Clinical and epidemiologic data in coronavirus disease (COVID-19) have accrued rapidly since the outbreak, but few address the underlying pathophysiology.
To ascertain the physiologic, hematologic, ...and imaging basis of lung injury in severe COVID-19 pneumonia.
Clinical, physiologic, and laboratory data were collated. Radiologic (computed tomography (CT) pulmonary angiography
= 39 and dual-energy CT DECT,
= 20) studies were evaluated: observers quantified CT patterns (including the extent of abnormal lung and the presence and extent of dilated peripheral vessels) and perfusion defects on DECT. Coagulation status was assessed using thromboelastography.
In 39 consecutive patients (male:female, 32:7; mean age, 53 ± 10 yr range, 29-79 yr; Black and minority ethnic,
= 25 64%), there was a significant vascular perfusion abnormality and increased physiologic dead space (dynamic compliance, 33.7 ± 14.7 ml/cm H
O; Murray lung injury score, 3.14 ± 0.53; mean ventilatory ratios, 2.6 ± 0.8) with evidence of hypercoagulability and fibrinolytic "shutdown". The mean CT extent (±SD) of normally aerated lung, ground-glass opacification, and dense parenchymal opacification were 23.5 ± 16.7%, 36.3 ± 24.7%, and 42.7 ± 27.1%, respectively. Dilated peripheral vessels were present in 21/33 (63.6%) patients with at least two assessable lobes (including 10/21 47.6% with no evidence of acute pulmonary emboli). Perfusion defects on DECT (assessable in 18/20 90%) were present in all patients (wedge-shaped,
= 3; mottled,
= 9; mixed pattern,
= 6).
Physiologic, hematologic, and imaging data show not only the presence of a hypercoagulable phenotype in severe COVID-19 pneumonia but also markedly impaired pulmonary perfusion likely caused by pulmonary angiopathy and thrombosis.
Purpose
Several factors are known to affect lung ablation zones. Questions remain as to why there are discrepancies between achieved and vendor-predicted ablation zones and what contributing factors ...can be modified to balance therapeutic effects with avoidance of complications. This retrospective study of lung tumour microwave ablation analyses day 1 post-treatment CT to assess the effects of lesion-specific and operator-dependent factors on ablation zones.
Methods and Materials
Consecutive patients treated at a tertiary centre from 2018 to 2021 were included. All ablations were performed using a single microwave ablation device under lung isolation. The lung tumours were categorised as primary or secondary, and their “resistance” to ablation was graded according to their locations. Intraprocedural pulmonary inflation was assessed as equal to or less than the contralateral non-isolated lung. Ablation energy was categorised as high, medium, or low. Ablation zone dimensions were measured on day 1 CT and compared to vendor reference charts. Ablations with multiple needle positions or indeterminate boundaries were excluded.
Results
A total of 47 lesions in 31 patients were analysed. Achieved long axes are longer than predicted by 5 mm or 14% (
p
< 0.01) without overall short axis discrepancy. Secondary tumours (
p
= 0.020), low-resistance location (
p
< 0.01), good lung inflation (
p
< 0.01), low (
p
= 0.003) and medium (
p
= 0.038) total energy produce lengthened long axes by 4–6 mm or 10–19%. High total energy results in shorter than predicated short axes by 6 mm or 18% (
p
= 0.010).
Conclusion
We identified several factors affecting ablation zone dimensions which may have implications for ablation planning and the avoidance of complications.
Graphical abstract
Severe coronavirus disease 2019 is associated with an extensive pneumonitis and frequent coagulopathy. We sought the true prevalence of thrombotic complications in critically ill patients with severe ...coronavirus disease 2019 on the ICU, with or without extracorporeal membrane oxygenation.
We undertook a single-center, retrospective analysis of 72 critically ill patients with coronavirus disease 2019-associated acute respiratory distress syndrome admitted to ICU. CT angiography of the thorax, abdomen, and pelvis were performed at admission as per routine institution protocols, with further imaging as clinically indicated. The prevalence of thrombotic complications and the relationship with coagulation parameters, other biomarkers, and survival were evaluated.
Coronavirus disease 2019 ICUs at a specialist cardiorespiratory center.
Seventy-two consecutive patients with coronavirus disease 2019 admitted to ICU during the study period (March 19, 2020, to June 23, 2020).
None.
All but one patient received thromboprophylaxis or therapeutic anticoagulation. Among 72 patients (male:female = 74%; mean age: 52 ± 10; 35 on extracorporeal membrane oxygenation), there were 54 thrombotic complications in 42 patients (58%), comprising 34 pulmonary arterial (47%), 15 peripheral venous (21%), and five (7%) systemic arterial thromboses/end-organ embolic complications. In those with pulmonary arterial thromboses, 93% were identified incidentally on first screening CT with only 7% suspected clinically. Biomarkers of coagulation (e.g., d-dimer, fibrinogen level, and activated partial thromboplastin time) or inflammation (WBC count, C-reactive protein) did not discriminate between patients with or without thrombotic complications. Fifty-one patients (76%) survived to discharge; 17 (24%) patients died. Mortality was significantly greater in patients with detectable thrombus (33% vs 10%; p = 0.022).
There is a high prevalence of thrombotic complications, mainly pulmonary, among coronavirus disease 2019 patients admitted to ICU, despite anticoagulation. Detection of thrombus was usually incidental, not predicted by coagulation or inflammatory biomarkers, and associated with increased risk of death. Systematic CT imaging at admission should be considered in all coronavirus disease 2019 patients requiring ICU.
Transcatheter aortic valve implantation (TAVI) is an effective treatment option for patients with severe degenerative aortic valve stenosis who are high risk for conventional surgery. Computed ...tomography (CT) performed prior to TAVI can detect pathologies that could influence outcomes following the procedure, however the incidence, cost, and clinical impact of incidental findings has not previously been investigated. 279 patients underwent CT; 188 subsequently had TAVI and 91 were declined. Incidental findings were classified as clinically significant (requiring treatment), indeterminate (requiring further assessment), or clinically insignificant. The primary outcome measure was all-cause mortality up to 3 years. Costs incurred by additional investigations resultant to incidental findings were estimated using the UK Department of Health Payment Tariff. Incidental findings were common in both the TAVI and medical therapy cohorts (54.8 vs. 70.3 %;
P
= 0.014). Subsequently, 45 extra investigations were recommended for the TAVI cohort, at an overall average cost of £32.69 per TAVI patient. In a univariate model, survival was significantly associated with the presence of a clinically significant or indeterminate finding (HR 1.61;
P
= 0.021). However, on multivariate analysis outcomes after TAVI were not influenced by any category of incidental finding. Incidental findings are common on CT scans performed prior to TAVI. However, the total cost involved in investigating these findings is low, and incidental findings do not independently identify patients with poorer outcomes after TAVI. The discovery of an incidental finding on CT should not necessarily influence or delay the decision to perform TAVI.
•No difference was found in uptake for lung cancer screening at a mobile vs fixed site.•Scanner location was felt to be the “right place for a scan” for >95 % of attendees at both sites.•Risk based ...selection of participants resulted in a prevalence of lung cancer of 2.5 %.•5/29 of those with lung cancer were not eligible for a scan according to the PLCOM2012 model.•All participants with lung cancer qualified for a scan using the LLPv2 risk model.
The West London lung screening pilot aimed to identify early-stage lung cancer by targeting low-dose CT (LDCT) to high risk participants. Successful implementation of screening requires maximising participant uptake and identifying those at highest risk. As well as reporting pre-specified baseline screening metrics, additional objectives were to 1) compare participant uptake between a mobile and hospital-based CT scanner and 2) evaluate the impact on cancer detection using two lung cancer risk models.
From primary care records, ever-smokers aged 60–75 were invited to a lung health check at a hospital or mobile site. Participants with PLCOM2012 6-yr risk ≥1.51 % and/or LLPv2 5-yr risk ≥2.0 % were offered a LDCT. Lung cancer detection rate, stage, and recall rates are reported. Participant uptake was compared at both sites (chi-squared test). LDCT eligibility and cancer detection rate were compared between those recruited under each risk model.
Of 8366 potential participants invited, 1047/5135 (20.4 %) invitees responded to an invitation to the hospital site, and 702/3231 (21.7 %) to the mobile site (p = 0.14). The median distance travelled to the hospital site was less than to the mobile site (3.3 km vs 6.4 km, p < 0.01). Of 1159 participants eligible for a scan, 451/1159 (38.9 %) had a LLPv2 ≥2.0 % only, 71/1159 (6.1 %) had a PLCOM2012 ≥1.5 % only; 637/1159 (55.0 %) met both risk thresholds. Recall rate was 15.9 %. Lung cancer was detected in 29/1145 (2.5 %) participants scanned (stage 1, 58.6 %); 5/29 participants with lung cancer did not meet a PLCOM2012 threshold of ≥1.51 %; all had a LLPv2 ≥2.0 %.
Targeted screening is effective in detecting early-stage lung cancer. Similar levels of participant uptake at a mobile and fixed site scanner were demonstrated, indicating that uptake was driven by factors in addition to scanner location. The LLPv2 model was more permissive; recruitment with PLCOM2012 alone would have missed several cancers.
Reply to Sanfilippo et al. and to Caviedes et al Arachchillage, Deepa J; Desai, Sujal R; Devaraj, Anand ...
American journal of respiratory and critical care medicine,
01/2021, Letnik:
203, Številka:
2
Journal Article
To assess if dual-energy computed tomographic pulmonary angiography (DECTPA) derived lobar iodine quantification can provide an accurate estimate of lobar perfusion in patients with severe emphysema, ...and offer an adjunct to single-photon emission CT perfusion scintigraphy (SPECT-PS) in assessing suitability for lung volume reduction (LVR).
Patients with severe emphysema (forced expiratory volume in 1 s <49% predicted) undergoing evaluation for LVR between May 2018 and April 2020 imaged with both SPECT-PS and DECTPA were included in this retrospective study. DECTPA perfused blood volume maps were automatically segmented and lobar iodine mass was estimated and compared with lobar technetium (Tc99m) distribution acquired with SPECT-PS. Pearson correlation and Bland-Altman analysis were used for intermodality comparison between DECTPA and SPECT-PS. Univariate and adjusted multivariate linear regression were modelled to ascertain the effect sizes of possible confounders of disease severity, sex, age, and body mass index on the relationship between lobar iodine and Tc99m values. Effective radiation dose and adverse reactions were recorded.
In all, 123 patients (64.5±8.8 y, 71 men; mean predicted forced expiratory volume in 1 s 32.1 ±12.7%,) were eligible for inclusion. There was a linear relationship between lobar perfusion values acquired using DECTPA and SPECT-PS with statistical significance ( P <0.001). Lobar relative perfusion values acquired using DECTPA and SPECT-PS had a consistent relationship both by linear regression and Bland-Altman analysis (mean bias, -0.01, mean r2 0.64; P <0.0001). Individual lobar comparisons demonstrated moderate correlation ( r =0.79, 0.78, 0.84, 0.78, 0.8 for the right upper, middle, lower, left upper, and lower lobes, respectively, P <0.0001). The relationship between lobar iodine and Tc99m values was not significantly altered after controlling for confounders including symptom and disease severity, age, sex, and body mass index.
DECTPA provides an accurate estimation of lobar perfusion, showing good agreement with SPECT-PS and could potentially streamline preoperative assessment for LVR.
Abstract For many years invasive angiographic techniques have been considered as the gold standard for the assessment of large arterial abnormalities. However, the complexities and complications ...inherent to invasive imaging have meant that more recently non-invasive techniques such as echocardiography, Magnetic Resonance Imaging (MRI) and multidetector CT (MDCT) have been increasingly used in congenital cardiovascular disorders. In particular, MDCT has emerged as a fundamental tool for the diagnosis and pre-surgical work-up of aortic abnormalities due to its high spatial resolution, large area of coverage, and short scan time, and therefore is now one of the most widely used modalities for the detection of congenital abnormalities of the aorta. The purpose of this pictorial review is to review the spectrum of abnormalities of the aorta than can be reliably detected by MDCT both in infants and in adulthood. Abnormalities of the aortic root, ascending aorta, aortic arch, and descending aorta will be described separately.
A Golden Conundrum Garner, Justin L; Donovan, Jackie; Meireles, Ines ...
American journal of respiratory and critical care medicine,
09/2019, Letnik:
200, Številka:
5
Journal Article
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