High-resolution Chest CT Scan Research Articles

A Case Report of an Endobronchial Tuberculosis-Challenges in Diagnosis and the Role of High-resolution CT Scans and Bronchoscopic Biopsy

Introduction:: Endobronchial tuberculosis is a challenging disease to diagnose, characterized by infection of the tracheobronchial tree caused by Mycobacterium Tuberculosis. The clinical presentation of endobronchial tuberculosis is nonspecific and variable, making it difficult to identify. Case Report:: This report explores the challenges faced during the diagnosis of endobronchial tuberculosis by a 63-year-old female patient presented with a chronic cough lasting over two months. Her chest X-ray revealed an inhomogeneous opacity in the left middle zone, accompanied by an air-bronchogram. Conventional sputum samples and other tests returned negative results. A high-resolution chest CT scan was almost complete consolidation in the lingular subsegment. A comprehensive re-evaluation was recommended in this case due to slow re-solving or non-resolving pneumonia. The histopathological examination of the biopsy sample revealed granulomatous inflammation with necrosis and lymphocytic infiltration, strongly indicating bronchial tuberculosis. The Hain test and MGIT culture confirmed the presence of Mycobacterium tuberculosis. Conclusion:: Diagnosing endobronchial tuberculosis can be challenging due to its nonspecific and variable clinical presentation. High-resolution CT scans provide valuable insights, but the absence of typical findings can complicate the diagnosis. Bronchoscopic biopsy proved to be the most reliable method for diagnosing endobronchial tuberculosis in this case. Early and accurate diagnosis is crucial for initiating appropriate treatment and preventing complications.

GDF15 as a potential biomarker to distinguish fibrotic from non-fibrotic hypersensitivity pneumonitis

Hypersensitivity Pneumonitis (HP) is an immune-mediated interstitial lung disease (ILD) characterized by fibrotic HP (fHP) or non-fibrotic HP (non-fHP). Fibrosis is associated with poor prognosis, emphasizing the need for biomarkers to distinguish fHP from non-fHP. This study aimed to determine the plasma levels of GDF15 in HP patients and assess its association with lung function and phenotype classification. GDF15 levels were quantified by ELISA in HP (n = 64), idiopathic pulmonary fibrosis (n = 54), and healthy control (n = 128) groups. Clinical, demographic, and functional data were obtained from medical records. High-resolution chest CT scans were used to classify HP patients into fHP and non-fHP groups. In addition, receiver operating characteristic analysis was performed to determine the cut-off point, sensitivity, and specificity. Our results revealed significantly elevated GDF15 levels in fHP compared to non-fHP (2539 ± 821 pg/ml versus 1783 ± 801 pg/ml; p = 0.009). The estimated cut-off point for plasma GDF15 levels to distinguish fHP from non-fHP was 2193.4 pg/ml (AUC 0.75). These findings suggest that GDF15 may serve as a valuable biomarker for differentiating between fHP and non-fHP, potentially indicating its involvement in lung fibrosis development in HP.

Management of COVID-19 Pneumonia: Experience in a Peripheral Tertiary Level Hospital in Bangladesh

Background: Since the detection of the first case of the novel SARS-CoV-2 virus in Wuhan, China, on December 31, 2019, the world stepped into an era of the pandemic as declared by WHO on March 11, 2020. With no prior knowledge regarding this new pandemic, the evidence-based practice of medical management was at stake. Experience sharing from different corners of the world played an essential role in building knowledge to save the world. Methods: The researchers collected data for this retrospective study, from hospital records of the COVID-19 dedicated unit of Sylhet Women’s Medical College, Sylhet, Bangladesh, that was formed temporarily in July 2020, in response to the pandemic situation in the country. This article includes data on 3408 admitted COVID-19 patients with moderate to severe symptoms, managed in the isolation unit including its intensive care unit (ICU) up to November 2021. Results: The mean age of the patients was 57.21±12.58 years and male to female ratio was 1:1.8. Fever (44.4%), cough (38.9), and fatigability (33.3%) were the common symptoms. Diabetes mellitus (67.7%), systemic hypertension (63.7%), asthma (8.65%), chronic obstructive pulmonary disease (21.94%), and, ischemic heart disease (31.2%) were the top co-morbid conditions. Of the study subjects, 68.2% were RT-PCR positive for COVID-19, 67.3% had an abnormal baseline chest X-ray, and 91.1% had a ground glass shadow on a high-resolution CT scan of chest. Average C-reactive protein, D-dimer, and serum ferritin values were 71.68±60.38, 1.16±2.11, and 839±748.57 respectively. Hypoxemia, which was a common problem among them, was managed with oxygen therapy with an appropriate delivery device, with or without supplementation by dexamethasone (78.3%), or methylprednisolone (18.8%). Eighteen (18) patients refused to receive any antiviral therapy, 61 received oral Favipiravir and the rest of them received injectable Remdesevir. Standard care was augmented with Baricitinib in 60 patients. Thirty-six (36) patients in the ICU, with poor response to standard care, were treated with Tocilizumab. Death rates were 9.46% in the non-ICU block, but they were 6-10 times higher in the ICU. Conclusion: Every medical professional learned from the initial two years of the COVID-19 pandemic. Lessons learnt from experience helped building up the knowledge pool necessary for generating effective protocols for COVID-19 pneumonia management.

Subclinical high-resolution chest CT scan features in psoriasis

BackgroundAlthough psoriasis is considered a systemic disease, no clear association has been established between psoriasis and lung diseases. This study aims to detect and describe subclinical pulmonary involvement in psoriasis patients with various degrees of cutaneous manifestations. MethodsAdult psoriasis patients with no known active pulmonary disease or respiratory symptoms were screened for subclinical pulmonary manifestations and possible parenchymal changes using high-resolution computed tomography (HRCT) scan of the chest. Patients were classified according to the severity of skin manifestations. The clinical characteristics and radiographic findings of these patients were evaluated. ResultsFifty-nine patients with psoriasis were included, among which 47 (79.7%) had abnormal HRCT scan features. Micronodules were the most common detected lung lesions (66.1%), followed by nonspecific interstitial changes (32.2%), including pleuro-parenchymal band/atelectasis, scarring, and focal ground-glass opacities. Other HRCT findings included emphysematous changes and calcified granulomas. Abnormal HRCT findings correlated with older age and duration of psoriasis but not with the severity of skin manifestations. ConclusionsMicronodules and minor focal nonspecific interstitial changes were the most detected lung alterations in patients with psoriasis. These findings of the pilot study highlight a possible pulmonary involvement in patients with psoriasis. Larger multicenter studies are needed to clarify these findings further. LimitationsA major limitation of the study, is the lack of a control group with similar radiologic findings of different conditions done in the same geographical region.

Atoll sign ieventail diagnostic

The atoll sign or inverted halot sign is seen on high-resolution chest CT scans as a central frosted glass area surrounded by peripheral condensation in a ring or crescent, the contours of which may be smooth or spiculated [1]. Histologically, the central zone (ground glass opacity) corresponds to alveolar septal inflammation and cellular debris in the alveolar spaces, while the condensed peripheral zone corresponds to granulomatous tissue in the distal air spaces [2]

Pulmonary veno-occlusive disease in Sjogren's syndrome: a case report

BackgroundPulmonary arterial hypertension (PAH) associated with connective tissue disease (CTD) belongs to Group 1 pulmonary hypertension. Pulmonary veno-occlusive disease (PVOD), which is characterized by venous system aberrations, has been previously reported in CTD-PAH; however, it has rarely been observed in Sjogren’s syndrome (SS).Case presentationOur 28-year-old female patient was admitted to the hospital with recurrent shortness of breath even after minimal physical activity. Her chest high-resolution CT scan demonstrated pulmonary artery dilatation and bilateral ground-glass nodules. A subsequent right heart catheterization confirmed pulmonary hypertension because her mean pulmonary arterial pressure was 62 mmHg. Our inquisitive genomic assessment identified a novel EIF2AK4 mutation at c.1021 C > T (p. Gln341*), the dominant causal gene of PVOD. Histological examination demonstrated stenosis and occlusions in the pulmonary veins. Because she presented with features such as dry eyes and Raynaud's phenomenon, we performed a biopsy on the labial salivary gland, which confirmed SS. Her treatment regimen included PAH-targeted therapies (tadalafil and macitentan) in combination with hydroxychloroquine. Although she was hospitalized several times due to acute exacerbation of PAH, her disease progression was under control, and she did not demonstrate any signs of pulmonary edema even after a three-year treatment period.ConclusionHere, we report the case of an SS-PAH patient with PVOD who carried a novel biallelic EIF2AK4 mutation, and PAH-targeted therapies were well tolerated by our patient.

P11 An unusual case of Systemic Sclerosis/JDM overlap in a child with PAX8-related congenital hypothyroidism

Introduction/BackgroundJuvenile dermatomyositis is a rare inflammatory disease with a reported incidence of 0.8–4.1 per million children per year. It presents with a constellation of symptoms and signs of inflammation of skin and muscle, and is associated with significant morbidity if untreated. Juvenile systemic sclerosis (JSSc) is an even rarer rheumatological condition of childhood with significant risk of internal organ involvement, especially cardiopulmonary disease. We herewith present the case of a 7-year-old boy with history of hypothyroidism associated with a PAX8 gene variant who presented with clinical features of an overlap of Systemic Sclerosis with JDM with supportive autoantibody profile.Description/MethodA 7-year-old boy presented with a history of restricted range of movements in his hands – noted due to difficulties with pen grip – and calcinosis. He reported symptoms of fatigue, intolerance to cold with colour changes to hands and feet, stiffness of movements particularly in the morning, and infrequent episodes of choking. His past medical history was significant for hypothyroidism secondary to a paternally inherited PAX8 missense mutation, and there is a family history of Raynaud’s and hypothyroidism. A detailed examination identified diffusely swollen hands with sclerodactyly, calcinosis of his elbows and fingertips, and limited flexion of his fingers and wrists. He also had telangiectasia of his upper eyelids, Gottron’s papules over his knees and elbows, and sluggish circulation in his hands and feet. He had evidence of mild proximal muscle weakness.His investigations revealed mild elevation of muscle enzymes with normal inflammatory markers. His autoantibody profile showed a moderately positive ANA titre of 1600 with a nucleolar pattern, and was positive for anti-NXP2 and anti-SCL-100 antibodies MRI scan of the pelvis showed no evidence of myositis, echocardiogram was normal and a high-resolution CT scan of chest was normal with no features of interstitial lung disease.The overall picture was one of Systemic Sclerosis/JDM overlap with CREST syndrome. He was commenced on induction therapy with IV Methylprednisolone and Cyclophosphamide in view of the calcinosis. After three cycles of Cyclophosphamide and weaning course of oral corticosteroids, his energy levels are significantly improved and he has better overall mobility with no significant proximal muscle weakness (Childhood Myositis Assessment Scale score 49/53). However, flexion of his fingers remains limited albeit better; he has ongoing fingertip calcinosis but fewer lesions over his elbows. He has been commenced on weekly subcutaneous Methotrexate as he completes Cyclophosphamide.Discussion/ResultsThis patient had an unusual medical history of early onset thyroid dysfunction, the genetic testing for which revealed a missense PAX8 gene variant [c.49G>Ap.(Gly17Arg)] (also present in his father, who is euthyroid). This was classified as being of uncertain significance, although felt to clinically be the most likely cause for his hypothyroidism. There was no evidence to suggest that PAX8 gene mutations increased the risk of autoimmune conditions. There is evidence that PAX8 gene mutations, when expressed on malignant cells, may confer resistance to chemotherapy, which made us rethink the plan to commence him on Cyclophosphamide. However, we were reassured that in constitutional variants, there is no increased risk of cancer, and no known history of resistance to Cyclophosphamide.This patient also demonstrated an interesting antibody pattern, as he was positive for anti-NXP2 antibodies (indicating high risk for calcinosis) and anti-SCL-100 antibodies, which are associated with a clinical subset of patients with overlap of Systemic Sclerosis and JDM and associated with extensive extra-muscular features. He had two distinct clinical phenotypes of calcinosis, which is probably explained by the presence of two autoantibodies that increase the risk of calcinosis.Key learning points/ConclusionAlthough JDM has bimodal age group for presentation in childhood, only 3% of systemic sclerosis are seen in childhood, which makes this an extremely unusual presentation, given the age, gender and the overlap features (clinical and immunological).We explored whether this rare presentation could be linked to the underlying PAX8 gene mutations, but we could not find any association.With the clinical diagnosis of systemic sclerosis, it was important to rule out cardiopulmonary complications.The other consideration was regarding the choice of therapeutic agent - whether the germline PAX8 gene variants could increase the risk of malignancies or cause resistance to chemotherapeutic agents like Cyclophosphamide, for neither of which we could find any evidence.Extensive calcinosis cutis in this patient could be explained by the presence of two risk factors (CREST syndrome and JDM with NXP2 antibodies).

Tuberculosis dissemination in kidney transplant recipient treated with anti-CD40 monoclonal antibody: a case report

BackgroundTuberculosis (TBC) in solid organ transplant recipients represents a severe complication. The incidence among transplant recipients is higher than in the general population, and the diagnosis and treatment remain challenging. We present a case of active disseminated tuberculosis in a kidney transplant recipient treated with an anti-CD40 monoclonal antibody, who had been previously exposed to an active form of the disease, but latent tuberculosis (LTBI) was repeatedly ruled out prior to transplantation. To the best of our knowledge, no other case has been reported in a patient treated with the anti-CD40 monoclonal antibody.Case presentationA 49-year-old patient, 1.5 years after primary kidney transplantation, presented with vocal cord problems, a dry irritating cough, and a sore throat. A detailed investigation, including a high-resolution chest CT scan, revealed the diagnosis of disseminated tuberculosis. The antituberculosis treatment consisting of rifampicin, isoniazid, pyrazinamide, and ethambutol was started immediately. The patient's condition became complicated by relapsing diarrhoea. The colonoscopy revealed a circular stenosis above Bauhin’s valve. Microscopical findings showed active colitis and vaguely formed collections of epithelioid macrophages without fully developed caseous granulomas and were consistent with the clinical diagnosis of tuberculosis. The antituberculosis treatment was subsequently enhanced by moxifloxacin and led to a great improvement in the patient’s condition.ConclusionIn this case, false negativity of interferon-γ release assays and possibly higher risk for intracellular infections in patients on costimulatory signal blockers are discussed.

A Case for Academic Teleradiology.

IntroductionAlthough many radiology departments already employed home-based or other remote PACS capabilities before the coronavirus disease 2019 (COVID-19) pandemic, we believe that many of the changes in teleradiology will continue beyond the acute phases of the pandemic, especially in academic radiology departments. Early in the pandemic, many academic radiology departments reduced in-house faculty and trainee presence to allow social distancing and reduce the risk that a large portion of the work force would become sick all at once. Departments that already had remote PACS capabilities were able to instantly provide ongoing radiology coverage, whereas others had to scramble to build and distribute PACS workstations. Besides diagnostic interpretations, academic radiology departments also needed to continue trainee education and multidisciplinary activities. Although in-house staffing has returned to prepandemic levels for many departments, remote interpretation, electronic messaging, and video conferencing have become important facets in our regular workday.Workforce ShortagesEven before the COVID-19 pandemic, recruiting faculty members to academic positions had been challenging for some departments. Factors such as geography, spousal or partner employment, family and school obligations, and economics had impacts on recruiting [1Bender C.E. Bansal S. Wolfman D. Parikh J.R. 2018 ACR Commission on Human Resources Workforce Survey.J Am Coll Radiol. 2019; 16: 508-512Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar]. Furthermore, some subspecialties, such as cardiothoracic and pediatric radiology, have been suffering from an ongoing workforce shortage because of increased demand for these specialties but stubbornly low numbers of trainees entering these fields [2Farmakis S.G. Chertoff J.D. Barth R.A. Pediatric radiologist workforce shortage: action steps to resolve.J Am Coll Radiol. 2021; 18: 1675-1677Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar].To address acute and long-term staffing needs, some academic departments contract with locum tenens companies for onsite radiologists or teleradiology companies for remote coverage. External teleradiology partnerships as a long-term solution are attractive given that there is no need to interview or vet potential hires, staffing can be augmented daily on the basis of imaging volume, and contracts can generally be rapidly dissolved or created if interpretations are not performed as a satisfactory level. However, the downsides to relying on teleradiology interpretations are myriad and include high cost, commoditization of radiology in the eyes of clinicians and hospital leadership, nonspecialized diagnostic interpretations of advanced imaging studies, and safety issues given difficulties in facilitating communication between teleradiologists and referring clinicians. In addition, the nature of these relationships leaves much if not all the educational and interdisciplinary activities to regular faculty members, further increasing the burden of non–relative value unit–related tasks to onsite academic faculty members.We believe that academic teleradiology is one potential solution to address these workforce challenges. Not only can remote faculty members provide diagnostic imaging interpretation, but with the right tools, faculty members can review cases one on one with trainees, engage in video consultations with clinical services, attend and participate in multidisciplinary conferences, and present lectures and case conferences to trainees and students [3O’Leary D. Joint Commission charts new course for quality assurance.Am J Hosp Pharm. 1986; 43: 2403PubMed Google Scholar, 4Fotos J.S. Beatty-Chadha J. Goldenberg M.D.F. Purposeful remote radiology education: strategies and recommendations.Radiographics. 2021; 41: E109-E116Crossref PubMed Scopus (4) Google Scholar, 5Matalon S.A. Souza D.A.T. Gaviola G.C. Silverman S.G. Mayo-Smith W.W. Lee L.K. Trainee and attending perspectives on remote radiology readouts in the era of the COVID-19 pandemic.Acad Radiol. 2020; 27: 1147-1153Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar].BurnoutRadiologists, like other physicians, report high levels of professional burnout [6Shanafelt T.D. West C.P. Sinsky C. et al.Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017.Mayo Clin Proc. 2019; 94: 1681-1694Abstract Full Text Full Text PDF PubMed Scopus (400) Google Scholar,7Mendoza D. Bertino F.J. Why radiology residents experience burnout and how to fix it.Acad Radiol. 2019; 26: 555-558Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. In addition to clinical work, educational and scholarly activities are also professional requirements of many academic radiologists. Some academic radiology departments have had to reduce protected time allotted for academic and administrative activities as clinical volumes increase, and some subspecialty sections lack adequate staffing. These reductions further strain faculty members, especially those early in their careers, often turning evenings, weekends, and holidays into de facto academic time.Academic teleradiology allows flexibility in clinical schedules, including expanding faculty coverage hours through remote work while letting radiologist work “swing” or evening shifts to better accommodate needs at home, such as child or elderly care. Many academic radiology departments are in large urban centers, where the cost of living can add to work-related stresses. The ability to live farther afield in more remote suburbs, smaller cities, or anywhere in the United States while practicing at a major academic medical center might be appealing to early-career faculty members or senior faculty members looking for a late career change without added financial pressures. Furthermore, time saved on commuting, which in some large cities could be 1 to 2 hours a day, could be used for academic and administrative tasks or wellness-focused activities.ChallengesAcademic teleradiology is not without challenges. First, the lack of a physical presence can leave radiologists working remotely feel less “a part of the team” than their onsite colleagues. Professional relationships with trainees and clinical colleagues developed in cyberspace can seem less personal. Second, engaging students and trainees over video conferencing and screen-sharing software might prove challenging for parties involved. Third, ideas for research and other scholarly activities often come about in casual conversation in hallways or at the coffee stand, activities not available to radiologists working remotely. Fourth, academic teleradiology is limited primarily to nonprocedural clinical activities. Fifth, some fear that the flexibility inherent to remote work may lead to lower productivity; however, recent data regarding residents reading remotely showed no significant decreased in productivity [8Freeman C.W. Dhanaliwala A. Moore S. Kunchala S. Scanlon M.H. Homeward bound: a comparison of resident case volume on home-read workstations and on-site during the COVID-19 pandemic.J Am Coll Radiol. 2022; 19: 476-479Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar]. Still, careful selection of candidates for remote work, including those with productivity-based compensation models, must be designed to ensure desired performance of remote readers. Finally, some jurisdictions and health care systems might have specific requirements for professional licensure and insurance coverage with respect to telemedicine.SolutionsDespite these challenges, solutions do exist. Academic radiologists working remotely could be asked to work in person a set number of days or weeks per year and, during those on-site workdays, participate in student and trainee clinical and didactic teaching, in-person multidisciplinary conferences, and departmental professional and social activities. Second, departmental and section faculty meetings and research team meetings could all offer remote attendance options. Although performing image-guided procedures will prove to be more challenging for academic radiologists who primarily work remotely, options may be available to perform some procedures if on-site work occurs frequently enough to ensure that skills are maintained. With the need for telemedicine during the COVID-19 pandemic, health care systems likely have updated policies and procedures for remote work for medical staff members, and legal support is typically available to navigate any medical licensure and insurance requirements.For academic departments, creating a critical mass of specialized radiologists can be leveraged to provide teleradiology services to community practices within the health care network. In this case, the teleradiology service would not be to primarily act as a release valve for imaging volume or act as a bridge during overnight or weekend hours. Instead, the main need would be that of interpretation of uncommon or specialized studies. For example, high-resolution chest CT (HRCT) scans are not commonly ordered in the community setting. Moreover, the overall confidence of the typical general radiologist is low when interpreting HRCT scans. An academic teleradiology service could interpret all HRCT scans from their community partners in their health care network. The same mechanism could be generalized to other specialized studies, such as cardiac MRI, cardiac CT angiography, prostate MRI, MRI lymphoscintigraphy, MRI of small joints, and so on.Academic teleradiology might also be an appealing practice alternative for faculty members who desire a change in their practice for personal reasons. Rather than losing talented faculty members to national teleradiology services, academic departments could transition some traditional faculty positions to remote positions, either with remote resident supervision or purely for independent clinical work. Opportunities for continued trainee engagement such as lectures, teaching sessions, and remote supervision could be offered. Faculty members could also continue to participate in multidisciplinary conferences, which are often not practical in the standard teleradiology framework. Compensation plans could be adjusted accordingly commensurate with duties to ensure fairness with faculty members’ remaining in more traditional roles.ConclusionsWe believe that academic teleradiology will continue to grow beyond the COVID-19 pandemic and will allow departments to hire and retain top talent. Academic radiology departments offering full-time or part-time remote work will have advantages in recruiting. IntroductionAlthough many radiology departments already employed home-based or other remote PACS capabilities before the coronavirus disease 2019 (COVID-19) pandemic, we believe that many of the changes in teleradiology will continue beyond the acute phases of the pandemic, especially in academic radiology departments. Early in the pandemic, many academic radiology departments reduced in-house faculty and trainee presence to allow social distancing and reduce the risk that a large portion of the work force would become sick all at once. Departments that already had remote PACS capabilities were able to instantly provide ongoing radiology coverage, whereas others had to scramble to build and distribute PACS workstations. Besides diagnostic interpretations, academic radiology departments also needed to continue trainee education and multidisciplinary activities. Although in-house staffing has returned to prepandemic levels for many departments, remote interpretation, electronic messaging, and video conferencing have become important facets in our regular workday. Although many radiology departments already employed home-based or other remote PACS capabilities before the coronavirus disease 2019 (COVID-19) pandemic, we believe that many of the changes in teleradiology will continue beyond the acute phases of the pandemic, especially in academic radiology departments. Early in the pandemic, many academic radiology departments reduced in-house faculty and trainee presence to allow social distancing and reduce the risk that a large portion of the work force would become sick all at once. Departments that already had remote PACS capabilities were able to instantly provide ongoing radiology coverage, whereas others had to scramble to build and distribute PACS workstations. Besides diagnostic interpretations, academic radiology departments also needed to continue trainee education and multidisciplinary activities. Although in-house staffing has returned to prepandemic levels for many departments, remote interpretation, electronic messaging, and video conferencing have become important facets in our regular workday. Workforce ShortagesEven before the COVID-19 pandemic, recruiting faculty members to academic positions had been challenging for some departments. Factors such as geography, spousal or partner employment, family and school obligations, and economics had impacts on recruiting [1Bender C.E. Bansal S. Wolfman D. Parikh J.R. 2018 ACR Commission on Human Resources Workforce Survey.J Am Coll Radiol. 2019; 16: 508-512Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar]. Furthermore, some subspecialties, such as cardiothoracic and pediatric radiology, have been suffering from an ongoing workforce shortage because of increased demand for these specialties but stubbornly low numbers of trainees entering these fields [2Farmakis S.G. Chertoff J.D. Barth R.A. Pediatric radiologist workforce shortage: action steps to resolve.J Am Coll Radiol. 2021; 18: 1675-1677Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar].To address acute and long-term staffing needs, some academic departments contract with locum tenens companies for onsite radiologists or teleradiology companies for remote coverage. External teleradiology partnerships as a long-term solution are attractive given that there is no need to interview or vet potential hires, staffing can be augmented daily on the basis of imaging volume, and contracts can generally be rapidly dissolved or created if interpretations are not performed as a satisfactory level. However, the downsides to relying on teleradiology interpretations are myriad and include high cost, commoditization of radiology in the eyes of clinicians and hospital leadership, nonspecialized diagnostic interpretations of advanced imaging studies, and safety issues given difficulties in facilitating communication between teleradiologists and referring clinicians. In addition, the nature of these relationships leaves much if not all the educational and interdisciplinary activities to regular faculty members, further increasing the burden of non–relative value unit–related tasks to onsite academic faculty members.We believe that academic teleradiology is one potential solution to address these workforce challenges. Not only can remote faculty members provide diagnostic imaging interpretation, but with the right tools, faculty members can review cases one on one with trainees, engage in video consultations with clinical services, attend and participate in multidisciplinary conferences, and present lectures and case conferences to trainees and students [3O’Leary D. Joint Commission charts new course for quality assurance.Am J Hosp Pharm. 1986; 43: 2403PubMed Google Scholar, 4Fotos J.S. Beatty-Chadha J. Goldenberg M.D.F. Purposeful remote radiology education: strategies and recommendations.Radiographics. 2021; 41: E109-E116Crossref PubMed Scopus (4) Google Scholar, 5Matalon S.A. Souza D.A.T. Gaviola G.C. Silverman S.G. Mayo-Smith W.W. Lee L.K. Trainee and attending perspectives on remote radiology readouts in the era of the COVID-19 pandemic.Acad Radiol. 2020; 27: 1147-1153Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar]. Even before the COVID-19 pandemic, recruiting faculty members to academic positions had been challenging for some departments. Factors such as geography, spousal or partner employment, family and school obligations, and economics had impacts on recruiting [1Bender C.E. Bansal S. Wolfman D. Parikh J.R. 2018 ACR Commission on Human Resources Workforce Survey.J Am Coll Radiol. 2019; 16: 508-512Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar]. Furthermore, some subspecialties, such as cardiothoracic and pediatric radiology, have been suffering from an ongoing workforce shortage because of increased demand for these specialties but stubbornly low numbers of trainees entering these fields [2Farmakis S.G. Chertoff J.D. Barth R.A. Pediatric radiologist workforce shortage: action steps to resolve.J Am Coll Radiol. 2021; 18: 1675-1677Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar]. To address acute and long-term staffing needs, some academic departments contract with locum tenens companies for onsite radiologists or teleradiology companies for remote coverage. External teleradiology partnerships as a long-term solution are attractive given that there is no need to interview or vet potential hires, staffing can be augmented daily on the basis of imaging volume, and contracts can generally be rapidly dissolved or created if interpretations are not performed as a satisfactory level. However, the downsides to relying on teleradiology interpretations are myriad and include high cost, commoditization of radiology in the eyes of clinicians and hospital leadership, nonspecialized diagnostic interpretations of advanced imaging studies, and safety issues given difficulties in facilitating communication between teleradiologists and referring clinicians. In addition, the nature of these relationships leaves much if not all the educational and interdisciplinary activities to regular faculty members, further increasing the burden of non–relative value unit–related tasks to onsite academic faculty members. We believe that academic teleradiology is one potential solution to address these workforce challenges. Not only can remote faculty members provide diagnostic imaging interpretation, but with the right tools, faculty members can review cases one on one with trainees, engage in video consultations with clinical services, attend and participate in multidisciplinary conferences, and present lectures and case conferences to trainees and students [3O’Leary D. Joint Commission charts new course for quality assurance.Am J Hosp Pharm. 1986; 43: 2403PubMed Google Scholar, 4Fotos J.S. Beatty-Chadha J. Goldenberg M.D.F. Purposeful remote radiology education: strategies and recommendations.Radiographics. 2021; 41: E109-E116Crossref PubMed Scopus (4) Google Scholar, 5Matalon S.A. Souza D.A.T. Gaviola G.C. Silverman S.G. Mayo-Smith W.W. Lee L.K. Trainee and attending perspectives on remote radiology readouts in the era of the COVID-19 pandemic.Acad Radiol. 2020; 27: 1147-1153Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar]. BurnoutRadiologists, like other physicians, report high levels of professional burnout [6Shanafelt T.D. West C.P. Sinsky C. et al.Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017.Mayo Clin Proc. 2019; 94: 1681-1694Abstract Full Text Full Text PDF PubMed Scopus (400) Google Scholar,7Mendoza D. Bertino F.J. Why radiology residents experience burnout and how to fix it.Acad Radiol. 2019; 26: 555-558Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. In addition to clinical work, educational and scholarly activities are also professional requirements of many academic radiologists. Some academic radiology departments have had to reduce protected time allotted for academic and administrative activities as clinical volumes increase, and some subspecialty sections lack adequate staffing. These reductions further strain faculty members, especially those early in their careers, often turning evenings, weekends, and holidays into de facto academic time.Academic teleradiology allows flexibility in clinical schedules, including expanding faculty coverage hours through remote work while letting radiologist work “swing” or evening shifts to better accommodate needs at home, such as child or elderly care. Many academic radiology departments are in large urban centers, where the cost of living can add to work-related stresses. The ability to live farther afield in more remote suburbs, smaller cities, or anywhere in the United States while practicing at a major academic medical center might be appealing to early-career faculty members or senior faculty members looking for a late career change without added financial pressures. Furthermore, time saved on commuting, which in some large cities could be 1 to 2 hours a day, could be used for academic and administrative tasks or wellness-focused activities. Radiologists, like other physicians, report high levels of professional burnout [6Shanafelt T.D. West C.P. Sinsky C. et al.Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017.Mayo Clin Proc. 2019; 94: 1681-1694Abstract Full Text Full Text PDF PubMed Scopus (400) Google Scholar,7Mendoza D. Bertino F.J. Why radiology residents experience burnout and how to fix it.Acad Radiol. 2019; 26: 555-558Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. In addition to clinical work, educational and scholarly activities are also professional requirements of many academic radiologists. Some academic radiology departments have had to reduce protected time allotted for academic and administrative activities as clinical volumes increase, and some subspecialty sections lack adequate staffing. These reductions further strain faculty members, especially those early in their careers, often turning evenings, weekends, and holidays into de facto academic time. Academic teleradiology allows flexibility in clinical schedules, including expanding faculty coverage hours through remote work while letting radiologist work “swing” or evening shifts to better accommodate needs at home, such as child or elderly care. Many academic radiology departments are in large urban centers, where the cost of living can add to work-related stresses. The ability to live farther afield in more remote suburbs, smaller cities, or anywhere in the United States while practicing at a major academic medical center might be appealing to early-career faculty members or senior faculty members looking for a late career change without added financial pressures. Furthermore, time saved on commuting, which in some large cities could be 1 to 2 hours a day, could be used for academic and administrative tasks or wellness-focused activities. ChallengesAcademic teleradiology is not without challenges. First, the lack of a physical presence can leave radiologists working remotely feel less “a part of the team” than their onsite colleagues. Professional relationships with trainees and clinical colleagues developed in cyberspace can seem less personal. Second, engaging students and trainees over video conferencing and screen-sharing software might prove challenging for parties involved. Third, ideas for research and other scholarly activities often come about in casual conversation in hallways or at the coffee stand, activities not available to radiologists working remotely. Fourth, academic teleradiology is limited primarily to nonprocedural clinical activities. Fifth, some fear that the flexibility inherent to remote work may lead to lower productivity; however, recent data regarding residents reading remotely showed no significant decreased in productivity [8Freeman C.W. Dhanaliwala A. Moore S. Kunchala S. Scanlon M.H. Homeward bound: a comparison of resident case volume on home-read workstations and on-site during the COVID-19 pandemic.J Am Coll Radiol. 2022; 19: 476-479Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar]. Still, careful selection of candidates for remote work, including those with productivity-based compensation models, must be designed to ensure desired performance of remote readers. Finally, some jurisdictions and health care systems might have specific requirements for professional licensure and insurance coverage with respect to telemedicine. Academic teleradiology is not without challenges. First, the lack of a physical presence can leave radiologists working remotely feel less “a part of the team” than their onsite colleagues. Professional relationships with trainees and clinical colleagues developed in cyberspace can seem less personal. Second, engaging students and trainees over video conferencing and screen-sharing software might prove challenging for parties involved. Third, ideas for research and other scholarly activities often come about in casual conversation in hallways or at the coffee stand, activities not available to radiologists working remotely. Fourth, academic teleradiology is limited primarily to nonprocedural clinical activities. Fifth, some fear that the flexibility inherent to remote work may lead to lower productivity; however, recent data regarding residents reading remotely showed no significant decreased in productivity [8Freeman C.W. Dhanaliwala A. Moore S. Kunchala S. Scanlon M.H. Homeward bound: a comparison of resident case volume on home-read workstations and on-site during the COVID-19 pandemic.J Am Coll Radiol. 2022; 19: 476-479Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar]. Still, careful selection of candidates for remote work, including those with productivity-based compensation models, must be designed to ensure desired performance of remote readers. Finally, some jurisdictions and health care systems might have specific requirements for professional licensure and insurance coverage with respect to telemedicine. SolutionsDespite these challenges, solutions do exist. Academic radiologists working remotely could be asked to work in person a set number of days or weeks per year and, during those on-site workdays, participate in student and trainee clinical and didactic teaching, in-person multidisciplinary conferences, and departmental professional and social activities. Second, departmental and section faculty meetings and research team meetings could all offer remote attendance options. Although performing image-guided procedures will prove to be more challenging for academic radiologists who primarily work remotely, options may be available to perform some procedures if on-site work occurs frequently enough to ensure that skills are maintained. With the need for telemedicine during the COVID-19 pandemic, health care systems likely have updated policies and procedures for remote work for medical staff members, and legal support is typically available to navigate any medical licensure and insurance requirements.For academic departments, creating a critical mass of specialized radiologists can be leveraged to provide teleradiology services to community practices within the health care network. In this case, the teleradiology service would not be to primarily act as a release valve for imaging volume or act as a bridge during overnight or weekend hours. Instead, the main need would be that of interpretation of uncommon or specialized studies. For example, high-resolution chest CT (HRCT) scans are not commonly ordered in the community setting. Moreover, the overall confidence of the typical general radiologist is low when interpreting HRCT scans. An academic teleradiology service could interpret all HRCT scans from their community partners in their health care network. The same mechanism could be generalized to other specialized studies, such as cardiac MRI, cardiac CT angiography, prostate MRI, MRI lymphoscintigraphy, MRI of small joints, and so on.Academic teleradiology might also be an appealing practice alternative for faculty members who desire a change in their practice for personal reasons. Rather than losing talented faculty members to national teleradiology services, academic departments could transition some traditional faculty positions to remote positions, either with remote resident supervision or purely for independent clinical work. Opportunities for continued trainee engagement such as lectures, teaching sessions, and remote supervision could be offered. Faculty members could also continue to participate in multidisciplinary conferences, which are often not practical in the standard teleradiology framework. Compensation plans could be adjusted accordingly commensurate with duties to ensure fairness with faculty members’ remaining in more traditional roles. Despite these challenges, solutions do exist. Academic radiologists working remotely could be asked to work in person a set number of days or weeks per year and, during those on-site workdays, participate in student and trainee clinical and didactic teaching, in-person multidisciplinary conferences, and departmental professional and social activities. Second, departmental and section faculty meetings and research team meetings could all offer remote attendance options. Although performing image-guided procedures will prove to be more challenging for academic radiologists who primarily work remotely, options may be available to perform some procedures if on-site work occurs frequently enough to ensure that skills are maintained. With the need for telemedicine during the COVID-19 pandemic, health care systems likely have updated policies and procedures for remote work for medical staff members, and legal support is typically available to navigate any medical licensure and insurance requirements. For academic departments, creating a critical mass of specialized radiologists can be leveraged to provide teleradiology services to community practices within the health care network. In this case, the teleradiology service would not be to primarily act as a release valve for imaging volume or act as a bridge during overnight or weekend hours. Instead, the main need would be that of interpretation of uncommon or specialized studies. For example, high-resolution chest CT (HRCT) scans are not commonly ordered in the community setting. Moreover, the overall confidence of the typical general radiologist is low when interpreting HRCT scans. An academic teleradiology service could interpret all HRCT scans from their community partners in their health care network. The same mechanism could be generalized to other specialized studies, such as cardiac MRI, cardiac CT angiography, prostate MRI, MRI lymphoscintigraphy, MRI of small joints, and so on. Academic teleradiology might also be an appealing practice alternative for faculty members who desire a change in their practice for personal reasons. Rather than losing talented faculty members to national teleradiology services, academic departments could transition some traditional faculty positions to remote positions, either with remote resident supervision or purely for independent clinical work. Opportunities for continued trainee engagement such as lectures, teaching sessions, and remote supervision could be offered. Faculty members could also continue to participate in multidisciplinary conferences, which are often not practical in the standard teleradiology framework. Compensation plans could be adjusted accordingly commensurate with duties to ensure fairness with faculty members’ remaining in more traditional roles. ConclusionsWe believe that academic teleradiology will continue to grow beyond the COVID-19 pandemic and will allow departments to hire and retain top talent. Academic radiology departments offering full-time or part-time remote work will have advantages in recruiting. We believe that academic teleradiology will continue to grow beyond the COVID-19 pandemic and will allow departments to hire and retain top talent. Academic radiology departments offering full-time or part-time remote work will have advantages in recruiting.

High Resolution Computed Tomography Chest Findings in Patients with Positive RT-PCR of Covid-19

High-resolution CT chest abnormalities in patients with higher RT-PCR among those with COVID-19 have been poorly studied. It remained unknown what mechanism was responsible for the rise in COVID-19 cases. Objective: Observations from high-resolution chest CT scans in patients with a negative RT-PCR for COVID-19. Methods: A total of 400 male and female samples were collected using a simple random sampling method. The research method used was a descriptive one. The researchers used CT scans and in-depth interviews to compile their data. The current version of SPSS (21.0.0) was utilized for the statistical analysis. Results: There were a total of 245 men and 155 females in the sample pool for this investigation. COVID-19 was present in all of these patients. Based on the findings of the study, the patients were diagnosed with respiratory symptoms as fever, breathlessness, and cough. High resolution computed CT revealed, however, that these patients also have Ground glass opacities, heterogeneous patterns, septal thickening, consolidations, and pleural effusion. The patient population also included smokers. Conclusion: High-resolution computed CT results consistent with COVID-19 infection were found to include ground glassware opacities, mixed patterning, septal thickness, restructurings, CORAD classifications, nodules, bronchiectasis, crazy paving, and pleural effusion. Negative RT-PCR results in people with COVID-19 symptoms (such as cough, illness, fever, and shortness of breath) received little to no attention. The HRCT should be used for the overall diagnosis of COVID-19, and this should be the centre of learning and treatment for the population that tested negative with the RT-PCR.

Chest CT-based Assessment of 1-year Outcomes after Moderate COVID-19 Pneumonia.

COVID-19 pneumonia may lead to pulmonary fibrosis in the long term. Chest CT is useful to evaluate changes in the lung parenchyma over time. To illustrate the temporal change of lung abnormalities on chest CT scans associated with COVID-19 pneumonia over 1 year. In this prospective study, patients previously hospitalized due to COVID-19 pneumonia who visited the radiology department of a tertiary care center for imaging follow-up were consecutively enrolled between March 2020 and July 2021. Exclusion criteria were acute respiratory distress syndrome, requirement of intubation and/or mechanical ventilation, pulmonary embolism, and any interstitial lung disease. High-resolution volumetric noncontrast chest CT scans were acquired at 3, 6, and 12 months from the first diagnosis and were compared with baseline CT scans. The imaging features analyzed were ground-glass opacity (GGO), consolidation, pleuroparenchymal band, linear atelectasis, bronchiectasis and/or bronchiolectasis, reticulation, traction bronchiectasis and/or bronchiolectasis, and honeycombing. The prevalence distribution of lung abnormalities was recorded at all time points. Eighty-four participants (56 men; mean age, 61 years ± 11 [SD]) were studied. GGOs and consolidations represented the main baseline lung abnormalities, accounting for a median severity score of 9 (IQR, 7-12.7; maximum possible score, 20), which indicates moderate lung involvement. The baseline prevalence of GGOs decreased from 100% to 2% of participants at 1 year, and that of consolidations decreased from 71% to 0% at 6 months. Fibrotic-like abnormalities (pleuroparenchymal bands, linear atelectasis, bronchiectasis and/or bronchiolectasis) were detected at 3 months (50% of participants), 6 months (42% of participants), and 1 year (5% of participants). Among these, pleuroparenchymal bands were the most represented finding. Fibrotic changes (reticulation and traction bronchiectasis and/or bronchiolectasis) were detected at 3-6 months (2%) and remained stable at 1 year, with no evidence of honeycombing. At 1 year, lung abnormalities due to COVID-19 pneumonia were completely resolved in 78 of 84 (93%) participants. Residual lung abnormalities in individuals hospitalized with moderate COVID-19 pneumonia were infrequent, with no evidence of fibrosis at 1-year chest CT. © RSNA, 2022.

Role of Computed Tomography in Diagnosis and Assessment of Disease Severity in Covid 19; Trends in Pakistan

Objective: To observe and compare relationship of High Resolution Computed Tomography severity score with presenting symptoms of COVID-19 positive patients in mild, moderate and severe disease and to analyze the trends of morbidity and mortality in Pakistan. Study Design: Retrospective Observational study Subjects and Methods: All OPD and admitted adult male and female patients serially presented to Fatima Memorial and Sir Ganga Ram Hospital Lahore with positive COVID PCR test or clinical symptoms were included in the study. These patients were classified in three groups; Group I: Mild disease, i.e. symptomatic patients who didn’t need hospital admission or oxygen support. Group II: Moderate disease, i.e. patients having oxygen saturation more than 90% & needing oxygen support at times, and Group III: severe disease, i.e. patients needing hospital admission or ventilator support and having oxygen saturation less than 90%. High resolution chest CT scan was the approach in all cases. CT severity score was used to assess the severity of lung parenchymal involvement by COVID-19 on all the HRCT. Data collected was entered and analysis made using SPSS v 25. Results: Total number of patients were 200(100%) with age ranging from 14-85 years and mean age was 49.5+ 5 years, out of which 135(67%) were males and 65(32%) were females with male to female ratio 2:1. HRCT scans of all patients were done with COVID PCR test positive in 146(73%) patients. Group I had 98(49%) patients, 87(43.5%) patients were included in Group II and 15(7.5%) patients in Group III. Oxygen was required in 78(39%) patients from group II and 14(7%) patients from severe disease required ventilator. Conclusion: Our research work presented the trends of CT severity scoring having positive correlation to clinical symptoms of patients. Moreover, most of the patients in our country were having mild and moderate disease and only 7% patients showed severe disease symptoms and CT scoring in our study. Out of those severe disease patients, mortality was only 1% as compared to 2.89% mortality reported in Iran. Keywords: COVID-19 infection, HRCT Chest, Severity score

Diagnostic Value of High-Resolution Computed Tomography Scan in COVID-19: Do We Need to Think Outside the Box?

Background and objectiveThe ambiguous nature and high infectivity of the coronavirus disease 2019 (COVID-19) have caused soaring morbidity and mortality worldwide. Real-time polymerase chain reaction (RT-PCR) is preferred for detecting COVID-19. However, its poor sensitivity and the emerging use of high-resolution CT (HRCT) scan for disease severity make the use of RT-PCR quite obsolete. In light of this, our study aimed to explore the beneficial role of HRCT and compare the HRCT findings across various patient demographics and parameters.MethodsThis cross-sectional study included 100 patients with clinical suspicion of COVID-19. All patients underwent a chest HRCT scan preceded by RT-PCR testing. We used the CT severity score (CTSS) of the chest to calculate disease severity. Demographical data and results of radiological findings were tabulated and compared across RT-PCR positivity, age, and gender. Independent samples t-test and chi-square test were used to analyze the data.ResultsGlass ground opacity was the most prevalent finding in 99% of the patients, followed by lymph node involvement, consolidation, and crazy-paving pattern. Pleural effusion was observed in only 10% of the patients while pericardial effusion and hiatal hernia were present in 5%. In RT-PCR-positive patients, the posterior basal segment of the lower lobe of the right and left lungs were found to be dominantly involved; however, the upper and middle lobes of the right lung were more commonly involved than the left lung. The mean CTSS was significantly higher in patients aged above 50 years (p<0.001). The mean CTSS of RT-PCR-negative patients was higher than that of RT-PCR-positive patients (15.18 vs. 14.31, p=0.537).ConclusionRT-PCR has a limited role in the diagnosis of COVID-19. The HRCT scan can detect typical COVID-19 findings even in patients with negative RT-PCR results. Moreover, the use of HRCT scan in determining the disease severity and extent of lung damage can lead to a better assessment of critically ill patients.

[A preliminary investigation on a deep learning convolutional neural networks based pulmonary tuberculosis CT diagnostic model].

Objective: To evaluate the clinical value of a pulmonary tuberculosis CT diagnostic model based on deep learning convolutional neural networks (CNN). Methods: From March 2017 to March 2018,a total of 1 764 patients with positive sputum for tuberculous bacterium and had received high-resolution chest CT scan in radiology department of Hebei province chest hospital were enrolled. Among them, 937 were male, and 827 were female, aging from 17-73 years (average 38.4). A total of 20 139 CT images (17 kinds of image features) classified by 4 radiologists were used as training dataset to create a tuberculosis CT CNN diagnostic model. The top 5 image features in training set were: infiltrative pulmonary tuberculosis, cavitary pulmonary tuberculosis, pleural thickening, caseous pneumonia and pleural effusion. A total of 302 images were randomly selected from the marked images as testing dataset. The diagnosis of 2 senior radiologists was taken as "golden standard". The differences of sensitivity and accuracy in CT diagnosis between the CNN diagnostic model and the radiologists were compared. The classification error types and numbers of the CNN diagnostic model were recorded. FROC(free response operating characteristic curve)curve was drawn and the highest diagnostic efficiency of the model was measured. Results: The diagnostic accuracy of infiltrative pulmonary tuberculosis, cavitary pulmonary tuberculosis, pleural thickening, caseous pneumonia and pleural effusion by the CNN diagnostic model were 95.33%(10 982/11 520), 73.68%(2 151/2 920), 73.07%(1 128/1544), 83.33%(1 020/1225)and 94.11%(814/865), respectively. The overall diagnostic sensitivity and accuracy of the CNN model were 95.49%(339/355)and 90.40%(339/375), respectively, and the corresponding values ​​of radiologists were 93.80%(348/371)and 92.80%(348/375), respectively, and there was no statistical difference between the CNN model and the radiologists(sensitivity χ2=1.022,P=0.312;accuracy χ2=1.404,P=0.236). FROC curve showed that when sensitivity of the CNN model was 78% and FPI value was 2.48, it reached the highest diagnostic efficiency. The classification error of CNN diagnostic models was mainly confusion of fiber stripe components, cavitary pulmonary tuberculosis, caseous pneumonia and infiltrative pulmonary tuberculosis. Conclusions: The CNN-based pulmonary tuberculosis CT diagnostic model exhibited high sensitivity and accuracy (95.49% and 90.40% respectively). It could assist radiologists in CT diagnosis of pulmonary tuberculosis and deserve further clinical application.

Clinical Significance of Interstitial Lung Disease and Its Acute Exacerbation in Microscopic Polyangiitis

Presence of interstitial lung disease (ILD) is thought to be associated with mortality in microscopic polyangiitis (MPA); however, evidence on MPA-ILD remains lacking. Acute exacerbation (AE) refers to rapidly progressive, fatal respiratory deterioration that may develop in patients with various ILDs. No study has investigated the clinical significance of AE in MPA-ILD. We aimed to determine the clinical picture and prognostic factors, the incidence of AE, and the risk factors in patients with MPA-ILD. Eighty-four consecutive patients with MPA-ILD and 95 patients with MPA-non-ILD were analyzed. We also compared 80 patients with MPA-ILD and 80 patients with idiopathic interstitial pneumonia without myeloperoxidase-antineutrophil cytoplasmic antibody positivity (ILD alone), who were matched for age, sex, and chest high-resolution CT scan pattern. The MPA-ILD group had a higher frequency of men and smokers and was associated with higher mortality than the MPA-non-ILD group. The matched MPA-ILD group had a higher mortality rate than the matched ILD alone group. There was no significant difference in AE incidence between the matched MPA-ILD and ILD alone groups (1-year AE cumulative incidence rate, 7.5%and 5.2%, respectively; P= .75). In the MPA-ILD group, a lower percent predicted FVC (%FVC) was independently associated with a higher mortality rate (hazard ratio [HR], 0.96 per 1%increase; P< .01) and a higher AE incidence rate (HR, 0.96 per 1%increase; P= .01). On multivariable Cox regression analysis with time-dependent covariates, developing AE during their clinical course was strongly associated with shorter survival (HR, 17.1; P< .001). MPA-ILD represented a distinct phenotype with poor prognosis. Lower %FVC was an independent prognostic factor. Patients with lower %FVC had a risk of developing AE, which was a strong prognostic determinant. The specific management for MPA-ILD and AE should be established.

Spontaneous pneumomediastinum in COVID-19 pneumonia.

Spontaneous pneumomediastinum is a benign entity but can worsen the underlying condition with which it is associated. We evaluated the incidence and the clinical relevance of spontaneous pneumomediastinum in a consecutive series of 102 patients with COVID-19 pneumonia. Six cases of pneumomediastinum were identified by high-resolution chest CT-scan. Three patients required early intubation, and one of them died, while in in the remaining subjects the clinical course was benign. The presence of pneumomediastinum required some changes in the management of mechanical ventilation. In conclusion, spontaneous pneumomediastinum is a possible complication of severe COVID-19 pneumonia that can affect patient management and clinical outcomes.

Clinical features and high resolution CT imaging findings of preliminary COVID-19

Objective To summarize the clinical and high resolution CT(HRCT) characteristics of 141 patients with COVID-19. Methods From January 20 to 28, 2020, 141 COVID-19 patients, 77 males and 64 females, with a median age of 49 (9, 87), were enrolled in the study. The clinical features, laboratory test results and HRCT findings of all patients were analyzed retrospectively. Results In all of the patients, the decreasing leukocyte countin 38 (26.95%) and lymphocyte ratio in 71 (50.35%), a fever over 37.5 ℃ in 139 (98.58%), coughing in 106 (75.18%), headache in 11 (7.80%), expectoration in 41 (29.08%), chest distress in 93 (65.96%), and diarrhea in 4 (2.84%) were found. The HRCT of all patients were abnormal, including ground glass opacity (GGO) with patchy opacity in 52 (36.88%) mainly distributed along subpleural area, GGO with focal consolidation in 23 (16.31%),small patchy opacity in 27 (19.15%),large patchy consolidation in 20 (14.18%),thickened bronchovascular bundleing and blood vessel crossing the lesion in 48 (34.04%), air bronchus sign in 5 (3.55%), small nodule in 7 (4.96%),fibrous stripes and reticular opacities in 5 (3.55%), bilateral pleural effusion in 7 (4.96%), and mediastinal or bilateral hilar lymphadenopathy in 4 (2.84%). Conclusions The clinical and HRCT manifestations of COVID-19 are various. Under the specific epidemiological background of COVID-19, chest HRCT scan should be carried out as soon as possible for early warning of this disease. Key words: COVID-19; Tomography, X-ray computed

Imaging features of the initial chest high resolution CT scan in juvenile patient with coronavirus disease 2019

The coronavirus disease 2019 (COVID-19) was confirmed by nucleic acid test in 15 juvenile patients aged 4-17 years in Hangzhou Xixi Hospital from January 24 to February 10, 2020. The clinical data and the initial chest high resolution CT (HRCT) findings were retrospectively analyzed.Among 15 cases, 8 patients with a mean age of (6.5±2.3) years (4-11 year) had normal HRCT manifestations (mild disease), while 7 patients with a mean age of (11.9±3.0) years (7-17 years) showed abnormal manifestations (moderate disease). In the 7 moderate cases the CT findings included local thickening of bronchial wall in 2 cases, single lesion in 1 case, bilateral pulmonary lesions in 4 cases. There were total 11 lesions, 6 of which were ground glass and slightly high-density nodules, 5 of which were speckled ground glass and 2 with a little consolidation. There were 10 subpleural lesions, including 7 in the lower lobe of the two lungs, and 1 non-subpleural lesion; the thickened local bronchioles were observed in 3 cases. None of them had hilum and mediastinal lymph node enlargement or pleural effusion. Key words: Coronavirus infection; Coronavirus disease 2019; Minors; Tomography, X-ray computed; Diagnosis

Possible Role of Chest Ultrasonography for the Evaluation of Peripheral Fibrotic Pulmonary Changes in Patients Affected by Idiopathic Pulmonary Fibrosis—Pilot Case Series

Lung ultrasonography (LUS) provides an estimation of peripheral airspace (PAS) geometry of the lung. Altered PAS produces sonographic interstitial syndrome (SIS). Idiopathic pulmonary fibrosis (IPF) involves peripheral lung with altered PAS. The aim of the study is to correlate echographic patterns with peripheral fibrotic changes on high-resolution Chest CT scan (HRCT). Patients underwent LUS and HRCT on the same date. Four LUS patterns were described: (1) near normal; (2) SIS with predominance of reverberant artifacts; (3) SIS with vertical predominance; (4) white lung. Four HRCT grades of peripheral fibrotic infiltrates were reported: grade 1 mild; grade 2 moderate; grade 3 severe; grade 4 massive or honeycomb. LUS pattern 1 was indicative of mild to moderate fibrotic alterations in 100% of cases. LUS pattern 2 matched with HRCT grade 2 in 24 out of 30 cases (77%). Huge discordance in four cases because of large honeycomb cysts. LUS pattern 3 was indicative of severe to massive alterations in 100% of cases. LUS pattern 4 showed a heterogeneous distribution of HRCT grades, severe changes, and ground glass opacities (GGO). This preliminary work demonstrates some level of agreement between LUS patterns and HRCT grades. Limitations and methodological issues have been shown to support subsequent studies of agreement.

Clinical features and high resolutionCT imaging findings of preliminary diagnosis novel coronavirus pneumonia

Objective To summarize the clinical characteristics of 141 patients with novel coronavirus pneumonia (NCP) and the imaging characteristics of High Resolution CT(HRCT) in the chest. Methods From January 20, 2020 to 28, 141 NCP patients, 77 males and 64 females, with a median age of 49 (9,87), were retrospectively analyzed. The clinical features, laboratory examination indexes and HRCT findings of 141 NCP patients were analyzed. Results In 141 NCP patients, 38 (26.95%) had a decrease in leukocyte count and 71 (50.35%) had a decrease in lymphocyte ratio. Among 141 NCP patients, 139 (98.58%) had fever (over 37.5 ° C), 106 (75.18%) coughed, 11 (7.80%) had headache, 41 (29.08%) coughed up sputum, 93 (65.96%) had chest distress, and 4 (2.84%) had diarrhea. HRCT of 141 NCP patients were abnormal, 52 (36.88%) showed ground glass shadow (GGO) and patchy shadow, mainly subpleural distribution; 23 (16.31%) showed GGO with focal consolidation; 27 (19.15%) had small patchy blur; 20 (14.18%) had large patchy consolidation; 48 (34.04%) had bronchovascular bundle thickening and vascular perforator sign; 5 (3.55%) had Air bronchus sign; small nodule shadow in 7 cases (4.96%); fibrosis, grid shadow or strip shadow in 5 cases (3.55%); bilateral pleural effusion in 7 cases (4.96%); mediastinal or bilateral hilar lymphadenopathy in 4 cases (2.84%). Conclusions The clinical features and HRCT images of NCP are various. Under the specific epidemiological background of NCP, HRCT scan of chest should be carried out in time to make early warning of disease. Key words: Novel coronavirus pneumonia; Tomography, X-ray computed