Anomalous origin of the circumflex artery from the right pulmonary artery.

Anomalous origin of the circumflex artery from the pulmonary artery (ACxAPA) is a rare but clinically significant condition in which the circumflex artery arises from either the main pulmonary artery or one of its main branches. Untreated patients with ACxAPA may develop severe heart failure or sudden cardiac death. Diagnosis is established with either catheter or CT angiography. We present a case of an adult male with no prior known cardiac history who was found to have ACxAPA after presenting to our institution in acute decompensated heart failure.

False-Positive and False-Negative Contrast-enhanced Mammograms: Pitfalls and Strategies to Improve Cancer Detection.

Contrast-enhanced mammography (CEM) is a relatively new breast imaging modality that uses intravenous contrast material to increase detection of breast cancer. CEM combines the structural information of conventional mammography with the functional information of tumor neovascularity. Initial studies have demonstrated that CEM and MRI perform with similar accuracies, with CEM having a slightly higher specificity (fewer false positives), although larger studies are needed. There are various reasons for false positives and false negatives at CEM. False positives at CEM can be caused by benign lesions with vascularity, including benign tumors, infection or inflammation, benign lesions in the skin, and imaging artifacts. False negatives at CEM can be attributed to incomplete or inadequate visualization of lesions, marked background parenchymal enhancement (BPE) obscuring cancer, lack of lesion contrast enhancement due to technical issues or less-vascular cancers, artifacts, and errors of lesion perception or characterization. When possible, real-time interpretation of CEM studies is ideal. If additional views are necessary, they may be obtained while contrast material is still in the breast parenchyma. Until recently, a limitation of CEM was the lack of CEM-guided biopsy capability. However, in 2020, the U.S. Food and Drug Administration cleared two devices to support CEM-guided biopsy using a stereotactic biopsy technique. The authors review various causes of false-positive and false-negative contrast-enhanced mammograms and discuss strategies to reduce these diagnostic errors to improve cancer detection while mitigating unnecessary additional imaging and procedures. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Weight-Bearing CT with Maximum Ankle Dorsiflexion to Identify Impingement and Tibial Plafond Stress Fracture: A Case Report.

CASE: A 25-year-old male pole vaulter presented with several months of right ankle pain. Radiographs showed an anterior tibial osteophyte with a small intra-articular body suggesting impingement. Weight-bearing computed tomography (CT) revealed an associated tibial plafond stress fracture. Subsequent arthroscopy with osteophyte resection and loose body removal significantly improved symptoms, and he gradually resumed training. CONCLUSION: Stress fractures should always be considered in athletes with ankle pain. A unique aspect of this case was the use of weight-bearing CT in diagnosis and surgical planning. To our knowledge, this is the first described case in which weight-bearing CT was used in this fashion.

Charting Trends in Medicare Reimbursement for Lower Extremity Imaging.

Background: Medicare reimbursement is rapidly declining in many specialties. An in-depth analysis of Medicare reimbursement for routinely performed diagnostic imaging procedures in the United States is warranted. Purpose/Hypothesis: The purpose of this study was to evaluate Medicare reimbursement trends for the 20 most common lower extremity imaging procedures performed between 2005 and 2020, including radiographs, computed tomography (CT), and magnetic resonance imaging (MRI). We hypothesized that Medicare reimbursement for imaging procedures would decline substantially over the studied period. Study Design: Cohort study. Methods: The Physician Fee Schedule Look-up Tool from the Centers for Medicare and Medicaid Services was analyzed for reimbursement rates and relative value units associated with the top 20 most utilized Current Procedural Terminology (CPT) codes in lower extremity imaging from 2005 to 2020. Reimbursement rates were adjusted for inflation and listed in 2020 US dollars using the US Consumer Price Index. To compare year-to-year changes, the percentage change per year and compound annual growth rate were calculated. A 2-tailed t test was used to compare the unadjusted and adjusted percentage change over the 15-year period. Results: After adjusting for inflation, mean reimbursement for all procedures decreased by 32.41% (P = .013). The mean adjusted percentage change per year was -2.82%, and the mean compound annual growth rate was -1.03%. Compensation for the professional and technical components for all CPT codes decreased by 33.02% and 85.78%, respectively. Mean compensation for the professional component decreased by 36.46% for radiography, 37.02% for CT, and 24.73% for MRI. Mean compensation for the technical component decreased by 7.76% for radiography, 127.66% for CT, and 207.88% for MRI. Mean total relative value units decreased by 38.7%. The commonly billed imaging procedure CPT 73720 (MRI lower extremity, other than joint, with and without contrast) had the greatest adjusted decrease of 69.89%. Conclusion: Medicare reimbursement for the most billed lower extremity imaging studies decreased by 32.41% between 2005 and 2020. The greatest decreases were noted in the technical component. Of the modalities, MRI had the largest decrease, followed by CT and then radiography.

A Case of Disseminated Cutaneous Herpes Simplex Virus-1 as the First Manifestation of Human Immunodeficiency Virus Infection.

Reported clinical manifestations of active herpes simplex virus type 1 (HSV-1) infection include typically painful vesicular cutaneous rash in a dermatomal distribution, temporal lobe encephalitis, and rarely, fulminant septic shock with multiorgan failure. In immunocompromised patients, the cutaneous rash can become disseminated. We report a case of a 33-year-old male patient with undiagnosed human immunodeficiency virus (HIV) infection who presented to our emergency department (ED) with a disseminated cutaneous rash. The rash was extensive, involved 90% of his total body surface area. It began 5 days prior as small ulcerations localized to the left arm, sought care at an outside ED, diagnosed as severe dermatitis with bacterial superinfection and discharged with a cephalexin prescription. Laboratory results were positive for HIV test with a CD4 count of 254, white blood cell count (WBC) of 7.4 k/microL with 54% neutrophils, 9% lymphocytes, 0% eosinophils, 0% basophils, and serum creatinine and sodium of 3.05 mg/dL and 119 mEq/L, respectively. The burn team and dermatology ruled out Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis due to the absence of mucosal involvement, negative nikolsky sign, and absence of skin sloughing. Polymerase chain reaction of samples obtained from the skin lesions was positive for HSV-1. The rash resolved with intravenous acyclovir and was started on highly active antiretroviral therapy (HAART) on outpatient follow-up. To the best of our knowledge, comparable cases of significantly disseminated cutaneous HSV-1 infection as the initial presentation of HIV infection have been rarely reported.

Car Seat Heater Burns: Awareness and Prevention.

The demand for car seat heaters is on the rise due to the added comfort they offer passengers. However, such luxury is not without risk and prolonged exposure to high surface temperatures of the seat may result in severe burns. We present a unique case of an 18-year-old paraplegic patient who sustained severe full-thickness burns requiring operative intervention after prolonged exposure to a car seat heater. We then tested 10 car seat heaters manufactured after 2014 to establish maximum temperature settings and safety features. We also examine the importance of raising awareness to this issue and share the concerns of previous publications regarding the lack of manufacturer standards in car seat heaters.