Meningococcal carriage among Georgia and Maryland high school students.

BACKGROUND: Meningococcal disease incidence in the United States is at an all-time low. In a previous study of Georgia high school students, meningococcal carriage prevalence was 7%. The purpose of this study was to measure the impact of a meningococcal conjugate vaccine on serogroup Y meningococcal carriage and to define the dynamics of carriage in high school students. METHODS: This was a prospective cohort study at 8 high schools, 4 each in Maryland and Georgia, during a school year. Students at participating schools received quadrivalent meningococcal conjugate vaccine that uses diphtheria toxoid as the protein carrier (MCV4-DT). In each state, 2 high schools were randomly assigned for MCV4-DT receipt by students at the beginning of the study, and 2 were randomly assigned for MCV4-DT receipt at the end. Oropharyngeal swab cultures for meningococcal carriage were performed 3 times during the school year. RESULTS: Among 3311 students, the prevalence of meningococcal carriage was 3.21%-4.01%. Phenotypically nongroupable strains accounted for 88% of carriage isolates. There were only 5 observed acquisitions of serogroup Y strains during the study; therefore, the impact of MCV4-DT on meningococcal carriage could not be determined. CONCLUSIONS: Meningococcal carriage rates in US high school students were lower than expected, and the vast majority of strains did not express capsule. These findings may help explain the historically low incidence of meningococcal disease in the United States.

Thoracic diseases associated with HIV infection in the era of antiretroviral therapy: clinical and imaging findings.

The human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) pandemic has entered its 4th decade. Since the introduction of combination antiretroviral therapy (ART) in 1996, the number of AIDS-related deaths has plateaued worldwide. Today, owing to the effectiveness of ART, the HIV-infected population is aging and HIV infection has become a chronic illness. Non-AIDS comorbidities are increasing, and the spectrum of HIV-related thoracic diseases is evolving. In developed countries, bacterial pneumonia has become more common than Pneumocystis pneumonia. Its imaging appearance depends on the responsible organism, most commonly Streptococcus pneumoniae. Mycobacterium tuberculosis continues to be a major threat. Its imaging patterns vary depending on CD4 count. Primary lung cancer and Hodgkin lymphoma are two important non-AIDS-defining malignancies that are increasingly encountered at chest imaging. Human herpesvirus 8, also known as Kaposi sarcoma-associated herpesvirus (KSHV), is strongly linked to HIV-related diseases, including Kaposi sarcoma, multicentric Castleman disease, KSHV inflammatory cytokine syndrome, and primary effusion lymphoma. Immune reconstitution inflammatory syndrome is a direct complication of ART whose manifestations vary with the underlying disease. Given the high rate of smoking among HIV-infected patients, chronic obstructive pulmonary disease is another important cause of morbidity and mortality. A high degree of suspicion is required for the early diagnosis of pulmonary arterial hypertension and lymphocytic interstitial pneumonia, given their nonspecific manifestations. Finally, multilocular thymic cyst manifests as a cystic anterior mediastinal mass. Recognition of the clinical and radiologic manifestations of these less traditional HIV-related diseases can expedite diagnosis and treatment in the ART era.

Tumors and tumorlike conditions of the large airways.

OBJECTIVE: Large-airway tumors and tumorlike conditions are uncommon, but a systematic approach aids in narrowing the differential diagnosis. In this article, we describe an approach to dealing with large-airway lesions and discuss their imaging characteristics and clinical presentations. CONCLUSION: We have found it useful to separate these entities into groups on the basis of the distribution pattern (focal vs diffuse) and location (trachea vs bronchi).

Outbreak of leptospirosis among Adventure Race participants in Florida, 2005.

BACKGROUND: On 21 November 2005, a 32-year-old male resident of New York was hospitalized with suspected leptospirosis. He had participated in an endurance-length swamp race on 4-5 November 2005 outside of Tampa, Florida. METHODS: We interviewed racers to assess illness, medical care, and race activities. A suspected case was defined as fever plus > or = 2 signs or symptoms of leptospirosis occurring in a racer after 4 November 2005. Individuals with suspected cases were referred for treatment as needed and were asked to submit serum samples for microscopic agglutination testing (MAT) and for rapid testing by the dot enzyme-linked immunosorbent assay dipstick immunoglobulin M immunoassay. RESULTS: The Centers for Disease Control and Prevention and participating state health departments interviewed 192 (96%) of 200 racers from 32 states and Canada. Forty-four (23%) of 192 racers met the definition for a suspected case. The median age of the patients was 37 years (range, 19-66 years), and 128 (66.7%) were male. Fourteen (45%) of the 31 patients with suspected cases who were tested had their cases confirmed by serological testing (a single sample with MAT titer > or = 400), including the index case patient. Organisms of a potential novel serovar (species Leptospira noguchii) were isolated in culture from 1 case patient. Factors associated with increased risk of leptospirosis included swallowing river water (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.6-7.0), swallowing swamp water (OR, 2.4; 95% CI, 1.1-5.2), and being submerged in any water (OR, 2.3; 95% CI, 1.1-4.7). CONCLUSIONS: This report describes a leptospirosis outbreak that resulted in a high rate of symptomatic infection among adventure racers in Florida. The growing popularity of adventure sports may put more people at risk for leptospirosis, even in areas that have not previously been considered areas of leptospirosis endemicity.

Epidemiologic investigation and targeted vaccination initiative in response to an outbreak of meningococcal disease among illicit drug users in Brooklyn, New York.

BACKGROUND: An outbreak of serogroup C meningococcal disease that involved illicit drug users and their contacts occurred in Brooklyn, New York, during 2005 and 2006. METHODS: The objectives of this study were to identify the population at risk for meningococcal disease, describe efforts to interrupt disease transmission, and assess the impact of a vaccine initiative. Descriptive and molecular epidemiological analysis was used to define the extent of the outbreak and the common risk factors among outbreak-related cases. A vaccine initiative that used community-based service providers was targeted to illicit drug users and their close contacts. The vaccine initiative was assessed through cessation of outbreak-related cases and the reduction in carriage rate. RESULTS: The investigation identified 23 outbreak-related cases of serogroup C meningococcal disease; 17 isolates were indistinguishable and 4 isolates were closely related according to pulsed-field gel electrophoresis. Two additional culture-negative cases had epidemiological links to laboratory-confirmed cases. The median age of patients with outbreak-related cases was 41 years, and 19 (83%) of 23 patients reported an association with illicit drug use. There were 7 outbreak-related deaths. Vaccination was administered to 2763 persons at 29 community locations, including methadone treatment centers, syringe-exchange programs, and soup kitchens. Three additional cases of meningococcal disease due to strains with the same pulsed-field gel electrophoresis pattern were identified after the vaccination initiative. CONCLUSIONS: Community-based outbreaks of meningococcal disease are difficult to control, and the decision to vaccinate is not straightforward. Current national guidelines for implementing a vaccination campaign are not strict criteria and cannot be expected to accommodate the myriad of factors that occur in community-based invasive meningococcal disease outbreaks, such as the inability to enumerate the population at risk.

Imaging of Small Airway Disease (SAD).

This article comprehensively reviews and illustrates the imaging features of small airway diseases. The authors discuss the imaging findings of small airway diseases in general and how to differentiate them from other findings that can be confused with small airway diseases. The authors also discuss the features that aid in diagnosing specific diseases that affect the small airways.

Incidence and outcomes of acute lung injury.

BACKGROUND: Acute lung injury is a critical illness syndrome consisting of acute hypoxemic respiratory failure with bilateral pulmonary infiltrates that are not attributed to left atrial hypertension. Despite recent advances in our understanding of the mechanism and treatment of acute lung injury, its incidence and outcomes in the United States have been unclear. METHODS: We conducted a prospective, population-based, cohort study in 21 hospitals in and around King County, Washington, from April 1999 through July 2000, using a validated screening protocol to identify patients who met the consensus criteria for acute lung injury. RESULTS: A total of 1113 King County residents undergoing mechanical ventilation met the criteria for acute lung injury and were 15 years of age or older. On the basis of this figure, the crude incidence of acute lung injury was 78.9 per 100,000 person-years and the age-adjusted incidence was 86.2 per 100,000 person-years. The in-hospital mortality rate was 38.5 percent. The incidence of acute lung injury increased with age from 16 per 100,000 person-years for those 15 through 19 years of age to 306 per 100,000 person-years for those 75 through 84 years of age. Mortality increased with age from 24 percent for patients 15 through 19 years of age to 60 percent for patients 85 years of age or older (P<0.001). We estimate that each year in the United States there are 190,600 cases of acute lung injury, which are associated with 74,500 deaths and 3.6 million hospital days. CONCLUSIONS: Acute lung injury has a substantial impact on public health, with an incidence in the United States that is considerably higher than previous reports have suggested.

2017 ACR Annual Meeting Open-Microphone Session: Navigating the Landscape of Changing Practice Models: Private Practice, Corporate Radiology, and Enterprise Systems.

Many practice groups are considering adopting new practice models, primarily to secure their practices by adapting to new payment models, government compliance and regulation, and increasing IT and infrastructure costs. As we move toward value-based care and capitation, the value equation (value = quality/cost) will lead us to also compete on cost to improve value. No matter what payment models ultimately dominate, we need to be prepared to lead in a value-based care environment. Measures of value will either be defined by radiologists or imposed by outside entities. It is critical to our continued success that practices and practice leaders continue to fully and strongly support the ACR to avoid the possibility of a decline in membership that may accompany a lack of practice engagement. Consolidation appears inevitable, but with the help of the ACR, radiologists should have a vibrant future if investments are made now in determining appropriate radiology-specific value measures that are meaningful in consolidated health care environments.

Nonvascular mediastinal trauma.

This article discusses the radiologic and clinical features of nonvascular mediastinal trauma, and focuses on the tracheobronchial tree, the esophagus, and the thoracic duct. Blunt chest and penetrating trauma account for most of the causes of such nonvascular injuries, but iatrogenic and inhalation injuries are other well-known causes. The injury distribution and clinical manifestations are different for each structure. In our combined experience at a level 1 trauma center, the overall prevalence of injury in each organ is low compared with vascular injuries. As such, and given the frequent nonspecific nature of clinical signs and symptoms of nonvascular mediastinal injuries, the diagnosis often is delayed and results in poor treatment outcome.

ACR CT Accreditation Program and the Lung Cancer Screening Program Designation.

The ACR recognizes that low-dose CT for lung cancer screening has the potential to significantly reduce mortality from lung cancer in the appropriate high-risk population. The ACR supports the recommendations of the US Preventive Services Task Force and the National Comprehensive Cancer Network for screening patients. To be effective, lung cancer screening should be performed at sites providing high-quality low-dose CT examinations overseen and interpreted by qualified physicians using a structured reporting and management system. The ACR has developed a set of tools necessary for radiologists to take the lead on the front lines of lung cancer screening. The ACR Lung Cancer Screening Center designation is built upon the ACR CT accreditation program and requires use of Lung-RADS or a similar structured reporting and management system. This designation provides patients and referring providers with the assurance that they will receive high-quality screening with appropriate follow-up care.

Entrustable Professional Activities: Ten Things Radiologists Do.

RATIONALE AND OBJECTIVES: Learner assessment in medical education has undergone tremendous change over the past two decades. During this time frame, the concept of Entrustable Professional Activities (EPAs) was introduced to guide the faculty when making competency-based decisions on the level of supervision required by trainees. EPAs are gaining momentum in medical education as a basis for decisions related to transitioning from residency training to clinical practice. The purpose of this article is twofold: (1) define EPAs for radiology (EPA-R) and (2) illustrate radiology-specific examples of these EPAs. MATERIALS AND METHODS: A multi-institutional work group composed of members of the Alliance of Directors and Vice Chairs of Education in Radiology convened at the 2015 Association of University Radiologists annual meeting to discuss radiology EPAs. The EPAs initially developed by the Accreditation Council for Graduate Medical Education (ACGME) Radiology milestone work group and the resultant ACGME Radiology milestones formed the basis for this discussion. RESULTS: A total of 10 radiology EPAs and illustrative vignettes were developed to help radiology educators and trainees better understand milestone assessment and how this translates to the necessary skills and responsibilities of practicing radiologists. Examples of EPA mapping to the ACGME subcompetencies and methods of assessment were included. CONCLUSIONS: EPAs offer an opportunity to improve our approach to training by increasing our focus on how we provide appropriate supervision to our residents and assess their progress. In this work, through suggested lists and vignettes, we have attempted to establish the framework for further discussion and development of EPA-Rs.

Chest radiographic evolution in fat embolism syndrome.

OBJECTIVE: To characterize the temporal chest radiographic findings of fat embolism syndrome. MATERIAL AND METHOD: Twenty-nine patients with clinically diagnosed fat embolism syndrome between 1988-1999 were retrospectively identified from the Trauma Registry of Haborview Medical Center, University of Washington. In twenty-two patients, complete medical records and serial chest radiographs were available. All images were reviewed by a dedicated thoracic radiologist. RESULTS: Two of 22 patients had normal radiographs throughout hospitalization, while 20/22 developed abnormal chest radiographs. The radiographic findings were consistent with non-specific diffuse pulmonary edema in all abnormal cases. The time to appearance of evident radiographic lung injury was < 24 hours of initial trauma in 10/20 (50%), between 24-48 hours in 4/20 (20%), between 48-72 hours in 5/20 (25%), and 1 patient (1/20, 5%) developed an abnormal chest radiograph after 72 hours. Ten of 20 patients (50%) with abnormal radiographs had complete resolution of the edema pattern within 1 week of development of opacities, 3/20 (15%) cases showed complete radiographic resolution between 1-2 weeks, 2/20 (10%) cases showed complete radiographic resolution between 2-3 weeks, 1/20 (5%) showed complete radiographic resolution between 3-4 weeks, and 4/20 (20%) died without resolution of the radiographic finding. CONCLUSION: The chest radiographic appearance of fat embolism syndrome is non-specific. Normal radiographs can also be seen. Most patients presenting with a normal initial radiograph develop radiographic evident abnormalities within 72 hours of injury and most cases showed radiographic resolution within 2 weeks of hospitalization. Although chest imaging play a little role in the clinical management of fat embolism syndrome, understanding of temporal presentation and evolution of the otherwise non-specific pulmonary opacities may help to avoid unnecessary evaluation in selected patients.

ACR CT accreditation program and the lung cancer screening program designation.

The ACR recognizes that low-dose CT for lung cancer screening has the potential to significantly reduce mortality from lung cancer in the appropriate high-risk population. The ACR supports the recommendations of the US Preventive Services Task Force and the National Comprehensive Cancer Network for screening patients. To be effective, lung cancer screening should be performed at sites providing high-quality low-dose CT examinations overseen and interpreted by qualified physicians using a structured reporting and management system. The ACR has developed a set of tools necessary for radiologists to take the lead on the front lines of lung cancer screening. The ACR Lung Cancer Screening Center designation is built upon the ACR CT accreditation program and requires use of Lung-RADS or a similar structured reporting and management system. This designation provides patients and referring providers with the assurance that they will receive high-quality screening with appropriate follow-up care.

High-resolution CT of peripheral airways diseases.

Bronchiolitis and bronchiolectasis are nonspecific inflammatory processes of the small airways that have a variable, but often characteristic, appearance on HRCT. Familiarity with the imaging features of these disorders is crucial in rendering an accurate radiographic diagnosis.

That darn scapula: a common pitfall in interpreting the chest radiograph.

For the inexperienced interpreter of chest radiographs, the normal scapula can mimic some very common and potentially serious abnormalities. Failure to recognize this normal bony structure can lead to needless diagnostic work up and treatment. The potentially mimicked abnormalities fall into 3 major categories: lung parenchymal abnormalities, pleural abnormalities, and bone abnormalities. This report discusses scapula anatomy as it pertains to chest radiographic anatomy, and the reasons for misinterpretations, and shows examples of the scapula mimicking pathologic processes.

Warfarin-induced tracheobronchial calcification.

Calcification of the trachea and proximal bronchi is a common, normal finding on chest radiographs in the elderly population, especially in women. More extensive airway calcification is also a rare manifestation of many pathologic conditions. The authors report a case of pathologic tracheobronchial calcification associated with long-term warfarin therapy. Chest radiographs showed prominent, diffuse calcification of the tracheobronchial tree. Computed tomography showed extensive calcification of the airway walls, extending from the trachea to the lung periphery.

Diffuse pulmonary ossification.

Diffuse pulmonary ossification (DPO) is an uncommon condition that is characterized by metaplastic bone formation in the lung parenchyma. It is usually not diagnosed clinically and may be apparent radiographically only when extensive. However, it is occasionally encountered at autopsy or on pathologic evaluation of surgical specimens. This article will review the clinical, histologic, and radiographic manifestations of DPO, focusing primarily on the chest radiograph and CT findings, both of which may be underappreciated, for even experienced radiologists may confuse DPO with other entities such as metastatic calcification as seen in chronic renal failure or chronic granulomatous disease.

Proceedings from the first Global Summit on Radiological Quality and Safety.

The ACR, the European Society of Radiology, and the International Society of Radiology held the first joint Global Summit on Radiological Quality and Safety in May 2013. The program was divided into 3 day-long themes: appropriateness of imaging, radiation protection/infrastructure, and quality and safety. Participants came from global organizations, including the International Atomic Energy Agency, the World Health Organization, and other institutions; industry and patient advocacy groups with an interest in imaging were also represented. The goal was to exchange ideas and solutions and share concerns to arrive at a better and more uniform approach to quality and safety. Participants were asked to use the information presented to develop strategies and tactics to harmonize and promote best practices worldwide. These strategies were summarized at the conclusion of the meeting.

Thoracic radiologic manifestations of melioidosis.

Melioidosis (Burkholderia pseudomallei) is a gram-negative bacterial infection that is highly endemic in Southeast Asia and Oceania. Pulmonary disease is the most common form of involvement. The clinical-radiologic thoracic manifestations of melioidosis can be classified as acute, subacute, subclinical, and chronic forms. Radiographic findings include nodular, alveolar, or mixed infiltration/consolidation with or without cavities. Pleural effusion, pneumothorax, and pericardial involvement can be seen. Melioidosis can easily be confused with other infections, especially tuberculosis. Suspicion of this disease in the proper clinical radiologic setting is important for early diagnosis and treatment. In this article, we provide a broad clinical overview of melioidosis, review the radiologic thoracic manifestations of melioidosis with appropriate clinical correlation, as well as compare and contrast the imaging findings of thoracic melioidosis with other similar pulmonary infections.

Benign metastasizing leiomyoma.

Pulmonary metastases from benign-appearing smooth muscle tumors of the uterus are rare, and are termed benign metastasizing leiomyoma (BML). Affected patients usually present with single or multiple lung nodules and are usually women who have undergone hysterectomy. Only a few cases of BML with lung cysts have been reported, with 2 patients presenting with spontaneous pneumothoraces. We report a case of BML in a 29-year-old woman with an abnormal preoperative chest radiograph who several years after hysterectomy developed spontaneous bilateral pneumothoraces.