High-Resolution Computed Tomography and Lung Ultrasound in Patients with Systemic Sclerosis: Which One to Choose?

The Performance of Pulmonary Function Tests in Predicting Systemic Sclerosis-Interstitial Lung Disease in the European Scleroderma Trial and Research Database

BACKGROUND AND OBJECTIVES

In SSc, ILD is a major cause of morbidity and mortality. We aimed to investigate the performance of DLCO (diffusing capacity of lung carbon monoxide) and FVC (forced vital capacity) delta change (Δ) and baseline values in predicting the development of SSc-ILD.

METHODS

Longitudinal data of DLCO, FVC, and ILD on the HRCT of SSc patients from the EUSTAR database were evaluated at baseline (t0) and after 12 (±4) (t1) and 24 (±4) (t2) months.

RESULTS

474/17805 patients were eligible for the study (403 females); 46 (9.7%) developed ILD at t2. Positivity for anti-topoisomerase antibodies (117 patients) showed an association with ILD development at t2 (p = 0.0031). Neither the mean t0 to t1 change (Δ) of DLCO nor the mean t0 to t1 FVCΔ predicted the appearance of ILD at t2. Investigating the possible role of baseline DLCO and FVC values in predicting ILD appearance after 24 (±4) months, we observed a moderate predictive capability of t0 DLCO < 80%, stronger than that of FVC < 80%.

CONCLUSIONS

We suggest that an impaired baseline DLCO may be predictive of the appearance of ILD after 2 years of follow-up. This result advances the hypothesis that a reduction in gas exchange may be considered an early sign of lung involvement. However, further rigorous studies are warranted to understand the predictive role of DLCO evaluation in the course of SSc.

Biomarkers in Systemic Sclerosis: An Overview

Systemic sclerosis (SSc) is a complex autoimmune disease characterized by significant fibrosis of the skin and internal organs, with the main involvement of the lungs, kidneys, heart, esophagus, and intestines. SSc is also characterized by macro- and microvascular damage with reduced peripheral blood perfusion. Several studies have reported more than 240 pathways and numerous dysregulation proteins, giving insight into how the field of biomarkers in SSc is still extremely complex and evolving. Antinuclear antibodies (ANA) are present in more than 90% of SSc patients, and anti-centromere and anti-topoisomerase I antibodies are considered classic biomarkers with precise clinical features. Recent studies have reported that trans-forming growth factor β (TGF-β) plays a central role in the fibrotic process. In addition, interferon regulatory factor 5 (IRF5), interleukin receptor-associated kinase-1 (IRAK-1), connective tissue growth factor (CTGF), transducer and activator of transcription signal 4 (STAT4), pyrin-containing domain 1 (NLRP1), as well as genetic factors, including DRB1 alleles, are implicated in SSc damage. Several interleukins (e.g., IL-1, IL-6, IL-10, IL-17, IL-22, and IL-35) and chemokines (e.g., CCL 2, 5, 23, and CXC 9, 10, 16) are elevated in SSc. While adiponectin and maresin 1 are reduced in patients with SSc, biomarkers are important in research but will be increasingly so in the diagnosis and therapeutic approach to SSc. This review aims to present and highlight the various biomarker molecules, pathways, and receptors involved in the pathology of SSc.

COVID-19 in Infants and Children under 2 Years-Could Lung Ultrasound Score Be Correlated with Biomarkers and Symptoms?

INTRODUCTION

It is already well known that infants and children infected with COVID-19 develop mild to moderate forms of the disease, with fever and oropharyngeal congestion being the most common symptoms. However, there are instances when patients claim to be experiencing respiratory symptoms. Because of the repeated lung examinations required in these situations, non-irradiating imaging techniques are preferred. This study's objective is to ascertain the value of lung ultrasonography (LUS) in the medical management of these specific cases.

METHODS

Infants and children under two years old with SARS-CoV-2 infection were evaluated using LUS. Patients with other respiratory pathologies were excluded by using specific tests. The LUS score (LUSS) was correlated with biomarkers and clinical findings using the Mann-Whitney U test and Spearman's rank correlation rho.

RESULTS

The LUSS for each patient varied from 1 to 8 points out of a maximum of 36 points. The arithmetic mean was 4.47 ± 2.36 (S.D), while the 95% CI for the arithmetic mean was 3.33 to 5.61. Sparse B-lines were present in all enrolled infants and children (100%), while only 36.84% developed alveolar syndrome (confluent B-lines). The lung changes were correlated with their biomarkers, specifically inflammatory markers. The correlation between LUSS and LDH, D-dimers, and IL-6 was a strongly positive one with rho = 0.55 (p = 0.001, 95% CI 0.13 to 0.80) between the LUSS and D-dimer levels and rho = 0.60 (p = 0.03, 95% CI 0.04 to 0.87) between LUSS and D-dimer levels at symptomatic infants and children (with respiratory involvement).

CONCLUSIONS

Infants and children under the age of two are prone to develop mild forms of COVID-19 disease with a B-line pattern on LUS, although inflammatory markers have elevated blood levels. Despite the small sample, D-dimer levels and O2 saturation were correlated with LUSS in patients with respiratory involvement, while similar results were also found in the entire lot.

Thoracic ultrasound combined with low-dose computed tomography may represent useful screening strategy in highly exposed population in the industrial city of Taranto (Italy)

Objectives

We validated a screening protocol in which thoracic ultrasound (TUS) acts as a first-line complementary imaging technique in selecting patients which may deserve a second-line low-dose high resolution computed tomography (HRCT) scan among a population of asymptomatic high-risk subjects for interstitial lung abnormalities (ILA) and lung cancer. Due to heavy environmental pollution burden, the district Tamburi of Taranto has been chosen as "case study" for this purpose.

Methods

From July 2018 to October 2020, 677 patients aged between 45 and 65 year and who had been living in the Tamburi district of Taranto for at least 10 years were included in the study. After demographic, clinical and risk factor exposition data were collected, each participant underwent a complete TUS examination. These subjects were then asked to know if they agreed to perform a second-level examination by low-dose HRCT scan.

Results

On a total of 167 subjects (24.7%) who agreed to undergo a second-level HRCT, 85 patients (50.9%) actually showed pleuro-pulmonary abnormalities. Interstitial abnormalities were detected in a total of 36 patients on HRCT scan. In particular, 34 participants presented subpleural ILAs, that were classified in the fibrotic subtype in 7 cases. The remaining 2 patients showed non-subpleural interstitial abnormalities. Subpleural nodules were observed in 46 patients. TUS showed an overall diagnostic accuracy of 88.6% in detecting pleuro-pulmonary abnormalities in comparison with HRCT scan, with a sensitivity of 95.3%, a specificity of 81.7%, a positive predictive value of 84.4% and a negative predictive value of 94.4%. The matched evaluation of specific pulmonary abnormalities on HRTC scan (i.e., interstitial abnormalities or pulmonary nodules) with determinate sonographic findings revealed a reduction in both TUS sensibility and specificity. Focusing TUS evaluation on the assessment of interstitial abnormalities, a thickened pleural line showed a sensitivity of 63.9% and a specificity of 69.5%, hypoechoic striae showed a sensitivity of 38.9% and a specificity of 90.1% and subpleural nodules showed a sensitivity of 58.3% and a specificity of 77.1%. Regarding to the assessment of subpleural nodules, TUS showed a sensitivity of 60.9% and a specificity of 81.0%. However, the combined employment of TUS examination and HRCT scans allowed to identify 34 patients with early subpleural ILA and to detect three suspicious pulmonary nodules (of which two were intraparenchymal and one was a large subpleural mass), which revealed to be lung cancers on further investigations.

Conclusion

A first-line TUS examination might aid the identification of subjects highly exposed to environmental pollution, who could benefit of a second-line low-dose HRCT scan to find early interstitial lung diseases as well as lung cancer.

Protocol registration code

PLEURO-SCREENING-V1.0_15 Feb, 17.

Pulmonary Ultrasonography in Systemic Sclerosis-Induced Interstitial Lung Disease-A Systematic Review and Meta-Analysis

BACKGROUND

The aim of the current systematic review was to summarize and evaluate the overall advantages of lung ultrasonography (LUS) examination using high-resolution computed tomography (HRCT) as a reference standard in assessing the presence of interstitial lung disease (ILD) in systemic sclerosis (SSc) patients.

METHODS

Databases PubMed, Scopus, and Web of Science were searched for studies evaluating LUSs in ILD assessments including SSc patients on 1 February 2023. In assessing risk of bias and applicability, the Revised Tool for the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) was used. A meta-analysis was performed and the mean specificity, sensitivity, and diagnostic odds ratio (DOR) with a 95% confidence interval (CI) were obtained. In addition, in a bivariate meta-analysis, the summary receiver operating characteristic (SROC) curve area was additionally calculated.

RESULTS

Nine studies with a total of 888 participants entered the meta-analysis. A meta-analysis was also performed without one study that used pleural irregularity to assess the diagnostic accuracy of LUSs using B-lines (with a total of 868 participants). Overall sensitivity and specificity did not differ significantly, with only the analysis of the B-lines having a specificity of 0.61 (95% CI 0.44-0.85) and a sensitivity of 0.93 (95% CI 0.89-0.98). The diagnostic odds ratio of univariate analysis of the eight studies using the B-lines as a criterion for ILD diagnosis was 45.32 (95% CI 17.88-114.89). The AUC value of the SROC curve was 0.912 (and 0.917 in consideration of all nine studies), which indicates high sensitivity and a low false-positive rate for the majority of the included studies.

CONCLUSIONS

LUS examination proved to be a valuable tool in discerning which SSc patients should receive additional HRCT scans to detect ILD and therefore reduces the doses of ionizing radiation exposure in SSc patients. However, further studies are needed to achieve consensus in scoring and the evaluation methodology of LUS examination.

B-Lines Lung Ultrasonography Simulation Using Finite Element Method

Introduction: Lung Ultrasonography (LUS) is a fast technique for the diagnosis of patients with respiratory syndromes. B-lines are seen in response to signal reverberations and amplifications into sites with peripheral lung fluid concentration or septal thickening. Mathematical models are commonly applied in biomedicine to predict biological responses to specific signal parameters. Objective: This study proposes a Finite-Element numerical model to simulate radio frequency ultrasonic lines propagated from normal and infiltrated lung structures. For tissue medium, a randomized inhomogeneous data method was used. The simulation implemented in COMSOL® used Acoustic Pressure and Time-Explicit models, which are based on the discontinuous Galerkin method (dG). Results: The RF signals, processed in MATLAB®, resulted in images of horizontal A-lines and vertical B-lines, which were reasonably similar to real images. Discussion: The use of inhomogeneous materials in the model was good enough to simulate the scattering response, similar to others in the literature. The model is useful to study the impact of the lung infiltration characteristics on the appearance of LUS images.

The associations of radiological features of high-resolution computed tomography with the outcomes of transbronchial cryobiopsy in interstitial lung diseases: A cohort study

Background

Transbronchial cryobiopsy (TBCB) is a critical procedure in the diagnosis of interstitial lung diseases (ILD). The associations between high-resolution computed tomography (HRCT) features and outcomes of TBCB were unknown.

Methods

This study was conducted as a single-center prospective cohort study between September 2018 and January 2020 (NCT04047667). HRCT was obtained before performing TBCB. The clinical and radiological characteristics, complications, pathological and multidisciplinary discussion (MDD) diagnoses were recorded. The relationships between HRCT features and outcomes of TBCB were analyzed.

Results

TBCB was performed on 216 ILD patients. The radiological features usually interstitial pneumonia (UIP) or probable UIP, indeterminate for UIP, ground-glass opacities (GGO) and cysts were found in 55 (25.5%), 38 (17.6%), 84 (38.9%) and 9 (4.2%) patients, respectively. And 118 (54.6%) patients had high HRCT score (involved lung proportion ≥50%) in the biopsied lobe. Multivariate analysis suggested radiological probable UIP pattern may be an independent risk factor for moderate bleeding (OR = 4.304; 95% CI: 1.383–13.393; P = 0.012), while GGO may be a protective factor from moderate bleeding (OR = 0.173, 95% CI: 0.043–0.687; P = 0.013). The pathological diagnostic yield in patients presenting cysts on HRCT was significantly lower than others (44.4 vs. 87.9%; P = 0.009). While performing TBCB in the lobe with high HRCT score increased pathological diagnostic yield (91.5 vs. 79.6%; P = 0.022). Neither pneumothorax nor MDD diagnostic yields were found to be associated with HRCT features.

Conclusions

HRCT features were associated with moderate bleeding and pathological diagnosis. Pre-TBCB assessments of HRCT pattern and scores were helpful for bronchoscopists to make a better patient selection and procedure planning.

The Role of Lung Ultrasound in SARS-CoV-19 Pneumonia Management

Purpose: We aimed to assess the role of lung ultrasound (LUS) in the diagnosis and prognosis of SARS-CoV-2 pneumonia, by comparing it with High Resolution Computed Tomography (HRCT). Patients and methods: All consecutive patients with laboratory-confirmed SARS-CoV-2 infection and hospitalized in COVID Centers were enrolled. LUS and HRCT were carried out on all patients by expert operators within 48−72 h of admission. A four-level scoring system computed in 12 regions of the chest was used to categorize the ultrasound imaging, from 0 (absence of visible alterations with ultrasound) to 3 (large consolidation and cobbled pleural line). Likewise, a semi-quantitative scoring system was used for HRCT to estimate pulmonary involvement, from 0 (no involvement) to 5 (>75% involvement for each lobe). The total CT score was the sum of the individual lobar scores and ranged from 0 to 25. LUS scans were evaluated according to a dedicated scoring system. CT scans were assessed for typical findings of COVID-19 pneumonia (bilateral, multi-lobar lung infiltration, posterior peripheral ground glass opacities). Oxygen requirement and mortality were also recorded. Results: Ninety-nine patients were included in the study (male 68.7%, median age 71). 40.4% of patients required a Venturi mask and 25.3% required non-invasive ventilation (C-PAP/Bi-level). The overall mortality rate was 21.2% (median hospitalization 30 days). The median ultrasound thoracic score was 28 (IQR 20−36). For the CT evaluation, the mean score was 12.63 (SD 5.72), with most of the patients having LUS scores of 2 (59.6%). The bivariate correlation analysis displayed statistically significant and high positive correlations between both the CT and composite LUS scores and ventilation, lactates, COVID-19 phenotype, tachycardia, dyspnea, and mortality. Moreover, the most relevant and clinically important inverse proportionality in terms of P/F, i.e., a decrease in P/F levels, was indicative of higher LUS/CT scores. Inverse proportionality P/F levels and LUS and TC scores were evaluated by univariate analysis, with a P/F−TC score correlation coefficient of −0.762, p < 0.001, and a P/F−LUS score correlation coefficient of −0.689, p < 0.001. Conclusions: LUS and HRCT show a synergistic role in the diagnosis and disease severity evaluation of COVID-19.

Lung Ultrasound B-Lines in the Evaluation of the Extent of Interstitial Lung Disease in Systemic Sclerosis

Background: Chest computed tomography (CT) is the gold standard for the evaluation of systemic sclerosis-related interstitial lung disease (SSc-ILD). Lung ultrasound (LUS) is a radiation-free tool that identifies the B-lines as a main feature of ILD. We aimed to investigate the role of LUS in the evaluation of the extent of SSc-ILD. Methods: Adult SSc patients underwent pulmonary function tests (PFTs), LUS and CT. The CT images were qualitatively, semi-quantitatively (the Wells score on five levels and the categorical Goh et al. staging) and quantitatively (histogram-based densitometry) analysed for ILD. LUS quantified B-lines in 21 intercostal spaces on both the anterior and posterior chest wall. Results: Out of the 77 SSc patients eligible for the study, 35 presented with ILD on CT (21 limited, 14 extensive). Total B-lines significantly differentiated ILD vs. no ILD (median 24 vs. 8, p < 0.001). Posterior and total B-lines significantly differentiated limited from absent ILD, while anterior B-lines distinguished extensive from limited ILD. Total B-lines correlated with the Wells score (r = 0.446, p < 0.001) and MLA (r = −0.571, p < 0.001); similar results were confirmed when anterior and posterior B-lines were analysed separately. Conclusions: LUS is a useful tool to identify SSc-ILD and to correlate with different evaluations of ILD extent and severity.

An Overview of Different Techniques for Improving the Treatment of Pulmonary Hypertension Secondary in Systemic Sclerosis Patients

In systemic sclerosis (SSc) mortality is mainly linked to lung involvement which is characterized by interstitial lung disease (ILD) and pulmonary hypertension (PH). In SSc, PH may be due to different etiologies, including ILD, chronic thromboembolic disease, pulmonary veno-occlusive disease, and pulmonary arterial hypertension (PAH). The main tool to screen PAH is transthoracic echocardiography (TTE), which has a sensitivity of 90%, even if definitive diagnosis should be confirmed by right heart catheterization (RHC). The radiological evaluation (i.e., HRTC) plays an important role in defining the possible causes and in monitoring the evolution of lung damage. For PAH, identifying individuals who have borderline elevation of pulmonary arterial pressure needs to be appropriately managed and followed. In the past few years, the strategy for the management of PAH has significantly evolved and new trials are underway to test other therapies. This review provides an overview of the tools to evaluate PAH in SSc patients and on treatment options for these patients.