing in the ED. Group 1 patients had reverse transcription polymerase chain reaction (RT-PCR) results obtained before CT scan reading (COVID-19 suspected on presentation); group 2 had RT-PCR results obtained after CT scans were read (COVID-19 not suspected). Presentation and imaging findings were compared, and outcomes were evaluated. Descriptive statistics and Fisher exact tests were used for analysis. Results Group 1 comprised 62 patients (31 men, 31 women; mean age, 67 years ±17 [standard deviation]), and group 2 comprised 57 patients (28 men, 29 women; mean age, 63 years ± 16). Cough and fever were more common in group 1 (37 of 62 [60%] and 29 of 62 [47%], respectively) than in group 2 (nine of 57 [16%] and 12 of 57 [21%], respectively), with no significant difference in the remaining symptoms. There were 101 CT scans of the abdomen or pelvis and 18 CT scans of the cervical spine or neck. In group 1, non-chest CT findings provided the initial evidence of COVID-19-related pneumonia in 32 of 62 (52%) patients. In group 2, the evidence was found in 44 of 57 (77%) patients. Overall, the most common CT findings were ground-glass opacity (114 of 119, 96%) and consolidation (47 of 119, 40%). Major interventions (vasopressor medication or intubation) were required for 29 of 119 (24%) patients, and 27 of 119 (23%) died. Patients who underwent CT of the cervical spine or neck had worse outcomes than those who underwent abdominal or pelvic CT (P = .01). Conclusion In a substantial percentage of patients with primary nonrespiratory symptoms who underwent non-chest CT, CT provided evidence of coronavirus disease 2019-related pneumonia. © RSNA, 2020.

Management of Lung Nodules and Lung Cancer Screening During the COVID-19 Pandemic: CHEST Expert Panel Report.

BACKGROUND: The risks from potential exposure to coronavirus disease 2019 (COVID-19), and resource reallocation that has occurred to combat the pandemic, have altered the balance of benefits and harms that informed current (pre-COVID-19) guideline recommendations for lung cancer screening and lung nodule evaluation. Consensus statements were developed to guide clinicians managing lung cancer screening programs and patients with lung nodules during the COVID-19 pandemic. METHODS: An expert panel of 24 members, including pulmonologists (n = 17), thoracic radiologists (n = 5), and thoracic surgeons (n = 2), was formed. The panel was provided with an overview of current evidence, summarized by recent guidelines related to lung cancer screening and lung nodule evaluation. The panel was convened by video teleconference to discuss and then vote on statements related to 12 common clinical scenarios. A predefined threshold of 70% of panel members voting agree or strongly agree was used to determine if there was a consensus for each statement. Items that may influence decisions were listed as notes to be considered for each scenario. RESULTS: Twelve statements related to baseline and annual lung cancer screening (n = 2), surveillance of a previously detected lung nodule (n = 5), evaluation of intermediate and high-risk lung nodules (n = 4), and management of clinical stage I non-small-cell lung cancer (n = 1) were developed and modified. All 12 statements were confirmed as consensus statements according to the voting results. The consensus statements provide guidance about situations in which it was believed to be appropriate to delay screening, defer surveillance imaging of lung nodules, and minimize nonurgent interventions during the evaluation of lung nodules and stage I non-small-cell lung cancer. CONCLUSIONS: There was consensus that during the COVID-19 pandemic, it is appropriate to defer enrollment in lung cancer screening and modify the evaluation of lung nodules due to the added risks from potential exposure and the need for resource reallocation. There are multiple local, regional, and patient-related factors that should be considered when applying these statements to individual patient care.