Imaging the coronavirus disease COVID-19

[Shamim Ansary]

Imaging the coronavirus disease COVID-19
Chest X-ray is the first imaging method to diagnose COVID-19 coronavirus infection in Spain, but in the light of new evidence this may change soon, according to Milagros Martí de Gracia, Vice President of the Spanish Society of Radiology (SERAM) and head of the emergency radiology unit at La Paz Hospital in Madrid, one of the hot spots for viral re-production of COVID-19.

Interview: Mélisande Rouger

HiE: How are you coping with the outbreak at your hospital?

Milagros Martí de Gracia: ‘We’ve been preparing for this situation for several days; the number of patients has grown progressively, and has surged this past couple of days. We now have 200 patients with confirmed COVID-19 coronavirus infection (as of March 12). Patients have been gradually placed in wards that can accommodate between 14 and 25 persons each. We have five wards dedicated exclusively to patients with suspected infection.

‘Naturally, this has had an impact on the organisation of the emergency radiology unit. Patients with very high suspicion and confirmed infection are examined with portable radiology equipment. Suspicious patients are examined in the emergency radiology room, which is currently exclusively dedicated to this purpose. Patients without suspected infection are waiting to be attended or are located in other wards. Radiological examinations are done in another area of the hospital, away from the main area, so that patients do not mix.’

HiE: How do these measures affect your department’s workflow?

Milagros Martí de Gracia is Vice President of the Spanish Society of Radiology (SERAM), President of the Spanish Society of Emergency Radiology (SERAU) and head of the department of emergency radiology at La Paz Hospital in Madrid

MMG: ‘The request for chest radiographs has grown exponentially and proportionally with the number of patients visiting the emergency department. A chest X-ray is performed in suspected or confirmed patients through specific circuits. Rooms with dedicated equipment are allocated exclusively for possible patients. Portable radiology equipment is available for confirmed or suspected patients.

‘This is easier to organise when teams are dedicated exclusively to the emergency department, or when emergency radiology units are integrated in the emergency department.’

MMG: ‘We attend more than 400 daily emergencies only in the general hospital. Every day we receive around 140 alerts. Today, on March 12, more than 200 patients have been confirmed with the virus, many of whom have already been admitted.

‘At first, the epidemiological criterion was the most important information, i.e. having travelled or contacted someone from China or Korea. Later the criterion was having had contact with someone infected or coming back from Italy. But now in Madrid, we only need to assess the symptoms, which are very nonspecific (cough, fever and respiratory distress). However, there may be other symptoms that complicate suspicion. Analytical alterations such as lymphopenia, elevation of transaminases or lactate dehydrogenase augment the degree of suspicion.’

HiE: What is the protocol?

MMG: ‘Patients with respiratory symptoms must remain isolated and wear a mask. If clinical suspicion persists after the examination, a sample of nasopharyngeal exudate is taken to test reverse-transcription polymerase chain reaction (RT-PCR). Then, we perform a chest X-ray. Getting the results of the PCR test may take several hours. The chest X-ray is a discriminating element; if the clinical situation and the chest X-ray film are normal, patients can go home and wait for the results of the etiological test. But if the film shows pathological findings, patients are admitted to the hospital for observation.

‘Usually the absence or presence of pathological findings on chest X-ray is determining to send the patient home or keep him/her under observation But if the clinical suspicion is high and the PCR or/and chest X-ray is normal, a chest CT is indicated.

‘This is a fast-evolving issue and today’s recommendations might not be valid tomorrow. The SERAM is developing and updating guidelines for radiologists that are available on our website. We have also created working groups to help not only diagnose the virus, but also to promote safe management among patients and healthcare staff.’

HiE: How important is radiology in diagnosing COVID-19 infection?

MMG: ‘Radiology is fundamental in this process. The radiologist's main contribution is to facilitate and expedite as much as possible the exploration, help design specific circuits and provide a fast and accurate report of the radiological findings that should indicate whether or not these are consistent with the COVID-19 coronavirus infection.’

These two X-ray images are from a 72-year-old woman who has a cough and respiratory distress from last year (left) and now. The yellow circle and ovoid indicate the typical subpleural peripheral opacities

HiE: What are the typical radiological findings?

MMG: ‘The findings that make us strongly suspect that we are dealing with a COVID-19 infection are the ground glass patterned areas, which, even in the initial stages, affect both lungs, in particular the lower lobes, and especially the posterior segments, with a fundamentally peripheral and subpleural distribution. These findings are present on chest CT in practically 50% of patients in the first two days; For this, in China, CT is being used as a screening or diagnostic method.

‘These lesions progress in the following days until they become more diffuse. If they associate with septal thickening, they will present with a crazy paving pattern. In general, they progress in extension and also towards the consolidation that is done concomitantly with the ground glass pattern, which can present a rounded morphology. It is very rare that it associates lymphadenopathy or capitation or pneumothorax, as the Middle East respiratory syndrome coronavirus (MERS-CoV) did.’

With a case fatality rate of 35 percent, a Middle East respiratory syndrome-related coronavirus (MERS-CoV) infection – also called camel flu – is a dangerous disease. About seven years ago, when the virus was first isolated, mortality was close to 100 percent since only severe infections that led to the patient being in intensive care were recorded. Today the environment of each victim is…

HiE: Do you also use imaging to follow-up the disease?

MMG: ‘We have had little time to discuss our experience in the follow-up of infected patients so far. But, for the time being, radiology is playing a crucial role in the diagnosis and identification of patients for observation in the hospital admission or at home. The most commonly used diagnostic modality is chest radiography. At the moment, computed tomography (CT) plays a limited role and is carried out in cases of clinical mismatch and PCR, i.e. in patients with high suspicion of being infected but with negative or inconclusive PCR. CT is also indicated for the recognition of possible complications that are not obvious on the chest radiograph, or to diagnose very serious patients quickly, whose PCR results are not yet available, for placement in a specific coronavirus intensive surveillance unit.

‘In other countries like China, CT is being used as a diagnostic modality because of its high sensitivity to show lung lesions before PCR. The WHO considers typical CT findings as a diagnostic criterion since February 17. We have published our recommendations on our website https://www.seram.es, and will update them soon.’

Read More: CT outperforms lab diagnosis for coronavirus infection https://healthcare-in-europe.com/en/news/ct-outperforms-lab-diagnosis-for-coronavirus-infection.html

In a study of more than 1,000 patients published in Radiology, chest CT outperformed lab testing in the diagnosis of 2019 novel coronavirus disease (COVID-19). Researchers at Tongji Hospital in Wuhan, China, concluded that CT should be used as the primary screening tool for COVID-19. In the absence of specific therapeutic drugs or vaccines for COVID-19, it is essential to detect the disease at an…

HiE: After a decade of healthcare budget cuts in Spain, do you have enough equipment to face the outbreak?

MMG: ‘Certainly the high number of infected is a great challenge for public health in Madrid and Spain because we have suffered great cuts due to the crisis. In my department, a priori, we did not have enough equipment to face the crisis but agreements have been reached for its immediate acquisition of several digital portable equipment for the radiology department and mechanical ventilation equipment for the ICUs.’

HiE: Really, how dangerous is COVID-19?

MMG: ‘It has been compared a lot with ‘flu, but really the only thing it has in common is that it is transmitted through the flow drops and by contact. COVID-19 is much more contagious; unlike the flu, there is no vaccine and for our immune system it is an absolute unknown because we have never been in contact with it.’

HiE: What do you think of the response of Madrid’s authorities to this virus spread?

    It’s very difficult when decisions have such important economic repercussions. But people's health is the most important
    Milagros Martí de Gracia

MMG: ‘It‘s certainly very difficult to make decisions and choose the right time to minimise impact, knowing that you have to make these decisions as soon as possible. It’s very difficult when decisions have such important economic repercussions. But people's health is the most important.’

HiE: The UK has called back retired physicians to help. Could this be a viable strategy for Madrid?

MMG: ‘Here, now, emergencies need support and reinforcement, which can be offered by doctors from other specialties inside the hospital. I don’t know if the possibility of calling retired doctors is being considered, but numerous doctors and nurses have been hired to reinforce guards in strategic places, such as intensive microbiology and emergencies.’

HiE: Have we just seen the tip of the iceberg? What are the projections for the next few weeks or months?

MMG: ‘From what I’ve read, COVID-19 shares many characteristics similar to SARS and MERS. So, we all believe that the beginning of the ‘hot’ season will actually reduce the transmission capacity of the virus, and it becomes a seasonal virus.’

HiE: What do you recommend to fellow radiologists?

MMG: ‘I encourage all my fellow radiologists to participate actively in the protocols of action within the hospital and provide what radiologists do best: the radiological report. That is our most important added value.

‘The epidemic is still in the ascending phase, and it’s very likely that it will not stabilise until the next few weeks. That’s why containment measures are so important: we know that a large part of the population is going to be infected but it is essential that this contagion is made in a staggered way, with a curve as flat and slow as possible to avoid the collapse of the healthcare system.’

Source: https://healthcare-in-europe.com/en/news/imaging-the-coronavirus-disease-covid-19.html

[Shamim Ansary]

There is currently no effective cure for this virus and there is an urgent need to increase global knowledge in its mechanisms of infection, lung parenchyma damage distribution and associated patterns.

Artificial Intelligence and radiomics applied to X-Ray and Computed Tomography are useful tools in the detection and follow-up of the disease.

In December 2019 the city of Wuhan (China) became the center of a pneumonia outbreak of an unknown cause with global implications. In early 2020, Chinese scientists isolated a novel coronavirus (CoV), from patients in Wuhan, formerly  known as 2019-nCoV 1 and now renamed as Covid-19 by the World Health Organization (WHO). Patients infected with this strain present a wide range of symptoms 2, most seem to have mild disease, with about 20% appear to progress to severe disease, including pneumonia, respiratory failure and in around 2% of cases death 3. Common signs of infection include respiratory symptoms, shortness of breath and breathing difficulties, fever and cough 4.

Coronaviruses (CoV) are a large family of viruses that cause illness ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV). This novel coronavirus (nCoV) is a new strain not previously identified in humans. Although this outbreak had its start in China, today there are several countries around the world with identified cases, making it a worldwide public health concern.

Confirmed cases of COVID-19 acute respiratory disease reported by provinces, regions and cities in China, 13 February 2020*

Table 1. Confirmed cases of COVID-19 acute respiratory disease reported by provinces, regions and cities in China, 13 February 2020*

How could AI and imaging biomarkers aid to fight against this emerging zoonotic illness?

There is currently no effective cure for this virus and there is an urgent need to increase global knowledge in its mechanisms of infection, lung parenchyma damage distribution and associated patterns, not only for disease detection or to complement the diagnosis, but also to support the design of a curative therapy. AI and radiomics applied to X-Ray and Computed Tomography are useful tools in the detection and follow-up of the disease. As stated in 5, conspicuous ground grass opacity lesions in the peripheral and posterior lungs on CT images are indicative of Covid-19 pneumonia. Therefore, CT can play an important role in the diagnosis of Covid-19 as an advanced imaging evidence once findings in chest radiographs are indicative of coronavirus. AI algorithms and radiomics features derived from Chest X-rays would be of huge help to undertake massive screening programs that could take place in any country with access to X-ray equipment and aid in the diagnosis of Covid-19 6.

FIGURE 1: QUIBIM – Quantitative Structured Report – Chest X-Ray Classifier

In order to speed up the discovery of disease mechanisms, QUIBIM’s Chest X-Ray Classifier (Figure 1) can be used to detect abnormalities and extract textural features of the altered lung parenchima that could be related to specific signatures of the Covid-19 virus. We have combined all our knowledge in AI and radiomics in this novel analysis pipeline specifically designed to extract disease patterns. First, the Chest X-Ray is automatically analyzed using a deep learning classifier to provide an abnormality score between 0 and 1. Any abnormality score above 0.3 is considered as an abnormal case. After this initial analysis, lungs are automatically segmented using a Mask R-CNN like convolutional neural network architecture and finally, a massive extraction of texture features is applied (figure header). This pipeline has been completely automated and will serve to provide additional information to the diagnosis of Covid-19.

QUIBIM is committed to provide access to our existing AI technology to find new diagnostic tools and ways to understand the mechanisms and aggressiveness of the disease, contributing to the efforts to find a cure.  Any clinician can fill this form created by QUIBIM to get free credentials for the use of the AI Chest X-Ray classification analysis technology available in the QUIBIM Precision Cloud platform. This research tool is offered to any doctor worldwide with the need of analyzing Chest X-Rays with suspicion of Covid-19.

Author: Rafael López González – R&D Engineer

Source: https://quibim.com/tag/chest-x-ray/

[Shamim Ansary]

-System analyses hundreds of images in seconds, then advises doctors what to do next

-China has offered free use of the machine around the world, but US Centres for Disease Control says it does not recommend using scans to diagnose Covid-19

The first case of someone in China suffering from Covid-19
, the disease caused by the novel coronavirus
, can be traced back to November 17, according to government data seen by the South China Morning Post.

Chinese authorities have so far identified at least 266 people who were infected last year, all of whom came under medical surveillance at some point.

Some of the cases were likely backdated after health authorities had tested specimens taken from suspected patients.

Interviews with whistle-blowers from the medical community suggest Chinese doctors only realised they were dealing with a new disease in late December.

The first known case of Covid-19 in China dates back to November, but the hunt for “patient zero” goes on. Photo: EPA-EFEThe first known case of Covid-19 in China dates back to November, but the hunt for “patient zero” goes on. Photo: EPA-EFE
The first known case of Covid-19 in China dates back to November, but the hunt for “patient zero” goes on. Photo: EPA-EFE
The first case of someone in China suffering from Covid-19
, the disease caused by the novel coronavirus
, can be traced back to November 17, according to government data seen by the South China Morning Post.

Chinese authorities have so far identified at least 266 people who were infected last year, all of whom came under medical surveillance at some point.

Some of the cases were likely backdated after health authorities had tested specimens taken from suspected patients.

Interviews with whistle-blowers from the medical community suggest Chinese doctors only realised they were dealing with a new disease in late December.

Scientists have been trying to map the pattern of the early transmission of Covid-19 since an epidemic was reported in the central China city of Wuhan in January, two months before the outbreak became a global health crisis.

Understanding how the disease spread and determining how undetected and undocumented cases contributed to its transmission will greatly improve their understanding of the size of that threat.

According to the government data seen by the Post, a 55 year-old from Hubei province could have been the first person to have contracted Covid-19 on November 17.

From that date onwards, one to five new cases were reported each day. By December 15, the total number of infections stood at 27 – the first double-digit daily rise was reported on December 17 – and by December 20, the total number of confirmed cases had reached 60.

On December 27, Zhang Jixian, a doctor from Hubei Provincial Hospital of Integrated Chinese and Western Medicine, told China’s health authorities that the disease was caused by a new coronavirus. By that date, more than 180 people had been infected, though doctors might not have been aware of all of them at the time.

By the final day of 2019, the number of confirmed cases had risen to 266, On the first day of 2020 it stood at 381.

While the government records have not been released to the public, they provide valuable clues about how the disease spread in its early days and the speed of its transmission, as well as how many confirmed cases Beijing has recorded.

Scientists are now keen to identify the so-called patient zero, which could help them to trace the source of the coronavirus, which is generally thought to have jumped to humans from a wild animal, possibly a bat.

Of the first nine cases to be reported in November – four men and five women – none has been confirmed as being “patient zero”. They were all aged between 39 and 79, but it is unknown how many were residents of Wuhan, the capital of Hubei and the epicentre of the outbreak.

The first known case of Covid-19 in China dates back to November, but the hunt for “patient zero” goes on. Photo: EPA-EFEThe first known case of Covid-19 in China dates back to November, but the hunt for “patient zero” goes on. Photo: EPA-EFE
The first known case of Covid-19 in China dates back to November, but the hunt for “patient zero” goes on. Photo: EPA-EFE
The first case of someone in China suffering from Covid-19
, the disease caused by the novel coronavirus
, can be traced back to November 17, according to government data seen by the South China Morning Post.

Chinese authorities have so far identified at least 266 people who were infected last year, all of whom came under medical surveillance at some point.

Some of the cases were likely backdated after health authorities had tested specimens taken from suspected patients.

Interviews with whistle-blowers from the medical community suggest Chinese doctors only realised they were dealing with a new disease in late December.

Scientists have been trying to map the pattern of the early transmission of Covid-19 since an epidemic was reported in the central China city of Wuhan in January, two months before the outbreak became a global health crisis.

Understanding how the disease spread and determining how undetected and undocumented cases contributed to its transmission will greatly improve their understanding of the size of that threat.

According to the government data seen by the Post, a 55 year-old from Hubei province could have been the first person to have contracted Covid-19 on November 17.
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From that date onwards, one to five new cases were reported each day. By December 15, the total number of infections stood at 27 – the first double-digit daily rise was reported on December 17 – and by December 20, the total number of confirmed cases had reached 60.

On December 27, Zhang Jixian, a doctor from Hubei Provincial Hospital of Integrated Chinese and Western Medicine, told China’s health authorities that the disease was caused by a new coronavirus. By that date, more than 180 people had been infected, though doctors might not have been aware of all of them at the time.
With pandemic declared, the race is on to develop a coronavirus vaccine
13 Mar 2020

By the final day of 2019, the number of confirmed cases had risen to 266, On the first day of 2020 it stood at 381.

While the government records have not been released to the public, they provide valuable clues about how the disease spread in its early days and the speed of its transmission, as well as how many confirmed cases Beijing has recorded.

Scientists are now keen to identify the so-called patient zero, which could help them to trace the source of the coronavirus, which is generally thought to have jumped to humans from a wild animal, possibly a bat.

Of the first nine cases to be reported in November – four men and five women – none has been confirmed as being “patient zero”. They were all aged between 39 and 79, but it is unknown how many were residents of Wuhan, the capital of Hubei and the epicentre of the outbreak.

It is possible that there were reported cases dating back even earlier than those seen by the Post.
According to the World Health Organisation
’s website, the first confirmed Covid-19 case in China was on December 8, but the global body does not track the disease itself but relies on nations to provide such information.

A report published in medical journal The Lancet by Chinese doctors from Jinyintan Hospital in Wuhan, which treated some of the earliest patients, put the date of the first known infection at December 1.

Dr Ai Fen, the first known whistle-blower, told People magazine in an interview that was later censored, that tests showed that a patient at Wuhan Central Hospital was diagnosed on December 16 as having contracted an unknown coronavirus.

Accounts by other doctors seem to suggest the medical community in Wuhan became aware of the disease in late December.

Previous reports said that although doctors in the city collected samples from suspected cases in late December, they could not confirm their findings because they were bogged down by bureaucracy, such as having to get approval from the Chinese Centre for Disease Control and Prevention, which could take days. They were also ordered not to disclose any information about the new disease to the public.

As late as January 11, Wuhan’s health authorities were still claiming there were just 41 confirmed cases.

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Source: https://www.scmp.com/news/china/society/article/3075153/coronavirus-chinese-supercomputer-uses-artificial-intelligence