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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Rahman NM, Chapman SJ, Davies RJ. Pleural effusion: a structured approach to care. [Review] [49 refs]. Br Med Bull. 72:31-47, 2004. Review/Other-Dx N/A To the investigation of the patient with a pleural effusion. This should allow an accurate diagnosis to be made with the minimum number of invasive and time-consuming investigations. No results stated in the abstract. 4
2. Kruger D. Evaluating the adult with new-onset pleural effusion. [Review]. JAAPA. 26(7):20-7, 2013 Jul. Review/Other-Dx N/A To reviews risk factors, patient assessment, diagnostic testing, initial management, and treatment. No results stated in the abstract. 4
3. Maskell NA, Butland RJ, Pleural Diseases Group, Standards of Care Committee, British Thoracic Society. BTS guidelines for the investigation of a unilateral pleural effusion in adults. Thorax. 58 Suppl 2:ii8-17, 2003 May. Review/Other-Dx N/A To discuss the investigation of of a unilateral pleural effusion in adults. No results stated in the abstract 4
4. Light RW, Macgregor MI, Luchsinger PC, Ball WC, Jr. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med 1972;77:507-13. Review/Other-Dx N/A To discuss the the diagnostic separation of transudates and exudates. No results stated in the abstract. 4
5. Ferreiro L, Toubes ME, San Jose ME, Suarez-Antelo J, Golpe A, Valdes L. Advances in pleural effusion diagnostics. [Review]. Expert Rev Respir Med. 14(1):51-66, 2020 01. Review/Other-Dx N/A To provide an overview of latest advances in the diagnosis of pleural effusion based on the best evidence available For pleural fluid tests to have a good diagnostic value, it is necessary that data obtained from clinical history, physical examination, and radiological studies are correctly interpreted. Thoracentesis and pleural biopsy should always be performed under image guidance to improve its diagnostic sensitivity and prevent complications. Nucleic acid amplification tests, pleural tissue cultures, and collection of pleural fluid in blood culture bottles improve the diagnostic yield of pleural fluid cultures. Although undiagnosed pleural effusions generally have a favorable prognosis, follow-up is recommended to prevent the development of a malignant pleural effusion. 4
6. Light RW. Pleural effusions. [Review]. Med Clin North Am. 95(6):1055-70, 2011 Nov. Review/Other-Dx N/A To discuss diseases that cause Pleural Effusion. No results stated in the abstract. 4
7. Hooper C, Lee YC, Maskell N, BTS Pleural Guideline Group. Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 65 Suppl 2:ii4-17, 2010 Aug. Review/Other-Dx N/A To present new recommendations regarding image guidance of pleural procedures with clear benefits to patient comfort and safety, optimum pleural fluid sampling and processing and the particular value of thoracoscopic pleural biopsies and to review recent evidence for the use of new biomarkers including N-terminal pro-brain natriuretic peptide (NT-proBNP), mesothelin and surrogate markers of tuberculous pleuritis. No abstract available. 4
8. Shellenberger RA, Balakrishnan B, Avula S, Ebel A, Shaik S. Diagnostic value of the physical examination in patients with dyspnea. [Review]. Cleve Clin J Med. 84(12):943-950, 2017 Dec. Review/Other-Dx N/A To review the evidence for the diagnostic accuracy of the physical examination in diagnosing pneumonia, pleural effusion, chronic obstructive pulmonary disease, and congestive heart failure in patients with dyspnea and found that the physical examination has reliable diagnostic accuracy for these common conditions. No results stated in the abstract. 4
9. Yalcin NG, Choong CK, Eizenberg N. Anatomy and pathophysiology of the pleura and pleural space. [Review]. Thorac Surg Clin. 23(1):1-10, v, 2013 Feb. Review/Other-Dx N/A To review the anatomy and pathophysiology of the pleura and pleural space. No results stated in the abstract. 4
10. Porcel JM. Chest imaging for the diagnosis of complicated parapneumonic effusions. [Review]. Curr Opin Pulm Med. 24(4):398-402, 2018 07. Observational-Dx N/A To provide an overview of the contribution of thoracic ultrasound (TUS) and computed tomography (CT) in the identification of complicated parapneumonic effusions (CPPE), defined as those which need chest tube drainage for resolution. A recent retrospective study found that visualization of complex (nonanechoic) effusions on TUS (likelihood ratio positive = 6.92) outperformed the recognition of loculated/septated effusions on CT (likelihood ratio = 2.20) or chest radiographs (likelihood ratio = 1.54) for predicting a CPPE. In another retrospective study, a weighted CT scoring system consisting of pleural contrast enhancement (three points), pleural microbubbles, increased extrapleural fat attenuation, and fluid volume at least 400 ml (one point each) had relatively good accuracy for labeling CPPE (likelihood ratio positive = 3.4; likelihood ratio negative = 0.22) when four or more points were achieved. 2
11. Moy MP, Levsky JM, Berko NS, Godelman A, Jain VR, Haramati LB. A new, simple method for estimating pleural effusion size on CT scans. Chest. 143(4):1054-1059, 2013 Apr. Observational-Dx 34 patients To discuss a simple method for estimating pleural effusion size on CT scans. The CT imaging features found to best classify effusions as small, moderate, or large were anteroposterior (AP) quartile and maximum AP depth measured at the midclavicular line. According to the decision rule, first AP-quartile effusions are small, second AP-quartile effusions are moderate, and third or fourth AP-quartile effusions are large. In borderline cases, AP depth is measured with 3-cm and 10-cm thresholds for the upper limit of small and moderate, respectively. Use of the rule improved interobserver agreement from ? = 0.56 to 0.79 for all physicians, 0.59 to 0.73 for radiology residents, 0.54 to 0.76 for pulmonologists, and 0.74 to 0.85 for cardiothoracic radiologists. 2
12. American College of Radiology. ACR–NASCI–SIR–SPR Practice Parameter for the Performance and Interpretation of Body Computed Tomography Angiography (CTA). Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/body-cta.pdf. Review/Other-Dx N/A Guidance document to promote the safe and effective use of diagnostic and therapeutic radiology by describing specific training, skills and techniques. No abstract available. 4
13. Shen KR, Bribriesco A, Crabtree T, et al. The American Association for Thoracic Surgery consensus guidelines for the management of empyema. [Review]. J Thorac Cardiovasc Surg. 153(6):e129-e146, 2017 06. Review/Other-Dx N/A To establish The American Association for Thoracic Surgery (AATS) evidence-based guidelines for the management of empyema. No abstract available. 4
14. Zettinig D, D'Antonoli TA, Wilder-Smith A, Bremerich J, Roth JA, Sexauer R. Diagnostic Accuracy of Imaging Findings in Pleural Empyema: Systematic Review and Meta-Analysis. [Review]. J. imaging. 8(1), 2021 Dec 28. Review/Other-Dx N/A To identify informative findings for structured reporting ON Diagnostic Accuracy of Imaging Findings in Pleural Empyema: CT C: culture/gram-stain/pathology/pus, O: Diagnostic accuracy measures), data extraction, and risk of bias assessment of studies published between 01-1980 and 10-2021 on Pubmed, Embase, and Web of Science (WOS) were performed independently by two reviewers. CT findings with pooled diagnostic odds ratios (DOR) with 95% confidence intervals, not including 1, were considered as informative. Summary estimates of diagnostic accuracy for CT findings were calculated by using a bivariate random-effects model and heterogeneity sources were evaluated. Ten studies with a total of 252 patients with and 846 without empyema were included. From 119 overlapping descriptors, five informative CT findings were identified: Pleural enhancement, thickening, loculation, fat thickening, and fat stranding with an AUC of 0.80 (hierarchical summary receiver operating characteristic, HSROC). Potential sources of heterogeneity were different thresholds, empyema prevalence, and study year. 4
15. Franklin J, Talwar A, Addala D, et al. CT appearances of pleural infection: analysis of the Second Multi-centre Intra-pleural Sepsis Trial (MIST 2) cohort. Clin Radiol 2021;76:436-42. Observational-Dx 81 patients To determine the prevalence of pleural abnormalities and describe the computed tomography (CT) features observed in a well-characterised population of patients with pleural infection. Eighty-one patients were included. Parietal pleural thickening and enhancement were seen in 98.7% of patients. Visceral pleural changes were observed in most, including several previously undescribed features. Consolidation was observed in 61.7% of patients and there was a significant association of parenchymal consolidation with CT evidence of small airways infection (p<0.001) and visceral pleural thickening and enhancement (p<0.05). Features of parenchymal infection were absent in one third of patients. 2
16. Porcel JM, Pardina M, Aleman C, Pallisa E, Light RW, Bielsa S. Computed tomography scoring system for discriminating between parapneumonic effusions eventually drained and those cured only with antibiotics. Respirology. 22(6):1199-1204, 2017 08. Observational-Dx 59 patients. To develop and validate a computed tomography (CT)-based scoring system for identifying those parapneumonic effusions (PPEs) requiring drainage. CT scores predicting CPPE were pleural contrast enhancement (3 points), pleural microbubbles, increased extrapleural fat attenuation and fluid volume =400 mL (1 point each). A sum score of =4 yielded 84% sensitivity (95% CI: 62-85%), 75% specificity (95% CI: 62-85%), 81% diagnostic accuracy (95% CI: 73-86%), likelihood ratio (LR) positive of 3.4 (95% CI: 2.1-5.4), LR negative of 0.22 (95% CI: 0.13-0.36) and area under the receiver operating characteristic curve (AUC) of 0.829 (95% CI: 0.754-0.904) for labelling CPPE in the derivation set. These results were reproduced in the validation sample. The CT grading scale also exhibited a fair ability to identify patients who needed surgery or would die from the pleural infection (AUC: 0.76, 95% CI: 0.61-0.9). 2
17. Tsujimoto N, Saraya T, Light RW, et al. A Simple Method for Differentiating Complicated Parapneumonic Effusion/Empyema from Parapneumonic Effusion Using the Split Pleura Sign and the Amount of Pleural Effusion on Thoracic CT. PLoS ONE. 10(6):e0130141, 2015. Observational-Dx 83 patients To develop a simple method to distinguish complicated parapneumonic effusion (CPPE)/empyema from parapneumonic effusion (PPE) using computed tomography (CT) focusing on the split pleura sign, fluid attenuation values (HU: Hounsfield units), and amount of fluid collection measured on thoracic CT prior to diagnostic thoracentesis. On univariate analysis, the split pleura sign (odds ratio (OR), 12.1; p<0.001), total amount of pleural effusion (>/=30 mm) (OR, 6.13; p<0.001), HU value>/=10 (OR, 5.94; p=0.001), and the presence of septum (OR, 6.43; p=0.018), atelectasis (OR, 6.83; p=0.002), or air (OR, 9.90; p=0.002) in pleural fluid were significantly higher in the CPPE/empyema group than in the PPE group. On multivariate analysis, only the split pleura sign (hazard ratio (HR), 6.70; 95% confidence interval (CI), 1.91-23.5; p=0.003) and total amount of pleural effusion (>/=30 mm) on thoracic CT (HR, 7.48; 95%CI, 1.76-31.8; p=0.006) were risk factors for empyema. Sensitivity, specificity, positive predictive value, and negative predictive value of the presence of both split pleura sign and total amount of pleural effusion (>/=30 mm) on thoracic CT for CPPE/empyema were 79.4%, 80.9%, 75%, and 84.4%, respectively, with an area under the curve of 0.801 on receiver operating characteristic curve analysis. 2
18. Moffett BK, Panchabhai TS, Anaya E, et al. Computed tomography measurements of parapneumonic effusion indicative of thoracentesis. European Respiratory Journal. 38(6):1406-11, 2011 Dec. Observational-Dx 1,460 patients To identify a parapneumonic effusions (PPE) measurement by CCT that indicates the need for thoracentesis. A secondary data analysis of two pneumonia databases was conducted to identify patients with parapneumonic effusions (PPE). To discuss the data analysis of two pneumonia databases was conducted to identify patients with parapneumonic effusions (PPE). PPE was identified in 419 out of 1,460 patients with possible pneumonia. PPE measurements of 1 cm and 5 cm by LDR and LER, respectively, correlated with a measurement of 2.5 cm by CCT. Out of 95 patients with CCT measurements <2.5 cm, 31 poor clinical outcomes were reported: outcome was PPE related (n = 1); outcome was PPE unrelated (n = 26); and outcome was not evaluable (n = 4). The single case of poor outcome also measured <1 cm by LDR. This study indicates that patients with community-acquired pneumonia and a PPE measuring <2.5 cm by CCT can be managed without the need for thoracentesis. 2
19. Raj V, Kirke R, Bankart MJ, Entwisle JJ. Multidetector CT imaging of pleura: comparison of two contrast infusion protocols. Br J Radiol. 84(1005):796-9, 2011 Sep. Observational-Dx 40 patients To compare two contrast protocols for assessing pleural pathology on MDCT. 40 patients (20 in each group) who had pleural enhancement on MDCT were included for final analysis. The mean pleural enhancement value was 83 HU (Group A) vs 59 HU (Group B) (p = 0.0004). The mean aortic enhancement was 241 HU (A) vs 141 HU (B) (p<0.0001); main pulmonary artery enhancement was 208 HU (A) vs 139 HU (B) (p<0.0002); portal venous enhancement was 169 HU (A) vs 115 HU (B) (p<0.0001); and the superior mesenteric artery enhancement was 215 HU (A) vs 128 HU (B) (p<0.0001). 1
20. Reza A, Kalia P, Gandy N, Chana H. Arterial versus pleural phase CT chest: an assessment of image quality and radiation dose. Clin Radiol 2020;75:E8. Review/Other-Dx N/A To discuss an assessment of image quality and radiation dose of Arterial versus pleural phase CT chest. No results stated in the abstract. 4
21. Spoto S, Ciccozzi M, Angeletti S. A rare case of subcutaneous abscess with intercostal muscles involvement by pleural tuberculosis in a Malagasy young traveller. J Travel Med 2017;24. Review/Other-Dx N/A To discuss a rare case of subcutaneous abscess with intercostal muscles involvement by pleural tuberculosis in a Malagasy young traveller No results stated in the abstract. 4
22. Sodhi KS, Bhatia A, Nichat V, et al. Chest MRI as an emerging modality in the evaluation of empyema in children with specific indications: Pilot study. Pediatr Pulmonol 2021;56:2668-75. Observational-Dx 19 Patients To assess the diagnostic role of chest magnetic resonance imaging (MRI) for evaluating empyema in children with specific indications. The kappa test showed almost perfect agreement (? = 1) between MRI and MDCT for detecting fluid, pleural thickening, pleural enhancement, drainage tube tip localization, consolidation, and lymphadenopathy. Septations within the fluid were detected in 16 (84.2%) patients on MRI, and in 14 (73.7%) patients on MDCT. Almost perfect agreement (? = 0.81-1.00) was seen for all the findings on CT and MRI between the two radiologists, except for pleural thickening for which a strong agreement (? = 0.642) was observed. 2
23. Konietzke P, Mueller J, Wuennemann F, et al. The value of chest magnetic resonance imaging compared to chest radiographs with and without additional lung ultrasound in children with complicated pneumonia. PLoS ONE. 15(3):e0230252, 2020. Observational-Dx 33 patients To evaluate the potential of radiation-free chest magnetic resonance imaging (MRI) to detect complications at baseline and follow-up, compared to CXR with and without additional lung ultrasound (LUS). 33 pediatric patients (6.3±4.6 years), who had 33 paired MRI and CXR scans at baseline and 12 at follow-up were included. MRI detected significantly more lung abscess formations with a prevalence of 72.7% compared to 27.3% by CXR at baseline (p = 0.001), whereas CXR+LUS was nearly as good as MRI. MRI also showed a higher sensitivity in detecting empyema (p = 0.003). At follow-up, MRI also showed a slightly better sensitivity regarding residual abscesses. The overall severity of disease was rated higher on MRI. Contrast material did not improve detection of abscesses or empyema by MRI. 2
24. Stein R, Manson D. Magnetic resonance imaging findings of empyema necessitatis in a child with a group A streptococcus infection. J Thorac Imaging 2012;27:W13-4. Review/Other-Dx N/A To present the magnetic resonance imaging findings of a rare case of a child with empyema necessitatis due to a group A streptococcal agent. No results stated in the abstract. 4
25. Inan N, Arslan A, Akansel G, Arslan Z, Elemen L, Demirci A. Diffusion-weighted MRI in the characterization of pleural effusions. Diagn Interv Radiol 2009;15:13-8. Review/Other-Dx N/A To evaluate the value of diffusion-weighted imaging (DWI) in the differential diagnosis of pleural effusions. On visual evaluation, most of the transudative effusions were isointense, while most of the exudative effusions were hyperintense on DWI with b factors of 500 and 1000 s/mm (2). Quantitatively, with a b factor of 500 and 1000 s/mm(2), effusion-to-paraspinal muscle SI ratios of the exudative effusions were significantly higher than those of transudative effusions. The ADCs of the exudative effusions were significantly lower than those of transudative effusions (mean ADC was 3.3 x 10 (-3)+/- 0.7 mm(2)/s for exudative effusions, and 3.7 x 10 (-3)+/-0.3 mm(2)/s for transudative effusions). Setting the cutoff value at 3.6 x 10(-3), ADC had a sensitivity of 71% and a specificity of 63% for differentiating transudative from exudative effusions. 4
25. Metlay JP, Kapoor WN, Fine MJ. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA 1997;278:1440-5. Review/Other-Dx N/A To reviews the literature on the appropriate use of the history and physical examination in diagnosing community-acquired pneumonia. No results stated in the abstract 4
26. Rosmini S, Seraphim A, Knott K, et al. Non-invasive characterization of pleural and pericardial effusions using T1 mapping by magnetic resonance imaging. Eur Heart J Cardiovasc Imaging 2022;23:1117-26. Observational-Dx 55 patients To Differentiate exudative from transudative effusions is clinically important and is currently performed via biochemical analysis of invasively obtained samples using Light's criteria. A phantom consisting of serially diluted human albumin solutions (25-200 g/L) was constructed and scanned at 1.5 T to derive the relationship between fluid T1 values and fluid albumin concentration. Native T1 values of pleural and pericardial effusions from 86 patients undergoing clinical CMR studies retrospectively analysed at four tertiary centres. Effusions were classified using Light's criteria where biochemical data was available (n = 55) or clinically in decompensated heart failure patients with presumed transudative effusions (n = 31). Fluid T1 and protein values were inversely correlated both in the phantom (r = -0.992) and clinical samples (r = -0.663, P < 0.0001). T1 values were lower in exudative compared to transudative pleural (3252 ± 207 ms vs. 3596 ± 213 ms, P < 0.0001) and pericardial (2749 ± 373 ms vs. 3337 ± 245 ms, P < 0.0001) effusions. The diagnostic accuracy of T1 mapping for detecting transudates was very good for pleural and excellent for pericardial effusions, respectively [area under the curve 0.88, (95% CI 0.764-0.996), P = 0.001, 79% sensitivity, 89% specificity, and 0.93, (95% CI 0.855-1.000), P < 0.0001, 95% sensitivity; 81% specificity]. 2
26. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007; 44 Suppl 2:S27-72. Review/Other-Dx N/A Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. No abstract available. 4
27. Moffett BK, Panchabhai TS, Nakamatsu R, et al. Comparing posteroanterior with lateral and anteroposterior chest radiography in the initial detection of parapneumonic effusions. Am J Emerg Med. 34(12):2402-2407, 2016 Dec. Observational-Dx N/A To identify which technique is preferred for detection of PPEs using chest computed tomography (CCT) as a reference standard. There was a statistically significant difference between the sensitivity of AP (67.3%) and PA/Lat (83.9%) chest radiography for the initial detection of CR-PPE. Of 16 CR-PPEs initially missed by AP radiography, 7 either required drainage initially or developed empyema within 30 days, whereas no complicated PPE or empyema was found in those missed by PA/Lat radiography. 2
28. Brixey AG, Luo Y, Skouras V, Awdankiewicz A, Light RW. The efficacy of chest radiographs in detecting parapneumonic effusions. Respirology. 16(6):1000-4, 2011 Aug. Observational-Dx 61 patients To hypothesize that anteroposterior (AP) CXRs are not as sensitive as posteroanterior (PA) and lateral radiographs in identifying PPEs and should not be routinely used in patients with suspected pneumonia. Lateral, PA and AP radiographs were equivalent in identifying the presence of PPEs. All three views missed more than 10% of PPEs. The sensitivities of lateral, PA and AP CXRs were 85.7%, 82.1% and 78.4%, respectively (P = 0.749); the specificity was 87.5%, 81.3% and 76.4%, respectively (P = 0.198). The majority of effusions missed in each view were on films with lower lobe consolidation. 2
29. Svigals PZ, Chopra A, Ravenel JG, Nietert PJ, Huggins JT. The accuracy of pleural ultrasonography in diagnosing complicated parapneumonic pleural effusions. Thorax. 72(1):94-95, 2017 01.Thorax. 72(1):94-95, 2017 01. Observational-Dx 66 patients To determine radiographic complexity in predicting a complicated parapneumonic effusion (CPPE) defined by pleural fluid analysis. Pleural ultrasound had a sensitivity of 69.2% (95% CI 48.2% to 85.7%) and specificity of 90.0% (95% CI 76.3% to 97.2%). Chest computed tomography (CT) had a sensitivity of 76.9% (95% CI 56.3% to 91.0%) and specificity of 65.0% (95% CI 48.3% to 79.4%). Chest radiograph (CXR) had a sensitivity of 61.5% (95% CI 40.6% to 79.8%) and specificity of 60.0% (95% CI 43.3% to 75.1%). 3
30. Laursen CB, Clive A, Hallifax R, et al. European Respiratory Society statement on thoracic ultrasound. [Review]. Eur Respir J. 57(3), 2021 03. Review/Other-Dx N/A To produce a statement on thoracic ultrasound for pulmonologists using thoracic ultrasound within the field of respiratory medicine. No results stated in the abstract. 4
31. Chen KY, Liaw YS, Wang HC, Luh KT, Yang PC. Sonographic septation: a useful prognostic indicator of acute thoracic empyema. J Ultrasound Med 2000;19:837-43. Observational-Dx 163 patients To identify sonographic predictors of patient outcomes or need for surgical intervention of acute thoracic empyema. A total of 163 consecutive patients were included in the study (83 patients with septated and 80 with nonseptated sonographic images). The mean duration of hospital stay (35.4 versus 27.0 days, P = 0.009) and chest tube drainage (13.1 versus 7.6 days, P < 0.001) for the patients with septa were significantly longer than for those without septa. The patients with septa were more likely to undergo intrapleural fibrinolytic therapy (63.8% versus 38.8%, odds ratio 2.79, P = 0.001) and surgical intervention (24.3% versus 7.5%, odds ratio 3.92, P = 0.004). 2
32. Chen CH, Chen W, Chen HJ, et al. Transthoracic ultrasonography in predicting the outcome of small-bore catheter drainage in empyemas or complicated parapneumonic effusions. Ultrasound Med Biol. 35(9):1468-74, 2009 Sep. Observational-Dx 141 patients To investigate the outcomes of patients who had been diagnosed with empyema and CPPE and had received ultrasound-guided small-bore catheter (size from 12F to 16F) drainage in a tertiary university hospital from September 2005 to August 2007. Patients were excluded when empyemas or CPPEs were traumatic, they were less than 18 years old or their charts were incomplete. We evaluated 141 small-bore catheters in 70 patients with empyemas and 71 patients with CPPEs over a two-year period. The mean age was 58+/-15 y and the male gender was more frequent (112 men, 79%). The overall successful rate of small-bore catheter drainage in empyemas or CPPEs was 63% (89/141). The sonographic appearances of these empyemas or CPPEs exhibited a complex septated pattern in 57% (81/141) of patients and a complex nonseptated pattern in 43% (60/141) of patients. The success rate in a complex nonseptated sonographic pattern was significantly higher than in a complex septated sonographic pattern (48/60, 80% vs. 41/81, 51%, respectively; p=0.001). Moreover, patients with complex septated sonographic patterns also had higher intensive care unit admission rates compared with nonseptated sonographic patterns (22/81, 27%, vs. 8/60, 13%, respectively; p=0.0047), as well as infection-related mortality rates (17/81, 21% vs. 4/60, 7%, respectively; p=0.018). The appearance of sonographic septation is a useful sign to help predict the outcome of small-bore catheter drainage in cases of empyemas or CPPEs. Patients with a complex septated sonographic pattern have a poorer prognosis for a successful outcome, higher ICU admission rate and a higher mortality rate. 2
33. James CA, Braswell LE, Pezeshkmehr AH, Roberson PK, Parks JA, Moore MB. Stratifying fibrinolytic dosing in pediatric parapneumonic effusion based on ultrasound grade correlation. Pediatr Radiol. 47(1):89-95, 2017 Jan. Observational-Dx 32 patients To evaluate experience with lower fibrinolytic dose for parapneumonic effusions and to assess potential dose stratification based on a simple ultrasound grading system. Of 32 patients with parapneumonic effusion, all except one received at least some 1-mg tPA doses. Dosing was solely 1-mg tPA in 81% of subjects; 19% of subjects also received 2-mg tPA doses. Mean fibrinolytic duration was 3.1 days for grade 1 effusions compared to 5.4 days for grade 2 effusions. A second pleural procedure was required in 15.6% of children. Pleural drainage with fibrinolytic therapy was successful in 97%; only one child required surgical drainage. Grade 2 US differed significantly from grade 1 US, with grade 2 occurring in younger patients (P< 0.0001), smaller patients (P < 0.0001), those needing a second procedure (P= 0.001), those with positive pleural culture or polymerase chain reaction test (P= 0.006), and those with longer treatment duration (P=0.03). 3
34. Maffey A, Colom A, Venialgo C, et al. Clinical, functional, and radiological outcome in children with pleural empyema. Pediatr Pulmonol. 54(5):525-530, 2019 05. Observational-Dx 30 patients To evaluate clinical, pulmonary, and diaphragmatic function and radiological outcome in patients hospitalized with pleural empyema. Thirty patients were included. Nineteen (63%) were male, with an age of (mean ± SD) 9.7 ± 3.2 years, and body mass index (mean ± SD) 18.6 ± 3. Twelve patients (40%) were treated with chest tube drainage only, 12 (40%) exclusively with surgery, and 6 (20%) completed treatment with surgery due to an ineffective chest tube drainage. At hospital discharge, 26 (87%) of patients had abnormal breath sounds at the site of infection, 28 (93%) had a spirometric restrictive pattern, 19 (63%) diaphragmatic motion impairment, and 29 (97%) presented radiological involvement of pleural space, mainly pleural thickening. All patients had recovered diaphragmatic motion and were asymptomatic at 90- and 120-day follow-up control, respectively. Then, with a great individual variability, radiological findings, and lung function returned to normal at 60 days (range 30-180) and 90 days (range 30-180) after hospital discharge, respectively. 2
35. Lin FC, Chou CW, Chang SC. Usefulness of the suspended microbubble sign in differentiating empyemic and nonempyemic hydropneumothorax. J Ultrasound Med. 20(12):1341-5, 2001 Dec. Observational-Dx 31 patients To evaluate the clinical usefulness of the suspended microbubble sign in differentiating empyemic and nonempyemic hydropneumothorax. The suspended microbubble sign was shown on ultrasonography in all 8 patients with empyemic hydropneumothorax but was absent in the 23 patients with nonempyemic hydropneumothorax. These findings were supported by the observation that the pus seemed to mix with and trap the air more easily than did the nonpurulent pleural fluid, as shown in vitro. In this selected population, the sensitivity and specificity of the suspended microbubble sign in aiding a diagnosis of empyemic hydropneumothorax were both 100%. 2
36. Kurian J, Levin TL, Han BK, Taragin BH, Weinstein S. Comparison of ultrasound and CT in the evaluation of pneumonia complicated by parapneumonic effusion in children. AJR Am J Roentgenol. 193(6):1648-54, 2009 Dec. Observational-Dx 19 children To compare chest ultrasound and chest CT in children with complicated pneumonia and parapneumonic effusion. Eighteen of 19 patients had an effusion on both chest ultrasound and chest CT. The findings of effusion loculation as well as parenchymal consolidation and necrosis or abscess were similar between the two techniques. Chest ultrasound was better able to visualize fibrin strands within the effusions. Of the 14 patients who underwent video-assisted thoracoscopy, five had surgically proven parenchymal abscess or necrosis. Preoperatively, chest ultrasound was able to show parenchymal abscess or necrosis in four patients, whereas chest CT was able to show parenchymal abscess or necrosis in three. 3
37. Shyu JY, Khurana B, Soto JA, et al. ACR Appropriateness Criteria® Major Blunt Trauma. J Am Coll Radiol 2020;17:S160-S74. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for major blunt trauma. No results stated in abstract. 4
38. Langdorf MI, Medak AJ, Hendey GW, et al. Prevalence and Clinical Import of Thoracic Injury Identified by Chest Computed Tomography but Not Chest Radiography in Blunt Trauma: Multicenter Prospective Cohort Study. Ann Emerg Med. 66(6):589-600, 2015 Dec. Observational-Dx 5,912 patients To characterize the degree and pattern of improved sensitivity of chest CT over chest radiography for thoracic injuries and determined the clinical import by tracking subsequent management. Two thousand forty-eight patients (34.6%) had chest injury on chest radiography or chest CT, whereas 1,454 of these patients (71.0%, 24.6% of all patients) had occult injury. Of these, in 954 patients (46.6% of injured, 16.1% of total), chest CT found injuries not observed on immediately preceding chest radiography. In 500 more patients (24.4% of injured patients, 8.5% of all patients), chest radiography found some injury, but chest CT found occult injury. Chest radiography found all injuries in only 29.0% of injured patients. Two hundred and two patients with occult injury (of 1,454, 13.9%) had major interventions, 343 of 1,454 (23.6%) had minor interventions, and 909 (62.5%) had no intervention. Patients with occult injury included 514 with pulmonary contusions (of 682 total, 75.4% occult), 405 with pneumothorax (of 597 total, 67.8% occult), 184 with hemothorax (of 230 total, 80.0% occult), those with greater than 2 rib fractures (n¼672/1,120, 60.0% occult) or sternal fracture (n¼269/281, 95.7% occult),12 with great vessel injury (of 18 total, 66.7% occult), 5 with diaphragm injury (of 6, 83.3% occult), and 537 with multiple occult injuries. Interventions for patients with occult injury included mechanical ventilation for 31 of 514 patients with pulmonary contusion (6.0%), chest tube for 118of 405 patients with pneumothorax (29.1%), and 75 of 184 patients with hemothorax (40.8%). Inpatient pain control or observation greater than 24 hours was conducted for 183 of 672 patients with rib fractures (27.2%) and 79 of 269 with sternal fractures (29.4%). Three of 12 (25%) patients with occult great vessel injuries had surgery. Repeated imaging was conducted for 50.6% of patients with occult injury (88.1% chest radiography, 11.9% chest CT, 7.5% both). For patients with occult injury, 90.9% (1,321/1,454) were admitted, with 9.1% observed in the ED for median 6.9 hours. Forty-four percent of observed patients were then admitted (4.0% of patients with occult injury). 3
39. Kroczek EK, Wieners G, Steffen I, et al. Non-traumatic incidental findings in patients undergoing whole-body computed tomography at initial emergency admission. Emerg Med J. 34(10):643-646, 2017 Oct. Observational-Dx 2440 patients To evaluate the number, localisation and importance of non-traumatic incidental findings (IFs) in patients with suspected or obvious multiple trauma undergoing whole-body CT (WBCT) in a level-1 trauma centre. Altogether, 5440 IFs in 2440 patients (1735 male, 705 female; mean age 45.1 years) were documented. In 204 patients (8.4%) urgent category 1 findings were reported, 766 patients (31.4%) had category 2 findings, 1236 patients (50.7%) had category 3 findings and 1173 patients (48.1%) had category 4 findings. Most IFs were detected in the abdomen/pelvis (42.5%). 602 (24.7%) of the patients had no IFs. 4
40. Rodriguez RM, Canseco K, Baumann BM, et al. Pneumothorax and Hemothorax in the Era of Frequent Chest Computed Tomography for the Evaluation of Adult Patients With Blunt Trauma. Annals of Emergency Medicine. 73(1):58-65, 2019 01.Ann Emerg Med. 73(1):58-65, 2019 01. Observational-Dx 21,382 patients To determine the incidence of pneumothorax and hemothorax observed on CT only and the incidence of isolated pneumothorax and hemothorax (pneumothorax and hemothorax occurring without other thoracic injuries), and describe the clinical implications of these injuries. Of 21,382 enrolled subjects, 1,064 (5%) had a pneumothorax and 384 (1.8%) had a hemothorax. Of the 8,661 patients who received both a chest radiograph and a chest CT, 910 (10.5%) had a pneumothorax, with 609 (67%) observed on CT only; 319 (3.7%) had a hemothorax, with 254 (80%) observed on CT only. Of 1,117 patients with pneumothorax, hemothorax, or both, 108 (10%) had isolated pneumothorax or hemothorax. Patients with pneumothorax observed on CT only had a lower chest tube placement rate (30% versus 65%; difference in proportions [?] -35%; 95% confidence interval [CI] -28% to 42%), admission rate (94% versus 99%; ? 5%; 95% CI 3% to 8%), and median length of stay (5 versus 6 days; difference 1 day; 95% CI 0 to 2 days) but similar mortality compared with patients with pneumothorax observed on chest radiograph and CT. Patients with hemothorax observed on CT had only a lower chest tube placement rate (49% versus 68%; ? -19%; 95% CI -31% to -5%) but similar admission rate, mortality, and median length of stay compared with patients with hemothorax observed on chest radiograph and CT. Compared with patients with other thoracic injury, those with isolated pneumothorax or hemothorax had a lower chest tube placement rate (20% versus 43%; ? -22%; 95% CI -30% to -13%), median length of stay (4 versus 5 days; difference -1 day; 95% CI -3 to 1 days), and admission rate (44% versus 97%; ? -53%; 95% CI -62% to -43%), with an admission rate comparable to that of patients without pneumothorax or hemothorax (49%). 2
41. Liu F, Huang YC, Ng Y-B, Liang JH. Differentiate pleural effusion from hemothorax after blunt chest trauma; comparison of computed tomography attenuation values. Journal of Acute Medicine 2016;6:1-6. Observational-Dx N/A To discuss the comparison of computed tomography attenuation to differentiate pleural effusion from hemothorax after blunt chest trauma No results stated in the abstract. 2
42. Rodriguez RM, Hendey GW, Mower W, et al. Derivation of a decision instrument for selective chest radiography in blunt trauma. J Trauma. 71(3):549-53, 2011 Sep. Observational-Dx 2,628 patients To derive a decision instrument (DI) that identifies patients who have virtually no risk of significant intrathoracic injury (SITI) visible on chest radiography and, therefore, no need for chest imaging. Of the 2,628 subjects enrolled, 271 (10.3%) were diagnosed with a total of 462 SITIs, with rib fractures (73%), pneumothorax (38%), and pulmonary contusion (29%) as the most common injuries. Chest pain and chest wall tenderness had the highest sensitivity for SITI (65%). The DI of chest pain, distracting injury, chest wall tenderness, intoxication, age >60 years, rapid deceleration, and altered alertness/mental status had the following screening performance: sensitivity 99.3% (95% confidence interval [CI], 97.4-99.8), specificity 14.0% (95% CI, 12.6-15.4), negative predictive value 99.4% (95% CI, 97.8-99.8), and positive predictive value 11.7% (95% CI, 10.5-13.1). All seven criteria in the DI met the predetermined cut off for acceptable ? (range, 0.51-0.81). 2
43. Rodriguez RM, Langdorf MI, Nishijima D, et al. Derivation and validation of two decision instruments for selective chest CT in blunt trauma: a multicenter prospective observational study (NEXUS Chest CT). PLoS Medicine / Public Library of Science. 12(10):e1001883, 2015 Oct. Observational-Dx 11,477 patients To prospectively derive and validate two decision instruments (DIs) for selective chest computed tomography (CT) in adult blunt trauma patients. The Chest CT-Major DI had the same criteria without rapid deceleration mechanism. In the validation phase, Chest CT-All had a sensitivity of 99.2% (95% CI 95.4%-100%), a specificity of 20.8% (95% CI 19.2%-22.4%), and a negative predictive value (NPV) of 99.8% (95% CI 98.9%-100%) for major injury, and a sensitivity of 95.4% (95% CI 93.6%-96.9%), a specificity of 25.5% (95% CI 23.5%-27.5%), and a NPV of 93.9% (95% CI 91.5%-95.8%) for either major or minor injury. Chest CT-Major had a sensitivity of 99.2% (95% CI 95.4%-100%), a specificity of 31.7% (95% CI 29.9%-33.5%), and a NPV of 99.9% (95% CI 99.3%-100%) for major injury and a sensitivity of 90.7% (95% CI 88.3%-92.8%), a specificity of 37.9% (95% CI 35.8%-40.1%), and a NPV of 91.8% (95% CI 89.7%-93.6%) for either major or minor injury. Regarding the limitations of our work, some clinicians may disagree with our injury classification and sensitivity thresholds for injury detection. 1
44. Rahimi-Movaghar V, Yousefifard M, Ghelichkhani P, et al. Application of Ultrasonography and Radiography in Detection of Hemothorax; a Systematic Review and Meta-Analysis. Emerg (Tehran) 2016;4:116-26. Meta-analysis 12 studies To evaluate the diagnostic value of chest ultrasonography and radiography in detection of hemothorax through a systematic review and meta-analysis. Data from 12 studies were extracted and included in the meta-analysis (7361 patients, 77.1% male). Pooled sensitivity and specificity of ultrasonography in detection of hemothorax were 0.67 (95% CI: 0.41-0.86; I2= 68.38, p<0.001) and 0.99 (95% CI: 0.95-1.0; I2= 88.16, p<0.001), respectively. These measures for radiography were 0.54 (95% CI: 0.33-0.75; I2= 92.85, p<0.001) and 0.99 (95% CI: 0.94-1.0; I2= 99.22, p<0.001), respectively. Subgroup analysis found operator of the ultrasonography device, frequency of the transducer and sample size to be important sources of heterogeneity of included studies. Good
45. Tataroglu O, Erdogan ST, Erdogan MO, et al. Diagnostic Accuracy of InitiaI Chest X-Rays in Thorax Trauma. Jcpsp, Journal of the College of Physicians & Surgeons - Pakistan. 28(7):546-548, 2018 Jul. Review/Other-Dx 23 patients To evaluate the efficacy, sensitivity and specificity of chest x-ray as a diagnostic imaging tool in management of thorax traumas. Nine of 23 pneumothorax patients were diagnosed by chest X-ray. Sensitivity and specificity of PA chest X-ray in the diagnosis of pneumothorax was 39.1% and 100%, respectively. Positive predictive values of chest X-ray for diagnosis of pneumothorax was 100% and negative predictive value was 97.1%. Twenty-four patients had pleural effusions on CT scans, while only 15 could be diagnosed in chest X-rays. Chest X-rays were 62.5% sensitive and 100% specific with positive and negative predictive values of 100% and 98.1%, respectively. Twenty of 41 rib fractures were diagnosed with X-rays. Chest x rays had a 48.8% sensitivity and 100% specificity, and positive and negative predictive values were 100% and 95.6%, respectively. 4
46. Misthos P, Kakaris S, Sepsas E, Athanassiadi K, Skottis I. A prospective analysis of occult pneumothorax, delayed pneumothorax and delayed hemothorax after minor blunt thoracic trauma. Eur J Cardiothorac Surg. 25(5):859-64, 2004 May. Observational-Dx 709 patients To define the incidence of occult pneumothorax (OPX), delayed pneumothorax (DPX) and delayed hemothorax (DHX) and to propose an algorithm for surveillance. OPX was present in 28 patients (4%) detected only with eCXR on admission, 14 patients developed DPX (2%) at 24-48 h later, and 52 patients presented up to 14 days later with DHX (7.4%). Of all DHX 42 (80.7%) required chest tube drainage, eight thoracentesis (16%) and only two (4%) were subjected after 1 month to decortication. No related morbidity was recorded. All the patients with the DHX had at least one rib fractured. Only one death among the DHX patients was documented. 2
47. Plourde M, Emond M, Lavoie A, et al. Cohort study on the prevalence and risk factors for delayed pulmonary complications in adults following minor blunt thoracic trauma. CJEM, Can. j. emerg. med. care. 16(2):136-43, 2014 Mar. Observational-Dx 450 patients To determine the prevalence, risk factors, and time to onset of delayed hemothorax and pneumothorax in adults who experienced a minor blunt thoracic trauma. Delayed hemothorax occurred in 11.8% (95% CI 8.8-14.8), and delayed pneumothorax occurred in 0.9% (95% CI 0.2-2.3) of participants. During the 14-day follow-up period, 87.0% of these delayed complications developed in the first week. In the multivariate analysis, the only statistically significant risk factor for delayed complications was the location of fractures on the x-ray of the hemithorax. The adjusted odds ratio was 1.52 (95% CI 0.62-3.73) for the lower ribs (tenth to twelfth rib), 3.11 (95% CI 1.60-6.08) for the midline ribs (sixth to ninth rib), and 5.05 (95% CI 1.80-14.19) for the upper ribs (third to fifth rib) versus patients with no fractures. 2
48. Emond M, Guimont C, Chauny JM, et al. Clinical prediction rule for delayed hemothorax after minor thoracic injury: a multicentre derivation and validation study. CMAJ Open. 5(2):E444-E453, 2017 Jun 12. Observational-Dx 1382 patients To sought to derive and validate a clinical decision rule to predict hemothorax in patients discharged from the emergency department. A total of 1382 patients were included: 830 in the derivation phase and 552 in the validation phase. Of these, 151 (10.9%) had hemothorax at the 14-day follow-up. Patients 65 years of age or older represented 25.3% (210/830) and 23.7% (131/552) of the derivation and validation cohorts, respectively. The final clinical decision rule included a combination of age (> 70 yr, 2 points; 45-70 yr, 1 point), fracture of any high to mid thorax rib (ribs 3-9, 2 points) and presence of 3 or more rib fractures (1 point). Twenty (30.8%) of the 65 high-risk patients (score = 4) experienced hemothorax during the follow-up period. The clinical decision rule had a high specificity (90.7%, 95% confidence interval 87.7%-93.1%) in this high-risk group, thus guiding appropriate post-emergency care. 2
49. Staub LJ, Biscaro RRM, Kaszubowski E, Maurici R. Chest ultrasonography for the emergency diagnosis of traumatic pneumothorax and haemothorax: A systematic review and meta-analysis. [Review]. Injury. 49(3):457-466, 2018 Mar. Meta-analysis 19 studies To assess the accuracy of the chest ultrasonography for the emergency diagnosis of traumatic pneumothorax and haemothorax in adults. Nineteen studies were included in the review, 17 assessing pneumothorax and 5 assessing haemothorax. The reference standard was always chest tomography, alone or in parallel with chest radiography and observation of the chest tube. The overall methodological quality of the studies was low. The diagnostic accuracy of chest ultrasonography had an area under the curve (AUC) of 0.979 for pneumothorax (Fig). The absence of lung sliding and comet-tail artefacts was the most reported sonographic sign of pneumothorax, with a sensitivity of 0.81 (95% confidence interval [95%CI], 0.71-0.88), specificity of 0.98 (95%CI, 0.97-0.99), LR+ of 67.9 (95%CI, 26.3-148) and LR- of 0.18 (95%CI, 0.11-0.29). An echo-poor or anechoic area in the pleural space was the only sonographic sign for haemothorax, with a sensitivity of 0.60 (95%CI, 0.31-0.86), specificity of 0.98 (95%CI, 0.94-0.99), LR+ of 37.5 (95%CI, 5.26-207.5), LR- of 0.40 (95%CI, 0.17-0.72) and AUC of 0.953. Good
50. Reuter S, Lindgaard D, Laursen C, Fischer BM, Clementsen PF, Bodtger U. Computed tomography of the chest in unilateral pleural effusions: outcome of the British Thoracic Society guideline. J. thorac. dis.. 11(4):1336-1346, 2019 Apr. Observational-Dx 465 patients To investigate if clinicians follow BTS guidelines' recommendations with respect to CT in patients with unilateral pleural effusions. Secondly, to investigate the diagnostic consequences of following and not following this recommendation. In total, 323 of the 465 included patients underwent CT (69%). CT was performed in the majority of patients not having an exudate (transudates: n=40; 54%; Light's criteria not assessed: n=111; 67%). 18F-FDG positron emission tomography (PET)/CT without prior CT was performed in 32 patients with an exudate (58%). The sensitivity of a non-guideline supported CT (70%) was significantly higher compared to a guideline supported CT (47%), P value <0.045. The post-test probability of a positive guideline-supported CT [likelihood ratio (LR) positive 3.26] for a later diagnosis of thoracic malignancy increased the probability from 25% to 52%. A negative CT (LR negative 0.62) decreased the probability to 17%. For a non-guideline-supported CT the numbers were (LR positive 3.42) 53% and (LR negative 0.38) 11%, respectively. 1
51. Traill ZC, Davies RJ, Gleeson FV. Thoracic computed tomography in patients with suspected malignant pleural effusions. Clin Radiol. 56(3):193-6, 2001 Mar. Observational-Dx 40 patients To assess the role of contrast-enhanced computed tomography (CT) prospectively in patients with suspected malignant pleural effusions. Pleural effusions were malignant in 32 patients and benign in eight patients. Pleural surfaces assessed at CT showed features of malignancy in 27 out of 32 patients with a malignant effusion (sensitivity 84%, specificity 100%). Overall, CT appearances indicated the presence of malignancy in 28 of 32 (87%) patients. All eight patients with benign pleural disease were correctly diagnosed by CT. 2
52. Korczynski P, Gorska K, Konopka D, Al-Haj D, Filipiak KJ, Krenke R. Significance of congestive heart failure as a cause of pleural effusion: Pilot data from a large multidisciplinary teaching hospital. Cardiol J. 27(3):254-261, 2020. Observational-Dx 2835 patients To investigate the causes of PE and to assess 30-day mortality rate in unselected adult patients treated in a large, multidisciplinary hospital. The leading causes of PE were as follows: congestive heart failure (CHF; 37.4%), pneumonia (19.5%), malignancy (15.4%), liver cirrhosis (4.2%) and pulmonary embolism. The cause of PE in 6.7% patients was not established. There was a significant predominance of small volume PE as compared to a moderate or large volume PEs (153, 28 and 14 patients, respectively). Almost 80% of patients with CHF presented with small volume PE, while almost 50% of patients with malignant PE demonstrated moderate or large volume PE. Thirty-day mortality rate ranged from 0% for tuberculous pleurisy to 40% for malignant PE (MPE). 4
53. Walker SP, Morley AJ, Stadon L, et al. Nonmalignant Pleural Effusions: A Prospective Study of 356 Consecutive Unselected Patients. Chest. 151(5):1099-1105, 2017 05. Observational-Dx 782 patients To discuss the analysis  356 patients with Nonmalignant pleural effusion (NMPE). Of the 782 patients, 356 were diagnosed with NMPE (46%). These patients had a mean age of 68 years (SD, 17 years) with 69% of them being men. Patients with cardiac, renal, and hepatic failure had 1-year mortality rates of 50%, 46%, and 25%, respectively. Bilateral effusions (hazard ratio [HR], 3.55; 95% CI, 2.22-5.68) and transudative effusions (HR, 2.78; 95% CI, 1.81-4.28) were associated with a worse prognosis in patients with NMPE, with a 57% and 43% 1-year mortality rate, respectively. 2
54. Liu M, Cui A, Zhai ZG, et al. Incidence of pleural effusion in patients with pulmonary embolism. Chin Med J. 128(8):1032-6, 2015 Apr 20. Observational-Dx 3141 patients To investigate the frequency of PE in a Chinese population of patients with pulmonary embolism. From January 2008 until December 2013, PE was identified in 423 of 3141 patients (13.5%) with clinically suspected pulmonary embolism who underwent CTPA. The incidence of PE in patients with pulmonary embolism (19.9%) was significantly higher than in those without embolism (9.4%) (P < 0.001). Majority of PEs in pulmonary embolism patients were small to moderate and were unilateral. The locations of emboli and the numbers of arteries involved, CT pulmonary obstruction index, and parenchymal abnormalities at CT were not associated with the development of PE. 2
55. Yamada Y, Tanno J, Nakano S, Kasai T, Senbonmatsu T, Nishimura S. Clinical implications of pleural effusion in patients with acute type B aortic dissection. Europ Heart J Acute Cardiovasc Care. 5(7):72-81, 2016 Nov. Observational-Dx 105 patients To identify the relationships between the quantity and side of the pleural effusion, biomarkers and outcomes in patients with ABAD. The median estimated peak volume (median 6.7 days after onset) was 129 ml (63-192, range 26-514 ml) on the left and 11 ml (6-43, range 2-300 ml) on the right. On univariate analysis, the volume of bilateral effusions was associated with anaemia, hypoalbuminaemia and inflammatory markers, whereas the volume of left-sided effusions was associated with older age, low diastolic blood pressure and maximum aortic diameter. Multivariate analysis revealed that hypoalbuminaemia was independently associated with bilateral effusion volume ( P<0.001), while maximum aortic diameter was associated with left-sided effusion volume ( P=0.019). A greater volume of bilateral plural effusion was associated with longer intensive care unit stay. 4
56. Porcel JM, Madronero AB, Pardina M, Vives M, Esquerda A, Light RW. Analysis of pleural effusions in acute pulmonary embolism: radiological and pleural fluid data from 230 patients. Respirology. 12(2):234-9, 2007 Mar. Observational-Dx 230 patients To describe the frequency and radiographical characteristics of pleural effusions in a large population of patients with acute pulmonary embolism (PE) and characterize the pleural fluid biochemistry in those patients who underwent diagnostic thoracentesis. Pleural effusions were observed in 32% and 47% of patients by CXR and CT, respectively. Typically, pleural effusions were small (90% occupied less than one third of the hemithorax) and unilateral (85%), but occasionally they reached more than a half of the hemithorax. On CT, 21% of pleural effusions showed loculation. In patients with loculated pleural fluid the diagnosis of PE had been delayed for a mean of 12.2 days after symptoms developed. The presence of pleural fluid was not related to infarction. Twenty-six of 93 (28%) patients with effusions on imaging underwent thoracentesis. All the fluids met Light's criteria for exudate, 58% contained erythrocyte counts >10,000/microL and 46% showed neutrophilic predominance. 2
57. Schiebler ML, Ahuja J, Repplinger MD, et al. Incidence of actionable findings on contrast enhanced magnetic resonance angiography ordered for pulmonary embolism evaluation. Eur J Radiol. 85(8):1383-9, 2016 Aug. Observational-Dx 100 males and 480 females To determine the incidence of actionable findings on contrast-enhanced magnetic resonance angiography (MRA) scans performed for the primary diagnosis of pulmonary embolism (PE) and to compare these results with the published data for computed tomographic angiography (CTA) in this same scenario.. 580 MRA scans for PE were performed. There were 561/580 (97%) technically adequate exams. Of these, 514/580 (89%) were negative and 47/580 (8%) were positive for PE. In the PE negative group of 514 exams, Type 1 findings were identified in 85/514 (17%), 188/514 (36%) cases were Type 2 and 241/514 (47.0%) were Type 3. There was no significant difference between the incidence of Type 1 and the combination of Type 2 and Type 3 findings on MRA and the reported incidence of actionable findings derived from CTA negative exams for PE (p < 0.5). 3
58. Ziegler CE, Painter DM, Borawski JB, Kim RJ, Kim HW, Limkakeng AT Jr. Unexpected Cardiac MRI Findings in Patients Presenting to the Emergency Department for Possible Acute Coronary Syndrome. Crit. pathw. cardiol.. 17(3):167-171, 2018 09. Observational-Dx 391 patients To hypothesize that Stress cardiac magnetic resonance imaging (CMR) detects a number of alternative diagnoses (diagnoses other than ACS that could explain symptoms) and incidental findings in patients presenting to the ED for potential acute coronary syndrome (ACS). A total of 391 patients were included. On stress CMR, abnormalities attributable to coronary artery disease (CAD) were found in 106 (27.1%) of patients. Previously undiagnosed moderate to severe valvular disease was the most common non-CAD cardiac finding, occurring in 20 (5.1%) cases. Other alternative diagnoses were rare with 7 cases of cardiomyopathy, 1 case of aortic aneurysm, 1 case of aortic dissection, 1 case of acute myocarditis, 3 cases of pericarditis, and 2 cases of moderate pleural effusion. Cardiac incidental findings were rare. Extracardiac incidental findings were found in 79 patients (20.2%). Only 18.6% of the patients recommended for follow-up imaging had this completed within 1 year after CMR. 2
59. McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 42(36):3599-3726, 2021 09 21. Review/Other-Dx N/A To discuss the guidelines for the diagnosis and treatment of acute and chronic heart failure. No results sated in the abstract. 4
60. Gallard E, Redonnet JP, Bourcier JE, et al. Diagnostic performance of cardiopulmonary ultrasound performed by the emergency physician in the management of acute dyspnea. Am J Emerg Med. 33(3):352-8, 2015 Mar. Observational-Dx 130 patients To evaluate the performance of cardiopulmonary ultrasound compared with usual care for the etiologic diagnosis of acute dyspnea in the emergency department (ED). One hundred thirty patients were analyzed. For the diagnosis of acute left-sided heart failure, cardiopulmonary ultrasound had an accuracy of 90% (95% confidence interval [CI], 84-95) vs 67% (95% CI, 57-75), P = .0001 for clinical examination, and 81% (95% CI, 72-88), P = .04 for the combination "clinical examination-NT-proBNP-x-ray". Cardiopulmonary ultrasound led to the diagnosis of pneumonia or pleural effusion with an accuracy of 86% (95% CI, 80-92) and decompensated chronic obstructive pulmonary disease or asthma with an accuracy of 95% (95% CI, 92-99). Cardiopulmonary ultrasound lasted an average of 12 +/- 3 minutes. 2
61. Hansell L, Milross M, Delaney A, Tian DH, Ntoumenopoulos G. Lung ultrasound has greater accuracy than conventional respiratory assessment tools for the diagnosis of pleural effusion, lung consolidation and collapse: a systematic review. J Physiother. 67(1):41-48, 2021 Jan. Observational-Dx 253 patients To discuss the review of the assessment of tools for the diagnosis of pleural effusion, lung consolidation and collapse. Seven eligible studies were identified, five of which (with 253 participants) were included in the meta-analysis. It was found that LUS had a pooled sensitivity of 92% and 91% in the diagnosis of consolidation and pleural effusion, respectively, and pooled specificity of 92% for both pathologies. CXR had a pooled sensitivity of 53% and 42% and a pooled specificity of 78% and 81% in the diagnosis of consolidation and pleural effusion, respectively. A meta-analysis for lung auscultation was not possible, although a single study reported a sensitivity and specificity of 8% and 100%, respectively, for diagnosing consolidation, and a sensitivity and specificity of 42% and 90%, respectively, for diagnosing pleural effusion. 2
62. Zanobetti M, Scorpiniti M, Gigli C, et al. Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED. Chest. 151(6):1295-1301, 2017 06. Observational-Dx 2,683 patients The aim of the present study was to evaluate the feasibility and diagnostic accuracy of point-of-care ultrasonography (PoCUS) for the management of patients with acute dyspnea in the emergency department (ED). A total of 2,683 patients were enrolled. The average time needed to formulate the ultrasound diagnosis was significantly lower than that required for ED diagnosis (24 ± 10 min vs 186 ± 72 min; P = .025). The ultrasound and the ED diagnoses showed good overall concordance (k = 0.71). There were no statistically significant differences in the accuracy of PoCUS and the standard ED evaluation for the diagnosis of acute coronary syndrome, pneumonia, pleural effusion, pericardial effusion, pneumothorax, and dyspnea from other causes. PoCUS was significantly more sensitive for the diagnosis of heart failure, whereas a standard ED evaluation performed better in the diagnosis of COPD/asthma and pulmonary embolism. 2
63. Belloni E, Tentoni S, Fiorina I, et al. Reported and Unreported Potentially Important Incidental Findings in Urgent Nonenhanced Abdominal CT for Renal Colic. Med Princ Pract. 30(4):355-360, 2021. Observational-Dx 312 patients To retrospectively evaluate the prevalence of reported and unreported potentially important incidental findings (PIFs) in consecutive nonenhanced abdominal CTs performed specifically for renal colic in the urgent setting. The CTs of 312 patients were included in the study. Thirty-eight findings were reported in 38 different CTs, whereas the re-evaluation added 47 unreported findings in 47 different CTs, adding to total of 85 findings (27%). The difference in the proportion of reported and unreported PIFs between the original report and re-evaluation was significant (p < 0.001). No significant difference was found between the age of patients with and without reported findings. The proportion of potentially important findings did not vary significantly among the 3 shifts in the original report and in re-evaluation. The most frequent findings, both reported and unreported, were pleural effusion, lymphadenopathies, and liver nodules. 2
64. Kaplan EÇ, E. Incidental thorax imaging findings in abdominal computed tomography: Results of a tertiary center. J Surg Med 2021;5:500-03. Review/Other-Dx N/A To discuss the Incidental thorax imaging findings in abdominal computed tomography No results stated in the abstract. 4
65. Sohns JM, Menke J, Bergau L, et al. Extra-vascular findings in patients undergoing magnetic resonance angiography of the abdomen, pelvis and lower extremities: A retrospective study of 352 patients. Vascular. 26(1):27-38, 2018 Feb. Observational-Dx 352 patients To assess the prevalence and clinical significance of extra-vascular findings in patients undergoing magnetic resonance angiography of the abdomen, pelvis and lower extremities. A total of 2152 clinically relevant vascular findings was identified (6.1/patient). The most frequent vascular finding was femoral artery stenosis (10.6%). Four hundred fifty-one extra-vascular findings were observed (1.3/patient) and classified into Group A (78%), Group B (19.5%) and Group C findings (2.4%). The most frequent malignant findings were lung cancer, lymphoma, osteosarcoma, hepatocellular carcinoma and renal cell carcinoma (7/352 patients). Conclusions Extravascular findings are frequently encountered in magnetic resonance angiography performed for vascular indications. Clinically relevant findings are seen in a substantial part of patients and should prompt further diagnostic work-up. 2
66. Glockner JF. Incidental findings on renal MR angiography. AJR Am J Roentgenol. 189(3):693-700, 2007 Sep. Observational-Dx 380 patients To assess the incidence of incidental vascular and nonvascular findings in patients undergoing renal MR angiography and to determine the extent to which these findings alter patient management. Overall, 151 (40%) of 380 patients had one or more additional vascular findings not related to the renal arteries, and 221 (58%) of 380 patients had one or more additional nonvascular findings. Vascular findings included mesenteric artery stenosis or occlusion in 33% of patients, moderate to severe aortic atherosclerosis in 17%, aortic aneurysms in 7%, and aortic dissection in 2%. Incidental malignancies were detected in 10 patients (3%), and indeterminate lesions requiring follow-up imaging, biopsy, or surgery were noted in 18 patients (5%). Overall, management in 5% of patients was significantly altered (i.e., required biopsy, surgery, or other intervention) by incidental findings detected on renal MR angiography. Benign lesions not requiring additional imaging or follow-up occurred in 54% of patients and consisted predominantly of renal cysts. 2
67. Sohns JM, Staab W, Dabir D, et al. Current role and future potential of magnetic resonance cholangiopancreatography with an emphasis on incidental findings. Clin Imaging. 38(1):35-41, 2014 Jan-Feb. Observational-Dx 384 patients To investigate the incidence of relevant biliary and extrabiliary findings in patients undergoing magnetic resonance cholangiopancreatography (MRCP). Four hundred twenty-two biliary findings were identified in 384 patients (75%; 1.1 per patient). Ninety-five patients were free of any relevant biliary finding (25%). Incidental extrabiliary findings were observed in 763 patients (1.98/patient). 2
68. Zidan MMA, Hassan IA, Elnour AM, et al. Incidental Extraspinal Findings in the Thoracic Spine during Magnetic Resonance Imaging of Intervertebral Discs. J Clin Imaging Sci 2019;9:37. Observational-Dx 120 patients The purpose of this research was to determine the frequency of incidental extraspinal findings in the thoracic spine on magnetic resonance imaging (MRI). Out of the 120 patients, incidental extraspinal findings were found in 16 patients (13.3%). Various incidental findings (IFs) were seen, including renal cysts, liver mass, thyroid goiter, and pleural effusion. Out of these IFs, 37.5% were considered clinically significant. 2
69. Chen G, Xue Y, Wei J, Duan Q. The undiagnosed potential clinically significant incidental findings of neck CTA: A large retrospective single-center study. Medicine (Baltimore) 2020;99:e22440. Observational-Dx 88 patients To assess the prevalence and missed reporting rate of potential clinically-significant incidental findings (IFs) in the neck CTA scans. All consecutive patients undergoing neck CTA imaging, from January 1, 2017 to December 31, 2018, were retrospectively evaluated by a radiologist for the presence of incidental findings in the upper chest, lower head and neck regions. A total of 376 potential clinically significant IFs were detected in 1,698 (91.19%) patients, of which 175 IFs were classified as highly significant findings (Type I), and 201 (53.46%) as moderately significant findings (Type II). The most common potential clinically significant findings included thyroid nodules (n = 88, 23.40%), pulmonary nodules (n = 56, 14.89%), sinus disease (n = 39, 10.37%), intracranial or cervical artery aneurysms (n = 30, 7.98%), enlarged lymph nodes (n = 24, 6.38%), and pulmonary embolism (n = 19, 5.05%). In addition, 184 (48.94%) of them were not mentioned in the initial report. The highest incidence of missed potential clinical findings were pulmonary embolism and pathologic fractures and erosions (100% for both). The unreported rate of the chest group was significantly higher than that of the head or neck one, regardless of Type I, Type II or all potential clinically significant IFs (? = 32.151, ? = 31.211, ? = 65.286, respectively; P < .001 for all).Important clinically significant incidental findings are commonly found in a proportion of patients undergoing neck CTA, in which nearly half of these patients have had potential clinically significant IFs not diagnosed in the initial report. Therefore, radiologists should beware of the importance of and the necessity to identify incidental findings in neck CTA scans. 2
70. Preus A, Schaafs LA, Werncke T, Steffen IG, Hamm B, Elgeti T. Run-Off Computed Tomography Angiography (CTA) for Discriminating the Underlying Causes of Intermittent Claudication. PLoS ONE. 11(4):e0152780, 2016. Observational-Dx 214 Patients To evaluate run-off computed tomography angiography (CTA) of abdominal aorta and lower extremities for detecting musculoskeletal pathologies and clinically relevant extravascular incidental findings in patients with intermittent claudication (IC) and suspected peripheral arterial disease (PAD). While focused on vascular imaging, CTA image quality was sufficient for evaluation of the MSK system in all cases. The underlying cause of IC was diagnosed in run-off CTA as vascular, MSK and a combination in n = 138 (65%), n = 10 (4%), and n = 66 (31%) cases, respectively. Specific vascular or MSK therapy was recorded in n = 123 and n = 9 cases. In n = 82, no follow-up was possible. Clinically relevant extravascular incidental findings were detected in n = 65 patients (30%) with neoplasia, ascites and pleural effusion being the most common findings. 2
71. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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