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INTRODUCTIONChest imaging is necessary for diagnosis of COVID-19 pneumonia, but current risk stratification tools do not consider radiographic severity. We quantified radiographic heterogeneity among inpatients with COVID-19 with the Radiographic Assessment of Lung Edema (RALE) score on Chest X-rays (CXRs).METHODSWe performed independent RALE scoring by ≥2 reviewers on baseline CXRs from 425 inpatients with COVID-19 (discovery dataset), we recorded clinical variables and outcomes, and measured plasma host-response biomarkers and SARS-CoV-2 RNA load from subjects with available biospecimens.RESULTSWe found excellent inter-rater agreement for RALE scores (intraclass correlation co-efficient=0.93). The required level of respiratory support at the time of baseline CXRs (supplemental oxygen or non-invasive ventilation [n=178]; invasive-mechanical ventilation [n=234], extracorporeal membrane oxygenation [n=13]) was significantly associated with RALE scores (median [interquartile range]: 20.0[14.1-26.7], 26.0[20.5-34.0] and 44.5[34.5-48.0], respectively, pCONCLUSIONReproducible assessment of radiographic severity revealed significant associations with clinical and physiologic severity, host-response biomarkers and clinical outcome in COVID-19 pneumonia. Incorporation of radiographic severity assessments may provide prognostic and treatment allocation guidance in patients hospitalized with COVID-19.

Severity of radiographic abnormalities on chest radiograph in subjects with COVID-19 has been shown to be associated with worse outcomes, but studies are limited by different scoring systems, sample size, subject age, and study duration. Data regarding the longitudinal evolution of radiographic abnormalities and its association with outcomes are scarce. We sought to evaluate these questions using a well-validated scoring system (the Radiographic Assessment of Lung Edema [RALE] score) using data over 6 months from a large, multihospital health care system.We collected clinical and demographic data and quantified radiographic edema on chest radiograph obtained in the emergency department (ED) as well as on days 1-2 and 3-5 (in those admitted) in subjects with a nasopharyngeal swab positive for SARS-CoV-2 by polymerase chain reaction (PCR) visiting the ED for coronavirus disease 2019 (COVID)-19-related complaints between March-September 2020. We examined the association of baseline and longitudinal evolution of radiographic edema with severity of hypoxemia and clinical outcomes.Eight hundred and seventy subjects were included (median age 53.6; 50.8% female). Inter-rate agreement for RALE scores was excellent (interclass correlation coefficient 0.84 [95% CI 0.82-0.87],The RALE score was reproducible and easily implementable in adult subjects presenting to the ED with COVID-19. Its association with physiologic parameters and outcomes at baseline and longitudinally makes it a readily available tool for prognostication and early ICU triage, particularly in patients with worsening radiographic edema.

ObjectivesTo reliably quantify the radiographic severity of COVID-19 pneumonia with the Radiographic Assessment of Lung Edema (RALE) score on clinical chest X-rays among inpatients and examine the prognostic value of baseline RALE scores on COVID-19 clinical outcomes.SettingHospitalised patients with COVID-19 in dedicated wards and intensive care units from two different hospital systems.Participants425 patients with COVID-19 in a discovery data set and 415 patients in a validation data set.Primary and secondary outcomesWe measured inter-rater reliability for RALE score annotations by different reviewers and examined for associations of consensus RALE scores with the level of respiratory support, demographics, physiologic variables, applied therapies, plasma host–response biomarkers, SARS-CoV-2 RNA load and clinical outcomes.ResultsInter-rater agreement for RALE scores improved from fair to excellent following reviewer training and feedback (intraclass correlation coefficient of 0.85 vs 0.93, respectively). In the discovery cohort, the required level of respiratory support at the time of CXR acquisition (supplemental oxygen or non-invasive ventilation (n=178); invasive-mechanical ventilation (n=234), extracorporeal membrane oxygenation (n=13)) was significantly associated with RALE scores (median (IQR): 20.0 (14.1–26.7), 26.0 (20.5–34.0) and 44.5 (34.5–48.0), respectively, pConclusionsWith a reproducible method to measure radiographic severity in COVID-19, we found significant associations with clinical and physiologic severity, host inflammation and clinical outcomes. The incorporation of radiographic severity assessments in clinical decision-making may provide important guidance for prognostication and treatment allocation in COVID-19.

BackgroundSeverity of radiographic abnormalities on chest X-ray (CXR) in patients with COVID-19 has been shown to be associated with worse outcomes, but studies are limited by different scoring systems, sample size, patient age and study duration. Data regarding the longitudinal evolution of radiographic abnormalities and its association with outcomes is scarce. We sought to evaluate these questions using a well-validated scoring system (the Radiographic Assessment of Lung Edema [RALE] score) using data over 6 months from a large, multi-hospital healthcare system.MethodsWe collected clinical and demographic data and quantified radiographic edema on CXRs obtained in the emergency department (ED) as well as on days 1-2 and 3-5 (in those admitted) in patients with a nasopharyngeal swab positive for SARS-CoV-2 PCR visiting the ED for COVID-19-related complaints between March and September 2020. We examined the association of baseline and longitudinal evolution of radiographic edema with severity of hypoxemia and clinical outcomes.Results870 patients were included (median age 53.6, 50.8% female). Inter-rate agreement for RALE scores was excellent (ICC = 0.84, 95% CI 0.82 - 0.87, p < 0.0001). RALE scores correlated with hypoxemia as quantified by SpO2-FiO2 ratio (r = -0.42, p < 0.001). Admitted patients had higher RALE scores than those discharged (6 [2, 11] vs 0 [0, 3], p < 0.001). An increase of RALE score of 4 or more was associated with worse 30-day survival (p < 0.01). Larger increases in the RALE score were associated with worse survival.ConclusionsThe RALE score is reproducible and easily implementable in adult patients presenting to the ED with COVID-19. Its association with physiologic parameters and outcomes at baseline and longitudinally makes it a readily available tool for prognostication and early ICU triage, particularly in patients with worsening radiographic edema.

Background: Severity of radiographic abnormalities on chest X-rays (CXR) obtained in the emergency department (ED) in patients diagnosed with COVID-19 has been shown to be associated with outcomes, but studies are limited by different scoring systems, sample size, patient age and study duration. We sought to evaluate this question using a well-validated scoring system (the Radiographic Assessment of Lung Edema [RALE] score) using data over 6 months from a large, multi-hospital healthcare system including all adult (age >= 18) patients. Methods: We collected CXRs, demographic, historic and clinical data from patients with a nasoand/ or oropharyngeal swab positive for SARS-CoV-2 PCR visiting the ED for COVID-19-related complaints between March and September 2020. Two independent reviewers quantified radiographic edema using the RALE scoring system. Fraction of inspired oxygen (FiO2) was calculated using 1 liter per minute (lpm) supplemental O2 to 3% FiO2 conversion and capped at 15 lpm O2. We examined the association of radiographic edema with hypoxemia, need for hospital admission, ICU admission, need for mechanical ventilation within 7 days of admission and 30-day mortality. Results: 453 patients met criteria for inclusion (median age 54, 51% female). Inter-rate agreement for RALE score was excellent (interclass correlation coefficient = 0.89, 95% CI 0.87-0.92, p < 0.0001). 99 patients had a normal (RALE = 0) CXR on ED visit. Median RALE score was 3. RALE scores negatively correlated with degree of hypoxemia as quantified by SpO2-FiO2 (SF) ratio (r =-0.34, p < 0.001). Patients admitted to the hospital had higher RALE scores than those who were discharged home (median 2 IQR [0, 6] vs 3 [10, 17], p < 0.001). Among 199 patients admitted to the hospital, RALE scores were higher in those requiring admission to the ICU compared to those who did not (7 [14,20], 2 [8,16], p = 0.007). Patients in the 3rd and 4th RALE quartiles were more likely to require mechanical ventilation and had higher 30-day mortality compared to those with RALE scores below the median, even after adjustment for age, SF ratio and history of diabetes (p < 0.02 for all). Conclusions: The RALE score is highly reproducible and easily implementable in adult patients presenting to the ED with COVID-19. Its association with physiologic parameters and outcomes makes it a readily available tool for prognostication and early ICU triage, particularly in patients with severe radiographic edema as quantified by the RALE score.

Rationale: The neutrophil-to-lymphocyte ratio (NLR) as a predictor of outcomes has been studied in different disease states such as sepsis, ARDS and pancreatitis. In COVID-19 patients, NLR has been shown to be an independent risk factor associated with disease severity with a few studies suggesting an association between NLR and outcomes. Using data from a large multi-hospital healthcare system over a 6-month period, we sought to independently evaluate the NLR's ability to predict need for hospitalization, ICU admission, need for mechanical ventilation, 30-day mortality, and its association with hypoxemia. Methods: We collected demographic, historic and clinical data from patients with a naso-and/or oropharyngeal swab positive for SARS-CoV-2 PCR visiting the ED for COVID-19-related complaints between March-September 2020. Fraction of inspired oxygen (FiO2) was calculated using 1 liter per minute (lpm) supplemental O2 to 3% FiO2 conversion and capped at 15 lpm O2. We examined the association of NLR with hypoxemia, need for hospitalization, ICU admission, need for mechanical ventilation within 7 days of ED visit and 30-day mortality after adjustment for history of hypertension, diabetes, severity of hypoxemia and age. Results: From 510 patients analyzed, 357 had a complete blood count (CBC) drawn (median age 57, 51% female). Median NLR was 2.09 with IQR of 3.69-5.88. NLR negatively correlated with degree of hypoxemia as quantified by SpO2-FiO2 (SF) ratio (Rho =-0.33, p < 0.001). Patients requiring hospital admission had higher NLR compared to those who did not (median 2.59 IQR [4.45-7.6] vs 1.57 [2.75-4.36], p < 0.001). In patients admitted to the hospital, NLR was higher in those requiring ICU admission compared to those who did not [2.99 [6.21-10.8] vs 2.37 [4.05-6.05], p < 0.01]. In those with NLR above the median there was a trend towards higher need for intubation within 7 days, although this did not achieve statistical significance (OR 2.28, 95% CI 0.94-5.53, p = 0.07). 30-day mortality was higher in those with NLR above the median compared to those below the median (OR 2.84, 95% CI 1.29-6.28, p < 0.01). Conclusions: In patients presenting to the ED with COVID-19, an increased NLR is associated with need for hospitalization, ICU admission and worse 30-day mortality while being inversely correlated with degree of hypoxemia. The cost-effectiveness and wide-spread availability of CBC testing makes NLR an easily implementable prognostication tool in COVID-19 patients.

1105 Background: Survivors of breast cancer who are obese have a greater than two-fold increase in mortality compared to their counterparts. We assessed the feasibility of an individualized nutrition counseling and exercise program with the goal of helping participants achieve a loss of 10% body weight. Secondary endpoints included impact on multiple metabolic parameters, cardiovascular health, and quality of life. Methods: We present preliminary data from a single-arm pilot trial (NCT04365569) whereby survivors of breast cancer with BMI ≥ 25 kg/m2 participated in a 6-month, individualized counseling program. A registered dietitian (RD) counseled patients based upon recommendations by the American Cancer Society. The intervention included in-person (baseline, months 3 and 6) and telephone visits (months 1, 2, 4, and 5). The nutrition component included weight and body composition measures and blood work, including lipid panel and hemoglobin A1c. Cardiovascular fitness and extrapolated VO2 max were measured using SHAPE study. Quality of life was evaluated using: the Functional Assessment of Cancer Therapy – Breast Cancer (FACT-B), the Brief Pain Inventory (BPI), the Generalized Anxiety Disorder-7 (GAD-7), the Patient Health Questionnaire-9 (PHQ-9), and the NCCN Distress Thermometer. Paired statistics were used to compare changes in these aforementioned outcomes pre-and post-intervention. Results: A total of n=55 female breast cancer survivors (mean age 58.1± 9.13) were enrolled. N=28 completed the trial to date. While 14.3% of participants lost >10% of their baseline weight, 21.4% lost 5-10 % of their weight. Patients had a mean 45.30% drop in body fat composition overall (p2 max of -4.71 (SD 4.71, p

Pulmonary hypertension (PH) is a disease in which there is an elevated pressure in the pulmonary vasculature leading to anatomic changes that can be identified on imaging. While right heart catheterization (RHC) is the gold standard for definitive diagnosis, there are many steps prior to catheterization in evaluating a patient with suspected PH. Computed Tomography (CT) is often used as one of the initial imaging modalities in the workup of suspected PH and is usually obtained in all patients with suspected or confirmed PH. In other cases, CT scans done for other purposes can suggest findings of PH that would alert clinicians to an additional possible diagnosis. Patients diagnosed with PH often have very complex hemodynamics as well as medical comorbidities, and referral to a center that specializes in PH is always recommended. There have been newly proposed classifications for the different groups of PH as well as a new definition for the diagnosis of PH. Various findings may require a specific CT to be completed with or without contrast or an electrocardiogram (ECG)-gated CT. This article reviews the current literature and provides a pictorial reference of CT findings associated with PH that can lead to a proposed diagnosis and, possibly, the underlying etiology of PH.