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To assess radiology representation, multimedia content, and multilingual content of United States lung cancer screening (LCS) program websites.We identified the websites of US LCS programs with the Google internet search engine using the search terms lung cancer screening, low-dose CT screening, and lung screening. We used a standardized checklist to assess and collect specific content, including information regarding LCS staff composition and references to radiologists and radiology. We also tabulated types and frequencies of included multimedia and multilingual content and patient narratives.We analyzed 257 unique websites. Of these, only 48% (124 of 257) referred to radiologists or radiology in text, images, or videos. Radiologists were featured in images or videos on only 14% (36 of 257) of websites. Radiologists were most frequently acknowledged for their roles in reading or interpreting imaging studies (35% [90 of 574]). Regarding multimedia content, only 36% (92 of 257) of websites had 1 image, 27% (70 of 257) included 2 or more images, and 26% (68 of 257) of websites included one or more videos. Only 3% (7 of 257) of websites included information in a language other than English. Patient narratives were found on only 15% (39 of 257) of websites.The field of Radiology is mentioned in text, images, or videos by less than half of LCS program websites. Most websites make only minimal use of multimedia content such as images, videos, and patient narratives. Few websites provide LCS information in languages other than English, potentially limiting accessibility to diverse populations.

Lymphoma is the most common hematologic malignancy comprising a diverse group of neoplasms arising from multiple blood cell lineages. Any structure of the thorax may be involved at any stage of disease. Imaging has a central role in the initial staging, response assessment, and surveillance of lymphoma, and updated standardized assessment criteria are available to assist with imaging interpretation and reporting. Radiologists should be aware of the modern approaches to lymphoma treatment, the role of imaging in posttherapeutic surveillance, and manifestations of therapy-related complications.

Clinical risk prediction requires comprehensive integration of clinical information and concurrent radiological findings. We present an upgraded chest radiograph (CXR) explainable artificial intelligence (xAI) model, which was trained on 241,723 well-annotated CXRs obtained prior to the onset of the COVID-19 pandemic. Mean area under the receiver operating characteristic curve (AUROC) for detection of 20 radiographic features was 0.955 (95% CI 0.938-0.955) on PA view and 0.909 (95% CI 0.890-0.925) on AP view. Coexistent and correlated radiographic findings are displayed in an interpretation table, and calibrated classifier confidence is displayed on an AI scoreboard. Retrieval of similar feature patches and comparable CXRs from a Model-Derived Atlas provides justification for model predictions. To demonstrate the feasibility of a fine-tuning approach for efficient and scalable development of xAI risk prediction models, we applied our CXR xAI model, in combination with clinical information, to predict oxygen requirement in COVID-19 patients. Prediction accuracy for high flow oxygen (HFO) and mechanical ventilation (MV) was 0.953 and 0.934 at 24 hours and 0.932 and 0.836 at 72 hours from the time of emergency department (ED) admission, respectively. Our CXR xAI model is auditable and captures key pathophysiological manifestations of cardiorespiratory diseases and cardiothoracic comorbidities. This model can be efficiently and broadly applied via a fine-tuning approach to provide fully automated risk and outcome predictions in various clinical scenarios in real-world practice.

Imaging plays an integral role in the initial diagnosis and longitudinal care of patients with cancer. Liquid biopsies, which most commonly involve genetic analysis of circulating free DNA, have emerged as important complementary tools in cancer care with the potential to interface with imaging at each step of the cancer care continuum. Here, the authors use non-small-cell lung cancer as a paradigm to elucidate factors driving the need for liquid biopsy in the spectrum of lung cancer care, demonstrate ways in which liquid biopsy has already changed standard clinical practice, and discuss anticipated synergies of liquid biopsy and imaging in screening and early detection and in monitoring of disease.

Purpose We aimed to evaluate the feasibility, accuracy, and complications of computed tomography (CT)-guided percutaneous transthoracic needle biopsy (PTNB) of cavitary lesions. Methods Consecutive PTNB procedures in an academic institution over a 4-year period were reviewed, 53 of which were performed on patients with cavitary lesions. The demographic data of patients, lesion characteristics, biopsy technique and complications, initial pathologic results, and final diagnosis were reviewed. A final diagnosis was established through surgical correlation, microbiology or clinico-radiologic follow-up for at least 18 months after biopsy. Results The overall accuracy of PTNB was 81%. In 33 patients (62%) the cavitary lesion was found to be malignant (23 lung cancers and 10 metastases). The sensitivity and specificity for malignancy was 91% and 100%, respectively. In 20 patients (38%) a benign etiology was established (16 infections and 4 noninfectious etiologies), with PTNB demonstrating a sensitivity of 81% and specificity of 100% for infection. Wall thickness at the biopsy site, lesion in lower lobe, and malignancy were significant independent risk factors for diagnostic success. Minor complications occurred in 28% of cases: 13 pneumothoraces (5 requiring chest tube), 1 small hemothorax, and 1 mild hemoptysis. A nonsignificant higher chest tube insertion rate was seen in cavities with a thinner wall. Conclusion PTNB of cavitary lesions provides high accuracy, sensitivity, and specificity for both malignancy and infection and has an acceptable complication rate. Wall thickness at the biopsy site, lesion in lower lobe, and malignancy were significant independent risk factors for diagnostic success. Samples for microbiology should be obtained in all patients, especially in the absence of on-site cytology, due to the high prevalence of infection in cavitary lesions.

A 52-Year-Old Man with Fever, Cough, and Hypoxemia A 52-year-old man presented to the hospital for evaluation and treatment of hypoxemia. Seven days before presentation, nonproductive cough and a t...

ObjectivesTo assess the diagnostic performance of lung point-of-care ultrasound (POCUS) compared to either a positive nucleic acid test (NAT) or a COVID-19-typical pattern on computed tomography (CT) and to evaluate opportunities to simplify a POCUS algorithm.MethodsHospital-admitted adult inpatients with (1) either confirmed or suspected COVID-19 and (2) a completed or ordered CT within the preceding 24 hours were recruited. Twelve lung zones were scanned with a handheld POCUS machine. POCUS, CT, and X-ray (CXR) images were reviewed independently by blinded experts. A simplified POCUS algorithm was developed via machine learning.ResultsOf 79 enrolled subjects, 26.6% had a positive NAT and 31.6% had a CT typical for COVID-19. The receiver operator curve (ROC) for a 12-zone POCUS protocol had an area under the curve (AUC) of 0.787 for positive NAT and 0.820 for typical CT. A simplified four-zone protocol had an AUC of 0.862 for typical CT and 0.862 for positive NAT. CT had an AUC of 0.815 for positive NAT; CXR had AUCs of 0.793 for positive NAT and 0.733 for typical CT. Performance of the four-zone protocol was superior to CXR for positive NAT (p=0.0471). Using a two-point cutoff system, the four-zone POCUS protocol had a sensitivity of 0.920 and 0.904 compared to CT and NAT, respectively, at the lower cutoff; it had a specificity of 0.926 and 0.948 at the higher cutoff, respectively.ConclusionPOCUS outperformed CXR to predict positive NAT. POCUS could potentially replace other chest imaging for persons under investigation for COVID-19.

Objective To identify factors associated with delayed adherence to follow-up in lung cancer screening. Methods Utilizing a data warehouse and lung cancer screening registry, variables were collected from a referred sample of 3110 unique participants with follow-up CT during the study period (1 January 2016 to 17 October 2018). Adherence was defined as undergoing chest CT within 90 days and 30 days of the recommended time for follow-up and was determined using proportions and multiple variable logistic regression models across the American College of Radiology Lung Imaging Reporting and Data System (Lung-RADS®) categories. Results Of 1954 lung cancer screening participants (51.9% (1014/1954) males, 48.1% (940/1954) female; mean age 65.7 (range 45–87), smoking history median 40 pack-years, 60.2% and 44.5% did not follow-up within 30 and 90 days, respectively. Participants receiving Lung-RADS® category 1 or 2 presented later than those with Lung-RADS® category 3 at 90 days (coefficient −27.24, 95% CI −51.31, −3.16, p = 0.027). Participants with Lung-RADS® category 1 presented later than those with Lung-RADS® category 2 at both 90- and 30-days past due (OR 0.76 95% CI [0.59–0.97], p = 0.029 and OR 0.63 95% CI [0.48–0.83], p = 0.001, respectively). Conclusions Adherence to follow-up was higher among participants receiving more suspicious Lung-RADS® results at index screening CT and among those who had undergone more non-lung cancer screening imaging examinations prior to index lung cancer screening CT. These observations may inform strategies aimed at prospectively identifying participants at risk for delayed or nonadherence to prevent potential morbidity and mortality from incident lung cancers.

Highlights • CT-guided fine needle aspirate is accurate in the diagnoses of subsolid nodules. • CT-guided fine needle aspirate of subsolid nodules is safe. • A core needle biopsy is not always necessary., Purpose To assess the success of determining malignancy in subsolid lung nodules by fine needle aspirate of CT-guided transthoracic needle biopsy. Material and method This IRB approved retrospective study analyzed CTguided transthoracic needle biopsy of 86 consecutive subsolid nodules (size 25 + 14 mm; Age 71 + 10 years: M: F, 27:59), with ground glass opacity of = 50% in 64 (74%) and size < 2 cm in 38 (44%). Fine needle aspirate was performed in all and additional core biopsy in 21 (24%). The biopsy results were correlated with resected surgical pathology in 59 (69%) and by long term clinical and imaging follow-up in 27 (31%). The statistical analysis was performed by Fischer exact test to determine the success rate in < 2cm and =2cm nodules and those with 0.05), with a specificity 100% in both groups. Core biopsy altered the diagnosis only in 1/21 (4.8%). The nondiagnostic biopsy rate was 18 and 11% for lesions with =50% and 0.05). The incidence of pneumothorax was 21%, none requiring chest tube, and mild hemoptysis in 8%. Conclusion CT-guided transthoracic needle biopsy of both small and large subsolid nodules is highly sensitive and very specific for making the diagnosis of malignancy with a low rate of complications. Additional core biopsy offered no significant advantage over fine needle aspirate biopsy alone.

This cross-sectional study evaluates the informational content and readability of US lung cancer screening program websites., Key Points Question Is the informational content of lung cancer screening program websites in the United States accurate, complete, and presented at an appropriate reading level for most patients? Findings In this cross-sectional study of 257 lung cancer screening program websites, there was large variability regarding information on enrollment criteria, benefits and risks, logistics, and costs of lung cancer screening. The reading level of the websites was consistently above that of the average adult in the United States and the level recommended by the American Medical Association and the National Institutes of Health. Meaning Efforts to improve the content and readability of program websites may be warranted to improve patient understanding of lung cancer screening., Importance The internet is an important source of medical information for many patients and may have a key role in the education of patients about lung cancer screening (LCS). Although most LCS programs in the United States have informational websites, the accuracy, completeness, and readability of these websites have not previously been studied. Objective To evaluate the informational content and readability of US LCS program websites. Design, Setting, and Participants This cross-sectional study assessed US LCS program websites identified on September 15, 2018. A standardized checklist was used to assess key informational content of each website, and text was analyzed for reading level, word count, and reading time. Links to US websites of national advocacy organizations with LCS program content were tabulated. All functional LCS program websites in Google internet search engine results using the search terms lung cancer screening, low-dose CT screening, and lung screening were included in the analysis. Main Outcomes and Measures Radiologists used a standardized checklist to evaluate content, and readability was assessed with validated scales. Website word count, reading time, and number of links to outside LCS informational websites were assessed. Results A total of 257 LCS websites were included in the analysis. The word count ranged from 73 to 4410 (median, 571; interquartile range, 328-909). The reading time ranged from 0.3 to 19.6 minutes (median, 2.5; interquartile range, 1.5-4.0). The median reading level of all websites was grade 10 (interquartile range, 9-11). Only 26% (n = 66) of websites had at least 1 web link to a national website with additional information on LCS. There was wide variability regarding reported eligibility age criteria, with ages 55 to 77 years most frequently cited (42% [n = 108]). Only 56% (n = 143) of websites mentioned smoking cessation. The subject of patient cost was mentioned on 75% (n = 192) of websites. Although major LCS benefits, such as detection of lung cancer, were discussed by most (93% [n = 239]) websites, less than half of the websites (45% [n = 115]) made any mention of possible risks associated with screening. Conclusions and Relevance There appears to be marked variability in the informational content of US LCS program websites, and the reading level of most websites is above that recommended by the American Medical Association and the National Institutes of Health. Efforts to improve website content and readability may be warranted.

Objective Pulmonary nodules found incidentally or by lung cancer screening differ in prevalence, risk profile, and diagnostic intervention. The results of surgical intervention for incidental versus screening lung nodules during multidisciplinary Pulmonary Nodule and Lung Cancer Screening Clinic (PNLCSC) follow-up have not been reported. Methods All patients evaluated at a PNLCSC from 2012 to 2018 following referral by primary care physicians, specialist physicians, or self-referral after computed tomography (CT) identified nodules on routine diagnostic CT (incidental group) or lung cancer screening CT (screening group) were included. Follow-up interval, invasive intervention, histology, postoperative events, survival, and recurrence were compared. Results Of 747 patients evaluated in the PNLCSC, 129 (17.2%) underwent surgical intervention. The surgical cohort consisted of 104 (80.6%) incidental and 25 (19.3%) screening patients followed over a mean of 122 and 70 days, respectively. More benign lesions were excised in the incidental group (20.2%, 21/104)—representing 3.3% (21/632) of all incidental nodules evaluated—than in the screening group (4%, 1/25) (P = .038). Operative mortality was zero. Among 99 patients with primary lung cancer, 87% (screening) and 86.8% (incidental) were pathologic stage Ia. Complete follow-up was available in 725 of 747 (97%), and no patient developed progressive disease. Disease-free survival at 5 years was 74.9% (incidental) and 89.3% (screening) (P = .48). Conclusions A unique multidisciplinary PNLCSC for incidental and lung cancer screening–detected nodules with individualized risk assessment reliably identifies primary and metastatic tumors while exposing few patients to diagnostic excision for benign disease. Longer-term outcomes, strategies to limit radiation exposure, and cost control need further study.

The purpose of this study was to evaluate the diagnostic yield and accuracy of CT-guided percutaneous biopsy of anterior mediastinal masses and assess prebiopsy characteristics that may help to select patients with the highest diagnostic yield.Retrospective review of all CT-guided percutaneous biopsies of the anterior mediastinum conducted at our institution from January 2003 through December 2012 was performed to collect data regarding patient demographics, imaging characteristics of biopsied masses, presence of complications, and subsequent surgical intervention or medical treatment (or both). Cytology, core biopsy pathology, and surgical pathology results were recorded. A per-patient analysis was performed using two-tailed t test, Fisher's exact test, and Pearson chi-square test.The study cohort included 52 patients (32 men, 20 women; mean age, 49 years) with mean diameter of mediastinal mass of 6.9 cm. Diagnostic yield of CT-guided percutaneous biopsy was 77% (40/52), highest for thymic neoplasms (100% [11/11]). Non-diagnostic results were seen in 12 of 52 patients (23%), primarily in patients with lymphoma (75% [9/12]). Fine-needle aspiration yielded the correct diagnosis in 31 of 52 patients (60%), and core biopsy had a diagnostic rate of 77% (36/47). None of the core biopsies were discordant with surgical pathology. There was no statistically significant difference between the diagnostic and the nondiagnostic groups in patient age, lesion size, and presence of necrosis. The complication rate was 3.8% (2/52), all small self-resolving pneumothoraces.CT-guided percutaneous biopsy is a safe diagnostic procedure with high diagnostic yield (77%) for anterior mediastinal lesions, highest for thymic neoplasms (100%), and can potentially obviate more invasive procedures.

Rationale and Objectives Cardiac computed tomography (CT) has emerged as a robust modality for imaging coronary stenosis and has recently been used to evaluate myocardial abnormalities such as ischemic perfusion defects and infarction. We developed a new image analysis algorithm for the semiautomatic and quantitative assessment of myocardial perfusion by CT. Materials and Methods The algorithm semiautomatically segments two-dimensional short-axis reformatted DICOM images of the left ventricle into regions of interest (ROIs) in accordance with American Heart Association (AHA) standards and is capable of creating nine further ROI subsegments. This includes separate endocardial, mid-ventricle, and epicardial layers. Image intensity values (Hounsfield unit) and relative myocardial thickness are quantitatively reported for each ROI and segment. Results The algorithm allows comparison of the HU values at the same ROI locations between rest and stress. The reproducibility is very good; ICC 0.89 for rest images, 0.83 for stress images. The mean time for generating ROIs for the entire heart was 11 minutes versus 22 minutes for manual tracing. Conclusion The algorithm reports parameters relevant for evaluation of stress perfusion CT studies and will allow more accurate and reproducible analysis in cardiac CT research.

Objective To determine the accuracy of dual-source CT (DSCT) to quantify coronary stenosis compared to intravascular ultrasound (IVUS) and quantitative coronary angiography (QCA). Methods 21 patients (23 vessels) were examined with DSCT, IVUS and invasive coronary angiography. Coronary minimal luminal diameter (MLD) and area (MLA) were measured in cross-sectional multi-planar reformatted images perpendicular to the vessel long-axis. The vessel cross-sectional area stenosis (MLA/CSA ratio) was calculated. DSCT results were compared with IVUS and QCA. Results A good correlation between DSCT and IVUS was noted for diameter and area stenosis (r = 0.69 and r = 0.73), with an overestimation of MLD stenosis by DSCT (+9.1%) and an underestimation of MLA stenosis (−5.8%). For MLD and MLA, high correlation coefficients (r = 0.78 and r = 0.90, respectively) were found between DSCT and IVUS; and the bias was almost zero (−0.41 mm and +0.1 mm2, respectively). The correlation between DSCT and QCA was moderate (r = 0.60) for MLD stenosis with minor overestimation by DSCT (+4.0%) and moderate (r = 0.59) for MLD (bias, +0.01 mm). The cross-sectional area stenosis showed a moderate correlation (r = 0.59) between DSCT and IVUS (+0.00). Conclusions DSCT allows accurate quantification of coronary stenosis as compared to IVUS. An excellent correlation was found for the MLA between DSCT and IVUS.

Background Multidetector computed tomography (MDCT) has recently emerged as a potential noninvasive alternative for high-resolution imaging of coronary arteries. Objective In this study, we evaluated 64-slice MDCT for detection, quantification, and characterization of atherosclerotic plaque burden in nonculprit lesions. Methods Data from 11 patients who underwent both MDCT and intravascular ultrasound (IVUS) for suspected coronary artery disease were collected, and a total of 17 coronary segments and 122 cross-sectional slices were analyzed by MDCT and IVUS. Coronary segments on MDCT were coregistered to IVUS, and each obtained slice was scored by 2 blinded observers for presence and type of plaque. Quantitative measurements included cross-sectional vessel area, lumen area, wall area, plaque volume, and plaque burden. Mean and standard deviation of Hounsfield units (HUs) were recorded for plaque when present. Results Overall sensitivity for plaque detection was 95.0%, and specificity, positive predictive value, negative predictive value were 88.7%, 89.1%, and 94.8%, respectively. Spearman's correlation coefficients were 0.85, 0.75, 0.70, 0.89, and 0.54 for cross-sectional vessel area, lumen area, wall area, plaque volume, and plaque burden, respectively. The interobserver variability for plaque burden and plaque volume measurements between readers on 64-MDCT was high at 32.7% and 30.4%, respectively. Combined noncalcified plaque had a mean MDCT density significantly different from that of calcified plaque. Soft and fibrous plaques were not able to be distinguished based on their HU values. Conclusion Sixty-four–slice MDCT had good correlation with IVUS but with high interobserver variability. Plaque characterization remains a challenge with present MDCT technology.

ObjectivesThis study sought to determine the feasibility of performing a comprehensive cardiac computed tomographic (CT) examination incorporating stress and rest myocardial perfusion imaging together with coronary computed tomography angiography (CTA).BackgroundAlthough cardiac CT can identify coronary stenosis, very little data exist on the ability to detect stress-induced myocardial perfusion defects in humans.MethodsThirty-four patients who had a nuclear stress test and invasive angiography were included in the study. Dual-source computed tomography (DSCT) was performed as follows: 1) stress CT: contrast-enhanced scan during adenosine infusion; 2) rest CT: contrast-enhanced scan using prospective triggering; and 3) delayed scan: acquired 7 min after rest CT. Images for CTA, computed tomography perfusion (CTP), and single-photon emission computed tomography (SPECT) were each read by 2 independent blinded readers.ResultsThe DSCT protocol was successfully completed for 33 of 34 subjects (average age 61.4 ± 10.7 years; 82% male; body mass index 30.4 ± 5 kg/m2) with an average radiation dose of 12.7 mSv. On a per-vessel basis, CTP alone had a sensitivity of 79% and a specificity of 80% for the detection of stenosis ≥50%, whereas SPECT myocardial perfusion imaging had a sensitivity of 67% and a specificity of 83%. For the detection of vessels with ≥50% stenosis with a corresponding SPECT perfusion abnormality, CTP had a sensitivity of 93% and a specificity of 74%. The CTA during adenosine infusion had a per-vessel sensitivity of 96%, specificity of 73%, and negative predictive value of 98% for the detection of stenosis ≥70%.ConclusionsAdenosine stress CT can identify stress-induced myocardial perfusion defects with diagnostic accuracy comparable to SPECT, with similar radiation dose and with the advantage of providing information on coronary stenosis.

Intro : The feasibility and accuracy of performing a comprehensive CT exam incorporating coronary, stress and rest perfusion, and delayed enhancement (DE) imaging is unknown. Our goal was to determine the feasibility of stress DSCT in identifying and quantifying the extent of ischemic and infarcted myocardium as compared to nuclear myocardial perfusion imaging (MPI) and invasive angiography (IA). Methods : 12 consecutive pts who had a prior MPI & subsequently underwent IA were included in study. DSCT (2×32×.6) performed as follows: Stress CT (SCT) - retrospectively gated scan with tube current modulation and pitch adaptation obtained 3 min post adenosine (.14 mg/kg/min) with Isovue @ 4 –5 ml/s; Rest CT (RCT) - non-helical prospective scan, Isovue @ 4 –5 ml/s; DE Scan - prospective acquisition 7 min post RCT, 100kV. CT perfusion, CT angiography (CTA), MPI, and IA were each read blinded to results of other tests. For DSCT & MPI, perfusion defect (pd) severity & reversibility were scored for ea. of the 17 segments. CT interpretation used 10mm multi planar reformation in short axis. Per vessel results of SCT were compared to the following references S-MPI IA≥50% IA≥70% CTA severe stenosis & S-MPI & IA≥50. Results : Protocol was successfully completed for all 12 pts (44±11 yrs; 10 males; BMI 31.5±7 kg/m 2 ) 11/12 pts had prior CAD; 5/12 had a prior MI and 3/12 had a prior PCI. Total contrast dose was 151cc; Average radiation dose of protocol 13mSv (8.8, 2.8, and 1.3mSv for SCT, RCT, and DE respectively). Average HR was 71 for RCT & 80 for SCT. Out of 204 segments (17×12pts), RCT pd were identified in 39 (5tr=transmural), SCT pd in 86 (40tr) and DE in 22 (3tr). S-MPI pd were present in 66 segments. Per vessel analysis: IA>70% lesions in 19/36, SCT identified pd in 25/36 and S-MPI in 21/36. Compared to MPI, SCT had a sensitivity (Sn) of 91% & specificity (Sp) of 43%. When IA>70%, used as the reference the Sn & Sp were: 79 & 41% for SCT, 63 & 47% for S-MPI, 89 & 65% for CTA, and 84 & 71% when abnormal on both CTA & SCT (p=NS). Conclusions : Adenosine stress CT can accurately identify both anatomical stenosis as well as reversible and nonreversible perfusion defects. The role of stress CT is unknown at this time and larger datasets will be necessary for accurate comparison with nuclear MPI.

Lead poisoning from novel environmental sources continues to present a challenge to clinicians who treat infants and children.A 12 month old infant of Thai parents was found during well child care to have a venous blood lead concentration of 61 mcg/dL. He was hospitalized for parenteral chelation with CaNa2EDTA and subsequently managed as an outpatient with oral succimer, with a reduction in blood lead concentration to 23 mcg/dL. Chronic lead poisoning was attributed to the use of a Thai tongue powder by the parents for the first seven months of the infant's life. This ethnic remedy was applied to the tongue to absorb toxins, reduce white patches present after milk feedings, and preserve the infant's health.Lead contaminated the powder at 109,000 ppm as measured by x-ray fluorescence spectrometry. Two poison centers in Thailand were contacted and initiated a public health inquiry with the Thai FoodDrug Administration (Thai FDA) to remove contaminated products from the marketplace. Their investigation found six additional contaminated tongue powders (of 10 tested) in a Bangkok shop offering Chinese remedies, some with lead levels9000 ppm. These products, unregistered with the Thai FDA, were confiscated and the shop closed. Local media attention and case-finding activities of health officials identified one additional infant suffering from lead poisoning due to tongue powders.Asian tongue powders can be a source of lead poisoning. Medical toxicologists, poison centers, and public health agencies can work together internationally to accomplish effective post-marketing product surveillance.