Contrast-enhanced mammography for the assessment of screening recalls: a two-centre study.

OBJECTIVES: To evaluate the potential of contrast-enhanced mammography (CEM) for reducing the biopsy rate of screening recalls. METHODS: Recalled women were prospectively enrolled to undergo CEM alongside standard assessment (SA) through additional views, tomosynthesis, and/or ultrasound. Exclusion criteria were symptoms, implants, allergy to contrast agents, renal failure, and pregnancy. SA and CEM were independently evaluated by one of six radiologists, who recommended biopsy or 2-year follow-up. Biopsy rates according to SA or recombined CEM (rCEM) were compared with the McNemar's test. Diagnostic performance was calculated considering lesions with available final histopathology. RESULTS: Between January 2019 and July 2021, 220 women were enrolled, 207 of them (median age 56.6 years) with 225 suspicious findings analysed. Three of 207 patients (1.4%) developed mild self-limiting adverse reactions to iodinated contrast agent. Overall, 135/225 findings were referred for biopsy, 90/225 by both SA and rCEM, 41/225 by SA alone and 4/225 by rCEM alone (2/4 being one DCIS and one invasive carcinoma). The rCEM biopsy rate (94/225, 41.8%, 95% CI 35.5-48.3%) was 16.4% lower (p < 0.001) than the SA biopsy rate (131/225, 58.2%, 95% CI 51.7-64.5%). Considering the 124/135 biopsies with final histopathology (44 benign, 80 malignant), rCEM showed a 93.8% sensitivity (95% CI 86.2-97.3%) and a 65.9% specificity (95% CI 51.1-78.1%), all 5 false negatives being ductal carcinoma in situ detectable as suspicious calcifications on low-energy images. CONCLUSIONS: Compared to SA, the rCEM-based work-up would have avoided biopsy for 37/225 (16.4%) suspicious findings. Including low-energy images in interpretation provided optimal overall CEM sensitivity. KEY POINTS: • The work-up of suspicious findings detected at mammographic breast cancer screening still leads to a high rate of unnecessary biopsies, involving between 2 and 6% of screened women. • In 207 recalled women with 225 suspicious findings, recombined images of contrast-enhanced mammography (CEM) showed a 93.8% sensitivity and a 65.9% specificity, all 5 false negatives being ductal carcinoma in situ detectable on low-energy images as suspicious calcifications. • CEM could represent an easily available one-stop shop option for the morphofunctional assessment of screening recalls, potentially reducing the biopsy rate by 16.4%.

Gene expression plasticity, genetic variation and fatty acid remodelling in divergent populations of a tropical bivalve species.

Ocean warming challenges marine organisms' resilience, especially for species experiencing temperatures close to their upper thermal limits. A potential increase in thermal tolerance might significantly reduce the risk of population decline, which is intrinsically linked to variability in local habitat temperatures. Our goal was to assess the plastic and genetic potential of response to elevated temperatures in a tropical bivalve model, Pinctada margaritifera. We benefit from two ecotypes for which local environmental conditions are characterized by either large diurnal variations in the tide pools (Marquesas archipelago) or low mean temperature with stable to moderate seasonal variations (Gambier archipelago). We explored the physiological basis of individual responses to elevated temperature, genetic divergence as well as plasticity and acclimation by combining lipidomic and transcriptomic approaches. We show that P. margaritifera has certain capacities to adjust to long-term elevated temperatures that was thus far largely underestimated. Genetic variation across populations overlaps with gene expression and involves the mitochondrial respiration machinery, a central physiological process that contributes to species thermal sensitivity and their distribution ranges. Our results present evidence for acclimation potential in P. margaritifera and urge for longer term studies to assess populations resilience in the face of climate change.

Le réchauffement des océans remet en question la résilience des organismes marins, en particulier pour les espèces connaissant des températures proches de leurs limites thermiques supérieures. Une augmentation potentielle de la tolérance thermique pourrait ainsi réduire considérablement le risque de déclin de la population. L'objectif de cette étude était d'évaluer le potentiel plastique et génétique de la réponse à l'exposition courte et chronique à températures élevées chez une espèce de bivalve tropical, Pinctada margaritifera. Ce modèle bénéficie de l'existence de deux écotypes pour lesquels les conditions environnementales locales sont caractérisées soit par de fortes variations diurnes associées aux marées (archipel des Marquises) soit par une température moyenne plus basse et des variations saisonnières prononcées (archipel des Gambier). Nous avons exploré les bases physiologiques des réponses individuelles ainsi que la divergence génétique et quantifié la plasticité en combinant des approches lipidomique et transcriptomique. Nous montrons que P. margaritifera possède des capacités d'acclimatation à des températures élevées sur le long terme jusqu'à présent largement sous-estimées. La divergence génétique entre populations est par ailleurs associée à des différences d'expression des gènes et implique la machinerie respiratoire mitochondriale, un processus physiologique central qui contribue à la sensibilité thermique des espèces et à leurs répartitions. Nos résultats présentent les bases des potentiels d'acclimatation chez P. margaritifera et soulignent l'importance d'études à plus long terme pour évaluer la résilience des populations face au changement climatique.

Opposing life stage-specific effects of ocean warming at source and sink populations of range-shifting coral-reef fishes.

Climate change is altering the latitudinal distributions of species, with their capacity to keep pace with a shifting climate depending on the stochastic expression of population growth rates, and the influence of compensatory density feedback on age-specific survival rates. We use population-abundance time series at the leading edge of an expanding species' range to quantify the contribution of stochastic environmental drivers and density feedbacks to the dynamics of life stage-specific population growth. Using a tropical, range-shifting Indo-Pacific damselfish (Abudefduf vaigiensis) as a model organism, we applied variants of the phenomenological Gompertz-logistic model to a 14-year dataset to quantify the relative importance of density feedback and stochastic environmental drivers on the separate and aggregated population growth rates of settler and juvenile life stages. The top-ranked models indicated that density feedback negatively affected the growth of tropical settlers and juveniles. Rates of settlement were negatively linked to temperatures experienced by parents at potential source populations in the tropics, but their subsequent survival and that of juveniles increased with the temperatures experienced at the temperate sink. Including these stochastic effects doubled the deviance explained by the models, corroborating an important role of temperature. By incorporating sea-surface temperature projections for the remainder of this century into these models, we anticipate improved conditions for the population growth of juvenile coral-reef fishes, but not for settlers in temperate ecosystems. Previous research has highlighted the association between temperature and the redistribution of species. Our analyses reveal the contrasting roles of different life stages in the dynamics of range-shifting species responding to climate change, as they transition from vagrancy to residency in their novel ranges.

Dietary generalism accelerates arrival and persistence of coral-reef fishes in their novel ranges under climate change.

Climate change is redistributing marine and terrestrial species globally. Life-history traits mediate the ability of species to cope with novel environmental conditions, and can be used to gauge the potential redistribution of taxa facing the challenges of a changing climate. However, it is unclear whether the same traits are important across different stages of range shifts (arrival, population increase, persistence). To test which life-history traits most mediate the process of range extension, we used a 16-year dataset of 35 range-extending coral-reef fish species and quantified the importance of various traits on the arrival time (earliness) and degree of persistence (prevalence and patchiness) at higher latitudes. We show that traits predisposing species to shift their range more rapidly (large body size, broad latitudinal range, long dispersal duration) did not drive the early stages of redistribution. Instead, we found that as diet breadth increased, the initial arrival and establishment (prevalence and patchiness) of climate migrant species in temperate locations occurred earlier. While the initial incursion of range-shifting species depends on traits associated with dispersal potential, subsequent establishment hinges more on a species' ability to exploit novel food resources locally. These results highlight that generalist species that can best adapt to novel food sources might be most successful in a future ocean.

A computer-aided diagnosis system for the assessment and characterization of low-to-high suspicion thyroid nodules on ultrasound.

AIM OF THE STUDY: To compare the diagnostic performance of a commercially available computer-aided diagnosis (CAD) system for thyroid ultrasound (US) with that of a non-computer-aided radiologist in the characterization of low-to-high suspicion thyroid nodules. METHODS: This retrospective study included a consecutive series of adult patients referred for US-guided fine-needle aspiration biopsy (FNAB) of a thyroid nodule. All patients were eligible for thyroid nodule FNAB according to the current international guidelines. An interventional radiologist experienced in thyroid imaging acquired the US images subsequently used for post-processing, performed FNAB and provided the US features of each nodule. A radiology resident and an endocrinology resident in consensus performed post-processing using the CAD system to assess the same nodule characteristics. The diagnostic performance and agreement of US features between the CAD system and the radiologist were compared. RESULTS: Sixty-two patients (50 F; age 60 ± 12 years) were enrolled: 77.4% (48/62) of thyroid nodules were benign, 22.6% (14/62) were undetermined to malignant and required follow-up or surgery. Interobserver agreement between the CAD system and the radiologist was substantial for orientation (K = 0.69), fair for composition (K = 0.36), echogenicity (K = 0.36), K-TIRADS (K = 0.29), and slight for margins (K = 0.03). The radiologist demonstrated a significantly higher sensitivity than the CAD system (78.6% vs. 21.4%; P = 0.008), while there was no statistical difference in specificity (66.7% vs. 81.3%; P = 0.065). CONCLUSION: This CAD system is less sensitive than an experienced radiologist and showed slight-to-substantial agreement with the radiologist for the characterization of thyroid nodules. Although it is an innovative tool with good potential, additional efforts are needed to improve its diagnostic performance.

DEB-TACE: a standard review.

Drug-eluting bead transarterial chemoembolization (DEB-TACE) is a relative new endovascular treatment based on the use of microspheres to release chemotherapeutic agents within a target lesion with controlled pharmacokinetics. This aspect justifies the immediate success of DEB-TACE, that nowadays represents one of the most used treatments for unresectable hepatocellular carcinoma. However, there is no consensus about the choice of the best embolotherapy technique. In this review, we describe the available microspheres and report the results of the main comparative studies, to clarify the role of DEB-TACE in the hepatocellular carcinoma management. We underline that there is no evidence about the superiority of DEB-TACE over conventional TACE in terms of efficacy, but there may be some benefits with respect to safety especially with the improvement of new technologies.

Decoupling of behavioural and physiological thermal performance curves in ectothermic animals: a critical adaptive trait.

Thermal performance curves (TPCs) represent an increasingly popular tool in ecology for anticipating species responses to climate change. TPC theory has been developed using species that experience similar temperatures during activity and at rest and consequently exhibit thermal ranges for activity that closely coincide with their physiological thermal tolerances. Many species, however, experience other stressors, such as desiccation, that limit active behaviour at temperatures below the maximum values experienced. As a result, activity is constrained to a narrow thermal window that is a subset of the range of temperatures that can be tolerated physiologically. This results in a decoupling of behavioural and physiological TPCs that does not conform to the present paradigm. To test the generality of TPC theory, we measured thermal responses for behaviour (crawling speed) and physiological tolerance (heart rate) for six rocky shore gastropods spanning a thermal/desiccation stress gradient. We hypothesized a positive relationship between shore level and the degree of decoupling of behavioural and physiological TPCs. This prediction was confirmed, and was explained by the extension of the physiological TPC beyond the range of the behavioural TPC. Decoupling of behavioural and physiological TPCs is central to predicting accurately the fitness dynamics of ectothermic species subject to multiple stressors. We believe that this decoupling should be explicitly considered as an adaptive trait defining an organism's thermal niche.

Benign thyroid nodules treatment using percutaneous laser ablation (PLA) and radiofrequency ablation (RFA).

PURPOSE: To evaluate the reduction over time of benign thyroid nodules treated using percutaneous laser ablation (PLA) and radiofrequency ablation (RFA) by the same equipe. MATERIALS AND METHODS: Ninety patients (age 55.6 ± 14.1 years) underwent ablation for benign thyroid nodule causing compression/aesthetic dissatisfaction from 2011. Fifty-nine (age 55.8 ± 14.1 years) underwent RFA and 31 (age 55.2 ± 14.2 years) PLA, ultrasound guided. Technical success, complications, duration of ablation and treatment, energy deployed, volumetric percentage reduction at 1, 6 and 12 months were derived. A regression model for longitudinal measurements was used with random intercept and random slope. Values are expressed as mean ± standard deviation or N (%). RESULTS: Technical success was always obtained. No major complications occurred. Mean ablation time was 30.1 ± 13.8 vs. 13.9 ± 5.9 min (p < .0001) and mean energy deployment was 5422.3 ± 2484.5 J vs. 34 662.7 ± 15 812.3 J in PLA vs. RFA group. Mean volume reduced from 20.3 ± 16.4 ml to 13.17 ± 10.74 ml (42% ± 17% reduction) at 1st month, 8.7 ± 7.4 ml (60% ± 15% reduction) at 6th month and 7.1 ± 7.7 ml (70%% ± 16% reduction) at 12th month, in PLA group, and from 32.7 ± 19.5 ml to 17.2 ± 12.9 ml (51%±15% reduction) at 1st month, 12.8 ± 9.6 ml (64 ± 14% reduction) at 6th month and 9.9 ± 9.2 ml (74% ± 14% reduction) at 12th month in RFA group. No difference in time course of the relative volume reduction between the two techniques was found. CONCLUSIONS: RFA and PLA are similarly feasible, safe and effective in treating benign thyroid nodules when performed by the same equipe. RFA is faster than PLA but require significantly higher energy.

Personality, foraging behavior and specialization: integrating behavioral and food web ecology at the individual level.

Behavioral traits and diet were traditionally thought to be highly plastic within individuals. This view was espoused in the widespread use of optimality models, which broadly predict that individuals can modify behavioral traits and diet across ecological contexts to maximize fitness. Yet, research conducted over the past 15 years supports an alternative view; fundamental behavioral traits (e.g., activity level, exploration, sociability, boldness and aggressiveness) and diet often vary among individuals and this variation persists over time and across contexts. This phenomenon has been termed animal personality with regard to behavioral traits and individual specialization with regard to diet. While these aspects of individual-level phenotypic variation have been thus far studied in isolation, emerging evidence suggests that personality and individual specialization may covary, or even be causally related. Building on this work, we present the overarching hypothesis that animal personality can drive specialization through individual differences in various aspects of consumer foraging behavior. Specifically, we suggest pathways by which consumer personality traits influence foraging activity, risk-dependent foraging, roles in social foraging groups, spatial aspects of foraging and physiological drivers of foraging, which in turn can lead to consistent individual differences in food resource use. These pathways provide a basis for generating testable hypotheses directly linking animal personality to ecological dynamics, a major goal in contemporary behavioral ecology.

Comparison of in situ black-lipped oyster spat collection and larval dispersal modelling results in semi-closed pearl-farming lagoons of the Tuamotu Archipelago.

Spat collection of the pearl oyster Pinctada margaritifera in atoll lagoons of French Polynesia is the fundamental sustain of black pearl farming. Spat collection has always yielded variable results in space and time, but obvious signs of steady decreases, even collapses, have emerged in several lagoons. Spat collection materializes the ecological connectivity pathways between wild spawning populations and the location of artificial larval settlement substrates. To assess if oyster larval dispersal modelling could capture such pathways, we compared four six-week long spat collector deployment periods with dispersal simulations in two different lagoons. Spat collectors displayed wide spatial and temporal variations. Numerical modelling and field experiments were generally not in agreement. Although both methods have limitations, they can still approximate each other. But the accuracy of model simulations cannot be ascertained with spat collection data only. Using a SWOT (Strength-Weakness-Opportunities-Threats) analysis, we emphasize the complementarity of both approaches for management decisions.

Conservation of thermal physiology in tropical intertidal snails following an evolutionary transition to a cooler ecosystem: climate change implications.

Predictions for animal responses to climate warming usually assume that thermal physiology is adapted to present-day environments, and seldom consider the influence of evolutionary background. Little is known about the conservation of warm-adapted physiology following an evolutionary transition to a cooler environment. We used cardiac thermal performance curves (cTPCs) of six neritid gastropod species to study physiological thermal trait variation associated with a lineage transition from warmer rocky shores to cooler mangroves. We distinguished between functional thermal performance traits, related to energy homeostasis (slope gradient, slope curvature, HRmax, maximum cardiac activity and Topt, the temperature that maximizes cardiac activity) and a trait that limits performance (ULT, the upper lethal temperature). Considering the theory of optimal thermal performance, we predicted that the functional traits should be under greater selective pressure to change directionally and in magnitude than the thermal limit, which is redundant in the cooler environment. We found little variation in all traits across species, habitats and ecosystems, despite a ~20°C reduction in maximum habitat temperature in the mangrove species over 50 million years. While slope gradient was significantly lowered in the mangrove species, the effect difference was negated by greater thermal plasticity in the rocky shore species. ULT showed the least variation and suggested thermal specialization in the warmest habitat studied. The observed muted variation of the functional traits among the species may be explained by their limited role in energy acquisition and rather their association with heat tolerance adaptation, which is redundant in the mangrove species. These findings have implications for the conservation of habitat of intertidal gastropods that transition to cooler environments. Furthermore, they highlight the significance of evolutionary history and physiological conservation when predicting species responses to climate change.

Informing spread predictions of two alien snails using movement traits.

Invasive alien species are a growing global problem, and aquatic ecosystems have been regarded as particularly vulnerable. Biological invasions can alter ecosystem functioning, threaten native biodiversity and burden the global economy. Understanding alien species ability to disperse via locomotion following arrival to new environments is critical for prediction of spread rates. Here, we quantified in-field densities and compared movement traits between two widespread invasive alien snails, Tarebia granifera and Physa acuta. We measured the: (i) net distance and velocity to determine dispersal potential; and (ii) turning angles (both absolute and relative) and straightness index as proxies for exploratory behaviour. Tarebia granifera exhibited a significantly greater velocity and covered a significantly larger net distance (i.e., greater spread rate) than Physa acuta. In-field densities were marked for both species (T. granifera: mean 351 individuals m-2; P. acuta: mean 235 individuals m-2), but differed spatially. The exploratory behavior (i.e., mean or absolute turning angles and straightness index) did not differ significantly between the two alien species; both species showed a slight tendency to turn counterclockwise. The present study suggests a more rapid capacity to self-disperse in T. granifera than P. acuta, which could facilitate rapid spread within and between aquatic systems. Thus, this current study highlights the often-overlooked role of animal behaviour in promoting invasion; this autecological information can help inform predictive models for the spread of alien snails within freshwater ecosystems.

Guiding vacuum-assisted biopsy in prone position: digital breast tomosynthesis vs stereotactic.

PURPOSE: To compare the performance of prone digital breast tomosynthesis (DBT)-vacuum-assisted biopsy (VAB) with prone stereotactic-guided VAB (sVAB), focusing on time of procedure, number of expositions, average glandular dose, and complications. METHODS: The institutional review board approved this retrospective study and informed consent was waived. From July 2015 to January 2017, 306 patients with 306 suspicious mammographic findings (BI-RADS ⩾4) underwent mammography-guided biopsy, prone sVAB, or prone DBT-VAB. Student t test, chi-square, and multivariate regression statistics were used. RESULTS: During the study period, 155 prone sVAB procedures in 155 patients (mean age, 56 years; age range, 39-84 years) and 151 DBT-VABs in 151 patients (mean age, 57 years; age range, 33-84 years) were performed. Mean procedure time was shorter with DBT-VAB versus sVAB (14.5 versus 17.4 minutes, respectively; p < 0.001), and fewer images were acquired with DBT-VAB versus sVAB (8 vs 11, respectively; p < 0.001); the average glandular dose was significantly lower in DBT-VAB versus sVAB (11.8 mGy versus 18 mGy, respectively; p < 0.001). There were no differences in the distribution of histologic results (p = 0.74) or breast density (p = 0.09) between the two groups. No major complications were observed in either group. CONCLUSION: Performance of prone DBT-VAB was superior to prone sVAB because it allowed a faster procedure with fewer radiologic expositions and lower radiation dose.

Mismatch between the ecological processes driving early life-stage dynamics of bivalves at two contrasting French Polynesian lagoons.

The pearl-farming industry depends mostly on the natural recruitment of pearl oysters. Little is known about the relative influence of different ecological processes on the natural recruitment of pearl oysters across biogeographical scales. Spatio-temporal dynamics of bivalve larvae and spats were described at Ahe and Mangareva, 1500 km apart across French Polynesia. We quantified the effect of candidate environmental predictors on the dynamics of larvae. Both lagoons showed similar temporal dynamics with twice more larvae and 6 times more spat in Ahe. Pinctada maculata spat were more abundant than for P. margaritifera at both lagoons. While the temporal dynamics in larvae abundance were best explained by a positive effect of temperature in Ahe, the dynamics in Mangareva were poorly predicted by the environmental variables, meaning bivalve early-life stages perform better in Ahe than Mangareva suggesting a mismatch between the relevant environmental forces driving larval dynamics at these two contrasting lagoons.

Tipping points, thresholds and the keystone role of physiology in marine climate change research.

The ongoing and future effects of global climate change on natural and human-managed ecosystems have led to a renewed interest in the concept of ecological thresholds or tipping points. While generalizations such as poleward range shifts serve as a useful heuristic framework to understand the overall ecological impacts of climate change, sophisticated approaches to management require spatially and temporally explicit predictions that move beyond these oversimplified models. Most approaches to studying ecological thresholds in marine ecosystems tend to focus on populations, or on non-linearities in physical drivers. Here we argue that many of the observed thresholds observed at community and ecosystem levels can potentially be explained as the product of non-linearities that occur at three scales: (a) the mechanisms by which individual organisms interact with their ambient habitat, (b) the non-linear relationship between organismal physiological performance and variables such as body temperature and (c) the indirect effects of physiological stress on species interactions such as competition and predation. We explore examples at each of these scales in detail and explain why a failure to consider these non-linearities - many of which can be counterintuitive - can lead to Type II errors (a failure to predict significant ecological responses to climate change). Specifically, we examine why ecological thresholds can occur well before concomitant thresholds in physical drivers are observed, i.e. how even small linear changes in the physical environment can lead to ecological tipping points. We advocate for an integrated framework that combines biophysical, ecological and physiological methods to generate hypotheses that can be tested using experimental manipulation as well as hindcasting and nowcasting of observed change, on a spatially and temporally explicit basis.

Ectoparasites reduce scope for growth in a rocky-shore mussel (Perna perna) by raising maintenance costs.

Endolithic cyanobacteria are ubiquitous colonisers of organic and inorganic carbonate substrata that frequently attack the shells of mussels, eroding the shell to extract carbon, often with population infestation rates of >80%. This reduces host physiological condition and ultimately leads to shell collapse and mortality, compromising the services provided by these important ecosystem engineers. While the ecological implications of this and similar interactions have been examined, our understanding of the underlying mechanisms driving the physiological responses of infested hosts remains limited. Using field and laboratory experiments, we assessed the energetic costs of cyanobacterial infestation to the intertidal brown mussel (Perna perna). In the field we found that growth (measured as both increase in shell length and rate of biomineralization) and reproductive potential of clean mussels are greater than those of infested individuals. To explore the mechanisms behind these effects, we compared the energy allocation of parasite-free and infested mussels using the scope for growth (SFG) framework. This revealed a lower SFG in parasitized mussels attributed to an energetic imbalance caused by increased standard metabolic rates, without compensation through increased feeding or reduced excretion of ammonia. Separate laboratory assays showed no differences in calcium uptake rates, indicating that infested mussels do not compensate for shell erosion through increased mineralization. This suggests that the increased maintenance costs detected reflect repair of the organic component of the inner nacreous layer of the shell, an energetically more demanding process than mineralization. Thus, parasite-inflicted damage reduces SFG directly through the need for increased basal metabolic rate to drive shell repair without compensatory increases in energy intake. This study provides a first perspective of the physiological mechanisms underlying this parasite-host interaction, a critical step towards a comprehensive understanding of the ecological processes driving dynamics of this intertidal ecosystem engineer.

Dynamic Energy Budget model suggests feeding constraints and physiological stress in black-lip pearl oysters, 5 years post mass-mortality event.

Mass-mortality events of marine species can disturb the structure of communities. While identifying the causes of mass-mortality events is crucial for implementing recovery strategies, monitoring is challenging in remote locations. Black-lip pearl oysters (Pinctada margaritifera) are farmed for producing black pearls within remote atolls of French Polynesia. Previous mass-mortality events have resulted in the collapse of oysters and other species; however, the causes and conditions that favour recovery are unclear. We investigated the potential for oyster population recovery 5 years after a mortality event at Takaroa Atoll (Tuamotu Archipelago). Temperature, food availability (total chlorophyll-a), growth and reproduction were monitored. Growth was also simulated using a Dynamic Energy Budget model. Despite favourable conditions, reduced growth and reproduction signalled an energetic deficit. The model overpredicted growth, and supported the hypotheses that individuals are unable to profit from the phytoplankton available and maintenance costs are high in Takaroa, ultimately explaining their poor physiological condition.

Chest x-ray in the COVID-19 pandemic: Radiologists' real-world reader performance.

PURPOSE: To report real-world diagnostic performance of chest x-ray (CXR) readings during the COVID-19 pandemic. METHODS: In this retrospective observational study we enrolled all patients presenting to the emergency department of a Milan-based university hospital from February 24th to April 8th 2020 who underwent nasopharyngeal swab for reverse transcriptase-polymerase chain reaction (RT-PCR) and anteroposterior bedside CXR within 12 h. A composite reference standard combining RT-PCR results with phone-call-based anamnesis was obtained. Radiologists were grouped by CXR reading experience (Group-1, >10 years; Group-2, <10 years), diagnostic performance indexes were calculated for each radiologist and for the two groups. RESULTS: Group-1 read 435 CXRs (77.0 % disease prevalence): sensitivity was 89.0 %, specificity 66.0 %, accuracy 83.7 %. Group-2 read 100 CXRs (73.0 % prevalence): sensitivity was 89.0 %, specificity 40.7 %, accuracy 76.0 %. During the first half of the outbreak (195 CXRs, 66.7 % disease prevalence), overall sensitivity was 80.8 %, specificity 67.7 %, accuracy 76.4 %, Group-1 sensitivity being similar to Group-2 (80.6 % versus 81.5 %, respectively) but higher specificity (74.0 % versus 46.7 %) and accuracy (78.4 % versus 69.0 %). During the second half (340 CXRs, 81.8 % prevalence), overall sensitivity increased to 92.8 %, specificity dropped to 53.2 %, accuracy increased to 85.6 %, this pattern mirrored in both groups, with decreased specificity (Group-1, 58.0 %; Group-2, 33.3 %) but increased sensitivity (92.7 % and 93.5 %) and accuracy (86.5 % and 81.0 %, respectively). CONCLUSIONS: Real-world CXR diagnostic performance during the COVID-19 pandemic showed overall high sensitivity with higher specificity for more experienced radiologists. The increase in accuracy over time strengthens CXR role as a first line examination in suspected COVID-19 patients.

Chest x-ray severity score in COVID-19 patients on emergency department admission: a two-centre study.

BACKGROUND: Integration of imaging and clinical parameters could improve the stratification of COVID-19 patients on emergency department (ED) admission. We aimed to assess the extent of COVID-19 pulmonary abnormalities on chest x-ray (CXR) using a semiquantitative severity score, correlating it with clinical data and testing its interobserver agreement. METHODS: From February 22 to April 8, 2020, 926 consecutive patients referring to ED of two institutions in Northern Italy for suspected SARS-CoV-2 infection were reviewed. Patients with reverse transcriptase-polymerase chain reaction positive for SARS-CoV-2 and CXR images on ED admission were included (295 patients, median age 69 years, 199 males). Five readers independently and blindly reviewed all CXRs, rating pulmonary parenchymal involvement using a 0-3 semiquantitative score in 1-point increments on 6 lung zones (range 0-18). Interobserver agreement was assessed with weighted Cohen's κ, correlations between median CXR score and clinical data with Spearman's ρ, and the Mann-Whitney U test. RESULTS: Median score showed negative correlation with SpO2 (ρ = -0.242, p < 0.001), positive correlation with white cell count (ρ = 0.277, p < 0.001), lactate dehydrogenase (ρ = 0.308, p < 0.001), and C-reactive protein (ρ = 0.367, p < 0.001), being significantly higher in subsequently dead patients (p = 0.003). Considering overall scores, readers' pairings yielded moderate (κ = 0.449, p < 0.001) to almost perfect interobserver agreement (κ = 0.872, p < 0.001), with better interobserver agreement between readers of centre 2 (up to κ = 0.872, p < 0.001) than centre 1 (κ = 0.764, p < 0.001). CONCLUSIONS: Proposed CXR pulmonary severity score in COVID-19 showed moderate to almost perfect interobserver agreement and significant but weak correlations with clinical parameters, potentially furthering CXR integration in patients' stratification.

Pulmonary thromboembolism in hospitalised COVID-19 patients at moderate to high risk by Wells score: a report from Lombardy, Italy.

OBJECTIVES: To present a single-centre experience on CT pulmonary angiography (CTPA) for the assessment of hospitalised COVID-19 patients with moderate-to-high risk of pulmonary thromboembolism (PTE). METHODS: We analysed consecutive COVID-19 patients (RT-PCR confirmed) undergoing CTPA in March 2020 for PTE clinical suspicion. Clinical data were retrieved. Two experienced radiologists reviewed CTPAs to assess pulmonary parenchyma and vascular findings. RESULTS: Among 34 patients who underwent CTPA, 26 had PTE (76%, 20 males, median age 61 years, interquartile range 54-70), 20/26 (77%) with comorbidities (mainly hypertension, 44%), and 8 (31%) subsequently dying. Eight PTE patients were under thromboprophylaxis with low-molecular-weight heparin, four PTE patients had lower-limbs deep vein thrombosis at ultrasound examination (performed in 33/34 patients). Bilateral PTE characterised 19/26 cases, with main branches involved in 10/26 cases. Twelve patients had a parenchymal involvement >75%, the predominant pneumonia pattern being consolidation in 10/26 patients, ground glass opacities in 9/26, crazy paving in 5/26, and both ground glass opacities and consolidation in 2/26. CONCLUSION: COVID-19 patients are prone to PTE. ADVANCES IN KNOWLEDGE: PTE, potentially attributable to an underlying thrombophilic status, may be more frequent than expected in COVID-19 patients. Extension of prophylaxis and adaptation of diagnostic criteria should be considered.