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Øvrebotten T, Mecinaj A, Stavem K, Ghanima W, Brønstad E, Durheim MT, Lerum TV, Josefsen T, Grimsmo J, Heck SL, Omland T, Ingul CB, Einvik G, Myhre PL. Trajectory of cardiac troponin T following moderate-to-severe COVID-19 and the association with cardiac abnormalities. BMC Cardiovasc Disord 2024; 24:206. [PMID: 38614990 PMCID: PMC11015606 DOI: 10.1186/s12872-024-03854-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 03/21/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND COVID-19 has been associated with cardiac troponin T (cTnT) elevations and changes in cardiac structure and function, but the link between cardiac dysfunction and high-sensitive cardiac troponin T (hs-cTnT) in the acute and convalescent phase is unclear. OBJECTIVE To assess whether hs-cTnT concentrations are associated with cardiac dysfunction and structural abnormalities after hospitalization for COVID-19, and to evaluate the performance of hs-cTnT to rule out cardiac pathology. METHODS Patients hospitalized with COVID-19 had hs-cTnT measured during the index hospitalization and after 3-and 12 months, when they also underwent an echocardiographic study. A subset also underwent cardiovascular magnetic resonance imaging (CMR) after 6 months. Cardiac abnormalities were defined as left ventricular hypertrophy or dysfunction, right ventricular dysfunction, or CMR late gadolinium. RESULTS We included 189 patients with hs-cTnT concentrations measured during hospitalization for COVID-19, and after 3-and 12 months: Geometric mean (95%CI) 13 (11-15) ng/L, 7 (6-8) ng/L and 7 (6-8) ng/L, respectively. Cardiac abnormalities after 3 months were present in 45 (30%) and 3 (8%) of patients with hs-cTnT ≥ and < 5 ng/L at 3 months, respectively (negative predictive value 92.3% [95%CI 88.5-96.1%]). The performance was similar in patients with and without dyspnea. Hs-cTnT decreased from hospitalization to 3 months (more pronounced in intensive care unit-treated patients) and remained unchanged from 3 to 12 months, regardless of the presence of cardiac abnormalities. CONCLUSION Higher hs-cTnT concentrations in the convalescent phase of COVID-19 are associated with the presence of cardiac pathology and low concentrations (< 5 ng/L) may support in ruling out cardiac pathology following the infection.
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Affiliation(s)
- Tarjei Øvrebotten
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- K.G. Jebsen Center for Cardiac Biomarkers, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Albulena Mecinaj
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- K.G. Jebsen Center for Cardiac Biomarkers, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Knut Stavem
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
- Department of Pulmonary Medicine, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Waleed Ghanima
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Hemato-oncology, Østfold Hospital Kalnes, Østfold, Norway
| | - Eivind Brønstad
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Thoracic Department, St. Olavs Hospital, Trondheim, Norway
| | - Michael T Durheim
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Respiratory Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Tøri V Lerum
- Department of Pulmonary Medicine, Oslo University Hospital Ullevål, Oslo, Norway
| | - Tony Josefsen
- Department of Cardiology, Østfold Hospital Kalnes, Østfold, Norway
| | - Jostein Grimsmo
- Department of cardiac and pulmonary rehabilitation, Cathinka Guldberg's Hospital, Lovisenberg Rehabilitation, Jessheim, Norway
| | - Siri L Heck
- K.G. Jebsen Center for Cardiac Biomarkers, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway
| | - Torbjørn Omland
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- K.G. Jebsen Center for Cardiac Biomarkers, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Charlotte B Ingul
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Gunnar Einvik
- Department of Pulmonary Medicine, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Peder L Myhre
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway.
- K.G. Jebsen Center for Cardiac Biomarkers, Institute for Clinical Medicine, University of Oslo, Oslo, Norway.
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Honchar O, Ashcheulova T, Chumachenko T, Chumachenko D, Bobeiko A, Blazhko V, Khodosh E, Matiash N, Ambrosova T, Herasymchuk N, Kochubiei O, Smyrnova V. A prognostic model and pre-discharge predictors of post-COVID-19 syndrome after hospitalization for SARS-CoV-2 infection. Front Public Health 2023; 11:1276211. [PMID: 38094237 PMCID: PMC10716462 DOI: 10.3389/fpubh.2023.1276211] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/25/2023] [Indexed: 12/18/2023] Open
Abstract
Background Post-COVID-19 syndrome (PCS) has been increasingly recognized as an emerging problem: 50% of patients report ongoing symptoms 1 year after acute infection, with most typical manifestations (fatigue, dyspnea, psychiatric and neurological symptoms) having potentially debilitating effect. Early identification of high-risk candidates for PCS development would facilitate the optimal use of resources directed to rehabilitation of COVID-19 convalescents. Objective To study the in-hospital clinical characteristics of COVID-19 survivors presenting with self-reported PCS at 3 months and to identify the early predictors of its development. Methods 221 hospitalized COVID-19 patients underwent symptoms assessment, 6-min walk test, and echocardiography pre-discharge and at 1 month; presence of PCS was assessed 3 months after discharge. Unsupervised machine learning was used to build a SANN-based binary classification model of PCS development. Results PCS at 3 months has been detected in 75% patients. Higher symptoms level in the PCS group was not associated with worse physical functional recovery or significant echocardiographic changes. Despite identification of a set of pre-discharge predictors, inclusion of parameters obtained at 1 month proved necessary to obtain a high accuracy model of PCS development, with inputs list including age, sex, in-hospital levels of CRP, eGFR and need for oxygen supplementation, and level of post-exertional symptoms at 1 month after discharge (fatigue and dyspnea in 6MWT and MRC Dyspnea score). Conclusion Hospitalized COVID-19 survivors at 3 months were characterized by 75% prevalence of PCS, the development of which could be predicted with an 89% accuracy using the derived neural network-based classification model.
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Affiliation(s)
- Oleksii Honchar
- Department of Propedeutics of Internal Medicine No.1, Fundamentals of Bioethics and Biosafety, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Tetiana Ashcheulova
- Department of Propedeutics of Internal Medicine No.1, Fundamentals of Bioethics and Biosafety, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Tetyana Chumachenko
- Department of Epidemiology, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Dmytro Chumachenko
- Department of Mathematical Modelling and Artificial Intelligence, National Aerospace University "Kharkiv Aviation Institute", Kharkiv, Ukraine
| | - Alla Bobeiko
- Department of Pulmonology, MNE “Clinical City Hospital No.13” of Kharkiv City Council, Kharkiv, Ukraine
| | - Viktor Blazhko
- Department of Pulmonology, MNE “Clinical City Hospital No.13” of Kharkiv City Council, Kharkiv, Ukraine
| | - Eduard Khodosh
- Department of Pulmonology, MNE “Clinical City Hospital No.13” of Kharkiv City Council, Kharkiv, Ukraine
| | - Nataliia Matiash
- Department of Pulmonology, MNE “Clinical City Hospital No.13” of Kharkiv City Council, Kharkiv, Ukraine
| | - Tetiana Ambrosova
- Department of Propedeutics of Internal Medicine No.1, Fundamentals of Bioethics and Biosafety, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Nina Herasymchuk
- Department of Propedeutics of Internal Medicine No.1, Fundamentals of Bioethics and Biosafety, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Oksana Kochubiei
- Department of Propedeutics of Internal Medicine No.1, Fundamentals of Bioethics and Biosafety, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Viktoriia Smyrnova
- Department of Propedeutics of Internal Medicine No.1, Fundamentals of Bioethics and Biosafety, Kharkiv National Medical University, Kharkiv, Ukraine
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Honchar O, Ashcheulova T. Short-term echocardiographic follow-up after hospitalization for COVID-19: a focus on early post-acute changes. Front Cardiovasc Med 2023; 10:1250656. [PMID: 38075959 PMCID: PMC10703357 DOI: 10.3389/fcvm.2023.1250656] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 11/06/2023] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND Impaired physical functional status is one of the typical long-term sequelae of COVID-19 infection that significantly affects the quality of life and work capacity. Minor changes in cardiac structure and function that are unable to cause the manifestation of overt heart failure may remain undetected in COVID-19 convalescents, at the same time potentially contributing to the persistence of symptoms and development of long COVID syndrome. PURPOSE To study the typical features and short-term dynamics of cardiac remodeling and possible signs of cardiac dysfunction following hospitalization for COVID-19. METHODS This is a combined cross-sectional and longitudinal cohort study in which 176 hospitalized patients (93 female and 83 male, mean age 53.4 ± 13.6 years) with COVID-19 infection underwent comprehensive transthoracic echocardiography pre-discharge (22.6 ± 7.1 days from the onset of symptoms) with repeated evaluation after 1 month. The control group included 88 age-, sex-, height- and weight-matched healthy individuals, with a subset of those (n = 53) matched to the subset of non-hypertensive study participants (n = 106). RESULTS Concentric left ventricular geometry was revealed in 59% of participants, including 43% of non-hypertensive subjects; predominantly Grade I diastolic dysfunction was found in 35 and 25% of patients, respectively. Other findings were naturally following from described phenotype of the left venticle and included a mild increase in the absolute and relative wall thickness (0.45 ± 0.07 vs. 0.39 ± 0.04, p < 0.001), worsening of diastolic indices (e' velocity 9.2 ± 2.2 vs. 11.3 ± 2.6 cm/s, p < 0.001, E/e' ratio 7.5 ± 1.8 vs. 6.8 ± 1.7, p = 0.002) and global longitudinal strain (17.5 ± 2.4 vs. 18.6 ± 2.2, p < 0.001). No significant improvement was found on re-evaluation at 1 month. CONCLUSIONS Hospitalized patients recovering from COVID-19 were characterized by a high prevalence of left ventricular concentric remodeling, predominantly Grade I diastolic dysfunction, and a mild decrease in the longitudinal systolic function. These changes were less frequent but still prevalent in the non-hypertensive subgroup and largely persisted throughout the 1-month follow-up.
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Mojica-Pisciotti ML, Panovský R, Holeček T, Opatřil L, Feitová V. Lower ventricular and atrial strain in patients who recovered from COVID-19 assessed by cardiovascular magnetic resonance feature tracking. Front Cardiovasc Med 2023; 10:1293105. [PMID: 38028469 PMCID: PMC10679333 DOI: 10.3389/fcvm.2023.1293105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction One of the most common complications of coronavirus disease 2019 (COVID-19) is myocardial injury, and although its cause is unclear, it can alter the heart's contractility. This study aimed to characterize the ventricular and atrial strain in patients who recovered from COVID-19 using cardiovascular magnetic resonance feature-tracking (CMR-FT). Methods In this single-center study, we assessed left ventricle (LV) and right ventricular (RV) global circumferential strain (GCS), global longitudinal strain (GLS), global radial strain (GRS), left atrial (LA) and right atrial (RA) longitudinal strain (LS) parameters by CMR-FT. The student's t-test and Wilcoxon rank-sum test were used to compare the variables. Results We compared seventy-two patients who recovered from COVID-19 (49 ± 16 years) to fifty-four controls (49 ± 12 years, p = 0.752). The patients received a CMR examination 48 (34 to 165) days after the COVID-19 diagnosis. 28% had LGE. Both groups had normal LV systolic function. Strain parameters were significantly lower in the COVID-19 survivors than in controls. Discussion Patients who recovered from COVID-19 exhibited significantly lower strain in the left ventricle (through LVGCS, LVGLS, LVGRS), right ventricle (through RVGLS and RVGRS), left atrium (through LALS), and right atrium (through RALS) than controls.
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Affiliation(s)
- Mary Luz Mojica-Pisciotti
- International Clinical Research Center, St. Anne’s University Hospital, Brno, Czech Republic
- 1st Department of Internal Medicine/Cardioangiology, St. Anne's University Hospital, Brno, Czech Republic
| | - Roman Panovský
- International Clinical Research Center, St. Anne’s University Hospital, Brno, Czech Republic
- 1st Department of Internal Medicine/Cardioangiology, St. Anne's University Hospital, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Tomáš Holeček
- International Clinical Research Center, St. Anne’s University Hospital, Brno, Czech Republic
- Department of Medical Imaging, St. Anne’s University Hospital, Brno, Czech Republic
- Department of Biomedical Engineering, Brno University of Technology, Brno, Czech Republic
| | - Lukáš Opatřil
- International Clinical Research Center, St. Anne’s University Hospital, Brno, Czech Republic
- 1st Department of Internal Medicine/Cardioangiology, St. Anne's University Hospital, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Věra Feitová
- International Clinical Research Center, St. Anne’s University Hospital, Brno, Czech Republic
- Department of Medical Imaging, St. Anne’s University Hospital, Brno, Czech Republic
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Rosca CI, Branea HS, Sharma A, Nicoras VA, Borza C, Lighezan DF, Morariu SI, Kundnani NR. Rhythm Disturbances in Post-Acute COVID-19 Syndrome in Young Men without Pre-Existing Known Cardiovascular Disease-A Case Series. Biomedicines 2023; 11:biomedicines11041146. [PMID: 37189764 DOI: 10.3390/biomedicines11041146] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/24/2023] [Accepted: 04/03/2023] [Indexed: 05/17/2023] Open
Abstract
Current data indicate the existence of post-acute COVID-19 syndrome frequently expressing as cardiovascular and respiratory health issues. The long-term evolution of these complications is not yet fully known or predictable. Among the most common clinical manifestations of post-acute COVID-19 syndrome are dyspnea, palpitations, and fatigue, in most cases being transient and without underlying any morphological or functional changes. A single-center retrospective observational study was performed on cases that had presented with new-onset cardiac symptoms post-COVID-19 infection. Records of three male patients without pre-existing chronic cardiovascular pathology who had presented for dyspnea, fatigue, and palpitations around four weeks post-COVID-19 acute phase were studied in detail. The three post-COVID-19 cases exhibited arrhythmic complications after completely healing from the acute phase of the infection. Palpitations, along with chest pain, and possible aggravation or appearance of dyspnea, with syncopal episodes, were found to be present. All the three cases were non-vaccinated against COVID-19 infection. Isolated case reports showing arrhythmic complications such as atrial fibrillation and ventricular tachycardia on a small number of patients with these complications indicate the need for arrhythmic evaluation of large groups of patients in the post-acute stage of the COVID-19 syndrome for a better understanding of the phenomenon and implicitly better care of these patients. It would also be useful to evaluate large groups of patients divided into vaccinated/non-vaccinated against COVID-19 categories to determine whether vaccination per se can provide protection in the occurrence of these types of complications.
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Affiliation(s)
- Ciprian Ilie Rosca
- Center of Advanced Research in Cardiovascular Pathology and Haemostasis, Department of Internal Medicine I-Medical Semiotics I, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Horia Silviu Branea
- Department of Internal Medicine I-Medical Semiotics II, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Abhinav Sharma
- Department of Cardiology-Internal Medicine and Ambulatory Care, Prevention and Cardiovascular Recovery, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | | | - Claudia Borza
- Center for Translational Research and Systems Medicine, Department of Pathophysiology, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Daniel Florin Lighezan
- Center of Advanced Research in Cardiovascular Pathology and Haemostasis, Department of Internal Medicine I-Medical Semiotics I, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Stelian I Morariu
- General Medicine Faculty, "Vasile Goldis" West University, 473223 Arad, Romania
| | - Nilima Rajpal Kundnani
- Department of Cardiology-Internal Medicine and Ambulatory Care, Prevention and Cardiovascular Recovery, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
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Mudgal SK, Gaur R, Rulaniya S, T L, Agarwal R, Kumar S, Varshney S, Sharma S, Bhattacharya S, Kalyani V. Pooled Prevalence of Long COVID-19 Symptoms at 12 Months and Above Follow-Up Period: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e36325. [PMID: 37077615 PMCID: PMC10108372 DOI: 10.7759/cureus.36325] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2023] [Indexed: 03/19/2023] Open
Abstract
Current data suggests that coronavirus disease 2019 (COVID-19) survivors experience long-lasting problems. It is not yet understood how long these symptoms last. The goal of this study was to compile all the data that was currently available to evaluate COVID-19's long-term effects at 12 months and above. We looked for studies published by December 15, 2022, in PubMed and Embase that discussed follow-up findings for COVID-19 survivors who had been alive for at least a year. A random-effect model was carried out to determine the combined prevalence of different long-COVID symptoms. The Joanna Briggs Institute tool was used to assess the risk of bias for the included studies, and the I2 statistics were used to evaluate the heterogeneity. After reviewing 3,209 studies, 46 were deemed admissible, with an aggregate COVID-19 population of 17976. At 12 months and above, 57% of patients reported a minimum of one symptom, and the five most prevalent symptoms were: dyspnea on exertion (34%, 95% CI 0.2; 0.94); difficulty in concentration (32%, 95% CI 0.16; 0.52); fatigue (31%, 95% CI 0.22; 0.40); frailty (31%, 95% CI 0.06; 0.78); and arthromyalgia (28%, 95% CI 0.09; 0.6). The findings of the present study showed that at 12 months and beyond, a sizable fraction of COVID-19 survivors still have lasting symptoms that impair several body systems. Long-COVID patients require an urgent understanding of pathophysiological processes and the development of tailored treatments.
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Lerum TV, Meltzer C, Rodriguez JR, Aaløkken TM, Brønstad E, Aarli BB, Aarberg-Lund KM, Durheim MT, Ashraf H, Einvik G, Skjønsberg OH, Stavem K. A prospective study of pulmonary outcomes and chest computed tomography in the first year after COVID-19. ERJ Open Res 2023; 9:00575-2022. [PMID: 36915802 PMCID: PMC9790092 DOI: 10.1183/23120541.00575-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 11/17/2022] [Indexed: 12/24/2022] Open
Abstract
COVID-19 primarily affects the respiratory system. We aimed to evaluate how pulmonary outcomes develop after COVID-19 by assessing participants from the first pandemic wave prospectively 3 and 12 months following hospital discharge. Pulmonary outcomes included self-reported dyspnoea assessed with the modified Medical Research Council dyspnoea scale, 6-min walk distance (6MWD), spirometry, diffusing capacity of the lung for carbon monoxide (D LCO), body plethysmography and chest computed tomography (CT). Chest CT was repeated at 12 months in participants with pathological findings at 3 months. The World Health Organization (WHO) ordinal scale for clinical improvement defined disease severity in the acute phase. Of 262 included COVID-19 patients, 245 (94%) and 222 (90%) participants attended the 3- and 12-month follow-up, respectively. Self-reported dyspnoea and 6MWD remained unchanged between the two time points, while D LCO and total lung capacity improved (0.28 mmol·min-1·kPa-1, 95% CI 0.12-0.44, and 0.13 L, 95% CI 0.02-0.24, respectively). The prevalence of fibrotic-like findings on chest CT at 3 and 12 months in those with follow-up chest CT was unaltered. Those with more severe disease had worse dyspnoea, D LCO and total lung capacity values than those with mild disease. There was an overall positive development of pulmonary outcomes from 3 to 12 months after hospital discharge. The discrepancy between the unaltered prevalence of self-reported dyspnoea and the improvement in pulmonary function underscores the complexity of dyspnoea as a prominent factor of long-COVID. The lack of increase in fibrotic-like findings from 3 to 12 months suggests that SARS-CoV-2 does not induce a progressive fibrotic process in the lungs.
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Affiliation(s)
- Tøri Vigeland Lerum
- Department of Pulmonary Medicine, Oslo University Hospital, Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Carin Meltzer
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Trond Mogens Aaløkken
- Institute for Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Eivind Brønstad
- Thoracic Department, St Olav's Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, NTNU, Trondheim, Norway
| | - Bernt B Aarli
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Michael T Durheim
- Institute for Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Respiratory Medicine, Oslo University Hospital, Oslo, Norway
| | - Haseem Ashraf
- Institute for Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway
| | - Gunnar Einvik
- Institute for Clinical Medicine, University of Oslo, Oslo, Norway.,Pulmonary Department, Akershus University Hospital, Lørenskog, Norway
| | - Ole Henning Skjønsberg
- Department of Pulmonary Medicine, Oslo University Hospital, Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Knut Stavem
- Institute for Clinical Medicine, University of Oslo, Oslo, Norway.,Pulmonary Department, Akershus University Hospital, Lørenskog, Norway.,Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
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