RadioGraphics Update: The 10 Pillars of Lung Cancer Screening-Rationale and Logistics of a Lung Cancer Screening Program.

Editor's Note.-RadioGraphics Update articles supplement or update information found in full-length articles previously published in RadioGraphics. These updates, written by at least one author of the previous article, provide a brief synopsis that emphasizes important new information such as technological advances, revised imaging protocols, new clinical guidelines involving imaging, or updated classification schemes.

Chronic Pulmonary Manifestations of COVID-19 Infection: Imaging Evaluation.

This case presents a patient with severe COVID-19 pneumonia requiring intensive care unit admission and a prolonged hospital stay. The infection resulted in long-term morbidity, functional decline, and abnormal chest CT findings. The mechanisms for long-term lung injury after COVID-19 infection, imaging appearances, and the role of imaging in follow-up are discussed.

Long-term Lung Abnormalities Associated with COVID-19 Pneumonia.

In the 3rd year of the SARS-CoV-2 pandemic, much has been learned about the long-term effects of COVID-19 pneumonia on the lungs. Approximately one-third of patients with moderate-to-severe pneumonia, especially those requiring intensive care therapy or mechanical ventilation, have residual abnormalities at chest CT 1 year after presentation. Abnormalities range from parenchymal bands to bronchial dilation to frank fibrosis. Less is known about the long-term pulmonary vascular sequelae, but there appears to be a persistent, increased risk of venothromboembolic events in a small cohort of patients. Finally, the associated histologic abnormalities resulting from SARS-CoV-2 infection are similar to those seen in patients with other causes of acute lung injury.

Rate of True-Positive Findings of COVID-19 Typical Appearance at Chest CT per RSNA Consensus Guidelines in an Increasingly Vaccinated Population.

Background RSNA consensus guidelines for COVID-19-related chest CT are widely used but, to the knowledge of the authors, their rate of true-positive findings for COVID-19 pneumonia in vaccinated patients has not been assessed. Purpose To assess the rate of true-positive findings of typical appearance for COVID-19 at chest CT by using RSNA guidelines in fully vaccinated patients with polymerase chain reaction (PCR)-confirmed COVID-19 infection compared with unvaccinated patients. Materials and Methods Included were patients with COVID-19 who had typical appearance on chest CT images and one PCR test for COVID-19 with a positive result or two tests with negative results within 7 days of undergoing chest CT between January 2021 and January 2022 at a quaternary academic medical center. True-positive findings were defined as chest CT images interpreted as COVID-19 typical appearance and PCR-confirmed COVID-19 infection within 7 days. Logistic regression models were constructed to quantify the association between PCR results and vaccination status, vaccination status and COVID-19 variants, and vaccination status and number of months. Results Included were 652 patients (median age, 59 years; IQR, 48-72 years; 371 men [57%]) with CT scans classified as typical appearance. Of those patients, 483 (74%) were unvaccinated and 169 (26%) were fully vaccinated. The overall rate of true-positive findings on CT images rated as typical appearance was lower in vaccinated versus unvaccinated patients (70 of 169 [41%; 95% CI: 34, 49] vs 352 of 483 [73%; 95% CI: 69, 77]; odds ratio [OR], 3.8 [95% CI: 2.6, 5.5]; P < .001). Unvaccinated patients were more likely to have true-positive findings on CT images compared with fully vaccinated patients during the peaks of COVID-19 variants Alpha (OR, 16; 95% CI: 6, 42; P < .001) and Delta (OR, 8; 95% CI: 4, 16; P < .001), but no statistical differences were found during the peak of the Omicron variant (OR, 1.7; 95% CI: 0.3, 11; P = .56). Conclusion Fully vaccinated patients with confirmed COVID-19 breakthrough infections had lower rates of true-positive findings of COVID-19 typical appearance at chest CT. © RSNA, 2022 Supplemental material is available for this article.

U.S. Newspaper Coverage of Lung Cancer Screening From 2010 to 2022.

BACKGROUND. Newspapers are an important source of information for the public about low-dose CT (LDCT) lung cancer screening (LCS) and may influence public perception and knowledge of this important cancer screening service. OBJECTIVE. The purpose of this article was to evaluate the volume, content, and other characteristics of articles pertaining to LCS that have been published in U.S. newspapers. METHODS. The ProQuest U.S. Newsstream database was searched for U.S. newspaper articles referring to LCS published between January 1, 2010 (the year of publication of the National Lung Screening Trial results), and March 28, 2022. Search terms included "lung cancer screening(s)," "lung screening(s)," "low dose screening(s)," and "LDCT." Search results were reviewed to identify those articles mentioning LCS. Characteristics of included articles and originating newspapers were extracted. Articles were divided among nine readers, who independently assessed article sentiment regarding LCS and additional article content using a standardized form. RESULTS. The final analysis included 859 articles, comprising 816 nonsyndicated articles published in a single newspaper and 43 syndicated articles published in multiple newspapers. Sentiment regarding LCS was positive in 76% (651/859) of articles, neutral in 21% (184/859), and negative in 3% (24/859). Frequency of positive sentiment was lowest (61%) for articles published from 2010 to 2012; frequency of negative sentiment was highest (8%) for articles published in newspapers in the highest quartile for weekly circulation. LCS enrollment criteria were mentioned in 52% of articles, smoking cessation programs in 28%, need for annual CT in 27%, and shared decision-making in 4%. Cost or insurance coverage for LCS was mentioned in 33% in articles. A total of 64% of articles mentioned at least one benefit of LCS (most commonly early detection or possible cure of lung cancer), and 23% mentioned at least one harm (most commonly false-positives). A total of 9% of articles interviewed or mentioned a radiologist. CONCLUSION. The sentiment of U.S. newspaper articles covering LCS from 2010 to 2022 was overall positive. However, certain key elements of LCS were infrequently mentioned. CLINICAL IMPACT. The findings highlight areas for potential improvement of LCS media coverage; radiologists have an opportunity to take a more active role in this coverage.

Abdominal Imaging Findings on Computed Tomography as a Tool for COVID-19 Mortality Risk Assessment: Comparison With Chest Radiograph Severity Scores.

OBJECTIVE: To quantify the association between computed tomography abdomen and pelvis with contrast (CTAP) findings and chest radiograph (CXR) severity score, and the incremental effect of incorporating CTAP findings into predictive models of COVID-19 mortality. METHODS: This retrospective study was performed at a large quaternary care medical center. All adult patients who presented to our institution between March and June 2020 with the diagnosis of COVID-19 and had a CXR up to 48 hours before a CTAP were included. Primary outcomes were the severity of lung disease before CTAP and mortality within 14 and 30 days. Logistic regression models were constructed to quantify the association between CXR score and CTAP findings. Penalized logistic regression models and random forests were constructed to identify key predictors (demographics, CTAP findings, and CXR score) of mortality. The discriminatory performance of these models, with and without CTAP findings, was summarized using area under the characteristic (AUC) curves. RESULTS: One hundred ninety-five patients (median age, 63 years; 119 men) were included. The odds of having CTAP findings was 3.89 times greater when a CXR score was classified as severe compared with mild (P = 0.002). When CTAP findings were included in the feature set, the AUCs for 14-day mortality were 0.67 (penalized logistic regression) and 0.71 (random forests). Similar values for 30-day mortality were 0.76 and 0.75. When CTAP findings were omitted, all AUC values were attenuated. CONCLUSIONS: The CTAP findings were associated with more severe CXR score and may serve as predictors of COVID-19 mortality.

Vasculopathy and Increased Vascular Congestion in Fatal COVID-19 and Acute Respiratory Distress Syndrome.

Rationale: The leading cause of death in coronavirus disease 2019 (COVID-19) is severe pneumonia, with many patients developing acute respiratory distress syndrome (ARDS) and diffuse alveolar damage (DAD). Whether DAD in fatal COVID-19 is distinct from other causes of DAD remains unknown. Objective: To compare lung parenchymal and vascular alterations between patients with fatal COVID-19 pneumonia and other DAD-causing etiologies using a multidimensional approach. Methods: This autopsy cohort consisted of consecutive patients with COVID-19 pneumonia (n = 20) and with respiratory failure and histologic DAD (n = 21; non-COVID-19 viral and nonviral etiologies). Premortem chest computed tomography (CT) scans were evaluated for vascular changes. Postmortem lung tissues were compared using histopathological and computational analyses. Machine-learning-derived morphometric analysis of the microvasculature was performed, with a random forest classifier quantifying vascular congestion (CVasc) in different microscopic compartments. Respiratory mechanics and gas-exchange parameters were evaluated longitudinally in patients with ARDS. Measurements and Main Results: In premortem CT, patients with COVID-19 showed more dilated vasculature when all lung segments were evaluated (P = 0.001) compared with controls with DAD. Histopathology revealed vasculopathic changes, including hemangiomatosis-like changes (P = 0.043), thromboemboli (P = 0.0038), pulmonary infarcts (P = 0.047), and perivascular inflammation (P < 0.001). Generalized estimating equations revealed significant regional differences in the lung microarchitecture among all DAD-causing entities. COVID-19 showed a larger overall CVasc range (P = 0.002). Alveolar-septal congestion was associated with a significantly shorter time to death from symptom onset (P = 0.03), length of hospital stay (P = 0.02), and increased ventilatory ratio [an estimate for pulmonary dead space fraction (Vd); p = 0.043] in all cases of ARDS. Conclusions: Severe COVID-19 pneumonia is characterized by significant vasculopathy and aberrant alveolar-septal congestion. Our findings also highlight the role that vascular alterations may play in Vd and clinical outcomes in ARDS in general.

Radiology Implementation Considerations for Artificial Intelligence (AI) Applied to COVID-19, From the AJR Special Series on AI Applications.

Hundreds of imaging-based artificial intelligence (AI) models have been developed in response to the COVID-19 pandemic. AI systems that incorporate imaging have shown promise in primary detection, severity grading, and prognostication of outcomes in COVID-19, and have enabled integration of imaging with a broad range of additional clinical and epidemiologic data. However, systematic reviews of AI models applied to COVID-19 medical imaging have highlighted problems in the field, including methodologic issues and problems in real-world deployment. Clinical use of such models should be informed by both the promise and potential pitfalls of implementation. How does a practicing radiologist make sense of this complex topic, and what factors should be considered in the implementation of AI tools for imaging of COVID-19? This critical review aims to help the radiologist understand the nuances that impact the clinical deployment of AI for imaging of COVID-19. We review imaging use cases for AI models in COVID-19 (e.g., diagnosis, severity assessment, and prognostication) and explore considerations for AI model development and testing, deployment infrastructure, clinical user interfaces, quality control, and institutional review board and regulatory approvals, with a practical focus on what a radiologist should consider when implementing an AI tool for COVID-19.

Lung cancer screening eligibility and use with low-dose computed tomography: Results from the 2018 Behavioral Risk Factor Surveillance System cross-sectional survey.

BACKGROUND: In randomized controlled trials, lung cancer screening with low-dose chest computed tomography (LCS) has been reported to reduce lung cancer mortality. Although initial studies suggested that only approximately 5% of eligible patients have undergone LCS, recent studies have indicated that use of LCS may be increasing nationwide. The objective of the current study was to estimate recent LCS use using cross-sectional survey data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) survey. METHODS: The BRFSS is a nationally representative, cross-sectional telephone survey of adults in the United States (response rate of approximately 50%). The 2018 BRFSS survey included questions regarding LCS eligibility and use in 8 states. The primary outcome was the percentage of participants (aged 55-79 years with a smoking history of >30 pack-years) who reported undergoing LCS. Logistic regression analyses evaluated the association between LCS use and sociodemographic characteristics, adjusted for potential confounders and accounting for complex survey design elements. RESULTS: A total of 26,910 participants were included, 9.9% of whom were eligible for LCS (95% CI, 8.8%-10.6%). Of the eligible patients, 19.2% reported undergoing LCS (95% CI, 14.0%-24.4%). Approximately 16.4% of current smokers were eligible for LCS (95% CI, 14.2%-18.6%). In our multiple variable analyses of eligible patients, age, sex, marital status, current smoking status, and race were not found to be associated with statistically significant differences in reported LCS (P > .05). Retired patients, patients with personal physicians, and patients who did not complete a high school education were more likely to report receiving LCS (P < .05). CONCLUSIONS: Compared with previously published studies, the results of the current study suggested that LCS use is increasing. However, LCS use remains low (19%) among eligible participants.

Racial and Ethnic Disparities in Lung Cancer Screening Eligibility.

Background To address disparities in lung cancer screening (LCS) that may exclude large numbers of high-risk African American smokers, revised U.S. Preventive Services Task Force (USPSTF) recommendations lowered LCS eligibility thresholds. However, there are limited recent data about the impact of newly revised guidelines on disparities in LCS eligibility. Purpose To evaluate the impact of revised USPSTF guidelines on racial and ethnic disparities in LCS eligibility. Materials and Methods Cross-sectional survey data from 20 states were retrospectively evaluated from the 2019 Behavioral Risk Factor Surveillance System survey (median response rate, 49.4%). Respondents without a history of lung cancer aged 55-79 years (ie, under the previous guidelines) or aged 50-79 years (ie, under the revised guidelines) were included. Multivariable logistic regression analyses were performed to evaluate the association between race and ethnicity and LCS eligibility. All analyses were performed accounting for complex survey design features (ie, weighting, stratification, and clustering). Results Under previous guidelines, 11% of 67 567 weighted survey respondents were eligible for LCS (White [12%], Hispanic [4%], African American [7%], American Indian [17%], Asian or Pacific Islander [4%], and other [12%]). Under revised USPSTF guidelines, 14% of 77 689 weighted survey respondents were eligible for LCS (White [15%], Hispanic [5%], African American [9%], American Indian [21%), Asian or Pacific Islander [5%], and other [18%]). Compared with White respondents, African American respondents (adjusted odds ratio [OR] = 0.36; 95% CI: 0.27, 0.47; P < .001) and Hispanic respondents (adjusted OR = 0.15; 95% CI: 0.09, 0.24; P < .001) were less likely to be eligible for LCS under previous guidelines. African American respondents (adjusted OR = 0.39; 95% CI: 0.32, 0.47; P < .001) and Hispanic respondents (adjusted OR = 0.15; 95% CI: 0.10, 0.23; P < .001) were less likely to be eligible under the revised guidelines. The Wald test showed no evidence of differences in the degree to which racial and ethnic minority groups were less likely to be eligible for LCS when comparing previous versus revised USPSTF guidelines (P = .76). Conclusion The revised U.S. Preventive Services Task Force guidelines (version 2.0) may perpetuate lung cancer disparities, as racial and ethnic minority groups are still less likely to be eligible for lung cancer screening. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Jacobs and Springfield in this issue.

COVID-19 Imaging: What We Know Now and What Remains Unknown.

Infection with SARS-CoV-2 ranges from an asymptomatic condition to a severe and sometimes fatal disease, with mortality most frequently being the result of acute lung injury. The role of imaging has evolved during the pandemic, with CT initially being an alternative and possibly superior testing method compared with reverse transcriptase-polymerase chain reaction (RT-PCR) testing and evolving to having a more limited role based on specific indications. Several classification and reporting schemes were developed for chest imaging early during the pandemic for patients suspected of having COVID-19 to aid in triage when the availability of RT-PCR testing was limited and its level of performance was unclear. Interobserver agreement for categories with findings typical of COVID-19 and those suggesting an alternative diagnosis is high across multiple studies. Furthermore, some studies looking at the extent of lung involvement on chest radiographs and CT images showed correlations with critical illness and a need for mechanical ventilation. In addition to pulmonary manifestations, cardiovascular complications such as thromboembolism and myocarditis have been ascribed to COVID-19, sometimes contributing to neurologic and abdominal manifestations. Finally, artificial intelligence has shown promise for use in determining both the diagnosis and prognosis of COVID-19 pneumonia with respect to both radiography and CT.

Practical application and validation of the 2018 ATS/ERS/JRS/ALAT and Fleischner Society guidelines for the diagnosis of idiopathic pulmonary fibrosis.

BACKGROUND: Accurate diagnosis of idiopathic pulmonary fibrosis (IPF) is essential to inform prognosis and treatment. In 2018, the ATS/ERS/JRS/ALAT and Fleischner Society released new diagnostic guidelines for usual interstitial pneumonitis (UIP)/IPF, adding Probable UIP as a CT category based on prior studies demonstrating this category had relatively high positive predictive value (PPV) for histopathologic UIP/Probable UIP. This study applies the 2018 ATS/ERS/JRS/ALAT and Fleischner Society guidelines to determine test characteristics of CT categories in academic clinical practice. METHODS: CT and histopathology were evaluated by three thoracic radiologists and two thoracic pathologists. Comparison of consensus categorization by the 2018 ATS and Fleischner Society guidelines by CT and histopathology was performed. RESULTS: Of patients with CT UIP, 87% (PPV, 95% CI: 60-98%) had histopathologic UIP with 97% (CI: 90-100%) specificity. Of patients with CT Probable UIP, 38% (PPV, CI: 14-68%) had histopathologic UIP and 46% (PPV, CI: 19-75%) had either histopathologic UIP or Probable UIP, with 88% (CI: 77-95%) specificity. Patients with CT Indeterminate and Alternative Diagnosis had histopathologic UIP in 27% (PPV, CI: 6-61%) and 21% (PPV, CI: 11-33%) of cases with specificities of 90% (CI: 80-96%) and 25% (CI: 16-37%). Interobserver variability (kappa) between radiologists ranged 0.32-0.81. CONCLUSIONS: CT UIP and Probable UIP have high specificity for histopathologic UIP, and CT UIP has high PPV for histopathologic UIP. PPV of CT Probable UIP was 46% for combined histopathologic UIP/Probable UIP. Our results indicate that additional studies are needed to further assess and refine the guideline criteria to improve classification performance.

Comparison of Chest CT Findings of COVID-19, Influenza, and Organizing Pneumonia: A Multireader Study.

BACKGROUND. Previous studies compared CT findings of COVID-19 pneumonia with those of other infections; however, to our knowledge, no studies to date have included noninfectious organizing pneumonia (OP) for comparison. OBJECTIVE. The objectives of this study were to compare chest CT features of COVID-19, influenza, and OP using a multireader design and to assess the performance of radiologists in distinguishing between these conditions. METHODS. This retrospective study included 150 chest CT examinations in 150 patients (mean [± SD] age, 58 ± 16 years) with a diagnosis of COVID-19, influenza, or non-infectious OP (50 randomly selected abnormal CT examinations per diagnosis). Six thoracic radiologists independently assessed CT examinations for 14 individual CT findings and for Radiological Society of North America (RSNA) COVID-19 category and recorded a favored diagnosis. The CT characteristics of the three diagnoses were compared using random-effects models; the diagnostic performance of the readers was assessed. RESULTS. COVID-19 pneumonia was significantly different (p < .05) from influenza pneumonia for seven of 14 chest CT findings, although it was different (p < .05) from OP for four of 14 findings (central or diffuse distribution was seen in 10% and 7% of COVID-19 cases, respectively, vs 20% and 21% of OP cases, respectively; unilateral distribution was seen in 1% of COVID-19 cases vs 7% of OP cases; non-tree-in-bud nodules was seen in 32% of COVID-19 cases vs 53% of OP cases; tree-in-bud nodules were seen in 6% of COVID-19 cases vs 14% of OP cases). A total of 70% of cases of COVID-19, 33% of influenza cases, and 47% of OP cases had typical findings according to RSNA COVID-19 category assessment (p < .001). The mean percentage of correct favored diagnoses compared with actual diagnoses was 44% for COVID-19, 29% for influenza, and 39% for OP. The mean diagnostic accuracy of favored diagnoses was 70% for COVID-19 pneumonia and 68% for both influenza and OP. CONCLUSION. CT findings of COVID-19 substantially overlap with those of influenza and, to a greater extent, those of OP. The diagnostic accuracy of the radiologists was low in a study sample that contained equal proportions of these three types of pneumonia. CLINICAL IMPACT. Recognized challenges in diagnosing COVID-19 by CT are furthered by the strong overlap observed between the appearances of COVID-19 and OP on CT. This challenge may be particularly evident in clinical settings in which there are substantial proportions of patients with potential causes of OP such as ongoing cancer therapy or autoimmune conditions.

Imaging Manifestations of Chest Trauma.

Trauma is the leading cause of death among individuals under 40 years of age, and pulmonary trauma is common in high-impact injuries. Unlike most other organs, the lung is elastic and distensible, with a physiologic capacity to withstand significant changes in contour and volume. The most common types of lung parenchymal injury are contusions, lacerations, and hematomas, each having characteristic imaging appearances. A less common type of lung injury is herniation. Chest radiography is often the first-line imaging modality performed in the assessment of the acutely injured patient, although there are inherent limitations in the use of this modality in trauma. CT images are more accurate for the assessment of the nature and extent of pulmonary injury than the single-view anteroposterior chest radiograph that is typically obtained in the trauma bay. However, the primary limitations of CT concern the need to transport the patient to the CT scanner and a longer processing time. The American Association for the Surgery of Trauma has established the most widely used grading scale to describe lung injury, which serves to communicate severity, guide management, and provide useful prognostic factors in a systematic fashion. The authors provide an in-depth exploration of the most common types of pulmonary parenchymal, pleural, and airway injuries. Injury grading, patient management, and potential complications of pulmonary injury are also discussed. ©RSNA, 2021.

Right Ventricular Strain Is Common in Intubated COVID-19 Patients and Does Not Reflect Severity of Respiratory Illness.

BACKGROUND: Right ventricular (RV) dysfunction is common and associated with worse outcomes in patients with coronavirus disease 2019 (COVID-19). In non-COVID-19 acute respiratory distress syndrome, RV dysfunction develops due to pulmonary hypoxic vasoconstriction, inflammation, and alveolar overdistension or atelectasis. Although similar pathogenic mechanisms may induce RV dysfunction in COVID-19, other COVID-19-specific pathology, such as pulmonary endothelialitis, thrombosis, or myocarditis, may also affect RV function. We quantified RV dysfunction by echocardiographic strain analysis and investigated its correlation with disease severity, ventilatory parameters, biomarkers, and imaging findings in critically ill COVID-19 patients. METHODS: We determined RV free wall longitudinal strain (FWLS) in 32 patients receiving mechanical ventilation for COVID-19-associated respiratory failure. Demographics, comorbid conditions, ventilatory parameters, medications, and laboratory findings were extracted from the medical record. Chest imaging was assessed to determine the severity of lung disease and the presence of pulmonary embolism. RESULTS: Abnormal FWLS was present in 66% of mechanically ventilated COVID-19 patients and was associated with higher lung compliance (39.6 vs 29.4 mL/cmH2O, P = 0.016), lower airway plateau pressures (21 vs 24 cmH2O, P = 0.043), lower tidal volume ventilation (5.74 vs 6.17 cc/kg, P = 0.031), and reduced left ventricular function. FWLS correlated negatively with age (r = -0.414, P = 0.018) and with serum troponin (r = 0.402, P = 0.034). Patients with abnormal RV strain did not exhibit decreased oxygenation or increased disease severity based on inflammatory markers, vasopressor requirements, or chest imaging findings. CONCLUSIONS: RV dysfunction is common among critically ill COVID-19 patients and is not related to abnormal lung mechanics or ventilatory pressures. Instead, patients with abnormal FWLS had more favorable lung compliance. RV dysfunction may be secondary to diffuse intravascular micro- and macro-thrombosis or direct myocardial damage. TRIAL REGISTRATION: National Institutes of Health #NCT04306393. Registered 10 March 2020, https://clinicaltrials.gov/ct2/show/NCT04306393.

Racial and Ethnic Disparities in Disease Severity on Admission Chest Radiographs among Patients Admitted with Confirmed Coronavirus Disease 2019: A Retrospective Cohort Study.

Background Disease severity on chest radiographs has been associated with higher risk of disease progression and adverse outcomes from coronavirus disease 2019 (COVID-19). Few studies have evaluated COVID-19-related racial and/or ethnic disparities in radiology. Purpose To evaluate whether non-White minority patients hospitalized with confirmed COVID-19 infection presented with increased severity on admission chest radiographs compared with White or non-Hispanic patients. Materials and Methods This single-institution retrospective cohort study was approved by the institutional review board. Patients hospitalized with confirmed COVID-19 infection between March 17, 2020, and April 10, 2020, were identified by using the electronic medical record (n = 326; mean age, 59 years ±17 [standard deviation]; male-to-female ratio: 188:138). The primary outcome was the severity of lung disease on admission chest radiographs, measured by using the modified Radiographic Assessment of Lung Edema (mRALE) score. The secondary outcome was a composite adverse clinical outcome of intubation, intensive care unit admission, or death. The primary exposure was the racial and/or ethnic category: White or non-Hispanic versus non-White (ie, Hispanic, Black, Asian, or other). Multivariable linear regression analyses were performed to evaluate the association between mRALE scores and race and/or ethnicity. Results Non-White patients had significantly higher mRALE scores (median score, 6.1; 95% confidence interval [CI]: 5.4, 6.7) compared with White or non-Hispanic patients (median score, 4.2; 95% CI: 3.6, 4.9) (unadjusted average difference, 1.8; 95% CI: 0.9, 2.8; P < .01). For both White (adjusted hazard ratio, 1.3; 95% CI: 1.2, 1.4; P < .001) and non-White (adjusted hazard ratio, 1.2; 95% CI: 1.1, 1.3; P < .001) patients, increasing mRALE scores were associated with a higher likelihood of experiencing composite adverse outcome with no evidence of interaction (P = .16). Multivariable linear regression analyses demonstrated that non-White patients presented with higher mRALE scores at admission chest radiography compared with White or non-Hispanic patients (adjusted average difference, 1.6; 95% CI: 0.5, 2.7; P < .01). Adjustment for hypothesized mediators revealed that the association between race and/or ethnicity and mRALE scores was mediated by limited English proficiency (P < .01). Conclusion Non-White patients hospitalized with coronavirus disease 2019 infection were more likely to have a higher severity of disease on admission chest radiographs than White or non-Hispanic patients, and increased severity was associated with worse outcomes for all patients. © RSNA, 2020 Online supplemental material is available for this article.

Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia: Imaging and Clinical Features of a Frequently Delayed Diagnosis.

OBJECTIVE. The purpose of this study was to assess features of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) on CT, clinical presentation, and delays in radiologic and clinical diagnosis in a series of 32 patients. MATERIALS AND METHODS. Medical records of patients with DIPNECH from the years 2000-2017 were obtained from an institutional data warehouse. Inclusion criteria were an available CT examination and either a pathologic diagnosis of DIPNECH or pathologic findings of multiple carcinoid tumorlets or carcinoid tumor with CT features suggesting DIPNECH. Two thoracic radiologists with 10 and 14 years of experience reviewed CT examinations and scored cases in consensus. RESULTS. All 32 patients were women, and most had never smoked (69%). The mean age at presentation was 61 years. Symptoms included chronic cough (59%) or dyspnea (28%), and the initial clinical diagnosis was asthma in 41%. DIPNECH was clinically suspected at presentation in only one case and was mentioned by the interpreting radiologist in only 31% of cases. CT characteristics included numerous nodules with a lower zone and peribronchiolar predominance, mosaic attenuation, and nodular bronchial wall thickening. Number of nodules at least 5 mm in diameter showed strong inverse correlations with the percentage predicted for both forced vital capacity and forced expiratory volume in 1 second and a moderate inverse correlation with total lung capacity percentage predicted. In cases with a follow-up CT interval of 3 years or longer, 85% of patients showed an increase in size of the largest nodule, and 70% had an increase in size in multiple nodules. CONCLUSION. Many cases of DIPNECH are originally missed or misdiagnosed by radiologists and clinicians. Awareness of the typical clinical and imaging features of DIPNECH may prompt earlier diagnosis of this condition.

CT Features of Coronavirus Disease (COVID-19) in 30 Pediatric Patients.

OBJECTIVE. The purpose of this study is to characterize the CT findings of 30 children from mainland China who had laboratory-confirmed coronavirus disease (COVID-19). Although recent American College of Radiology recommendations assert that CT should not be used as a screening or diagnostic tool for patients with suspected COVID-19, radiologists should be familiar with the imaging appearance of this disease to identify its presence in patients undergoing CT for other reasons. MATERIALS AND METHODS. We retrospectively reviewed the CT findings and clinical symptoms of 30 pediatric patients with laboratory-confirmed COVID-19 who were seen at six centers in China from January 23, 2020, to February 8, 2020. Patient age ranged from 10 months to 18 years. Patients older than 18 years of age or those without chest CT examinations were excluded. Two cardiothoracic radiologists and a cardiothoracic imaging fellow characterized and scored the extent of lung involvement. Cohen kappa coefficient was used to calculate interobserver agreement between the readers. RESULTS. Among children, CT findings were often negative (77%). Positive CT findings seen in children included ground-glass opacities with a peripheral lung distribution, a crazy paving pattern, and the halo and reverse halo signs. There was a correlation between increasing age and increasing severity of findings, consistent with reported symptomatology in children. Eleven of 30 patients (37%) underwent follow-up chest CT, with 10 of 11 examinations (91%) showing no change, raising questions about the utility of CT in the diagnosis and management of COVID-19 in children. CONCLUSION. The present study describes the chest CT findings encountered in children with COVID-19 and questions the utility of CT in the diagnosis and management of pediatric patients.