[Cardiomegalia gigante].

Eighty-year old woman with a medical history of arterial hypertension, rheumatic valvular heart disease with mitral and aortic valve replacement, chronic atrial fibrillation and congestive heart failure dependent on domiciliary chronic oxygen for 17 daily hours. The reason for arrival to the hospital was a stroke of cardioembolic etiology.

Mujer de 80 años con antecedentes de hipertensión arterial, valvulopatía reumática con recambio valvular mitral y aórtica, fibrilación auricular crónica e insuficiencia cardiaca congestiva dependiente de oxígeno crónico domiciliario durante 17 horas diarias. El motivo de llegada al hospital fue ictus cerebral de etiología cardioembólica.

Acquired heart disease in adults: what can a chest X-ray tell us? / La patología cardiaca adquirida del adulto: ¿qué se puede decir con la radiografía de tórax?

The last 25 to 30 years have seen enormous advances in imaging techniques for the diagnosis of heart disease (echocardiography, cardiac MRI, CT angiography, etc.). Nevertheless, the first imaging test done in patient with heart disease continues to be plain-film chest X-rays. This economical, widely available technique makes it possible to follow up patients with heart disease and even to assess the severity of disease in some cases. This article explains how to read a chest X-ray systematically and the radiologic signs that make possible to suspect heart disease; it also provides detailed information about the signs of heart failure and the meaning of cardiac calcifications. CONCLUSION: Plain-film chest X-rays provide valuable additional information in the diagnosis and management of adult patients with heart disease.

Pitfalls and variants in pediatric chest imaging. / Pitfalls y variantes del tórax pediátrico.

Most pitfalls in the interpretation of pediatric chest imaging are closely related with the technique used and the characteristics of pediatric patients. To obtain a quality image that will enable the correct diagnosis, it is very important to use an appropriate technique. It is important to know how technical factors influence the image and to be aware of the possible artifacts that can result from poor patient cooperation. Moreover, radiologists need to be familiar with the normal anatomy in children, with the classic radiologic findings, and with the anatomic and developmental variants to avoid misinterpreting normal findings as pathological.

Diagnostic imaging in spontaneous rupture of a thoracic duct cyst in the mediastinum. / Diagnóstico por imagen de rotura espontánea de quiste mediastínico del conducto torácico.

Thoracic duct cysts in the mediastinum are extremely rare; they can give rise to chylothorax when they spontaneously rupture or after they are operated on. We present the case of an adult woman with a thoracic duct cyst in the mediastinum and chylothorax from its spontaneous rupture; to our knowledge, this phenomenon has not been specifically reported before. We describe the clinical and radiological findings, the therapeutic management, and the pathology findings, reviewing the literature for this entity.

What can happen after lung transplantation and the importance of the time since transplantation: radiological review of post-transplantation complications. / Qué puede pasar tras el trasplante pulmonar y la importancia del tiempo transcurrido. Revisión radiológica de las complicaciones postrasplante.

Lung transplantation is the best treatment option in the final stages of diseases such as cystic fibrosis, pulmonary hypertension, chronic obstructive pulmonary disease, or idiopathic pulmonary fibrosis. Better surgical techniques and advances in immunosuppressor treatments have increased survival in lung transplant recipients, making longer follow-up necessary because complications can occur at any time after transplantation. For practical purposes, complications can be classified as early (those that normally occur within two months after transplantation), late (those that normally occur more than two months after transplantation), or time-independent (those that can occur at any time after transplantation). Many complications have nonspecific clinical and radiological manifestations, so the time factor is key to narrow the differential diagnosis. Imaging can guide interventional procedures and can detect complications early. This article aims to describe and illustrate the complications that can occur after lung transplantation from the clinical and radiological viewpoints so that they can be detected as early as possible.

[Intrathoracic migration of a ventriculoperitoneal shunt catheter: a case report]. / Migración intratorácica de catéter de derivación ventriculoperitoneal: a propósito de un caso.

BACKGROUND: The intrathoracic complications from ventriculoperitoneal shunt placement are very rare. However, they are potentially serious if not treated. CLINICAL CASE: We report the case of thoracic migration of a peritoneal catheter after ventriculoperitoneal shunt and we also review the literature references with discussion of the different mechanisms of shunt-tip migration described. No case of previous sternotomy as in our patient has been found published. CONCLUSION: All reports recommend early catheter repositioning into the peritoneal cavity after diagnosing the migration described, to prevent worse complications. Moreover, it is important to keep in mind that intrathoracic migration can happen and it is necessary to palpate the catheter continuously during passage through subcutaneous tunnelling to prevent it.

[Diagnosing pneumothorax with ultrasonography]. / Diagnóstico ecográfico del neumotórax.

The ultrasonographic diagnosis of pneumothorax is based on the analysis of artifacts. It is possible to confirm or rule out pneumothorax by combining the following signs: lung sliding, the A and B lines, and the lung point. One fundamental advantage of lung ultrasonography is its easy access in any critical situation, especially in patients in the intensive care unit. For this reason, chest ultrasonography can be used as an alternative to plain-film X-rays and computed tomography in critical patients and in patients with normal plain films in whom pneumothorax is strongly suspected, as well as to evaluate the extent of the pneumothorax and monitor its evolution.

[Chest ultrasonography in pleurapulmonary disease]. / La ecografía torácica en la enfermedad pleuro-pulmonar.

Although the initial diagnosis and follow-up of pleuropulmonary disease are normally done with plain chest films and the gold standard for chest disease is computed tomography, diverse studies have established the usefulness of chest ultrasonography in the diagnosis of different pleuropulmonary diseases like pleural effusion and lung consolidation, among others. In this article, we show the different ultrasonographic patterns for pleuropulmonary disease. The availability of ultrasonography in different areas (ICU, recovery areas) makes this technique especially important for critical patients because it obviates the need to transfer the patient. Moreover, ultrasonography is noninvasive and easy to repeat. On the other hand, it enables the direct visualization of pleuropulmonary disease that is necessary for interventional procedures.

[Patterns of pulmonary vascularization on plain-film chest X-rays]. / Los patrones de vascularización pulmonar en la radiografía simple de tórax.

Plain chest films are a fundamental tool in the practice of medicine. The apparent simplicity of plain chest films sometimes leads us to forget that interpreting them correctly can provide very valuable information, especially if the interpretation is grounded in key clinical information. To interpret a plain chest film, it is important to pay attention to the pulmonary vascularization. This article reviews the normal shape and distribution of the pulmonary vessels on plain chest films and the most common pathologic vascular patterns, including those seen in pulmonary hypertension, hyperemia, hypovascularization, and alternative perfusion.

[Manifestations of lobar atelectasis on chest x-rays and correlation with computed tomography findings]. / Manifestaciones radiográficas de las atelectasias pulmonares lobares en la radiografía de tórax y su correlación con la tomografía computarizada.

Atelectasis is an important indicator of potentially severe underlying disease that must be diagnosed as early as possible. One of the most common mechanisms is the reabsorption of air distal to respiratory tract obstruction. The chest x-ray is an excellent tool to diagnose atelectasis, and it is especially useful for ruling out central bronchial obstructions (e.g., from endobronchial tumors). If the signs of volume loss are not recognized correctly, the diagnosis and treatment can be delayed. This article describes the main findings of lobar atelectasis on chest x-rays and their correlations with CT findings, including the classic signs described in the literature and other, less known and sometimes subtle signs.

[Lateral chest X-rays. Radiographic anatomy]. / Radiografía lateral de tórax. Anatomía radiográfica.

Lateral chest views constitute an essential part of chest X-ray examinations, so it is fundamental to know the anatomy on these images and to be able to detect the variations manifested on these images in different diseases. The aim of this article is to review the normal anatomy and main normal variants seen on lateral chest views. For teaching purposes, we divide the thorax into different spaces and analyze each in an orderly way, especially emphasizing the anatomic details that are most helpful for locating lesions that have already been detected in the posteroanterior view or for detecting lesions that can be missed in the posteroanterior view.

[Lung cancer screening]. / Cribado del cáncer de pulmón.

Lung cancer is a very important disease, curable in early stages. There have been trials trying to show the utility of chest x-ray or computed tomography in Lung Cancer Screening for decades. In 2011, National Lung Screening Trial results were published, showing a 20% reduction in lung cancer mortality in patients with low dose computed tomography screened for three years. These results are very promising and several scientific societies have included lung cancer screening in their guidelines. Nevertheless we have to be aware of lung cancer screening risks, such as: overdiagnosis, radiation and false positive results. Moreover, there are many issues to be solved, including choosing the appropriate group to be screened, the duration of the screening program, intervals between screening and its cost-effectiveness. Ongoing trials will probably answer some of these questions. This article reviews the current evidence on lung cancer screening.

Utility of artificial intelligence for detection of pneumothorax on chest radiopgraphs done after transthoracic percutaneous transthoracic biopsy guided by computed tomography.

OBJETIVE: To assess the ability of an artificial intelligence software to detect pneumothorax in chest radiographs done after percutaneous transthoracic biopsy. MATERIAL AND METHODS: We included retrospectively in our study adult patients who underwent CT-guided percutaneous transthoracic biopsies from lung, pleural or mediastinal lesions from June 2019 to June 2020, and who had a follow-up chest radiograph after the procedure. These chest radiographs were read to search the presence of pneumothorax independently by an expert thoracic radiologist and a radiodiagnosis resident, whose unified lecture was defined as the gold standard, and the result of each radiograph after interpretation by the artificial intelligence software was documented for posterior comparison with the gold standard. RESULTS: A total of 284 chest radiographs were included in the study and the incidence of pneumothorax was 14.4%. There were no discrepancies between the two readers' interpretation of any of the postbiopsy chest radiographs. The artificial intelligence software was able to detect 41/41 of the present pneumothorax, implying a sensitivity of 100% and a negative predictive value of 100%, with a specificity of 79.4% and a positive predictive value of 45%. The accuracy was 82.4%, indicating that there is a high probability that an individual will be adequately classified by the software. It has also been documented that the presence of Port-a-cath is the cause of 8 of the 50 of false positives by the software. CONCLUSIONS: The software has detected 100% of cases of pneumothorax in the postbiopsy chest radiographs. A potential use of this software could be as a prioritisation tool, allowing radiologists not to read immediately (or even not to read) chest radiographs classified as non-pathological by the software, with the confidence that there are no pathological cases.

The role of chest X-ray in the early diagnosis and staging of sarcoidosis: Is it really should be done?

BACKGROUND: Sarcoidosis is a chronic granulomatous disease characterized by non-caseating granuloma. The conventional chest X-ray (CXR) has important role in the diagnosis, staging and follow-up of disease. Computed tomography (CT) is a second-line imaging method used to determine the extent, complications and differential diagnosis of sarcoidosis. OBJECTIVES: To determine the role of CXR in the early diagnosis and staging of sarcoidosis and to compare with CT imaging. METHODS: One hundred and nine sarcoidosis patients followed at a single center were included in the study. Demographic, radiological, and clinical data of 81 patients were obtained from a total of 109 patients, and the record data of these 81 patients were evaluated. Patients who could not be reached for all tests were excluded from the study. CXR and CT imaging taken at diagnosis were evaluated retrospectively independently from two radiologists and one rheumatologist. RESULTS: Among 109 patients, eighty-one patients CXR and CT imaging taken at the same center has been reached. Among 81 sarcoidosis patients 23 (28.4%) were male, 58 (71.6%) were female. The mean patients age was 46.4 years and the mean disease duration was 3.8 years. CXR is regarded as normal at diagnosis in 30 patients (37%), while all of these patients had findings consistent with sarcoidosis on CT imaging. CT imaging are more superior than CXR in the early diagnosis and staging of sarcoidosis (p=0.001). Also CT imaging is more superior for detection of disease extent and complications. CONCLUSIONS: In this study, we observed that CT imaging outperforms CXR in terms of early detection and staging of sarcoidosis. The use of CT imaging is important for early diagnosis and staging of sarcoidosis. The low performance of CXR is a condition that requires the discussion of this method. Multicenter prospective study is needed in this regard.

[Diagnostic performance of artificial intelligence algorithms for detection of pulmonary involvement by COVID-19 based on portable radiography]. / Rendimiento diagnóstico de algoritmos de inteligencia artificial para detección de compromiso pulmonar por COVID-19 basados en radiografía portátil.

INTRODUCTION AND OBJECTIVES: To evaluate the diagnostic performance of different artificial intelligence (AI) algorithms for the identification of pulmonary involvement by SARS-CoV-2 based on portable chest radiography (RX). MATERIAL AND METHODS: Prospective observational study that included patients admitted for suspected COVID-19 infection in a university hospital between July and November 2020. The reference standard of pulmonary involvement by SARS-CoV-2 comprised a positive PCR test and low-tract respiratory symptoms. RESULTS: 493 patients were included, 140 (28%) with positive PCR and 32 (7%) with SARS-CoV-2 pneumonia. The AI-B algorithm had the best diagnostic performance (areas under the ROC curve AI-B 0.73, vs. AI-A 0.51, vs. AI-C 0.57). Using a detection threshold greater than 55%, AI-B had greater diagnostic performance than the specialist [(area under the curve of 0.68 (95% CI 0.64-0.72), vs. 0.54 (95% CI 0.49-0.59)]. CONCLUSION: AI algorithms based on portable RX enabled a diagnostic performance comparable to human assessment for the detection of SARS-CoV-2 lung involvement.

Comparative analysis of chest radiography and lung ultrasound to predict intra-hospital prognosis of patients admitted for acute SARS-CoV-2 pneumonia (COVID-19). / Análisis comparativo de la radiografía de tórax y la ecografía pulmonar para predecir el pronóstico intrahospitalario de pacientes ingresados por neumonía secundaria a SARS-CoV-2 (COVID-19).

BACKGROUND: Point of care lung ultrasound (POCUS) has been recently used to assess prognosis in COVID-19 patients. However, there are no data comparing POCUS and chest-X ray, a technique widely used. PATIENTS AND METHODS: Retrospective analysis in stable COVID-19 patients. Schalekamp radiological lung scale and LUZ-Score ultrasound scale were compared. Primary end-point was in-hospital death and/or need for Intensive Care Unit admission. RESULTS: A total of 138 patients were included. Median Schalekamp scale was 2 (2) and median LUZ-Score scale was 21 (10). No significant correlation was observed between both techniques. Patients with a LUZ-Score ≥21points at admission had worse lung function and higher concentrations of LDH, CRP and Interleuquine-6. Schalekamp scale failed to identify patients at a higher risk at admission for the primary end-point. Addition of POCUS to a previous clinical model, improved risk prediction (AUC 0.805 [95%CI: 0.662-0.948]; P=<.001). CONCLUSIONS: Chest X-ray and POCUS showed no correlation at admission in this analysis. Only POCUS identified a group of patients with greater clinical and analytical involvement. POCUS improved, previous clinical model, while chest X-ray did not add relevant predictive information for the primary endpoint.

Prognostic Significance of Findings on CTPA Supporting an Alternative Diagnosis to PE Among Patients Hospitalized for an Exacerbation of COPD: Predefined Subanalysis of the SLICE Trial. / Significado pronóstico de los diagnósticos alternativos a la TEP hallados en la tomografía computarizada de tórax de pacientes ingresados por agudización de EPOC: subanálisis predefinido del ensayo SLICE.

BACKGROUND: Among patients hospitalized for an exacerbation of chronic obstructive pulmonary disease (COPD), the SLICE trial showed that the addition of an active diagnostic strategy for pulmonary embolism (PE) to usual care compared with usual care alone did not improve a composite set of health outcomes. The objective of this subanalysis was to determine the frequency and prognostic significance of findings on computed tomography pulmonary angiogram (CTPA) supporting an alternative diagnosis to PE. METHODS: We analyzed all patients randomized to the intervention in the SLICE trial who received a CTPA that did not show PE. We used multivariable logistic regression to assess the independent association between findings supporting an alternative diagnosis to PE and a composite of readmission for COPD or death within 90 days after randomization. RESULTS: Among the 746 patients who were randomized, this subanalysis included 175 patients in the intervention group who received a CTPA that did not show PE. Eighty-four (48.0%) patients had acute bronchial infection, 13 (7.4%) had lung cancer, 10 (5.7%) had congestive heart failure, 8 (4.6%), 18 (10.3%) had other diagnoses, and 42 (24.0%) had a normal CTPA. In multivariable analysis, findings supporting an alternative diagnosis to PE were not significantly associated with the primary outcome (odds ratio: 0.64; 95% confidence interval: 0.30-1.38; P=0.26). CONCLUSIONS: Among patients hospitalized for an exacerbation of COPD, CTPA identified an alternative diagnosis in 76% of the patients. However, specific management of these patients was not associated with improved outcomes within 90 days after randomization.

[Residual lesions on chest-Xray after SARS-CoV-2 pneumonia: Identification of risk factors]. / Lesiones residuales en radiografía simple de tórax tras neumonía por SARS-CoV-2: identificación de factores de riesgo.

INTRODUCTION: COVID-19 pneumonia is the most frequent clinical manifestation of this disease, and its long-term sequelae and possible progression to pulmonary fibrosis are still unknown. The aim of this study is a mid-term review of the sequelae on plain chest radiography (CXR) in patients with a previous diagnosis of COVID-19 pneumonia. PATIENTS AND METHODS: Retrospective review of patients with a diagnosis of COVID-19 pneumonia, assessing the persistence of residual lesions in the control CXR and analysing their possible relationship with epidemiological factors, risk factors, treatments received and initial radiological patterns. RESULTS: A total of 143 patients (52 women and 91 men) were analysed. Mean age was 64 years. Radiological complete resolution (CR) was observed in 104 (73%) and partial resolution (PR) in 39 (27%). Of the risk factors only age was significantly related to persistence of residual lesions (OR 1.06 CI 95% (1.02,1.10). In relation to treatments, significant differences were found with tocilizumab and glucocorticoids, where treated patients had a higher risk of residual lesions (OR 2.44 (1.03,5.80) and 3.05(1.43,6.51) respectively. In the analysis of radiological patterns, significant differences were observed in patients with peripheral condensations in the acute course and a pattern of early radiological worsening. A clinical-radiological dissociation was evident: 83% of patients with residual lesions had no respiratory symptoms. DISCUSSION: COVID19 pneumonias may have a slower radiological resolution in older patients with certain initial radiological patterns, but the development of pulmonary fibrosis in these patients is still questionable.

Chest calcifications beyond the lung parenchyma-A review.

OBJECTIVE: Thoracic calcifications are frequently found in chest radiographs and CTs, occurring in a wide variety of disorders. Although most calcifications are harmless sequelae of previous disease, they provide important information to establish the diagnosis. This article reviews the different types of calcified lesions found in the chest, focusing on lesions outside the lung parenchyma. A location-based approach to the differential diagnosis is used, while providing the reader with diagnostic pearls and discussing the clinical importance of the different types of calcifications. CONCLUSION: Chest calcifications are a common finding in routine chest imaging. Understanding the different etiologies and radiologic manifestations provide the radiologist with the necessary tools to elaborate a differential diagnosis, as well as to correctly differentiate the findings that need further work-up from the ones that can be dismissed.

The hilum of the lung: Two classical radiological signs to decipher it.

Assessing the hilum of the lung is a common challenge in daily practice because various structures converge in this complex anatomic region. Because chest X-rays are widely available and deliver relatively low doses of radiation, they continue to be the most common imaging test, although new imaging modalities have decreased the use of chest X-rays for differentiating between true abnormalities and superimposed lung opacities. This article reviews the literature and describes the principal anatomic relations of the lung hilum through illustrative cases to enable the two most important radiologic signs to be identified: "hilum overlay" and "hilum convergence". In the initial imaging evaluation of patients with cardiothoracic disease, knowledge of these basic principles facilitates the three-dimensional location of lesions in a single-plane image, optimizing time and resources.