Quantitative ultrasonography reveals skeletal muscle abnormalities in carriers of DMD pathogenic variants.

INTRODUCTION/AIMS: Carriers of DMD pathogenic variants may become symptomatic and develop muscle-related manifestations. Despite that, few studies have attempted to characterize changes in the muscles of these carriers using imaging tools, particularly muscle ultrasound (MUS). The aim of this study was to compare lower limb MUS findings in carriers of DMD pathogenic variants (cDMD) vs healthy controls. METHODS: Twenty-eight women (15 cDMD and 13 controls) underwent clinical evaluation and MUS. We collected information about muscle-related symptoms and assessed muscle strength. MUS was performed by a single physician (blind to the genetic status of subjects). The following muscles were assessed: rectus femoris, sartorius, tibialis anterior, and medial gastrocnemius. For each site, we computed data on muscle thickness, cross-sectional area, sound attenuation index, and elastography. Between-group comparisons were assessed using nonparametric tests and p-values <.05 were deemed significant. RESULTS: None of the subjects had objective muscle weakness, but exercise intolerance/fatigue was reported by four cDMDs and only one control. Regarding MUS, sound attenuation indices were significantly higher among carriers for all muscles tested. Longitudinal and axial deep echo intensities for the rectus femoris and tibialis anterior were also higher in the cDMD group compared with controls. No significant between-group differences were noted for elastography values, muscle area, or mean echo intensities. DISCUSSION: cDMD have skeletal muscle abnormalities that can be detected using quantitative MUS. Further studies are needed to determine whether such abnormalities are related to muscle symptoms in these patients.

Hepatobiliary phases in magnetic resonance imaging using liver-specific contrast for focal lesions in clinical practice.

BACKGROUND: Challenging lesions, difficult to diagnose through non-invasive methods, constitute an important emotional burden for each patient regarding a still uncertain diagnosis (malignant x benign). In addition, from a therapeutic and prognostic point of view, delay in a definitive diagnosis can lead to worse outcomes. One of the main innovative trends currently is the use of molecular and functional methods to diagnosis. Numerous liver-specific contrast agents have been developed and studied in recent years to improve the performance of liver magnetic resonance imaging (MRI). More recently, one of the contrast agents introduced in clinical practice is gadoxetic acid (gadoxetate disodium). AIM: To demonstrate the value of the hepatobiliary phases using gadoxetic acid in MRI for the characterization of focal liver lesions (FLL) in clinical practice. METHODS: Overall, 302 Lesions were studied in 136 patients who underwent MRI exams using gadoxetic acid for the assessment of FLL. Two radiologists independently reviewed the MRI exams using four stages, and categorized them on a 6-point scale, from 0 (lesion not detected) to 5 (definitely malignant). The stages were: stage 1- images without contrast, stage 2- addition of dynamic phases after contrast (analogous to usual extracellular contrasts), stage 3- addition of hepatobiliary phase after 10 min (HBP 10'), stage 4- hepatobiliary phase after 20 min (HBP 20') in addition to stage 2. RESULTS: The interobserver agreement was high (weighted Kappa coefficient: 0.81- 1) at all stages in the characterization of benign and malignant FLL. The diagnostic weighted accuracy (Az) was 0.80 in stage 1 and was increased to 0.90 in stage 2. Addition of the hepatobiliary phase increased Az to 0.98 in stage 3, which was also 0.98 in stage 4. CONCLUSION: The hepatobiliary sequences improve diagnostic accuracy. With growing potential in the era of precision medicine, the improvement and dissemination of the method among medical specialties can bring benefits in the management of patients with FLL that are difficult to diagnose.

Lung Lesion Burden found on Chest CT as a Prognostic Marker in Hospitalized Patients with High Clinical Suspicion of COVID-19 Pneumonia: a Brazilian experience.

OBJECTIVE: To investigate the relationship between lung lesion burden (LLB) found on chest computed tomography (CT) and 30-day mortality in hospitalized patients with high clinical suspicion of coronavirus disease 2019 (COVID-19), accounting for tomographic dynamic changes. METHODS: Patients hospitalized with high clinical suspicion of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in a dedicated and reference hospital for COVID-19, having undergone at least one RT-PCR test, regardless of the result, and with one CT compatible with COVID-19, were retrospectively studied. Clinical and laboratory data upon admission were assessed, and LLB found on CT was semi-quantitatively evaluated through visual analysis. The primary outcome was 30-day mortality after admission. Secondary outcomes, including the intensive care unit (ICU) admission, mechanical ventilation used, and length of stay (LOS), were assessed. RESULTS: A total of 457 patients with a mean age of 57±15 years were included. Among these, 58% presented with positive RT-PCR result for COVID-19. The median time from symptom onset to RT-PCR was 8 days [interquartile range 6-11 days]. An initial LLB of ≥50% using CT was found in 201 patients (44%), which was associated with an increased crude at 30-day mortality (31% vs. 15% in patients with LLB of <50%, p<0.001). An LLB of ≥50% was also associated with an increase in the ICU admission, the need for mechanical ventilation, and a prolonged LOS after adjusting for baseline covariates and accounting for the CT findings as a time-varying covariate; hence, patients with an LLB of ≥50% remained at a higher risk at 30-day mortality (adjusted hazard ratio 2.17, 95% confidence interval 1.47-3.18, p<0.001). CONCLUSION: Even after accounting for dynamic CT changes in patients with both clinical and imaging findings consistent with COVID-19, an LLB of ≥50% might be associated with a higher risk of mortality.

Evaluation of the RSNA and CORADS classifications for COVID-19 on chest computed tomography in the Brazilian population.

OBJECTIVE: To determine the correlation between the two tomographic classifications for coronavirus disease (COVID-19), COVID-19 Reporting and Data System (CORADS) and Radiological Society of North America Expert Consensus Statement on Reporting Chest Computed Tomography (CT) Findings Related to COVID-19 (RSNA), in the Brazilian population and to assess the agreement between reviewers with different experience levels. METHODS: Chest CT images of patients with reverse transcriptase-polymerase chain reaction (RT-PCR)-positive COVID-19 were categorized according to the CORADS and RSNA classifications by radiologists with different levels of experience and who were initially unaware of the RT-PCR results. The inter- and intra-observer concordances for each of the classifications were calculated, as were the concordances between classifications. RESULTS: A total of 100 patients were included in this study. The RSNA classification showed an almost perfect inter-observer agreement between reviewers with similar experience levels, with a kappa coefficient of 0.892 (95% confidence interval [CI], 0.788-0.995). CORADS showed substantial agreement among reviewers with similar experience levels, with a kappa coefficient of 0.642 (95% CI, 0.491-0.793). There was inter-observer variation when comparing less experienced reviewers with more experienced reviewers, with the highest kappa coefficient of 0.396 (95% CI, 0.255-0.588). There was a significant correlation between both classifications, with a Kendall coefficient of 0.899 (p<0.001) and substantial intra-observer agreement for both classifications. CONCLUSION: The RSNA and CORADS classifications showed excellent inter-observer agreement for reviewers with the same level of experience, although the agreement between less experience reviewers and the reviewer with the most experience was only reasonable. Combined analysis of both classifications with the first RT-PCR results did not reveal any false-negative results for detecting COVID-19 in patients.

Chest computed tomography in the diagnosis of COVID-19 in patients with false negative RT-PCR.

OBJECTIVE: To evaluate the role of chest computed tomography in patients with COVID-19 who presented initial negative result in reverse transcriptase-polymerase chain reaction (RT-PCR). METHODS: A single-center, retrospective study that evaluated 39 patients with negative RT-PCR for COVID-19, who underwent chest computed tomography and had a final clinical or serological diagnosis of COVID-19. The visual tomographic classification was evaluated according to the Consensus of the Radiological Society of North America and software developed with artificial intelligence for automatic detection of findings and chance estimation of COVID-19. RESULTS: In the visual tomographic analysis, only one of them (3%) presented computed tomography classified as negative, 69% were classified as typical and 28% as indeterminate. In the evaluation using the software, only four (about 10%) had a probability of COVID-19 <25%. CONCLUSION: Computed tomography can play an important role in management of suspected cases of COVID-19 with initial negative results in RT-PCR, especially considering those patients outside the ideal window for sample collection for RT-PCR.

Thoracic tomographic manifestations in symptomatic respiratory patients with COVID-19.

China was the epicenter for the novel coronavirus disease (COVID-19), which quickly spread to other Asian countries and later to Western countries; subsequently, COVID-19 was categorized as a pandemic by the World Health Organization. Diagnosis primarily depends on viral detection in respiratory samples; however, available kits are limited, lack high sensitivity, and have a long turnaround time for providing results. In this scenario, computed tomography has emerged as an efficient and available high-sensitivity method, allowing radiologists to readily recognize findings related to COVID-19. The objective of this article is to demonstrate the main tomographic findings in symptomatic respiratory patients with COVID-19 to assist medical professionals during this critical moment.

A doença pelo novo coronavírus (COVID-19) teve epicentro na China e rapidamente se espalhou pelos demais países asiáticos e, posteriormente, para os países ocidentais, sendo definida como pandemia pela Organização Mundial da Saúde. O diagnóstico da COVID-19 é primariamente dependente da pesquisa do vírus nas vias aéreas superiores, mas os kits para sua confirmação ainda são limitados, não apresentam sensibilidade elevada e os resultados são demorados. Nesse cenário, a tomografia computadorizada surge como método eficiente e disponível e com alta sensibilidade, cabendo a nós radiologistas reconhecer prontamente os achados relacionados a essa doença. O objetivo deste artigo é demonstrar os principais achados tomográficos de tórax em pacientes sintomáticos respiratórios infectados pela COVID-19, de modo a auxiliar os colegas nesse momento crítico.

Imaging findings in COVID-19 pneumonia.

The coronavirus disease (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in Wuhan city and was declared a pandemic in March 2020. Although the virus is not restricted to the lung parenchyma, the use of chest imaging in COVID-19 can be especially useful for patients with moderate to severe symptoms or comorbidities. This article aimed to demonstrate the chest imaging findings of COVID-19 on different modalities: chest radiography, computed tomography, and ultrasonography. In addition, it intended to review recommendations on imaging assessment of COVID-19 and to discuss the use of a structured chest computed tomography report. Chest radiography, despite being a low-cost and easily available method, has low sensitivity for screening patients. It can be useful in monitoring hospitalized patients, especially for the evaluation of complications such as pneumothorax and pleural effusion. Chest computed tomography, despite being highly sensitive, has a low specificity, and hence cannot replace the reference diagnostic test (reverse transcription polymerase chain reaction). To facilitate the confection and reduce the variability of radiological reports, some standardizations with structured reports have been proposed. Among the available classifications, it is possible to divide the radiological findings into typical, indeterminate, atypical, and negative findings. The structured report can also contain an estimate of the extent of lung involvement (e.g., more or less than 50% of the lung parenchyma). Pulmonary ultrasonography can also be an auxiliary method, especially for monitoring hospitalized patients in intensive care units, where transfer to a tomography scanner is difficult.

Characteristics of training and motivation of physicians working in emergency medicine.

INTRODUCTION:: Emergency medicine is an area in which correct decisions often need to be made fast, thus requiring a well-prepared medical team. There is little information regarding the profile of physicians working at emergency departments in Brazil. OBJECTIVE:: To describe general characteristics of training and motivation of physicians working in the emergency departments of medium and large hospitals in Salvador, Brazil. METHOD:: A cross-sectional study with standardized interviews applied to physicians who work in emergency units in 25 medium and large hospitals in Salvador. At least 75% of the professionals at each hospital were interviewed. One hospital refused to participate in the study. RESULTS:: A total of 659 physicians were interviewed, with a median age of 34 years (interquartile interval: 29-44 years), 329 (49.9%) were female and 96 (14.6%) were medical residents working at off hours. The percentage of physicians who had been trained with Basic Life Support, Advanced Cardiovascular Life Support and Advanced Trauma Life Support courses was 5.2, 18.4 and 11.0%, respectively, with a greater frequency of Advanced Cardiovascular Life Support training among younger individuals (23.6% versus 13.9%; p<0.001). Thirteen percent said they were completely satisfied with the activity, while 81.3% expressed a desire to stop working in emergency units in the next 15 years, mentioning stress levels as the main reason. CONCLUSION:: The physicians interviewed had taken few emergency immersion courses. A low motivational level was registered in physicians who work in the emergency departments of medium and large hospitals in Salvador.

Agreement between three perioperative risk scores.

OBJECTIVE: To evaluate the agreement between the three scores proposed by the II Guideline for Perioperative Evaluation of the Brazilian Society of Cardiology (SBC): the American College of Physicians algorithm (ACP), the Multicenter Study of Perioperative Evaluation (EMAPO) and Lee's Revised Cardiac Risk Index (RCRI). METHOD: Patients evaluated preoperatively for non-cardiac surgery by the anesthesiology service were classified as low, moderate or high-risk according to the 3 algorithms suggested by the II Guideline. To calculate the strength of agreement between the scores, the kappa agreement index was used. RESULTS: Four hundred and one patients were included in the sample. Cohen's kappa inter-rater agreement between scores was 0.270 (CI: 0.222 to 0.318), corresponding to a weak agreement. Analyzing in pairs, the best correlation was between EMAPO and ACP, with kappa = 0.327. Lee's score was the one that classified more patients as low-risk: 98.3%, while EMAPO and ACP classified as low risk 91.3% and 92.5%, respectively. CONCLUSION: There is poor correlation among the risk scores proposed by the II Perioperative Evaluation Guideline of the SBC.

Evaluation of the RSNA and CORADS classifications for COVID-19 on chest computed tomography in the Brazilian population

OBJECTIVE: To determine the correlation between the two tomographic classifications for coronavirus disease (COVID-19), COVID-19 Reporting and Data System (CORADS) and Radiological Society of North America Expert Consensus Statement on Reporting Chest Computed Tomography (CT) Findings Related to COVID-19 (RSNA), in the Brazilian population and to assess the agreement between reviewers with different experience levels. METHODS: Chest CT images of patients with reverse transcriptase-polymerase chain reaction (RT-PCR)-positive COVID-19 were categorized according to the CORADS and RSNA classifications by radiologists with different levels of experience and who were initially unaware of the RT-PCR results. The inter- and intra-observer concordances for each of the classifications were calculated, as were the concordances between classifications. RESULTS: A total of 100 patients were included in this study. The RSNA classification showed an almost perfect inter-observer agreement between reviewers with similar experience levels, with a kappa coefficient of 0.892 (95% confidence interval [CI], 0.788-0.995). CORADS showed substantial agreement among reviewers with similar experience levels, with a kappa coefficient of 0.642 (95% CI, 0.491-0.793). There was inter-observer variation when comparing less experienced reviewers with more experienced reviewers, with the highest kappa coefficient of 0.396 (95% CI, 0.255-0.588). There was a significant correlation between both classifications, with a Kendall coefficient of 0.899 (p<0.001) and substantial intra-observer agreement for both classifications. CONCLUSION: The RSNA and CORADS classifications showed excellent inter-observer agreement for reviewers with the same level of experience, although the agreement between less experience reviewers and the reviewer with the most experience was only reasonable. Combined analysis of both classifications with the first RT-PCR results did not reveal any false-negative results for detecting COVID-19 in patients.

Lung lesion burden found on chest ct as a prognostic marker in hospitalized patients with high clinical suspicion of COVID-19 pneumonia: a brazilian experience

OBJECTIVE: To investigate the relationship between lung lesion burden (LLB) found on chest computed tomography (CT) and 30-day mortality in hospitalized patients with high clinical suspicion of coronavirus disease 2019 (COVID-19), accounting for tomographic dynamic changes. METHODS: Patients hospitalized with high clinical suspicion of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in a dedicated and reference hospital for COVID-19, having undergone at least one RT-PCR test, regardless of the result, and with one CT compatible with COVID-19, were retrospectively studied. Clinical and laboratory data upon admission were assessed, and LLB found on CT was semi-quantitatively evaluated through visual analysis. The primary outcome was 30-day mortality after admission. Secondary outcomes, including the intensive care unit (ICU) admission, mechanical ventilation used, and length of stay (LOS), were assessed. RESULTS: A total of 457 patients with a mean age of 57±15 years were included. Among these, 58% presented with positive RT-PCR result for COVID-19. The median time from symptom onset to RT-PCR was 8 days [interquartile range 6-11 days]. An initial LLB of ≥50% using CT was found in 201 patients (44%), which was associated with an increased crude at 30-day mortality (31% vs. 15% in patients with LLB of <50%, p<0.001). An LLB of ≥50% was also associated with an increase in the ICU admission, the need for mechanical ventilation, and a prolonged LOS after adjusting for baseline covariates and accounting for the CT findings as a time-varying covariate; hence, patients with an LLB of ≥50% remained at a higher risk at 30-day mortality (adjusted hazard ratio 2.17, 95% confidence interval 1.47-3.18, p<0.001). CONCLUSION: Even after accounting for dynamic CT changes in patients with both clinical and imaging findings consistent with COVID-19, an LLB of ≥50% might be associated with a higher risk of mortality.

Chest computed tomography in the diagnosis of COVID-19 in patients with false negative RT-PCR / Tomografia computadorizada de tórax no diagnóstico de COVID-19 em pacientes com resultado falso-negativo na RT-PCR

ABSTRACT Objective To evaluate the role of chest computed tomography in patients with COVID-19 who presented initial negative result in reverse transcriptase-polymerase chain reaction (RT-PCR). Methods A single-center, retrospective study that evaluated 39 patients with negative RT-PCR for COVID-19, who underwent chest computed tomography and had a final clinical or serological diagnosis of COVID-19. The visual tomographic classification was evaluated according to the Consensus of the Radiological Society of North America and software developed with artificial intelligence for automatic detection of findings and chance estimation of COVID-19. Results In the visual tomographic analysis, only one of them (3%) presented computed tomography classified as negative, 69% were classified as typical and 28% as indeterminate. In the evaluation using the software, only four (about 10%) had a probability of COVID-19 <25%. Conclusion Computed tomography can play an important role in management of suspected cases of COVID-19 with initial negative results in RT-PCR, especially considering those patients outside the ideal window for sample collection for RT-PCR.

RESUMO Objetivo Avaliar o papel da tomografia computadorizada de tórax em pacientes com COVID-19 que apresentaram reação em cadeia da polimerase via transcriptase reversa (RT-PCR) inicial falsamente negativa. Métodos Estudo retrospectivo de centro único que avaliou 39 pacientes com RT-PCR negativa para COVID-19, submetidos à tomografia computadorizada de tórax e que tiveram diagnóstico final clínico ou serológico de COVID-19. A classificação tomográfica visual foi avaliada de acordo com o Consenso da Radiological Society of North America e o software desenvolvido com inteligência artificial para detecção automática de achados e estimativa de probabilidade de COVID-19. Resultados Na análise tomográfica visual, somente um deles (3%) apresentou tomografia computadorizada classificada como tendo resultado negativo, 69% foram classificados como típicos e 28% como indeterminados. Na avaliação com uso de software, somente quatro (cerca de 10%) tiveram probabilidade de COVID-19 <25%. Conclusão A tomografia computadorizada pode desempenhar papel importante no manejo de casos suspeitos de COVID-19 com RT-PCR inicialmente negativa, principalmente levando-se em consideração os pacientes que estão fora da janela ideal para coleta de amostra para RT-PCR.

Imaging findings in COVID-19 pneumonia

The coronavirus disease (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in Wuhan city and was declared a pandemic in March 2020. Although the virus is not restricted to the lung parenchyma, the use of chest imaging in COVID-19 can be especially useful for patients with moderate to severe symptoms or comorbidities. This article aimed to demonstrate the chest imaging findings of COVID-19 on different modalities: chest radiography, computed tomography, and ultrasonography. In addition, it intended to review recommendations on imaging assessment of COVID-19 and to discuss the use of a structured chest computed tomography report. Chest radiography, despite being a low-cost and easily available method, has low sensitivity for screening patients. It can be useful in monitoring hospitalized patients, especially for the evaluation of complications such as pneumothorax and pleural effusion. Chest computed tomography, despite being highly sensitive, has a low specificity, and hence cannot replace the reference diagnostic test (reverse transcription polymerase chain reaction). To facilitate the confection and reduce the variability of radiological reports, some standardizations with structured reports have been proposed. Among the available classifications, it is possible to divide the radiological findings into typical, indeterminate, atypical, and negative findings. The structured report can also contain an estimate of the extent of lung involvement (e.g., more or less than 50% of the lung parenchyma). Pulmonary ultrasonography can also be an auxiliary method, especially for monitoring hospitalized patients in intensive care units, where transfer to a tomography scanner is difficult.

Characteristics of training and motivation of physicians working in emergency medicine

Summary Introduction: Emergency medicine is an area in which correct decisions often need to be made fast, thus requiring a well-prepared medical team. There is little information regarding the profile of physicians working at emergency departments in Brazil. Objective: To describe general characteristics of training and motivation of physicians working in the emergency departments of medium and large hospitals in Salvador, Brazil. Method: A cross-sectional study with standardized interviews applied to physicians who work in emergency units in 25 medium and large hospitals in Salvador. At least 75% of the professionals at each hospital were interviewed. One hospital refused to participate in the study. Results: A total of 659 physicians were interviewed, with a median age of 34 years (interquartile interval: 29-44 years), 329 (49.9%) were female and 96 (14.6%) were medical residents working at off hours. The percentage of physicians who had been trained with Basic Life Support, Advanced Cardiovascular Life Support and Advanced Trauma Life Support courses was 5.2, 18.4 and 11.0%, respectively, with a greater frequency of Advanced Cardiovascular Life Support training among younger individuals (23.6% versus 13.9%; p<0.001). Thirteen percent said they were completely satisfied with the activity, while 81.3% expressed a desire to stop working in emergency units in the next 15 years, mentioning stress levels as the main reason. Conclusion: The physicians interviewed had taken few emergency immersion courses. A low motivational level was registered in physicians who work in the emergency departments of medium and large hospitals in Salvador.

Agreement between three perioperative risk scores / Concordância entre três escores de risco perioperatório

SUMMARY Objective: To evaluate the agreement between the three scores proposed by the II Guideline for Perioperative Evaluation of the Brazilian Society of Cardiology (SBC): the American College of Physicians algorithm (ACP), the Multicenter Study of Perioperative Evaluation (EMAPO) and Lee’s Revised Cardiac Risk Index (RCRI). Method: Patients evaluated preoperatively for non-cardiac surgery by the anesthesiology service were classified as low, moderate or high-risk according to the 3 algorithms suggested by the II Guideline. To calculate the strength of agreement between the scores, the kappa agreement index was used. Results: Four hundred and one patients were included in the sample. Cohen’s kappa inter-rater agreement between scores was 0.270 (CI: 0.222 to 0.318), corresponding to a weak agreement. Analyzing in pairs, the best correlation was between EMAPO and ACP, with kappa = 0.327. Lee’s score was the one that classified more patients as low-risk: 98.3%, while EMAPO and ACP classified as low risk 91.3% and 92.5%, respectively. Conclusion: There is poor correlation among the risk scores proposed by the II Perioperative Evaluation Guideline of the SBC.

RESUMO Objetivo: avaliar a concordância entre os três escores propostos pela II Diretriz de Avaliação Perioperatória da Sociedade Brasileira de Cardiologia (SBC): algoritmo do American College of Physicians (ACP), Estudo Multicêntrico de Avaliação Perioperatória (Emapo) e Índice de Risco Cardíaco Revisado de Lee (IRCR). Método: pacientes avaliados no pré-operatório para cirurgia não cardíaca em serviço de anestesiologia foram classificados em baixo, moderado ou alto risco pelas três escalas sugeridas pela II Diretriz. Para avaliar o grau de concordância entre as classificações, calculou-se o índice de concordância kappa. Resultados: quatrocentos e um pacientes foram incluídos. O índice kappa de Cohen de concordância entre os três escores foi de 0,270 (IC: 0,222-0,318), correspondendo a uma concordância fraca. Analisando aos pares, a melhor correlação foi entre Emapo e ACP, com kappa de 0,327. O escore de Lee foi o que classificou mais pacientes como baixo risco: 98,3%, ao passo que Emapo e ACP classificaram como baixo risco 91,3 e 92,5%, respectivamente. Conclusão: há uma baixa concordância entre os escores de risco propostos pela II Diretriz de Avaliação Perioperatória da SBC.