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Stoleriu MG, Pienn M, Joerres RA, Alter P, Fero T, Urschler M, Kovacs G, Olschewski H, Kauczor HU, Wielpütz M, Jobst B, Welte T, Behr J, Trudzinski FC, Bals R, Watz H, Vogelmeier CF, Biederer J, Kahnert K. Expiratory Venous Volume and Arterial Tortuosity are Associated with Disease Severity and Mortality Risk in Patients with COPD: Results from COSYCONET. Int J Chron Obstruct Pulmon Dis 2024; 19:1515-1529. [PMID: 38974817 PMCID: PMC11227296 DOI: 10.2147/copd.s458905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 06/10/2024] [Indexed: 07/09/2024] Open
Abstract
Purpose The aim of this study was to evaluate the association between computed tomography (CT) quantitative pulmonary vessel morphology and lung function, disease severity, and mortality risk in patients with chronic obstructive pulmonary disease (COPD). Patients and Methods Participants of the prospective nationwide COSYCONET cohort study with paired inspiratory-expiratory CT were included. Fully automatic software, developed in-house, segmented arterial and venous pulmonary vessels and quantified volume and tortuosity on inspiratory and expiratory scans. The association between vessel volume normalised to lung volume and tortuosity versus lung function (forced expiratory volume in 1 sec [FEV1]), air trapping (residual volume to total lung capacity ratio [RV/TLC]), transfer factor for carbon monoxide (TLCO), disease severity in terms of Global Initiative for Chronic Obstructive Lung Disease (GOLD) group D, and mortality were analysed by linear, logistic or Cox proportional hazard regression. Results Complete data were available from 138 patients (39% female, mean age 65 years). FEV1, RV/TLC and TLCO, all as % predicted, were significantly (p < 0.05 each) associated with expiratory vessel characteristics, predominantly venous volume and arterial tortuosity. Associations with inspiratory vessel characteristics were absent or negligible. The patterns were similar for relationships between GOLD D and mortality with vessel characteristics. Expiratory venous volume was an independent predictor of mortality, in addition to FEV1. Conclusion By using automated software in patients with COPD, clinically relevant information on pulmonary vasculature can be extracted from expiratory CT scans (although not inspiratory scans); in particular, expiratory pulmonary venous volume predicted mortality. Trial Registration NCT01245933.
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Affiliation(s)
- Mircea Gabriel Stoleriu
- Division for Thoracic Surgery Munich, Ludwig-Maximilians-University of Munich (LMU) and Asklepios Medical Center; Munich-Gauting, Gauting, 82131, Germany
- Institute for Lung Health and Immunity and Comprehensive Pneumology Center with the CPC-M bioArchive; Helmholtz Center Munich; Member of the German Lung Research Center (DZL), Munich, 81377, Germany
| | - Michael Pienn
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Rudolf A Joerres
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Hospital of Ludwig-Maximilians-University Munich (LMU), Munich, 80336, Germany
| | - Peter Alter
- Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg (UMR), Member of the German Center for Lung Research (DZL), Marburg, 35033, Germany
| | - Tamas Fero
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Urschler
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Gabor Kovacs
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- University Clinic for Internal Medicine, Medical University of Graz, Division of Pulmonology, Graz, Austria
| | - Horst Olschewski
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- University Clinic for Internal Medicine, Medical University of Graz, Division of Pulmonology, Graz, Austria
| | - Hans-Ulrich Kauczor
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany
| | - Mark Wielpütz
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany
| | - Bertram Jobst
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany
| | - Tobias Welte
- Department of Respiratory Medicine and Infectious Disease, Member of the German Center of Lung Research, Hannover School of Medicine, Hannover, Germany
| | - Jürgen Behr
- Institute for Lung Health and Immunity and Comprehensive Pneumology Center with the CPC-M bioArchive; Helmholtz Center Munich; Member of the German Lung Research Center (DZL), Munich, 81377, Germany
- Department of Medicine V, LMU University Hospital, LMU Munich, Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Franziska C Trudzinski
- Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany
- Department of Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
| | - Robert Bals
- Department of Internal Medicine V-Pulmonology, Allergology and Respiratory Critical Care Medicine, Saarland University, Homburg, 66421, Germany
- Helmholtz Institute for Pharmaceutical Research, Saarbrücken, 66123, Germany
| | - Henrik Watz
- Pulmonary Research Institute at LungenClinic Grosshansdorf, Airway Research Centre North, German Centre for Lung Research, Großhansdorf, Germany
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg (UMR), Member of the German Center for Lung Research (DZL), Marburg, 35033, Germany
| | - Jürgen Biederer
- Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany
- Faculty of Medicine, Christian-Albrechts-Universität Zu Kiel, Kiel, Germany
- University of Latvia, Faculty of Medicine, Riga, LV-1586, Latvia
| | - Kathrin Kahnert
- Institute for Lung Health and Immunity and Comprehensive Pneumology Center with the CPC-M bioArchive; Helmholtz Center Munich; Member of the German Lung Research Center (DZL), Munich, 81377, Germany
- Department of Medicine V, LMU University Hospital, LMU Munich, Member of the German Center for Lung Research (DZL), Munich, Germany
- MediCenterGermering, Germering, Germany
| | - On behalf of the COSYCONET Study Group
- Division for Thoracic Surgery Munich, Ludwig-Maximilians-University of Munich (LMU) and Asklepios Medical Center; Munich-Gauting, Gauting, 82131, Germany
- Institute for Lung Health and Immunity and Comprehensive Pneumology Center with the CPC-M bioArchive; Helmholtz Center Munich; Member of the German Lung Research Center (DZL), Munich, 81377, Germany
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Hospital of Ludwig-Maximilians-University Munich (LMU), Munich, 80336, Germany
- Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg (UMR), Member of the German Center for Lung Research (DZL), Marburg, 35033, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
- University Clinic for Internal Medicine, Medical University of Graz, Division of Pulmonology, Graz, Austria
- Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany
- Department of Respiratory Medicine and Infectious Disease, Member of the German Center of Lung Research, Hannover School of Medicine, Hannover, Germany
- Department of Medicine V, LMU University Hospital, LMU Munich, Member of the German Center for Lung Research (DZL), Munich, Germany
- Department of Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
- Department of Internal Medicine V-Pulmonology, Allergology and Respiratory Critical Care Medicine, Saarland University, Homburg, 66421, Germany
- Helmholtz Institute for Pharmaceutical Research, Saarbrücken, 66123, Germany
- Pulmonary Research Institute at LungenClinic Grosshansdorf, Airway Research Centre North, German Centre for Lung Research, Großhansdorf, Germany
- Faculty of Medicine, Christian-Albrechts-Universität Zu Kiel, Kiel, Germany
- University of Latvia, Faculty of Medicine, Riga, LV-1586, Latvia
- MediCenterGermering, Germering, Germany
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Kwon OB, Lee HU, Park HE, Choi JY, Kim JW, Lee SH, Yeo CD. Predicting Postoperative Lung Function in Patients with Lung Cancer Using Imaging Biomarkers. Diseases 2024; 12:65. [PMID: 38667523 PMCID: PMC11049658 DOI: 10.3390/diseases12040065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/19/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024] Open
Abstract
There have been previous studies conducted to predict postoperative lung function with pulmonary function tests (PFTs). Computing tomography (CT) can quantitatively measure small airway walls' thickness, lung volume, pulmonary vessel volume, and emphysema area, which reflect the severity of respiratory diseases. These measurements are considered imaging biomarkers. This study aimed to predict postoperative lung function with imaging biomarkers. A retrospective analysis of 79 patients with lung cancer who had undergone lung surgery was completed. Postoperative lung function measured by forced expiratory volume in one second (FEV1) was defined as an outcome. Preoperative clinico-pathological parameters and imaging biomarkers representing airway walls' thickness, severity of emphysema, total lung volume, and pulmonary vessel volume were measured quantitatively in chest CT by an automated segmentation software, AVIEW COPD. Pi1 was defined as the first percentile along the histogram of lung attenuation that represents the degree of emphysema. Wafw was defined as the airway thickness, which was calculated by the full-width at half-maximum method. Logistic and linear regressions were used to assess these variables. If the actual postoperative FEV1 was higher than the postoperative FEV1 projected by a formula, the group was considered to be preserved. Among the 79 patients, 16 of the patients were grouped as a non-preserved group, and 63 of them were grouped as a preserved group. The patients in the preserved FEV1 group had a higher vessel volume than the non-preserved group. Pi1 and Wafw were independent predictors of postoperative lung function. Imaging biomarkers can be considered significant variables in predicting postoperative lung function in patients with lung cancer.
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Affiliation(s)
- Oh-Beom Kwon
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (O.-B.K.); (J.-Y.C.); (J.-W.K.); (S.-H.L.)
- Department of Internal Medicine, Kangwon National University Hospital, Chuncheon 24289, Republic of Korea
| | - Hae-Ung Lee
- Coreline Soft Co., Ltd., Seoul 03991, Republic of Korea; (H.-U.L.); (H.-E.P.)
| | - Ha-Eun Park
- Coreline Soft Co., Ltd., Seoul 03991, Republic of Korea; (H.-U.L.); (H.-E.P.)
| | - Joon-Young Choi
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (O.-B.K.); (J.-Y.C.); (J.-W.K.); (S.-H.L.)
| | - Jin-Woo Kim
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (O.-B.K.); (J.-Y.C.); (J.-W.K.); (S.-H.L.)
| | - Sang-Haak Lee
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (O.-B.K.); (J.-Y.C.); (J.-W.K.); (S.-H.L.)
| | - Chang-Dong Yeo
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (O.-B.K.); (J.-Y.C.); (J.-W.K.); (S.-H.L.)
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Huang YS, Chen ZW, Lee WJ, Wu CK, Kuo PH, Hsu HH, Tang SY, Tsai CH, Su MY, Ko CL, Hwang JJ, Lin YH, Chang YC. Treatment Response Evaluation by Computed Tomography Pulmonary Vasculature Analysis in Patients With Chronic Thromboembolic Pulmonary Hypertension. Korean J Radiol 2023; 24:349-361. [PMID: 36907594 PMCID: PMC10067691 DOI: 10.3348/kjr.2022.0675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 12/21/2022] [Accepted: 01/28/2023] [Indexed: 03/14/2023] Open
Abstract
OBJECTIVE To quantitatively assess the pulmonary vasculature using non-contrast computed tomography (CT) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) pre- and post-treatment and correlate CT-based parameters with right heart catheterization (RHC) hemodynamic and clinical parameters. MATERIALS AND METHODS A total of 30 patients with CTEPH (mean age, 57.9 years; 53% female) who received multimodal treatment, including riociguat for ≥ 16 weeks with or without balloon pulmonary angioplasty and underwent both non-contrast CT for pulmonary vasculature analysis and RHC pre- and post-treatment were included. The radiographic analysis included subpleural perfusion parameters, including blood volume in small vessels with a cross-sectional area ≤ 5 mm² (BV5) and total blood vessel volume (TBV) in the lungs. The RHC parameters included mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR), and cardiac index (CI). Clinical parameters included the World Health Organization (WHO) functional class and 6-minute walking distance (6MWD). RESULTS The number, area, and density of the subpleural small vessels increased after treatment by 35.7% (P < 0.001), 13.3% (P = 0.028), and 39.3% (P < 0.001), respectively. The blood volume shifted from larger to smaller vessels, as indicated by an 11.3% increase in the BV5/TBV ratio (P = 0.042). The BV5/TBV ratio was negatively correlated with PVR (r = -0.26; P = 0.035) and positively correlated with CI (r = 0.33; P = 0.009). The percent change across treatment in the BV5/TBV ratio correlated with the percent change in mPAP (r = -0.56; P = 0.001), PVR (r = -0.64; P < 0.001), and CI (r = 0.28; P = 0.049). Furthermore, the BV5/TBV ratio was inversely associated with the WHO functional classes I-IV (P = 0.004) and positively associated with 6MWD (P = 0.013). CONCLUSION Non-contrast CT measures could quantitatively assess changes in the pulmonary vasculature in response to treatment and were correlated with hemodynamic and clinical parameters.
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Affiliation(s)
- Yu-Sen Huang
- Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Zheng-Wei Chen
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Wen-Jeng Lee
- Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Cho-Kai Wu
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ping-Hung Kuo
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsao-Hsun Hsu
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shu-Yu Tang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Cheng-Hsuan Tsai
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Mao-Yuan Su
- Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chi-Lun Ko
- Departments of Nuclear Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Juey-Jen Hwang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Yen-Hung Lin
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yeun-Chung Chang
- Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
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Cheng Y, Li L, Tu X, Pei R. The Main Pulmonary Artery to the Ascending Aorta Diameter Ratio (PA/A) as a Predictor of Worse Outcomes in Hospitalized Patients with AECOPD. Int J Chron Obstruct Pulmon Dis 2022; 17:1157-1165. [PMID: 35601020 PMCID: PMC9122045 DOI: 10.2147/copd.s357696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/30/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose The main pulmonary artery (PA) to ascending aorta diameter ratio (PA/A) greater than one is a promising indicator of pulmonary hypertension (PH) in acute exacerbation (AE) of chronic obstructive pulmonary disease (COPD) (AECOPD). This study aims to disclose the associations between the PA/A ratio and clinical outcomes in hospitalized patients with AECOPD. Patients and Methods Consecutive AECOPD patients admitted to the Department of Respiratory Medicine from September 2017 to July 2021 were reviewed. The treatment success of AECOPD patients was defined as improvement in the clinical condition when discharged from the hospital. Conversely, treatment failure was considered to be an event of in-hospital death or deterioration of the clinical condition prior to discharge. Results A total of 118 individuals were ultimately reviewed in this study: 74 individuals with a PA/A ratio <1 and 44 individuals with a PA/A ratio ≥1. The outcomes of 21 patients were treatment failure, and 97 patients were considered successes. Patients with a PA/A ratio ≥1 had significantly higher PaCO2, red cell distribution width, brain natriuretic peptide, PA diameters, RICU admission rates, and proportions of treatment failure than patients with PA/A ratios <1 (P < 0.05). The PA diameter and PA/A ratio were significantly increased in the treatment failure group compared with the success group (P < 0.05). A survival analysis indicated that patients with a PA/A ratio ≥1 had worse outcomes than patients with a PA/A ratio <1 during hospitalization (P < 0.05). A multivariate analysis showed that a PA/A ratio ≥1 was an independent risk factor for treatment failure in patients with AECOPD. Conclusions AECOPD patients with a PA/A ratio ≥1 may have worse outcomes during hospitalization. A PA/A ratio ≥1 may be a promising predictor of treatment failure in patients with AECOPD.
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Affiliation(s)
- Yusheng Cheng
- Department of Respiratory Medicine, Yijishan Hospital, Wannan Medical College, Wuhu, People’s Republic of China
| | - Lingling Li
- Department of Respiratory Medicine, Yijishan Hospital, Wannan Medical College, Wuhu, People’s Republic of China
| | - Xiongwen Tu
- Department of Respiratory Medicine, Yijishan Hospital, Wannan Medical College, Wuhu, People’s Republic of China
| | - Renguang Pei
- Department of Interventional Therapy, Yijishan Hospital, Wannan Medical College, Wuhu, People’s Republic of China
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Park SW, Lim MN, Kim WJ, Bak SH. Quantitative assessment the longitudinal changes of pulmonary vascular counts in chronic obstructive pulmonary disease. Respir Res 2022; 23:29. [PMID: 35164757 PMCID: PMC8842934 DOI: 10.1186/s12931-022-01953-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 02/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chest computed tomography (CT) is a widely used method to assess morphological and dynamic abnormalities in chronic obstructive pulmonary disease (COPD). The small pulmonary vascular cross-section (CSA), quantitatively extracted from volumetric CT, is a reliable indicator for predicting pulmonary vascular changes. CSA is associated with the severity of symptoms, pulmonary function tests (PFT) and emphysema and in COPD patients the severity increases over time. We analyzed the correlation longitudinal changes in pulmonary vascular parameters with clinical parameters in COPD patients. MATERIALS AND METHODS A total of 288 subjects with COPD were investigated during follow up period up to 6 years. CT images were classified into five subtypes from normal to severe emphysema according to percentage of low-attenuation areas less than -950 and -856 Hounsfield units (HU) on inspiratory and expiratory CT (LAA-950, LAA-856exp). Total number of vessels (Ntotal) and total number of vessels with area less than 5 mm2 (N<5 mm) per 1 cm2 of lung surface area (LSA) were measured at 6 mm from the pleural surface. RESULTS Ntotal/LSA and N<5 mm/LSA changed from 1.16 ± 0.27 to 0.87 ± 0.2 and from 1.02 ± 0.22 to 0.78 ± 0.22, respectively, during Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage progression. Both parameters changed from normal to severe emphysema according to CT subtype from 1.39 ± 0.21 to 0.74 ± 0.17 and from 1.18 ± 0.19 to 0.67 ± 0.15, respectively. LAA-950 and LAA-856exp were negatively correlated with Ntotal/LSA (r = - 0.738, - 0.529) and N<5 mm /LSA (r = - 0.729, -- .497). On the other hand, pulmonary function test (PFT) results showed a weak correlation with Ntotal/LSA and N<5 mm/LSA (r = 0.205, 0.210). The depth in CT subtypes for longitudinal change both Ntotal/LSA and N<5 mm/LSA was (- 0.032, - 0.023) and (- 0.027) in normal and SAD, respectively. CONCLUSIONS Quantitative computed tomography features faithfully reflected pulmonary vessel alterations, showing in particular that pulmonary vascular alteration started.
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Affiliation(s)
- Sang Won Park
- Department of Big Data Medical Convergence, School of Medicine, Kangwon National University, Chuncheon, Republic of Korea
| | - Myoung-Nam Lim
- Department of Biomedical Research Institute, Kangwon National University Hospital, Chuncheon, Republic of Korea
- Department of Environmental Health Center, Kangwon National University Hospital, Chuncheon, Republic of Korea
| | - Woo Jin Kim
- Department of Biomedical Research Institute, Kangwon National University Hospital, Chuncheon, Republic of Korea
- Department of Environmental Health Center, Kangwon National University Hospital, Chuncheon, Republic of Korea
- Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon, Republic of Korea
| | - So Hyeon Bak
- Department of Radiology, School of Medicine, Kangwon National University, 1 Kangwondaehak-gil, Chuncheon, Gangwon-do, 24341, Republic of Korea.
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