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Different subtypes of non-small cell lung cancer (NSCLC) are associated with different patterns of metastatic spread. Anatomic location of lesions in the chest may influence patterns of cancer growth and the shrinkage to therapy. Consequently, lesion location could affect apparent response rates per RECIST. We sought to explore this and develop, as needed, treatment response assessments less affected by the location.Cases of advanced oncogene-addicted NSCLC (EGFR, ALK, and ROS1) with pre- and on-therapy imaging during initial targeted therapy were identified. Lesions located in the lung parenchyma, pleural space or intra-thoracic lymph nodes were identified and analyzed separately from each other by RECIST 1.1 (unidimensional measurements) and by a novel MAX methodology (bidimensional measurements) which takes the axis with the greatest absolute percentage change on therapy in each location as the representative measurement.Three hundred three patients with 446 unidimensional measured lesions were included for RECIST analysis. Two hundred forty nine patients with 386 bidimensional measured lesions were included for MAX analysis, as well as the analysis comparing RECIST and MAX. Intrathoracic location significantly impacted percentage shrinkage and the response rate per RECIST. The response rates for pleural, intra-parenchymal and nodal lesions were 34.1%, 49.6%, and 68.3%, respectively (P = .0002). The MAX methodology both increased the apparent treatment effect and made it consistent between intrathoracic locations. For pleural, parenchymal and nodal lesions, the MAX calculated response rate were 83.7%, 72.2%, and 75.4%, respectively (P-value = .24).Intrathoracic lesion location affects RECIST-based treatment effectiveness estimations. The MAX methodology neutralizes location effect when examining impact of treatment and should be explored further.

Background Lung cancer screening (LCS) implementation is complicated by the Centers for Medicare and Medicaid Services reimbursement requirements of shared decision-making and tobacco cessation counseling. LCS programs can utilize different structures to meet these requirements, but the impact of programmatic structure on provider behavior and screening outcomes is poorly described. Patients and Methods In a retrospective chart review of 624 patients in a hybrid structure, academic LCS program, we compared characteristics and outcomes of primary care provider (PCP)- and specialist-screened patients. We also assessed the impact of the availability of an LCS specialty clinic and best practice advisory (BPA) on PCP ordering patterns using electronic medical record generated reports. Results During the study period of July 1, 2014 through June 30, 2018, 48% of patients were specialist-screened and 52% were PCP-screened; there were no clinically relevant differences in patient characteristics or screening outcomes between these populations. PCPs demonstrate distinct practice patterns when offered the choice of specialist-driven or PCP-driven screening. Increased exposure to a LCS BPA is associated with increased PCP screening orders. The addition of a nurse navigator into the LCS program increased documentation of shared decision-making and tobacco cessation counseling to > 95% and virtually eliminated screening of ineligible patients. Conclusions Systematic interventions including a BPA and nurse navigator are associated with increased screening and improved program quality, as evidenced by reduced screening of ineligible patients, increased lung cancer risk of the screened population, and improved compliance with LCS guidelines. Individual PCPs demonstrate clear preferences regarding LCS that should be considered in program design.

BACKGROUND The ability for patients to directly view their radiology images through secure electronic portals is rare in the American health care system. We previously surveyed patients within our health system and found that a large majority wanted to view their own radiology images online, and we have since implemented this new feature. OBJECTIVE We aim to understand patient experiences, opinions, and actions taken after viewing their own radiology images online. METHODS We emailed a web-based survey to patients who recently viewed their radiology images via our electronic patient portal. RESULTS We sent 1825 surveys to patients and received 299 responses (response rate 16.4%). Patients reported a favorable experience (258/299, 86.3% agree) viewing their radiology images online. Patients found value in reading their radiology reports (288/299, 96.3% agree) and viewing their images (267/299, 89.3% agree). Overall, patients felt that accessing and viewing their radiology images online increased their understanding of their medical condition (258/299, 82.9%), made them feel more in control and reassured (237/299, 79.2% and 220/299, 73.6%, respectively), and increased levels of trust (214/299, 71.6%). Only 6.4% (19/299) of the patients indicated concerns with finding errors, 6.4% (19/299) felt that viewing their images online made them worry more, and 7% (21/299) felt confused when viewing their images online. Of patients who viewed their images online, 45.2% (135/299) took no action with their images, 32.8% (98/299) saved a copy for their records, 25.4% (76/299) shared them with their doctor, and 14.7% (44/299) shared them with another doctor for a second opinion. A total of 9 patients (3%) shared their radiology images on Facebook, Instagram, or both, primarily to inform family and friends. Approximately 10.4% (31/299) of the patients had questions about their radiology images after viewing them online, with the majority (20/31, 65%) seeking out a doctor, and far fewer (5/31, 16%) choosing to ask a family member about their images. Finally, respondents viewed their images online using 1 or more devices, including computers, smartphones, tablets, or a combination of these devices. Approximately 26.7% (103/385) of the responses noted technical difficulties, with the highest incidence rate occurring with smartphones. CONCLUSIONS We report the first known survey results from patients who viewed their own radiology images through a web-based portal. Patients reported high levels of satisfaction and increased levels of trust, autonomy, reassurance, and medical understanding. Only a small minority of patients expressed anxiety or confusion. We suggest that patient access to radiology images, such as patient access to radiology reports, is highly desired by patients and is operationally practical. Other health care institutions should consider offering patients access to their radiology images online in the pursuit of information transparency.

Aortic intramural hematoma (IMH) is a pathologic process with a clinical presentation identical to aortic dissection and associated with significant morbidity and mortality. Radiologists must be familiar with the imaging appearances of IMH as computed tomography (CT) plays a critical role in both diagnosis and patient management. The course of IMH is variable and the process may regress, remain stable, or progress in extent, and therefore imaging findings associated with a negative prognosis must be recognized and included in the formal radiology report. Potentially life-threatening complications and findings associated with IMH include hemopericardium and cardiac tamponade, coexisting aortic dissection, ulcer-like projection, intramural blood pool, and extension of hematoma along the pulmonary or coronary arteries, which are identifiable with aortic protocol CT. The purpose of this pictorial review is to provide the reader with an image-based review of the diagnostic criteria, related complications, and associated critical prognostic features in patients presenting with aortic IMH.

Background: Although patient data is available through electronic portals, little information exists about the benefits and/or challenges of providing patients with online access to their radiology images. Objective: The aims of this quality improvement project were to understand patient attitudes toward being able to view their radiology images online and determine how information should be presented to ensure the images are helpful to the patients, rather than causing confusion and anxiety. Methods: An online survey of consumers was conducted to evaluate attitudes toward online access to personal radiological images. Results: A total of 105 responses were received from 686 community members (15.3%). Of 105 consumers, 94 (89.5%) reported a desire to have access to the radiology images within their online patient portal; 86.7% (91/105) believed it would help them better understand their medical conditions and 81.0% (85/105) said this would help them feel more in control of their care. Most respondents (74/105, 70.5%) said it would help them feel reassured that their doctor was doing the right thing, and 63.8% (67/105) said it would increase their level of trust in their doctor. Among surveyed patients, 78.1% (82/105) valued viewing their radiology images online, while 92.4% (97/105) valued their online radiology reports. Most patients (69/105, 65.7%) wished to discuss their results with their ordering clinician, 29.5% (31/105) wished to discuss with their interpreting radiologist, and 3.8% (4/105) wished to share their images on social media. The biggest potential concern among 23.8% (25/105) was that the images would be confusing. Conclusions: A large majority of surveyed patients desired the ability to view their radiology images online and anticipated many benefits and few risks. Health care organizations with electronic health records and online patient portals should consider augmenting their existing portals with this highly desired feature. To avoid the biggest patient concern, radiology reports should accompany images. Patients wanted to discuss their results with their ordering physician and their interpreting radiologist. Some even would like to share results on social media. Further research on the actual experience with such a tool will be needed.

Lung cancer is the leading cause of cancer-related mortality in the United States and worldwide. Early detection of lung cancer is an important opportunity for decreasing mortality. Data support using low-dose computed tomography (LDCT) of the chest to screen select patients who are at high risk for lung cancer. Lung screening is covered under the Affordable Care Act for individuals with high-risk factors. The Centers for Medicare & Medicaid Services (CMS) covers annual screening LDCT for appropriate Medicare beneficiaries at high risk for lung cancer if they also receive counseling and participate in shared decision-making before screening. The complete version of the NCCN Guidelines for Lung Cancer Screening provides recommendations for initial and subsequent LDCT screening and provides more detail about LDCT screening. This manuscript focuses on identifying patients at high risk for lung cancer who are candidates for LDCT of the chest and on evaluating initial screening findings.

The Lung CT Screening Reporting and Data System (Lung-RADS™) is an algorithm that can be used to classify lung nodules in patients with significant smoking histories. It is published in table format but can be implemented as a computer program. The aim of this study was to assess the efficiency and accuracy of the use of a computer program versus the table in categorizing lung nodules.The Lung-RADS algorithm was implemented as a computer program. Through the use of a survey tool, respondents were asked to categorize 13 simulated lung nodules using the computer program and the Lung-RADS table as published. Data were gathered regarding time to completion, accuracy of each nodule's categorization, users' subjective categorization confidence, and users' perceived efficiency using each method.The use of a computer program to categorize lung nodules resulted in significantly increased interpretation speed (80.8 ± 37.7 vs 156 ± 105 seconds, P.0001), lung nodule classification accuracy (99.6% vs 76.5%, P.0001), and perceived confidence and efficiency compared with the use of the table. There were no significant differences in accuracy when comparing thoracic radiologists with the remainder of the group.Radiologists were both more efficient and more accurate in lung nodule categorization when using computerized decision support tools. The authors propose that other institutions use computerized implementations of Lung-RADS in the interests of both efficiency and patient outcomes through proper management. Furthermore, they suggest the ACR design future iterations of the Lung-RADS algorithm with computerized decision support in mind.

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Lung Cancer Screening provide recommendations for selecting individuals for lung cancer screening, and for evaluation and follow-up of nodules found during screening, and are intended to assist with clinical and shared decision-making. These NCCN Guidelines Insights focus on the major updates to the 2015 NCCN Guidelines for Lung Cancer Screening, which include a revision to the recommendation from category 2B to 2A for one of the high-risk groups eligible for lung cancer screening. For low-dose CT of the lung, the recommended slice width was revised in the table on "Low-Dose Computed Tomography Acquisition, Storage, Interpretation, and Nodule Reporting."

We developed a faculty professional development seminar series in order to facilitate the integration of our numerous new faculty into academics. The changing nature of the healthcare system, increasing clinical and administrative responsibility, and lack of access to senior mentors can hinder junior faculty productivity and possibly increase attrition. Given that no ready-made resources existed to address these issues we established a Professional Development Committee, developed a curriculum that covers relevant topics including promotion, mentorship, conflict management and feedback, and effective presentation of scientific data, and instituted changes iteratively based upon feedback. We used surveys from successive years of this seminar series to assess effectiveness, and our data demonstrate that our Professional Development Seminar Series was valued by its participants and that individual lectures improved from year to year. While it is too early to determine whether our efforts will lead to long-term changes in promotion success or faculty retention, our initial data are promising.

Building and maintaining a comprehensive yet simple set of standardized protocols for a cross-sectional image can be a daunting task. A single department may have difficulty preventing “protocol creep,” which almost inevitably occurs when an organized “playbook” of protocols does not exist and individual radiologists and technologists alter protocols at will and on a case-by-case basis. When multiple departments or groups function in a large health system, the lack of uniformity of protocols can increase exponentially. In 2012, the University of Colorado Hospital formed a large health system (UCHealth) and became a 5-hospital provider network. CT and MR imaging studies are conducted at multiple locations by different radiology groups. To facilitate consistency in ordering, acquisition, and appearance of a given study, regardless of location, we minimized the number of protocols across all scanners and sites of practice with a clinical indication-driven protocol selection and standardization process. Here we review the steps utilized to perform this process improvement task and insure its stability over time. Actions included creation of a standardized protocol template, which allowed for changes in electronic storage and management of protocols, designing a change request form, and formation of a governance structure. We utilized rapid improvement events (1 day for CT, 2 days for MR) and reduced 248 CT protocols into 97 standardized protocols and 168 MR protocols to 66. Additional steps are underway to further standardize output and reporting of imaging interpretation. This will result in an improved, consistent radiologist, patient, and provider experience across the system.

Objective To evaluate the presence of pulmonary abnormalities in rheumatoid arthritis (RA)–related autoantibody–positive subjects without inflammatory arthritis. Methods Forty-two subjects who did not have inflammatory arthritis but were positive for anti–cyclic citrullinated peptide antibodies and/or ≥2 rheumatoid factor isotypes (a profile that is 96% specific for RA), 15 autoantibody-negative controls, and 12 patients with established seropositive early RA (

Multislice computed tomography technology has enabled sophisticated insights into the evaluation of collateral venous pathways in the thorax. A small but well-established body of literature has described the multiple venous pathways in patients with central venous obstruction. In unusual circumstances, however, physiologically maladaptive pathways have been described involving systemic to pulmonary venous shunts. This paper describes 21 patients with systemic to pulmonary venous shunts having a wide spectrum of etiologies. Clinical presentations typically include cardiopulmonary symptomatology and paradoxical emboli. Ultrafast magnetic resonance and multislice computed tomography established the diagnosis of this uncommon but important entity.

Electronic health record (EHR) implementation has dramatically impacted all facets of radiology workflow. Many departments find themselves unprepared for the multiple issues that surface following EHR deployment and the ongoing need for workflow optimization. This paper reviews the structure and processes utilized by the team, developed at the University of Colorado Hospital to evaluate, prioritize, and implement requests for workflow repairs and improvements within the EHR. The evolution of this team as the academic hospital formed a health system with two community hospital sites is also described. This structure may serve as a useful template for others considering EHR deployment or struggling to manage radiology workflow within an existing EHR environment.

OBJECTIVE. This essay depicts recent advances of MDCT in the evaluation of aortic valvular disease.CONCLUSION. Aortic valvular disease can be assessed with current MDCT technology. The improved imaging characteristics of MDCT have significantly decreased artifacts traditionally seen with prosthetic aortic valves and enabled excellent visualization of valve function. Advances in ECG-gated MDCT technology offer the opportunity to evaluate a variety of aortic valvular abnormalities.

WHY COMMERCIAL DECISION SUPPORT Clinical decision support (CDS) has emerged as a tool to improve patient care across many specialties [1]. Broadly defined, CDS is a method of delivering organized clinical knowledge and recommendations to a clinician to assist in selecting the best course of action for a specific clinical scenario. With regard to imaging, the purpose of CDS is to assist a referring physician in requesting the most appropriate imaging study for a specific clinical scenario [2]. CDS for imaging has been integrated into electronic ordering systems at other institutions with success. Some institutions have reported adoption across virtually all specialties, reduction in low-yield imaging, and even elimination of the need for preauthorization by thirdparty payers when using CDS [3-6]. Therefore, one can reasonably infer that a successful CDS system for imagingcouldnotonly improvepatientcare but might also aid in cost containment and compliance with meaningful use requirements [7,8]. As a result of the positive gains reported at other institutions, our department embraced CDS for computerized physician order entry (CPOE) of imaging studies. However, successful implementation of CDS into the CPOE for imaging studies has only been reported at institutions with “homegrown” CDS programs, which are programs developed by and for the institutions at which they were ultimately used, an approach that likely mitigated or eliminated many of the potential problems associated with CDSCPOE integration. The objective of this paper is to describe our experience at the University of Colorado attempting to integrate a third-party commercial CDS product into our health care system.

OBJECTIVE. The objective of our study was to describe cardiac applications for digital radiography with dual-energy subtraction.CONCLUSION. Dual-energy subtraction digital radiography offers potentially important new information in the assessment of coronary artery disease.

In the transition from paper to electronic workflow, the University of Colorado Health System’s implementation of a new electronic health record system (EHR) forced all clinical groups to reevaluate their practices including the infrastructure surrounding clinical trials. Radiological imaging is an important piece of many clinical trials and requires a high level of consistency and standardization. With EHR implementation, paper orders were manually transcribed into the EHR, digitizing an inefficient work flow. A team of schedulers, radiologists, technologists, research personnel, and EHR analysts worked together to optimize the EHR to accommodate the needs of research imaging protocols. The transition to electronic workflow posed several problems: (1) there needed to be effective communication throughout the imaging process from scheduling to radiologist interpretation. (2) The exam ordering process needed to be automated to allow scheduling of specific research studies on specific equipment. (3) The billing process needed to be controlled to accommodate radiologists already supported by grants. (4) There needed to be functionality allowing exams to finalize automatically skipping the PACS and interpretation process. (5) There needed to be a way to alert radiologists that a specialized research interpretation was needed on a given exam. These issues were resolved through the optimization of the “visit type,” allowing a high-level control of an exam at the time of scheduling. Additionally, we added columns and fields to work queues displaying grant identification numbers. The build solutions we implemented reduced the mistakes made and increased imaging quality and compliance.

Using clinically acquired x-ray angiography image sequences, we compared three algorithms for creating a single diagnostic quality image that combined input images containing flowing contrast agent. These image-stacking algorithms were: maximum opacity with the minimum gray-scale value across time recorded at each spatial location, (REC) recursive temporal filtering followed by a maximum opacity operation, and (AMF) an approximate matched filter consisting of a convolution with a kernel approximating the matched filter followed by a maximum opacity operation. Eighteen clinical exams of the peripheral arteries of the legs were evaluated. AMF gave 2.7 times greater contrast to noise ratio than the single best subtraction image and 1.3 times improvement over REC, the second best stacking algorithm. This is consistent with previous simulations showing that AMF performs nearly equal to the optimal result from matched filtering without the well-known limitations. For example, unlike matched filtering, AMF filter coefficients were obtained automatically using an image-processing algorithm. AMF effectively brought out small collateral arteries, otherwise difficult to see, without degrading artery sharpness or stenosis grading. Comparing results using reduced and full contrast agent volumes demonstrated that contrast agent load could be reduced to one-third of the conventional amount with AMF processing. By simulating reduced x-ray exposures on clinical exams, we determined that x-ray exposure could be reduced by 80% with AMF processing. We conclude that AMF is a promising, potential technique for reducing contrast agent load and for improving vessel visibility, both very important characteristics for vascular imaging.

The electronic medical record (EMR) has significantly improved efficiency in many areas of radiology workflow. Following implementation of an electronic protocol selection process for cross-sectional imaging at the University of Colorado Hospital, the interventional radiology (IR) division desired to have a similar tool. Evaluation of the IR workflow demonstrated the need for a multilayered solution, which accounted for consultation, physician review, authorization and scheduling, pre-procedural nursing evaluation, physician rounding, and resource allocation and prioritization. This paper outlines the rationale for and components of this process.

b s b q i A m i t R f I a t c c r S t c s DESCRIPTION OF THE PROBLEM Portable intensive care unit (ICU) chest radiography is the mainstay in confirming proper placement and evaluating continued position and function of support catheters, lines, and tubes [1]. However, portable radiographs are often suboptimal because of patient positioning, severe cardiopulmonary disease, or body habitus. Additionally, multiple devices, overlying leads and wires, and dressings or bed sheets can further obscure imaging findings. Direct communication in the PACS era between clinicians and reading radiologists is often very limited, and this lack of communication can lead to serious consequences. Pikwer et al [2] investigated the umber of malpositioned central enous catheters and their correlaion with radiographic findings. he investigators found an approxmate 3.3% incidence of malposiioned central venous catheters. uhm et al [3] followed a series of hest radiographs that were obained for confirmation of central enous catheter placement. This roup found an overall 1.82% rate f catheter misplacement, using ortable radiography for identificaion. However, the group also reorted a case that was not identified n chest radiography; this case reulted in a life-threatening compliation. Giantsou and Gunning [4] performed a retrospective analysis of patients after nasogastric tube placement. In their analysis, the verall incidence of incorrectly ositioned nasogastric tube placeent was 1% to 3%, with approxmately half of these cases occurring n mechanically ventilated patients. erious complications, particularly neumothorax, occurred in 66% of hese cases. Hence, the presence of malpositioned catheter represents significant clinical issue. The failre of a radiologist to accurately dentify an inappropriately posiioned catheter can result in a igher risk for significant patient orbidity. This undertaking was prompted y a case in which a malpositioned upport device was not identified y a junior resident on call. Subseuent use of this catheter resulted n significant patient morbidity. multidisciplinary morbidity and ortality conference was held and ncluded discussion by represenatives from the Department of adiology, the Department of Proessional Risk Management, and CU nursing staff. All parties greed that improved communicaion among ICU staff members, linicians, and radiologists could derease the number of interpretive erors related to tube and line position. everal individuals inquired whether he electronic medical record (EMR) ould be used as a tool to facilitate uch communication.

We report a patient on warfarin prophylaxis who had major intraperitoneal hemorrhage 17 days following percutaneous liver biopsy (PLBx). Selective hepatic angiography revealed a pseudoaneurysm of a branch of the right hepatic artery, associated with an arterio-portal venous fistula. Ultrasound with Doppler studies showed flow through the pseudoaneurysm. Embolization with platinum micro-coils resulted in cessation of flow through the pseudoaneurysm, and closure of the arterio-portal venous fistula. Anticoagulation was then resumed without recurrent bleeding. Pseudoaneurysms and arteriovenous fistulas may be mechanisms by which delayed bleeding occurs after PLBx. Doppler ultrasonography and hepatic angiography are useful in the evaluation and management of this event.

Computed tomography (CT)-guided liver biopsy has become an accepted part of the diagnostic evaluation of patients with benign and malignant hepatic disease The advantages of imaging guidance over blind percutaneous biopsy are now well established in the literature. Controversy continues to exist, however, over the safety and accuracy of the procedure, as well as over the proper choice of needle: large-caliber cutting needle versus small caliber aspiration needle. In 1984, our group reported the results in a preliminary set of 180 patients in whom CT-guided biopsy of focal liver lesions was performed. The study indicated that cutting-needle sampling could provide increased diagnostic accuracy over fine-needle aspiration in both benign and malignant hepatic disease without a significant increase in complications. This paper reports the results in a series of 179 new patients who underwent CT-guided liver biopsy using a variety of needles. Comparison is again made between fine-needle and cutting-needle biopsy with respect to diagnostic accuracy and safety. A detailed discussion of the proper choice of biopsy needle as well as of the causes of both biopsy failure and complications is provided.

We report a child who developed a hepatic artery pseudoaneurysm following blunt hepatic injury. This is a rare complication of hepatic trauma in children. The imaging evaluation and clinical management of hepatic artery pseudoaneurysms are presented.

Emerging applications in digital radiography offer exciting advances in the evaluation of lung disease. Dual energy subtraction techniques have been recognized as a promising technique in the detection and characterization of pulmonary nodules. This essay will demonstrate a significantly expanded diagnostic role in the assessment of cardiothoracic disease with dual energy subtraction and digital radiography.

Advances in MSCT have enabled assessment of cardiac function and anatomy, and ECG gating has allowed increasingly accurate depiction of coronary artery grafts and native coronary arteries. These capabilities now offer a comprehensive evaluation of the preoperative surgical patient. This essay outlines the important imaging issues and opportunities in the evaluation of the cardiac surgery patient.

Describes a method for using multiple regions of interest to register the digital subtraction angiography images. For each region of interest (ROI) placed on the mask image, similarity measures are optimized to determine the best sub-pixel x and y shifts. A figure of merit is calculated for each ROI and used to determine the best pixel shift vector for the entire image. Preliminary results indicate that the method is robust. >

We describe the MR and MR angiographic findings of a popliteal artery pseudoaneurysm in a patient with hereditary multiple exostoses

frames but may carefully examine only 1 or 2 frames. Obviously, this "wastes" x-ray dose. It is well knownthat contrast agent poses significant acute and chronic risk to patients. These adverse reactions range fromdiscomfort, nausea, and hives to renal toxicity and even death. Considering economics, contrast agent costsabout $250 per patient study. In addition, the cost of treatment in response to adverse contrast agent reactioncan be quite significant. Thus, it is desirable to minimize x-ray dose and contrast agent volume.In this paper, we use a mathematical model of flowing contrast agent in blood and couple this with aninjector, x-ray system, and image processor to create a final output image. With this specification, we canexamine the extent to which contrast agent can be efficiently used. We examine the tradeoffs between contrastagent volume, x-ray dose, frame rate, and other clinical variables in this preliminary study.Our measure of image quality is the contrast to noise ratio (CNR). Previous studies reported improvementsin CNR at a given artery location,1 however, they cannot be directly translated into contrast agent savings.We can better assess the relationships with a mathematical model of the system. With such a model, we can

Background/objectives Elevations of serum autoantibodies (Abs) prior to joint symptoms suggest that rheumatoid arthritis (RA) may be initiated outside of the joints. This site is unknown, although several factors suggest that it may be the lungs including the association of inhaled factors such as smoking with RA. Our purpose herein was to evaluate a hypothesis that the lung is a site of initiation of RA-related autoimmunity by comparing lung findings in RA-related Ab+ subjects at risk for future RA but without current inflammatory arthritis (IA) to Ab- controls and patients with established early RA. Materials/methods 45 Ab+ cases without IA on 68 joint exam were identified from the Studies of the aetiology of RA project, a prospective study of preclinical RA. These cases were positive for Abs >96% specific for future RA: anti cyclic citrullinated peptides (CCP2) (Axis-Shield) or CCP3.1 (INOVA, San Diego, CA, USA), and/or ≥2 rheumatoid factor (RF) isotypes (IgA, M, G) (INOVA) (N=9 CCP2+; N=25 CCP3.1+; N=11 RFs+ only). Additionally, 16 Ab-sera controls (frequency matched to Ab+ cases on age, sex and smoking) and 12 patients with early RF/aCCP2+ RA ( et al 2008). To evaluate for synovitis not detected on joint exam, a subset of Ab+ cases underwent contrasted MRI of the metacarpophalangeals, wrists and metatarsophalangeals, scored for synovitis by two joint radiologists using the outcome measures in rheumatoid arthritis clinical trials/rheumatoid arthritis MRI scoring system protocols. Results 45 Ab+ cases were a mean age of 54, 56% female and 33% smokers (no significant differences from Ab-controls). 77% of Ab+ cases had airways disease on HRCT including bronchial wall thickening, bronchiectasis, centrilobular opacities and air trapping, compared to 31% of Ab-controls (p et al 1988) ∼13 mos. after lung study. Finally, 9/12 (75%) of early RA subjects (mean age 50, 58% female, 42% smokers) studied in parallel had radiographically indistinguishable airways abnormalities when compared to the Ab+ cases (p>0.5). Conclusions Airways abnormalities are present in a high proportion of RA-specific Ab+ cases without IA (examination or MRI), and these lung abnormalities are similar to those in patients diagnosed with early RA. This suggests that there is a continuum of lung injury during the development of RA, and that lungs are either a site of RA-related autoimmune-mediated injury during the presymptomatic phase of disease, or more likely a site of initiation of RA-related autoimmunity perhaps due to external factors beyond smoking that generate local inflammation, especially since the airways interact substantially with the environment. Prospective studies are ongoing to evaluate the generation of RA-specific in the lungs, and to follow the evolution of autoimmunity and IA in these subjects.

The usefulness of lymphangiography and CT in the diagnosis and localization of laceration of the thoracic duct was evaluated in 12 patients with chylothorax or chylous ascites after surgery. Bipedal lymphangiography was performed in all 12 patients. The last four patients studied also had CT after lymphangiography. Seven patients had abnormal findings on lymphangiograms; five with leaks from the thoracic duct, one with a lymphocele in a nephrectomy bed, and one with obstructed intestinal lymphatic vessels after thoracotomy. Five patients had no evidence of lymphatic leakage. CT in one patient with evidence of a leak on lymphangiography showed extravasation of contrast medium into the mediastinum and pleural space. CT in three patients with no abnormalities on lymphangiography also showed no abnormalities. Four of the five thoracic duct lacerations and the lymphocele were confirmed surgically. The diagnosis of obstructed intestinal lymphatic vessels was supported clinically. Four of the five patients with normal findings on lymphangiograms had resolution of their pleural effusions and no evidence of recurrence during a follow-up period of 1-27 months. One patient with normal findings on lymphangiography had an alternative diagnosis established at surgery. Laceration of the thoracic duct was accurately diagnosed and localized with lymphangiography, which allowed definitive surgical repair. CT was of little additional value in diagnosing these injuries.