Utility of visual coronary artery calcification on non-cardiac gated thoracic CT in predicting clinical severity and outcome in COVID-19

BackgroundAssessment of visual-coronary artery calcification on non-cardiac gated CT in COVID-19 patients could provide an objective approach to rapidly identify and triage clinically severe patients for early hospital admission to avert worse prognosis.PurposeTo ascertain the role of semi-quantitative scoring in visual-coronary artery calcification score (V-CACS) for predicting the clinical severity and outcome in patients with COVID-19.Materials and methodsWith institutional review board approval this study included 67 COVID-19 confirmed patients who underwent non-cardiac gated CT chest in an inpatient setting. Two blinded radiologist (Radiologist-1 &2) assessed the V-CACS, CT Chest severity score (CT-SS). The clinical data including the requirement for oxygen support, assisted ventilation, ICU admission and outcome was assessed, and patients were clinically subdivided depending on clinical severity. Logistic regression analyses were performed to identify independent predictors. ROC curves analysis is performed for the assessment of performance and Pearson correlation were performed to looks for the associations.ResultsV-CACS cut off value of 3 (82.67% sensitivity and 54.55% specificity; AUC 0.75) and CT-SS with a cut off value of 21.5 (95.7% sensitivity and 63.6% specificity; AUC 0.87) are independent predictors for clinical severity and also the need for ICU admission or assisted ventilation. The pooling of both CT-SS and V-CACS (82.67% sensitivity and 86.4% specificity; AUC 0.92) are more reliable in terms of predicting the primary outcome of COVID-19 patients. On regression analysis, V-CACS and CT-SS are individual independent predictors of clinical severity in COVID-19 (Odds ratio, 1.72; 95% CI, 0.99–2.98; p = 0.05 and Odds ratio, 1.22; 95% CI, 1.08–1.39; p = 0.001 respectively). The area under the curve (AUC) for pooled V-CACS and CT-SS was 0.96 (95% CI 0.84–0.98) which correctly predicted 82.1% cases.ConclusionLogistic regression model using pooled Visual-Coronary artery calcification score and CT Chest severity score in non-cardiac gated CT can predict clinical severity and outcome in patients with COVID-19.     

Chest CT findings of coronavirus disease 2019 (COVID-19): A comprehensive meta-analysis of 9907 confirmed patients

ObjectivesWe performed a systematic review and meta-analysis of the prevalence of chest CT findings in patients with confirmed COVID-19 infection.MethodsSystematic review of the literature was performed using PubMed, Scopus, Embase, and Google Scholar to retrieve original studies on chest CT findings of patients with confirmed COVID-19, available up to 10 May 2020. Data on frequency and distribution of chest CT findings were extracted from eligible studies, pooled and meta-analyzed using random-effects model to calculate the prevalence of chest CT findings.ResultsOverall, 103 studies (pooled population: 9907 confirmed COVID-19 patients) were meta-analyzed. The most common CT findings were ground-glass opacities (GGOs) (77.18%, 95%CI = 72.23–81.47), reticulations (46.24%, 95%CI = 38.51–54.14), and air bronchogram (41.61%, 95%CI = 32.78–51.01). Pleural thickening (33.35%, 95%CI = 21.89–47.18) and bronchial wall thickening (15.48%, 95%CI = 8.54–26.43) were major atypical and airway findings. Lesions were predominantly distributed bilaterally (75.72%, 95%CI = 70.79–80.06) and peripherally (65.64%, 95%CI = 58.21–72.36), while 8.20% (95%CI = 6.30–10.61) of patients had no abnormal findings and pre-existing lung diseases were present in 6.01% (95%CI = 4.37–8.23).ConclusionsThe most common CT findings in COVID-19 are GGOs with/without consolidation, reticulations, and air bronchogram, which often involve both lungs with peripheral distribution. However, COVID-19 might present with atypical manifestations or no abnormal findings in chest CT, which deserve clinicians' notice.     

Mediastinal lymphadenopathy may predict 30-day mortality in patients with COVID-19

PurposeThere is scarce data on the impact of the presence of mediastinal lymphadenopathy on the prognosis of coronavirus-disease 2019 (COVID-19). We aimed to investigate whether its presence is associated with increased risk for 30-day mortality in a large group of patients with COVID-19.MethodIn this retrospective cross-sectional study, 650 adult laboratory-confirmed hospitalized COVID-19 patients were included. Patients with comorbidities that may cause enlarged mediastinal lymphadenopathy were excluded. Demographics, clinical characteristics, vital and laboratory findings, and outcome were obtained from electronic medical records. Computed tomography scans were evaluated by two blinded radiologists. Univariate and multivariate logistic regression analyses were performed to determine independent predictive factors of 30-day mortality.ResultsPatients with enlarged mediastinal lymphadenopathy (n = 60, 9.2%) were older and more likely to have at least one comorbidity than patients without enlarged mediastinal lymphadenopathy (p = 0.03, p = 0.003). There were more deaths in patients with enlarged mediastinal lymphadenopathy than in those without (11/60 vs 45/590, p = 0.01). Older age (OR:3.74, 95% CI: 2.06–6.79; p < 0.001), presence of consolidation pattern (OR:1.93, 95% CI: 1.09–3.40; p = 0.02) and enlarged mediastinal lymphadenopathy (OR:2.38, 95% CI:1.13–4.98; p = 0.02) were independently associated with 30-day mortality.ConclusionIn this large group of hospitalized patients with COVID-19, we found that in addition to older age and consolidation pattern on CT scan, enlarged mediastinal lymphadenopathy were independently associated with increased mortality. Mediastinal evaluation should be performed in all patients with COVID-19.     

Diagnostic accuracy of CT and radiographic findings for novel coronavirus 2019 pneumonia: Systematic review and meta-analysis

PurposeTo evaluate pooled prevalence, sensitivity, and specificity of chest computed tomography (CT) and radiographic findings for novel coronavirus-2019 (COVID-19) pneumonia.MethodsWe performed systematic literature search in PubMed and Embase to identify articles reporting baseline imaging findings of COVID-19 pneumonia. The quality of the articles was assessed using NIH quality assessment tool for case series studies. The pooled prevalence, sensitivity, specificity, and diagnostic odds ratio of imaging findings were calculated.ResultsFifty-six studies (6007 patients, age, 2.1–70 years, 2887 females, 5762 CT, 396 radiographs,) were included. The mean interval between onset of symptoms and CT acquisition was 1–8 days. On CT, the pooled prevalence of ground glass opacities (GGO), GGO plus consolidation, and consolidation only was 66.9% (95% CI 60.8–72.4%), 44.9% (38.7–51.3%), and 32.1 (23.6–41.9%) respectively. Pooled sensitivity and specificity of GGO on CT was 73% (71%–80%) and 61% (41%–78%), respectively. For GGO plus consolidation and consolidation only, the pooled sensitivities/ specificities were 58% (48%–68%)/ 58% (41%–73%) and 49% (20%–78%)/ 56% (30%–78%), respectively. The pooled prevalence of GGO and consolidation on chest radiograph was 38.7% (22.2%–58.3%) and 46.9% (29.7%–64.9%), respectively. The diagnostic accuracy of radiographic findings could not be assessed due to small number of studies.ConclusionGGO on CT has the highest diagnostic performance for COVID-19 pneumonia, followed by GGO plus consolidation and consolidation only. However, the moderate to low sensitivity and specificity suggest that CT should not be used as the primary tool for diagnosis. Chest radiographic abnormalities are seen in half of the patients.     

Role of complementary Ct chest in patients presenting with acute abdominal symptoms during covid-19 pandemic: a UK experience

BackgroundIn March 2020, the UK Intercollegiate General Surgery Guidance on COVID-19 recommended that patients undergoing emergency abdominal CT should have a complementary CT chest for COVID-19 screening.PurposeTo establish if complementary CT chest was performed as recommended, and if CT chest influenced surgical intervention decision. To assess detection rate of COVID-19 on CT and its correlation with RT-PCR swab results. To determine if COVID-19 changes is reliably detected within the lung bases which are usually imaged in standard abdominal CT.MethodsPatients with acute abdominal symptoms presenting to a single institution between 1st and 30th April 2020 who had abdominal CT and complementary CT chest were retrospectively extracted from Computerised Radiology Information System. CT COVID-19 changes were categorised according to British Society of Thoracic Radiology reporting guidance. Patient demographics (age and gender), RT-PCR swab results and management pathway (conservative or intervention) were recorded from electronic patient records. Statistical analyses were performed to evaluate any significant association between variables. p values ≤0.05 were regarded as statistically significant.ResultsCompliancy rate in performing complementary CT chest was 92.5% (148/160). Thirty-five patients (35/148,23.6%) underwent intervention during admission. There was no significant association (p = 0.9085) between acquisition of CT chest and management pathway (conservative vs intervention). CT chest had 57% sensitivity (CI 18.41% to 90.1%) and 100% specificity (CI 92% to 100%) in COVID-19 diagnosis. Three of ten patients who had classic COVID-19 changes on CT chest did not have corresponding changes in lung bases.ConclusionCompliance with performing complementary CT chest in acute abdomen patients for COVID-19 screening was high and it did not influence subsequent surgical or interventional management.     

Prediction of Patient Management in COVID-19 Using Deep Learning-Based Fully Automated Extraction of Cardiothoracic CT Metrics and Laboratory Findings

ObjectiveTo extract pulmonary and cardiovascular metrics from chest CTs of patients with coronavirus disease 2019 (COVID-19) using a fully automated deep learning-based approach and assess their potential to predict patient management.Materials and MethodsAll initial chest CTs of patients who tested positive for severe acute respiratory syndrome coronavirus 2 at our emergency department between March 25 and April 25, 2020, were identified (n = 120). Three patient management groups were defined: group 1 (outpatient), group 2 (general ward), and group 3 (intensive care unit [ICU]). Multiple pulmonary and cardiovascular metrics were extracted from the chest CT images using deep learning. Additionally, six laboratory findings indicating inflammation and cellular damage were considered. Differences in CT metrics, laboratory findings, and demographics between the patient management groups were assessed. The potential of these parameters to predict patients'' needs for intensive care (yes/no) was analyzed using logistic regression and receiver operating characteristic curves. Internal and external validity were assessed using 109 independent chest CT scans.ResultsWhile demographic parameters alone (sex and age) were not sufficient to predict ICU management status, both CT metrics alone (including both pulmonary and cardiovascular metrics; area under the curve [AUC] = 0.88; 95% confidence interval [CI] = 0.79–0.97) and laboratory findings alone (C-reactive protein, lactate dehydrogenase, white blood cell count, and albumin; AUC = 0.86; 95% CI = 0.77–0.94) were good classifiers. Excellent performance was achieved by a combination of demographic parameters, CT metrics, and laboratory findings (AUC = 0.91; 95% CI = 0.85–0.98). Application of a model that combined both pulmonary CT metrics and demographic parameters on a dataset from another hospital indicated its external validity (AUC = 0.77; 95% CI = 0.66–0.88).ConclusionChest CT of patients with COVID-19 contains valuable information that can be accessed using automated image analysis. These metrics are useful for the prediction of patient management.     

Coronary artery calcification in COVID-19 patients: an imaging biomarker for adverse clinical outcomes

BackgroundRecent studies have demonstrated a complex interplay between comorbid cardiovascular disease, COVID-19 pathophysiology, and poor clinical outcomes. Coronary artery calcification (CAC) may therefore aid in risk stratification of COVID-19 patients.MethodsNon-contrast chest CT studies on 180 COVID-19 patients ≥ age 21 admitted from March 1, 2020 to April 27, 2020 were retrospectively reviewed by two radiologists to determine CAC scores. Following feature selection, multivariable logistic regression was utilized to evaluate the relationship between CAC scores and patient outcomes.ResultsThe presence of any identified CAC was associated with intubation (AOR: 3.6, CI: 1.4–9.6) and mortality (AOR: 3.2, CI: 1.4–7.9). Severe CAC was independently associated with intubation (AOR: 4.0, CI: 1.3–13) and mortality (AOR: 5.1, CI: 1.9–15). A greater CAC score (UOR: 1.2, CI: 1.02–1.3) and number of vessels with calcium (UOR: 1.3, CI: 1.02–1.6) was associated with mortality. Visualized coronary stent or coronary artery bypass graft surgery (CABG) had no statistically significant association with intubation (AOR: 1.9, CI: 0.4–7.7) or death (AOR: 3.4, CI: 1.0–12).ConclusionCOVID-19 patients with any CAC were more likely to require intubation and die than those without CAC. Increasing CAC and number of affected arteries was associated with mortality. Severe CAC was associated with higher intubation risk. Prior CABG or stenting had no association with elevated intubation or death.     

Relation of nonalcoholic fatty liver disease to the metabolic syndrome: The Multi-Ethnic Study of Atherosclerosis

BackgroundAn overlap exists between risk factors for metabolic syndrome (MetS) and nonalcoholic fatty liver disease (NAFLD).ObjectivesWe studied the association of MetS and its components with NAFLD in a multi-ethnic population.MethodsCross-sectional study was designed, including 6814 participants from the Multi-Ethnic Study of Atherosclerosis. Liver fat content was measured with cardiac CT scans by using liver-to-spleen ratio of <1.0 and liver attenuation < 40 HU. Participants with heavy alcohol intake (>14 drinks/week for men and >7 drinks/week for women), self-reported history of cirrhosis, and missing information were excluded. A total of 4140 participants met the criteria for inclusion in the study.ResultsThe odds ratios (ORs) for presence of NAFLD were highest for persons with diabetes (OR, 4.16; 95% CI, 3.24–5.33), followed by presence of MetS (OR, 3.97; 95% CI, 3.26–4.83). Among components of MetS central obesity was associated with higher odds for presence (OR, 3.41; 95% CI, 2.77–4.20) and severity (OR, 5.58; 95% CI, 3.86–8.06) of NAFLD . The ORs for moderate-to-severe NAFLD were higher for presence of MetS (OR, 5.92; 95% CI, 4.29–8.19)] by using <40 HU as the cutoff. However, odds of NAFLD increased significantly for combination of MetS components: 9.49 (95% CI, 5.67–15.90) and 24.05 (95% CI, 12.73–45.45) for presence of 3 and 5 MetS components, respectively.ConclusionComponents of MetS are associated with increased odds for presence and severity of NAFLD and increased risk with increasing number of MetS components in a multi-ethnic population of middle-to-old age persons.     

Complications in COVID-19 patients: Characteristics of pulmonary embolism

ObjectiveThe purpose of this study is to evaluate chest CT imaging features, clinical characteristics, laboratory values of COVID-19 patients who underwent CTA for suspected pulmonary embolism. We also examined whether clinical, laboratory or radiological characteristics could be associated with a higher rate of PE.Materials and methodsThis retrospective study included 84 consecutive patients with laboratory-confirmed SARS-CoV-2 who underwent CTA for suspected PE. The presence and localization of PE as well as the type and extent of pulmonary opacities on chest CT exams were examined and correlated with the information on comorbidities and laboratory values for all patients.ResultsOf the 84 patients, pulmonary embolism was discovered in 24 patients. We observed that 87% of PE was found to be in lung parenchyma affected by COVID-19 pneumonia. Compared with no-PE patients, PE patients showed an overall greater lung involvement by consolidation (p = 0.02) and GGO (p < 0.01) and a higher level of D-Dimer (p < 0,01). Moreover, the PE group showed a lower level of saturation (p = 0,01) and required more hospitalization (p < 0,01).ConclusionOur study showed a high incidence of PE in COVID-19 pneumonia. In 87% of patients, PE was found in lung parenchyma affected by COVID-19 pneumonia with a worse CT severity score and a greater number of lung lobar involvement compared with non-PE patients. CT severity, lower level of saturation, and a rise in D-dimer levels could be an indication for a CTPA.Advances in knowledgeCertain findings of non-contrast chest CT could be an indication for a CTPA.     

Hallazgos tomográficos entre sobrevivientes y no-sobrevivientes con COVID-19 y utilidad clínica de una puntuación de tomografía torácica

BackgroundMany patients with coronavirus disease 2019 (COVID-19) have been diagnosed with computed tomography (CT). A prognostic tool based on CT findings could be useful for predicting death from COVID-19.ObjectivesTo compare the chest CT findings of patients who survived COVID-19 versus those of patients who died of COVID-19 and to determine the usefulness the clinical usefulness of a CT scoring system for COVID-19.MethodsWe included 124 patients with confirmed SARS-CoV-2 infections who were hospitalized between April 1, 2020 and July 25, 2020.ResultsWhereas ground-glass opacities were the most common characteristic finding in survivors (75%), crazy paving was the most characteristic finding in non-survivors (65%). Atypical findings were present in 46% of patients. The chest CT score was directly proportional to mortality; a score ≥ 18 was the best cutoff for predicting death, yielding 70% sensitivity (95%CI: 47%-87%).ConclusionsOur results suggest that atypical lesions are more prevalent in this cohort. The chest CT score had high sensitivity for predicting hospital mortality     

Systematic Review and Meta-Analysis of Drug-Coated Balloon Angioplasty for In-Stent Restenosis in Femoropopliteal Artery Disease

PurposeThe present meta-analysis evaluated the role of drug-coated balloon (DCB) angioplasty for in-stent restenosis (ISR) in femoropopliteal artery disease.Materials and MethodsCochrane Library, Embase, and PubMed were searched without language restrictions from inception to May 10, 2020. The endpoints included target lesion revascularization (TLR), recurrent ISR, clinical improvement, ankle-brachial index (ABI), and death. There were 5 randomized controlled trials with 425 patients (218 with DCB angioplasty and 207 with plain old balloon angioplasty [POBA]) were included in the meta-analysis.ResultsCompared with POBA, DCB angioplasty was associated with lower risk of TLR (odds ratio [OR], 0.21; 95% confidence interval [CI]: 0.09–0.49, P < .001 at 6 months and OR, 0.15; 95% CI, 0.08–0.30; P < .001 at 12 months) and recurrent ISR (OR, 0.22; 95% CI, 0.13–0.38; P < .001 at 6 months and OR, 0.31; 95% CI, 0.16–0.61; P < .001 at 12 months), and superior clinical improvement (OR, 1.98; 95% CI, 1.07–3.65; P = .03 at 6 months and OR, 2.84; 95% CI: 1.50–5.35; P = .001 at 12 months). There were no significant differences between groups in ABI and death. Subgroup analysis for patients with DCB angioplasty showed similar rates of TLR, recurrent ISR, clinical improvement, and death between the short lesion (<15 cm) and long lesion group (≥15 cm) (P > .05).ConclusionsThe current meta-analysis suggests that DCB angioplasty is an improvement over POBA for femoropopliteal ISR. Future studies about the effect of lesion length on DCB performance are still needed.     

Chest CT features and progression of patients with coronavirus disease 2019

Objectives:Coronavirus disease 2019 (COVID-19) is a major public health emergency. It poses a grave threat to human life and health. The purpose of the study is to investigate the chest CT findings and progression of the disease observed in COVID-19 patients.Methods:Forty-nine confirmed cases of adult COVID-19 patients with common type, severe and critically severe type were included in this retrospective single-center study. The thin-section chest CT features and progress of the disease were evaluated. The clinical and chest imaging findings of COVID-19 patients with different severity types were compared. The CT severity score and MuLBSTA score (a prediction of mortality risk) were calculated in those patients.Results:Among the 49 patients, 35 patients (71%) were common type and 14 patients (28%) were severe and critically severe type. Nearly all patients (98%) had pure ground-glass opacities (GGO) in CT imaging. Of the severe and critically severe type patients, 86% exhibited GGO with consolidation, in comparison with 54% of the patients with common type. Fibrosis presented in 79% of the severe and critically severe type patients and 43% of the common type patients. The severe and critically severe type patients were significantly more prone to experience five-lobe involvement compared to the common type patients (p = 0.002). The severe and critically severe type patients also had higher CT severity and MuLBSTA scores than the common type patients (5.43 ± 2.38 vs 3.37 ± 2.40, p < 0.001;and 10.21 ± 3.83 vs 4.63 ± 3.43, p < 0.001, respectively). MuLBSTA score was positively correlated with admittance to the intensive care unit (p = 0.005, r = 0.351). Nineteen patients underwent three times CT scan. The interval between first and second CT scan was 4[4,8] days, second and third was 3[2,4] days. There were greater improvements in the third CT follow-up findings compared to the second (p = 0.002).Conclusions:The severe and critically severe type patients often experienced more severe lung lesions, including GGO with consolidation. The CT severity score and MuLBSTA score may be helpful for the assessment of COVID-19 severity and progression.Advances in knowledge:Chest CT has the value of evaluated radiographical features of COVID-19 and allow for dynamic observation of the disease progression. Considering coagulation disorder of COVID-19, MuLBSTA score may need to be updated to increase new understanding of COVID-19.     

Diagnostic accuracy of thoracic imaging modalities for the detection of COVID-19

The ongoing coronavirus disease 2019 (COVID-19) pandemic continues to present diagnostic challenges. The use of thoracic radiography has been studied as a method to improve the diagnostic accuracy of COVID-19. The ‘Living’ Cochrane Systematic Review on the diagnostic accuracy of imaging tests for COVID-19 is continuously updated as new information becomes available for study. In the most recent version, published in March 2021, a meta-analysis was done to determine the pooled sensitivity and specificity of chest X-ray (CXR) and lung ultrasound (LUS) for the diagnosis of COVID-19. CXR gave a sensitivity of 80.6% (95%CI: 69.1-88.6) and a specificity of 71.5% (95%CI: 59.8-80.8). LUS gave a sensitivity rate of 86.4% (95%CI: 72.7-93.9) and specificity of 54.6% (95%CI: 35.3-72.6). These results differed from the findings reported in the recent article in this journal where they cited the previous versions of the study in which a meta-analysis for CXR and LUS could not be performed. Additionally, the article states that COVID-19 could not be distinguished, using chest computed tomography (CT), from other respiratory diseases. However, the latest review version identifies chest CT as having a specificity of 80.0% (95%CI: 74.9-84.3), which is much higher than the previous version which indicated a specificity of 61.1% (95%CI: 42.3-77.1). Therefore, CXR, chest CT and LUS have the potential to be used in conjunction with other methods in the diagnosis of COVID-19.     

Correlation of chest radiography findings with the severity and progression of COVID-19 pneumonia

PurposeAim is to assess the temporal changes and prognostic value of chest radiograph (CXR) in COVID-19 patients.Material and methodsWe performed a retrospective study of confirmed COVID-19 patients presented to the emergency between March 07–17, 2020. Clinical & radiological findings were reviewed. Clinical outcomes were classified into critical & non-critical based on severity. Two independent radiologists graded frontal view CXRs into COVID-19 pneumonia category 1 (CoV-P1) with <4 zones and CoV-P2 with ≥4 zones involvement. Interobserver agreement of CoV-P category for the CXR preceding the clinical outcome was assessed using Kendall's τ coefficient. Association between CXR findings and clinical deterioration was calculated along with temporal changes of CXR findings with disease progression.ResultsSixty-two patients were evaluated for clinical features. 56 of these (total: 325 CXRs) were evaluated for radiological findings. Common patterns were progression from lower to upper zones, peripheral to diffuse involvement, & from ground glass opacities to consolidation. Consolidations starting peripherally were noted in 76%, 93% and 48% with critical outcomes, respectively. The interobserver agreement of the CoV-P category of CXRs in the critical and non-critical outcome groups were good and excellent, respectively (τ coefficient = 0.6 & 1.0). Significant association was observed between CoV-P2 and clinical deterioration into a critical status (χ2 = 27.7, p = 0.0001) with high sensitivity (95%) and specificity (71%) within a median interval time of 2 days (range: 0–4 days).ConclusionInvolvement of predominantly 4 or more zones on frontal chest radiograph can be used as predictive prognostic indicator of poorer outcome in COVID-19 patients.