Fibrotic-Like Pulmonary Radiographic Patterns Are Not Associated With Adverse Outcomes in COVID-19 Chronic Critical Illness.

OBJECTIVES: Pulmonary fibrosis is a feared complication of COVID-19. To characterize the risks and outcomes associated with fibrotic-like radiographic abnormalities in patients with COVID-19-related acute respiratory distress syndrome (ARDS) and chronic critical illness. DESIGN: Single-center prospective cohort study. SETTING: We examined chest CT scans performed between ICU discharge and 30 days after hospital discharge using established methods to quantify nonfibrotic and fibrotic-like patterns. PATIENTS: Adults hospitalized with COVID-19-related ARDS and chronic critical illness (> 21 d of mechanical ventilation, tracheostomy, and survival to ICU discharge) between March 2020 and May 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We tested associations of fibrotic-like patterns with clinical characteristics and biomarkers, and with time to mechanical ventilator liberation and 6-month survival, controlling for demographics, comorbidities, and COVID-19 therapies. A total of 141 of 616 adults (23%) with COVID-19-related ARDS developed chronic critical illness, and 64 of 141 (46%) had a chest CT a median (interquartile range) 66 days (42-82 d) after intubation. Fifty-five percent had fibrotic-like patterns characterized by reticulations and/or traction bronchiectasis. In adjusted analyses, interleukin-6 level on the day of intubation was associated with fibrotic-like patterns (odds ratio, 4.40 per quartile change; 95% CI, 1.90-10.1 per quartile change). Other inflammatory biomarkers, Sequential Organ Failure Assessment score, age, tidal volume, driving pressure, and ventilator days were not. Fibrotic-like patterns were not associated with longer time to mechanical ventilator liberation or worse 6-month survival. CONCLUSIONS: Approximately half of adults with COVID-19-associated chronic critical illness have fibrotic-like patterns that are associated with higher interleukin-6 levels at intubation. Fibrotic-like patterns are not associated with longer time to liberation from mechanical ventilation or worse 6-month survival.

The Macklin effect closely correlates with pneumomediastinum in acutely ill intubated patients with COVID-19 infection.

PURPOSE: Patients with COVID-19 infection are frequently found to have pulmonary barotrauma. Recent work has identified the Macklin effect as a radiographic sign that often occurs in patients with COVID-19 and may correlate with barotrauma. METHODS: We evaluated chest CT scans in COVID-19 positive mechanically ventilated patients for the Macklin effect and any type of pulmonary barotrauma. Patient charts were reviewed to identify demographic and clinical characteristics. RESULTS: The Macklin effect on chest CT scan was identified in a total of 10/75 (13.3%) COVID-19 positive mechanically ventilated patients; 9 developed barotrauma. Patients with the Macklin effect on chest CT scan had a 90% rate of pneumomediastinum (p < 0.001) and a trend toward a higher rate of pneumothorax (60%, p = 0.09). Pneumothorax was most frequently omolateral to the site of the Macklin effect (83.3%). CONCLUSION: The Macklin effect may be a strong radiographic biomarker for pulmonary barotrauma, most strongly correlating with pneumomediastinum. Studies in ARDS patients without COVID-19 are needed to validate this sign in a broader population. If validated in a broad population, future critical care treatment algorithms may include the Macklin sign for clinical decision making and prognostication.

Characteristic patterns of SARS-CoV-2 on chest CT suggests a hematologic pathway for viral entry into the lung.

Many SARS-CoV-2 studies have supported the theory that the Type II alveolar epithelial cells (AEC-2) are the primary portal of entry of the virus into the lung following its brief nasal occupation. However, the theory of inhalational transmission of the virus from the ciliated and goblet nasal cells to the lung parenchyma is not supported by the imaging findings on chest computerized tomography (CT), leading the authors to consider an alternative pathway from the nose to the lung parenchyma that could explain the peripheral, basilar predominant pattern of early disease. Imaging supports that the pulmonary capillaries may be an important vehicle for transmission of the virus and/or associated inflammatory mediators to the lung epithelium.

Impact of the COVID-19 Pandemic on Trends in Cardiothoracic Imaging.

Introduction: Here, we evaluate the effect of the COVID-19 pandemic on utilization of cardiothoracic imaging studies. Methods: We queried our radiology record system to retrospectively identify numbers of specific key cardiothoracic imaging studies for five years prior and during the COVID-19 pandemic. Statistical analysis was performed to evaluate changes in the number of exams in 2020 and 2021 compared to 2019. Results: Five-year retrospective analysis demonstrated progressive increases in nearly all cross-sectional studies. In 2020, daily chest radiograph utilization decreased with an overall number of daily radiographs of 406 (SD = 73.1) compared to 480 per day in 2019 (SD = 82.6) (p < 0.0001). Portable radiograph utilization was increased in 2020 averaging 320 (SD = 68.2) films daily in 2020 compared to 266 (SD = 29.1) in 2019 (p < 0.0001). Utilization of thoracic CT was decreased during the pandemic, with 21.8 (SD = 12.9) studies daily compared to 52.0 (SD = 21.4) (p < 0.0001) studies daily in 2019. Cardiac imaging utilization was also substantially decreased in 2020 compared to 2019, averaging a total of 3.8 (SD = 3.2) versus 10.8 (SD = 6.6) studies daily and 0.88 (SD = 1.7) versus 2.5 (SD = 2.3) studies daily for CT and MRI, respectively. Evaluation of cardiothoracic imaging for the subsequent 18 months after New York's entry to phase I recovery in June 2020 demonstrated that by one year after the emergence of COVID-19 imaging utilization had recovered to prepandemic levels. Cardiac imaging continued to increase throughout the chronic phase of the COVID-19 pandemic, reaching almost twice the prepandemic levels by the end of 2021. Conclusion: COVID-19 has had far-reaching effects on medicine and public health. Here, we demonstrate decreases in all cross-sectional cardiothoracic imaging studies, closely mirroring findings in other fields during the height of the pandemic, which have since rebounded.

The impact of the COVID-19 pandemic on neuroimaging volume in New York City.

BACKGROUND AND PURPOSE: The COVID-19 pandemic acutely disrupted all facets of healthcare, with future implications that are expected to resonate for many years. We investigated the effect of the pandemic on neuroimaging volume, hypothesizing that all representative studies would experience a reduction in volume, with those typically performed in the inpatient setting (noncontrast enhanced CT head and CTA head/neck) taking longer to recover to pre-pandemic volumes compared to studies typically performed in the outpatient setting (MR brain with and without and MR lumbar spine without). MATERIALS AND METHODS: We retrospectively queried our institution's radiology reporting system to collect weekly data for 1 year following the World Health Organization declaration of a pandemic (11 March 2020-9 March 2021) and compared them to imaging volumes from the previous year (11 March 2019-9 March 2020). We subsequently analyzed quarterly data (e.g., first quarter comparison: 3/11/2020-6/9/2020 was compared to 3/11/2019-6/9/2019). RESULTS: All studies experienced decreased volume during the first quarter of the year following onset of the COVID-19 pandemic, with noncontrast enhanced CT head failing to recover to pre-pandemic volumes. CTA head/neck actually surpassed pre-pandemic volume by the second quarter of the year. MRI brain w/wo and MRI lumbar spine without recovered to baseline volume by the second quarter. CONCLUSION: Noncontrast enhanced CT head did not recover pre-pandemic imaging volume. CTA head/neck volume initially decreased, however volume increased above pre-pandemic levels during the second quarter; this finding may be attributable to a prothrombotic state in COVID-19 patients.

Pulmonary fibrosis 4 months after COVID-19 is associated with severity of illness and blood leucocyte telomere length.

The risk factors for development of fibrotic-like radiographic abnormalities after severe COVID-19 are incompletely described and the extent to which CT findings correlate with symptoms and physical function after hospitalisation remains unclear. At 4 months after hospitalisation, fibrotic-like patterns were more common in those who underwent mechanical ventilation (72%) than in those who did not (20%). We demonstrate that severity of initial illness, duration of mechanical ventilation, lactate dehydrogenase on admission and leucocyte telomere length are independent risk factors for fibrotic-like radiographic abnormalities. These fibrotic-like changes correlate with lung function, cough and measures of frailty, but not with dyspnoea.

Acute myocardial infarction secondary to COVID-19 infection: A case report and review of the literature.

BACKGROUND: Thrombotic complications of COVID-19 infection have become increasingly apparent as the disease has infected a growing number of individuals. Although less common than upper respiratory symptoms, thrombotic complications are not infrequent and may result in severe and long-term sequelae. Common thrombotic complications include pulmonary embolism, cerebral infarction, or venous thromboembolism; less commonly seen are acute myocardial injury, renal artery thrombosis, and mesenteric ischemia. Several case reports and case series have described acute myocardial injury in patients with COVID-19 characterized by elevations in serum biomarkers. CASE REPORT: Here, we report the first case to our knowledge of a patient with acute coronary syndrome confirmed on catheter angiography and cardiac MRI. This patient was found to additionally have a left ventricular thrombus and ultimately suffered an acute cerebral infarction. Recognition of thrombotic complications in the setting of COVID-19 infection is essential for initiating appropriate therapy. CONCLUSIONS: In acute myocardial injury, given the different treatment strategies for myocarditis versus acute myocardial infarction secondary to coronary artery thrombus, imaging can play a key role in clinical decision making for patients.