What Do Program and Geographic Preference Signals Signal? A Survey of Diagnostic Radiology and Integrated Interventional Radiology Residency Applicants

RATIONALE AND OBJECTIVES

As part of the 2022-2023 Diagnostic/Interventional Radiology residency application process, applicants could participate in the ERAS supplemental application, including sending up to six preference signals and three geographic signals. Our goal was to survey Diagnostic Radiology and Integrated Interventional Radiology applicants at two large academic institutions in different geographic locations regarding their perceived impact of program and geographic preference signaling on the application process.

METHODS

An anonymous survey was sent to 282 applicants between two academic medical centers asking about their participation in program and geographic preference signaling as well as their perception on its impact on the application process.

RESULTS

105 applicants responded to the survey (37.2% [105/282]). Most applicants (26% [27/102]) received four interviews from signaled programs. When prompted to best describe their sentiments with respect to program signaling (one being most negative and five being most positive), the plurality of applicants reported a positive sentiment of four (36% [37/103]). Applicants that received four to six interviews from signaled programs were significantly more likely to feel positively towards program signaling than those that received one to three interviews (p = 0.01). Geography was the most important deciding factor on which programs to signal for applicants (57% [58/101]).

DISCUSSION

Our survey results demonstrate that most applicants felt positively towards program signaling and it increased their odds of receiving interviews from preferred programs, which is consistent with the current literature.

CONCLUSION

Program and geographic signaling are relatively new features of the ERAS residency application process and therefore, their effects on the match outcome are still in question. However, our study results indicate that they are perceived positively by most applicants and that they boost their chances in finding their ideal match.

Metastatic Pulmonary Calcification: Single-Center Review of Typical and Atypical Imaging Features

PURPOSE

The purpose of this study is to bring attention to an atypical form of metastatic pulmonary calcification, which is conventionally described as a metabolic process with upper lobe predominance in patients with a specific clinical history, which has not been reported as a distinct entity.

METHODS

Patients with metastatic pulmonary calcification (MPC) were first identified with mPower keyword search, including MPC or metastatic calcifications on computed tomography chest radiological reports. Patients were then filtered on likelihood of MPC based off imaging reports. Images were then reviewed by three senior radiologists for pertinent characteristics such as location of MPC, degree of calcifications and pleural effusions. Based on the predominant location of MPC, cases were labeled as either typical or atypical. Clinical and imaging characteristics relevant to MPC were noted and compared across typical and atypical cases.

RESULTS

In our study, we describe 25 patients with MPC, 13 defined as typical MPC and 12 with atypical MPC. Through consensus of senior radiologists, MPC was deemed to be mild (52%), moderate (44%), or severe (4%). Twenty-three patients (92%) had underlying renal disease including 21 requiring dialysis at the time of diagnosis. Outside of age at diagnosis, there was no significant clinical difference between the two groups. Evaluation of imaging characteristics (average HU attenuation, 267; range, 186-295), pattern and distribution of calcification, and clinical history strongly supported a diagnosis of atypical MPC.

CONCLUSION

This study presents several cases of lower lobe subpleural MPC associated with pleural effusions, which has not been reported as a distinct entity, despite comprising a significant portion of MPC cases at our institution.

Lung-Reporting and Data System 2.0: Impact of the Updated Approach to Juxtapleural Nodules During Lung Cancer Screening Using the National Lung Cancer Screening Trial Data Set

PURPOSE

To determine the frequency of malignancy of nonperifissural juxtapleural nodules (JPNs) measuring 6 to < 10 mm in a subset of low-dose chest computed tomographies from the National Lung Cancer Screening Trial and the rate of down-classification of such nodules in Lung-Reporting and Data System (RADS) 2.0 compared with Lung-RADS 1.1.

MATERIALS AND METHODS

A secondary analysis of a subset of the National Lung Screening Trial was performed. An exemption was granted by the Institutional Review Board. The dominant noncalcified nodule measuring 6 to <10 mm was identified on all available prevalence computed tomographies. Nodules were categorized as pleural or nonpleural. Benign or malignant morphology was recorded. Initial and updated categories based on Lung-RADS 1.1 and Lung-RADS 2.0 were assigned, respectively. The impact of the down-classification of JPN was assessed. Both classification schemes were compared using the McNemar test (P < 0.01).

RESULTS

A total of 2813 patients (62 ± 5 y, 1717 men) with 4408 noncalcified nodules were studied. One thousand seventy-three dominant nodules measuring 6 to <10 mm were identified. Three hundred forty-eight (32.4%) were JPN. The updated scheme allowed down-classification of 310 JPN from categories 3 (n = 198) and 4A (n = 112) to category 2. We, therefore, estimate a 4.8% rate of down-classification to category 2 in the entire National Lung Screening Trial screening group. Two/348 (0.57%) JPN were malignant, both nonbenign in morphology. The false-positive rate decreased in the updated classification (P < 0.01).

CONCLUSION

This study demonstrates the low malignant potential of benign morphology JPN measuring 6 mm to <10 mm. The Lung-RADS 2.0 approach to JPN is estimated to reduce short-term follow-ups and false-positive results.

Clinical Profiles and Outcomes of Cytomegalovirus Positive Renal Transplant Patients in Early Post-Transplant Period

Cytomegalovirus infection can cause increased mortality and morbidity in renal transplant recipient. The purpose of the present study was to observe the clinical profiles and outcomes of Cytomegalovirus positive renal transplant patients in early post-transplant period. This prospective cohort study was conducted in the Department of Nephrology at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from September 2016 to August 2017. Adult patients who had undergone renal transplantation were selected as study population. CMV serology (CMV IgM and CMV IgG) of both donor and recipient were detected before renal transplantation. Cytomegalovirus viral DNA was extracted from both serum by using a commercially available DNA extraction kit and PCR was done by the StepOne™ PCR machine using real time PCR kit in all patient during the early post-transplant period. During this period, sign symptoms of patients with cytomegalovirus infection as well as clinical outcomes were also noted. Total number of 32 patients was included in this study with the mean age of 31.15±11.56 years. Cytomegalovirus was found positive in 11(34.4%) patients and negative in 21(65.6%) patients. Anorexia was the most common presentation which was found in 81.8% cases followed by renal impairment, fever, diarrhea, cough and weight loss which were present in 6(54.5%), 3(27.3%), 2(18.2%), 2(18.2%) and 2(18.2%) cases respectively. The outcomes of cytomegalovirus positive patients in first 6 months after renal transplantation revealed 25.0% patients had cytomegalovirus infection; 6.2% patients had cytomegalovirus disease and 6.2% patients were died. However, 9.4% patients had co-infection in the form of UTI and 6.2% patients had re activation of hepatitis C infection associated with cytomegalovirus infection. Cytomegalovirus was found positive in approximately one third of renal transplant recipients in early post-transplant period. Careful clinical evaluation and appropriate laboratory parameters should be looked over for timely diagnosis and management of these cases.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

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.

The Effect of Virtual Interviews and Social Media on Applicant Decision-Making During The 2020-2021 Resident Match Cycle

RATIONALE AND OBJECTIVES

The COVID-19 pandemic significantly altered the residency application and interview process. Due to social distancing concerns, residency programs have had to virtually showcase their program to applicants, many utilizing social media. Similarly, applicants have had to devise novel ways of assessing "goodness of fit", one of the top factor's applicants use when ranking programs (1). Whether or not these attempts made an impact on an applicant's decision-making process has yet to be determined.

MATERIALS AND METHODS

Residency candidates interviewing for a diagnostic and/or interventional radiology residency position at our institution completed an online survey. The goal of the survey was to assess the potential influence of virtual interviews, social media, and virtual events on an applicant's decision to apply to, interview at, and rank residency programs.

RESULTS

78/156 (50%) candidates completed the survey. Thirty-five percent reported applying to more programs and 58% reported accepting more interviews than they would have if interviews were not virtual. Forty-two percent reported that social media played a vital role during the application season and 71% reported using social media to learn more about the program. Sixty-nine percent attended a virtual open house, 57% of whom reported that attending the open house influenced their decision to apply to a program. Sixty-three percent reported that attending a virtual reception influenced a program's ranking.

CONCLUSION

Social media has had a growing role in the medical community, and the COVID-19 pandemic likely accelerated an inevitable shift in residency program "branding" and how applicants perceive overall "goodness of fit".

Plastic waste recycling: existing Indian scenario and future opportunities

This review article aims to suggest recycling technological options in India and illustrates plastic recycling clusters and reprocessing infrastructure for plastic waste (PW) recycling in India. The study shows that a majority of states in India are engaged in recycling, road construction, and co-processing in cement kilns while reprocessing capabilities among the reprocessors are highest for polypropylene (PP) and polyethylene (PE) polymer materials. This review suggests that there are key opportunities for mechanical recycling, chemical recycling, waste-to-energy approaches, and bio-based polymers as an alternative to deliver impact to India's PW problem. On the other hand, overall, polyurethane, nylon, and polyethylene terephthalate appear most competitive for chemical recycling. Compared to conventional fossil fuel energy sources, polyethylene (PE), polypropylene (PP), and polystyrene are the three main polymers with higher calorific values suitable for energy production. Also, multi-sensor-based artificial intelligence and blockchain technology and digitization for PW recycling can prove to be the future for India in the waste flow chain and its management. Overall, for a circular plastic economy in India, there is a necessity for a technology-enabled accountable quality-assured collaborative supply chain of virgin and recycled material.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13762-022-04079-x.

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.

Potential Impact of a Pass or Fail United States Medical Licensing Exam Step 1 Scoring System on Radiology Residency Applications

RATIONALE AND OBJECTIVES

To assess the anticipated impact of the change in United States Medical Licensing Examination Step 1 scoring from numerical to pass or fail on the future selection of radiology residents.

MATERIALS AND METHODS

An anonymous electronic 14-item survey was distributed to 308 members of the Association of Program Directors in Radiology and included questions regarding the anticipated importance of various application metrics when Step 1 becomes pass or fail. Secondary analyses compared responses based on the current use of a Step 1 scoring screen.

RESULTS

Eighty eight respondents (28.6% [88/308]) completed the survey. Most (64% [56/88]) noted that the United States Medical Licensing Examination Step 2 Clinical Knowledge (CK) score will likely be one of the top three most important factors in assessing applicants, followed by class ranking or quartile (51% [45/88]) and the Medical Student Performance Evaluation/Dean's Letter (42% [37/88]). Over 90% (82/88) of respondents anticipate potentially or definitively requiring Step 2 CK scores before application review, and 50% (44/88) of respondents anticipate extending interview invites at a later date to receive Step 2 CK scores. These results did not significantly differ between programs who currently use a Step 1 scoring screen and those who do not.

CONCLUSION

As Step 1 transitions from a numerical score to pass or fail, radiology residency program directors will likely rely on Step 2 CK scores as an objective and standardized metric to screen applicants. Further investigation is needed to identify other objective metrics to evaluate applicants before Step 1 becomes pass or fail.

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.

Rapid Onset Development of Myocardial Calcifications in the Setting of Renal Failure and Sepsis

Myocardial calcifications can arise following damage to myocardial tissue or in the setting of disturbances in the calcium and phosphorus balance. They are associated with a number of cardiac sequelae, as well as higher mortality. Three cases of rapid-onset myocardial calcifications that developed within the course of 5 to 13 weeks in patients who had a history of sepsis and renal failure while undergoing hemodialysis are described. Baseline imaging from several weeks prior without myocardial calcification are shown for each of the three patients, demonstrating the rapid onset of these calcifications. The clinical significance of these findings is discussed. © RSNA, 2021.

Lung-RADS Version 1.0 versus Lung-RADS Version 1.1: Comparison of Categories Using Nodules from the National Lung Screening Trial

Background The American College of Radiology updated Lung Imaging Reporting and Data System (Lung-RADS) version 1.0 to version 1.1 in May 2019, with the two key changes involving perifissural nodules (PFNs) and ground-glass nodules (GGNs) now designated as a negative screening result. This study examines the effects of these changes using National Lung Screening Trial (NLST) data. Purpose To determine the frequency of PFNs and GGNs reclassified from category 3 or 4A to the more benign category 2 in the updated Lung-RADS version 1.1, as compared with Lung-RADS version 1.0, using CT scans from the NLST. Materials and Methods In this secondary analysis of the NLST, the authors studied all noncalcified nodules (NCNs) found on the incident scan. Nodules were evaluated using criteria from both Lung-RADS version 1.0 and version 1.1, which were compared to determine changes in the number of nodules deemed benign. A McNemar test was used to assess statistical significance. Results A total of 2813 patients (mean age ± standard deviation, 62 years ± 5; 1717 men) with 4408 NCNs were studied. Of the largest 1092 solid NCNs measuring at least 6 mm but less than 10 mm, 216 (19.8%) were deemed PFNs (category 2) using Lung-RADS version 1.1. Eleven of the 1092 solid NCNs (1.0%) were malignant, but none were PFNs. Of 161 GGNs, three (1.9%) were category 3 according to Lung-RADS version 1.0, of which two (66.7%) were down-classified to category 2 with version 1.1. One of the three down-categorized GGNs (version 1.1) proved to be malignant (false-negative finding). Statistically significant improvement for Lung-RADS version 1.1 was found for total nodules (P < .01) and PFNs (P < .01), but not GGNs (P = .48). Conclusion This secondary analysis of National Lung Screening Trial data shows that Lung Imaging Reporting and Data System version 1.1 decreased the number of false-positive results. This was related to the down-classification of perifissural nodules in the range of 6 up to 10 mm. The increase in allowable nodule size for ground-glass nodules in category 2 from 20 mm (version 1.0) to 30 mm (version 1.1) showed no benefit. © RSNA, 2021 See also the editorial by Mayo and Lam in this issue.

Dual-energy CT evidence of pulmonary microvascular occlusion in patients with sickle cell disease experiencing acute chest syndrome

PURPOSE

Acute chest syndrome (ACS), defined by the presence of a chest radiographic opacity in sickle cell disease patients experiencing respiratory symptoms is a leading cause of death in these patients. The etiology is ACS is not well understood however pulmonary microvascular occlusion has been postulated to be a major pathophysiologic driver. Our study aims to assess the value of dual-energy CT (DECT) as a marker of pulmonary microvascular occlusion.

MATERIALS/METHODS

A search tool was used to identify CT angiography studies from 1/1/2017 to 9/15/2019 with any variation of the phrases "Acute chest syndrome" and "Sickle cell". These studies were manually reviewed for the use of DECT technique. An age-matched control group was created. DECT pulmonary blood volume (PBV) maps were reviewed semi-quantitatively for the presence of iodine defects and the number of involved bronchopulmonary segments were scored. Other recorded values included type of parenchymal opacities, diameter of main pulmonary artery (MPA) and presence of right ventricular dilatation. Mean values between cases and controls were compared using a two-sample t-test.

RESULTS

Nine sickle cell DECT cases with PBV maps and nine age-matched controls were evaluated. Bronchopulmonary segments with iodine defects were significantly higher in cases vs controls (mean: 4.7 vs 0.3, p < 0.003). PBV defects were more extensive than parenchymal findings. MPA diameter was higher in cases (2.9 cm) vs control (2.4 cm), P < 0.03.

CONCLUSIONS

DECT demonstrates abnormal PBV in sickle cell patients, often the predominant abnormality identified early, and likely reflects the presence of pulmonary microvascular occlusion.

Interobserver Reliability of the Coronary Artery Disease Reporting and Data System in Clinical Practice

PURPOSE

This study aimed to evaluate interobserver reproducibility between cardiothoracic radiologists applying the Coronary Artery Disease Reporting and Data System (CAD-RADS) to describe atherosclerotic burden on coronary computed tomography angiography.

METHODS

Forty clinical computed tomography angiography cases were retrospectively and independently evaluated by 3 attending and 2 fellowship-trained cardiothoracic radiologists using the CAD-RADS lexicon. Radiologists were blinded to patient history and underwent initial training using a practice set of 10 subjects. Interobserver reproducibility was assessed using an intraclass correlation (ICC) on the basis of single-observer scores, absolute agreement, and a 2-way random-effects model. Nondiagnostic studies were excluded. ICC was also performed for CAD-RADS scores grouped by management recommendations for absent (0), nonobstructive (1 to 2), and potentially obstructive (3 to 5) CAD.

RESULTS

Interobserver reproducibility was moderate to good (ICC: 0.748, 95% confidence interval [CI]: 0.639-0.842, P<0.0001), with higher agreement among cardiothoracic radiology fellows (ICC: 0.853, 95% CI: 0.730-0.922, P<0.0001) than attending radiologists (ICC: 0.711, 95% CI: 0.568-0.824, P<0.0001). Interobserver reproducibility for clinical management categories was marginally decreased (ICC: 0.692, 95% CI: 0.570-0.802, P<0.0001). The average percent agreement between pairs of radiologists was 84.74%. Percent observer agreement was significantly reduced in the presence (M=62.22%, SD=15.17%) versus the absence (M=80.91%, SD=17.97%) of modifiers, t(37.95)=3.566, P=0.001.

CONCLUSIONS

Interobserver reliability and agreement with the CAD-RADS terminology are moderate to good in clinical practice. However, further investigations are needed to characterize the causes of interobserver disagreement that may lead to differences in management recommendations.

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.

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.

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.

Organizing pneumonia co-existing with carcinoid tumour: complete resolution with bronchoscopic tumour resection

Organizing pneumonia is a well-known clinical entity resulting in response to noxious stimuli causing lung injury. It is known to occur with infectious disease processes, neoplasms, post lung surgery or radiation therapy and when idiopathic, is called cryptogenic organizing pneumonia. We present an unusual case of a 48-year-old woman who presented with chronic cough and progressive dyspnoea while being on macrolide therapy for Lyme disease. Computerized tomography of chest demonstrated a well-circumscribed nodule in the lingula and bilateral central ground glass opacities. Transbronchial biopsies were consistent with carcinoid tumour in the lingula and organizing pneumonia in bilateral lung fields. Bronchoscopic relief of obstruction was performed by mechanical debulking of the tumour, with subsequent complete resolution of bilateral opacities, consistent with resolution of organizing pneumonia without the need for steroid therapy.

Intracavitary Coronary Artery: An Unusual Coronary Anomaly

PURPOSE

A few case reports of intracavitary coronary arteries (ICCA) have been reported and only a single case series on the coronary computed tomography angiography (CCTA) prevalence rate of ICCA of the right coronary artery (RCA). We describe several cases of ICCA that were noted incidentally and also determine the overall prevalence rate of anomalous ICCA.

MATERIALS AND METHODS

A retrospective analysis of ICCA was performed consisting of consecutive CCTA cases as well as a group of ICCA from teaching files. To establish a prevalence rate, we reviewed 464 consecutive CCTA referred to our center for transcatheter aortic valve replacement. The presence of ICCA and several imaging features were evaluated.

RESULTS

Our cohort comprises a total of 12 patients with ICCA, with 1 patient containing 2 anomalous ICCA. 83.3% of affected patients were adult males, with an average age of 69.8 years. The RCA was the most commonly affected vessel (53.8%). The mean length of the intracavitary segment was 33.4 mm for the RCA and 27 mm for the LAD. No cases involved the left circumflex coronary artery. Six of the cases were identified routinely as part of clinical practice and therefore not included in the prevalence analysis. On review of our transcatheter aortic valve replacement database, there was a 1.3% prevalence rate of ICCA. RCA had a prevalence of 0.4%, whereas LAD had a prevalence of 0.9%.

CONCLUSIONS

Although rare, our study suggests that ICCA may be more common than previously described. Its presence is important to communicate to clinicians prior to invasive cardiac procedures to prevent potentially catastrophic outcomes.

Missed Lung Cancer

The chest radiograph is one of the most commonly used imaging studies and is the modality of choice for initial evaluation of many common clinical scenarios. Over the last two decades, chest computed tomography has been increasingly used for a wide variety of indications, including respiratory illnesses, trauma, oncologic staging, and more recently lung cancer screening. Diagnostic radiologists should be familiar with the common causes of missed lung cancers on imaging studies in order to avoid detection and interpretation errors. Failure to detect these lesions can potentially have serious implications for both patients as well as the interpreting radiologist.

Stability of retained austenite in high carbon steel under compressive stress: an investigation from macro to nano scale

Although high carbon martensitic steels are well known for their industrial utility in high abrasion and extreme operating environments, due to their hardness and strength, the compressive stability of their retained austenite, and the implications for the steels’ performance and potential uses, is not well understood. This article describes the first investigation at both the macro and nano scale of the compressive stability of retained austenite in high carbon martensitic steel. Using a combination of standard compression testing, X-ray diffraction, optical microstructure, electron backscattering diffraction imaging, electron probe micro-analysis, nano-indentation and micro-indentation measurements, we determined the mechanical stability of retained austenite and martensite in high carbon steel under compressive stress and identified the phase transformation mechanism, from the macro to the nano level. We found at the early stage of plastic deformation hexagonal close-packed (HCP) martensite formation dominates, while higher compression loads trigger body-centred tetragonal (BCT) martensite formation. The combination of this phase transformation and strain hardening led to an increase in the hardness of high carbon steel of around 30%. This comprehensive characterisation of stress induced phase transformation could enable the precise control of the microstructures of high carbon martensitic steels, and hence their properties.

The laminin alpha-1 chain derived peptide, AG73, increases fibronectin levels in breast and melanoma cancer cells

Laminin-111 promotes the malignant phenotype, and a 12-mer synthetic peptide (AG73, RKRLQVQLSIRT) from the carboxyl terminus of the alpha1 chain increases B16F10 melanoma metastasis to the lung and liver. Using an antibody array, fibronectin was identified as an up-regulated protein in B16F10 cells after incubation with this peptide. The increased fibronectin is cell-associated with no increase in soluble fibronectin. The AG73 peptide increased the number and size of bone metastases with both B16F10 melanoma and MDA-231 breast carcinoma cells in an intracardiac injection model. Using siRNA transfection, we found that a reduction in fibronectin expression did not reduce bone metastasis in the presence of the metastasis-promoting peptide AG73. We conclude that the laminin peptide AG73 increases metastasis independently of fibronectin expression.

Heparanase cleavage of perlecan heparan sulfate modulates FGF10 activity during ex vivo submandibular gland branching morphogenesis

Heparan sulfate proteoglycans are essential for biological processes regulated by fibroblast growth factors (FGFs). Heparan sulfate (HS) regulates the activity of FGFs by acting as a coreceptor at the cell surface, enhancing FGF-FGFR affinity, and being a storage reservoir for FGFs in the extracellular matrix (ECM). Here we demonstrate a critical role for heparanase during mouse submandibular gland (SMG) branching morphogenesis. Heparanase, an endoglycosidase, colocalized with perlecan in the basement membrane and in epithelial clefts of SMGs. Inhibition of heparanase activity in organ culture decreased branching morphogenesis, and this inhibition was rescued specifically by FGF10 and not by other FGFs. By contrast, exogenous heparanase increased SMG branching and MAPK signaling and, surprisingly, when isolated epithelia were cultured in a three-dimensional ECM with FGF10, it increased the number of lateral branches and end buds. In a solid-phase binding assay, an FGF10-FGFR2b complex was released from the ECM by heparanase. In addition, surface plasmon resonance (SPR) analysis showed that FGF10 and the FGF10-FGFR2b complex bound to purified perlecan HS and could be released by heparanase. We used the FGF10-FGFR2b complex as a probe for HS in SMGs, and it colocalized with perlecan in the basement membrane and partly colocalized with syndecan 1 in the epithelium, and binding was reduced by treatment with heparanase. In summary, our results show heparanase releases FGF10 from perlecan HS in the basement membrane, increasing MAPK signaling, epithelial clefting, and lateral branch formation, which results in increased branching morphogenesis.

Risk of preterm delivery in relation to vaginal bleeding in early pregnancy

OBJECTIVE

To examine the relationship between vaginal bleeding during early pregnancy and preterm delivery.

METHODS

Study subjects (N=2678) provided information regarding socio-demographic, biomedical, and lifestyle characteristics. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

Any vaginal bleeding in early pregnancy was associated with a 1.57-fold increased risk of preterm delivery (95% CI: 1.16-2.11). Vaginal bleeding was most strongly related with spontaneous preterm labor (OR=2.10) and weakly associated with preterm premature rupture of membrane (OR=1.36) and medically induced preterm delivery (OR=1.32). As compared to women with no bleeding, those who bled during the first and second trimesters had a 6.24-fold increased risk of spontaneous preterm labor; and 2-3-fold increased risk of medically induced preterm delivery and preterm premature rupture of membrane, respectively.

CONCLUSION

Vaginal bleeding, particularly bleeding that persists across the first two trimesters, is associated with an increased risk of preterm delivery.

Laminin alpha5 chain metastasis- and angiogenesis-inhibiting peptide blocks fibroblast growth factor 2 activity by binding to the heparan sulfate chains of CD44

Recently, we reported that the laminin alpha5 synthetic peptide A5G27 (RLVSYNGIIFFLK, residues 2,892-2,904) binds to the CD44 receptor of B16-F10 melanoma cells via the glycosaminoglycans on CD44 and inhibits tumor cell migration, invasion, and angiogenesis in a dominant-negative manner. Here, we have identified the potential mechanism of A5G27 activity using WiDr human colorectal carcinoma cells. WiDr cells bound to the laminin A5G27 peptide via the heparin-like and chondroitin sulfate B glycosaminoglycan side chains of CD44. Cell binding to fibroblast growth factor (FGF2) was blocked by laminin peptide A5G27 but not by either a scrambled version of this peptide or by another laminin peptide known to bind cell surface proteoglycans. FGF2 signaling involving tyrosine phosphorylation was also blocked by laminin peptide A5G27 but was not affected by peptide controls. Finally, we have shown that peptide A5G27 directly blocks FGF2 binding to heparin. Peptide A5G27 has sequence homology to a region on FGF2 that binds heparin and the FGF receptor and is important in FGF2 central cavity formation. We conclude that peptide A5G27 inhibits metastasis and angiogenesis by blocking FGF2 binding to the heparan sulfate side chains of CD44 variant 3, thus decreasing FGF2 bioactivity.