Evaluating the performance of artificial intelligence software for lung nodule detection on chest radiographs in a retrospective real-world UK population.

OBJECTIVES: Early identification of lung cancer on chest radiographs improves patient outcomes. Artificial intelligence (AI) tools may increase diagnostic accuracy and streamline this pathway. This study evaluated the performance of commercially available AI-based software trained to identify cancerous lung nodules on chest radiographs. DESIGN: This retrospective study included primary care chest radiographs acquired in a UK centre. The software evaluated each radiograph independently and outputs were compared with two reference standards: (1) the radiologist report and (2) the diagnosis of cancer by multidisciplinary team decision. Failure analysis was performed by interrogating the software marker locations on radiographs. PARTICIPANTS: 5722 consecutive chest radiographs were included from 5592 patients (median age 59 years, 53.8% women, 1.6% prevalence of cancer). RESULTS: Compared with radiologist reports for nodule detection, the software demonstrated sensitivity 54.5% (95% CI 44.2% to 64.4%), specificity 83.2% (82.2% to 84.1%), positive predictive value (PPV) 5.5% (4.6% to 6.6%) and negative predictive value (NPV) 99.0% (98.8% to 99.2%). Compared with cancer diagnosis, the software demonstrated sensitivity 60.9% (50.1% to 70.9%), specificity 83.3% (82.3% to 84.2%), PPV 5.6% (4.8% to 6.6%) and NPV 99.2% (99.0% to 99.4%). Normal or variant anatomy was misidentified as an abnormality in 69.9% of the 943 false positive cases. CONCLUSIONS: The software demonstrated considerable underperformance in this real-world patient cohort. Failure analysis suggested a lack of generalisability in the training and testing datasets as a potential factor. The low PPV carries the risk of over-investigation and limits the translation of the software to clinical practice. Our findings highlight the importance of training and testing software in representative datasets, with broader implications for the implementation of AI tools in imaging.

Clinical profile, prognosis and post COVID-19 syndrome among UNRWA staff in Jordan: A clinical case-series study.

BACKGROUND: The clinical manifestations of Corona Virus Disease of 2019 (COVID-19) varied from patient to patient with evidence of multi-organ involvement. Many patients continue to have a wide range of symptoms for variable periods of time. The long-term effects of COVID-19 infection (post COVID-19 illness or syndrome) are not yet fully explored. This study aims to shed light on the clinical manifestations of the acute COVID-19 infection as well as post COVID-19 syndrome among the United Nations Relief and Works Agency for Palestine Refugee (UNRWA) staff in Jordan. METHODS: A clinical case-series was conducted on a sample of COVID-19 positive employees of the UNRWA staff in Jordan. A structured questionnaire based mainly on World Health Organization (WHO) Case Report Form (CRF) verified tool for post COVID-19 was used. A sample of 366 out of a total of 1322 confirmed cases was systemically selected and included in the present study. Data were collected from UNRWA medical records and phone interviews. Data were analyzed using the Statistical Package for Social Sciences (SPSS) software. RESULTS: The calculated Case Fatality Ratio was 0.7%. The incidence of COVID-19 among UNRWA staff in Jordan during the period of our study was 20.1%. A total of 366 respondents, 220 (60.1%) females and 146 (39.9%) males were included in the study. The mean (SD) age was 44.2 (8.0) years. Most of the infected (97.8%) developed acute COVID-19 symptoms. Fatigue, fever, joint pain, loss of smell and taste, and cough were the most common symptoms. According to WHO clinical classification of acute illness severity, 65.0% had mild illness. Only 28.7% of all subjects fully recovered from the infection, while most of them (71.3%) continued to suffer from many symptoms. Persistent fatigue (39.7%), shortness of breath (SOB) with activity (18.8%), anxiety (17.4%), forgetfulness (16.9%), trouble in concentrating (16.7%), and depressed mood (15.8%) were the most frequently reported. CONCLUSION: Post COVID-19 illness was very common (71.3%) calling for UNRWA to continue assessment of post COVID-19 syndrome and the medical and psychological needs of affected staff. Despite vaccination, only 2.2% of the infected were asymptomatic. Reinfection was unusually high (24%).

Non-invasive detection of severe PH in lung disease using magnetic resonance imaging.

Introduction: Severe pulmonary hypertension (mean pulmonary artery pressure ≥35 mmHg) in chronic lung disease (PH-CLD) is associated with high mortality and morbidity. Data suggesting potential response to vasodilator therapy in patients with PH-CLD is emerging. The current diagnostic strategy utilises transthoracic Echocardiography (TTE), which can be technically challenging in some patients with advanced CLD. The aim of this study was to evaluate the diagnostic role of MRI models to diagnose severe PH in CLD. Methods: 167 patients with CLD referred for suspected PH who underwent baseline cardiac MRI, pulmonary function tests and right heart catheterisation were identified. In a derivation cohort (n = 67) a bi-logistic regression model was developed to identify severe PH and compared to a previously published multiparameter model (Whitfield model), which is based on interventricular septal angle, ventricular mass index and diastolic pulmonary artery area. The model was evaluated in a test cohort. Results: The CLD-PH MRI model [= (-13.104) + (13.059 * VMI)-(0.237 * PA RAC) + (0.083 * Systolic Septal Angle)], had high accuracy in the test cohort (area under the ROC curve (0.91) (p < 0.0001), sensitivity 92.3%, specificity 70.2%, PPV 77.4%, and NPV 89.2%. The Whitfield model also had high accuracy in the test cohort (area under the ROC curve (0.92) (p < 0.0001), sensitivity 80.8%, specificity 87.2%, PPV 87.5%, and NPV 80.4%. Conclusion: The CLD-PH MRI model and Whitfield model have high accuracy to detect severe PH in CLD, and have strong prognostic value.

Endovascular aneurysm repair offers a survival advantage and is cost-effective compared with conservative management in patients physiologically unfit for open repair.

OBJECTIVE: The endovascular aneurysm repair-2 (EVAR-2) trial suggested that EVAR in patients unfit for open surgical repair (OSR) failed to provide a significant overall survival advantage compared with conservative management. The aim is to compare survival and cost-effectiveness in patients with poor cardiopulmonary exercise test (CPET) metrics who underwent EVAR or were managed conservatively. METHODS: A prospective database of all CPETs (1435 patients) performed to assess preoperative fitness for abdominal aortic aneurysm repair was maintained. A total of 350 patients deemed unfit for OSR underwent EVAR or were managed conservatively. A 1:1 propensity-matched analysis incorporating age, gender, anaerobic threshold, and aneurysm size was used to compare survival. Cost-effectiveness analysis was based on the economic model for the National Institute for Health and Care Excellence clinical guideline on abdominal aortic aneurysm treatment. RESULTS: Propensity matching produced 122 pairs of patients in the EVAR and conservative management groups. The median overall survival for the EVAR group was significantly longer than that for the conservative management group (84 vs 30 months, P < .001). One-, three-, and five-year mortality in the EVAR group was 7%, 40%, and 68%, respectively, compared with 25%, 68%, and 82% in the conservative management group, all P < .001. The increment cost-effectiveness ratio for EVAR was £8023 (US$11,644) per quality-adjusted life year gained compared with £430,602 (US$624,967) in the National Institute for Health and Care Excellence guideline, which is based on EVAR-2 results. CONCLUSIONS: EVAR offers a survival advantage and is cost-effective in selected patients deemed unfit for OSR based on CPET compared with conservative management.

Quantitative CT Evaluation of Small Pulmonary Vessels Has Functional and Prognostic Value in Pulmonary Hypertension.

Background The in vivo relationship between peel pulmonary vessels, small pulmonary vessels, and pulmonary hypertension (PH) is not fully understood. Purpose To quantitatively assess peel pulmonary vessel volumes (PPVVs) and small pulmonary vessel volumes (SPVVs) as estimated from CT pulmonary angiography (CTPA) in different subtypes of PH compared with controls, their relationship to pulmonary function and right heart catheter metrics, and their prognostic value. Materials and Methods In this retrospective single-center study performed from January 2008 to February 2018, quantitative CTPA analysis of total SPVV (TSPVV) (0.4- to 2-mm vessel diameter) and PPVV (within 15, 30, and 45 mm from the lung surface) was performed. Results A total of 1823 patients (mean age, 69 years ± 13 [SD]; 1192 women [65%]) were retrospectively analyzed; 1593 patients with PH (mean pulmonary arterial pressure [mPAP], 43 mmHg ± 13 [SD]) were compared with 230 patient controls (mPAP, 19 mm Hg ± 3). The mean vessel volumes in pulmonary peels at 15-, 30-, and 45-mm depths were higher in pulmonary arterial hypertension (PAH) and PH secondary to lung disease compared with chronic thromboembolic PH (45-mm peel, mean difference: 6.4 mL [95% CI: 1, 11] [P < .001] vs 6.8 mL [95% CI: 1, 12] [P = .01]). Mean small vessel volumes at a diameter of less than 2 mm were lower in PAH and PH associated with left heart disease compared with controls (1.6-mm vessels, mean difference: -4.3 mL [95% CI: -8, -0.1] [P = .03] vs -6.8 mL [95% CI: -11, -2] [P < .001]). In patients with PH, the most significant positive correlation was noted with forced vital capacity percentage predicted (r = 0.30-0.40 [all P < .001] for TSPVVs and r = 0.21-0.25 [all P < .001] for PPVVs). Conclusion The volume of pulmonary small vessels is reduced in pulmonary arterial hypertension and pulmonary hypertension (PH) associated with left heart disease, with similar volume of peel vessels compared with controls. For chronic thromboembolic PH, the volume of peel vessels is reduced. In PH, small pulmonary vessel volume is associated with pulmonary function tests. Clinical trial registration no. NCT02565030 Published under a CC BY 4.0 license Online supplemental material is available for this article.

Validation of Artificial Intelligence Cardiac MRI Measurements: Relationship to Heart Catheterization and Mortality Prediction.

Background Cardiac MRI measurements have diagnostic and prognostic value in the evaluation of cardiopulmonary disease. Artificial intelligence approaches to automate cardiac MRI segmentation are emerging but require clinical testing. Purpose To develop and evaluate a deep learning tool for quantitative evaluation of cardiac MRI functional studies and assess its use for prognosis in patients suspected of having pulmonary hypertension. Materials and Methods A retrospective multicenter and multivendor data set was used to develop a deep learning-based cardiac MRI contouring model using a cohort of patients suspected of having cardiopulmonary disease from multiple pathologic causes. Correlation with same-day right heart catheterization (RHC) and scan-rescan repeatability was assessed in prospectively recruited participants. Prognostic impact was assessed using Cox proportional hazard regression analysis of 3487 patients from the ASPIRE (Assessing the Severity of Pulmonary Hypertension In a Pulmonary Hypertension Referral Centre) registry, including a subset of 920 patients with pulmonary arterial hypertension. The generalizability of the automatic assessment was evaluated in 40 multivendor studies from 32 centers. Results The training data set included 539 patients (mean age, 54 years ± 20 [SD]; 315 women). Automatic cardiac MRI measurements were better correlated with RHC parameters than were manual measurements, including left ventricular stroke volume (r = 0.72 vs 0.68; P = .03). Interstudy repeatability of cardiac MRI measurements was high for all automatic measurements (intraclass correlation coefficient range, 0.79-0.99) and similarly repeatable to manual measurements (all paired t test P > .05). Automated right ventricle and left ventricle cardiac MRI measurements were associated with mortality in patients suspected of having pulmonary hypertension. Conclusion An automatic cardiac MRI measurement approach was developed and tested in a large cohort of patients, including a broad spectrum of right ventricular and left ventricular conditions, with internal and external testing. Fully automatic cardiac MRI assessment correlated strongly with invasive hemodynamics, had prognostic value, were highly repeatable, and showed excellent generalizability. Clinical trial registration no. NCT03841344 Published under a CC BY 4.0 license. Online supplemental material is available for this article. See also the editorial by Ambale-Venkatesh and Lima in this issue. An earlier incorrect version appeared online. This article was corrected on June 27, 2022.

Right ventricular remodelling in pulmonary arterial hypertension predicts treatment response.

OBJECTIVES: To determine the prognostic value of patterns of right ventricular adaptation in patients with pulmonary arterial hypertension (PAH), assessed using cardiac magnetic resonance (CMR) imaging at baseline and follow-up. METHODS: Patients attending the Sheffield Pulmonary Vascular Disease Unit with suspected pulmonary hypertension were recruited into the ASPIRE (Assessing the Spectrum of Pulmonary hypertension Identified at a REferral Centre) Registry. With exclusion of congenital heart disease, consecutive patients with PAH were followed up until the date of census or death. Right ventricular end-systolic volume index adjusted for age and sex and ventricular mass index were used to categorise patients into four different volume/mass groups: low-volume-low-mass, low-volume-high-mass, high-volume-low-mass and high-volume-high-mass. The prognostic value of the groups was assessed with one-way analysis of variance and Kaplan-Meier plots. Transition of the groups was studied. RESULTS: A total of 505 patients with PAH were identified, 239 (47.3%) of whom have died at follow-up (median 4.85 years, IQR 4.05). The mean age of the patients was 59±16 and 161 (32.7%) were male. Low-volume-low-mass was associated with CMR and right heart catheterisation metrics predictive of improved prognosis. There were 124 patients who underwent follow-up CMR (median 1.11 years, IQR 0.78). At both baseline and follow-up, the high-volume-low-mass group had worse prognosis than the low-volume-low-mass group (p<0.001). With PAH therapy, 73.5% of low-volume-low-mass patients remained in this group, whereas only 17.4% of high-volume-low-mass patients transitioned into low-volume-low-mass. CONCLUSIONS: Right ventricular adaptation assessed using CMR has prognostic value in patients with PAH. Patients with maladaptive remodelling (high-volume-low-mass) are at high risk of treatment failure.

Severe pulmonary hypertension associated with lung disease is characterised by a loss of small pulmonary vessels on quantitative computed tomography.

Background: Pulmonary hypertension (PH) in patients with chronic lung disease (CLD) predicts reduced functional status, clinical worsening and increased mortality, with patients with severe PH-CLD (≥35 mmHg) having a significantly worse prognosis than mild to moderate PH-CLD (21-34 mmHg). The aim of this cross-sectional study was to assess the association between computed tomography (CT)-derived quantitative pulmonary vessel volume, PH severity and disease aetiology in CLD. Methods: Treatment-naïve patients with CLD who underwent CT pulmonary angiography, lung function testing and right heart catheterisation were identified from the ASPIRE registry between October 2012 and July 2018. Quantitative assessments of total pulmonary vessel and small pulmonary vessel volume were performed. Results: 90 patients had PH-CLD including 44 associated with COPD/emphysema and 46 with interstitial lung disease (ILD). Patients with severe PH-CLD (n=40) had lower small pulmonary vessel volume compared to patients with mild to moderate PH-CLD (n=50). Patients with PH-ILD had significantly reduced small pulmonary blood vessel volume, compared to PH-COPD/emphysema. Higher mortality was identified in patients with lower small pulmonary vessel volume. Conclusion: Patients with severe PH-CLD, regardless of aetiology, have lower small pulmonary vessel volume compared to patients with mild-moderate PH-CLD, and this is associated with a higher mortality. Whether pulmonary vessel changes quantified by CT are a marker of remodelling of the distal pulmonary vasculature requires further study.

CMR Measures of Left Atrial Volume Index and Right Ventricular Function Have Prognostic Value in Chronic Thromboembolic Pulmonary Hypertension.

Providing prognostic information is important when counseling patients and planning treatment strategies in chronic thromboembolic pulmonary hypertension (CTEPH). The aim of this study was to assess the prognostic value of gold standard imaging of cardiac structure and function using cardiac magnetic resonance imaging (CMR) in CTEPH. Consecutive treatment-naive patients with CTEPH who underwent right heart catheterization and CMR between 2011 and 2017 were identified from the ASPIRE (Assessing-the-Specturm-of-Pulmonary-hypertensIon-at-a-REferral-center) registry. CMR metrics were corrected for age and sex where appropriate. Univariate and multivariate regression models were generated to assess the prognostic ability of CMR metrics in CTEPH. Three hundred and seventy-five patients (mean+/-standard deviation: age 64+/-14 years, 49% female) were identified and 181 (48%) had pulmonary endarterectomy (PEA). For all patients with CTEPH, left-ventricular-stroke-volume-index-%predicted (LVSVI%predicted) (p = 0.040), left-atrial-volume-index (LAVI) (p = 0.030), the presence of comorbidities, incremental shuttle walking test distance (ISWD), mixed venous oxygen saturation and undergoing PEA were independent predictors of mortality at multivariate analysis. In patients undergoing PEA, LAVI (p < 0.010), ISWD and comorbidities and in patients not undergoing surgery, right-ventricular-ejection-fraction-%predicted (RVEF%pred) (p = 0.040), age and ISWD were independent predictors of mortality. CMR metrics reflecting cardiac function and left heart disease have prognostic value in CTEPH. In those undergoing PEA, LAVI predicts outcome whereas in patients not undergoing PEA RVEF%pred predicts outcome. This study highlights the prognostic value of imaging cardiac structure and function in CTEPH and the importance of considering left heart disease in patients considered for PEA.

Imaging and Risk Stratification in Pulmonary Arterial Hypertension: Time to Include Right Ventricular Assessment.

Background: Current European Society of Cardiology and European Respiratory Society guidelines recommend regular risk stratification with an aim of treating patients with pulmonary arterial hypertension (PAH) to improve or maintain low-risk status (<5% 1-year mortality). Methods: Consecutive patients with PAH who underwent cardiac magnetic resonance imaging (cMRI) were identified from the Assessing the Spectrum of Pulmonary hypertension Identified at a Referral centre (ASPIRE) registry. Kaplan-Meier survival curves, locally weighted scatterplot smoothing regression and multi-variable logistic regression analysis were performed. Results: In 311 consecutive, treatment-naïve patients with PAH undergoing cMRI including 121 undergoing follow-up cMRI, measures of right ventricular (RV) function including right ventricular ejection fraction (RVEF) and RV end systolic volume and right atrial (RA) area had prognostic value. However, only RV metrics were able to identify a low-risk status. Age (p < 0.01) and RVEF (p < 0.01) but not RA area were independent predictors of 1-year mortality. Conclusion: This study highlights the need for guidelines to include measures of RV function rather than RA area alone to aid the risk stratification of patients with PAH.

Machine learning cardiac-MRI features predict mortality in newly diagnosed pulmonary arterial hypertension.

Aims: Pulmonary arterial hypertension (PAH) is a rare but serious disease associated with high mortality if left untreated. This study aims to assess the prognostic cardiac magnetic resonance (CMR) features in PAH using machine learning. Methods and results: Seven hundred and twenty-three consecutive treatment-naive PAH patients were identified from the ASPIRE registry; 516 were included in the training, and 207 in the validation cohort. A multilinear principal component analysis (MPCA)-based machine learning approach was used to extract mortality and survival features throughout the cardiac cycle. The features were overlaid on the original imaging using thresholding and clustering of high- and low-risk of mortality prediction values. The 1-year mortality rate in the validation cohort was 10%. Univariable Cox regression analysis of the combined short-axis and four-chamber MPCA-based predictions was statistically significant (hazard ratios: 2.1, 95% CI: 1.3, 3.4, c-index = 0.70, P = 0.002). The MPCA features improved the 1-year mortality prediction of REVEAL from c-index = 0.71 to 0.76 (P ≤ 0.001). Abnormalities in the end-systolic interventricular septum and end-diastolic left ventricle indicated the highest risk of mortality. Conclusion: The MPCA-based machine learning is an explainable time-resolved approach that allows visualization of prognostic cardiac features throughout the cardiac cycle at the population level, making this approach transparent and clinically interpretable. In addition, the added prognostic value over the REVEAL risk score and CMR volumetric measurements allows for a more accurate prediction of 1-year mortality risk in PAH.

The impact of e-health system implementation on UNWRA health services: an observational study.

BACKGROUND: The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) provides primary-health-care services to more than 5 million Palestinian refugees in five operational fields (Jordan, Syria, Lebanon, West Bank, and Gaza) through 144 health centres. UNRWA developed its electronic health records (e-Health) system to improve monitoring and facilitation of health services provided to Palestinian refugees. By the end of 2017, the system had been deployed in 129 health centres, included the health files of 3 million patients, and managed more than 8 million visits per year. We assessed whether preventive-health-care services had improved following implementation of the system. METHODS: This observational study used three key performance indicators to assess preventive-health-care services reported in UNRWA's annual reports in 2012-17: the percentage of targeted people aged 40 years and older screened for diabetes; the percentage of pregnant women with a livebirth who attended at least four antenatal visits; and the prevalence of growth problems (underweight, stunting, wasting, and overweight or obesity) in children younger than 5 years. Simple descriptive analysis was conducted with Microsoft Excel 2010. Ethical approval was obtained from the UNRWA Headquarters Department of Health. FINDINGS: Screening for diabetes significantly increased from 13% in 2012 to 21% in 2017 (p<0·0001) since the e-Health system started sending alerts to clerks at health centres. The percentage of pregnant women with a livebirth who attended at least four antenatal visits, increased from 87% in 2012 to 92% in 2017, when the e-Health System allowed health-care providers to log all pregnant women who missed their appointments to enable follow-up. Additionally, an electronic maternal and child health mobile application, sends regular reminders to mothers about appointments for themselves and their children. The percentages of underweight, stunting, wasting, and overweight or obesity among children younger than 5 years increased respectively from 3%, 4%, 2%, and 2% in 2014 to 5%, 7%, 4%, and 5% in 2017, but this was due to the increased detection of growth problems through the e-Health system. INTERPRETATION: The e-Health system improved detection and monitoring by UNRWA health-care providers and access to health services for Palestinian refugees in all three indicator categories. This study has several limitations. It is an observational study based on assessing health records of children rather than a prospective study over time. The focus of the study was to assess the impact of the eHealth system on health-care delivery and not to assess the changes in health-care delivery itself. The electronic health records that were reviewed are for the Palestine refugees who are registered at UNRWA health clinics and not for other refugees or residents of the five countries. Strengths of the study are that it is based on electronic health records which contain data recorded by the treating staff; the e-health system used by UNRWA clinics staff is centralised and the data are aggregated agency wide; and the growth monitoring indicators used by UNRWA were derived from the WHO Multi-center Growth Reference Study to assess the growth of children from birth up to age 5 years. FUNDING: None.

Non-communicable diseases among Palestinian refugees from Syria: a cross-sectional study on prevalence, case management, access to and utilisation of UNRWA Health Services.

BACKGROUND: As of Feb 14, 2014, UNRWA had registered almost 53 000 Palestinian refugees from Syria (PRS) who had fled to Lebanon as the result of the conflict in Syria. Half of the PRS had gone to one of the 12 Palestinian camps, which are overcrowded and of poor infrastructure. Consequently, there is concern for the wellbeing of PRS; in particular, their health status and access to medical care. Little attention has been given to non-communicable diseases (NCDs) in the acute phases of emergencies. Therefore, an assessment of the prevalence of NCDs among PRS, as well as the patterns of use of available health care services by PRS, is warranted. METHODS: A cross-sectional study was conducted in April, 2018, with 1100 PRS residing inside and outside refugee camps across all governorates of Lebanon. A listing of all PRS families was the sampling frame. A random sample of families was selected and contacted, and then one adult randomly selected from each family was approached for data collection. Pregnant women and participants who were too ill to participate were excluded. After obtaining informed verbal consent, we did face-to-face interviews to collect data on household details (such as type of settlement, source of income) and sociodemographic information, major NCDs (for the household representative), lifestyle behaviours, and health-care use. We invited all participants to UNRWA clinics for physical and biochemical measurements. The study protocol was approved by the Institutional Review Board of the American University of Beirut. FINDINGS: We surveyed 959 PRS (59% male [465], 82% married [785], mean age 43 years [SD 12]). A quarter of those interviewed had at least one NCD; the most prevalent were hypertension (23%; 221 of 959), rheumatic diseases (17%; 166), cardiovascular diseases (CVDs, 13%; 126), diabetes (13%; 124), and chronic respiratory diseases (CRDs) (10%; 100). All these NCDs were more prevalent among PRS inside camps than in those residing outside camps, except for diabetes. Most participants who had been diagnosed with NCDs were adhering to their prescribed medications (90-98%). However, of those reporting CVDs, only 56% (71 of 126) had attended at least one follow-up appointment, and of those reporting rheumatic diseases, only 33% (55 of 166) had attended at least one follow-up appointment. About half of participants reported that they checked their blood pressure (55%; 528 of 959) or blood glucose (45%; 430). 111 of 221 (50%) participants with hypertension monitored their blood pressure, and 78 of 124 (63%) participants with diabetes monitored their blood glucose. 133 participants attended UNRWA clinics for measurements; 40% (54) had obesity (>30 kg/cm2), 10% (13) had elevated blood pressure, 12% (16) had stage 1 hypertension, and 8% (10) had stage 2 hypertension. Most participants had normal glucose (67%; 89 of 133), cholesterol (65%; 87), triglyceride (58%; 77), and glycosylated haemoglobin levels (64; 85). A substantial proportion of participants who were tested had undiagnosed diabetes (14%; 33 of 108 reporting no diabetes), undiagnosed hypertension (23%; 19 of 81), uncontrolled diabetes (79% of participants with diabetes; 19 of 24), or uncontrolled hypertension (64% of participants with hypertension; 29 of 45). INTERPRETATION: Further study is needed to understand why the prevalence of NCDs among PRS residing in Palestinian camps is higher than among those living outside, and to understand whether and why access to medicines is a problem, particularly outside camps. The burden of NCDs among PRS is high and their access to services is not optimal; therefore UNRWA should pay special attention to NCD services in this population. UNRWA should invest in efforts to increase awareness of free blood pressure and blood glucose monitoring services in its clinics, and could actively offer free testing in public areas inside camps. Doctors at UNRWA clinics should recommend that patients monitor their disease more frequently and educate them on how to do so. A limitation of the study was the low percentage of participants who attended UNRWA clinics for physical and biochemical measurements. FUNDING: UNRWA.

Myocardial T1-mapping and extracellular volume in pulmonary arterial hypertension: A systematic review and meta-analysis.

INTRODUCTION: Elevated myocardial T1-mapping and extracellular volume (ECV) measured on cardiac MR (CMR) imaging is associated with myocardial abnormalities such as oedema or fibrosis. This meta-analysis aims to provide a summary of T1-mapping and ECV values in pulmonary arterial hypertension (PAH) and compare their values with controls. METHODS: We searched CENTRAL, MEDLINE, Embase, and Web of Science in August 2020. We included CMR studies reporting T1-mapping or ECV values in adults with any type of PAH. We calculated the mean difference of T1-values and ECV between PAH and controls. RESULTS: We included 12 studies with 674 participants. T1-values were significantly higher in PAH with the highest mean difference (MD) recorded at the RV insertion points (RVIP) (108 milliseconds (ms), 95% confidence intervals (CI) 89 to 128), followed by the RV free wall (MD 91 ms, 95% CI 56 to 126). The pooled mean T1-value in PAH at the RVIP was 1084, 95% CI (1071 to 1097) measured using 1.5 Tesla Siemens systems. ECV was also higher in PAH with an MD of 7.5%, 95% CI (5.9 to 9.1) at the RV free wall. CONCLUSION: T1 mapping values in PAH patients are on average 9% higher than healthy controls when assessed under the same conditions including the same MRI system, magnetic field strength or sequence used for acquisition. The highest T1 and ECV values are at the RVIP. T1 mapping and ECV values in PH are higher than the values reported in cardiomyopathies and were associated with poor RV function and RV dilatation.

Repeatability and sensitivity to change of non-invasive end points in PAH: the RESPIRE study.

End points that are repeatable and sensitive to change are important in pulmonary arterial hypertension (PAH) for clinical practice and trials of new therapies. In 42 patients with PAH, test-retest repeatability was assessed using the intraclass correlation coefficient and treatment effect size using Cohen's d statistic. Intraclass correlation coefficients demonstrated excellent repeatability for MRI, 6 min walk test and log to base 10 N-terminal pro-brain natriuretic peptide (log10NT-proBNP). The treatment effect size for MRI-derived right ventricular ejection fraction was large (Cohen's d 0.81), whereas the effect size for the 6 min walk test (Cohen's d 0.22) and log10NT-proBNP (Cohen's d 0.20) were fair. This study supports further evaluation of MRI as a non-invasive end point for clinical assessment and PAH therapy trials.Trial registration number NCT03841344.

Patterns of thromboembolic pulmonary vascular disease in COVID-19.

SARS-CoV-2 (COVID-19) is associated with increased thrombosis. Here, we demonstrate patterns of pulmonary vascular disease in COVID-19 including classical acute pulmonary embolism and subsegmental perfusion defects in the absence of acute pulmonary embolism suggestive of microvascular thrombosis.

Cardiac-MRI Predicts Clinical Worsening and Mortality in Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis.

OBJECTIVES: This meta-analysis evaluates assessment of pulmonary arterial hypertension (PAH), with a focus on clinical worsening and mortality. BACKGROUND: Cardiac magnetic resonance (CMR) has prognostic value in the assessment of patients with PAH. However, there are limited data on the prediction of clinical worsening, an important composite endpoint used in PAH therapy trials. METHODS: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Web of Science databases were searched in May 2020. All CMR studies assessing clinical worsening and the prognosis of patients with PAH were included. Pooled hazard ratios of univariate regression analyses for CMR measurements, for prediction of clinical worsening and mortality, were calculated. RESULTS: Twenty-two studies with 1,938 participants were included in the meta-analysis. There were 18 clinical worsening events and 8 deaths per 100 patient-years. The pooled hazard ratios show that every 1% decrease in right ventricular (RV) ejection fraction is associated with a 4.9% increase in the risk of clinical worsening over 22 months of follow-up and a 2.1% increase in the risk of death over 54 months. For every 1 ml/m2 increase in RV end-systolic volume index or RV end-diastolic volume index, the risk of clinical worsening increases by 1.3% and 1%, respectively, and the risk of mortality increases by 0.9% and 0.6%. Every 1 ml/m2 decrease in left ventricular stroke volume index or left ventricular end-diastolic volume index increased the risk of death by 2.5% and 1.8%. Left ventricular parameters were not associated with clinical worsening. CONCLUSIONS: This review confirms CMR as a powerful prognostic marker in PAH in a large cohort of patients. In addition to confirming previous observations that RV function and RV and left ventricular volumes predict mortality, RV function and volumes also predict clinical worsening. This study provides a strong rationale for considering CMR as a clinically relevant endpoint for trials of PAH therapies.