Initial CXR Research Articles

Radiographic patterns and severity scoring of COVID-19 pneumonia in children: a retrospective study

BackgroundChest radiography (CXR) is an adjunct tool in treatment planning and monitoring of the disease course of COVID-19 pneumonia. The purpose of the study was to describe the radiographic patterns and severity scores of abnormal CXR findings in children diagnosed with COVID-19 pneumonia.MethodsThis retrospective study included children with confirmed COVID-19 by reverse transcriptase-polymerase chain reaction test who underwent CXR at the arrival. The CXR findings were reviewed, and modified radiographic scoring was assessed.ResultsThe number of abnormal CXR findings was 106 of 976 (10.9%). Ground-glass opacity (GGO) was commonly found in children aged > 9 years (19/26, 73.1%), whereas peribronchial thickening was predominantly found in children aged < 5 years (25/54, 46.3%). Overall, the most common radiographic finding was peribronchial thickening (54/106, 51%). The lower lung zone (56/106, 52.8%) was the most common affected area, and there was neither peripheral nor perihilar predominance (84/106, 79.2%). Regarding the severity of COVID-19 pneumonia based on abnormal CXR findings, 81 of 106 cases (76.4%) had mild lung abnormalities. Moderate and severe lung abnormalities were found in 21 (19.8%) and 4 (3.8%) cases, respectively. While there were no significant differences in the radiographic severity scores among the various pediatric age groups, there were significant disparities in severity scores in the initial CXR and medical treatments.ConclusionsThis study clarified the age distribution of radiographic features across the pediatric population. GGO was commonly found in children aged > 9 years, whereas peribronchial thickening was predominant in children aged < 5 years. The lower lung zone was the most common affected area, and the high severity lung scores required more medical treatments and oxygen support.

Temporal evolution of chest radiographic appearances in COVID-19 with clinicoradiological associations: a multicentre United Kingdom resident-led study

To describe the (a) frequency of improving, static, and worsening chest radiograph (CXR) appearances; (b) differences in demographic, initial rudimentary haematological and CXR variables and these patterns; and (c) frequency of different trajectories of serial CXR evolution, in COVID-19 patients presenting consecutively. This multicentre retrospective study included all COVID-19 patients admitted from 1-30 April 2020, meeting the inclusion criteria across 24 (blinded) hospitals. Follow-up CXRs on admission, the subsequent (where available), and at 4-8 weeks were scored for the presence of parenchymal opacities across six zones. Three cohorts were defined: improved, static, and/or worsened. The chi-squared and Kruskal-Wallis tests were used to compare demographic, laboratory, and CXR variables. Trajectories of CXR evolution were assessed when all three CXRs were available (226 patients). Of 452 included patients (median age 66 years, interquartile range 54.3-79, 262 men), 211 (46.7%) improved, 140 (31%) were static, and 101 (22.3%) worsened. Improving patients were more likely younger, with a classic COVID-19 radiograph and higher initial CXR zonal severity scores (both p<0.001), while worsening patients had lower initial lymphocyte counts (p=0.008). The most frequent trajectory was worsened then improved (n=63, 27.9%) followed by static then improved (n=46, 20.4%) and static (n=42, 18.6%). Most patients with COVID-19 during the first wave of the pandemic demonstrated radiographic improvement; these patients were more likely younger with classic COVID-19 appearances and initially more extensive abnormality. Conversely, radiographic deterioration was associated with lower lymphocyte counts. The three most common trajectories were worsening then improvement, static then improvement, and static throughout.

Twenty-year perspective on blunt traumatic diaphragmatic injury in level 1 trauma centre: Early versus delayed diagnosis injury patterns and outcomes.

Blunt traumatic diaphragmatic injury (TDI) is typically associated with severe trauma and concomitant injuries. It is a diagnostic challenge in the setting of blunt trauma and can be easily overlooked especially in the acute phase often dominated by concurrent injuries. A retrospective review was conducted of patients with blunt-TDI identified from a level 1 trauma registry. Variables associated with early versus delayed diagnosis as well as non-survivor and survivor groups were collected to examine factors associated with delayed diagnosis. A total of 155 patients were included (mean age 46 ± 20, 60.6% male). Diagnosis was made <24 h in 126 (81.3%), and >24 h in 29 (18.7%). Of the delayed diagnosis group, 14 (48%) were diagnosed >7 days. Overall, 27 (21.4%) patients had a diagnostic initial CXR and 64 (50.8%) had a diagnostic initial CT. Fifty-eight (37.4%) patients were diagnosed intraoperatively. Of the delayed diagnosis group, 22 (75.9%) had no initial signs on CXR or CT, 15 (52%) of this group had persistent pleural-effusions/elevated-hemidiaphragm leading to further investigation and diagnosis. No significant difference in survival was observed between early and delayed diagnoses, no clinically significant injury patterns to predict delayed diagnoses were noted. The diagnosis of TDI is challenging. Without frank signs of herniation of abdominal contents on CXR or CT, the diagnosis is often not made on initial imaging. In patients with the evidence of blunt traumatic injury in the lower-chest/upper-abdomen, a high degree of clinical suspicion should be held and follow-up CXRs/CTs arranged.

Are Chest Radiographs or Ultrasound More Accurate in Predicting a Pneumothorax or Need for a Thoracostomy Tube in Trauma Patients?

Historically, chest radiographs (CXR) have been used to quickly diagnose pneumothorax (PTX) and hemothorax in trauma patients. Over the last 2 decades, chest ultrasound (CUS) as part of Extended Focused Assessment with Sonography in Trauma (eFAST) has also become accepted as a modality for the early diagnosis of PTX in trauma patients. We queried our institution's trauma databases for all trauma team activations from 2021 for patients with eFAST results. Demographics, injury variables, and the following were collected: initial eFAST CUS, CXR, computed tomography (CT) scan, and thoracostomy tube procedure notes. We then compared PTX detection rates on initial CXR and CUS to those on thoracic CT scans. 580 patients were included in the analysis after excluding patients without a chest CT scan within 2hours of arrival. Extended Focused Assessment with Sonography in Trauma was 68.4% sensitive and 87.5% specific for detecting a moderate-to-large PTX on chest CT, while CXR was 23.5% sensitive and 86.3% specific. Extended Focused Assessment with Sonography in Trauma was 69.8% sensitive for predicting the need for tube thoracostomy, while CXR was 40.0% sensitive. At our institution, eFAST CUS was superior to CXR for diagnosing the presence of a PTX and predicting the need for a thoracostomy tube. However, neither test is accurate enough to diagnose a PTX nor predict if the patient will require a thoracostomy tube. Based on the specificity of both tests, a negative CXR or eFAST means there is a high probability that the patient does not have a PTX and will not need a chest tube.

Deep Learning With Chest Radiographs for Making Prognoses in Patients With COVID-19: Retrospective Cohort Study.

An artificial intelligence (AI) model using chest radiography (CXR) may provide good performance in making prognoses for COVID-19. We aimed to develop and validate a prediction model using CXR based on an AI model and clinical variables to predict clinical outcomes in patients with COVID-19. This retrospective longitudinal study included patients hospitalized for COVID-19 at multiple COVID-19 medical centers between February 2020 and October 2020. Patients at Boramae Medical Center were randomly classified into training, validation, and internal testing sets (at a ratio of 8:1:1, respectively). An AI model using initial CXR images as input, a logistic regression model using clinical information, and a combined model using the output of the AI model (as CXR score) and clinical information were developed and trained to predict hospital length of stay (LOS) ≤2 weeks, need for oxygen supplementation, and acute respiratory distress syndrome (ARDS). The models were externally validated in the Korean Imaging Cohort of COVID-19 data set for discrimination and calibration. The AI model using CXR and the logistic regression model using clinical variables were suboptimal to predict hospital LOS ≤2 weeks or the need for oxygen supplementation but performed acceptably in the prediction of ARDS (AI model area under the curve [AUC] 0.782, 95% CI 0.720-0.845; logistic regression model AUC 0.878, 95% CI 0.838-0.919). The combined model performed better in predicting the need for oxygen supplementation (AUC 0.704, 95% CI 0.646-0.762) and ARDS (AUC 0.890, 95% CI 0.853-0.928) compared to the CXR score alone. Both the AI and combined models showed good calibration for predicting ARDS (P=.079 and P=.859). The combined prediction model, comprising the CXR score and clinical information, was externally validated as having acceptable performance in predicting severe illness and excellent performance in predicting ARDS in patients with COVID-19.

Comparison of outcomes between observation and tube thoracostomy for small traumatic pneumothoraces

BackgroundTraumatic pneumothorax management has evolved to include the use of smaller caliber tube thoracostomy and even observation alone. Data is limited comparing tube thoracostomy to observation for small traumatic pneumothoraces. We aimed to investigate whether observing patients with a small traumatic pneumothorax on initial chest radiograph (CXR) is associated with improved outcomes compared to tube thoracostomy. MethodsWe retrospectively reviewed trauma patients at our level 1 trauma center from January 1, 2016 through December 31, 2020. We included those with a pneumothorax size <30 mm as measured from apex to cupola on initial CXR. We excluded patients with injury severity score ≥ 25, operative requirements, hemothorax, bilateral pneumothoraces, and intensive care unit admission. Patients were grouped by management strategy (observation vs tube thoracostomy). Our primary outcome was length of stay with secondary outcomes of pulmonary infection, failed trial of observation, readmission, and mortality. Results are listed as mean ± standard error of the mean. ResultsOf patients who met criteria, 39 were in the observation group, and 34 were in the tube thoracostomy group. Baseline characteristics were similar between the groups. Average pneumothorax size on CXR was 18 ± 1.0 mm in the observation group and 18 ± 0.84 mm in the tube thoracostomy group (p > 0.99). Average pneumothorax sizes on computed tomography were 25 ± 2.1 and 37 ± 3.9 mm in the observation and tube thoracostomy groups, respectively (p = 0.01). Length of stay in the observation group was significantly shorter than the tube thoracostomy group (3.6 ± 0.33 vs 5.8 ± 0.81 days, p < 0.01). While pneumothorax size on computed tomography was associated with tube thoracostomy, only tube thoracostomy correlated with length of stay on multivariable analysis; pneumothorax size on CXR and computed tomography did not. There were no deaths or readmissions in either cohort. One patient in the observation group required tube thoracostomy after 18 h for worsening subcutaneous emphysema, and one patient in the tube thoracostomy group developed an empyema. ConclusionsSelect patients with small traumatic pneumothoraces on initial chest radiograph who were treated with observation experienced an average length of stay over two days shorter than those treated with tube thoracostomy. Outcomes were otherwise similar between the two groups suggesting that an observation-first strategy may be a superior treatment approach for these patients.

882: A CASE OF VENTILATOR MALFUNCTION-INDUCED PNEUMOTHORAX

Introduction: Mechanical ventilation is one of the major advances in modern medicine, used in multiple conditions including respiratory or cardiac failure. Ventilator associated lung injuries are not uncommon and are associated with high airway volumes or pressures. This case highlights a patient with no pulmonary concerns, on minimal vent settings who developed a pneumothorax from an uncommon issue with the ventilator. Description: The patient is an adult male with no known prior diagnosis, brought in from a shelter with concerns for encephalopathy from drug overdose. In the ED he had a temp 105.8F and was obtunded. He was intubated for severe encephalopathy. Initial ICU CXR was unremarkable with ET tube in good position. Vent settings: AC-VC,TV 450/RR20/FiO2 40/PEEP 5 for IBW 72kg.On day 2,it was observed that the ET tube end adaptor kept popping out causing the vent alarms to go off. Changing the adaptor and later the ET tube did not resolve the issue. The ventilator then detected low exhaled volumes with alarm messages “Low tidal volume” and “airway obstruction”. His peak/plateau pressures also became high. Both were normal the day prior. New findings of poor air entry in the right lung was later noted with ultrasound demonstrating absence of lung slide and CXR confirming pneumothorax. Chest tube was placed with lung expansion confirmed. Despite this the vent still showed low expiratory volumes with alarm messages of airway obstruction and high airway pressures. The vent circuit was changed and other vent settings were tried but failed. Finally the vent itself was changed and his readings immediately normalized and alarms ceased. Retrospective analysis revealed the vent had a faulty exhalation valve preventing air return from the circuit, causing buildup of inspiratory volumes, high airway pressures and pneumothorax. Discussion: Ventilators are frequently tested to mitigate malfunction. Most have self-diagnostic software but this is not infallible. It is rare but not unheard of for a ventilator fault to cause a number of varied pathologies which in this case resulted in a pneumothorax. We seldom consider the vent as the cause in maladaptive respiratory scenarios. Though “faulty device” may be low on our differentials, it should never be off it when troubleshooting an alarming ventilator.

Abstract 14105: Stent Ahoy: Ventricular Tachycardia Due to Stent Migration Into the Right Ventricle

Case: A 46-year-old female with PMHx of ESRD on dialysis and prothrombin gene mutation presented with acute onset of left breast swelling, redness and pain for nearly 24 hours. She was found to have SVC occlusion and underwent successful SVC recanalization and stent placement with an uncovered 14x40 mm nitinol stent. She presented 4 days later with complaints of chest pain and shortness of breath. Initial vitals were notable for tachypnea with oxygen saturations of nearly 70%, and a blood pressure of 114/71 mmHg. Physical exam demonstrated an obese female in distress. Shortly after arrival in the emergency department, she developed a non-sustained episode of ventricular tachycardia (NSVT). Amiodarone and lidocaine were started, however, she continued to have runs of NSVT. Initial CXR found no acute process but failed to demonstrate the previously placed SVC stent. ECG demonstrated normal sinus rhythm with frequent PVCs and runs of NSVT. A limited echo demonstrated a free edge of an endovascular stent within the right ventricle. TEE demonstrated the stent appeared to be tethered to the septal leaflet of the tricuspid valve with the leading edge free within the right ventricle. Endovascular retrieval was proposed but given the degree of entanglement within the tricuspid leaflets, large stent size, and recurrent NSVT, was deemed an unsuitable therapeutic strategy. Urgent open-heart surgery was performed for removal. The patient tolerated the procedure well and had no further recurrence of NSVT. Discussion: Stent migration is a rare but feared complication of venous stent deployment, with only 32 reported cases over the past 30 years. While NSVT is often attributed to the RVOT, the etiology being the result of migrated stents has been rarely reported. This is the first case to our knowledge of SVC stent migration leading to runs of NSVT. Conclusion: Clinicians must remain cognizant of the risk for venous stent migration and unusual clinical presentations resulting from migration.

RENAL CELL CARCINOMA PRESENTING AS LUNG COLLAPSE

RENAL CELL CARCINOMA PRESENTING AS LUNG COLLAPSE

CXR severity scores of COVID 19 infection in Sri Lanka: findings of a multicenter study during the first wave of the pandemic

Introduction: Chest X-ray initially remained the only imaging modality in the first wave of the COVID -19 pandemic in Sri Lanka similar to many other low resource settings. Sri Lanka claimed a cluster epidemic status achieving a case fatality rate well below the global rate during the first wave. Objectives: To describe degree of lung involvement on CXR as a severity score and correlate severity scores with symptom duration, presence of comorbidities and demographic factors. Methods: A retrospective study at four main hospitals in Sri Lanka included all RT-PCR positive COVID-19 patients who underwent CXR from January to mid May, 2020. Both initial and follow-up CXR were independently double reported by a team of four radiologists and discrepancy reported by a fifth radiologist for radiographic findings and lung involvement. Clinical and demographic data was retrieved from hospital records. A severity score was calculated for each CXR. Associations were analyzed for CXRs with a severity score of 1 or more. Results: 217 CXRs of 133 patients (99 men, mean age 43.9±15.7 years;133 initial CXRs of 132 symptomatic patients; 84 follow-up radiographs of 33 patients) revealed 96(96/133;72.2%) normal initial CXRs. 12 patients with normal initial CXRs(12/96;12.5%) underwent follow up CXR but none was abnormal. Majority (21/37;56.75%) with abnormal CXR had mild (severity score 1-2) lung involvement. A severity score of 1 or more was associated with comorbidities (OR=3.14), male sex (OR=5.93) and increasing age (OR=1.06). Conclusion: Majority of CXR in COVID-19 patients were normal during first wave in Sri Lanka. Majority with abnormal CXR had mild lung involvement.

Diagnostic value of chest radiography in the early management of severely injured patients with mediastinal vascular injury

IntroductionTime is of the essence in the management of severely injured patients. This is especially true in patients with mediastinal vascular injury (MVI). This rare, yet life threatening injury needs early detection and immediate decision making. According to the ATLS guidelines [American College of Surgeon Committee on Trauma in Advanced Trauma Life Support (ATLS®), 10th edn, 2018], chest radiography (CXR) is one of the first-line imaging examinations in the Trauma Resuscitation Unit (TRU), especially in patients with MVI. Yet thorough interpretation and the competence of identifying pathological findings are essential for accurate diagnosis and drawing appropriate conclusion for further management. The present study evaluates the role of CXR in detecting MVI in the early management of severely injured patients.MethodWe addressed the question in two ways. (1) We performed a retrospective, observational, single-center study and included all primary blunt trauma patients over a period of 2 years that had been admitted to the TRU of a Level-I Trauma Center. Mediastinal/chest (M/C) ratio measurements were calculated from CXRs at three different levels of the mediastinum to identify MVI. Two groups were built: with MVI (VThx) and without MVI (control). The accuracy of the CXR findings were compared with the results of whole-body computed tomography scans (WBCT). (2) We performed another retrospective study and evaluated the usage of sonography, CXR and WBCT over 15 years (2005–2019) in level-I–III Trauma Centers in Germany as documented in the TraumaRegister DGU® (TR-DGU).ResultsStudy I showed that in 2 years 267 patients suffered from a significant blunt thoracic trauma (AIS ≥ 3) and met the inclusion criteria. 27 (10%) of them suffered MVI (VThx). Through the initial CXR in a supine position, MVI was detected in 56–92.6% at aortic arch level and in 44.4–100% at valve level, depending on different M/C-ratios (2.0–3.0). The specificity at different thresholds of M/C ratio was 63.3–2.9% at aortic arch level and 52.9–0.4% at valve level. The ROC curve showed a statistically random process. No significant differences of the cardiac silhouette were observed between VThx and Control (mean cardiac width was 136.5 mm, p = 0.44). Study II included 251,095 patients from the TR-DGU. A continuous reduction of the usage of CXR in the TRU could be observed from 75% in 2005 to 25% in 2019. WBCT usage increased from 35% in 2005 to 80% in 2019. This development was observed in all trauma centers independently from their designated level of care.ConclusionAccording to the TRU management guidelines (American College of Surgeon Committee on Trauma in Advanced Trauma Life Support (ATLS®), 10th edn, 2018; Reissig and Kroegel in Eur J Radiol 53:463–470, 2005) CXR in supine position is performed to detect pneumothorax, hemothorax and MVI. Our study showed that sensitivity and specificity of CXR in detecting MVI was statistically and clinically not reliable. Previous studies have already shown that CXR is inferior to sonography in detecting pneumothorax and hemothorax. Therefore, we challenge the guidelines and suggest that the use of CXR in the early management of severely injured patients should be individualized. If sonography and WBCT are available and reasonable, CXR is unnecessary and time consuming. The clinical reality reflected in the usage of CXR and WBCT over time, as documented in the TR-DGU, seems to support our statement.

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

PurposeTo determine the incidence and clinical predictors of intrathoracic complications in COVID-19 patients, and the association with outcomes. MethodsIn 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. ResultsThere 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). ConclusionIn 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. SummaryIntrathoracic 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.

VARICELLA PNEUMONIA: ADULT COMPLICATIONS OF A CHILDHOOD DISEASE

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Varicella has drastically declined since 1995 when vaccination was introduced in the United States. Children accounted for the majority of cases but adults were more likely to develop complicated disease. Pneumonia has been shown to be disproportionally present in adults and we present two such cases of varicella pneumonia. CASE PRESENTATION: A 25-year-old male who recently immigrated from Guatemala presented with a rash that began on his face and spread down to his trunk. He noted a dry cough, shortness of breath, fevers, sore throat and lethargy. He was febrile and tachycardic with a widespread vesicular rash, and lesions in varying stages of healing. His CT noted nodular opacities in the mid and upper lungs with a prominent 13mm nodule in the right apex. He was found to have a bandemia and a positive varicella IgM. He was treated with a course of IV acyclovir and was discharged with a plan to obtain repeat imaging to follow up the nodules.A 38-year-old man with polysubstance use and asthma presented with shortness of breath and a rash that started on his scalp and descended to his chest and back associated with a burning sensation. He had a cough without sputum production. He was afebrile on exam and had a diffuse rash over the face and trunk consistent with chickenpox. The initial CXR showed bilateral infiltrates and CT chest noted numerous pulmonary nodules throughout both lung fields. Atypical infection was the initial concern but a broad workup was otherwise unrevealing other than a positive zoster IgM. He was treated with valacyclovir and discharged with a plan for repeat imaging. DISCUSSION: With varicella vaccination efforts, incidence, hospitalizations and deaths have all decreased since 19954. Adults are more prone to pneumonia, which has been reported as the leading cause of complicated disease in adults, up to 1/400 patients, but total incidence is likely difficult to assess as many patients with mild symptoms may not have radiographs. Smoking, pregnancy, immunosuppression and male sex are considered risk factors for pneumonia. On xray diffuse bilateral infiltrates and nodularity can be seen, while CTs can show nodular opacities, patchy ground glass opacities, or even a miliary pattern that generally resolve as the rash does, but can persist as calcified nodules. CONCLUSIONS: These cases highlight the need for providers to be able to recognize vaccine preventable diseases, especially in patients not born in the United States. With the current climate of vaccine hesitancy, it is likely health care providers will experience the ill effects of adult varicella in the future as unvaccinated children become adults susceptible to more invasive disease. REFERENCE #1: Alanezi, M. (2007). Varicella pneumonia in adults: 13 Years' experience with review of literature. Annals of Thoracic Medicine, 2(4), 163–165. https://doi.org/10.4103/1817-1737.36551 REFERENCE #2: Franquet, T. (2011). Imaging of pulmonary viral pneumonia. Radiology, 260(1), 18–39. https://doi.org/10.1148/radiol.11092149 REFERENCE #3: Guris, D., Jumaan, A. O., Mascola, L., Watson, B. M., Zhang, J. X., Chaves, S. S., Gargiullo, P., Perella, D., Civen, R., & Seward, J. F. (2008). Changing varicella epidemiology in active surveillance sites - United States, 1995-2005. Journal of Infectious Diseases, 197(SUPPL. 2), 71–75. https://doi.org/10.1086/522156 DISCLOSURES: No relevant relationships by Jacqueline Burnell, source=Web Response No relevant relationships by Rohit Gupta, source=Web Response No relevant relationships by Truong-An Ho, source=Web Response

A CRACK LUNG WITH CRACK COCAINE

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Crack lung is an acute pulmonary syndrome with a spectrum of clinical and histopathologic findings occurring within 48 hours of smoking crack cocaine.1 Patients may present with clinical features of pneumonia. As such, it is important to differentiate the two clinical entities as the management approach differs. Here we present a case of acute pulmonary cocaine toxicity mimicking possible pneumonia. CASE PRESENTATION: A 40 year old man with a history of depression was brought in by paramedics after being found unconscious.He was given naloxone en route with improved consciousness but was tachypneic and hypoxic, requiring oxygen. On arrival to the Emergency Department, he admitted to having smoked crack cocaine which was impure.He reported having hemoptysis and rhinorrhea but denied any chest pain, fever or any gastrointestinal symptoms.There was no personal or family history of lung or autoimmune disease. On presentation he was afebrile, tachycardic, tachypneic and persistently hypoxic requiring high flow nasal cannula (HFNC). Pertinent findings were diminished breath sounds with diffuse rales, with an otherwise unremarkable exam. Laboratory results were notable for cocaine on urine toxicology, leukocytosis with neutrophilia, elevated procalcitonin with normal CRP, BNP, serial troponins, lactic acid, COVID-19 test and HIV. Initial CXR showed bilateral extensive nodular interstitial lung pattern. He was admitted for acute hypoxic respiratory failure (AHRF) secondary to crack lung syndrome with superimposed pneumonia on HFNC and started on empiric antibiotics as well as methylprednisolone. Unfortunately, he remained persistently tachypneic and required non-invasive ventilation (NIV) and transfer to the intensive care unit. On day 2, his respiratory status markedly improved and he was weaned from NIV to room air. Final blood cultures and mycoplasma antibody were negative and the rest of his hospital stay was uneventful. DISCUSSION: In 2018, approximately 5.5 million persons aged ≥ 12 years reported cocaine use within the past year of which 757,000 used crack cocaine.2,3 With likely underreported usage, the deleterious pulmonary complications related to cocaine use including pulmonary edema, alveolar hemorrhage, eosinophilic pneumonia, pneumothorax, thromboembolic disease and AHRF,4 are clinically relevant. However, the diagnosis of cocaine-induced pulmonary diseases remains challenging for clinicians given that the clinical features and chest images are non specific and can mimic several other processes e.g. pneumonia.5 This distinction is important as mortality for pneumonia requiring ICU admission approaches 30%,6 while acute eosinophilic pneumonia portends an excellent prognosis with rapid clinical recovery. CONCLUSIONS: This case highlights that "Crack Lung" should be considered as a differential diagnosis in patients with AHRF and diffuse bilateral pulmonary infiltrates. REFERENCE #1: Forrester, J. M., Steele, A. W., Waldron, J. A., & Parsons, P. E. (1990). Crack lung: an acute pulmonary syndrome with a spectrum of clinical and histopathologic findings. The American review of respiratory disease, 142(2), 462–467. https://doi.org/10.1164/ajrccm/142.2.462 REFERENCE #2: National Institute on Drug Abuse.(2020) What is the scope of cocaine use in the United States? Available from:https://www.drugabuse.gov/publications/research-reports/cocaine/what-scope-cocaine-use-in-united-states REFERENCE #3: 3.Center for Disease Control and Prevention. (2019). Annual surveillance report of drug-related risks and outcome. Available from:https://www.cdc.gov/drugoverdose/pdf/pubs/2019-cdc-drug-surveillance-report.pdf DISCLOSURES: No relevant relationships by Sahai Donaldson, source=Web Response No relevant relationships by Lorenzo Leys, source=Web Response No relevant relationships by Alicia Thomas, source=Web Response No relevant relationships by Felix Wireko, source=Web Response

Chest X-ray sensitivity and lung cancer outcomes: a retrospective observational study.

BackgroundChest X-ray (CXR) is the first-line investigation for lung cancer in many healthcare systems. An understanding of the consequences of false-negative CXRs on time to diagnosis, stage, and survival is limited.AimTo determine the sensitivity of CXR for lung cancer and to compare stage at diagnosis, time to diagnosis, and survival between those with CXR that detected, or did not detect, lung cancer.Design and settingRetrospective observational study using routinely collected healthcare data.MethodAll patients diagnosed with lung cancer in Leeds Teaching Hospitals NHS Trust during 2008–2015 who had a GP-requested CXR in the year before diagnosis were categorised based on the result of the earliest CXR performed in that period. The sensitivity of CXR was calculated and analyses were performed with respect to time to diagnosis, survival, and stage at diagnosis.ResultsCXR was negative for 17.7% of patients (n = 376/2129). Median time from initial CXR to diagnosis was 43 days for those with a positive CXR and 204 days for those with a negative CXR. Of those with a positive CXR, 29.8% (95% confidence interval [CI] = 27.9% to 31.8%) were diagnosed at stage I or II, compared with 33.5% (95% CI = 28.8% to 38.6%) with a negative CXR.ConclusionGPs should consider lung cancer in patients with persistent symptoms even when CXR is negative. Despite longer duration to diagnosis for those with false-negative CXRs, there was no evidence of an adverse impact on stage at diagnosis or survival; however, this comparison is likely to be affected by confounding variables.

Initial chest radiograph scores inform COVID-19 status, intensive care unit admission and need for mechanical ventilation

AIMTo evaluate whether portable chest radiography (CXR) scores are associated with coronavirus disease 2019 (COVID-19) status and various clinical outcomes.MATERIALS AND METHODSThis retrospective study included 500 initial CXR from COVID-19-suspected patients. Each CXR was scored based on geographic extent and degree of opacity as indicators of disease severity. COVID-19 status and clinical outcomes including intensive care unit (ICU) admission, mechanical ventilation, mortality, length of hospitalisation, and duration on ventilator were collected. Multivariable logistic regression analysis was performed to evaluate the relationship between CXR scores and COVID-19 status, CXR scores and clinical outcomes, adjusted for code status, age, gender and co-morbidities.RESULTSThe interclass correlation coefficients amongst raters were 0.94 and 0.90 for the extent score and opacity score, respectively. CXR scores were significantly (p < 0.01) associated with COVID-19 positivity (odd ratio [OR] = 1.49; 95% confidence interval [CI]: 1.27 - 1.75 for extent score and OR = 1.75; 95% CI: 1.42 - 2.15 for opacity score), ICU admission (OR = 1.19; 95% CI: 1.09 - 1.31 for extent score and OR = 1.26; 95% CI: 1.10 - 1.44 for opacity score), and invasive mechanical ventilation (OR = 1.22; 95% CI: 1.11 - 1.35 for geographic score and OR = 1.21; 95% CI: 1.05 - 1.38 for opacity score). CXR scores were not significantly different between survivors and non-survivors after adjusting for code status (p>0.05). CXR scores were not associated with length of hospitalisation or duration on ventilation (p>0.05).CONCLUSIONSInitial CXR scores have prognostic value and are associated with COVID-19 positivity, ICU admission, and mechanical ventilation.

Portable Chest Radiography as an Exclusionary Test for Adverse Clinical Outcomes During the COVID-19 Pandemic

BackgroundChest 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 QuestionIs portable CXR an effective exclusionary test for future adverse clinical outcomes in patients suspected of having COVID-19?Study Design and MethodsCharts 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.ResultsThree 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.InterpretationInitial 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.

Role of chest radiography in the management of COVID-19 pneumonia: An overview and correlation with pathophysiologic changes.

Background:Chest radiography (CXR) is a widely available baseline radiological modality in evaluating symptomatic patients with suspected or confirmed Covid-19 disease. Serial changes can help in monitoring the patients in conjunction with the clinical status of these patients in a hospital setting.Purpose:The purpose of this study was to analyse the patterns of radiological findings on chest radiograph (CXR) for suspected and confirmed COVID-19 patients on initial presentation to the emergency medical services (EMS) on admission and to assess the progression and resolution.Materials and Methods:In this study, patients who presented to EMS of a multispeciality hospital as suspected or confirmed Covid-19 on consecutive reverse transcriptase polymerase chain reaction (RT-PCR). CXR was examined for findings of haziness, patterns and distribution of opacities. Progression and regression of findings in serial CXR were studied and evaluated with the clinical and laboratory parameters. High resolution CT (HRCT) chest was performed initially for some patients.Results:756 RT-PCR confirmed COVID-19 patients were included in our study who had initial CXR. 510 (67.46%) of our patients with positive initial RT-PCR showed abnormal baseline CXR. The abnormal findings were described as haziness akin to ground glass opacities (GGO) on CT, peripheral opacities, patchy parenchymal opacities and consolidation. Peripheral opacities and lower zone distribution were the commonest pattern of CXR abnormalities with bilateral involvement. The severity of findings on serial CXR and radiographic regression was studied along with follow-up to assess response to treatment. Forty-six patients showed features of acute lung injury (ALI). Complications and new CXR findings were reported for patients who were given ventilator support.Conclusion:CXR is a valuable baseline radiological investigation on hospital admission in symptomatic patients with suspected or confirmed Covid-19 presenting to the EMS as it helps to monitor the progress and regression of the disease in conjunction with clinical findings.

Reliability of chest radiograph interpretation for pulmonary tuberculosis in the screening of childhood TB contacts and migrant children in the UK

To determine interobserver agreement between paediatric radiologists interpreting tuberculosis (TB) screening chest radiographs (CXR) in children in the UK, and the TB detection rate. A retrospective review was undertaken of electronic request, notes, and CXRs (>7 years) in children exposed to an infectious case of TB and new entrants to the UK, at a tertiary children's hospital. Included were those with positive Mantoux/interferon gamma release assay (IGRA), positive culture, or high clinical suspicion of TB. CXR reports were categorised as normal, abnormal without features of TB, or abnormal with features of pulmonary TB. Three paediatric radiologists from a dedicated paediatric radiology department evaluated available CXRs, aware of the TB screening indication, using a published CXR reporting tool and blinded to the initial CXR report and to each other. A majority decision was collated, and considered lymphadenopathy and miliary nodules as diagnostic of primary TB. Interobserver agreement was calculated using Cohen's kappa. One hundred and forty-eight children underwent TB screening with a CXR. One hundred and twenty-five had available CXR reports and case notes, which indicated 20/125 (16%) had CXR features of TB. One hundred and twenty-one of the 125 had CXRs available to for panel review. Twenty of these 121 (17%) yielded a majority decision of pulmonary TB. Inter-reader agreement was moderate in all aspects (kappa 0.4-0.6). The high percentage of pulmonary TB on CXR (16% original reports; 17% by panel review) suggests that it is worthwhile investigating childhood TB contacts; however, the routine use and recommendation for CXR is questionable because of only moderate interpretation reliability (kappa 0.5), even by experts.

Detection of COVID-19 Using Deep Learning Algorithms on Chest Radiographs.

To evaluate the performance of a deep learning (DL) algorithm for the detection of COVID-19 on chest radiographs (CXR). In this retrospective study, a DL model was trained on 112,120 CXR images with 14 labeled classifiers (ChestX-ray14) and fine-tuned using initial CXR on hospital admission of 509 patients, who had undergone COVID-19 reverse transcriptase-polymerase chain reaction (RT-PCR). The test set consisted of a CXR on presentation of 248 individuals suspected of COVID-19 pneumonia between February 16 and March 3, 2020 from 4 centers (72 RT-PCR positives and 176 RT-PCR negatives). The CXR were independently reviewed by 3 radiologists and using the DL algorithm. Diagnostic performance was compared with radiologists' performance and was assessed by area under the receiver operating characteristics (AUC). The median age of the subjects in the test set was 61 (interquartile range: 39 to 79) years (51% male). The DL algorithm achieved an AUC of 0.81, sensitivity of 0.85, and specificity of 0.72 in detecting COVID-19 using RT-PCR as the reference standard. On subgroup analyses, the model achieved an AUC of 0.79, sensitivity of 0.80, and specificity of 0.74 in detecting COVID-19 in patients presented with fever or respiratory systems and an AUC of 0.87, sensitivity of 0.85, and specificity of 0.81 in distinguishing COVID-19 from other forms of pneumonia. The algorithm significantly outperforms human readers (P<0.001 using DeLong test) with higher sensitivity (P=0.01 using McNemar test). A DL algorithm (COV19NET) for the detection of COVID-19 on chest radiographs can potentially be an effective tool in triaging patients, particularly in resource-stretched health-care systems.