Pulmonary vascular phenotype identified in patients with GDF2 (BMP9) or BMP10 variants: an international multicentre study

BACKGROUND

Bone morphogenetic proteins 9 and 10 (BMP9 and BMP10), encoded by GDF2 and BMP10, respectively, play a pivotal role in pulmonary vascular regulation. GDF2 variants have been reported in pulmonary arterial hypertension (PAH) and hereditary haemorrhagic telangiectasia (HHT). However, the phenotype of GDF2 and BMP10 carriers remains largely unexplored.

METHODS

We report the characteristics and outcomes of PAH patients in GDF2 and BMP10 carriers from the French and Dutch pulmonary hypertension registries. A literature review explored the phenotypic spectrum of these patients.

RESULTS

26 PAH patients were identified: 20 harbouring heterozygous GDF2 variants, one homozygous GDF2 variant, four heterozygous BMP10 variants, and one with both GDF2 and BMP10 variants. The prevalence of GDF2 and BMP10 variants was 1.3% and 0.4%, respectively. Median age at PAH diagnosis was 30 years, with a female/male ratio of 1.9. Congenital heart disease (CHD) was present in 15.4% of the patients. At diagnosis, most of the patients (61.5%) were in New York Heart Association Functional Class III or IV with severe haemodynamic compromise (median (range) pulmonary vascular resistance 9.0 (3.3-40.6) WU). Haemoptysis was reported in four patients; none met the HHT criteria. Two patients carrying BMP10 variants underwent lung transplantation, revealing typical PAH histopathology. The literature analysis showed that 7.6% of GDF2 carriers developed isolated HHT, and identified cardiomyopathy and developmental disorders in BMP10 carriers.

CONCLUSIONS

GDF2 and BMP10 pathogenic variants are rare among PAH patients, and occasionally associated with CHD. HHT cases among GDF2 carriers are limited according to the literature. BMP10 full phenotypic ramifications warrant further investigation.

Radiological pulmonary sequelae after COVID-19 and correlation with clinical and functional pulmonary evaluation: results of a prospective cohort

OBJECTIVES

Whether COVID-19 leads to long-term pulmonary sequelae or not remains unknown. The aim of this study was to assess the prevalence of persisting radiological pulmonary fibrotic lesions in patients hospitalized for COVID-19.

MATERIALS AND METHODS

We conducted a prospective single-center study among patients hospitalized for COVID-19 between March and May 2020. Patients with residual symptoms or admitted into intensive care units were investigated 4 months after discharge by a chest CT (CCT) and pulmonary function tests (PFTs). The primary endpoint was the rate of persistent radiological fibrotic lesions after 4 months. Secondary endpoints included further CCT evaluation at 9 and 16 months, correlation of fibrotic lesions with clinical and PFT evaluation, and assessment of predictive factors.

RESULTS

Among the 1151 patients hospitalized for COVID-19, 169 patients performed a CCT at 4 months. CCTs showed pulmonary fibrotic lesions in 19% of the patients (32/169). These lesions were persistent at 9 months and 16 months in 97% (29/30) and 95% of patients (18/19) respectively. There was no significant clinical difference based on dyspnea scale in patients with pulmonary fibrosis. However, PFT evaluation showed significantly decreased diffusing lung capacity for carbon monoxide (p < 0.001) and total lung capacity (p < 0.001) in patients with radiological lesions. In multivariate analysis, the predictive factors of radiological pulmonary fibrotic lesions were pulmonary embolism (OR = 9.0), high-flow oxygen (OR = 6.37), and mechanical ventilation (OR = 3.49).

CONCLUSION

At 4 months, 19% of patients investigated after hospitalization for COVID-19 had radiological pulmonary fibrotic lesions; they persisted up to 16 months.

CLINICAL RELEVANCE STATEMENT

Whether COVID-19 leads to long-term pulmonary sequelae or not remains unknown. The aim of this study was to assess the prevalence of persisting radiological pulmonary fibrotic lesions in patients hospitalized for COVID-19. The prevalence of persisting lesions after COVID-19 remains unclear. We assessed this prevalence and predictive factors leading to fibrotic lesions in a large cohort. The respiratory clinical impact of these lesions was also assessed.

KEY POINTS

• Nineteen percent of patients hospitalized for COVID-19 had radiological fibrotic lesions at 4 months, remaining stable at 16 months. • COVID-19 fibrotic lesions did not match any infiltrative lung disease pattern. • COVID-19 fibrotic lesions were associated with pulmonary function test abnormalities but did not lead to clinical respiratory manifestation.

Image quality assessment in low-dose COVID-19 chest CT examinations

BACKGROUND

Low-dose thoracic protocols were developed massively during the COVID-19 outbreak.

PURPOSE

To study the impact on image quality (IQ) and the diagnosis reliability of COVID-19 low-dose chest computed tomography (CT) protocols.

MATERIAL AND METHODS

COVID-19 low-dose protocols were implemented on third- and second-generation CT scanners considering two body mass index (BMI) subgroups (<25 kg/m2 and >25 kg/m2). Contrast-to-noise ratios (CNR) were compared with a Catphan phantom. Next, two radiologists retrospectively assessed IQ for 243 CT patients using a 5-point Linkert scale for general IQ and diagnostic criteria. Kappa score and Wilcoxon rank sum tests were used to compare IQ score and CTDIvol between radiologists, protocols, and scanner models.

RESULTS

In vitro analysis of Catphan inserts showed in majority significantly decreased CNR for the low dose versus standard acquisition protocols on both CT scanners. However, in vivo, there was no impact on the diagnosis: sensitivity and specificity were ≥0.8 for all protocols and CT scanners. The third-generation scanner involved a significantly lower dose compared to the second-generation scanner (CTDIvol of 1.8 vs. 2.6 mGy for BMI <25 kg/m2 and 3.3 vs. 4.6 mGy for BMI >25 kg/m2). Still, the third-generation scanner showed a significantly higher IQ with the low-dose protocol compared to the second-generation scanner (30.9 vs. 28.1 for BMI <25 kg/m2 and 29.9 vs. 27.8 for BMI >25 kg/m2). Finally, the two radiologists had good global inter-reader agreement (kappa ≥0.6) for general IQ.

CONCLUSION

Low-dose protocols provided sufficient IQ independently of BMI subgroups and CT models without any impact on diagnosis reliability.

Understanding a mass in the paraspinal region: an anatomical approach

The paraspinal region encompasses all tissues around the spine. The regional anatomy is complex and includes the paraspinal muscles, spinal nerves, sympathetic chains, Batson's venous plexus and a rich arterial network. A wide variety of pathologies can occur in the paraspinal region, originating either from paraspinal soft tissues or the vertebral column. The most common paraspinal benign neoplasms include lipomas, fibroblastic tumours and benign peripheral nerve sheath tumours. Tumour-like masses such as haematomas, extramedullary haematopoiesis or abscesses should be considered in patients with suggestive medical histories. Malignant neoplasms are less frequent than benign processes and include liposarcomas and undifferentiated sarcomas. Secondary and primary spinal tumours may present as midline expansile soft tissue masses invading the adjacent paraspinal region. Knowledge of the anatomy of the paraspinal region is of major importance since it allows understanding of the complex locoregional tumour spread that can occur via many adipose corridors, haematogenous pathways and direct contact. Paraspinal tumours can extend into other anatomical regions, such as the retroperitoneum, pleura, posterior mediastinum, intercostal space or extradural neural axis compartment. Imaging plays a crucial role in formulating a hypothesis regarding the aetiology of the mass and tumour staging, which informs preoperative planning. Understanding the complex relationship between the different elements and the imaging features of common paraspinal masses is fundamental to achieving a correct diagnosis and adequate patient management. This review gives an overview of the anatomy of the paraspinal region and describes imaging features of the main tumours and tumour-like lesions that occur in the region.

[Post-COVID-19 syndrome]

In the aftermath of acute infection with the severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2), a large number of symptoms persist or appear, constituting a real syndrome called "long COVID-19" or "post-COVID- 19" or "post-acute COVID-19 syndrome". Its incidence is very high, half of patients showing at least one symptom at 4-6 months after Coronarovirus infectious disease 2019 (COVID-19). They can affect many organs. The most common symptom is persistent fatigue, similar to that seen after other viral infections. Radiological pulmonary sequelae are relatively rare and not extensive. On the other hand, functional respiratory symptoms, primarily dyspnoea, are much more frequent. Dysfunctional breathing is a significant cause of dyspnoea. Cognitive disorders and psychological symptoms are also very common, with anxiety, depression and post-traumatic stress symptoms being widely described. On the other hand, cardiac, endocrine, cutaneous, digestive or renal sequelae are rarer. The symptoms generally improve after several months, even if their prevalence at two years remains significant. Most of the symptoms are favored by the severity of the initial illness, and the psychic symptoms by the female sex. The pathophysiology of most symptoms is poorly understood. The influence of the treatments used in the acute phase is also important. Vaccination, on the other hand, seems to reduce their incidence. The sheer number of affected patients makes long-term COVID-19 syndrome a public health challenge.

Functional respiratory complaints among COVID-19 survivors: a prospective cohort study

Background

Dyspnoea is a common persistent symptom after COVID-19. Whether it is associated with functional respiratory disorders remains unclear.

Methods

We assessed the proportion and characteristics of patients with “functional respiratory complaints” (FRCs) (as defined by Nijmegen Questionnaire>22) among 177 post-COVID-19 individuals who benefited from outclinic evaluation in the COMEBAC study (i.e., symptomatic and/or ICU survivors at 4 months). In a distinct explanatory cohort of 21 consecutive individuals with unexplained post-COVID-19 dyspnoea after routine tests, we also analysed the physiological responses to incremental cardio-pulmonary exercise testing (CPET).

Findings

In the COMEBAC cohort, 37 had significant FRCs (20.9%, IC95: 14.9–26.9). The prevalence of FRCs ranged from 7.2% (ICU patients) to 37.5% (non-ICU patients). The presence of FRCs was significantly associated with more severe dyspnoea, lower 6-minute walk distance, more frequent psychological and neurological symptoms (cognitive complaint, anxiety, depression, insomnia and post-traumatic stress disorders) and poorer quality of life (all p<0.01). In the explanatory cohort, 7/21 patients had significant FRCs. Based on CPET, dysfunctional breathing was identified in 12/21 patients, 5/21 had normal CPET, 3/21 had deconditioning and 1/21 had evidence of uncontrolled cardiovascular disease.

Interpretation

FRCs are common during post-COVID-19 follow-up, especially among patients with unexplained dyspnoea. Diagnosis of dysfunctional breathing should be considered in those cases.

Funding

Assistance Publique-Hôpitaux de Paris.

CX-DaGAN: Domain Adaptation for Pneumonia Diagnosis on a Small Chest X-Ray Dataset

Recent advances in deep learning led to several algorithms for the accurate diagnosis of pneumonia from chest X-rays. However, these models require large training medical datasets, which are sparse, isolated, and generally private. Furthermore, these models in medical imaging are known to over-fit to a particular data domain source, i.e., these algorithms do not conserve the same accuracy when tested on a dataset from another medical center, mainly due to image distribution discrepancies. In this work, a domain adaptation and classification technique is proposed to overcome the over-fit challenges on a small dataset. This method uses a private-small dataset (target domain), a public-large labeled dataset from another medical center (source domain), and consists of three steps. First, it performs a data selection of the source domain's most representative images based on similarity constraints through principal component analysis subspaces. Second, the selected samples from the source domain are fit to the target distribution through an image to image translation based on a cycle-generative adversarial network. Finally, the target train dataset and the adapted images from the source dataset are used within a convolutional neural network to explore different settings to adjust the layers and perform the classification of the target test dataset. It is shown that fine-tuning a few specific layers together with the selected-adapted images increases the sorting accuracy while reducing the trainable parameters. The proposed approach achieved a notable increase in the target dataset's overall classification accuracy, reaching up to 97.78 % compared to 90.03 % by standard transfer learning.

Comorbidity of long COVID and psychiatric disorders after a hospitalisation for COVID-19: a cross-sectional study

OBJECTIVES

Long COVID is a major public health issue. Whether long COVID is comorbid with psychiatric disorders remains unclear. Here, we investigate the association between long COVID, psychiatric symptoms and psychiatric disorders.

DESIGN

Cross-sectional.

SETTINGS

Bicêtre Hospital, France, secondary care.

PARTICIPANTS

One hundred seventy-seven patients admitted in intensive care unit during acute phase and/or reporting long COVID complaints were assessed 4 months after hospitalisation for an acute COVID.

MAIN OUTCOME MEASURES

Eight long COVID complaints were investigated: fatigue, respiratory and cognitive complaints, muscle weakness, pain, headache, paraesthesia and anosmia. The number of complaints, the presence/absence of each COVID-19 complaint as well as lung CT scan abnormalities and objective cognitive impairment) were considered. Self-reported psychiatric symptoms were assessed with questionnaires. Experienced psychiatrists assessed Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-based diagnoses of psychiatric disorders.

RESULTS

One hundred and fifteen (65%) patients had at least one long COVID complaint. The number of long COVID complaints was associated with psychiatric symptoms. The number of long COVID complaints was higher in patients with psychiatric disorders (mean (m) (SD)=2.47 (1.30), p<0.05), new-onset psychiatric disorders (m (SD)=2.41 (1.32), p<0.05) and significant suicide risk (m (SD)=2.67 (1.32), p<0.05) than in patients without any psychiatric disorder (m (SD)=1.43 (1.48)). Respiratory complaints were associated with a higher risk of psychiatric disorder and new-onset psychiatric disorder, and cognitive complaints were associated with a higher risk of psychiatric disorder.

CONCLUSIONS

Long COVID is associated with psychiatric disorders, new-onset psychiatric disorders and suicide risk. Psychiatric disorders and suicide risk should be systematically assessed in patients with long COVID.

Endoscopic ultrasound as a reliable tool for assessment of pancreatic adenocarcinoma treatment: Example of in situ gene therapy

Background and study aims  In pancreatic cancer, the antitumor effect can only be assessed by means of a computed tomography (CT) scan using RECIST (Response Evaluation Criteria in Solid Tumours) criteria. The aim of this study was to assess the intra-observer and interobserver agreement of endoscopic ultrasound (EUS) imaging in assessing tumor volume in primary pancreatic cancer. Patients and methods  During a Phase 1 gene therapy trial, 21 patients had EUS before the first and second EUS-guided in situ gene therapy injections. All anonymized EUS files were then randomly distributed to three gastroenterologists/endosonographers and three radiologists (blind status). The largest tumor diameter was measured and the intraclass correlation coefficient (ICC) was determined. Results  Intra-observer and interobserver agreements were good to excellent, regardless of operator experience (junior versus senior member of staff) (ICC: 0.65 to 0.84). A comparison of pretreatment and post-treatment measurements by the investigators highlighted a significant antitumor effect (-11 %; P  = 0.0098), similar to that obtained during the generic protocol (-10 %; P  = 0.0045). Conclusions  Interobserver agreement regarding primary pancreatic adenocarcinoma measurements appears good to excellent, thus paving the way for the future inclusion of EUS assessments, particularly in trials assessing local therapies for pancreatic tumors.

"Triple low" free-breathing CTPA protocol for patients with dyspnoea

AIM

To assess the performance of a "triple-low" free-breathing protocol for computed tomography pulmonary angiography (CTPA) evaluated on patients with dyspnoea and suspected pulmonary embolism and discuss its application in routine clinical practice for the study of the pulmonary parenchyma and vasculature.

MATERIAL AND METHODS

This study was conducted on a selected group of dyspnoeic patients referred for CTPA. The protocol was designed using fast free-breathing acquisition and a small, fixed volume (35 ml) of contrast agent in order to achieve a low-exposure dose. For each examination, radiodensity of the pulmonary trunk and ascending aorta, and the dose-length product (DLP) were recorded. A qualitative analysis was performed of pulmonary arterial enhancement and the pulmonary parenchyma.

RESULTS

This study included 134 patients. Contrast enhancement of the pulmonary arteries (409 ± 159 HU) was systematically >250 HU. The duration of acquisition ranged from 0.9 to 1.3 seconds for free-breathing imaging. The mean DLP was in the range of low-dose chest CT acquisitions (145 ± 73 mGy·cm). The analysis was deemed optimal in 90% (120/134) of cases for the pulmonary parenchyma. Sixty-nine per cent (92/134) of cases demonstrated homogeneous enhancement of the pulmonary arteries to the subsegmental level. Only 6% (8/134) of examinations were considered uninterpretable.

CONCLUSION

The present "triple-low" CTPA protocol allows convenient analysis of the pulmonary parenchyma and arteries without hindrance by respiratory motion artefacts in dyspnoeic patients.

Post-acute COVID-19 syndrome

Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the coronavirus disease 2019 (COVID-19) pandemic that has resulted in millions of deaths and a major strain on health systems worldwide. Medical treatments for COVID-19 (anticoagulants, corticosteroids, anti-inflammatory drugs, oxygenation therapy and ventilation) and vaccination have improved patient outcomes. The majority of patients will recover spontaneously or after acute-phase management, but clinicians are now faced with long-term complications of COVID-19 including a large variety of symptoms, defined as "post-acute COVID-19 syndrome". Most studies have focused on patients hospitalised for severe COVID-19, but acute COVID-19 syndrome is not restricted to these patients and exists in outpatients. Given the diversity of symptoms and the high prevalence of persistent symptoms, the management of these patients requires a multidisciplinary team approach, which will result in the consumption of large amounts of health resources in the coming months. In this review, we discuss the presentation, prevalence, pathophysiology and evolution of respiratory complications and other organ-related injuries associated with post-acute COVID-19 syndrome.

Respiratory symptoms and radiologic findings in post-acute COVID-19 syndrome

Rationale

The characteristics of patients with respiratory complaints and/or lung radiologic abnormalities after hospitalisation for coronavirus disease 2019 (COVID-19) are unknown. The objectives were to determine their characteristics and the relationships between dyspnoea, radiologic abnormalities and functional impairment.

Methods

In the COMEBAC (Consultation Multi-Expertise de Bicêtre Après COVID-19) cohort study, 478 hospital survivors were evaluated by telephone 4 months after hospital discharge, and 177 who had been hospitalised in an intensive care unit (ICU) or presented relevant symptoms underwent an ambulatory evaluation. New-onset dyspnoea and cough were evaluated, and the results of pulmonary function tests and high-resolution computed tomography of the chest were collected.

Results

Among the 478 patients, 78 (16.3%) reported new-onset dyspnoea, and 23 (4.8%) new-onset cough. The patients with new-onset dyspnoea were younger (56.1±12.3 versus 61.9±16.6 years), had more severe COVID-19 (ICU admission 56.4% versus 24.5%) and more frequent pulmonary embolism (18.0% versus 6.8%) (all p≤0.001) than patients without dyspnoea. Among the patients reassessed at the ambulatory care visit, the prevalence of fibrotic lung lesions was 19.3%, with extent <25% in 97% of the patients. The patients with fibrotic lesions were older (61±11 versus 56±14 years, p=0.03), more frequently managed in an ICU (87.9 versus 47.4%, p<0.001), had lower total lung capacity (74.1±13.7 versus 84.9±14.8% pred, p<0.001) and diffusing capacity of the lung for carbon monoxide (D_LCO) (73.3±17.9 versus 89.7±22.8% pred, p<0.001). The combination of new-onset dyspnoea, fibrotic lesions and D_LCO <70% pred was observed in eight out of 478 patients.

Conclusions

New-onset dyspnoea and mild fibrotic lesions were frequent at 4 months, but the association of new-onset dyspnoea, fibrotic lesions and low D_LCO was rare.

New-onset dyspnoea is a frequent complaint 4 months after #COVID19 and is generally multifactorial, and the combination of new-onset dyspnoea, fibrotic lesions and D_LCO <70% pred is rarely observedhttps://bit.ly/3q4hyyM

Right ventricular shotgun pellet embolism: Case report and radiological aspect

Pellet embolism to the heart following gunshot injuries is an unusual event that requires a fast diagnosis. Imaging assessment is necessary to locate the projectiles and look for associated injuries. We present a case of a 41-year-old woman admitted after sustaining 2 gunshot wounds in the abdomen and left thigh, with the initial computed tomography (CT) scan showing a metallic object next to the right ventricle. Further radiological evaluation included transthoracic echocardiography and electrocardiogram-gated cardiac CT scan which confirmed the diagnosis of a migrating pellet to the right ventricle, entrapped within the trabeculations. Electrocardiogram-gated cardiac CT has a major role in detailed evaluation of bullet embolism to the heart cavities and guides the management.

Prevalence of pulmonary embolism in patients with COVID-19 at the time of hospital admission

A high prevalence of venous thromboembolism (VTE) has been reported during intensive care unit (ICU) hospitalisation in patients with severe coronavirus disease 2019 (COVID-19) [1, 2]. In most cases, the diagnosis of pulmonary embolism (PE) was incidental as patients underwent computed tomography pulmonary angiography (CTPA) for aggravation of their respiratory condition. Higher mortality is also described in patients with high D-dimer levels suggesting that VTE complication may contribute to unfavourable prognosis [3, 4]. Even though, prevalence of thromboembolic complications during ICU hospitalisation seems to be high, the prevalence of pulmonary embolism at hospital admission for COVID-19 is unknown and may be underestimated.

There is a high prevalence of pulmonary embolism in patients with COVID-19 at the time of hospital admissionhttps://bit.ly/3reaLjv

Pulmonary Hypertension in Patients with Common Variable Immunodeficiency

PURPOSE

Common variable immunodeficiency (CVID) is known to cause infectious, inflammatory, and autoimmune manifestations. Pulmonary hypertension (PH) is an unusual complication of CVID with largely unknown characteristics and mechanisms.

METHODS

We report the clinical, functional, hemodynamics, radiologic and histologic characteristics, and outcomes of CVID-associated PH patients from the French PH Network.

RESULTS

Ten patients were identified. The median (range) age at CVID diagnosis was 36.5 (4-49) years and the median delay between CVID and PH diagnosis was 12 (0-30) years. CVID-associated PH affected predominantly women (female-to-male ratio 9:1). Most patients were New York Heart Association functional class III with a severe hemodynamic profile and frequent portal hypertension (n = 6). Pulmonary function tests were almost normal in 70% of patients and showed a mild restrictive syndrome in 30% of patients while the diffusing capacity for carbon monoxide was decreased in all but one patient. High-resolution computed tomography found enlarged mediastinal nodes, mild interstitial infiltration with reticulations and nodules. Two patients had a CIVD-interstitial lung disease, and one presented with bronchiectasis. Pathologic assessment of lymph nodes performed in 5 patients revealed the presence of granulomas (n = 5) and follicular lymphoid hyperplasia (n = 3). At last follow-up (median 24.5 months), 9 patients were alive, and one patient died of Hodgkin disease.

CONCLUSION

PH is a possible complication of CVID whose pathophysiological mechanisms, while still unclear, would be due to the inflammatory nature of CVID. CVID-associated PH presents as precapillary PH with multiple possible causes, acting in concert in some patients: a portal hypertension, a pulmonary vascular remodeling, sometimes a pulmonary parenchymal involvement and occasionally an extrinsic compression by mediastinal lymphadenopathies, which would be consistent with its classification in group 5 of the current PH classification.

Prevalence of Thoracic Aortic Aneurysms in Patients with Degenerative Abdominal Aortic Aneurysms: Results from the Prospective ACTA Study

OBJECTIVE

There are no recommendations for screening for thoracic aortic aneurysms (TAAs), even in patients with infrarenal abdominal aortic aneurysms (AAAs). The aims of this study were to determine the prevalence of TAAs in patients with AAAs and to analyse the risk factors for this association.

METHODS

This was a multicentre prospective study. The Aortic Concomitant Thoracic and Abdominal Aneurysm (ACTA) study included 331 patients with infrarenal AAAs > 40 mm between September 2012 and May 2016. These patients were prospectively enrolled in three French academic hospitals.

RESULTS

Patients were classified as having a normal, aneurysmal, or ectatic (non-normal, non-aneurysmal) thoracic aorta according to their maximum aortic diameter indexed by sex, age, and body surface area. Thoracic aortic ectasia (TAE) was defined as above or equal to the 90th percentile of normal aortic diameters according to gender and body surface area. Descending TAA was defined as ≥ 150% of the mean normal value, and ascending TAA as > 47 mm in men and 42 mm in women; 7.6% (n = 25) had either an ascending (seven cases; 2.2%) or descending aortic TAA (18 cases; 5.4%), and 54.6% (n = 181) had a TAE. Among the 25 patients with TAAs, five required surgery; two patients had TAAs related to penetrating aortic ulcers < 60 mm in diameter, and three had a TAA > 60 mm. In the multinomial regression analysis, atrial fibrillation (AF) (odds ratio [OR] 11.36, 95% confidence interval [CI] 2.18 - 59.13; p = .004) and mild aortic valvulopathy (OR 2.89, 1.04-8.05; p = .042) were independent factors associated with TAAs. Age (OR 1.06, CI 1.02 - 1.09; p = .003) and AF (OR 4.36, 1.21 - 15.61; p = .024) were independently associated with ectasia.

CONCLUSION

This study confirmed that TAAs coexisting with AAAs are not rare, and one fifth of these TAAs are treated surgically. Systematic screening by imaging the whole aorta in patients with AAAs is clinically relevant and should lead to an effective prevention policy.

Four-Month Clinical Status of a Cohort of Patients After Hospitalization for COVID-19

IMPORTANCE

Little is known about long-term sequelae of COVID-19.

OBJECTIVE

To describe the consequences at 4 months in patients hospitalized for COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

In a prospective uncontrolled cohort study, survivors of COVID-19 who had been hospitalized in a university hospital in France between March 1 and May 29, 2020, underwent a telephone assessment 4 months after discharge, between July 15 and September 18, 2020. Patients with relevant symptoms and all patients hospitalized in an intensive care unit (ICU) were invited for further assessment at an ambulatory care visit.

EXPOSURES

Survival of hospitalization for COVID-19.

MAIN OUTCOMES AND MEASURES

Respiratory, cognitive, and functional symptoms were assessed by telephone with the Q3PC cognitive screening questionnaire and a checklist of symptoms. At the ambulatory care visit, patients underwent pulmonary function tests, lung computed tomographic scan, psychometric and cognitive tests (including the 36-Item Short-Form Health Survey and 20-item Multidimensional Fatigue Inventory), and, for patients who had been hospitalized in the ICU or reported ongoing symptoms, echocardiography.

RESULTS

Among 834 eligible patients, 478 were evaluated by telephone (mean age, 61 years [SD, 16 years]; 201 men, 277 women). During the telephone interview, 244 patients (51%) declared at least 1 symptom that did not exist before COVID-19: fatigue in 31%, cognitive symptoms in 21%, and new-onset dyspnea in 16%. There was further evaluation in 177 patients (37%), including 97 of 142 former ICU patients. The median 20-item Multidimensional Fatigue Inventory score (n = 130) was 4.5 (interquartile range, 3.0-5.0) for reduced motivation and 3.7 (interquartile range, 3.0-4.5) for mental fatigue (possible range, 1 [best] to 5 [worst]). The median 36-Item Short-Form Health Survey score (n = 145) was 25 (interquartile range, 25.0-75.0) for the subscale "role limited owing to physical problems" (possible range, 0 [best] to 100 [worst]). Computed tomographic lung-scan abnormalities were found in 108 of 171 patients (63%), mainly subtle ground-glass opacities. Fibrotic lesions were observed in 33 of 171 patients (19%), involving less than 25% of parenchyma in all but 1 patient. Fibrotic lesions were observed in 19 of 49 survivors (39%) with acute respiratory distress syndrome. Among 94 former ICU patients, anxiety, depression, and posttraumatic symptoms were observed in 23%, 18%, and 7%, respectively. The left ventricular ejection fraction was less than 50% in 8 of 83 ICU patients (10%). New-onset chronic kidney disease was observed in 2 ICU patients. Serology was positive in 172 of 177 outpatients (97%).

CONCLUSIONS AND RELEVANCE

Four months after hospitalization for COVID-19, a cohort of patients frequently reported symptoms not previously present, and lung-scan abnormalities were common among those who were tested. These findings are limited by the absence of a control group and of pre-COVID assessments in this cohort. Further research is needed to understand longer-term outcomes and whether these findings reflect associations with the disease.

Integrating deep learning CT-scan model, biological and clinical variables to predict severity of COVID-19 patients

The SARS-COV-2 pandemic has put pressure on intensive care units, so that identifying predictors of disease severity is a priority. We collect 58 clinical and biological variables, and chest CT scan data, from 1003 coronavirus-infected patients from two French hospitals. We train a deep learning model based on CT scans to predict severity. We then construct the multimodal AI-severity score that includes 5 clinical and biological variables (age, sex, oxygenation, urea, platelet) in addition to the deep learning model. We show that neural network analysis of CT-scans brings unique prognosis information, although it is correlated with other markers of severity (oxygenation, LDH, and CRP) explaining the measurable but limited 0.03 increase of AUC obtained when adding CT-scan information to clinical variables. Here, we show that when comparing AI-severity with 11 existing severity scores, we find significantly improved prognosis performance; AI-severity can therefore rapidly become a reference scoring approach.

Blended learning of radiology improves medical students' performance, satisfaction, and engagement

Purpose

To evaluate the impact of blended learning using a combination of educational resources (flipped classroom and short videos) on medical students’ (MSs) for radiology learning.

Material and methods

A cohort of 353 MSs from 2015 to 2018 was prospectively evaluated. MSs were assigned to four groups (high, high-intermediate, low-intermediate, and low achievers) based on their results to a 20-MCQs performance evaluation referred to as the pretest. MSs had then free access to a self-paced course totalizing 61 videos based on abdominal imaging over a period of 3 months. Performance was evaluated using the change between posttest (the same 20 MCQs as pretest) and pretest results. Satisfaction was measured using a satisfaction survey with directed and spontaneous feedbacks. Engagement was graded according to audience retention and attendance on a web content management system.

Results

Performance change between pre and posttest was significantly different between the four categories (ANOVA, P = 10⁻⁹): low pretest achievers demonstrated the highest improvement (mean ± SD, + 11.3 ± 22.8 points) while high pretest achievers showed a decrease in their posttest score (mean ± SD, − 3.6 ± 19 points). Directed feedback collected from 73.3% of participants showed a 99% of overall satisfaction. Spontaneous feedback showed that the concept of “pleasure in learning” was the most cited advantage, followed by “flexibility.” Engagement increased over years and the number of views increased of 2.47-fold in 2 years.

Conclusion

Learning formats including new pedagogical concepts as blended learning, and current technologies allow improvement in medical student’s performance, satisfaction, and engagement.

Intercenter reproducibility of software-based fusion biopsies for grade group prediction when targeting suspicious MRI lesions

PURPOSE

To assess the intercenter reproducibility of software-based fusion targeted biopsy (TB) for grade-group assessment and pretherapeutic evaluation of highly suspicious MRI lesions.

PATIENTS AND METHODS

In this study, were included 380 consecutive patients who underwent radical prostatectomy (RP) after prostate cancer diagnosis and a prebiopsy MRI showing Prostate Imaging-Reporting and Data System (PIRADS) score 4 or 5 lesions. All patients underwent systematic biopsies (SB) combined with software-based fusion TB in the 2 centers. Biopsies were only performed by expert urologists or radiologists in a contemporary time frame. The primary endpoint was the center difference of concordance/upgrading rates between biopsy and RP specimens.

RESULTS

Pathological features on biopsy and RP specimens were significantly different among centers with more unfavourable disease in center 1. The rate of TB upgrading was 33.6% in center 1 vs. 35.4% (P = 0.860) in center 2. Grading concordance was also comparable among centers (50.0% vs. 47.1%) as well as the SB upgrading rate. Regression analysis did not find any baseline characteristics (Age, prostate-specific antigen, MRI lesions, center) predictive for TB upgrading. These findings were achieved by using fewer TB per lesion in center 1 (2.3 vs. 5.0, P < 0.001), at the expense of more SB cores (14.4 vs. 8.5, P < 0.001). The influence of MRI characteristics (lesion size and number, PIRADS score) on upgrading rates was consistent among centers.

CONCLUSIONS

Software-based fusion TB technique leads to comparable outcomes in terms of grade group prediction accuracy in PIRADS 4 to 5 lesions, insignificant between centers, in spite of different non imaging-based aggressiveness features.

Clear cell adenocarcinoma arising from the abdominal wall after cesarean section in a patient with uterine adenomyosis

Malignant transformation of abdominal wall endometriosis lesions developed in a cesarean section scar is a rare event. Patients with uterine adenomyosis but without endometriosis can also develop abdominal wall malignant carcinoma after a gynecologic surgery. The treatment of abdominal wall clear cell adenocarcinoma combines tumor surgical excision with free margins, radiotherapy and chemotherapy. We report a case of clear cell carcinoma arising from an abdominal wall cesarean section scar in a patient without history of endometriosis.

Combining Volumetric and Wall Shear Stress Analysis from CT to Assess Risk of Abdominal Aortic Aneurysm Progression

Background Despite known limitations, the decision to operate on abdominal aortic aneurysm (AAA) is primarily on the basis of measurement of maximal aneurysm diameter. Purpose To identify volumetric and computational fluid dynamics parameters to predict AAAs that are likely to progress in size. Materials and Methods This study, part of a multicenter prospective registry (NCT01599533), included 126 patients with AAA. Patients were sorted into stable (≤10-mL increase in aneurysm volume) and progression (>10-mL increase in aneurysm volume) groups. Initial AAA characteristics of the derivation cohort were analyzed (maximal diameter and surface, thrombus and lumen volumes, maximal wall pressure, and wall shear stress [WSS]) to identify relevant parameters for a logistic regression model. Model and maximal diameter diagnostic performances were assessed in both cohorts and for AAAs smaller than 50 mm by using area under the receiver operating characteristic curve (AUC). Results Eighty-one patients were included (mean age, 73 years ± 7 years [standard deviation]; 78 men). The derivation and validation cohorts included, respectively, 50 and 31 participants. In the derivation cohort, there was higher mean lumen volume and lower mean WSS in the progression group compared with the stable group (60 mL ± 14 vs 46 mL ± 18 [P = .005] and 66% ± 6 vs 53% ± 9 [P = .02], respectively). Mean lumen volume and mean WSS at baseline were correlated to total volume growth (r = 0.47 [P = .002] and -0.42 [P = .006], respectively). In the derivation cohort, a regression model including lumen volume and WSS to predict aneurysm enlargement was superior to maximal diameter alone (AUC, 0.78 vs 0.52, respectively; P = .003); although no difference was found in the validation cohort (AUC, 0.79 vs 0.71, respectively; P = .51). For AAAs smaller than 50 mm, a regression model that included both baseline WSS and lumen volume performed better than maximal diameter (AUC, 0.79 vs 0.53, respectively; P = .01). Conclusion Combined analysis of lumen volume and wall shear stress was associated with enlargement of abdominal aortic aneurysms at 1 year, particularly in aneurysms smaller than 50 mm in diameter. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Mitsouras and Leach in this issue.

Aortic abdominal dissection after retroperitoneal laparoscopic paraaortic lymphadenectomy

•Acute aortic abdominal dissection is a rare complication of retroperitoneal laparoscopic paraaortic lymph node dissection.•Aortic dissection may be part of differential diagnoses in patients with groin and abdominal pain after paraaortic staging.•Uncomplicated type B aortic abdominal dissection should be managed during the subacute phase.•Early contrast-enhanced computed tomography should be performed in case of abdominal pain after paraaortic lymphadenectomy.•Retroperitoneal laparoscopic paraaortic lymph node dissection should be performed at referral cancer centers.

Reconciling PC-MRI and CFD: An in-vitro study

Several well-resolved 4D Flow MRI acquisitions of an idealized rigid flow phantom featuring an aneurysm, a curved channel as well as a bifurcation were performed under pulsatile regime. The resulting hemodynamics were processed to remove MRI artifacts. Subsequently, they were compared with CFD predictions computed on the same flow domain, using an in-house high-order low dissipative flow solver. Results show that reaching a good agreement is not straightforward but requires proper treatments of both techniques. Several sources of discrepancies are highlighted and their impact on the final correlation evaluated. While a very poor correlation (r²  = 0.63) is found in the entire domain between raw MRI and CFD data, correlation as high as r²  = 0.97 is found when artifacts are removed by post-processing the MR data and down sampling the CFD results to match the MRI spatial and temporal resolutions. This work demonstrates that, in a well-controlled environment, both PC-MRI and CFD might bring reliable and correlated flow quantities when a proper methodology to reduce the errors is followed.

Prognostic impact of myocardial perfusion single photon emission computed tomography in patients with major extracardiac findings by computed tomography for attenuation correction

BACKGROUND

Attenuation correction computed tomography (CT) contributes to an improvement in the diagnostic accuracy of myocardial perfusion imaging (MPI) by single photon emission tomography (SPECT). The aim of this study was to explore the prognosis of patients with major findings by CT according to the results of MPI.

METHODS AND RESULTS

1506 patients who underwent MPI by SPECT were retrospectively included. Attenuation correction CT images were systematically analyzed for major and minor abnormalities. 830 (55.1%) and 212 (14.1%) patients had minor and major extracardiac findings, respectively. Among patients with major extracardiac findings, the abnormality was previously unknown in 113 (53.3%) patients. 90 (41.9%) had abnormal MPI, 73 (34.4%) had a myocardial infarction scar, 55 (25.9%) had myocardial ischemia, and 38 (17.7%) patients had both myocardial infarction scar and myocardial ischemia. Among the 201 patients available for survival analysis, there were 67 (31.2%) deaths over a follow-up period of 3.2±1.3 years. There was no significant impact on survival arising from MPI, whatever the result. The results were the same among the 103 patients with previously unknown major extracardiac findings.

CONCLUSION

Extracardiac findings by CT during MPI are frequent. Patients with major extracardiac findings have a poor mid-term outcome, whatever the results of the myocardial perfusion imaging. Extracardiac findings should be systematically checked when attenuation correction CT is performed.

Towards multi-phase postmortem CT angiography in children: a study on a porcine model

PURPOSE

Multi-phase postmortem computed tomography angiography (MPMCTA) is a growing technique, which is standardized for adults. Application of this protocol for a children population is not so well defined. Our study aims to adapt the adult's protocol to children, using a porcine model.

MATERIAL AND METHODS

Three groups of 18 pigs were studied, with a weight distribution between 4 and 48 kg. Different pump devices were used. Pigs of group I were studied using the Virtangio® machine, whereas pigs of groups II and III were studied using used the Medrad® machine. Study of vascular opacification was possible using a semi-quantitative method based on 26 arterial and 26 venous segments that were distributed over the entire body from the cephalic extremity to the posterior pawns.

RESULTS

While thoracic, abdominal, and pelvic vascular opacification were complete for each individual pig in a group, group III showed better vascular opacification for the cephalic extremity. This was also true for anterior and posterior pawns vascular opacification. Spearman correlation tests showed a significant relationship between anthropometric characteristics of pigs, injection parameters, and percentage of opacified segments. A higher percentage of opacification was obtained for individuals of lower weights, with comparatively lower quantities of contrast agent injected.

CONCLUSION

Postmortem computed tomography angiography (PMCTA) was possible for all the individuals, particularly for small weights (4 kg) using the Medrad® machine. However, further studies are needed to better understand the procedure.

Other non-surgical treatments for liver cancer

Interventional radiology plays a major role in the modern management of liver cancers, in primary hepatic malignancies or metastases and in palliative or curative situations. Radiological treatments are divided in two categories based on their approach: endovascular treatment and direct transcapsular access. Endovascular treatments include mainly three applications: transarterial chemoembolization (TACE), transarterial radioembolization (TARE) and portal vein embolization (PVE). TACE and TARE share an endovascular arterial approach, consisting of a selective catheterization of the hepatic artery or its branches. Subsequently, either a chemotherapy (TACE) or radioembolic (TARE) agent is injected in the target vessel to act on the tumor. PVE raises the volume of the future liver remnant in extended hepatectomy by embolizing a portal vein territory which results in hepatic regeneration. Direct transcapsular access treatments involve mainly three techniques: radiofrequency thermal ablation (RFA), microwave thermal ablation (MWA) and percutaneous ethanol injection (PEI). RFA and MWA procedures are almost identical, their clinical applications are similar. A probe is deployed directly into the tumor to generate heat and coagulation necrosis. PEI has known implications based on the chemical toxicity of intra-tumoral injection with highly concentrated alcohol by a thin needle.

US-guided Percutaneous Release of the Trigger Finger by Using a 21-gauge Needle: A Prospective Study of 60 Cases

Purpose To evaluate the efficacy of ultrasonographically (US)-guided percutaneous treatment of the trigger finger by releasing the A1 pulley with a 21-gauge needle. Materials and Methods This two-part study was approved by the ethics committee, and written consent was obtained from all patients. The first part consisted of 10 procedures on cadaver digits followed by dissection to analyze the effectiveness of the A1 pulley release and detect any collateral damage to the A2 pulley, interdigital nerves, or underlying flexor tendons. The second part was performed during an 18-month period starting in March 2013. It was a prospective clinical study of 60 procedures performed in 48 patients. Outcomes were evaluated through a clinical examination at day 0 and during a 6-month follow-up visit, where the trigger digit was evaluated clinically and the Quick Disabilities of the Arm, Shoulder and Hand outcome measure, or QuickDASH, and patient satisfaction questionnaires were administered. Results No complications were found during the cadaver study. However, the release was considered "partial" in all fingers. In the clinical study, the trigger finger was completely resolved in 81.7% (49 of 60) of cases immediately after the procedure. Moderate trigger finger persisted in 10 cases, and one thumb pulley could not be released. A US-guided corticosteroid injection was subsequently performed in these 11 cases. At 6-month follow-up, only two cases still had moderate trigger finger and there were no late complications. The mean QuickDASH questionnaire score was 4; all patients said they were satisfied. Conclusion US-guided treatment of the trigger finger by using a 21-gauge needle is feasible in current practice, with minimal complications. (©) RSNA, 2016 Online supplemental material is available for this article.

Acute Pancreatitis: Extrapancreatic Necrosis Volume as Early Predictor of Severity

PURPOSE

To determine the volume of extrapancreatic necrosis that predicts severe acute pancreatitis and to assess the reliability of this threshold in predicting severe acute pancreatitis compared with current scoring systems and C-reactive protein (CRP) levels.

MATERIALS AND METHODS

This institutional review board-approved, HIPAA-compliant retrospective study included patients with acute pancreatitis who were examined with computed tomography (CT) 2-6 days after disease onset. Extrapancreatic necrosis volume, Balthazar score, and CT severity index (CTSI) were calculated. CRP levels 48 hours after the onset of symptoms were reviewed. Outcome parameters included organ failure, infection, need for surgery or percutaneous intervention, duration of hospitalization, and/or death. Receiver operating characteristic (ROC) curves were constructed to determine the optimal threshold for predicting clinical outcomes. Pairwise comparisons of areas under ROC curves (AUCs) from the different grading systems were performed. Interobserver and intraobserver agreement in the grading of extrapancreatic necrosis was assessed by using κ statistics.

RESULTS

In 264 patients, significant relationships were found between extrapancreatic necrosis volume and organ failure, infection, duration of hospitalization, need for intervention, and death (P < .001 for all). The optimal threshold for predicting severe acute pancreatitis was 100 mL. Sensitivity and specificity were 95% (19 of 20) and 83% (142 of 172), respectively, for predicting organ failure (vs 100% [20 of 20] and 46% [79 of 172] for the Balthazar score and 25% [five of 20] and 95% [163 of 172] for the CTSI). The extrapancreatic necrosis AUC was the highest for all systems. Interobserver and intraobserver agreement based on the 100-mL threshold was considered to be excellent.

CONCLUSION

A simple grading system based on an objective criterion such as a threshold of 100 mL of extrapancreatic necrosis provides more reliable information for predicting acute pancreatitis outcomes than do the current scoring systems.

UNC-13 and UNC-10/rim localize synaptic vesicles to specific membrane domains

Synaptic vesicles undergo a maturation step, termed priming, in which they become competent to fuse with the plasma membrane. To morphologically define the site of vesicle priming and identify fusion-competent synaptic vesicles, we combined a rapid physical-fixation technique with immunogold staining and high-resolution morphometric analysis at Caenorhabditis elegans neuromuscular junctions. In these presynaptic terminals, a subset of synaptic vesicles contact the plasma membrane within approximately 100 nm of a presynaptic dense projection. UNC-13, a protein required for vesicle priming, localizes to this same region of the plasma membrane. In an unc-13 null mutant, few synaptic vesicles contact the plasma membrane, suggesting that membrane-contacting synaptic vesicles represent the morphological correlates of primed vesicles. Interestingly, a subpopulation of membrane-contacting vesicles, located within 30 nm of a dense projection, are unperturbed in unc-13 mutants. We show that UNC-10/Rim, a protein implicated in presynaptic plasticity, localizes to dense projections and that loss of UNC-10/Rim causes an UNC-13-independent reduction in membrane-contacting synaptic vesicles within 30 nm of the dense projections. Our data together identify a discrete domain for vesicle priming within 100 nm of dense projections and further suggest that UNC-10/Rim and UNC-13 separately contribute to the membrane localization of synaptic vesicles within this domain.