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Background: Many survivors of severe COVID-19 pneumonia experience lingering respiratory issues. There is limited research on follow-up chest imaging findings in patients with COVID-19 ARDS, particularly in relation to their mMRC dyspnea scores and pulmonary function tests (PFTs). This study addresses this gap by investigating the clinical characteristics, mMRC dyspnea scores, PFTs, and chest CT findings of COVID-19 ARDS patients at the 6 months post-recovery. By analyzing these variables together, we aim to gain a better understanding of the long-term health consequences of COVID-19 ARDS. Methods: This prospective observational study included 56 subjects with COVID-19 ARDS with dyspnea at the six-month follow-up visits. These patients were evaluated by chest CT, mMRC dyspnea scale, and PFT. The CT severity score was calculated individually for each of the four major imaging findings - ground glass opacities (GGOs), parenchymal/atelectatic bands, reticulations/septal thickening, and consolidation - using a modified CT severity scoring system. Statistics were carried out to find any association between individual CT chest findings and the mMRC dyspnea scale and forced vital capacity (FVC). p values < 0.05 were considered statistically significant. Results: Our study population had a mean age of 55.86 ± 9.60 years, with 44 (78.6%) being men. Grades 1, 2, 3, and 4 on the mMRC dyspnea scale were seen in 57.1%, 30.4%, 10.7%, and 1.8% of patients respectively. Common CT findings observed were GGOs (94.6%), reticulations/septal thickening (96.4%), parenchymal/atelectatic bands (92.8%), and consolidation (14.3%). The mean modified CT severity scores for GGOs, reticulations/septal thickening, parenchymal/atelectatic bands, and consolidation were 10.32 ± 5.51 (range: 0-21), 7.66 ± 4.33 (range: 0-19), 4.77 ± 3.03 (range: 0-14) and 0.29 ± 0.91 (range 0-5) respectively. Reticulations/septal thickening (p = 0.0129) and parenchymal/atelectatic bands (p = 0.0453) were associated with an increased mMRC dyspnea scale. Parenchymal/atelectatic bands were also associated with abnormal FVC (<80%) (p = 0.0233). Conclusion: Six-month follow-up chest CTs of COVID-19 ARDS survivors with persistent respiratory problems showed a statistically significant relationship between increased mMRC dyspnea score and imaging patterns of reticulations/septal thickening and parenchymal/atelectatic bands; while parenchymal/atelectatic bands also showed a statistically significant correlation with reduced FVC., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Garg, Prabhakar, Devkota, Dhooria, Debi, Dua, Singh, Malarakunte, Bhatia and Sandhu.)

Competing Interests: Declaration of competing interest The authors declare no conflict of interest.

Background: Differentiating cardiovascular causes of dyspnea in resource-limited healthcare settings can be challenging. The use of easy-to-train, point-of-care, focused cardiac ultrasound (FoCUS) protocols may potentially alleviate this challenge., Research Question: Can novices attain competency in FoCUS use after training using the cardiac ultrasound for resource-limited settings (CURLS) protocol?, Methods: A quasi-experimental study was conducted at the Kenyatta National Hospital in Nairobi, Kenya. Forty-five graduate medical pre-interns, novices in cardiac ultrasound, received simulated didactic and hands-on FoCUS skills training using the CURLS protocol and 2018 European Association of Cardiovascular Imaging (EACVI) FoCUS training and competence assessment recommendations. Competency was assessed in image interpretation, image acquisition, and image quality., Results: Aggregate image interpretation competency was attained by n = 38 (84%) of trainees with a median score of 80%. The proportion of trainees attaining category-specific image interpretation competency was as follows: pericardial effusion n = 44 (98%), left atrial enlargement n = 40 (89%), cardiomyopathy n = 38 (84%), left ventricular hypertrophy n = 37 (82%), and right ventricular enlargement n = 29 (64%). Image acquisition skills competency was attained by n = 36 (80%) of trainees. Three-quarters of trainee-obtained images were of good quality., Conclusion: Majority of the trainees attained competency. Training constraints limit the generalizability of our findings., (© 2024 Wiley Periodicals LLC.)

Objectives: To study the diagnostic performance of an ultrasound-based algorithm that includes the deceleration time (DT) of early mitral filling to establish a diagnosis of acute heart failure (AHF) in patients who come to an emergency department because of dyspnea., Material and Methods: Prospective analysis in a convenience sample of patients who came to a hospital emergency department with acute dyspnea. The algorithm included ultrasound findings and 4 echocardiographic findings as follows: mitral annular plane systolic excursion, Doppler mitral flow velocity, tissue Doppler imaging measure of the lateral annulus, and the DT of early mitral filling. The definitive diagnosis was made by 2 physicians blinded to each other's diagnosis and the ultrasound findings., Results: A total of 166 adult patients with a mean (SD) age of 76 (13) years were included; 79 (48%) were women. AHF was the definitive diagnosis in 62 patients (37%). Diagnostic agreement was good between the 2 physicians (κ = 0.71). The algorithm classified all the patients, and there were no undetermined diagnoses. Diagnostic performance indicators for the ultrasound-based algorithm integrating early DT findings were as follows: area under the receiver operating characteristic curve, 0.91 (95% CI, 0.86-0.96); sensitivity, 87% (95% CI, 76%-94%); specificity, 95% (95% CI, 89%-98%); positive likelihood ratio, 18.1 (95% CI, 7.7-42.8); and negative likelihood ratio, 0.14 (95% CI, 0.07-0.26)., Conclusion: The ultrasound-based algorithm integrating the DT of early mitral filling performs well for diagnosing AHF in emergency patients with dyspnea. The inclusion of early DT allows all patients to be diagnosed.

This methodological study aimed to validate the cardiac output (CO) measured by exercise-stress real-time phase-contrast cardiovascular magnetic resonance imaging (CMR) in patients with heart failure and preserved ejection fraction (HFpEF). 68 patients with dyspnea on exertion (NYHA ≥ II) and echocardiographic signs of diastolic dysfunction underwent rest and exercise stress right heart catheterization (RHC) and CMR within 24 h. Patients were diagnosed as overt HFpEF (pulmonary capillary wedge pressure (PCWP) ≥ 15mmHg at rest), masked HFpEF (PCWP ≥ 25mmHg during exercise stress but < 15mmHg at rest) and non-cardiac dyspnea. CO was calculated using RHC as the reference standard, and in CMR by the volumetric stroke volume, conventional phase-contrast and rest and stress real-time phase-contrast imaging. At rest, the CMR based CO showed good agreement with RHC with an ICC of 0.772 for conventional phase-contrast, and 0.872 for real-time phase-contrast measurements. During exercise stress, the agreement of real-time CMR and RHC was good with an ICC of 0.805. Real-time measurements underestimated the CO at rest (Bias:0.71 L/min) and during exercise stress (Bias:1.4 L/min). Patients with overt HFpEF had a significantly lower cardiac index compared to patients with masked HFpEF and with non-cardiac dyspnea during exercise stress, but not at rest. Real-time phase-contrast CO can be assessed with good agreement with the invasive reference standard at rest and during exercise stress. While moderate underestimation of the CO needs to be considered with non-invasive testing, the CO using real-time CMR provides useful clinical information and could help to avoid unnecessary invasive procedures in HFpEF patients., (© 2024. The Author(s).)

Purpose: This study aimed to determine the association between functional impairment in small airways and symptoms of dyspnea in patients with Long-coronavirus disease (COVID), using imaging and computational modeling analysis., Patients and Methods: Thirty-four patients with Long-COVID underwent thoracic computed tomography and hyperpolarized Xenon-129 magnetic resonance imaging (HP Xe MRI) scans. Twenty-two answered dyspnea-12 questionnaires. We used a computed tomography-based full-scale airway network (FAN) flow model to simulate pulmonary ventilation. The ventilation distribution projected on a coronal plane and the percentage lobar ventilation modeled in the FAN model were compared with the HP Xe MRI data. To assess the ventilation heterogeneity in small airways, we calculated the fractal dimensions of the impaired ventilation regions in the HP Xe MRI and FAN models., Results: The ventilation distribution projected on a coronal plane showed an excellent resemblance between HP Xe MRI scans and FAN models (structure similarity index: 0.87 ± 0.04). In both the image and the model, the existence of large clustered ventilation defects was not identifiable regardless of dyspnea severity. The percentage lobar ventilation of the HP Xe MRI and FAN model showed a strong correlation (ρ = 0.63, P < 0.001). The difference in the fractal dimension of impaired ventilation zones between the low and high dyspnea-12 score groups was significant (HP Xe MRI: 1.97 [1.89 to 2.04] and 2.08 [2.06 to 2.14], P = 0.005; FAN: 2.60 [2.59 to 2.64] and 2.64 [2.63 to 2.65], P = 0.056)., Conclusions: This study has identified a potential association of small airway functional impairment with breathlessness in Long-COVID, using fractal analysis of HP Xe MRI scans and FAN models., Competing Interests: J.H. has received the National Research Foundation of Korea grant funded by the Korean government (#NRF-2019R1I1A1A01063383). The remaining authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Guidelines recommend urgent chest X-ray for newly presenting dyspnoea or haemoptysis but there is little evidence about their implementation., Methods: We analysed linked primary care and hospital imaging data for patients aged 30+ years newly presenting with dyspnoea or haemoptysis in primary care during April 2012 to March 2017. We examined guideline-concordant management, defined as General Practitioner-ordered chest X-ray/CT carried out within 2 weeks of symptomatic presentation, and variation by sociodemographic characteristic and relevant medical history using logistic regression. Additionally, among patients diagnosed with cancer we described time to diagnosis, diagnostic route and stage at diagnosis by guideline-concordant status., Results: In total, 22 560/162 161 (13.9%) patients with dyspnoea and 4022/8120 (49.5%) patients with haemoptysis received guideline-concordant imaging within the recommended 2-week period. Patients with recent chest imaging pre-presentation were much less likely to receive imaging (adjusted OR 0.16, 95% CI 0.14-0.18 for dyspnoea, and adjusted OR 0.09, 95% CI 0.06-0.11 for haemoptysis). History of chronic obstructive pulmonary disease/asthma was also associated with lower odds of guideline concordance (dyspnoea: OR 0.234, 95% CI 0.225-0.242 and haemoptysis: 0.88, 0.79-0.97). Guideline-concordant imaging was lower among dyspnoea presenters with prior heart failure; current or ex-smokers; and those in more socioeconomically disadvantaged groups.The likelihood of lung cancer diagnosis within 12 months was greater among the guideline-concordant imaging group (dyspnoea: 1.1% vs 0.6%; haemoptysis: 3.5% vs 2.7%)., Conclusion: The likelihood of receiving urgent imaging concords with the risk of subsequent cancer diagnosis. Nevertheless, large proportions of dyspnoea and haemoptysis presenters do not receive prompt chest imaging despite being eligible, indicating opportunities for earlier lung cancer diagnosis., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Reduced lung diffusing capacity for carbon monoxide (DL CO ) at rest and increased ventilation ( ⩒ E )-carbon dioxide output ( ⩒ CO 2 ) during exercise are frequent findings in dyspneic smokers with largely preserved FEV 1 . It remains unclear whether low DL CO and high ⩒ E - ⩒ CO 2 are mere reflections of alveolar destruction (i.e. emphysema) or impaired pulmonary perfusion in non-emphysematous tissue contributes to these functional abnormalities. Sixty-four smokers (41 males, FEV 1 = 84 ± 13%predicted) underwent pulmonary function tests, an incremental exercise test, and quantitative chest computed tomography. Total pulmonary vascular volume (TPVV) was calculated for the entire segmented vascular tree (VIDA Vision™). Using the median % low attenuation area (-950 HU), participants were dichotomized into "Trace" or "Mild" emphysema (E), each group classified into preserved versus reduced DL CO . Within each emphysema subgroup, participants with abnormally low DL CO showed lower TPVV, higher ⩒ E - ⩒ CO 2 , and exertional dyspnea than those with preserved DL CO ( p  < 0.05). TPVV ( r  = 0.34; p  = 0.01), but not emphysema ( r = -0.05; p  = 0.67), correlated with lower DL CO after adjusting for age and height. Despite lower emphysema burden, Trace-E participants with reduced DL CO had lower TPVV, higher dyspnea, and lower peak work rate than the Mild-E with preserved DL CO ( p  < 0.05). Interestingly, TPVV (but not emphysema) correlated inversely with both dyspnea-work rate ( r = -0.36, p  = 0.004) and dyspnea- ⩒ E slopes ( r = -0.40, p  = 0.001). Reduced pulmonary vascular volume adjusted by emphysema extent is associated with low DL CO and heightened exertional ventilation in dyspneic smokers with minor emphysema. Impaired perfusion of non-emphysematous regions of the lungs has greater functional and clinical consequences than hitherto assumed in these subjects.

Background: HFA-PEFF and cardiopulmonary exercise testing (CPET) are comprehensive diagnostic tools for heart failure with preserved ejection fraction (HFpEF). We aimed to investigate the incremental prognostic value of CPET for the HFA-PEFF score among patients with unexplained dyspnea with preserved ejection fraction (EF)., Methods: Consecutive patients with dyspnea and preserved EF (n = 292) were enrolled between August 2019 and July 2021. All patients underwent CPET and comprehensive echocardiography, including two-dimensional speckle tracking echocardiography in the left ventricle, left atrium and right ventricle. The primary outcome was defined as a composite cardiovascular event including cardiovascular-related mortality, acute recurrent heart failure hospitalization, urgent repeat revascularization/myocardial infarction or any hospitalization due to cardiovascular events., Results: The mean age was 58 ± 14.5 years, and 166 (56.8%) participants were male. The study population was divided into three groups based on the HFA-PEFF score: < 2 (n = 81), 2-4 (n = 159), and ≥ 5 (n = 52). HFA-PEFF score ≥ 5, VE/VCO 2 slope, peak systolic strain rate of the left atrium and resting diastolic blood pressure were independently associated with composite cardiovascular events. Furthermore, the addition of VE/VCO 2 and HFA-PEFF to the base model showed incremental prognostic value for predicting composite cardiovascular events (C-statistic 0.898; integrated discrimination improvement 0.129, p = 0.032; net reclassification improvement 1.043, p ≤ 0.001)., Conclusions: CPET could be exploited for the HFA-PEFF approach in terms of incremental prognostic value and diagnosis among patients with unexplained dyspnea with preserved EF., Competing Interests: Declaration of Competing Interest Jung Sun Cho has no conflicts of interest to disclose., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: A proportion of coronavirus disease 2019 (COVID-19) survivors experience persistent dyspnoea without measurable impairments in lung function. We performed a systematic review and meta-analysis to determine relationships between dyspnoea and imaging abnormalities over time in post-COVID-19 patients., Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we analysed studies published prior to 15 September 2022 and indexed by Google Scholar, PubMed and LitCOVID which assessed chest imaging in adults ≥3 months after COVID-19. Demographic, chest imaging, spirometric and post-COVID-19 symptom data were extracted. The relationships between imaging abnormalities and dyspnoea, sex and age were determined using a random effects model and meta-regression., Results: 47 studies were included in the meta-analysis (n=3557). The most prevalent computed tomography (CT) imaging abnormality was ground-glass opacities (GGOs) (44.9% (95% CI 37.0-52.9%) at any follow-up time-point). Occurrence of reticulations significantly decreased between early and late follow-up (p=0.01). The prevalence of imaging abnormalities was related to the proportion of patients with dyspnoea (p=0.012). The proportion of females was negatively correlated with the presence of reticulations (p=0.001), bronchiectasis (p=0.001) and consolidations (p=0.025). Age was positively correlated with imaging abnormalities across all modalities (p=0.002) and imaging abnormalities present only on CT (p=0.001) (GGOs (p=0.004) and reticulations (p=0.001)). Spirometric values improved during follow-up but remained within the normal range at all time-points., Conclusions: Imaging abnormalities were common 3 months after COVID-19 and their occurrence was significantly related to the presence of dyspnoea. This suggests that CT imaging is a sensitive tool for detecting pulmonary abnormalities in patients with dyspnoea, even in the presence of normal spirometric measurements., Competing Interests: Conflict of interest: R.L. Eddy receives personal consulting fees from VIDA Diagnostics Inc., and lecture honoraria from AstraZeneca, outside the submitted work. S. Milne reports grants from British Columbia Lung Association, CHEST Foundation, Genome British Columbia, Mitacs and Michael Smith Health Research BC, and financial support from Chiesi Australia, outside the submitted work. D.D. Sin has received an honorarium for speaking engagements for COPD from GSK, AstraZeneca and Boehringer Ingelheim, and chairs a DSMB for an NHLBI-sponsored clinical trial in COPD, outside the submitted work. E. Guinto, F.V. Gerayeli and H. Lee do not declare any conflicts of interest., (Copyright ©The authors 2023.)

Background: Persistent dyspnea is frequent in post-COVID patients, even in the absence of pulmonary embolism (PE). In this scenario, the role of lung perfusion scintigraphy is unclear. The present study correlated scintigraphy-based semiquantitative perfusion parameters with chest high-resolution computed tomography (hrCT) volumetric indexes and clinical data in post-COVID patients with persistent dyspnea., Research Design and Methods: Sixty patients (30 post-COVID and 30 not previously affected by COVID-19) with persistent dyspnea submitted to lung perfusion scintigraphy and hrCT were retrospectively recruited. Perfusion rates of the pulmonary fields and hrCT-based normalized inflated, emphysematous, infiltrated, collapsed, and vascular lung volumes were calculated. Inflammatory and coagulation biomarkers were collected. PE at imaging was an exclusion criterion., Results: Compared to controls, reduced perfusion rates of the lower pulmonary fields and higher perfusion rates of the middle ones were observed in post-COVID patients, while hrCT findings were superimposable between the two groups. Perfusion rates of lower pulmonary fields were significantly associated only with abnormal lung volumes at hrCT., Conclusions: In post-COVID dyspnea without PE, lung perfusion scintigraphy may reveal a pulmonary involvement not detectable by hrCT. Post-COVID patients may show decreased perfusion rates of lower pulmonary fields in the presence of normal vascular density and markers of inflammation/coagulation.

Following the COVID-19 pandemic, a growing percentage of COVID-19 survivors exhibit post-COVID symptoms. This cross-sectional study aimed to assess radiological findings in individuals having post-COVID respiratory problems. This study was conducted in the Departments of Radiology and Imaging and Internal Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from November 2021 to June 2022 and included 30 COVID survivors aged 40 to 65 years. We employed a pre-tested semi-structured questionnaire including socio-demographic information, clinical data and CT chest imaging parameters. Pearson's correlation coefficient was calculated, as well as multiple linear regressions. Among 30 participants, 56.0% were male. The mean age of the respondents was 51.20 years (standard deviation of 7.09), ranging from 40 to 65 years. Approximately one-third of the participants had at least one co-morbid condition where hypertension (26.67%), diabetes (26.67%), chronic interstitial lung disease (16.67%) and obesity (16.67%) were most commonly recorded. Approximately 20.0% of participants were smokers. The incident of at least one post-COVID symptom was 100.0%. Approximately 73.0% presented with post-COVID lethargy, 16.67% with SoB (Shortness of Breath), and 90.0% of participants complaint of self-reported anxiety. We have found a positive correlation between age and overall lung involvement. The most common lung tomographic findings were fibrosis (93.0%) and diffuse ground glass opacity (70.0%). Interstitial lung thickening was found in 50.0% of cases and bronchiectasis accounted for 16.67%. In 6.6% of cases, there was no pulmonary lesion. It was notifiable that, with time, the feature of DGGO (diffuse ground glass opacity) became subtle and the total lung involvement decreased from 75.0% to about 25.0% during the post-COVID period. Timely assessment for post-COVID pulmonary sequelae by high-resolution CT chest scan might play an important role in modulating a treatment plan for patients suffering from the post-COVID syndrome.

The objective of this study was to determine whether echocardiographic views adapted for lung evaluation may aid in diagnosis of dyspnea in dogs. Fifteen chronic valvular heart disease (CVHD) dogs without cardiac remodeling, 30 CVHD dogs with cardiac remodeling, 15 CVHD dogs with cardiogenic pulmonary edema and 15 dogs with pulmonary disease were prospectively enrolled. Loop recordings of pericardial-lung ultrasound were gathered during echocardiographic evaluation, and four videos of 4 different adapted views were recorded for each dog. Chest X-rays were used as reference-standard for pulmonary edema and/or disease. The videos were classified based on the number of B- lines as NEGATIVE (0, 1, 2 or 3) or POSITIVE (> 3 or confluent). Accuracy of a POSITIVE classification in identifying pulmonary edema and/or disease was calculated. Multivariate analyses were performed using echocardiographic variables that reflect increased left ventricular filling pressure (LVFP) to distinguish pulmonary edema from disease. Results showed that a POSITIVE classification distinguished dogs with pulmonary edema or disease from asymptomatic CVHD dogs in all four views. The best views were right parasternal short axis at papillary muscle level and long axis 4- chamber view, both with the same sensitivity (86.7%) and a specificity of 95.6% and 82.2%, respectively. Multivariate analyses showed that adding cutoff values of peak E wave > 130, E/IVRT > 2.5 or LA/Ao > 2.0 distinguished pulmonary edema from disease with 100% specificity. In conclusion, echocardiographic views adapted for lung evaluation, in addition to conventional echocardiography, may help identify the cause of dyspnea in dogs., (© 2022. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Diagnostic uncertainty in patients with dyspnea is associated with worse outcomes. We hypothesized that prehospital point-of-care ultrasound (POCUS) can improve diagnostic accuracy., Methods: Prospective observational study of adult patients suffering dyspnea. Prehospital critical care physicians registered a suspected diagnosis based on clinical examination alone, performed POCUS of the heart and lungs, and finally registered suspected diagnoses based on their clinical examination supplemented with POCUS. Pre- and post-POCUS diagnoses were compared to endpoint committee adjudicated diagnoses. The primary outcome was improved sensitivity for diagnosing acute heart failure. Secondary outcomes included other diagnostic accuracy measures in relation to acute heart failure and other causes of dyspnea., Results: In total, 214 patients were included. The diagnosis of acute heart failure was suspected in 64/214 (30%) of patients before POCUS and 64/214 (30%) patients after POCUS, but POCUS led to reclassification in 53/214 (25%) patients. The endpoint committee adjudicated the diagnosis of acute heart failure in 87/214 (41%) patients. The sensitivity for the diagnosis of acute heart failure was 58% (95% CI 46%-69%) before POCUS compared to 65% (95% CI 53%-75%) after POCUS (p = 0.12). ROC AUC for the diagnosis acute heart failure was 0.72 (95% CI 0.66-0.78) before POCUS compared to 0.79 (0.73-0.84) after POCUS (p < 0.001). ROC AUC for the diagnosis acute exacerbation (AE) of chronic obstructive pulmonary disease (COPD) or asthma was 0.87 (0.82-0.91) before POCUS and 0.93 (0.88-0.97) after POCUS (p < 0.001). A POCUS finding of any of severely reduced left ventricular function, bilateral B-lines or bilateral pleural effusion demonstrated the highest sensitivity for acute heart failure at 88% (95% CI 79%-94%), whereas the combination of all of these three findings yielded the highest specificity at 99% (95% CI 95%-100%)., Conclusion: Supplementary prehospital POCUS leads to an improvement of diagnostic accuracy of both heart failure and AE-COPD/-asthma overall described by ROC AUC, but the increase in sensitivity for the diagnoses of acute heart failure did not reach statistical significance. Tailored use of POCUS findings optimizes diagnostic accuracy for rule-out and rule-in of acute heart failure., Trial Registration: Registered in Clinical Trials, 05.04.2019 (identifier: NCT03905460) https://clinicaltrials.gov/ct2/show/study/NCT03905460?term=NCT03905460&cond=Dyspnea&cntry=DK&draw=2&rank=1 ., (© 2023. The Author(s).)

History: A 45-year-old woman presented to the emergency department of an outside hospital with shortness of breath and cough. Five days after initial presentation, the patient presented again to the same emergency department with worsening headache and progressive left arm and left leg weakness. She was transferred to the neuroscience intensive care unit of our hospital with concern for an intracranial abnormality based on her work-up at the outside hospital. Her past medical history was notable only for a large uterine fibroid. In our hospital, CT of the brain and chest (Figs 1, 2) and MRI of the brain, including perfusion studies (Figs 3, 4), were performed. Additionally, CT venography of the brain was performed (Fig 5).

Background: The strategies for improving outcomes in heart failure with preserved ejection fraction (HFpEF) are insufficiently defined, which affects optimal patient management. The aim of the study was to compare the prognostic value of the previously validated Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) risk score with 2 approaches primarily dedicated to diagnosing HFpEF: the H 2 FPEF score (heavy, 2 or more hypertensive drugs, atrial fibrillation, pulmonary hypertension [pulmonary artery systolic pressure >35 mm Hg], elder age >60, elevated filling pressures [E/e' > 9]) and the HFA-PEFF algorithm (Heart Failure Association diagnostic algorithm-pretest assessment; echocardiography and natriuretic peptide score; functional testing; final etiology) in patients with exertional dyspnea categorized as HFpEF., Methods: Clinical and biochemical variables and echocardiographic resting and exercise data from 201 enrollees were retrospectively analyzed. Participants were followed for 48 (24-60) months for HF hospitalization and cardiovascular death., Results: Seventy-four patients (36.8%) met the study outcome. In sequential Cox analysis, the addition of MAGGIC risk score, H 2 FPEF score, and HFA-PEFF step 2 (including only resting echocardiographic evaluation) and step 3 (including also exercise diastolic data) algorithms to the base model comprising brain natriuretic peptide and peak oxygen uptake improved the predictive power for the study endpoint. Harrell's c statistic showed a greater predictive ability for the HFA-PEFF step 3 algorithm than for each of the other scores (c index 0.715 vs 0.637, 0.644, and 0.638 for MAGGIC, H 2 FPEF, and HFA-PEFF step 2, respectively; all P < .05). No significant differences were found for other between-score comparisons., Conclusion: In patients with exertional dyspnea and a possible HFpEF, the H 2 FPEF score and HFA-PEFF algorithm limited to resting echocardiography provide prognostic value comparable to the MAGGIC risk score. Extending the HFA-PEFF algorithm with exercise diastolic data is associated with a significant improvement in risk stratification., (Copyright © 2022 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Introduction: Sonography is a safe and simple diagnostic modality which can help emergency physicians in their clinical decision makings and improve the patient disposition process in emergency departments., Objective: This prospective multi-center study evaluates the role of bedside ultrasound performed by emergency physicians in accelerating the patient disposition process in cases with acute undifferentiated dyspnea., Methods: 103 patients were randomized to "early ultrasound" and "routine assessment" groups. In early ultrasound group, emergency physicians performed bedside ultrasound scans on heart and lungs as soon as possible after triage and randomization. In routine assessment group, ultrasound was used whenever the emergency physician or other consultant services ordered or performed it. Mean randomization-to-diagnosis time was compared in two studied groups., Results: Mean randomization-to-diagnosis time was 79.33 (± 38.90) min in routine assessment and 42.61 (± 19.20) min in early ultrasound groups, showing a statistically significant difference (p value < 0.01)., Conclusion: Using early sonography in assessing the patients with undifferentiated acute dyspnea in emergency department decreases the patient turnover time while increasing the diagnostic accuracy., (© 2021. Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB).)

Aim: To assess the performance of a "triple-low" free-breathing protocol for computed tomography pulmonary angiography (CTPA) evaluated on patients with dyspnoea and suspected pulmonary embolism and discuss its application in routine clinical practice for the study of the pulmonary parenchyma and vasculature., Material and Methods: This study was conducted on a selected group of dyspnoeic patients referred for CTPA. The protocol was designed using fast free-breathing acquisition and a small, fixed volume (35 ml) of contrast agent in order to achieve a low-exposure dose. For each examination, radiodensity of the pulmonary trunk and ascending aorta, and the dose-length product (DLP) were recorded. A qualitative analysis was performed of pulmonary arterial enhancement and the pulmonary parenchyma., Results: This study included 134 patients. Contrast enhancement of the pulmonary arteries (409 ± 159 HU) was systematically >250 HU. The duration of acquisition ranged from 0.9 to 1.3 seconds for free-breathing imaging. The mean DLP was in the range of low-dose chest CT acquisitions (145 ± 73 mGy·cm). The analysis was deemed optimal in 90% (120/134) of cases for the pulmonary parenchyma. Sixty-nine per cent (92/134) of cases demonstrated homogeneous enhancement of the pulmonary arteries to the subsegmental level. Only 6% (8/134) of examinations were considered uninterpretable., Conclusion: The present "triple-low" CTPA protocol allows convenient analysis of the pulmonary parenchyma and arteries without hindrance by respiratory motion artefacts in dyspnoeic patients., (Copyright © 2022 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

AN APPRECIATION of the utility of echocardiographic Doppler spectral profile analysis in diagnosing cardiac pathology and guiding surgical intervention more than justifies an investment in obtaining proficiency in these skills. Given the relatively low incidence of significant complications associated with transesophageal echocardiographic examination, the facile use of both spectral and color Doppler principles to diagnose unusual pathology is essential. Doppler modalities are used to characterize blood flow, pressure gradients, chamber dimensions, and other anatomic and physiological parameters. The authors present a case in which several Doppler principles were used to evaluate and diagnose the etiology of dyspnea and a high aortic valve gradient., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests: None declared.

Dyspnea is the symptom of perceived breathing discomfort and is commonly encountered in a variety of clinical settings. Cardiac etiologies of dyspnea are an important consideration; among these, valvular heart disease (Variant 1), arrhythmia (Variant 2), and pericardial disease (Variant 3) are reviewed in this document. Imaging plays an important role in the clinical assessment of these suspected abnormalities, with usually appropriate procedures including resting transthoracic echocardiography in all three variants, radiography for Variants 1 and 3, MRI heart function and morphology in Variants 2 and 3, and CT heart function and morphology with intravenous contrast for Variant 3. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2022 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

In this article, we report a patient with new-onset dyspnea and symptoms suggestive of heart failure, who had an unexpected diagnosis of a large left atrial myxoma with diastolic protrusion into the left ventricle. We further underline the role of cardiac Point-of-Care Ultrasound (POCUS) in the initial evaluation of patients with cardiac complaints in the emergency room setting. It can help to differentiate the patients' symptoms in order to achieve a more accurate diagnosis and thus increase the efficacy of the established therapy. In some cases, as with this patient, it can help to establish a diagnosis which needs prompt therapy.

Patients with aortic enlargement are recommended to undergo serial imaging and clinical follow-up until they reach surgical thresholds. This study aimed to identify aortic diameter and care of patients with aortic imaging before aortic dissection (AD). In a retrospective cohort of AD patients, we evaluated previous imaging results in addition to ordering providers and indications. Imaging was stratified as >1 or <1 year: 62 patients (53% men) had aortic imaging before AD (most recent test: 82% echo, 11% computed tomography, 6% magnetic resonance imaging). Imaging was ordered most frequently by primary care physicians (35%) and cardiologists (39%). The most frequent imaging indications were arrhythmia (11%), dyspnea (10%), before or after aortic valve surgery (8%), chest pain (6%), and aneurysm surveillance in 13%. Of all patients, 94% had aortic diameters below the surgical threshold before the AD. Imaging was performed <1 year before AD in 47% and aortic size was 4.4 ± 0.8 cm in ascending aorta and 4.0 ± 0.8 cm in sinus. In patients whose most recent imaging was >1 year before AD (1,317 ± 1,017 days), the mean ascending aortic diameter was 4.2 ± 0.4 cm. In conclusion, in a series of patients with aortic imaging before AD, the aortic size was far short of surgical thresholds in 94% of the group. In >50%, imaging was last performed >1 year before dissection., Competing Interests: Disclosures The authors have no conflicts of interest to declare., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Exercise intolerance is a primary manifestation in patients with heart failure with preserved ejection fraction (HFpEF) and is associated with abnormal hemodynamics and a poor quality of life. Two multiparametric scoring systems have been proposed to diagnose HFpEF. This study sought to determine the performance of the H 2 FPEF and HFA-PEFF scores for predicting exercise capacity and echocardiographic findings of intracardiac pressures during exercise in subjects with dyspnea on exertion referred for bicycle stress echocardiography. In a subset, simultaneous expired gas analysis was performed to measure the peak oxygen consumption (VO 2 ). Patients with HFpEF (n = 83) and controls without HF (n = 104) were enrolled. The H 2 FPEF score was obtainable for all patients while the HFA-PEFF score could not be calculated for 23 patients (feasibility 88%). Both H 2 FPEF and HFA-PEFF scores correlated with a higher E/e' ratio (r = 0.49 and r = 0.46), lower systolic tricuspid annular velocity (r =  - 0.44 and =  - 0.24), and lower cardiac output (r =  - 0.28 and r =  - 0.24) during peak exercise. Peak VO 2 and exercise duration decreased with an increase in H 2 FPEF scores (r =  - 0.40 and r =  - 0.32). The H 2 FPEF score predicted a reduced aerobic capacity (AUC 0.71, p = 0.0005), but the HFA-PEFF score did not (p = 0.07). These data provide insights into the role of the H 2 FPEF and HFA-PEFF scores for predicting exercise intolerance and abnormal hemodynamics in patients presenting with exertional dyspnea., (© 2022. The Author(s).)

Objectives: Cardiopulmonary ultrasound imaging can be useful for diagnosing acute heart failure (AHF). We aimed to evaluate the diagnostic performance of an algorithm based on point-of-care ultrasound (POCUS) in patients coming to the emergency department with acute dyspnea., Material and Methods: Prospective analysis of a convenience sample of patients with acute dyspnea in 2 hospital emergency departments. The POCUS algorithm included lung ultrasound findings and 3 echocardiographic measurements taken from an apical view of 4 chambers: mitral annular plane systolic excursion, Doppler mitral flow velocity, and tissue Doppler imaging of the lateral mitral annulus. The definitive diagnosis was made by 2 physicians blinded to the POCUS findings., Results: A total of 103 adult patients with a mean (SD) age of 73 (12) years were included; about half (51 patients) were women. Forty-two patients (41%) were finally diagnosed with AHF. Interindividual agreement on the physicians' diagnoses was good (k = 0.82). The POCUS algorithm assigned an AHF diagnosis to 76 patients (74%); 56 of them (85%) were in sinus rhythm. The diagnostic performance indicators for the algorithm were as follows: area under the receiver operating characteristic curve, 0.94 (95% CI, 0.88-1.00); sensitivity 96% (95% CI, 78%-100%); specificity, 93% (95% CI, 8%-98%); positive predictive value, 85% (95% CI, 67%-100%); negative predictive value, 98% (95% CI, 88%-100%)., Conclusion: The POCUS-based algorithm for diagnosing AHF performed well in patients coming to the emergency department with acute dyspnea.

Dyspnea is one of the major symptoms encountered in the emergency department, and lung ultrasound (LUS) is recommended for the rapid diagnosis of the underlying disease. B-lines, the "comet-tail"-like vertical lines moving with respiration, are an ultrasound finding relevant to the pulmonary congestion. They may be observed in the normal lung, but bilateral, ≥ 3 B-lines are considered pathological. B-lines with lung sliding (B profile) are a specific sign of heart failure, while B-lines with abolished lung sliding (B' profile) are related with the lung diseases such as acute respiratory distress syndrome. B profile is reported to detect pulmonary edema with about 95% sensitivity and 95% specificity in patients with dyspnea. LUS also can assess the severity of pulmonary congestion semi-quantitatively by counting the number of B-lines or that of positive areas. Whereas the original BLUE protocol requires scanning at 12 zones on the chest, more rapid 8- or 6-zone scan is sufficient for the diagnosis of heart failure, and 2- or 4-zone scan may be used for the critical patients. LUS may be used for the evaluation of heart failure treatment, or can be performed as a part of exercise stress test. LUS can be performed easily and rapidly at the bedside using almost any kind of ultrasound apparatus, and it should be performed more widely in the daily practice as well as in the emergent department., (© 2021. Japanese Society of Echocardiography.)

Objective: This study aimed to stratify the early pneumonia trajectory on chest radiographs and compare patient characteristics in dyspneic patients with coronavirus disease 2019 (COVID-19)., Materials and Methods: We retrospectively included 139 COVID-19 patients with dyspnea (87 men, 62.7±16.3 years) and serial chest radiographs from January to September 2020. Radiographic pneumonia extent was quantified as a percentage using a previously-developed deep learning algorithm. A group-based trajectory model was used to categorize the pneumonia trajectory after symptom onset during hospitalization. Clinical findings, and outcomes were compared, and Cox regression was performed for survival analysis., Results: Radiographic pneumonia trajectories were categorized into four groups. Group 1 (n = 83, 59.7%) had negligible pneumonia, and group 2 (n = 29, 20.9%) had mild pneumonia. Group 3 (n = 13, 9.4%) and group 4 (n = 14, 10.1%) showed similar considerable pneumonia extents at baseline, but group 3 had decreasing pneumonia extent at 1-2 weeks, while group 4 had increasing pneumonia extent. Intensive care unit admission and mortality were significantly more frequent in groups 3 and 4 than in groups 1 and 2 (P < .05). Groups 3 and 4 shared similar clinical and laboratory findings, but thrombocytopenia (<150×103/μL) was exclusively observed in group 4 (P = .016). When compared to groups 1 and 2, group 4 (hazard ratio, 63.3; 95% confidence interval, 7.9-504.9) had a two-fold higher risk for mortality than group 3 (hazard ratio, 31.2; 95% confidence interval, 3.5-280.2), and this elevated risk was maintained after adjusting confounders., Conclusion: Monitoring the early radiologic trajectory beyond baseline further prognosticated at-risk COVID-19 patients, who potentially had thrombo-inflammatory responses., Competing Interests: Soon Ho Yoon has read the journal’s policy and the authors of this manuscript have the following competing interests: employment as a chief medical officer in MEDICALIP. Other authors do not have any conflict of interest to declare.

To determine the diagnostic accuracy of lung ultrasound and chest X-ray in diagnosing Acute Pulmonary Oedema in patients presenting with acute dyspnoea in emergency department, a study was conducted at the emergency department of Shifa International Hospital, Islamabad, from July 31, 2018 to January 31, 2019. A total of 225 patients presenting with dyspnoea and satisfying the inclusion criteria were assessed through clinical examination, lung ultrasound (LUS) and chest X-ray. The results of chest X-ray and lung ultrasound were compared with clinical diagnosis. The study revealed sensitivity of chest X-ray and LUS (60.16% versus 91.05%), specificity (66.67% versus 91.18%), positive predictive value (68.52% versus 92.56%) and the negative predictive values (58.12% versus 89.42%) respectively. The present study revealed that the LUS has better accuracy than chest X-ray for diagnosis of acute pulmonary oedema.

In recent years, lung ultrasonography has acquired an important role as a valuable diagnostic tool in clinical practice. The lung is usually poorly explorable, but it provides more acoustic information in pathological conditions that modify the relationship between air, water and tissues. The different acoustic impedance of all these components makes the chest wall a powerful ultrasound reflector: this is responsible for the creation of several artifacts providing valuable information about lung pathophysiology. Lung ultrasonography helps in the diagnostic process of parenchymal and pleural pathologies, in the differential diagnosis of dyspnea and in the clinical and prognostic evaluation of the SARS-CoV-2 infection.

Introduction: To investigate chest respiratory artefact reduction using High Pitch Dual Source Computed Tomography (HPCT) compared to conventional CT (CCT) in symptomatic patients with shortness of breath., Methods: Forty patients were prospectively examined on a second-generation Dual Source scanner. They were randomly divided into two groups: twenty patients underwent an experimental HPCT protocol and twenty control cases CCT protocol. Respiratory artefacts were evaluated using an ordinal score (0, 1 and 2) assigned by two readers with five and thirty years of experience. A qualitative assessment was performed using two categorical groups, group 1 = acceptable and group 2 = unacceptable. Dose Length Product (DLP) was compared., Results: The two groups showed a statistical difference in artefacts reduction (p < 0.0001). HPCT demonstrated no artefacts in 82% of cases, while CCT showed no artefacts in 39% of cases. DLP showed no statistical differences (p = 0.6) with mean = 266.9 for HPCT and mean = 282.65 for CCT. HPCT provides high table speed in the z-direction allowing a high temporal resolution, which reduces respiratory artefacts during free-breathing acquisition. Despite the use of two x-ray tubes, the HPCT did not increase the dose to the patient but provided the highest images quality., Conclusions: In the emergency setting, HPCTs have been critical for achieving good image quality in uncooperative patients., Implications for Practice: Acute respiratory failure is a common emergency department presentation, and the choice of high-speed acquisition CT may increase image quality., Competing Interests: Conflict of interest statement None., (Copyright © 2021 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.)

Background: Dyspnea is a common and often debilitating symptom with a complex diagnostic work-up., Purpose: To evaluate the benefits, harms, and diagnostic test accuracy of point-of-care ultrasonography (POCUS) in patients with acute dyspnea. (PROSPERO: CRD42019126419)., Data Sources: Searches of multiple electronic databases without language limitations (January 2004 to August 2020) and reference lists of pertinent articles and reviews., Study Selection: Five randomized controlled trials (RCTs) and 44 prospective cohort-type studies in patients with acute dyspnea evaluated POCUS as a diagnostic tool to determine the underlying cause of dyspnea. Two investigators independently screened the literature for inclusion., Data Extraction: Data abstraction by a single investigator was confirmed by a second investigator; 2 investigators independently rated risk of bias and determined certainty of evidence., Data Synthesis: Point-of-care ultrasonography, when added to a standard diagnostic pathway, led to statistically significantly more correct diagnoses in patients with dyspnea than the standard diagnostic pathway alone. In-hospital mortality and length of hospital stay did not differ significantly between patients who did or did not receive POCUS in addition to standard diagnostic tests. Finally, POCUS consistently improved the sensitivities of standard diagnostic pathways to detect congestive heart failure, pneumonia, pulmonary embolism, pleural effusion, or pneumothorax; specificities increased in most but not all studies., Limitations: Most studies assessed diagnostic test accuracy, which has limited utility for clinical decision making. Studies rarely reported on the proportion of indeterminate sonography results, and no evidence is available on adverse health outcomes of false-positive or false-negative POCUS results., Conclusion: Point-of-care ultrasonography can improve the correctness of diagnosis in patients with acute dyspnea., Primary Funding Source: American College of Physicians.

Description: The American College of Physicians (ACP) developed this guideline to provide clinical recommendations on the appropriate use of point-of-care ultrasonography (POCUS) in patients with acute dyspnea in emergency department (ED) or inpatient settings to improve the diagnostic, treatment, and health outcomes of those with suspected congestive heart failure, pneumonia, pulmonary embolism, pleural effusion, or pneumothorax., Methods: The ACP Clinical Guidelines Committee based this guideline on a systematic review on the benefits, harms, and diagnostic test accuracy of POCUS; patient values and preferences; and costs of POCUS. The systematic review evaluated health outcomes, diagnostic timeliness, treatment decisions, and test accuracy. The critical health, diagnostic, and treatment outcomes evaluated were in-hospital mortality, time to diagnosis, and time to treatment. The important outcomes evaluated were intensive care unit admissions, correctness of diagnosis, disease-specific outcomes, hospital readmissions, length of hospital stay, and quality of life. The critical test accuracy outcomes included false-positive results for suspected pneumonia, pneumothorax, and pulmonary embolism and false-negative results for suspected congestive heart failure, pneumonia, pneumothorax, and pulmonary embolism. Important test accuracy outcomes included false-positive results for suspected congestive heart failure and false-negative and false-positive results for suspected pleural effusion. This guideline was developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method., Target Audience and Patient Population: The target audience is all clinicians, and the target patient population is adult patients with acute dyspnea in ED or inpatient settings., Recommendation: ACP suggests that clinicians may use point-of-care ultrasonography in addition to the standard diagnostic pathway when there is diagnostic uncertainty in patients with acute dyspnea in emergency department or inpatient settings (conditional recommendation; low-certainty evidence).

Objective: To describe a case of Burkitt lymphoma (BL) in a child manifesting with acute airway obstruction. To review available literature on the clinical features and characteristic presentation of this disease., Methods: Case report with literature review., Results: We present the case of an 8-year-old boy with nasopharyngeal BL manifesting initially as sore throat, nasal congestion, and snoring that progressed to dyspnea and, ultimately, acute airway obstruction requiring emergent tracheostomy. The child was treated with intensive chemotherapy and achieved complete response., Conclusion: This case highlights the importance of maintaining high clinical suspicion when evaluating common otolaryngologic symptoms and emphasizes the potential for Burkitt lymphoma to cause rapid patient deterioration., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Ultrasound plays an important role in several medical fields. The heart was the first organ for which ultrasound gained clinical utility, followed by obstetric and gynecological applications. Shortly thereafter, abdominal organs and blood vessels became targets for ultrasound examination. The lung was long considered inaccessible for ultrasound due to its high air content. Work since the 1990s has however established a role for lung ultrasound, in leveraging several technical artefacts generated in the normal lung and in conditions with reduced air content, to allow rapid diagnosis of interstitial fluid accumulation, pneumothorax, pneumonia among others. In this article, we provide an overview of the potential of lung ultrasound, particularly as a promising method for assessment of patients presenting with acute dyspnea in the emergency department and for monitoring residual fluid in patients with decompensated heart failure. We also discuss limitations and caveats of the method.

Background and Importance: Few studies are looking at the usefulness of lung ultrasound combined with inferior vena cava (ultrasound strategy) in the particularly challenging diagnosis of acute heart failure (AHF) in elderly dyspneic patients attending the emergency department (ED)., Objective, Design, Settings, and Participants: This was a prospective diagnostic study conducted in two French EDs from December 2015 to March 2019, aimed to determine the accuracy of an ultrasound strategy for the diagnosis of AHF in the elderly. Patients aged 65 and older referred to the ED for dyspnea were screened for inclusion., Intervention: An emergency physician, blinded to the first findings, performed chest ultrasound, and assessment of inferior vena cava (ultrasound strategy)., Outcome Measure and Analysis: The primary endpoint was a final diagnosis of AHF, adjudicated by two independent experts after reviewing the entire medical record. The sensitivity and specificity of ultrasound and standard strategies were calculated., Main Results: A total of 116 patients were included, mean age 84 years (SD 9). Among them, there were 76 (66%) cases of AHF and 51 (44%) cases of pneumonia. The ultrasound work up had a sensitivity of 82% [95% confidence interval (CI), 71-90] and a specificity of 68% (95% CI, 51-90] for AHF. The standard strategy had a sensitivity of 92% (95% CI, 84-97) and a specificity of 53% (95% CI, (36-68)., Conclusions: In this prospective study, there was no statistically significant difference between point-of-care ultrasound and a combination of clinical, radiographic, and biological findings for the diagnosis of acute heart failure., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: We evaluated the functional consequences of diaphragm involvement in patients with inclusion body myositis (IBM)., Methods: Ultrasound diaphragm thickening fraction (TFdi), lung function and dyspnea levels were compared between IBM patients and matched controls. Patients with IBM were grouped into "low" and "high" diaphragm activity based on TFdi values (with cutoff value being the lowest observed TFdi in the control group), and clinical characteristics were compared between groups., Results: 20 IBM patients were included. TFdi was significantly lower in patients and correlated with time since symptom onset (rho = 0.74, P < .001). Patients had significantly lower forced vital capacity and higher dyspnea scores than controls. IBM patients with "low" diaphragm activity (n = 9) had lower 6-min walking distance, higher resting and exertional dyspnea and a larger positional decrease in vital capacity (all P ≤ .03) than patients with 'high' activity. Timed Up and Go time and St. George's Respiratory Questionnaire were not different between groups., Conclusions: Diaphragm involvement in IBM is related to disease duration and has detrimental effects on lung function, dyspnea and exercise capacity. Further studies are required to investigate its potential as a therapeutic target., (© 2021 Wiley Periodicals LLC.)

Introduction: Patients at intermediate-high risk of developing a pulmonary embolism (PE) are very likely to experience adverse outcomes, such as cardiovascular instability and death. The role of thrombolytic therapy in intermediate-high-risk PE remains controversial., Objectives: This study aimed to determine the efficacy and safety of low-dose urokinase (UK) thrombolytic therapy for intermediate-high-risk PE., Patients and Methods: This retrospective study included 81 consecutive patients with intermediate-high-risk PE from two centers. Patients received low-dose UK or low-molecular-weight heparin (anticoagulant therapy group). The efficacy outcomes were mortality, computed tomography pulmonary angiography (CTPA)-confirmed absorption, and dyspnea. Safety was assessed as the incidence of bleedings., Results: The in-hospital mortality, 9-month mortality, and long-term mortality at the last follow-up were comparable for the low-dose UK group and the anticoagulant therapy group (6.45% vs. 0%, p = 0.144, 9.68% vs. 8.16%, p = 0.815, and 12.90% vs. 12.24%, p = 0.931, respectively). CTPA-confirmed absorption at one month after admission was higher in the low-dose UK group than in the anticoagulant therapy group (p = 0.016). The incidences of short-term dyspnea at discharge and long-term dyspnea at the last follow-up were lower in the low-dose UK group than in the anticoagulant therapy group (27.59% vs. 52%, p = 0.035, 33.33% vs. 58.14%, p = 0.043, respectively). No major bleeding occurred. The incidence of minor bleeding was not significantly different between the two groups (3.23% vs. 6%, p = 0.974)., Conclusion: In intermediate-high-risk PE, a low-dose UK might increase CTPA-confirmed absorption and improve short-term and long-term dyspnea without affecting mortality or increasing the bleeding risk., Competing Interests: The authors declare no conflict of interest.

With the growing number of COVID-19 cases in recent times. significant set of patients with extra pulmonary symptoms has been reported worldwide. Here we venture out to summarize the clinical profile, investigations, and radiological findings among patients with SARS-CoV-2-associated meningoencephalitis in the form of a systemic review. This review was carried out based on the existing PRISMA (Preferred Report for Systematic Review and Meta analyses) consensus statement. The data for this review was collected from four databases: Pubmed/Medline, NIH Litcovid, Embase, and Cochrane library and Preprint servers up till 30 June 2020. Search strategy comprised of a range of keywords from relevant medical subject headings which includes "SARS-COV-2," "COVID-19," and "meningoencephalitis." All peer reviewed, case-control, case report, pre print articles satisfying our inclusion criteria were involved in the study. Quantitative data was expressed in mean ± SD, while the qualitative date in percentages. Paired t test was used for analysing the data based on differences between mean and respective values with a p < 0.05 considered to be statistically significant. A total of 61 cases were included from 25 studies after screening from databases and preprint servers, out of which 54 of them had completed investigation profile and were included in the final analysis. Clinical, laboratory findings, neuroimaging abnormalities, and EEG findings were analyzed in detail. This present review summarizes the available evidences related to the occurrence of meningoencephalitis in COVID-19.

Opsoclonus-myoclonus-ataxia syndrome is a heterogeneous constellation of symptoms ranging from full combination of these three neurological findings to varying degrees of isolated individual sign. Since the emergence of coronavirus disease 2019 (COVID-19), neurological symptoms, syndromes, and complications associated with this multi-organ viral infection have been reported and the various aspects of neurological involvement are increasingly uncovered. As a neuro-inflammatory disorder, one would expect to observe opsoclonus-myoclonus syndrome after a prevalent viral infection in a pandemic scale, as it has been the case for many other neuro-inflammatory syndromes. We report seven cases of opsoclonus-myoclonus syndrome presumably parainfectious in nature and discuss their phenomenology, their possible pathophysiological relationship to COVID-19, and diagnostic and treatment strategy in each case. Finally, we review the relevant data in the literature regarding the opsoclonus-myoclonus syndrome and possible similar cases associated with COVID-19 and its diagnostic importance for clinicians in various fields of medicine encountering COVID-19 patients and its complications.