Prospective RandOmised Trial of Emergency Cardiac Computerised Tomography (PROTECCT).

OBJECTIVE: Many patients presenting with suspected acute coronary syndrome (ACS) have high-sensitivity cardiac troponin (hs-cTn) concentrations between rule-in and rule-out thresholds and hence need serial testing, which is time consuming. The Prospective RandOmised Trial of Emergency Cardiac Computerised Tomography (PROTECCT) assessed the utility of coronary CT angiography (CCTA) in patients with suspected ACS, non-ischaemic ECG and intermediate initial hs-cTn concentration. METHODS: Patients were randomised to CCTA-guided management versus standard of care (SOC). The primary outcome was hospital length of stay (LOS). Secondary outcomes included cost of in-hospital stay and major adverse cardiac events (MACE) at 12 months of follow-up. Data are mean (SD); for LOS harmonic means, IQRs are shown. RESULTS: 250 (aged 55 (14) years, 25% women) patients were randomised. Harmonic mean (IQR) LOS was 7.53 (6.0-9.6) hours in the CCTA arm and 8.14 (6.3-9.8) hours in the SOC arm (p=0.13). Inpatient cost was £1285 (£2216) and £1108 (£3573), respectively, p=0.68. LOS was shorter in the CCTA group in patients with <25% stenosis, compared with SOC; 6.6 (5.6-7.8) hours vs 7.5 (6.1-9.4) hours, respectively; p=0.021. More referrals for cardiology outpatient clinic review and cardiac CT-related outpatient referrals occurred in the SOC arm (p=0.01). 12-month MACE rates were similar between the two arms (7 (5.6%) in the CCTA arm and 8 (6.5%) in the SOC arm-log-rank p=0.78). CONCLUSIONS: CCTA did not lead to reduced hospital LOS or cost, largely because these outcomes were influenced by the detection of ≥25% grade stenosis in a proportion of patients. TRIAL REGISTRATION NUMBER: NCT03583320.

Persistent Post-COVID-19 Interstitial Lung Disease. An Observational Study of Corticosteroid Treatment.

Rationale: The natural history of recovery from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remains unknown. Because fibrosis with persistent physiological deficit is a previously described feature of patients recovering from similar coronaviruses, treatment represents an early opportunity to modify the disease course, potentially preventing irreversible impairment.Objectives: Determine the incidence of and describe the progression of persistent inflammatory interstitial lung disease (ILD) following SARS-CoV-2 when treated with prednisolone.Methods: A structured assessment protocol screened for sequelae of SARS-CoV-2 pneumonitis. Eight hundred thirty-seven patients were assessed by telephone 4 weeks after discharge. Those with ongoing symptoms had outpatient assessment at 6 weeks. Thirty patients diagnosed with persistent interstitial lung changes at a multidisciplinary team meeting were reviewed in the interstitial lung disease service and offered treatment. These patients had persistent, nonimproving symptoms.Results: At 4 weeks after discharge, 39% of patients reported ongoing symptoms (325/837) and were assessed. Interstitial lung disease, predominantly organizing pneumonia, with significant functional deficit was observed in 35/837 survivors (4.8%). Thirty of these patients received steroid treatment, resulting in a mean relative increase in transfer factor following treatment of 31.6% (standard deviation [SD] ± 27.6, P < 0.001), and forced vital capacity of 9.6% (SD ± 13.0, P = 0.014), with significant symptomatic and radiological improvement.Conclusions: Following SARS-CoV-2 pneumonitis, a cohort of patients are left with both radiological inflammatory lung disease and persistent physiological and functional deficit. Early treatment with corticosteroids was well tolerated and associated with rapid and significant improvement. These preliminary data should inform further study into the natural history and potential treatment for patients with persistent inflammatory ILD following SARS-CoV-2 infection.

Right ventricle in adulthood: CT and MR assessment.

Anatomical complexities coupled with a protracted subclinical disease course, particularly in the early stages, makes the right ventricle (RV) the less studied entity when compared with the left. RV failure is an important predictor of survival in patients with cardiovascular disease. Technological advances have made it possible to visualise and characterise a variety of diseases that affect the RV. This review article will give a broad overview of the main RV pathology to general radiologists in particular those that manifest in adulthood. Congenital heart disease is a vast topic that is beyond the scope of this paper.

Phenotypic comparison between smoking and non-smoking chronic obstructive pulmonary disease.

BACKGROUND: Although COPD among non-smokers (NS-COPD) is common, little is known about this phenotype. We compared NS-COPD subjects with smoking COPD (S-COPD) patients in a rural Indian population using a variety of clinical, physiological, radiological, sputum cellular and blood biomarkers. METHODS: Two hundred ninety subjects (118 healthy, 79 S-COPD, 93 NS-COPD) performed pre- and post-bronchodilator spirometry and were followed for 2 years to study the annual rate of decline in lung function. Body plethysmography, impulse oscillometry, inspiratory-expiratory HRCT, induced sputum cellular profile and blood biomarkers were compared between 49 healthy, 45 S-COPD and 55 NS-COPD subjects using standardized methods. Spirometric response to oral corticosteroids was measured in 30 female NS-COPD patients. RESULTS: Compared to all male S-COPD subjects, 47% of NS-COPD subjects were female, were younger by 3.2 years, had greater body mass index, a slower rate of decline in lung function (80 vs 130 mL/year), more small airways obstruction measured by impulse oscillometry (p < 0.001), significantly less emphysema (29% vs 11%) on CT scans, lower values in lung diffusion parameters, significantly less neutrophils in induced sputum (p < 0.05) and tended to have more sputum eosinophils. Hemoglobin and red cell volume were higher and serum insulin lower in S-COPD compared to NS-COPD. Spirometric indices, symptoms and quality of life were similar between S-COPD and NS-COPD. There was no improvement in spirometry in NS-COPD patients after 2 weeks of an oral corticosteroid. CONCLUSIONS: Compared to S-COPD, NS-COPD is seen in younger subjects with equal male-female predominance, is predominantly a small-airway disease phenotype with less emphysema, preserved lung diffusion and a slower rate of decline in lung function.

Non-invasive classification of non-small cell lung cancer: a comparison between random forest models utilising radiomic and semantic features.

OBJECTIVE: Non-invasive distinction between squamous cell carcinoma and adenocarcinoma subtypes of non-small-cell lung cancer (NSCLC) may be beneficial to patients unfit for invasive diagnostic procedures or when tissue is insufficient for diagnosis. The purpose of our study was to compare the performance of random forest algorithms utilizing CT radiomics and/or semantic features in classifying NSCLC. METHODS: Two thoracic radiologists scored 11 semantic features on CT scans of 106 patients with NSCLC. A set of 115 radiomics features was extracted from the CT scans. Random forest models were developed from semantic (RM-sem), radiomics (RM-rad), and all features combined (RM-all). External validation of models was performed using an independent test data set (n = 100) of CT scans. Model performance was measured with out-of-bag error and area under curve (AUC), and compared using receiver-operating characteristics curve analysis on the test data set. RESULTS: The median (interquartile-range) error rates of the models were: RF-sem 24.5 % (22.6 - 37.5 %), RF-rad 35.8 % (34.9 - 38.7 %), and RM-all 37.7 % (37.7 - 37.7). On training data, both RF-rad and RF-all gave perfect discrimination (AUC = 1), which was significantly higher than that achieved by RF-sem (AUC = 0.78; p < 0.0001). On test data, however, RM-sem model (AUC = 0.82) out-performed RM-rad and RM-all (AUC = 0.5 and AUC = 0.56; p < 0.0001), neither of which was significantly different from random guess ( p = 0.9 and 0.6 respectively). CONCLUSION: Non-invasive classification of NSCLC can be done accurately using random forest classification models based on well-known CT-derived descriptive features. However, radiomics-based classification models performed poorly in this scenario when tested on independent data and should be used with caution, due to their possible lack of generalizability to new data. ADVANCES IN KNOWLEDGE: Our study describes novel CT-derived random forest models based on radiologist-interpretation of CT scans (semantic features) that can assist NSCLC classification when histopathology is equivocal or when histopathological sampling is not possible. It also shows that random forest models based on semantic features may be more useful than those built from computational radiomic features.

Pictorial review: non-anatomical cardiovascular gas: causes, appearances and consequences.

Gas does not occur naturally in the cardiovascular system, although it is not unusual to identify it on imaging. The true incidence is difficult to know as asymptomatic cases are rarely recorded. In iatrogenic instance, this occurs when atmospheric air enters the cardiovascular system from a high to low pressure, or when gas is forcibly injected into a vessel. The source of air must be promptly identified and treatment must be expedited to reduce morbidity and mortality. This pictorial review aims to give an overview of the causes (with particular emphasis on the conditions that may be encountered by a Radiologist), appearances of cardiovascular gas, and any subsequent treatment.

Complementary role of cardiac CT in the assessment of aortic valve replacement dysfunction.

Aortic valve replacement is the second most common cardiothoracic procedure in the UK. With an ageing population, there are an increasing number of patients with prosthetic valves that require follow-up. Imaging of prosthetic valves is challenging with conventional echocardiographic techniques making early detection of valve dysfunction or complications difficult. CT has recently emerged as a complementary approach offering excellent spatial resolution and the ability to identify a range of aortic valve replacement complications including structural valve dysfunction, thrombus development, pannus formation and prosthetic valve infective endocarditis. This review discusses each and how CT might be incorporated into a multimodal cardiovascular imaging pathway for the assessment of aortic valve replacements and in guiding clinical management.

Congenital epicardial coronary artery to bilateral internal mammary artery fistulae.

A 39-year-old male ex-smoker gave a history of exertional chest pain ever since he suffered a respiratory tract infection. Clinical examination, electrocardiogram and echocardiography were normal and he was referred for a cardiac CT scan to assess coronary artery calcification and patency. The scan demonstrated incidental fistulae between the right internal mammary artery and the right coronary artery, and the left internal mammary artery and the left anterior descending artery.