Novel Coronavirus Disease 2019 (COVID-19) Pneumonia Progression Course in 17 Discharged Patients: Comparison of Clinical and Thin-Section Computed Tomography Features During Recovery

Temporal evolution of chest radiographic appearances in COVID-19 with clinicoradiological associations: a multicentre United Kingdom resident-led study

AIM

To describe the (a) frequency of improving, static, and worsening chest radiograph (CXR) appearances; (b) differences in demographic, initial rudimentary haematological and CXR variables and these patterns; and (c) frequency of different trajectories of serial CXR evolution, in COVID-19 patients presenting consecutively.

MATERIALS AND METHODS

This multicentre retrospective study included all COVID-19 patients admitted from 1-30 April 2020, meeting the inclusion criteria across 24 (blinded) hospitals. Follow-up CXRs on admission, the subsequent (where available), and at 4-8 weeks were scored for the presence of parenchymal opacities across six zones. Three cohorts were defined: improved, static, and/or worsened. The chi-squared and Kruskal-Wallis tests were used to compare demographic, laboratory, and CXR variables. Trajectories of CXR evolution were assessed when all three CXRs were available (226 patients).

RESULTS

Of 452 included patients (median age 66 years, interquartile range 54.3-79, 262 men), 211 (46.7%) improved, 140 (31%) were static, and 101 (22.3%) worsened. Improving patients were more likely younger, with a classic COVID-19 radiograph and higher initial CXR zonal severity scores (both p<0.001), while worsening patients had lower initial lymphocyte counts (p=0.008). The most frequent trajectory was worsened then improved (n=63, 27.9%) followed by static then improved (n=46, 20.4%) and static (n=42, 18.6%).

CONCLUSION

Most patients with COVID-19 during the first wave of the pandemic demonstrated radiographic improvement; these patients were more likely younger with classic COVID-19 appearances and initially more extensive abnormality. Conversely, radiographic deterioration was associated with lower lymphocyte counts. The three most common trajectories were worsening then improvement, static then improvement, and static throughout.

ERS International Congress 2023: highlights from the Thoracic Oncology Assembly

Lung cancer is the leading cause of cancer mortality in the world. It greatly affects the patients' quality of life, and is thus a challenge for the daily practice in respiratory medicine. Advances in the genetic knowledge of thoracic tumours' mutational landscape, and the development of targeted therapies and immune checkpoint inhibitors, have led to a paradigm shift in the treatment of lung cancer and pleural mesothelioma. During the 2023 European Respiratory Society Congress in Milan, Italy, experts from all over the world presented their high-quality research and reviewed best clinical practices. Lung cancer screening, management of early stages of lung cancer, application of artificial intelligence and biomarkers were discussed and they will be summarised here.

Comparison of the 12-month impact of COVID-19 and SARS on physiological capacity and health-related quality of life

BACKGROUND

Little is known about the differences in medium to long-term recovery on spirometry, 6-minute walking distance (6MWD) and health-related quality of life (HRQoL) between COVID-19 and SARS.

METHODS

We performed a 12-month prospective study on COVID-19 survivors. The changes in dynamic lung volumes at spirometry (%predicted FEV1, %predicted FVC), 6MWD and HRQoL at 1-3, 6 to 12 months were compared against a historical cohort of SARS survivors using the same study protocol. The residual radiological changes in HRCT in COVID-19 survivors were correlated with their functional capacity.

RESULTS

108 COVID-19 survivors of various disease severity (asymptomatic 2.9%, mild 33.3%, moderate 47.2%, severe 8.3%, critical 8.3%) were recruited. When compared with 97 SARS survivors, 108 COVID-19 survivors were older (48.1 ± 16.4 vs. 36.1 ± 9.5 years, p < 0.001) and required less additional support during hospitalization; with lower dynamic lung volumes, shorter 6MWD and better physical component score. Both groups of survivors had comparable changes in these parameters at subsequent follow-ups. Both COVID-19 and SARS survivors had similar mental component score (MCS) at 6 and 12 months. COVID-19 survivors initially experienced less (between-group difference, -3.1, 95% confidence interval [CI] -5.5 to -0.7, p = 0.012) and then more improvement (between-group difference 2.9, 95%, CI 0.8 to 5.1, p = 0.007) than SARS survivors in the MCS at 1-3 to 6 months and 6 to 12 months respectively. Forty (44.0%) out of 91 COVID-19 survivors had residual abnormalities on HRCT at 12 months, with a negative correlation between the severity scores of parenchymal changes and 6MWD (r=-0.239, p < 0.05).

CONCLUSIONS

COVID-19 survivors demonstrated a similar recovery speed in dynamic lung volumes and exercise capacity, but different paces of psychological recovery as SARS survivors in the convalescent phase. The severity of parenchymal changes in HRCT is negatively correlated with the 6MWD of COVID-19 survivors.

TRIAL REGISTRATION

This prospective study was registered at ClinicalTrials.gov on 2 November 2020 (Identifier: NCT04611243).

Long COVID in Young Patients: Impact on Lung Volume Evaluated Using Multidetector CT

PURPOSE

To evaluate using quantitative analysis on chest CT images a possible lung volume reduction in Long COVID patients who complain mild respiratory symptoms, with chest CT negative for inflammatory findings.

MATERIALS AND METHODS

CT images of patients from 18 to 40 years old who underwent chest CT scan at our institution were analyzed retrospectively, using AwServer Thoracic VCAR software for a quantitative study. Exclusion criteria were inflammatory findings at CT, previous lung surgery, lung cancer, and breath artifacts that invalidate the quality of images. Patients were divided into two groups: in the first one ("post-COVID") were patients who had previous SARS-CoV-2 infection, confirmed by an RT-PCR, who underwent chest CT from 3 to 6 months after their negativization for long COVID symptoms; in the control group ("non-COVID"), were enrolled patients who underwent a chest CT scan from January 2018 to December 2019, before the spread of COVID in Italy.

RESULTS

Our final population included 154 TC, 77 post-COVID patients (mean age 33 ± 6) and 77 non-COVID patients (mean age 33 ± 4.9). Non statistical significative differences were obtained between groups in terms of age, sex, and other characteristics that affect total lung capacity such as obesity, thoracic malformations, and smoking habit. Mean values of the total lung volume (TV), right-lung volume (RV), and left-lung volume (LV) in the post-COVID group compared with non-COVID group were, respectively: 5.25 ± 0.25 L vs. 5.72 ± 0.26 L (p = 0.01); 2.76 ± 0.14 L vs. 3 ± 0.14 L (p = 0.01); 2.48 ± 0.12 L vs. 2.72 ± 0.12 L (p = 0.01).

CONCLUSION

In patients with symptoms suggesting Long COVID and negative chest CT macroscopic findings, quantitative volume analysis demonstrated a mean value of reduction in lung volume of 10% compared to patients of the same age who never had COVID. A chest CT negative for inflammatory findings may induce clinicians to attribute Long COVID mild respiratory symptoms to anxiety, especially in young patients. Our study brings us beyond appearances and beyond the classic radiological signs, introducing a quantitative evaluation of lung volumes in these patients. It is hard to establish to what extent this finding may contribute to Long COVID symptoms, but this is another step to gain a wider knowledge of the potential long-term effects caused by this new virus.

Clinicopathological Outlines of Post-COVID-19 Pulmonary Fibrosis Compared with Idiopathic Pulmonary Fibrosis

This review brings together the current knowledge regarding the risk factors and the clinical, radiologic, and histological features of both post-COVID-19 pulmonary fibrosis (PCPF) and idiopathic pulmonary fibrosis (IPF), describing the similarities and the disparities between these two diseases, using numerous databases to identify relevant articles published in English through October 2022. This review would help clinicians, pathologists, and researchers make an accurate diagnosis, which can help identify the group of patients selected for anti-fibrotic therapies and future therapeutic perspectives.

Impact of admission viral load on respiratory outcomes in hospitalized SARS-CoV-2 infected patients with cancer and without cancer: A 2-, 4- and 6-months follow-up prospective study

BACKGROUND

This prospective follow-up study aimed to determine the temporal changes in respiratory outcomes over 6 months period in patients with and without cancer hospitalized for severe COVID-19 and to determine the associated risk factors based on admission viral load.

METHODS

All adult patients hospitalized with a confirmed diagnosis of severe SARS-CoV-2 infection were investigated using rRT-PCR on nasopharyngeal swab specimens. Patients were divided into three arbitrary groups according to their cycle threshold (C_T) values obtained at admission as high (C_T < 25.0), medium (C_T between 25.0 and 30.0), and low (C_T > 30.0) viral load. Patients had pulmonary function tests, chest high-resolution computed tomography (HRCT), and a 6-minute walking time distance measured at each follow-up visit.

RESULTS

This follow-up study had a total of 112 participants, of which 75 were cancer-free and 37 had active cancer. Overall, 29.5% had a low viral load, compared to 48.2% who had a high viral load, and 22.3% had a medium viral load. For patients who did not have cancer, the mean age was 57.3 (SD 15.4) and for those who had cancer, it was 62.3 (SD 18.4). Most patients had overall better temporal changes in pulmonary function and tolerance, as well as exercise capacity, even though severe and chronic respiratory abnormalities persisted in a fraction of the patients. In patients without cancer who had a high viral load, we have seen a substantial reduction in diffusion capacity of the lungs for carbon monoxide (DLCO) predicted value with a median of 65 (IQR 63-70) while in patients with cancer, it was 60 (IQR 56-67) at 2 months. At 4 and 6 months, the predicted DLCO values for patients without cancer were 65 (IQR 61-70), whereas the predicted DLCO values for patients with active cancer were 62 (IQR 60-67) and 67 (59-73). Importantly, radiological abnormalities persisted in 22 (29%) non-cancer patients and 16 (43%) cancer patients. Multivariate regression analysis showed an increased odds ratio of impaired HRCT associated with a high viral load of 3.04 (95% CI:1.68-6.14; p < 0.001) for patients without cancer and 5.07 (95% CI: 4.04-10.8; p < 0.0001) for patients with cancer. The CT pneumonia score at hospitalization was 2.25 (95% CI:1.76-3.08; p = 0.041) and 2.85 (95% CI:1.89-5.14; p = 0.031) for non-cancer and cancer patients respectively.

CONCLUSIONS

The evidence of persistent pulmonary abnormalities and radiographic changes was found in both patient groups who had high viral load at hospital admission and suggesting that SARS-CoV-2 viral load might serve as a useful indicator to predict the development of respiratory complications in patients with COVID-19.

COVID-19 diagnostic approaches with an extensive focus on computed tomography in accurate diagnosis, prognosis, staging, and follow-up

Although a long time has passed since its outbreak, there is currently no specific treatment for COVID-19, and it seems that the most appropriate strategy to combat this pandemic is to identify and isolate infected individuals. Various clinical diagnosis methods such as molecular techniques, serologic assays, and imaging techniques have been developed to identify suspected patients. Although reverse transcription-quantitative PCR (RT-qPCR) has emerged as a reference standard method for diagnosis of SARS-CoV-2, the high rate of false-negative results and limited supplies to meet current demand are the main shortcoming of this technique. Based on a comprehensive literature review, imaging techniques, particularly computed tomography (CT), show an acceptable level of sensitivity in the diagnosis and follow-up of COVID-19. Indeed, because lung infection or pneumonia is a common complication of COVID-19, the chest CT scan can be an alternative testing method in the early diagnosis and treatment assessment of the disease. In this review, we summarize all the currently available frontline diagnostic tools for the detection of SARS-CoV-2-infected individuals and highlight the value of chest CT scan in the diagnosis, prognosis, staging, management, and follow-up of infected patients.

Clinical and CT scan findings in patients with COVID-19 pneumonia: a comparison based on disease severity

Background

The SARS-CoV-2 can cause severe pneumonia and highly impact general health. We aimed to investigate different clinical features and CT scan findings of patients with COVID-19 based on disease severity to have a better understanding of this disease.

Methods

Ninety patients with coronavirus were divided into three categories based on the severity of the disease: mild/moderate, severe, and very severe. Clinical, laboratory, and CT scan findings of the patients were examined retrospectively. Any association between these features and disease severity was assessed.

Results

The mean age and duration of hospitalization of patients increased with increasing the severity of the disease. The most common clinical symptoms were shortness of breath, cough, and fever. As the severity of the disease increased from mild/moderate to very severe, there was an increase in neutrophil counts and a decrease in lymphocytes and white blood cells (WBC) showing excessive inflammation associated with severe forms of COVID-19. Subpleural changes (81%) and ground-glass opacification/opacity (GGO) lesions (73%) of the lung were the most common features in CT images of COVID-19 patients, and interlobular septal thickening (10%) was the lowest CT feature among patients. Regarding the affected parts of the lung in COVID-19 patients, bilateral, peripheral, and multiple lesions had the highest prevalence.

Conclusions

It has been shown that clinical, laboratory, and CT scan findings varied in COVID-19 patients based on disease severity, which need to be considered carefully in timely diagnosis and treatment of this illness.

Comparison of Chest CT and RT-PCR Assay for Indication of Disease Course of Coronavirus Disease 2019 (COVID-19) Pneumonia

BACKGROUND

COVID-19 patients' courses vary in length, indicating a variable prognosis. The disease duration revealed by different examination methods may differ.

OBJECTIVE

The study aims to compare the differences in the disease course of patients with COVID-19 by chest computed tomography (CT) and reverse-transcription polymerase chain reaction (RT-PCR) assay and explore the factors that affect the course of the illness.

METHODS

106 patients confirmed with COVID-19 were enrolled and divided into two groups (age <60 years and age ≥60 years). The clinical characteristics of the two groups were analyzed. The intervals from symptoms onset to initial positive time point (ISIP), symptoms onset to the initial negative time point (ISIN), and initial positive to initial negative time point (IIPN) indicated by chest CT and RTPCR assay were analyzed. Multiple regression analysis was performed to assess the correlations between independent factors and the intervals.

RESULTS

Chest CT showed an earlier positive time point, a later negative time point, and a longer disease duration than the RT-PCR assay (P<.001, respectively). Older patients over 60 years old showed a later negative time point and a longer disease duration by chest CT than younger patients (P<.01 vs. P<.05, respectively). The CT score and clinical grades of older patients were greater than those of younger patients (P<.001, respectively). Age and clinical grades were significantly correlated with the disease course shown by chest CT (P<.05, respectively), and CT score was positively correlated with the illness course shown by chest CT and RT-PCR assay (P<.01, respectively).

CONCLUSION

The disease course revealed by chest CT and RT-PCR assay was asynchronous. Chest CT showed a 17-day longer period compared to the RT-PCR assay. Older patients had a longer duration than younger ones. A prolonged course is predicted by increasing age, CT score, and clinical grades.

Radiology for Thoracic Conditions in Low- and Middle-Income Countries

With a disproportionately high burden of global morbidity and mortality caused by chronic respiratory diseases (CRDs) in low and middle-income countries (LMICs), access to radiological services is of critical importance for screening, diagnosis, and treatment guidance.

18 months computed tomography follow-up after Covid-19 interstitial pneumonia

Background: Our aim is to evaluate the possible persistence of lung parenchyma alterations, in patients who have recovered from Covid-19.

Design and methods: We enrolled a cohort of 115 patients affected by Covid-19, who performed a chest CT scan in the Emergency Department and a chest CT 18 months after hospital discharge. We performed a comparison between chest CT scan 18 months after discharge and spirometric data of patients enrolled. We obtained quantitative scores related to well-aerated parenchyma, interstitial lung disease and parenchymal consolidation. A radiologist recorded the characteristics indicated by the Fleischner Society and “fibrotic like” changes, expressed through a CT severity score ranging from 0 (no involvement) to 25 (maximum involvement).

Results: 115 patients (78 men, 37 women; mean age 60.15 years old ±12.52). On quantitative analysis, after 18 months, the volume of normal ventilated parenchyma was significantly increased (16.34 points on average ±14.54, p<0.0001). Groundglass opacities and consolidation values tend to decrease (-9.80 and -6.67 points, p<0.0001). On semiquantitative analysis, pneumonia extension, reactive lymph nodes and crazy paving reached statistical significance (p<0.0001). The severity score decreased by 2.77 points on average (SD 4.96; p<0.0001). There were not statistically significant changes on “fibrotic-like” changes correlated with level of treatment and there was not a statistically significant correlation between CT lung score and spirometric results obtained 18 months after discharge.

Conclusions: Patients recovered from Covid-19 seem to have an improvement of ventilated parenchyma and “fibrotic-like” alterations. The level of treatment does not appear to influence fibrotic changes.

COVID Tarnish Lung: Residual Radiological Lung Consequences of Infection with COVID-19

Background:

COVID-19 has still expressed as a mysterious viral infection with dramatic pulmonary consequences.

Objectives:

This article aims to study the radiological pulmonary consequences of respiratory covid-19 infection at 6 months and their relevance to the clinical stage, laboratory markers, and management modalities.

Patients and methods:

This study was implemented on two hundred and fifty (250) confirmed positive cases for COVID-19 infections. One hundred and ninety-seven cases (197) who completed the study displayed residual radiological lung shadowing (RRLS) on follow-up computed tomography (CT) of the chest. They were categorized by Simple clinical classification of COVID-19 into groups A, B and C.

Results:

GGO as well as reticulations were statistically significantly higher in group A than other two groups; however, bronchiectasis changes, parenchymal scarring, nodules as well as pleural tractions were statistically significantly higher in group C than the other two groups.

Conclusion:

Respiratory covid-19 infection might be linked to residual radiological lung shadowing. Ground glass opacities GGO, reticulations pervaded in mild involvement with lower inflammatory markers level, unlike, severe changes that expressed scarring, nodules and bronchiectasis changes accompanied by increased levels of inflammatory markers.

Antiphospholipid antibodies in COVID-19-associated pneumonia patients in intensive care unit

OBJECTIVES

Antiphospholipid antibodies (APAs) increase the risk of excessive blood clotting, but their role in COVID-19 remains unclear. We aimed to investigate the presence of conventional APAs used in the classification of antiphospholipid antibody syndrome in patients with severe lung infection with SARS-CoV-2 and to compare these results with non-COVID-19 critically ill patients.

METHODS

Thirty-one COVID-19 patients (COVID group) and 28 non-COVID-19 critically ill patients (non-COVID group), were included in the study. Anti-cardiolipin (ACA) (IgG, IgM), anti-β2-glycoprotein 1 (Anti-β2GPI) (IgG, IgM, and IgA), and if the patient had not received any anti thrombotic agent before blood collection, lupus anticoagulant (LAC) tests were studied from the plasma of the patients. For testing ACA and Anti-β2GPI, ELISA method was used, while fully automated coagulometer device was used for LAC test.

RESULTS

APAs were positive in 25.81% in the COVID group (8/31) and 25% in the non-COVID group (7/28). LAC was the most common APA present in 23.08% of the COVID-19 group, who underwent measurement (6/26), while 3.57% of the non-COVID group was LAC positive (1/28) (p = .047). In the COVID group, ACA IgM, and IgG were positive in 6.45% and 0%, respectively (2/31 vs 0/31). In the non-COVID group, ACA IgM was not positive in any patient, while ACA IgG was positive in 7.14% (2/28). Anti-β2GPI IgG and IgM tests were not positive in any patient in either the COVID or the non-COVID group. Anti-β2GPI IgA were positive in 6.45% and 14.29%, respectively (2/31 vs 4/28).

CONCLUSION

In this study, APAs were equally positive in critically ill patients among COVID-19 or non-COVID-19 patients. Only LAC was more observed in COVID-19 patients.

KEY MESSAGES

Laboratory manifestations and pathophysiological aspects of coronavirus disease 2019 pandemic: focusing on the digestive system

Since December 2019, the severe acute respiratory syndrome coronavirus 2 has constituted a serious threat to global health. So far, there is little published evidence on the laboratory features of coronavirus disease 2019 (COVID-19). We have reviewed laboratory findings from multiple studies, mostly relating to the digestive system, since the virus outbreak. Laboratory data from older coronaviruses endemics, as well as other RNA viruses, were also reported. Although the main route of transmission is considered to be respiratory droplets, the distribution of ACE2 receptors in the gastrointestinal tract in combination with the detection of the virus in feces may imply a potential fecal-oral transmission route, and thus, emphasis should be given to patients with gastrointestinal symptoms. Interestingly, there is evidence that severe acute respiratory syndrome coronavirus 2 displays similar laboratory and clinical findings with older members of the coronavirus family, and so, comparable diagnostic and therapeutic approaches may be used. Regarding laboratory abnormalities, lymphopenia appears to be the most common finding, together with coagulation disorders and inflammatory markers elevation, reflecting a sustained systemic response. Abnormal liver and, occasionally, pancreatic tests are also common and even more severe in patients with gastrointestinal symptoms or diseases. Thus, the aim of this study is to focus on the laboratory and pathophysiologic side of this novel disease in order to strengthen current knowledge and urge further research. Detailed investigation of numerous studies may suggest a common laboratory pattern between COVID-19 patients. It is important for clinicians not to underestimate patients with gastrointestinal comorbidities, as they have been associated with severe COVID-19 disease.

Changes in serum virus-specific IgM/IgG antibody in asymptomatic and discharged patients with reoccurring positive COVID-19 nucleic acid test (RPNAT)

BACKGROUND

Studies have demonstrated the diagnostic efficiency of antibody testing in COVID-19 infection. There is limited data on the IgM/IgG changes in asymptomatic and discharged patients with reoccurring positive nucleic acid test (RPNAT). This study aims to investigate these IgM/IgG changes.

METHODS

There were 111 patients with positive nucleic acid test (NAT) and 40 suspected patients enrolled in the study. The serum SARS-CoV-2 specific IgM/IgG antibody levels were retrospectively analysed with the disease progress in asymptomatic and RPNAT patients.

RESULTS

The best overall performance was found by combining the IgM, IgG, and CT; 95.1% sensitivity and 75% specificity. This was tested in 111 RT-PCR positive cases. The median IgM and IgG levels were lower in the asymptomatic group compared to the symptomatic group (p < .01). Among 15 RPNAT cases, the IgM levels of the RPNAT group at the time of discharge (IgM2.79, IQR: 0.95-5.37) and retest (IgM 2.35, IQR: 0.88-8.65) were significantly higher than those of the non-reoccurring positive nucleic acid test group (Non-RPNAT) (IgM on discharge: 0.59, IQR: 0.33-1.22, IgG on retest: 0.92, IQR: 0.51-1.58).

CONCLUSION

Serum SARS-CoV-2 specific IgM/IgG antibody levels remained at a low level during hospitalisation for asymptomatic patients. Elevated IgM levels may have implications in the identification of RPNAT patients before discharge. Key messages This study determined the IgM/IgG changes in asymptomatic and RPNAT patients. The rate of serum SARS-CoV-2 specific IgM/IgG antibody levels increase in the asymptomatic group was lower than in the symptomatic group during hospitalisation. The IgM level did not decrease significantly at discharge in the RPNAT patients, and was higher than that of the Non-RPNAT group on discharge. These results highlight the importance of timely monitoring of IgM levels to identify RPNAT patients before discharge.

The role of imaging techniques in understanding and evaluating the long-term pulmonary effects of COVID-19

INTRODUCTION

Limited data exist regarding the long-term pulmonary sequelae of COVID-19. Identifying features utilizing multiple imaging modalities engenders a clearer picture of the illness's long-term consequences.

AREAS COVERED

This review encompasses the common pulmonary findings associated with different imaging modalities during acute and late remission stages of COVID-19 pneumonia.

EXPERT OPINION

Chest x-ray, a common preliminary diagnostic imaging technique, is not optimal for extended care due to limited tissue contrast resolution providing suboptimal assessment of pulmonary pathology and subtle interval changes. Ultrasound may be utilized on a case-by-case basis in certain patient populations, or in countries with limited resources. Chest CT's accessibility, high tissue contrast and spatial resolution make it the foremost modality for long-term COVID-19 follow-up. While MRI can viably monitor extrapulmonary disease due to its lack of radiation and high inherent soft-tissue contrast, it has limited pulmonary utility due to motion artifact and alveolar gas decreasing lung signal. Although 18F-FDG-PET/CT is costly and has limited specificity, it can provide molecular level data and inflammation quantification. Lung perfusion scintigraphy may also explain COVID-19 induced thromboembolic events and persistent dyspnea despite normal structural imaging and testing results. Correlating the long-term pulmonary findings of COVID-19 with each imaging modality is essential in elucidating the post-recovery course.

Prognosis and antibody profiles in survivors of critical illness from COVID-19: a prospective multicentre cohort study

Background

There is a need to assess the long-term outcomes of survivors of critical illness from COVID-19.

Methods

Ninety-two survivors of critical illness from COVID-19 from four hospitals in Hubei Province, China participated in this prospective cohort study. Multiple characteristics, including lung function (lung volumes, diffusing capacity for carbon monoxide, chest computed tomography scores, and walking capacity); immune status (SARS-CoV-2-neutralising antibody and all subtypes of immunoglobulin (Ig) G against SARS-CoV-2, immune cells in response to ex vivo antigen peptide stimuli, and lymphocyte count and its subtypes); liver, coagulation, and kidney functions; quality of life; cognitive function; and mental status, were assessed after 3, 6, and 12 months of follow-up.

Results

Amongst the 92 enrolled survivors, 72 (78%) patients required mechanical ventilation. At 12 months, the predicted percentage diffusing capacity of lung for carbon monoxide was 82% (inter-quartile range [IQR]: 76–97%) with a residual volume of 77 (64–88)%. Other lung function parameters and the 6-min walk test improved gradually over time and were almost back to normal by 12 months. The titres of IgG and neutralising antibody to COVID-19 remained high at 12 months compared with those of controls who were not infected with COVID-19, although IgG titres decreased significantly from 34.0 (IQR: 23.8–74.3) to 15.0 (5.8–24.3) AU ml⁻¹ (P<0.001), whereas neutralising antibodies decreased from 29.99 (IQR: 19.43–53.93) AU ml⁻¹ at 6 months to 19.75 (13.1–29.8) AU ml⁻¹ (P<0.001) at 12 months. In general, liver, kidney, physical, and mental functions also improved over time.

Conclusions

Survivors of critical illness from COVID-19 show some persistent long-term impairments in lung function. However, a majority of these tests were normal by 12 months. These patients still had detectable levels of neutralising antibodies against SARS-CoV-2 and all types of IgG at 12 months, but the levels had declined over this time period.

Clinical trial registration

None.

Clinical Features and Temporal Lung Radiographic Changes in 25 Patients Recovering from COVID-19 Pneumonia: A Retrospective Case-Control Study

Background

Little is known of the changes in lung radiographic characteristics over time in patients recovering from COVID-19. This study analyzed the clinical features and temporal lung radiographic changes in patients with moderate and severe COVID-19 pneumonia who did not require invasive mechanical ventilation during the acute and convalescent periods.

Material/Methods

The data of 25 patients with COVID-19 pneumonia from January 29, 2020, to November 24, 2020, who did not require invasive mechanical ventilation and who were followed up were retrospectively collected. The 25 patients were divided into severe and moderate groups. Clinical characteristics and computed tomography (CT) manifestations were compared. A total of 121 consecutive thin-slice CT scans were collected at 4 weeks, 2 months, and 5 months after admission to evaluate lung abnormalities in the patients. The CT score was used to assess disease severity.

Results

The severe group had a lower rate of nucleic acid conversion within 10 days of admission and higher D-dimer, creatine kinase, and lactate dehydrogenase values. In the severe group, hospital stay was longer and hospitalization costs were higher. The average CT score of the severe group peaked in the second week, while the moderate group peaked in the first week and then decreased over time. There were no statistically significant differences in the average CT score between the 2 groups at the 5-month follow-up.

Conclusions

The pulmonary lesions of patients recovering from COVID-19 and who do not require invasive mechanical ventilation were gradually absorbed and resolved over time.

A Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Prediction Model From Standard Laboratory Tests

BACKGROUND

With the limited availability of testing for the presence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus and concerns surrounding the accuracy of existing methods, other means of identifying patients are urgently needed. Previous studies showing a correlation between certain laboratory tests and diagnosis suggest an alternative method based on an ensemble of tests.

METHODS

We have trained a machine learning model to analyze the correlation between SARS-CoV-2 test results and 20 routine laboratory tests collected within a 2-day period around the SARS-CoV-2 test date. We used the model to compare SARS-CoV-2 positive and negative patients.

RESULTS

In a cohort of 75 991 veteran inpatients and outpatients who tested for SARS-CoV-2 in the months of March through July 2020, 7335 of whom were positive by reverse transcription polymerase chain reaction (RT-PCR) or antigen testing, and who had at least 15 of 20 lab results within the window period, our model predicted the results of the SARS-CoV-2 test with a specificity of 86.8%, a sensitivity of 82.4%, and an overall accuracy of 86.4% (with a 95% confidence interval of [86.0%, 86.9%]).

CONCLUSIONS

Although molecular-based and antibody tests remain the reference standard method for confirming a SARS-CoV-2 diagnosis, their clinical sensitivity is not well known. The model described herein may provide a complementary method of determining SARS-CoV-2 infection status, based on a fully independent set of indicators, that can help confirm results from other tests as well as identify positive cases missed by molecular testing.

Development of a Machine Learning-Assisted Model for the Early Detection of Severe COVID-19 Cases Combining Blood Test and Quantitative Computed Tomography Parameters

<sec> <title>Purpose:</title> This study aimed to identify severe Coronavirus Disease 2019 (COVID-19) cases combining blood test results and imaging parameters based on a machine learning classifier at the initial admission. </sec> <sec> <title>Materials and methods:</title> Ninety-five non-severe and 22 severe laboratory-confirmed COVID-19 cases treated between January 23, 2020 and March 25, 2020 were examined in this retrospective trial. Blood test results and chest computed tomography (CT) images were obtained at the initial admission. The lesions on CT images were segmented using an artificial intelligent (AI) tool. Then, quantitative CT (QCT) parameters, including the volume, percentage, ground glass opacity (GGO) percentage and heterogeneity of the lesions were calculated. Correlations of blood test results and QCT parameters were analyzed by the Pearson test first. Then, discriminative features for detecting severe cases were selected by both the independent samples t test and least absolute shrinkage and selection operator (LASSO) regression. Next, support vector machine (SVM), Gaussian naïve Bayes (GNB), Knearest neighbor (KNN), decision tree (DT), random forest (RF) and multi-layer perceptron-neural net (MLP-NN) algorithms were used as classifiers, and their accuracies were assessed by 10-fold-cross-validation. </sec> <sec> <title>Results:</title> Blood test indexes and CT parameters were moderately to medially correlated. Of all selected features, lesion percentage contributed mostly to the classification of the two groups, followed by lesion volume, patient age, lymphocyte count, neutrophil count, GGO percentage and tumor heterogeneity. RF-assisted identification had the highest accuracy of 91.38%, followed by GNB (87.83%), KNN (87.93%), SVM (86.21%), MLP-NN (85.34%) and DT (84.48%). </sec> <sec> <title>Conclusions:</title> The RF-assisted model combining blood test and QCT parameters is helpful in the identification of severe COVID-19 cases. </sec>

Longitudinal Radiological Findings in Patients With COVID-19 With Different Severities: From Onset to Long-Term Follow-Up After Discharge

Objective: This study aimed to investigate the evolution of radiological findings in the patients with coronavirus disease 2019 (COVID-19) pneumonia with different severities from onset to 1-year follow-up and identify the predictive factors for different pulmonary lesion absorption status in the patients infected with COVID-19.

Methods: A retrospective study was performed on the clinical and radiological features of 175 patients with COVID-19 pneumonia hospitalized at three institutions from January 21 to March 20, 2020. All the chest CT scans during hospitalization and follow-ups after discharge were collected. The clinical and radiological features from the chest CT scans both at the peak stage and before discharge from the hospital were used to predict whether the pulmonary lesions would be fully absorbed after discharge by Cox regression. Then, these patients were stratified into two groups with different risks of pulmonary lesion absorption, and an optimal timepoint for the first CT follow-up was selected accordingly.

Results: A total of 132 (75.4%) patients were classified into the non-severe group, and 43 (24.6%) patients were classified into the severe group, according to the WHO guidelines. The opacification in both the groups changed from ground-glass opacity (GGO) to consolidation and then from consolidation to GGO. Among the 175 participants, 135 (112 non-severe and 23 severe patients with COVID-19) underwent follow-up CT scans after discharge. Pulmonary residuals could be observed in nearly half of the patients (67/135) with the presentation of opacities and parenchymal bands. The parenchymal bands in nine discharged patients got fully absorbed during the follow-up periods. The age of patient [hazard ratio (HR) = 0.95, 95% CI, 0.95–0.99], level of lactate dehydrogenase (LDH) (HR = 0.99; 95% CI, 0.99–1.00), level of procalcitonin (HR = 8.72; 95% CI, 1.04–73.03), existence of diffuse lesions (HR = 0.28; 95% CI, 0.09–0.92), subpleural distribution of lesions (HR = 2.15; 95% CI, 1.17–3.92), morphology of residuals (linear lesion: HR = 4.58, 95% CI, 1.22–17.11; nodular lesion: HR = 33.07, 95% CI, 3.58–305.74), and pleural traction (HR = 0.41; 95% CI, 0.22–0.78) from the last scan before discharge were independent factors to predict the absorption status of COVID-19-related pulmonary abnormalities after discharge. According to a Kaplan–Meier analysis, the probability of patients of the low-risk group to have pulmonary lesions fully absorbed within 90 days reached 91.7%.

Conclusion: The development of COVID-19 lesions followed the trend from GGO to consolidation and then from consolidation to GGO. The CT manifestations and clinical and laboratory variables before discharge could help predict the absorption status of pulmonary lesions after discharge. The parenchymal bands could be fully absorbed in some COVID-19 cases. In this study, a Cox regression analysis indicated that a timepoint of 3 months since onset was optimal for the radiological follow-up of discharged patients.

Review on radiological evolution of COVID-19 pneumonia using computed tomography

BACKGROUND

Pneumonia is the main manifestation of coronavirus disease 2019 (COVID-19) infection. Chest computed tomography is recommended for the initial evaluation of the disease; this technique can also be helpful to monitor the disease progression and evaluate the therapeutic efficacy.

AIM

To review the currently available literature regarding the radiological follow-up of COVID-19-related lung alterations using the computed tomography scan, to describe the evidence about the dynamic evolution of COVID-19 pneumonia and verify the potential usefulness of the radiological follow-up.

METHODS

We used pertinent keywords on PubMed to select relevant studies; the articles we considered were published until October 30, 2020. Through this selection, 69 studies were identified, and 16 were finally included in the review.

RESULTS

Summarizing the included works’ findings, we identified well-defined stages in the short follow-up time frame. A radiographic deterioration reaching a peak roughly within the first 2 wk; after the peak, an absorption process and repairing signs are observed. At later radiological follow-up, with the limitation of little evidence available, the lesions usually did not recover completely.

CONCLUSION

Following computed tomography scan evolution over time could help physicians better understand the clinical impact of COVID-19 pneumonia and manage the possible sequelae; a longer follow-up is advisable to verify the complete resolution or the presence of long-term damage.

Low CD4 T cell count predicts radiological progression in severe and critically ill COVID-19 patients: a case control study

Background

Novel coronavirus disease (COVID-19) has spread globally and caused over 3 million deaths, posing great challenge on public health and medical systems. Limited data are available predictive factors for disease progression. We aim to assess clinical and radiological predictors for pulmonary aggravation in severe and critically ill COVID-19 patients.

Methods

Patients with confirmed COVID-19 in Renmin Hospital of Wuhan University, China, between Feb. 6th, 2020 and Feb. 21st, 2020 were retrospectively collected. Enrolled patients were divided into non-progression group and progression group based on initial and follow-up chest CTs. Clinical, laboratory, and radiological variables were analyzed.

Results

During the study period, 162 patients were identified and a total of 126 patients, including 97 (77.0%) severe cases and 29 (23.0%) critically ill cases were included in the final analysis. Median age was 66.0 (IQR, 56.0–71.3) years. Median time from onset to initial chest CT was 15.0 (IQR, 12.0–20.0) days and median interval to follow-up was 7.0 (IQR, 5.0–7.0) days. Compared with those who did not progress (n=111, 88.1%), patients in the progression group (n=15, 11.9%) had significantly higher percentage of peak body temperature >38 °C (P=0.002), lower platelet count (P=0.011), lower CD4 T cell count (P=0.002), lower CD8 count (P=0.011), higher creatine kinase level (P=0.002), and lower glomerular filtration rate (P=0.018). On both univariate and multivariable analysis, only CD4 T cell count <200/µL was significant (OR, 6.804; 95% CI, 1.450–31.934; P=0.015) for predicting pulmonary progression.

Conclusions

Low CD4 T cell count predicts progression of pulmonary change in severe and critically ill patients with COVID-19.

Does COVID-19 pneumonia signify secondary organizing pneumonia?: A narrative review comparing the similarities between these two distinct entities

Multiple observational studies have described the similarities between COVID-19 pneumonia and organizing pneumonia (OP). These two entities clinically manifest with mild and subacute respiratory symptoms, often with a delayed diagnosis due to the atypical ARDS and silent hypoxemia presentation. Radiological features are often indistinguishable between the two. With the increase in antemortem lung biopsies and autopsies being performed, more histopathological findings of OP and its variant, acute fibrinous and organizing pneumonia (AFOP), are being diagnosed. These entities are known complications of viral infections as a delayed immunological process, explaining the favorable response to corticosteroids. Clinicians should be vigilant to diagnose this under-recognized entity of secondary OP in people with COVID-19 when clinical deterioration occurs, especially with compatible radiologic findings and recent cessation of corticosteroids. Despite the proven benefits of corticosteroids in treating COVID-19, treatment approaches can be more effective as OP often requires higher doses and a more prolonged therapy duration for remission and preventing relapses. The purpose of our narrative review is to compare the similarities between COVID-19 pneumonia and OP, emphasizing the clinical, radiological, and histopathological features based on the evidence available in the literature.

Chest CT findings in patients with coronavirus disease 2019 (COVID-19): a comprehensive review

The objective of this review was to summarize the most pertinent CT imaging findings in patients with coronavirus disease 2019 (COVID-19). A literature search retrieved eligible studies in PubMed, EMBASE, Cochrane Library and Web of Science up to June 1, 2020. A comprehensive review of publications of the Chinese Medical Association about COVID-19 was also performed. A total of 84 articles with more than 5340 participants were included and reviewed. Chest CT comprised 92.61% of abnormal CT findings overall. Compared with real-time polymerase chain reaction result, CT findings has a sensitivity of 96.14% but a low specificity of 40.48% in diagnosing COVID-19. Ground glass opacity (GGO), pure (57.31%) or mixed with consolidation (41.51%) were the most common CT features with a majority of bilateral (80.32%) and peripheral (66.21%) lung involvement. The opacity might associate with other imaging features, including air bronchogram (41.07%), vascular enlargement (54.33%), bronchial wall thickening (19.12%), crazy-paving pattern (27.55%), interlobular septal thickening (42.48%), halo sign (25.48%), reverse halo sign (12.29%), bronchiectasis (32.44%), and pulmonary fibrosis (26.22%). Other accompanying signs including pleural effusion, lymphadenopathy and pericardial effusion were rare, but pleural thickening was common. The younger or early stage patients tended to have more GGOs, while extensive/multilobar involvement with consolidation was prevalent in the older or severe population. Children with COVID-19 showed significantly lower incidences of some ancillary findings than those of adults and showed a better performance on CT during follow up. Follow-up CT showed GGO lesions gradually decreased, and the consolidation lesions first increased and then remained relatively stable at 6-13 days, and then absorbed and fibrosis increased after 14 days. Chest CT imaging is an important component in the diagnosis, staging, disease progression and follow-up of patients with COVID-19.

Twelve-month systemic consequences of COVID-19 in patients discharged from hospital: a prospective cohort study in Wuhan, China

Background

Follow-up study of coronavirus disease 2019 (COVID-19) survivors has rarely been reported. We aimed to investigate longitudinal changes in the characteristics of COVID-19 survivors after discharge.

Methods

A total of 594 COVID-19 survivors discharged from Tongji Hospital in Wuhan from February 10 to April 30, 2020 were included and followed up until May 17, 2021. Laboratory and radiological findings, pulmonary function tests, electrocardiogram, symptoms and signs were analyzed.

Results

257 (51.2%) patients had at least one symptom at 3 months post-discharge, which decreased to 169 (40.0%) and 138 (28.4%) at 6-month and 12-month visit respectively. During follow-up period, insomnia, chest tightness, and fatigue were the most prevalent symptoms. Most laboratory parameters returned to normal, whereas increased incidence of abnormal liver and renal function and cardiovascular injury was evidenced after discharge. Fibrous stripes (213; 42.4%), pleural thickening and adhesions (188; 37.5%) and enlarged lymph nodes (120; 23.9%) were the most common radiographical findings at 3 months post-discharge. The abnormalities of pulmonary function included obstructive, restrictive, and mixed, which were 5.5%, 4.0%, 0.9% at 6 months post, and 1.9%, 4.7%, 0.2% at 12 months. Electrocardiogram abnormalities occurred in 256 (51.0%) patients at 3 months post-discharge, including arrhythmia, ST-T change and conduction block, which increased to 258 (61.1%) cases at 6-month visit and were maintained at high frequency (242;49.8%) at 12-month visit.

Conclusions

Physiological, laboratory, radiological, or electrocardiogram abnormalities, particularly those related to renal, cardiovascular, and liver functions are common in patients who recovered from coronavirus disease 2019 (COVID-19) up to 12 months post-discharge.

Correlation of olfactory dysfunction with lung involvement and severity of COVID-19

Background

Olfactory dysfunction (OD) is a significant symptom of COVID-19 and may be the earliest symptom, or it may sometimes be the only manifestation of the disease.

Aims

To investigate whether OD is correlated with chest computed tomography (CT) findings, blood test parameters, and disease severity in COVID-19 patients.

Methods

The files of COVID-19 patients were retrospectively reviewed, and the ones who had information about smelling status and CT were taken into consideration. A total of 180 patients were divided into two groups: the OD group consisted of 89 patients with self-reported OD, and the No-OD group consisted of 91 subjects who did not complain of OD. The two groups were compared for the amount of lung consolidation on CT, intensive care unit (ICU) admission, and blood test parameters (complete blood count, alanine aminotransferase (ALT), aspartate aminotransferase (AST), creatine kinase (CK), lactate dehydrogenase (LDH), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), ferritin, D-dimer, interleukin-6 (IL-6)).

Results

The amount of lung consolidation and ICU admission were significantly higher in the No-OD group (p < 0.001 for both). White blood cell (p = 0.06), monocyte (p = 0.26), and platelet (p = 0.13) counts and hemoglobin (p = 0.63), ALT (p = 0.89), and D-dimer (p = 0.45) levels of the two groups were similar. Lymphocyte count (p = 0.01), neutrophil count (p = 0.01), and AST (p = 0.03), CK (p = 0.01), LDH (p < 0.001), CRP (p < 0.001), ESR (p < 0.001), ferritin (p < 0.001), and IL-6 (p < 0.001) levels were significantly higher in the No-OD group.

Conclusions

The patients presenting to the hospital with self-reported OD may have less lung involvement and a milder disease course compared to patients without OD on admission.

Application of Open-Hardware-Based Solutions for Rapid Transition From Stationary to the Remote Teaching Model During Pandemic

Contribution: While research indicates usefulness of remote laboratories in teaching of digital hardware systems, their main application is to complement stationary classes. This work presents a low-cost, scalable architecture that supports rapid transformation of teaching to a model based solely on remote access mechanisms. Background: Adaptation of online laboratory solutions from the literature to en-masse teaching of digital circuits is time-consuming and expensive. Solutions that permit cheap and rapid conversion of courses to remote environments seem to be of high value, especially when social distancing renders direct teaching impossible. Intended Outcomes: Demonstration of a flexible and cheap architecture that permits rapid transformation of digital circuits laboratories to the remote environment. Validation of system's performance and usefulness on a large group of students. Application Design: Remote digital circuits laboratories from the literature are designed to complement stationary classes. For successful teaching during pandemic, a low-cost, flexible, and efficient solution to online laboratory based on commonly available technologies is required. Findings: The proposed remote laboratory architecture enables rapid conversion of on-site teaching to online model, while supporting in-situupgrades and functionality enhancements. The presented solution proved to be a convenient substitute for conventional laboratories during pandemic.

Medical imaging and computational image analysis in COVID-19 diagnosis: A review

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The disease presents with symptoms such as shortness of breath, fever, dry cough, and chronic fatigue, amongst others. The disease may be asymptomatic in some patients in the early stages, which can lead to increased transmission of the disease to others. This study attempts to review papers on the role of imaging and medical image computing in COVID-19 diagnosis. For this purpose, PubMed, Scopus and Google Scholar were searched to find related studies until the middle of 2021. The contribution of this study is four-fold: 1) to use as a tutorial of the field for both clinicians and technologists, 2) to comprehensively review the characteristics of COVID-19 as presented in medical images, 3) to examine automated artificial intelligence-based approaches for COVID-19 diagnosis, 4) to express the research limitations in this field and the methods used to overcome them. Using machine learning-based methods can diagnose the disease with high accuracy from medical images and reduce time, cost and error of diagnostic procedure. It is recommended to collect bulk imaging data from patients in the shortest possible time to improve the performance of COVID-19 automated diagnostic methods.

How Loud and Clear Rung the Alarm Bell: The Communication Efforts of WHO on the Beginning of COVID-19 Outbreak

As seen clearly from the coronavirus disease 2019 (COVID-19) pandemic, health is an important foreign policy and diplomatic issue connected with security, economic well-being, and international development. According to risk communication researchers, effective, transparent, and timely information sharing is the most important tool after vaccines for responding to pandemics. This study aims to start a scholarly discussion on the risk communication efforts of the World Health Organization (WHO) during the COVID-19 outbreak. We analyzed WHO's communication efforts during the first 3 months of the COVID-19 pandemic. As the leading international health organization, WHO was responsible for providing rapid, up-to-date, and credible information for the public and the media. The selected research items were 42 news releases and statements provided by WHO between December 31, 2019, and March 30, 2020. These were subjected to qualitative and quantitative content analyses using the NVivo 12 qualitative analysis software program for coding. The data were coded under 6 variables (date of publication, topics, frequency, wording of the COVID-19 outbreak, sourcing, and themes of the releases). While 54.7% of WHO's communications were devoted to the COVID-19 outbreak, more than half were not issued until March. That is, instead of early risk communication and clear warnings about the outbreak, WHO acted overcautiously, preferring messages related to solidarity and cooperation during the most devastating pandemic of the 21st century.

Follow-Up Analysis of Pulmonary Function, Exercise Capacity, Radiological Changes, and Quality of Life Two Months after Recovery from SARS-CoV-2 Pneumonia

Background and objective: According to the World Health Organization (WHO), more than 100 million people have already recovered from SARS-CoV-2 infection. Therefore, it is imperative to understand the possible outcomes of COVID-19. The aim of our study was to evaluate pulmonary function, exercise capacity, residual radiological changes, and health-related quality of life (HRQoL) at follow-up in a cohort of SARS-CoV-2 pneumonia survivors. Materials and Methods: Patients with SARS-CoV-2 infection and radiologically confirmed lung injury, with no chronic lung disease prior to this infection, were included in the study. Patients’ evaluation 2 months after their discharge from hospital included spirometry (FVC, FEV1, FEV1/FVC), determination of lung volume (TLC, VC, RV) and diffusing capacity of lung for carbon monoxide (DLCO, adjusted for hemoglobin), 6-Minute Walk Test (6MWT), chest CT scan, and 36-Item Short Form General Health Survey (SF-36). Results: Fifty-one patients (25 men, 26 women) were included. The mean age was 56 years (SD-11,72). Eighteen patients (35.3%) had experienced moderate COVID-19, 21 (41.2%) severe COVID-19, and 12 (23.5%) were critically ill. The mean follow-up visit time after the discharge from hospital was 60 days (SD-17). Pulmonary function at follow-up was impaired in 24 (47.2%) patients. Reduced lung volume was observed in 15 (29.4%) patients, DLCO reduction in 15 (29.4%) patients, and only one patient displayed obstruction. Twelve patients out of 51 (12/51, 27.3%) showed reduced physical capacity in the 6 MWT, and 3/51 (9.1%) showed desaturation, with SO2 < 90%. Different levels of abnormality were found in 49/51 (96,1%) patients on follow-up chest CT; the median radiological score was 10.9 (SD ± 8.87, possible maximal score, 25). Ground-glass opacity was the most common radiological feature, found in 45 (88.2%) patients. The SF-36 scores demonstrated a reduction in health status across all domains, with the lowest scores for limitations in social activities because of physical problems, vitality, and general health. Conclusion: In the group of COVID-19 pneumonia survivors 2 months after hospital discharge, residual changes in the lungs on chest CT and in lung function and reduced physical and HRQoL status were found in a significant number of patients. To evaluate COVID-19 long-term consequences, a longer follow-up period is needed.

Clinical features and prognostic factors of intensive and non-intensive 1014 COVID-19 patients: an experience cohort from Alahsa, Saudi Arabia

BACKGROUND

COVID-19 is a worldwide pandemic and has placed significant demand for acute and critical care services on hospitals in many countries.

OBJECTIVES

To determine the predictors of severe COVID-19 disease requiring admission to an ICU by comparing patients who were ICU admitted to non-ICU groups.

METHODS

A cohort study was conducted for the laboratory-confirmed COVID-19 patients who were admitted to six Saudi Ministry of Health's hospitals in Alahsa, between March 1, 2020, and July 30, 2020, by reviewing patient's medical records retrospectively.

RESULTS

This cohort included 1014 patients with an overall mean age of 47.2 ± 19.3 years and 582 (57%) were males. A total of 205 (20%) of the hospitalized patients were admitted to the ICU. Hypertension, diabetes and obesity were the most common comorbidities in all study patients (27.2, 19.9, and 9%, respectively). The most prevalent symptoms were cough (47.7%), shortness of breath (35.7%) and fever (34.3%). Compared with non-ICU group, ICU patients had older age (p ≤ 0.0005) and comprised a higher proportion of the current smokers and had higher respiratory rates (p ≤ 0.0005), and more percentage of body temperatures in the range of 37.3-38.0 °C (p ≥ 0.0005); and had more comorbidities including diabetes (p ≤ 0.0005), hypertension (p ≥ 0.0005), obesity (p = 0.048), and sickle cell disease (p = 0.039). There were significant differences between the non-ICU and ICU groups for fever, shortness of breath, cough, fatigue, vomiting, dizziness; elevated white blood cells, neutrophils, alanine aminotransferase and alkaline aminotransferase, lactate dehydrogenase, and ferritin, and decreased hemoglobin; and proportion of abnormal bilateral chest CT images (p < 0.05). Significant differences were also found for multiple treatments (p < 0.05). ICU patients group had a much higher mortality rate than those with non-ICU admission (p ≤ 0.0005).

CONCLUSION

Identifying key clinical characteristics of COVID-19 that predict ICU admission and high mortality can be useful for frontline healthcare providers in making the right clinical decision under time-sensitive and resource-constricted environment.

COVID-19 pneumonia: current evidence of chest imaging features, evolution and prognosis

COVID-19 pneumonia represents a global threatening disease, especially in severe cases. Chest imaging, with X-ray and high-resolution computed tomography (HRCT), plays an important role in the initial evaluation and follow-up of patients with COVID-19 pneumonia. Chest imaging can also help in assessing disease severity and in predicting patient’s outcome, either as an independent factor or in combination with clinical and laboratory features. This review highlights the current knowledge of imaging features of COVID-19 pneumonia and their temporal evolution over time, and provides recent evidences on the role of chest imaging in the prognostic assessment of the disease.

Clinical, radiological and functional outcomes in patients with SARS-CoV-2 pneumonia: a prospective observational study

BACKGROUND

All over the world, SARS-CoV-2 pneumonia is causing a significant short-term morbidity and mortality, but the medium-term impact on lung function and quality of life of affected patients are still unknown.

METHODS

In this prospective observational study, 39 patients with SARS-CoV-2 pneumonia were recruited from a single COVID-19 hospital in Southern Switzerland. At three months patients underwent radiological and functional follow-up through CT scan, lung function tests, and 6 min walking test. Furthermore, quality of life was assessed through self-reported questionnaires.

RESULTS

Among 39 patients with SARS-CoV-2 pneumonia, 32 (82% of all participants) presented abnormalities in CT scan and 25 (64.1%) had lung function tests impairment at three months. Moreover, 31 patients (79.5%) reported a perception of poor health due to respiratory symptoms and all 39 patients showed an overall decreased quality of life.

CONCLUSIONS

Medium-term follow up at three months of patients diagnosed with SARS-CoV-2 pneumonia shows the persistence of abnormalities in CT scans, a significant functional impairment assessed by lung function tests and a decreased quality of life in affected patients. Further studies evaluating the long-term impact are warranted to guarantee an appropriate follow-up to patients recovering from SARS-CoV-2 pneumonia.

Persistent interstitial lung abnormalities in post-COVID-19 patients: a case series

A new concept of multisystem disease has emerged as a long-term condition following mild-severe COVID-19 infection. The main symptoms of this affection are breathlessness, chest pain, and fatigue. We present here the clinical case of four COVID-19 patients during hospitalization and 60 days after hospital discharge. Physiological impairment of all patients was assessed by spirometry, dyspnea score, arterial blood gas, and 6-minute walk test 60 days after hospital discharge, and computed tomographic scan 90 days after discharge. All patients had fatigue, which was not related to hypoxemia or impaired spirometry values, and interstitial lung alterations, which occurred in both mechanically ventilated and non-mechanically ventilated patients. In conclusion, identifying the prevalence and patterns of permanent lung damage is paramount in preventing and treating COVID-19-induced fibrotic lung disease. Additionally, and based on our preliminary results, it will be also relevant to establish long-term outpatient programs for these individuals.

Longitudinal Chest CT Features in Severe/Critical COVID-19 Cases and the Predictive Value of the Initial CT for Mortality

Purpose

To evaluate longitudinal computed tomography (CT) features and the predictive value of the initial CT and clinical characteristics for mortality in patients with severe/critical coronavirus disease 2019 (COVID-19) pneumonia.

Methods

A retrospective analysis was performed on patients with COVID-19 pneumonia confirmed by laboratory. By excluding mild and common patients, 155 severe/critical patients with definite outcome were finally enrolled. A total of 516 CTs of 147 patients were divided into four stages according to the time after onset (stage 1, 1–7 days; stage 2, 8–14 days; stage 3, 15–21 days, and stage 4, >21 days). The evolving imaging features between the survival and non-survival groups were compared by using Chi-square, Fisher’s exact test, student’s t-test or Mann–Whitney U-test, as appropriate. The predictive value of clinical and CT features at admission for mortality was analysed through logistic regression analysis. To avoid overfitting caused by CT scores, CT scores were divided into two parts, which were combined with clinical variables, respectively, to construct the models.

Results

Ground-glass opacities (GGO) patterns were predominant for stages 1 and 2 for both groups (both P>0.05). The numbers of consolidation lesions increased in stage 3 in both groups (P=0.857), whereas the linear opacity increased in the survival group but decreased in the non-survival group (P=0.0049). In stage 4, the survival group predominantly presented linear opacity patterns, whereas the non-survival group mainly showed consolidation patterns (P=0.007). Clinical and imaging characteristics correlated with mortality; multivariate analyses revealed age >71 years, neutrophil count >6.38 × 10⁹/L, aspartate aminotransferase (AST) >58 IU/L, and CT score (total lesions score >17 in model 1, GGO score >14 and consolidation score >2 in model 2) as independent risk factors (all P<0.05). The areas under the curve of the six independent risk factors alone ranged from 0.65 to 0.75 and were 0.87 for model 2, 0.89 for model 1, and 0.92 for the six variables combined. Statistical differences were observed between Kaplan Meier curves of groups separated by cut-off values of these six variables (all P<0.01).

Conclusion

Longitudinal imaging features demonstrated differences between the two groups, which may help determine the patient’s prognosis. The initial CT score combined with age, AST, and neutrophil count is an excellent predictor for mortality in COVID-19 patients.

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

PURPOSE

To evaluate pooled prevalence, sensitivity, and specificity of chest computed tomography (CT) and radiographic findings for novel coronavirus-2019 (COVID-19) pneumonia.

METHODS

We performed systematic literature search in PubMed and Embase to identify articles reporting baseline imaging findings of COVID-19 pneumonia. The quality of the articles was assessed using NIH quality assessment tool for case series studies. The pooled prevalence, sensitivity, specificity, and diagnostic odds ratio of imaging findings were calculated.

RESULTS

Fifty-six studies (6007 patients, age, 2.1-70 years, 2887 females, 5762 CT, 396 radiographs,) were included. The mean interval between onset of symptoms and CT acquisition was 1-8 days. On CT, the pooled prevalence of ground glass opacities (GGO), GGO plus consolidation, and consolidation only was 66.9% (95% CI 60.8-72.4%), 44.9% (38.7-51.3%), and 32.1 (23.6-41.9%) respectively. Pooled sensitivity and specificity of GGO on CT was 73% (71%-80%) and 61% (41%-78%), respectively. For GGO plus consolidation and consolidation only, the pooled sensitivities/ specificities were 58% (48%-68%)/ 58% (41%-73%) and 49% (20%-78%)/ 56% (30%-78%), respectively. The pooled prevalence of GGO and consolidation on chest radiograph was 38.7% (22.2%-58.3%) and 46.9% (29.7%-64.9%), respectively. The diagnostic accuracy of radiographic findings could not be assessed due to small number of studies.

CONCLUSION

GGO on CT has the highest diagnostic performance for COVID-19 pneumonia, followed by GGO plus consolidation and consolidation only. However, the moderate to low sensitivity and specificity suggest that CT should not be used as the primary tool for diagnosis. Chest radiographic abnormalities are seen in half of the patients.

Six-month Follow-up Chest CT Findings after Severe COVID-19 Pneumonia

Background Little is known about the long-term lung radiographic changes in patients who have recovered from coronavirus disease 2019 (COVID-19), especially those with severe disease. Purpose To prospectively assess pulmonary sequelae and explore the risk factors for fibrotic-like changes in the lung at 6-month follow-up chest CT of survivors of severe COVID-19 pneumonia. Materials and Methods A total of 114 patients (80 [70%] men; mean age, 54 years ± 12) were studied prospectively. Initial and follow-up CT scans were obtained a mean of 17 days ± 11 and 175 days ± 20, respectively, after symptom onset. Lung changes (opacification, consolidation, reticulation, and fibrotic-like changes) and CT extent scores (score per lobe, 0-5; maximum score, 25) were recorded. Participants were divided into two groups on the basis of their 6-month follow-up CT scan: those with CT evidence of fibrotic-like changes (traction bronchiectasis, parenchymal bands, and/or honeycombing) (group 1) and those without CT evidence of fibrotic-like changes (group 2). Between-group differences were assessed with the Fisher exact test, two-sample t test, or Mann-Whitney U test. Multiple logistic regression analyses were performed to identify the independent predictive factors of fibrotic-like changes. Results At follow-up CT, evidence of fibrotic-like changes was observed in 40 of the 114 participants (35%) (group 1), whereas the remaining 74 participants (65%) showed either complete radiologic resolution (43 of 114, 38%) or residual ground-glass opacification or interstitial thickening (31 of 114, 27%) (group 2). Multivariable analysis identified age of greater than 50 years (odds ratio [OR]: 8.5; 95% CI: 1.9, 38; P = .01), heart rate greater than 100 beats per minute at admission (OR: 5.6; 95% CI: 1.1, 29; P = .04), duration of hospital stay greater than or equal to 17 days (OR: 5.5; 95% CI: 1.5, 21; P = .01), acute respiratory distress syndrome (OR: 13; 95% CI: 3.3, 55; P < .001), noninvasive mechanical ventilation (OR: 6.3; 95% CI: 1.3, 30; P = .02), and total CT score of 18 or more (OR: 4.2; 95% CI: 1.2, 14; P = .02) at initial CT as independent predictors for fibrotic-like changes in the lung at 6 months. Conclusion Six-month follow-up CT showed fibrotic-like changes in the lung in more than one-third of patients who survived severe coronavirus disease 2019 pneumonia. These changes were associated with an older age, acute respiratory distress syndrome, longer hospital stays, tachycardia, noninvasive mechanical ventilation, and higher initial chest CT score. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Wells et al in this issue.

Pulmonary Function and Radiologic Features in Survivors of Critical COVID-19: A 3-Month Prospective Cohort

BACKGROUND

More than 20% of hospitalized patients with COVID-19 demonstrate ARDS requiring ICU admission. The long-term respiratory sequelae in such patients remain unclear.

RESEARCH QUESTION

What are the major long-term pulmonary sequelae in critical patients who survive COVID-19?

STUDY DESIGN AND METHODS

Consecutive patients with COVID-19 requiring ICU admission were recruited and evaluated 3 months after hospitalization discharge. The follow-up comprised symptom and quality of life, anxiety and depression questionnaires, pulmonary function tests, exercise test (6-min walking test [6MWT]), and chest CT imaging.

RESULTS

One hundred twenty-five patients admitted to the ICU with ARDS secondary to COVID-19 were recruited between March and June 2020. At the 3-month follow-up, 62 patients were available for pulmonary evaluation. The most frequent symptoms were dyspnea (46.7%) and cough (34.4%). Eighty-two percent of patients showed a lung diffusing capacity of less than 80%. The median distance in the 6MWT was 400 m (interquartile range, 362-440 m). CT scans showed abnormal results in 70.2% of patients, demonstrating reticular lesions in 49.1% and fibrotic patterns in 21.1%. Patients with more severe alterations on chest CT scan showed worse pulmonary function and presented more degrees of desaturation in the 6MWT. Factors associated with the severity of lung damage on chest CT scan were age and length of invasive mechanical ventilation during the ICU stay.

INTERPRETATION

Three months after hospital discharge, pulmonary structural abnormalities and functional impairment are highly prevalent in patients with ARDS secondary to COVID-19 who required an ICU stay. Pulmonary evaluation should be considered for all critical COVID-19 survivors 3 months after discharge.

The find of COVID-19 vaccine: Challenges and opportunities

Severe acute respiratory syndrome coronavirus (SARS-CoV-2), a novel corona virus, causing COVID-19 with Flu-like symptoms is the first alarming pandemic of the third millennium. SARS-CoV-2 belongs to beta coronavirus as Middle East respiratory syndrome coronavirus (MERS-CoV). Pandemic COVID-19 owes devastating mortality and destructively exceptional consequences on Socio-Economics life around the world. Therefore, the current review is redirected to the scientific community to owe comprehensive visualization about SARS-CoV-2 to tackle the current pandemic. As systematically shown through the current review, it indexes unmet medical problem of COVID-19 in view of public health and vaccination discovery for the infectious SARS-CoV-2; it is currently under-investigational therapeutic protocols, and next possible vaccines. Furthermore, the review extensively reports the precautionary measures to achieve" COVID-19/Flatten the curve". It is concluded that vaccines formulation within exceptional no time in this pandemic is highly recommended, via following the same protocols of previous pandemics; MERS-CoV and SARS-CoV, and excluding some initial steps of vaccination development process.

Early extrapulmonary prognostic features in chest computed tomography in COVID-19 pneumonia: Bone mineral density is a relevant predictor for the clinical outcome - A multicenter feasibility study

BACKGROUND

Besides throat-nose swab polymerase chain reaction (PCR), unenhanced chest computed tomography (CT) is a recommended diagnostic tool for early detection and quantification of pulmonary changes in COVID-19 pneumonia caused by the novel corona virus. Demographic factors, especially age and comorbidities, are major determinants of the outcome in COVID-19 infection. This study examines the extra pulmonary parameter of bone mineral density (BMD) from an initial chest computed tomography as an associated variable of pre-existing comorbidities like chronic lung disease or demographic factors to determine the later patient's outcome, in particular whether treatment on an intensive care unit (ICU) was necessary in infected patients.

METHODS

We analyzed 58 PCR-confirmed COVID-19 infections that received an unenhanced CT at admission at one of the included centers. In addition to the extent of pulmonary involvement, we performed a phantomless assessment of bone mineral density of thoracic vertebra 9-12.

RESULTS

In a univariate regression analysis BMD was found to be a significant predictor of the necessity for intensive care unit treatment of COVID-19 patients. In the subgroup requiring intensive care treatment within the follow-up period a significantly lower BMD was found. In a multivariate logistic regression model considering gender, age and CT measurements of bone mineral density, BMD was eliminated from the regression analysis as a significant predictor.

CONCLUSION

Phantomless assessed BMD provides prognostic information on the necessity for ICU treatment in course of COVID-19 pneumonia. We recommend using the measurement of BMD in an initial CT image to facilitate a potentially better prediction of severe patient outcomes within the 22 days after an initial CT scan. Consequently, in the present sample, additional bone density analysis did not result in a prognostic advantage over simply considering age. Significantly larger patient cohorts with a more homogenous patient age should be performed in the future to illustrate potential effects.

CLINICAL RELEVANCE

While clinical capacities such as ICU beds and ventilators are more crucial than ever to help manage the current global corona pandemic, this work introduces an approach that can be used in a cost-effective way to help determine the amount of these rare clinical resources required in the near future.

The incidence of pleural effusion in COVID-19 pneumonia: State-of-the-art review

BACKGROUND

COVID-19-related pleural effusions are frequently described during the ongoing pandemic.

OBJECTIVES

We described the incidence, characteristics, and outcomes of COVID-19-related pleural effusions based on the current evidence available in the literature.

METHODS

We searched MEDLINE, Pubmed, and Google Scholar databases using keywords of "coronavirus disease 2019 (COVID-19)," "severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)," "pleural effusion," "pleural fluid," and "pleura" from January 1st, 2020 to January 31st, 2021.

RESULTS

The incidence of pleural effusions was low at 7.3% among the 47 observational studies. Pleural effusions were commonly observed in critically ill patients and had Multisystem Inflammatory Syndrome (MIS). COVID-19-related pleural effusions were identified 5-7 days and 11 days, after hospital admission and onset of COVD-19 symptoms. The characteristic findings of pleural fluid were exudative, lymphocytic or neutrophilic-predominant pleural fluid with markedly elevated lactate dehydrogenase (LDH) levels and pleural fluid to serum LDH ratio.

CONCLUSION

A well-designed study is required to assess the significance of COVID-19-related pleural effusions during this current pandemic.

Correlation between early features and prognosis of symptomatic COVID-19 discharged patients in Hunan, China

To determine the correlation between the clinical, laboratory, and radiological findings and the hospitalization days in Coronavirus Infectious Disease-19 (COVID-19) discharged patients. We retrospectively identified 172 discharged patients with COVID-19 pneumonia from January 10, 2020, to February 28, 2020, in Hunan province. The patients were categorized into group 1 (≤ 19 days) and group 2 (> 19 days) based on the time from symptom onset to discharge. Cough during admission occurred more commonly in group 2 (68.4%) than in group 1 (53.1%, p = 0.042). White blood cell (p = 0.045), neutrophil counts (p = 0.023), Alanine aminotransferase (p = 0.029), Aspartate aminotransferase (p = 0.027) and Lactate dehydrogenase (p = 0.021) that were above normal were more common in group 2. Patients with single lesions were observed more in group 1(17.7%, p = 0.018) and multiple lesions observed more in group 2(86.8%, p = 0.012). The number of lobes involved (p = 0.008) in the CT score (p = 0.001) for each patient was all differences between the two groups with a statistically significant difference. Mixed ground-glass opacity (GGO) and consolidation appearances were observed in most patients. GGO components > consolidation appearance was more common in group 1 (25.0%) than in group 2 (8.0%) with a significant difference (0.015), GGO < consolidation was more common in group 2(71.1%, p = 0.012). From the logistic regression analysis, the CT score (OR, 1.223; 95% CI, 1.004 to 1.491, p = 0.046) and the appearance of GGO > consolidation (OR, 0.150; 95% CI, 0.034 to 0.660, p = 0.012) were independently associated with the hospitalization days. Thus, special attention should be paid to the role of radiological features in monitoring the disease prognosis.

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

OBJECTIVES

We performed a systematic review and meta-analysis of the prevalence of chest CT findings in patients with confirmed COVID-19 infection.

METHODS

Systematic review of the literature was performed using PubMed, Scopus, Embase, and Google Scholar to retrieve original studies on chest CT findings of patients with confirmed COVID-19, available up to 10 May 2020. Data on frequency and distribution of chest CT findings were extracted from eligible studies, pooled and meta-analyzed using random-effects model to calculate the prevalence of chest CT findings.

RESULTS

Overall, 103 studies (pooled population: 9907 confirmed COVID-19 patients) were meta-analyzed. The most common CT findings were ground-glass opacities (GGOs) (77.18%, 95%CI = 72.23-81.47), reticulations (46.24%, 95%CI = 38.51-54.14), and air bronchogram (41.61%, 95%CI = 32.78-51.01). Pleural thickening (33.35%, 95%CI = 21.89-47.18) and bronchial wall thickening (15.48%, 95%CI = 8.54-26.43) were major atypical and airway findings. Lesions were predominantly distributed bilaterally (75.72%, 95%CI = 70.79-80.06) and peripherally (65.64%, 95%CI = 58.21-72.36), while 8.20% (95%CI = 6.30-10.61) of patients had no abnormal findings and pre-existing lung diseases were present in 6.01% (95%CI = 4.37-8.23).

CONCLUSIONS

The most common CT findings in COVID-19 are GGOs with/without consolidation, reticulations, and air bronchogram, which often involve both lungs with peripheral distribution. However, COVID-19 might present with atypical manifestations or no abnormal findings in chest CT, which deserve clinicians' notice.

Lung Recruitment, Individualized PEEP, and Prone Position Ventilation for COVID-19-Associated Severe ARDS: A Single Center Observational Study

Background: Patients with coronavirus disease 2019 (COVID-19) may develop severe acute respiratory distress syndrome (ARDS). The aim of the study was to explore the lung recruitability, individualized positive end-expiratory pressure (PEEP), and prone position in COVID-19-associated severe ARDS. Methods: Twenty patients who met the inclusion criteria were studied retrospectively (PaO₂/FiO₂ 68.0 ± 10.3 mmHg). The patients were ventilated under volume-controlled mode with tidal volume of 6 mL/kg predicted body weight. The lung recruitability was assessed via the improvement of PaO₂, PaCO₂, and static respiratory system compliance (C_stat) from low to high PEEP (5-15 cmH₂O). Patients were considered recruitable if two out of three parameters improved. Subsequently, PEEP was titrated according to the best C_stat. The patients were turned to prone position for further 18-20 h. Results: For recruitability assessment, average value of PaO₂ was slightly improved at PEEP 15 cmH₂O (68.0 ± 10.3 vs. 69.7 ± 7.9 mmHg, baseline vs. PEEP 15 cmH₂O; p = 0.31). However, both PaCO₂ and C_stat worsened (PaCO₂: 72.5 ± 7.1 vs. 75.1 ± 9.0 mmHg; p < 0.01. C_stat: 17.5 ± 3.5 vs. 16.6 ± 3.9 ml/cmH₂O; p = 0.05). Only four patients (20%) were considered lung recruitable. Individually titrated PEEP was higher than the baseline PEEP (8.0 ± 2.1 cmH₂O vs. 5 cmH₂O, p < 0.001). After 18-20 h of prone positioning, investigated parameters were significantly improved compared to the baseline (PaO₂: 82.4 ± 15.5 mmHg. PaCO₂: 67.2 ± 6.4 mmHg. C_stat: 20.6 ± 4.4 ml/cmH₂O. All p < 0.001 vs. baseline). Conclusions: Lung recruitability was very low in COVID-19-associated severe ARDS. Individually titrated PEEP and prone positioning might improve lung mechanics and blood gasses.

Is liver involvement overestimated in COVID-19 patients? A meta-analysis

Background: Considering transaminase more than the upper limit of normal value as liver injury might overestimate the prevalence of liver involvement in COVID-19 patients. No meta-analysis has explored the impact of varied definitions of liver injury on the reported prevalence of liver injury. Moreover, few studies reported the extent of hypertransaminasemia stratified by COVID-19 disease severity. Methods: A literature search was conducted using PubMed and Embase. The pooled prevalence of liver injury and hypertransaminasemia was estimated. Results: In total, 60 studies were included. The overall prevalence of liver injury was 25%. Compared to subgroups with the non-strict definition of liver injury (33%) and subgroups without giving detailed definition (26%), the subgroup with a strict definition had a much lower prevalence of liver injury (9%). The overall prevalence of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) elevation was 19% and 22%. The prevalence of elevated ALT and AST were significantly higher in severe COVID-19 cases compare to non-severe cases (31% vs 16% and 44% vs 11%). In critically ill and fatal cases, no difference was found in the prevalence of elevated ALT (24% vs 30%) or AST (54% vs 49%). Sensitivity analyses indicated that the adjusted prevalence of ALT elevation, AST elevation, and liver injury decreased to 14%, 7%, and 12%. Conclusion: The overall prevalence of liver injury and hypertransaminasemia in COVID-19 patients might be overestimated. Only a small fraction of COVID-19 patients have clinically significant liver injury. The prevalence of hypertransaminasemia was significantly higher in severe COVID-19 cases compare to non-severe cases. Hence, in severe COVID-19 patients, more attention should be paid to liver function tests.