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Incidental Apical Pleuroparenchymal Scarring on Computed Tomography: Diagnostic Yield, Progression, Morphologic Features and Clinical Significance

Toussie, Danielle; Finkelstein, Mark; Mendoza, Dexter; Concepcion, Jose; Stojanovska, Jadranka; Azour, Lea; Ko, Jane P; Moore, William H; Singh, Ayushi; Sasson, Arielle; Bhattacharji, Priya; Eber, Corey
PURPOSE/OBJECTIVE:Apical pleuroparenchymal scarring (APPS) is commonly seen on chest computed tomography (CT), though the imaging and clinical features, to the best of our knowledge, have never been studied. The purpose was to understand APPS's typical morphologic appearance and associated clinical features. PATIENTS AND METHODS/METHODS:A random generator selected 1000 adult patients from all 21516 chest CTs performed at urban outpatient centers from January 1, 2016 to December 31, 2016. Patients with obscuring apical diseases were excluded to eliminate confounding factors. After exclusions, 780 patients (median age: 64 y; interquartile range: 56 to 72 y; 55% males) were included for analysis. Two radiologists evaluated the lung apices of each CT for the extent of abnormality in the axial plane (mild: <5 mm, moderate: 5 to 10 mm, severe: >10 mm), craniocaudal plane (extension halfway to the aortic arch, more than halfway, vs below the arch), the predominant pattern (nodular vs reticular and symmetry), and progression. Cohen kappa coefficient was used to assess radiologists' agreement in scoring. Ordinal logistic regression was used to determine associations of clinical and imaging variables with APPS. RESULTS:APPS was present on 65% (507/780) of chest CTs (54% mild axial; 80% mild craniocaudal). The predominant pattern was nodular and symmetric. Greater age, female sex, lower body mass index, greater height, and white race were associated with more extensive APPS. APPS was not found to be associated with lung cancer in this cohort. CONCLUSION/CONCLUSIONS:Classifying APPS by the extent of disease in the axial or craniocaudal planes, in addition to the predominant pattern, enabled statistically significant associations to be determined, which may aid in understanding the pathophysiology of apical scarring and potential associated risks.
PMID: 38798201
ISSN: 1536-0237
CID: 5663232

Barotrauma in COVID 19: Incidence, pathophysiology, and effect on prognosis

Steinberger, Sharon; Finkelstein, Mark; Pagano, Andrew; Manna, Sayan; Toussie, Danielle; Chung, Michael; Bernheim, Adam; Concepcion, Jose; Gupta, Sean; Eber, Corey; Dua, Sakshi; Jacobi, Adam H
OBJECTIVES/OBJECTIVE:To investigate the incidence, risk factors, and outcomes of barotrauma (pneumomediastinum and subcutaneous emphysema) in mechanically ventilated COVID-19 patients. To describe the chest radiography patterns of barotrauma and understand the development in relation to mechanical ventilation and patient mortality. METHODS:We performed a retrospective study of 363 patients with COVID-19 from March 1 to April 8, 2020. Primary outcomes were pneumomediastinum or subcutaneous emphysema with or without pneumothorax, pneumoperitoneum, or pneumoretroperitoneum. The secondary outcomes were length of intubation and death. In patients with pneumomediastinum and/or subcutaneous emphysema, we conducted an imaging review to determine the timeline of barotrauma development. RESULTS:Forty three out of 363 (12%) patients developed barotrauma radiographically. The median time to development of either pneumomediastinum or subcutaneous emphysema was 2 days (IQR 1.0-4.5) after intubation and the median time to pneumothorax was 7 days (IQR 2.0-10.0). The overall incidence of pneumothorax was 28/363 (8%) with an incidence of 17/43 (40%) in the barotrauma cohort and 11/320 (3%) in those without barotrauma (p ≤ 0.001). In total, 257/363 (71%) patients died with an increase in mortality in those with barotrauma 33/43 (77%) vs. 224/320 (70%). When adjusting for covariates, barotrauma was associated with increased odds of death (OR 2.99, 95% CI 1.25-7.17). CONCLUSION/CONCLUSIONS:Barotrauma is a frequent complication of mechanically ventilated COVID-19 patients. In comparison to intubated COVID-19 patients without barotrauma, there is a higher rate of pneumothorax and an increased risk of death.
PMID: 35926316
ISSN: 1873-4499
CID: 5364902

Portable Chest Radiography as an Exclusionary Test for Adverse Clinical Outcomes During the Coronavirus Disease 2019 Pandemic

Pagano, Andrew; Finkelstein, Mark; Overbey, Jessica; Steinberger, Sharon; Ellison, Trevor; Manna, Sayan; Toussie, Danielle; Cedillo, Mario; Jacobi, Adam; Gupta, Yogesh S; Bernheim, Adam; Chung, Michael; Eber, Corey; Fayad, Zahi A; Concepcion, Jose
BACKGROUND:Chest radiography (CXR) often is performed in the acute setting to help understand the extent of respiratory disease in patients with coronavirus disease 2019 (COVID-19), but a clearly defined role for negative chest radiograph results in assessing patients has not been described. RESEARCH QUESTION/OBJECTIVE:Is portable CXR an effective exclusionary test for future adverse clinical outcomes in patients suspected of having COVID-19? STUDY DESIGN AND METHODS/METHODS:Charts of consecutive patients suspected of having COVID-19 at five EDs in New York City between March 19, 2020, and April 23, 2020, were reviewed. Patients were categorized based on absence of findings on initial CXR. The primary outcomes were hospital admission, mechanical ventilation, ARDS, and mortality. RESULTS:Three thousand two hundred forty-five adult patients, 474 (14.6%) with negative initial CXR results, were reviewed. Among all patients, negative initial CXR results were associated with a low probability of future adverse clinical outcomes, with negative likelihood ratios of 0.27 (95% CI, 0.23-0.31) for hospital admission, 0.24 (95% CI, 0.16-0.37) for mechanical ventilation, 0.19 (95% CI, 0.09-0.40) for ARDS, and 0.38 (95% CI, 0.29-0.51) for mortality. Among the subset of 955 patients younger than 65 years and with a duration of symptoms of at least 5 days, no patients with negative CXR results died, and the negative likelihood ratios were 0.17 (95% CI, 0.12-0.25) for hospital admission, 0.09 (95% CI, 0.02-0.36) for mechanical ventilation, and 0.09 (95% CI, 0.01-0.64) for ARDS. INTERPRETATION/CONCLUSIONS:Initial CXR in adult patients suspected of having COVID-19 is a strong exclusionary test for hospital admission, mechanical ventilation, ARDS, and mortality. The value of CXR as an exclusionary test for adverse clinical outcomes is highest among young adults, patients with few comorbidities, and those with a prolonged duration of symptoms.
PMID: 33516703
ISSN: 1931-3543
CID: 4859082

Coronary artery calcification in COVID-19 patients: an imaging biomarker for adverse clinical outcomes

Gupta, Yogesh Sean; Finkelstein, Mark; Manna, Sayan; Toussie, Danielle; Bernheim, Adam; Little, Brent P; Concepcion, Jose; Maron, Samuel Z; Jacobi, Adam; Chung, Michael; Kukar, Nina; Voutsinas, Nicholas; Cedillo, Mario A; Fernandes, Ajit; Eber, Corey; Fayad, Zahi A; Hota, Partha
BACKGROUND:Recent studies have demonstrated a complex interplay between comorbid cardiovascular disease, COVID-19 pathophysiology, and poor clinical outcomes. Coronary artery calcification (CAC) may therefore aid in risk stratification of COVID-19 patients. METHODS:Non-contrast chest CT studies on 180 COVID-19 patients ≥ age 21 admitted from March 1, 2020 to April 27, 2020 were retrospectively reviewed by two radiologists to determine CAC scores. Following feature selection, multivariable logistic regression was utilized to evaluate the relationship between CAC scores and patient outcomes. RESULTS:The presence of any identified CAC was associated with intubation (AOR: 3.6, CI: 1.4-9.6) and mortality (AOR: 3.2, CI: 1.4-7.9). Severe CAC was independently associated with intubation (AOR: 4.0, CI: 1.3-13) and mortality (AOR: 5.1, CI: 1.9-15). A greater CAC score (UOR: 1.2, CI: 1.02-1.3) and number of vessels with calcium (UOR: 1.3, CI: 1.02-1.6) was associated with mortality. Visualized coronary stent or coronary artery bypass graft surgery (CABG) had no statistically significant association with intubation (AOR: 1.9, CI: 0.4-7.7) or death (AOR: 3.4, CI: 1.0-12). CONCLUSION/CONCLUSIONS:COVID-19 patients with any CAC were more likely to require intubation and die than those without CAC. Increasing CAC and number of affected arteries was associated with mortality. Severe CAC was associated with higher intubation risk. Prior CABG or stenting had no association with elevated intubation or death.
PMID: 33601125
ISSN: 1873-4499
CID: 4859092


Shahab, Hunaina; Ogawa, Makoto; Jacobi, Adam; Concepcion, Jose; Gupta, Yogesh Sean; Bander, Jeffrey; Shimony, Rony; Lerakis, Stamatios; Kukar, Nina
ISSN: 0735-1097
CID: 5449272

Spontaneous subcutaneous emphysema and pneumomediastinum in non-intubated patients with COVID-19 [Case Report]

Manna, Sayan; Maron, Samuel Z; Cedillo, Mario A; Voutsinas, Nicholas; Toussie, Danielle; Finkelstein, Mark; Steinberger, Sharon; Chung, Michael; Bernheim, Adam; Eber, Corey; Gupta, Yogesh Sean; Concepcion, Jose; Libes, Richard; Jacobi, Adam
PURPOSE/OBJECTIVE:We describe the presenting characteristics and hospital course of 11 novel coronavirus (COVID-19) patients who developed spontaneous subcutaneous emphysema (SE) with or without pneumomediastinum (SPM) in the absence of prior mechanical ventilation. MATERIALS AND METHODS/METHODS:A total of 11 non-intubated COVID-19 patients (8 male and 3 female, median age 61 years) developed SE and SPM between March 15 and April 30, 2020 at a multi-center urban health system in New York City. Demographics (age, gender, smoking status, comorbid conditions, and body-mass index), clinical variables (temperature, oxygen saturation, and symptoms), and laboratory values (white blood cell count, C-reactive protein, D-dimer, and peak interleukin-6) were collected. Chest radiography (CXR) and computed tomography (CT) were analyzed for SE, SPM, and pneumothorax by a board-certified cardiothoracic-fellowship trained radiologist. RESULTS:Eleven non-intubated patients developed SE, 36% (4/11) of whom had SE on their initial CXR. Concomitant SPM was apparent in 91% (10/11) of patients, and 45% (5/11) also developed pneumothorax. Patients developed SE on average 13.3 days (SD: 6.3) following symptom onset. No patients reported a history of smoking. The most common comorbidities included hypertension (6/11), diabetes mellitus (5/11), asthma (3/11), dyslipidemia (3/11), and renal disease (2/11). Four (36%) patients expired during hospitalization. CONCLUSION/CONCLUSIONS:SE and SPM were observed in a cohort of 11 non-intubated COVID-19 patients without any known cause or history of invasive ventilation. Further investigation is required to elucidate the underlying mechanism in this patient population.
PMID: 32871424
ISSN: 1873-4499
CID: 4859052

Clinical and Chest Radiography Features Determine Patient Outcomes in Young and Middle-aged Adults with COVID-19

Toussie, Danielle; Voutsinas, Nicholas; Finkelstein, Mark; Cedillo, Mario A; Manna, Sayan; Maron, Samuel Z; Jacobi, Adam; Chung, Michael; Bernheim, Adam; Eber, Corey; Concepcion, Jose; Fayad, Zahi A; Gupta, Yogesh Sean
Background Chest radiography has not been validated for its prognostic utility in evaluating patients with coronavirus disease 2019 (COVID-19). Purpose To analyze the prognostic value of a chest radiograph severity scoring system for younger (nonelderly) patients with COVID-19 at initial presentation to the emergency department (ED); outcomes of interest included hospitalization, intubation, prolonged stay, sepsis, and death. Materials and Methods In this retrospective study, patients between the ages of 21 and 50 years who presented to the ED of an urban multicenter health system from March 10 to March 26, 2020, with COVID-19 confirmation on real-time reverse transcriptase polymerase chain reaction were identified. Each patient's ED chest radiograph was divided into six zones and examined for opacities by two cardiothoracic radiologists, and scores were collated into a total concordant lung zone severity score. Clinical and laboratory variables were collected. Multivariable logistic regression was used to evaluate the relationship between clinical parameters, chest radiograph scores, and patient outcomes. Results The study included 338 patients: 210 men (62%), with median age of 39 years (interquartile range, 31-45 years). After adjustment for demographics and comorbidities, independent predictors of hospital admission (n = 145, 43%) were chest radiograph severity score of 2 or more (odds ratio, 6.2; 95% confidence interval [CI]: 3.5, 11; P < .001) and obesity (odds ratio, 2.4 [95% CI: 1.1, 5.4] or morbid obesity). Among patients who were admitted, a chest radiograph score of 3 or more was an independent predictor of intubation (n = 28) (odds ratio, 4.7; 95% CI: 1.8, 13; P = .002) as was hospital site. No significant difference was found in primary outcomes across race and ethnicity or those with a history of tobacco use, asthma, or diabetes mellitus type II. Conclusion For patients aged 21-50 years with coronavirus disease 2019 presenting to the emergency department, a chest radiograph severity score was predictive of risk for hospital admission and intubation. © RSNA, 2020 Online supplemental material is available for this article.
PMID: 32407255
ISSN: 1527-1315
CID: 4859022

Diagnosis of a Grave Disease in a Seemingly Asymptomatic Woman: Budd-Chiari With Portal Vein Thrombosis in Setting of Polycythemia Vera [Meeting Abstract]

El Halabi, Maan; Husney, Jack; Chen, Bing; Concepcion, Jose; Ascunce, Gil
ISSN: 0002-9270
CID: 5046232

A unique case of acute aortic dissection mimicking myocardial infarction

Siddique, Sabah; Kwan, Clara NK; Concepcion, Jose; Malik, Bilal A; Moskovits, Norbert; Hollander, Gerald M
ISSN: 2581-3544
CID: 5449282

Quality professionals around the world share similar concerns, experiences - A look at methodologies, new directions [Editorial]

Dedhia, NS; van Yperen, R; Vergara, R; Marino, H; Leiva, D; Angeli, II; Concepcion, JG; Chin, KS; Bester, Y; Kondo, Y; Friggieri, EJ; Minoza-Gatchalian, M; Gupta, Y; Howard, BR; Yasar, N; Thawani, S; Cardenas, AJ
ISSN: 0033-524x
CID: 5449262