Pulmonary diffusing capacity for carbon monoxide and nitric oxide after COVID-19: A prospective cohort study (the SECURe study).

Many patients exhibit persistently reduced pulmonary diffusing capacity after coronavirus disease 2019 (COVID-19). In this study, dual test gas diffusing capacity for carbon monoxide and nitric oxide (DL,CO,NO) metrics and their relationship to disease severity and physical performance were examined in patients who previously had COVID-19. An initial cohort of 148 patients diagnosed with COVID-19 of all severities between March 2020 and March 2021 had a DL,CO,NO measurement performed using the single-breath method at 5.7 months follow-up. All patients with at least one abnormal DL,CO,NO metric (n = 87) were revaluated at 12.5 months follow-up. The DL,CO,NO was used to provide the pulmonary diffusing capacity for nitric oxide (DL,NO), the pulmonary diffusing capacity for carbon monoxide (DL,CO,5s), the alveolar-capillary membrane diffusing capacity and the pulmonary capillary blood volume. At both 5.7 and 12.5 months, physical performance was assessed using a 30 s sit-to-stand test and the 6 min walk test. Approximately 60% of patients exhibited a severity-dependent decline in at least one DL,CO,NO metric at 5.7 months follow-up. At 12.5 months, both DL,NO and DL,CO,5s had returned towards normal but still remained abnormal in two-thirds of the patients. Concurrently, improvements in physical performance were observed, but with no apparent relationship to any DL,CO,NO metric. The severity-dependent decline in DL,NO and DL,CO observed at 5.7 months after COVID-19 appears to be reduced consistently at 12.5 months follow-up in the majority of patients, despite marked improvements in physical performance.

Predictors of reoperation after lung volume reduction surgery.

OBJECTIVES: Lung volume reduction surgery (LVRS) has proven an effective treatment for emphysema, by decreasing hyperinflation and improving lung function, activity level and reducing dyspnoea. However, postoperative air leak is an important complication, often leading to reoperation. Our aim was to analyse reoperations after LVRS and identify potential predictors. METHODS: Consecutive single-centre unilateral VATS LVRS performed from 2017 to 2022 were included. Typically, 3-5 minor resections were made using vascular magazines without buttressing. Data were obtained from an institutional database and analysed. Multivariable logistic regression was used to identify predictors of reoperation. Number and location of injuries were registered. RESULTS: In total, 191 patients were included, 25 were reoperated (13%). In 21 patients, the indication for reoperation was substantial air leak, 3 patients bleeding and 1 patient empyema. Length of stay (LOS) was 21 (11-33) vs. 5 days (3-11), respectively. Only 3 injuries were in the stapler line, 13 within < 2cm and 15 injuries were in another site. Multivariable logistic regression analysis showed that decreasing DLCO increased risk of reoperation, OR 1.1 (1.03, 1.18, P = 0.005). Resections in only one lobe, compared to resections in multiple lobes, were also a risk factor OR 3.10 (1.17, 9.32, P = 0.03). Patients undergoing reoperation had significantly increased 30-day mortality, OR 5.52 (1.03, 26.69, P = 0.02). CONCLUSIONS: Our incidence of reoperation after LVRS was 13% leading to prolonged LOS and increased 30-day mortality. Low DLCO and resections in a single lobe were significant predictors of reoperation. The air leak was usually not localized in the stapler line.

Lung Ultrasound in the Assessment of Pulmonary Complications After Lung Transplantation.

INTRODUCTION: Lung ultrasound (LUS) has a high diagnostic accuracy for identifying frequent conditions in the post-operative phase after lung transplantation (LTx). This study aimed to investigate the feasibility and clinical ability of LUS to identify pulmonary complications such as pleural effusions and pneumonias in the early postoperative phase after LTx. METHODS: A prospective cohort study of lung transplant recipients who consecutively underwent single LTx (SLTx) or double LTx (DLTx) at the National Lung Transplantation Center in Denmark from May 1 to October 31, 2015 was conducted. LUS was performed at four time points corresponding to post-transplant day 3, and weeks 2, 6, and 12 (LUS #1-4) to detect and monitor variation in pathological LUS findings over time. Concurrent with LUS #4, a high-resolution computed tomography examination of the thorax (HRCT) was also performed. RESULTS: 14 patients (1 SLTx/13 DLTx, 7 (50 %) women, mean age: 50.4 years) who had undergone the four prespecified LUS examinations were included. Pleural effusion was the most common condition and most pronounced at post-LTx week 2. Findings consistent with pneumonia increased during week 2 and subsequently decreased. Corresponding to LUS #1, 2, 3, and 4, pleural effusion occurred in 85.7 %, 92.9 %, 85.7 %, and 78.6 %, and pneumonia in 21.4 %, 28.6 %, 14.3 %, and 14.3 %, respectively. HRCT findings at post-LTx week 12 were predominantly presented by unspecific ground glass opacities. CONCLUSION: In a post-LTx setting, LUS represents a clinical novelty as a feasible diagnostic and monitoring tool to identify pathological pulmonary complications in the early post-operative phase.

Severe Emphysema Treated with Bilateral Lung Sealant: A Case Series with Long-Term Follow-Up.

Bronchoscopic lung volume reduction (BLVR) for emphysematous hyperinflation has evolved during the last two decades as an alternative to lung volume reduction surgery (LVRS) with lower morbidity and mortality. Emphysematous lung sealant (ELS) is a form of BLVR specifically aimed at patients with collateral ventilation (CV), shown to have favorable outcomes in lung function up to two years. This case series presents four emphysema patients treated bilaterally with ELS, with a follow-up period up to six years. Two of the patients had previously undergone LVRS and BLVR with valves. Following ELS installment, all patients showed positive changes in spirometric values, with varying durability between one and five years. Three patients reported an overall improvement in subjective symptoms after treatment as measured by the COPD Assessment Test (CAT), one of which had lasting improvement even after five years (CAT from 20 to 13). Two of the four treated patients suffered recurrent respiratory exacerbations and pneumonias requiring hospitalization. They both went on to receive lung transplantation within one and three years. This report concludes that ELS has a meaningful effect on reducing hyperinflation in emphysema with improving pulmonary function tests, and relieving symptoms of dyspnea for up to five years. Unfortunately, some patients develop complications leading to recurrent exacerbations. We were not able to show a survival benefit with ELS treatment. This article highlights the need for further research in order to predict who will benefit from this treatment and how to handle CV-positive patients.

Relation of Pulmonary Diffusing Capacity Decline to HRCT and VQ SPECT/CT Findings at Early Follow-Up after COVID-19: A Prospective Cohort Study (The SECURe Study).

A large proportion of patients exhibit persistently reduced pulmonary diffusion capacity after COVID-19. It is unknown whether this is due to a post-COVID restrictive lung disease and/or pulmonary vascular disease. The aim of the current study was to investigate the association between initial COVID-19 severity and haemoglobin-corrected diffusion capacity to carbon monoxide (DLco) reduction at follow-up. Furthermore, to analyse if DLco reduction could be linked to pulmonary fibrosis (PF) and/or thromboembolic disease within the first months after the illness, a total of 67 patients diagnosed with COVID-19 from March to December 2020 were included across three severity groups: 12 not admitted to hospital (Group I), 40 admitted to hospital without intensive care unit (ICU) admission (Group II), and 15 admitted to hospital with ICU admission (Group III). At first follow-up, 5 months post SARS-CoV-2 positive testing/4 months after discharge, lung function testing, including DLco, high-resolution CT chest scan (HRCT) and ventilation-perfusion (VQ) single photon emission computed tomography (SPECT)/CT were conducted. DLco was reduced in 42% of the patients; the prevalence and extent depended on the clinical severity group and was typically observed as part of a restrictive pattern with reduced total lung capacity. Reduced DLco was associated with the extent of ground-glass opacification and signs of PF on HRCT, but not with mismatched perfusion defects on VQ SPECT/CT. The severity-dependent decline in DLco observed early after COVID-19 appears to be caused by restrictive and not pulmonary vascular disease.

Lung Abnormalities in Severe Acute Respiratory Syndrome Coronavirus 2 Infection: An Analysis of Paired Computed Tomography Scans Before and After Infection.

Background: Studies on the pulmonary consequences of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are impeded by limited access to pre-SARS-CoV-2 examinations. Methods: We invited Copenhagen General Population Study participants with a confirmed SARS-CoV-2 polymerase chain reaction (PCR) test during the first and second coronavirus disease 2019 waves in Denmark for a repeat chest computed tomography (CT) scan. Paired CT scans were independently assessed for interstitial and noninterstitial abnormalities by 2 trained radiologists. A semiquantitative CT score (ranging from 0 to 20) was used to quantify the extent of interstitial abnormalities. Results: Of 111 SARS-CoV-2-infected individuals, 102 (91.2%) experienced symptoms and 12 (11.2%) were hospitalized. Follow-up examination was performed at median of 5.4 (interquartile range, 4.1-7.8) months after a positive SARS-CoV-2 PCR test. Of 67 individuals with paired CT scans, ground glass opacities and reticulation were present in 31 (46.3%) individuals post-SARS-CoV-2 compared to 23 (34.1%) pre-SARS-CoV-2 (mean CT score, 3.0 vs 1.3; P = .011). Results were similar for nonhospitalized individuals. We did not detect development of bronchiectasis, emphysema, or nodules. Conclusions: SARS-CoV-2 infection in predominantly nonhospitalized individuals with mild disease was associated with a small increase in only interstitial lung abnormalities.

Chest x-ray imaging score is associated with severity of COVID-19 pneumonia: the MBrixia score.

Spatial resolution in existing chest x-ray (CXR)-based scoring systems for coronavirus disease 2019 (COVID-19) pneumonia is low, and should be increased for better representation of anatomy, and severity of lung involvement. An existing CXR-based system, the Brixia score, was modified to increase the spatial resolution, creating the MBrixia score. The MBrixia score is the sum, of a rule-based quantification of CXR severity on a scale of 0 to 3 in 12 anatomical zones in the lungs. The MBrixia score was applied to CXR images from COVID-19 patients at a single tertiary hospital in the period May 4th-June 5th, 2020. The relationship between MBrixia score, and level of respiratory support at the time of performed CXR imaging was investigated. 37 hospitalized COVID-19 patients with 290 CXRs were identified, 22 (59.5%) were admitted to the intensive care unit and 10 (27%) died during follow-up. In a Poisson regression using all 290 MBrixia scored CXRs, a higher MBrixia score was associated with a higher level of respiratory support at the time of performed CXR. The MBrixia score could potentially be valuable as a quantitative surrogate measurement of COVID-19 pneumonia severity, and future studies should investigate the score's validity and capabilities of predicting clinical outcomes.

Acute Pulmonary Embolism Severity Assessment Evaluated with Dual Energy CT Perfusion Compared to Conventional CT Angiographic Measurements.

The purpose of the study was to investigate whether Dual Energy CT (DECT) can be used as a diagnostic tool to assess the severity of acute pulmonary embolism (PE) by correlating parenchymal perfusion defect volume, obstruction score and right ventricular-to-left ventricular (RV/LV) diameter ratio using CT angiography (CTA) and DECT perfusion imaging. A total of 43 patients who underwent CTA and DECT perfusion imaging with clinical suspicion of acute PE were retrospectively included in the study. In total, 25 of these patients had acute PE findings on CTA. DECT assessed perfusion defect volume (PDvol) were automatically and semiautomatically quantified. Overall, two CTA methods for risk assessment in patients with acute PE were assessed: the RV/LV diameter ratio and the Modified Miller obstruction score. Automatic PDvol had a weak correlation (r = 0.47, p = 0.02) and semiautomatic PDvol (r = 0.68, p < 0.001) had a moderate correlation to obstruction score in patients with confirmed acute PE, while only semiautomatic PDvol (r = 0.43, p = 0.03) had a weak correlation with the RV/LV diameter ratio. Our data indicate that PDvol assessed by DECT software technique may be a helpful tool to assess the severity of acute PE when compared to obstruction score and RV/LV diameter ratio.

Fulminant H1N1 and severe acute respiratory syndrome coronavirus-2 infections with a 4-year interval without an identifiable underlying cause: a case report.

BACKGROUND: The clinical presentation of severe acute respiratory syndrome coronavirus-2 infection is highly variable from asymptomatic infection to fulminant disease. The reasons for the variation are only starting to unravel, with risk factors including age and certain comorbidities as well as genetic defects causing immunological perturbations in the interferon pathways. CASE PRESENTATION: We report the case of an otherwise healthy Caucasian man, who at ages 60 and 64 years suffered from severe H1N1 influenza virus infection and severe acute respiratory syndrome coronavirus-2 infections, respectively. In both cases, there were acute kidney impairment and the need for intensive care unit admission as well as mechanical ventilation. Fortunately, after both infections there was full clinical recovery. The severity of the infections indicates an underlying impairment in the ability to control these kinds of infections. Challenge of patient peripheral blood mononuclear cells showed impaired type I and III antiviral interferon responses and reduced interferon-stimulated gene expression. However, despite investigation of patient samples by whole exome sequencing and enzyme-linked immunosorbent assay, no known disease-causing genetic variants related to interferon pathways were found, nor were interferon autoantibodies demonstrated. Thus, any underlying immunological cause of this unusual susceptibility to severe viral infections remains unresolved. CONCLUSION: The patient experienced very similar severe clinical pictures triggered by H1N1 and severe acute respiratory syndrome coronavirus-2 infections, indicating an underlying inability to contain these infections. We were unable to show that the patient had any of the currently known types of immune incompetence but identified genetic changes possibly contributing to the severe course of both infections. Further analyses to delineate contribution factors are needed.

Lung Ultrasound to Phenotype Chronic Lung Allograft Dysfunction in Lung Transplant Recipients. A Prospective Observational Study.

BACKGROUND: Bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS) are two distinct phenotypes of chronic lung allograft dysfunction (CLAD) in lung transplant (LTx) recipients. Contrary to BOS, RAS can radiologically present with a pleuroparenchymal fibroelastosis (PPFE) pattern. This study investigates lung ultrasound (LUS) to identify potential surrogate markers of PPFE in order to distinguish CLAD phenotype RAS from BOS. METHODS: A prospective cohort study performed at a National Lung Transplantation Center during June 2016 to December 2017. Patients were examined with LUS and high-resolution computed tomography of the thorax (HRCT). RESULTS: Twenty-five CLAD patients (72% males, median age of 54 years) were included, corresponding to 19/6 BOS/RAS patients. LUS-identified pleural thickening was more pronounced in RAS vs. BOS patients (5.6 vs. 2.9 mm) compatible with PPFE on HRCT. LUS-identified pleural thickening as an indicator of PPFE in RAS patients' upper lobes showed a sensitivity of 100% (95% CI; 54-100%), specificity of 100% (95% CI; 82-100%), PPV of 100% (95% CI; 54-100%), and NPV of 100% (95% CI; 82-100%). CONCLUSION: Apical pleural thickening detected by LUS and compatible with PPFE on HRCT separates RAS from BOS in patients with CLAD. We propose LUS as a supplementary tool for initial CLAD phenotyping.

[Management of thymomas and thymic carcinomas].

This review summarises the diagnostics, staging and treatment of thymic epithelial tumours, of which CT is the current primary imaging. The International Association for the Study of Lung Cancer/International Thymic Malignancy Interest Group TNM staging and the WHO histological classifications are described. Surgery done as total thymectomy with video-assisted thoracoscopic surgery in stage I and open sternotomy in larger stages is the primary treatment if possible. Presurgical tumour reduction with chemotherapy and the possibility of adjuvant radiotherapy after R+ resection is described. Radiotherapy or chemotherapy can be considered, if definite surgery is not possible. Relapse is treated after the same principles as primary disease.

Role of CT angiography in bilateral pulmonary sequestration: a case report.

Bilateral pulmonary sequestration (PS) is a very rare congenital malformation. We describe a case of bilateral intralobar pulmonary sequestration (ILS) in a newborn. Both sequestrations received arterial supply from separate branches of the descending aorta and venous drainage was into ipsilateral inferior pulmonary veins. Prenatal ultrasonography showed cystic changes in the lungs. Computed tomography angiography (CTA) with supplemental two-dimensional (2D) and three-dimensional (3D) images was performed to clearly define the pathology and revealed bilateral intralobar pulmonary sequestration with aberrant blood supply. The child underwent successful video-assisted thoracoscopic surgical (VATS) lobectomy on the left side and thoracoscopic wedge resection on the right side. There were no complications. CTA with supplemental 2D and 3D images plays a vital role in revealing the exact pathology in congenital pulmonary malformations associated with anomalous vasculature.

Validation of lung density indices by cardiac CT for quantification of lung emphysema.

OBJECTIVES: Cardiovascular disease is often associated with COPD. Lung density quantification of images obtained from cardiac computed tomography (CT) scans would allow simultaneous evaluation of emphysema and coronary artery calcification score and provide further mechanistic insight into the relationship between these syndromes. PATIENTS AND METHODS: We assessed the agreement between lung density indices obtained by cardiac and full-lung CT scans. Paired cardiac and chest CT scans were assessed in 156 individuals with and without airflow limitation. Quantitative threshold indices of low attenuation area (LAA) and 15th percentile density index (PD15) were compared in terms of precision using Spearman's correlation coefficient, accuracy using concordance correlation coefficient (CCC), and relative accuracy using P15 and P30. We also assessed the relationship between visually and quantitatively determined emphysema and used receiver operating characteristic curves to evaluate the ability of lung density indices to discriminate airflow limitation. RESULTS: Correlation coefficients between lung density indices obtained from cardiac and chest CT scans were 0.49 for percent LAA (%LAA)-950 and 0.71 for PD15. Corresponding values for CCC, P15, and P30 were 0.33, 3.2, and 5.1, respectively, for %LAA-950, and 0.34, 17.3, and 37.8, respectively, for PD15. For both cardiac and chest CT scans, visually determined emphysema was associated with higher %LAA-950 and lower PD15, and the ability of %LAA-950 and PD15 to discriminate airflow limitation were comparable. CONCLUSION: Although chest CT imaging is preferable, cardiac CT imaging may also be used for lung emphysema quantification where association measures are of primary interest.

Incidental lung cancers and positive computed tomography images in people living with HIV.

OBJECTIVE: Lung cancer screening with low-dose computed tomography (LDCT) of high-risk groups in the general population is recommended by several authorities. This may not be feasible in people living with HIV (PLWHIV) due to higher prevalence of nodules. We therefore assessed the prevalence of positive computed tomography (CT) images and lung cancers in PLWHIV. DESIGN: The Copenhagen comorbidity in HIV infection (COCOMO) study is an observational, longitudinal cohort study. Single-round LDCT was performed with subsequent clinical follow-up (NCT02382822). METHOD: Outcomes included histology-proven lung cancer identified by LDCT and positive CT images (noncalcified nodules) in the entire cohort and in the high-risk group (>50 years of age and >30 pack-years). We also assessed the procedures and adverse events, and clinical factors associated with a positive CT image. RESULTS: LDCT was performed in 901 patients, including 113 at high risk for lung cancer. A positive image was found in 28 (3.1% of the entire cohort and 9.7% of the high-risk group). Nine patients (all in the high-risk group) had invasive procedures undertaken with no serious adverse events. Lung cancer (stages IA, IIA, and IIIA) was diagnosed in three patients from the high-risk group (2.7%). CD4 cell count less than 500 cells/µl and CD4 nadir less than 200 cells/µl were each independently associated with increased odds of a positive image odds ratio 2.32 [95% confidence interval: 1.01-5.13, P = 0.04] and odds ratio 2.63 [95% confidence interval: 1.13-6.66, P = 0.03]. CONCLUSION: Randomized LDCT screening trials in PLWHIV are nonexistent, but these findings are comparable with screening rounds from the general population in terms of prevalence of lung cancer and positive CT images.

Bowel function and quality of life after colostomy in individuals with spinal cord injury.

OBJECTIVE: To evaluate the effect of colostomy on bowel function and quality of life (QoL) in individuals with spinal cord injury (SCI). DESIGN: Cross-sectional descriptive study. SETTING: Department for Spinal Cord Injuries and Departments of Gastroenterology and Radiology, Rigshospitalet. PARTICIPANTS: Eighteen individuals with SCI and a colostomy performed post injury, 12 males, 6 females, 8 with tetraplegia and 10 with paraplegia. Median age at time of study was 49.9 years, years since lesion was 3-56 years, and time since colostomy was performed 0.5 to 20 years. INTERVENTIONS: Questionnaires and measurement of gastrointestinal transit time (GITT). OUTCOME MEASURES: Retrospective data collection from patient records, a questionnaire on bowel management pre and post colostomy, quality of life (QoL) by SF-36, and GITT. RESULTS: Seventy-two percent significantly reduced their use of time on bowel emptying after the colostomy. All but one reported being content with the colostomy. Thirty-nine percent reported one or more problems related to the colostomy. Seventy-five percent had a GITT within normal range for able-bodied populations. When disregarding the physical component, QoL was not significantly lower in the total study group compared to a Danish norm group, but significantly lower when compared the subgroup of persons with tetraplegia. CONCLUSION: A colostomy reduces the time necessary for bowel management. The majority of individuals with SCI and a colostomy did not perceive bowel management as being a problem. The results indicate that colostomy is a favourable option for individuals with SCI, who spend long hours on bowel management and for whom non-invasive procedures did not improve the situation enough.

A chondrosarcoma in the anterior mediastinum mimicking a thymoma.

A chondrosarcoma in the anterior mediastinum is a rare finding with a relatively good prognosis. We describe a case of a 75-year-old man with a 2-year history of neck discomfort and weight loss. Imaging showed a homogenous tumor with a minor compression on the anterior part of the heart. It had close relation to the ribs, no surrounding fat, and a thymoma was suspected. Biopsy prior to surgery was impossible due to the location of the tumor. Unfortunately, final pathology from the surgical specimen revealed a chondrosarcoma.

The usefulness of ultrasound colour-Doppler twinkling artefact for detecting urolithiasis compared with low dose nonenhanced computerized tomography.

This prospective study evaluates the usefulness of the twinkling artefact (TA) seen on colour-Doppler ultrasound (US) in diagnosing urolithiasis. US and standard computed tomography (CT) were performed blinded on 105 patients. B-mode US and colour-Doppler used separately and in combination showed 55% sensitivity and 99% specificity (positive predictive value [PPV] 67% and negative predictive value [NPV] 98%). Of CT verified stones, 61% were ≤3 mm. TAs were present in 74% of the B-mode stones (43% of all CT verified stones). Patients with CT verified stone disease had significantly more TAs in other foci than the stone(s) found on CT, suggestive of microlithiasis. In conclusion, colour-Doppler TA is a helpful supplement for detecting urolithiasis when CT is contraindicated. In addition, US can be valuable in monitoring stones left to pass without intervention if they have presented a TA. CT, US and US with colour-Doppler TA can be useful as complementary techniques for detecting stones.