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the scientific community and health professionals are working on the development of new treatments and technologies to enable early diagnosis&#46; The role of chest imaging&#44; specifically radiography &#40;X-ray&#41; and computed tomography &#40;CT&#41;&#44; in the management of patients with suspected COVID-19 should be established taking into account factors such as respiratory disease severity&#44; pretest probability of the disease&#44; and the availability of resources&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Currently&#44; neither X-ray nor CT are recommended diagnostic criteria for COVID-19&#46; The only accepted diagnostic method is viral screening&#44; with the limitation that quantitative PCR results are only available after 6&#8211;48&#8239;h&#46; Therefore&#44; although viral testing is still required even when radiological findings are consistent with the disease&#44; radiological imaging findings should be taken into consideration to establish a suspected diagnosis aimed at providing a more efficient triage not only involves screening of patients but also decision like quarantine the patients&#44; admit them etc&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Most publications support the accuracy of CT in detecting viral pneumonia&#44; even in asymptomatic patients&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In patients with a high clinical probability of COVID-19 who are positive on CT but with a negative PCR test&#44; this imaging technique can be viewed as a screening tool&#44; and a repeat PCR is indicated&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The characteristic radiological findings of COVID-19 on CT include multiple peripheral pulmonary opacities&#44; with frequent bilateral involvement&#44; distributed predominantly in basal and posterior regions&#46; X-ray reveals similar characteristics&#44; but the sensitivity of CT is superior&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">No uniform criteria are available to guide the radiological evaluation of viral pneumonia in the context of a pandemic&#46; The choice of imaging techniques is based not only on the properties of imaging techniques themselves&#44; but also on the resources of the hospital&#44; the availability of viral testing&#44; expertise&#44; and ultimately depends on the judgement of the team of professionals directly involved in the management of these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Digital tomosynthesis &#40;DTS&#41; of the chest is a technique that provides multiple anatomical images in a single scan&#46; DTS shares some CT advantages and&#44; although less sensitive&#44; requires a lower dose of radiation &#40;CT vs&#46; DTS&#44; 49&#215;&#41;&#44; and reduces costs&#46; Aditionally&#44; it alsohas several advantages over chest X-ray&#58; 1&#41; it improves lesion detection by reducing artifacts caused by overlapping anatomical structures&#59; 2&#41; it facilitates 3-dimensional localization&#59; 3&#41; it offers improved contrast resolution&#59; and 4&#41; it is more sensitive&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#8211;15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">DTS consists of a conventional X-ray tube&#44; the movements of which are controlled from the console&#44; a detector panel and reconstruction algorithms that produce tomographic images&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Up to 60 low-dose exposures are obtained during each pass&#46; The data acquired are reconstructed in a group of coronal images of the chest&#44; parallel to the detector plane&#44; which can be reviewed sequentially in DICOM format on any standard workstation connected to the PACS&#46; All DTS include a conventional PA projection in addition to the tomograms&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The role of digital tomography in the assessment of infectious lung disease is not yet established&#44; although its efficacy in detecting pulmonary nodules and screening for breast cancer has been described&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In our radiology department&#44; DTS has been proposed as a preferred initial imaging technique for evaluating acute respiratory disease in patients with suspected COVID-19&#46; To date&#44; 62&#37; of patients admitted with COVID-19 confirmed by quantitative PCR &#40;n&#8239;&#61;&#8239;97&#59; 56 men and 41 women&#41; had baseline DTS&#44; and the remaining 38&#37;&#44; who presented a worse clinical condition underwent chest X-ray&#46; When the DTS radiological reports were classified according to the probability of COVID-19 as&#58; 1&#41; low&#59; 2&#41; intermediate&#59; 3&#41; high&#59; or 4&#41; no radiological alterations&#44; we found that the results of 53&#37; of the DTS performed prior to viral testing were highly probable and only 6&#37; were normal&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In total&#44; 13&#37; of PCR-positive patients were admitted after their second DTS because they did not initially meet clinical admission criteria&#46; In all cases&#44; progressive pulmonary opacities were observed on DTS&#44; in addition to worsening symptoms and clinical laboratory markers&#46; Four cases were reported as low probability in the first DTS and high probability in the second&#59; 2 patients had normal initial DTS and high probability in the second&#59; and another 2 cases were reported as low probability in the first DTS and intermediate probability in the second&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Our recent experience reporting DTS in patients with suspected COVID-19 suggests that this technique is more useful when pulmonary opacities are subtle and therefore more difficult to identify by X-ray&#46; It also facilitates the detection of multiple peripheral opacities&#44; confirming bilateral involvement in many cases&#59; characteristics that&#44; as already mentioned&#44; are associated with COVID-19&#46; In this respect&#44; DTS is more specific than chest X-ray in this disease&#46; By providing a series of coronal slices&#44; pulmonary opacities that may be faint or posterior can be more accurately located than with lateral X-ray &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; &#40;annex&#44; Supplementary Figs&#46; 1 and 2&#41;&#46; It is not a matter of opinion&#46; It is a conclusion generated by what was experienced with these patients&#46; The main limitation of this technique is the respiration-mediated artifacts caused by the difficulty of some patients in holding their breath during the examination&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Although more studies are needed to consolidate the utility of DTS in a scenario with high clinical suspicion for COVID-19&#44; it seems reasonable that a DTS positive for disease could obviate the need for CT&#46; In this context&#44; DTS use as primary imaging technique not only relieves the pressure on CT rooms&#44; but also reduces the radiation dose delivered to patients&#46; In conclusion&#44; our preliminary results suggest that DTS may play an important role in the initial evaluation of patients with suspected COVID-19&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Calvo I&#44; SantaCruz-Calvo S&#44; Aranzana MG&#44; M&#225;rmol P&#44; Luque J&#193;&#44; Ramos F&#44; et al&#46; Tomograf&#237;a Digital y COVID-19&#58; un avance en la valoraci&#243;n de opacidades pulmonares&#46; Arch Bronconeumol&#46; 2020&#59;56&#58;761&#8211;763&#46;</p>"
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            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Bilateral COVID-19 pneumonia&#46; A 52-year-old man&#44; family doctor by profession&#44; presented with a 10-day history of cough and myalgia&#46; Dyspnea and fever on examination&#46; Laboratory tests&#58; normal white cell count&#44; ferritin 545&#46;7&#8239;ng&#47;mL &#40;&#62;322&#41;&#44; and erythrocyte sedimentation rate 53&#8239;m&#47;n &#40;0&#8211;20&#41;&#46; PCR positive for SARS-CoV-2&#46; A&#8212; Posterior-anterior chest X-ray&#58; slight opacity in the periphery of the left hemitorax&#44; middle field&#46; B&#8212;Lateral chest X-ray with no obvious findings&#46; C&#8212;DTS&#58; Image no&#46; 8 &#40;anterior&#41;&#46; Extensive opacity in anterior region of left hemitorax &#40;arrows&#41;&#46; D&#8212;DTS&#58; Image no&#46; 14 &#40;central&#41;&#46; Bilateral pulmonary opacities&#44; in the left suprahilar region &#40;arrow&#41; and right lower lobe &#40;arrow&#41;&#46; E&#8212;DTS&#58; Image no&#46; 36 &#40;posterior&#41;&#46; Oval opacity in retro-cardiac region &#40;arrow&#41;&#46; F&#8212;Non-contrast chest CT scan&#44; sagittal reconstruction&#46; Oval opacity in the periphery of the left lower lobe &#40;arrow&#41;&#46;</p>"
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Scientific Letter
Digital Tomosynthesis and COVID-19: An improvement in the assessment of pulmonary opacities
Tomografía Digital y COVID-19: un avance en la valoración de opacidades pulmonares
Inmaculada Calvoa,
Corresponding author
, Sara SantaCruz-Calvob, María Gracia Aranzanaa, Patricia Mármola, Jorge Ángel Luquea, Inmaculada Perala, Eva María Quijadaa, Cristina Gómeza, Celia Borregoa, Jorge Marínc
a Servicio de Radiología, Hospital Comarcal de la Merced, Osuna, Sevilla, Spain
b Department of Pharmacology and Nutritional Sciences and the Barnstable Brown Diabetes and Obesity Center, University of Kentucky, Lexington, Kentucky, United States
c Servicio de Medicina Interna, Hospital Comarcal de la Merced, Osuna, Sevilla, Spain
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        "titulo" => "Tomograf&#237;a Digital y COVID-19&#58; un avance en la valoraci&#243;n de opacidades pulmonares"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Bilateral COVID-19 pneumonia&#46; A 52-year-old man&#44; family doctor by profession&#44; presented with a 10-day history of cough and myalgia&#46; Dyspnea and fever on examination&#46; Laboratory tests&#58; normal white cell count&#44; ferritin 545&#46;7&#8239;ng&#47;mL &#40;&#62;322&#41;&#44; and erythrocyte sedimentation rate 53&#8239;m&#47;n &#40;0&#8211;20&#41;&#46; PCR positive for SARS-CoV-2&#46; A&#8212; Posterior-anterior chest X-ray&#58; slight opacity in the periphery of the left hemitorax&#44; middle field&#46; B&#8212;Lateral chest X-ray with no obvious findings&#46; C&#8212;DTS&#58; Image no&#46; 8 &#40;anterior&#41;&#46; Extensive opacity in anterior region of left hemitorax &#40;arrows&#41;&#46; D&#8212;DTS&#58; Image no&#46; 14 &#40;central&#41;&#46; Bilateral pulmonary opacities&#44; in the left suprahilar region &#40;arrow&#41; and right lower lobe &#40;arrow&#41;&#46; E&#8212;DTS&#58; Image no&#46; 36 &#40;posterior&#41;&#46; Oval opacity in retro-cardiac region &#40;arrow&#41;&#46; F&#8212;Non-contrast chest CT scan&#44; sagittal reconstruction&#46; Oval opacity in the periphery of the left lower lobe &#40;arrow&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The outbreak of coronavirus disease &#40;COVID-19&#41; caused by severe acute respiratory syndrome-coronavirus-2 &#40;SARS-CoV-2&#41;&#44; emerged in China in late 2019 and was declared a pandemic by the World Health Organization on March 11&#44; 2020&#46; By May 4&#44; 215 countries had already been affected&#44; and more than 3 million cases had been confirmed worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This virus&#44; a member of the Coronaviridae family&#44; uses a spike protein to enter into the cell by binding to the angiotensin-converting enzyme 2 expressed in nasal&#44; oral&#44; lung&#44; and colon cells&#44; amongst other tissues&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">To address this global emergency and facilitate the overall management of this pandemic&#44; the scientific community and health professionals are working on the development of new treatments and technologies to enable early diagnosis&#46; The role of chest imaging&#44; specifically radiography &#40;X-ray&#41; and computed tomography &#40;CT&#41;&#44; in the management of patients with suspected COVID-19 should be established taking into account factors such as respiratory disease severity&#44; pretest probability of the disease&#44; and the availability of resources&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Currently&#44; neither X-ray nor CT are recommended diagnostic criteria for COVID-19&#46; The only accepted diagnostic method is viral screening&#44; with the limitation that quantitative PCR results are only available after 6&#8211;48&#8239;h&#46; Therefore&#44; although viral testing is still required even when radiological findings are consistent with the disease&#44; radiological imaging findings should be taken into consideration to establish a suspected diagnosis aimed at providing a more efficient triage not only involves screening of patients but also decision like quarantine the patients&#44; admit them etc&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Most publications support the accuracy of CT in detecting viral pneumonia&#44; even in asymptomatic patients&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In patients with a high clinical probability of COVID-19 who are positive on CT but with a negative PCR test&#44; this imaging technique can be viewed as a screening tool&#44; and a repeat PCR is indicated&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The characteristic radiological findings of COVID-19 on CT include multiple peripheral pulmonary opacities&#44; with frequent bilateral involvement&#44; distributed predominantly in basal and posterior regions&#46; X-ray reveals similar characteristics&#44; but the sensitivity of CT is superior&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">No uniform criteria are available to guide the radiological evaluation of viral pneumonia in the context of a pandemic&#46; The choice of imaging techniques is based not only on the properties of imaging techniques themselves&#44; but also on the resources of the hospital&#44; the availability of viral testing&#44; expertise&#44; and ultimately depends on the judgement of the team of professionals directly involved in the management of these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Digital tomosynthesis &#40;DTS&#41; of the chest is a technique that provides multiple anatomical images in a single scan&#46; DTS shares some CT advantages and&#44; although less sensitive&#44; requires a lower dose of radiation &#40;CT vs&#46; DTS&#44; 49&#215;&#41;&#44; and reduces costs&#46; Aditionally&#44; it alsohas several advantages over chest X-ray&#58; 1&#41; it improves lesion detection by reducing artifacts caused by overlapping anatomical structures&#59; 2&#41; it facilitates 3-dimensional localization&#59; 3&#41; it offers improved contrast resolution&#59; and 4&#41; it is more sensitive&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#8211;15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">DTS consists of a conventional X-ray tube&#44; the movements of which are controlled from the console&#44; a detector panel and reconstruction algorithms that produce tomographic images&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Up to 60 low-dose exposures are obtained during each pass&#46; The data acquired are reconstructed in a group of coronal images of the chest&#44; parallel to the detector plane&#44; which can be reviewed sequentially in DICOM format on any standard workstation connected to the PACS&#46; All DTS include a conventional PA projection in addition to the tomograms&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The role of digital tomography in the assessment of infectious lung disease is not yet established&#44; although its efficacy in detecting pulmonary nodules and screening for breast cancer has been described&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In our radiology department&#44; DTS has been proposed as a preferred initial imaging technique for evaluating acute respiratory disease in patients with suspected COVID-19&#46; To date&#44; 62&#37; of patients admitted with COVID-19 confirmed by quantitative PCR &#40;n&#8239;&#61;&#8239;97&#59; 56 men and 41 women&#41; had baseline DTS&#44; and the remaining 38&#37;&#44; who presented a worse clinical condition underwent chest X-ray&#46; When the DTS radiological reports were classified according to the probability of COVID-19 as&#58; 1&#41; low&#59; 2&#41; intermediate&#59; 3&#41; high&#59; or 4&#41; no radiological alterations&#44; we found that the results of 53&#37; of the DTS performed prior to viral testing were highly probable and only 6&#37; were normal&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In total&#44; 13&#37; of PCR-positive patients were admitted after their second DTS because they did not initially meet clinical admission criteria&#46; In all cases&#44; progressive pulmonary opacities were observed on DTS&#44; in addition to worsening symptoms and clinical laboratory markers&#46; Four cases were reported as low probability in the first DTS and high probability in the second&#59; 2 patients had normal initial DTS and high probability in the second&#59; and another 2 cases were reported as low probability in the first DTS and intermediate probability in the second&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Our recent experience reporting DTS in patients with suspected COVID-19 suggests that this technique is more useful when pulmonary opacities are subtle and therefore more difficult to identify by X-ray&#46; It also facilitates the detection of multiple peripheral opacities&#44; confirming bilateral involvement in many cases&#59; characteristics that&#44; as already mentioned&#44; are associated with COVID-19&#46; In this respect&#44; DTS is more specific than chest X-ray in this disease&#46; By providing a series of coronal slices&#44; pulmonary opacities that may be faint or posterior can be more accurately located than with lateral X-ray &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; &#40;annex&#44; Supplementary Figs&#46; 1 and 2&#41;&#46; It is not a matter of opinion&#46; It is a conclusion generated by what was experienced with these patients&#46; The main limitation of this technique is the respiration-mediated artifacts caused by the difficulty of some patients in holding their breath during the examination&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Although more studies are needed to consolidate the utility of DTS in a scenario with high clinical suspicion for COVID-19&#44; it seems reasonable that a DTS positive for disease could obviate the need for CT&#46; In this context&#44; DTS use as primary imaging technique not only relieves the pressure on CT rooms&#44; but also reduces the radiation dose delivered to patients&#46; In conclusion&#44; our preliminary results suggest that DTS may play an important role in the initial evaluation of patients with suspected COVID-19&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Calvo I&#44; SantaCruz-Calvo S&#44; Aranzana MG&#44; M&#225;rmol P&#44; Luque J&#193;&#44; Ramos F&#44; et al&#46; Tomograf&#237;a Digital y COVID-19&#58; un avance en la valoraci&#243;n de opacidades pulmonares&#46; Arch Bronconeumol&#46; 2020&#59;56&#58;761&#8211;763&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Bilateral COVID-19 pneumonia&#46; A 52-year-old man&#44; family doctor by profession&#44; presented with a 10-day history of cough and myalgia&#46; Dyspnea and fever on examination&#46; Laboratory tests&#58; normal white cell count&#44; ferritin 545&#46;7&#8239;ng&#47;mL &#40;&#62;322&#41;&#44; and erythrocyte sedimentation rate 53&#8239;m&#47;n &#40;0&#8211;20&#41;&#46; PCR positive for SARS-CoV-2&#46; A&#8212; Posterior-anterior chest X-ray&#58; slight opacity in the periphery of the left hemitorax&#44; middle field&#46; B&#8212;Lateral chest X-ray with no obvious findings&#46; C&#8212;DTS&#58; Image no&#46; 8 &#40;anterior&#41;&#46; Extensive opacity in anterior region of left hemitorax &#40;arrows&#41;&#46; D&#8212;DTS&#58; Image no&#46; 14 &#40;central&#41;&#46; Bilateral pulmonary opacities&#44; in the left suprahilar region &#40;arrow&#41; and right lower lobe &#40;arrow&#41;&#46; E&#8212;DTS&#58; Image no&#46; 36 &#40;posterior&#41;&#46; Oval opacity in retro-cardiac region &#40;arrow&#41;&#46; F&#8212;Non-contrast chest CT scan&#44; sagittal reconstruction&#46; Oval opacity in the periphery of the left lower lobe &#40;arrow&#41;&#46;</p>"
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Article information
ISSN: 15792129
Original language: English
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