Imaging in the Intensive Care Unit.

Radiology plays an important role in the management of the most seriously ill patients in the hospital. Over the years, continued advances in imaging technology have contributed to an improvement in patient care. However, even with such advances, the portable chest radiograph (CXR) remains one of the most commonly requested radiographic examinations. While they provide valuable information, CXRs remain relatively insensitive at revealing abnormalities and are often nonspecific. Chest computed tomography (CT) can display findings that are occult on CXR and is particularly useful at identifying and characterizing pleural effusions, detecting barotrauma including small pneumothoraces, distinguishing pneumonia from atelectasis, and revealing unsuspected or additional abnormalities which could result in increased morbidity and mortality if left untreated. CT pulmonary angiography is the modality of choice in the evaluation of pulmonary emboli which can complicate the hospital course of the ICU patient. This article will provide guidance for interpretation of CXR and thoracic CT images, discuss some of the invasive devices routinely used, and review the radiologic manifestations of common pathologic disease states encountered in ICU patients. In addition, imaging findings and complications of more specific clinical scenarios in which the incidence has increased in the ICU setting, such as patients who are immunocompromised, have interstitial lung disease, or COVID-19, will also be discussed. Communication between the radiologist and intensivist, particularly on complicated cases, is important to help increase diagnostic accuracy and leads to an improvement in the management of the most critically ill patients.

Incidence, clinical associations and outcomes of intrathoracic complications with and without ARDS in COVID-19 pneumonia.

PURPOSE: To determine the incidence and clinical predictors of intrathoracic complications in COVID-19 patients, and the association with outcomes. METHODS: In this retrospective cross-sectional study, we included 976 patients (age 61 ± 17 years, 62% male) who tested positive for SARS-CoV-2 between March 3-April 4, 2020 and underwent chest imaging. 3836 radiographs from 976 patients and 105 CTs from 88 patients were reviewed for intrathoracic complications, including pneumothorax, pneumomediastinum, pneumopericardium, lobar collapse, pleural effusion, and pneumatocele formation. RESULTS: There was a high rate of intrathoracic complications (197/976, 20%). Pleural effusion was the most common complication (168/976, 17%). Pneumothorax (30/976, 3%) and pneumatoceles (9/88, 10%) were also frequent. History of hypertension and high initial CXR severity score were independent risk factors for complications. Patients with any intrathoracic complication during admission had an over 11-fold risk of ICU admission (adjusted odds ratio [aOR] 11.2, p < 0.0001) and intubation (aOR 12.4, p < 0.0001), over 50% reduction in successful extubation (aOR 0.49, p = 0.02) and longer length of stay (median 13 versus 5 days, p < 0.0001). There was no difference in overall survival between patients with and without any complication (log-rank p = 0.94). CONCLUSION: In COVID-19 patients who underwent chest imaging, 1 in 5 patients have an intrathoracic complication, which are associated with higher level of care and prolonged hospital stay. Hypertension history and high CXR severity score confer an increased risk of complication. SUMMARY: Intrathoracic complications in COVID-19 are common and are predictive of ICU admission, need for intubation, less successful extubation, and longer length of stay but are not predictive of mortality.

Management of Incidental Pulmonary Nodules: Influencing Patient Care Through Subspecialized Imaging Review.

OBJECTIVE: To evaluate whether thoracic radiologist review of computed tomography-detected incidental pulmonary nodules initially reported by non-thoracic imagers would change management recommendations. MATERIALS AND METHODS: The Radiology Consultation Service identified 468 computed tomography scans (one per patient) performed through the adult emergency department from August 2018 through December 2020 that mentioned the presence of a pulmonary nodule. Forty percent (186/468) were read by thoracic radiologists and 60% (282/468) were read by non-thoracic radiologists. The Radiology Consultation Service contacted all patients in order to assess risk factors for lung malignancy. Sixty-seven patients were excluded because they were unreachable, declined participation, or were actively followed by a pulmonologist or oncologist. A thoracic radiologist assessed the nodule and follow up recommendations in all remaining cases. RESULTS: A total of 215 cases were re-reviewed by thoracic radiologists. The thoracic radiologist disagreed with the initial nodule recommendations in 38% (82/215) of cases and agreed in 62% (133/215) of cases. All discordant cases resulted in a change in management by the thoracic radiologist with approximately one-third (33%, 27/82) decreasing imaging utilization and two-thirds (67%, 55/82) increasing imaging utilization. Nodules were deemed benign and follow up eliminated in 11% (9/82) of discordant cases. DISCUSSION: Our study illustrates that nodule review by thoracic radiologists results in a change in management in a large percentage of patients. Continued research is needed to determine whether subspecialty imaging review results in increased or more timely lung cancer detection.

A unique case of unilateral pulmonary edema from partial anomalous pulmonary venous return in conjunction with superior vena cava stenosis.

While PAPVR is most commonly an incidental finding on chest CT, a unique case is presented where PAPVR in conjunction with SVC stenosis resulted in chronic symptomatic asymmetric pulmonary edema. The case reflects an unusual anatomic cause of unilateral edema, as a combination of both congenital and subsequently acquired anatomic anomalies.

Central paradiaphragmatic middle lobe involvement in nonspecific interstitial pneumonia.

OBJECTIVES: Nonspecific interstitial pneumonia (NSIP) lacks specific diagnostic guidelines or criteria for imaging diagnosis, and the need for more reliable computed tomography (CT) characterization remains. We hypothesized that central paradiaphragmatic middle lobe (ML) involvement is present in most patients with NSIP. The purpose of this study was to evaluate the prevalence of ML involvement and thus to assess its potential as a unique feature of NSIP. METHODS: We conducted a retrospective CT-imaging review of 40 patients with biopsy-proven (7/40, 18%) or clinically established (33/40, 82%) NSIP. Three subspecialty-trained thoracic radiologists reviewed CTs for ML involvement both independently and in consensus, and additional CT findings previously described in NSIP independently. RESULTS: ML involvement was present in most cases (70%, 28/40, independent review, 78%, 31/40, consensus reading), with substantial agreement among all three readers (κ = 0.65). Fibrosis was present in almost all cases (93%, 37/40). Subpleural sparing occurred in one-third of patients (30%, 12/40). Homogeneity (48%, 19/40), central bronchiectasis (45%, 18/40), and peripheral bronchiectasis (53%, 21/40) were present in about half of patients. Apart from substantial inter-reader agreement on fibrosis (κ = 0.65), the above-mentioned imaging characteristics had fair to slight universal agreement (κ = 0.07-0.30). CONCLUSIONS: Central paradiaphragmatic ML ground glass attenuation superimposed on reticulation and traction bronchiectasis occurs in most patients with NSIP, with high interobserver agreement. KEY POINTS: • Central paradiaphragmatic middle lobe ground glass attenuation superimposed on reticulation and traction bronchiectasis is common in nonspecific interstitial pneumonia (NSIP). • This finding occurs more frequently than subpleural sparing and has a better interobserver agreement.

Thoracic Manifestations of Rheumatoid Arthritis.

Rheumatoid arthritis (RA) is one of the most common chronic systemic inflammatory diseases and the most common chronic inflammatory arthritis. Classically a progressive symmetric polyarthritis, RA is characterized by inflammation, erosions, bone loss, and joint destruction. Up to half of patients with RA exhibit extra-articular manifestations (EAMs), which may precede articular disease and are more common in patients with seropositive RA (patients with detectable serum levels of rheumatoid factor and/or anticitrullinated peptide antibodies). Cardiovascular and pulmonary EAMs are the largest contributors to morbidity and mortality in RA and may be especially devastating. Imaging has a significant role in diagnosing these EAMs and assessing response to treatment. Although treatment with disease-modifying antirheumatic drugs has redefined the natural history of RA and helped many patients achieve low disease activity, patients are at risk for treatment-related complications, as well as infections. The clinical features of drug-induced lung disease and infection can overlap considerably with those of EAMs, presenting a diagnostic challenge. Radiologists, by recognizing the imaging characteristics and evolution of these various processes, are essential in diagnosing and distinguishing among EAMs, treatment-related complications, and unrelated processes and formulating an appropriate differential diagnosis. Moreover, recognizing these disease processes at imaging and contextualizing imaging findings with clinical information and laboratory and pathologic findings can facilitate definitive diagnosis and proper treatment. The authors review the articular and extra-articular thoracic imaging manifestations of RA, including cardiovascular, respiratory, and pleural diseases, as well as treatment-related complications and common infections. ©RSNA, 2021.

A Case-Based Review of Vaping-Induced Injury-Pulmonary Toxicity and Beyond.

The last 10 years has seen a steady rise in the use of electronic cigarettes ("e-cigarettes" or ECIGs) or "vape pens." Though initially developed to assist with smoking cessation, use among adolescents has been particularly high. A concomitant rise in ECIG-related injuries disproportionately affecting young patients has been recognized. This unique case series highlights both pulmonary and extra-pulmonary ECIG-induced injuries including vape tip ingestion, maxillofacial fractures after vape pen explosion, myocarditis, and several different manifestations of vaping-associated lung injury. Becoming familiar with expected imaging findings in the wide array of ECIG-induced complications will help radiologists recognize these findings, recommend further imaging as needed, facilitate early diagnosis by help referring clinicians elicit the relevant history from patients, and expedite appropriate treatment.

The importance of imaging - Perspectives from redeployment.

As the coronavirus disease 2019 (COVID-19) pandemic strains the healthcare system, radiology residents across the United States have become a vital part of the redeployed workforce. Through a series of four cases of COVID-19 patients encountered on the wards, we highlight the insight and unique set of skills redeployed radiology residents possess that are essential to patient care during this crisis. By increasing visibility through active participation on the clinical team, we demonstrate the fundamental role radiology has in the greater field of medicine.

Imaging & other potential predictors of deterioration in COVID-19.

This case report describes a young patient with COVID-19 who is initially diagnosed with CT chest imaging. Upon admission to the hospital, his clinical condition deteriorates requiring ventilatory support. We explore the value of imaging and other potential predictors of deterioration.

Imaging Utilization and Outcomes in Vulnerable Populations during COVID-19 in New York City.

BACKGROUND: Coronavirus disease 2019 (COVID-19) affects vulnerable populations (VP) adversely. PURPOSE: To evaluate overall imaging utilization in vulnerable subgroups (elderly, racial/ethnic minorities, socioeconomic status [SES] disadvantage) and determine if a particular subgroup has worse outcomes from COVID-19. MATERIALS/METHODS: Of 4110 patients who underwent COVID-19 testing from March 3-April 4, 2020 at NewYork-Presbyterian Hospital (NYP) health system, we included 1121 COVID-19 positive adults (mean age 59±18 years, 59% male) from two academic hospitals and evaluated imaging utilization rates and outcomes, including mortality. RESULTS: Of 897 (80%) VP, there were 465 (41%) elderly, 380 (34%) racial/ethnic minorities, and 479 (43%) SES disadvantage patients. Imaging was performed in 88% of patients and mostly portable/bedside studies, with 87% of patients receiving chest radiographs. There were 83% hospital admissions, 25% ICU admissions, 23% intubations, and 13% deaths. Elderly patients had greater imaging utilization, hospitalizations, ICU/intubation requirement, longer hospital stays, and >4-fold increase in mortality compared to non-elderlies (adjusted hazard ratio[aHR] 4.79, p<0.001). Self-reported minorities had fewer ICU admissions (p=0.03) and reduced hazard for mortality (aHR 0.53, p=0.004; complete case analysis: aHR 0.39, p<0.001 excluding "not reported"; sensitivity analysis: aHR 0.61, p=0.005 "not reported" classified as minorities) with similar imaging utilization, compared to non-minorities. SES disadvantage patients had similar imaging utilization and outcomes as compared to their counterparts. CONCLUSIONS: In a predominantly hospitalized New York City cohort, elderly patients are at highest mortality risk. Racial/ethnic minorities and SES disadvantage patients fare better or similarly to their counterparts, highlighting the critical role of access to inpatient medical care during the COVID-19 pandemic.

Pre and Post Procedure Imaging of the Watchman® Device with Cardiac Computed Tomography Angiography.

PURPOSE OF REVIEW: Left atrial appendage occlusion with the Watchman® device requires pre and post procedure imaging. Currently, transesophageal echocardiography is the recommended modality, though cardiac computed tomography angiography may be an acceptable alternative. RECENT FINDINGS: Cardiac computed tomography angiography can be used to safely and accurately predict Watchman® device sizing. It can also be used to detect post procedure complications similar to, or better than, transesophageal echocardiography. Cardiac computed tomography angiography is a viable alternative imaging modality for pre and post procedure evaluation for the Watchman device.

Radiology Research Funding: Current State and Future Opportunities.

Funding for research has become increasingly difficult to obtain in an environment of decreasing clinical revenue, increasing research costs, and growing competition for federal and nonfederal funding sources. This paper identifies critical requirements to build and sustain a successful radiology research program (eg, key personnel and leadership, research training and mentorship, infrastructure, institutional and departmental funding or support), reviews the current state of available funding for radiology (including federal, nonfederal, philanthropy, crowdfunding, and industry), and describes promising opportunities for future funding (eg, health services, comparative effectiveness, and patient-centered outcomes research). The funding climate, especially at the federal level, changes periodically, so it is important to have radiology-specific organizations such as the American College of Radiology and the Academy of Radiology Research serving as our key advocates. Key to obtaining any funding, no matter what the source, is a well-formulated grant proposal, so a review of opportunities specifically available to radiologists to develop and hone their grant-writing skills is provided. Effective and sustained funding for radiology research has the potential to cultivate young researchers, bolster quality research, and enhance health care. Those interested in pursuing research need to be aware of the ever-changing funding landscape, research priority areas, and the resources available to them to succeed. To succeed, radiology researchers need to think about diversification and flexibility in their interests, developing multidisciplinary and multi-institutional projects, and engaging a broader base of stakeholders that includes patients.

Effect of Massed Versus Interleaved Teaching Method on Performance of Students in Radiology.

PURPOSE: Radiology instruction is based on the principle that grouped (or massed) repetition of an intellectual activity leads to expertise. The aim of this study was to test the hypothesis that the spaced (or interleaved) method of teaching chest x-ray interpretation is more effective than the massed method. METHODS: After institutional review board approval was obtained, 40 first- and second-year medical students were randomized into two groups matched by age, gender, and education experience. Both groups saw six examples of 12 common chest radiographic patterns, one grouped, the other scrambled randomly without repeating strings. After a distraction, participants took a multiple-choice test consisting of two cases in each radiographic pattern, one previously shown, one new. Results were analyzed using two-tailed Student's t test of proportion. RESULTS: Comparing interleaved and massed groups, the average overall score was 57% versus 43% (P = .03), the recollection score was 61% versus 47% (P = .03), and the induction score was 53% versus 40% (P = 0.10), respectively. Comparing second- and first-year students, average scores were 67% and 39%, respectively (P < .01). First-year students in the interleaved and massed groups scored 55% and 36% (P = .02) in recall and 40% and 28% (P = .10) in induction. Second-year students in the interleaved and massed groups scored 71% and 63% (P = .36) in recall and 74% and 59% (P = .03) in induction. CONCLUSIONS: The interleaved method of instruction leads to better results than the massed method across all levels of education. A higher level of medical education improves performance independent of method of instruction.