When Will It Show Again Ct

* X.H. and Y.F. contributed as to this work.

Summary

This prospective longitudinal study found that approximately one-3rd of participants showed chest CT findings with pulmonary fibrosis-like changes inside half-dozen months of recovery from severe coronavirus affliction 2019 pneumonia.

Key Results

• ■ Approximately one-3rd of participants (40 of 114, 35%) recovered from astringent coronavirus illness 2019 developed fibrotic-like changes in the lung within 6 months of disease onset.

• ■ Older age (>50 years), astute respiratory distress syndrome, and higher baseline CT lung involvement score (≥18 out of a possible score of 25) were associated with fibrotic-similar changes in the lung.

• ■ Twenty-seven of 104 participants (26%) had an abnormal diffusing chapters of the lung for carbon monoxide, or DLco, at 6-month follow up, which more frequently occurred in participants with fibrotic-like changes in the lung than in those without fibrotic-like changes.

Introduction

Coronavirus disease 2019 (COVID-xix), caused by severe acute respiratory syndrome coronavirus 2, or SARS-CoV-2, has become a global pandemic. As of November 19, 2020, this disease has been found in more than 200 countries, with 55 659 785 confirmed cases and 1 338 769 deaths (1). Pathology studies (2,3) have shown that COVID-19 causes injuries in multiple organs and tissues, with extensive pulmonary involvement similar to that found in other coronavirus infections (ie, severe acute respiratory syndrome coronavirus and Middle East respiratory syndrome coronavirus infection).

Chest CT plays a crucial function in the diagnosis and follow-up of patients with COVID-19 pneumonia. Numerous studies have documented radiographic changes in the acute form of COVID-19, which range from mild to severe cases (4–vii). Recent publications (8,9) accept found that approximately 94% of hospitalized patients take persistent lung parenchymal findings on their belch CT scans. In addition, Liu et al (10) reported that lung opacities in 53.0% of patients with mild COVID-19 resolved with no adverse sequelae inside 3 weeks afterwards discharge. Information from previous coronavirus infections (ie, severe acute respiratory syndrome and Heart E respiratory syndrome) suggest that in that location may be substantial fibrotic consequences in patients with COVID-nineteen (11–13). Nonetheless, little is known about the long-term lung changes after COVID-xix infection. The purpose of this study was to evaluate pulmonary changes on half-dozen-calendar month follow-upward breast CT scans and to explore the take a chance factors for fibrotic-like changes in the lung in patients who recovered from astringent COVID-19 pneumonia.

Materials and Methods

Study Design and Participants

This prospective study obtained ethical approval from the ethics commissions of Wuhan Jinyintan Hospital and Wuhan Matrimony Hospital. All participants remained anonymous, and written informed content was caused. This trial was registered with the Chinese Clinical Trial Registry with identifier ChiCTR2000038609.

We prospectively enrolled 114 patients with astringent COVID-19 who had been discharged from the hospital after treatment for COVID-19 as inpatients between December 25, 2019, and February 20, 2020, at our institutions (Wuhan Jinyintan Hospital, n = 69; Wuhan Union Hospital, n = 45) (Fig ane). Throat swab samples were collected for confirmation of severe acute respiratory syndrome coronavirus 2 with a contrary-transcription polymerase chain reaction examination (Sansure Biotech) as previously described (xiv,15). The World Health Organization's acting guidance diagnostic criteria for adults with severe COVID-xix pneumonia were used (16). The discharge criteria were based on the sixth edition of the "Pneumonia Diagnosis and Treatment Plan for New Coronavirus Infection" in Cathay (17).

Figure 1: Participant flow diagram. COVID-19 = coronavirus disease 2019, RT-PCR = reverse-transcription polymerase chain reaction, SARS-CoV-two = astringent acute respiratory syndrome coronavirus 2, SpO2 = oxygen saturation as measured by pulse oximetry.

Effigy 1:

The medical records of each participant were reviewed past one of iv physicians (Y.50., X.H., North.L., or 10.J., with 7, 5, 4, and 3 years of experience in thoracic radiology, respectively). Age, sex, underlying comorbidities, onset of symptoms, height acute phase laboratory results, and the treatments received by individual patients were recorded. The durations from the onset of disease to infirmary access and breast CT were reviewed. The Berlin definition of astute respiratory distress syndrome (ARDS) was used (18).

The initial CT scans in each participant were obtained at access. Within ane week of the follow-upwards CT scans, 104 patients underwent standard pulmonary role testing for maximum vital capacity, forced expiratory volume in 1 second, forced vital capacity, diffusing capacity of the lung for carbon monoxide (DLco), and DLco divided by the alveolar volume measured in a single breath examination. The results were compared with those in historic period- and sex-matched control participants and reported every bit percentages of predicted values. Pulmonary diffusion was regarded as abnormal when DLco was less than 80% of the predicted value.

CT Image Acquisition and Interpretation

The initial CT examinations were performed with the patient in the supine position with i of two CT scanners: Somatom Definition Every bit+ or Somatom Perspective (Siemens Healthineers). Nonenhanced chest CT was performed with the acquisition from the thoracic inlet to the diaphragm. The post-obit parameters were used: detector collimation width of 64 × 0.6 mm or 128 × 0.six mm and a tube voltage of 120 kV. The tube current was regulated by an automatic exposure command system (Care Dose 4D, Siemens Healthineers). Images in 62 of the 114 patients (54%) were reconstructed with a section thickness of 5 mm and an interval of 5 mm. Images in 52 of the 114 patients (46%) were reconstructed with a section thickness of ane mm and an interval of ane mm. Images were reconstructed with a pulmonary B70f kernel and a mediastinal B30f kernel (Somatom Definition AS+) or a pulmonary B80s kernel and a mediastinal B30s kernel (Somatom Perspective).

All 114 patients underwent follow-upwards CT examinations using the same scanners used for the initial CT scans. Images in all patients were reconstructed with a section thickness of 1 mm and an interval of 1 mm. Before the prospectively planned six-month follow-up examination, 83 of the 114 patients (73%) underwent CT 3 months later on symptom onset to monitor the development of their lung disease.

All CT images were reviewed in random gild past iii senior cardiothoracic radiologists (H.Due south., Y.F., and J.1000., with 31, 13, and 10 years of feel in thoracic radiology, respectively) who were not aware of any clinical or laboratory findings or patient outcomes. The readers independently assessed the CT features using axial and multiplanar reconstructed images. The mediastinal window (center, l HU; width, 350 HU) and lung window (eye, −600 HU; width, 1200 HU) were obtained from the pic archiving and advice organisation (Vue PACS, version 11.3.5.8902; Carestream Health). Afterwards independent evaluation, the radiologists resolved whatever disagreement with word and consensus. For each patient with severe pneumonia, the predominant CT patterns co-ordinate to the Fleischner Society glossary (xix) were enumerated as follows: ground-drinking glass opacities (GGO), consolidation, reticulation, emphysema, thickening of the adjacent pleura, pleural effusion, presence of nodules or masses, honeycombing, bronchiectasis, and interlobar pleural traction (retraction of the interlobar pleura toward the lesions). The CT evidence of fibrotic-like changes was divers as the presence of traction bronchiectasis, parenchymal bands (12,20), and/or honeycombing (19) (Fig two).

Figure 2: Follow-up chest CT findings of coronavirus disease 2019 pneumonia. Scans prove, A, traction bronchiectasis (arrow), B, parenchymal bands (pointer), C, honeycombing, and, D, E, thickening of the adjacent pleura (pointer).

Figure ii:

To quantify the extent of pulmonary abnormalities (full lesions, GGO, consolidation, reticulation, and fibrotic-like changes), a semiquantitative CT score (21) was assigned on the ground of the area involved in each of the five lung lobes, as follows: 0, no involvement; 1, less than 5% involvement; 2, v%–25% involvement; iii, 26%–49% involvement; four, 50%–75% involvement; and 5, greater than 75% involvement. The full CT severity score was calculated past summing the private lobar scores, with possible scores ranging from 0 to 25.

Statistical Analysis

The analyses were performed using software (SAS, version ix.four; SAS Constitute). The Kolmogorov-Smirnov test was used to assess the normality of continuous data. Normally and nonnormally distributed data and categorical variables are presented as means ± standard deviations, medians with interquartile ranges (IQRs), and numbers with percentages, respectively. Betwixt-group differences in categorical variables were assessed using the Fisher exact test, and continuous variables with normally and nonnormally distributed data were assessed using the 2-sample t test or Isle of man-Whitney U examination, respectively. P values for multiple univariate testing on acute phase data were adjusted by using the Benjamini-Hochberg method. A cutoff CT score value of 18 was selected as suggested in a recent investigation (22), which indicated that a chest CT score of 18 or greater was correlated with disease severity and increased bloodshed risk in patients with COVID-19 pneumonia. Multiple logistic regression analyses were performed to place the independent predictive factors of fibrotic-like changes. The final model was determined using stepwise logistic regression, with significance level for option set at P = .05. Factors associated with the CT score of fibrotic-like changes were analyzed by calculating the Spearman correlation coefficient. Statistically significant difference was considered at P < .05 (2 tailed).

Results

Demographic and Participant Characteristics

A total of 114 participants (fourscore men, 34 women; mean age, 54 years ± 12; age range, 24–82 years) were included (Table 1). The initial and follow-upwardly scans were obtained a mean of 17 days ± 11 and 175 days ± 20 after disease onset, respectively. Evidence of fibrotic-like changes was observed on follow-upwards CT scans (Fig 3) in 40 of the 114 participants (35%) (group ane); 38 of those twoscore participants (95%) had de novo fibrotic abnormalities. The remaining 74 participants (65%) (group ii) showed either consummate radiologic resolution (43 of 114, 38%) (Fig 4) or residual GGO or interstitial thickening (31 of 114, 27%) (Fig v).

Table ane: Comparing of Demographic and Clinical Characteristics between Groups

Figure 3: Serial CT scans in a 46-year-old woman with severe coronavirus disease 2019 pneumonia. A–C, Scans obtained on day 32 subsequently symptom onset show multiple ground-drinking glass opacities and interstitial thickening with balmy cylindrical traction bronchiectasis involving the centre lobe and lower lobe of the right lung. D–F, Scans obtained on day 198 show partial absorption of the abnormalities, reduced extension, traction bronchiectasis (arrows in D and E), and localized "honeycombing" (arrow in F) in the subpleural region of the right heart lobe.

Effigy 3:

Figure 4: Serial CT scans in a 63-year-onetime man with emphysema and severe coronavirus disease 2019 pneumonia. A, Axial CT scan obtained on day 27 after onset of symptoms shows multiple ground-drinking glass opacities in the subpleural right lung. B, Scan obtained on day 72 shows obvious absorption of the abnormalities. C, Browse obtained on 24-hour interval 164 shows complete resolution.

Figure 4:

Effigy 5: Serial sparse-department CT scans in a 57-year-old homo with astringent coronavirus disease 2019 pneumonia. A, Axial and, B, coronal CT scans obtained on day nine after the onset of symptoms show extensive ground-glass opacities (GGO) and interstitial thickening bilaterally. C, Centric and, D, coronal scans obtained on day 46 show evolution to a mixed pattern of GGO and consolidation with almost the same extent of lesions. Due east, Axial and, F, coronal scans obtained on day 159 evidence a marked decrease in the attenuation of GGO, with a slightly increased extension of the GGO ("tinted" sign or "melting saccharide" sign, which is defined as an imaging advent of increased extension of the GGO or consolidation and decreased attenuation).

Figure five:

After correction for multiple comparisons (Tabular array one), participants in grouping 1 were significantly older than those in group two (mean age, 60 years ± 12 vs 51 years ± 11, respectively; P = .003), had a college heart rate at access (mean, 96 beats per infinitesimal ± 16 vs 87 beats per minute ± 12; P = .03), and had a greater frequency of ARDS (63% [25 of 40 participants] vs 8.ane% [six of 74 participants], P < .001) and other comorbidities (73% [29 of xl of participants] vs 41% [30 of 74 participants], P = .01), particularly chronic pulmonary illness (28% [11 of 40 participants] vs six.8% [v of 74 participants], P = .02). The median infirmary stay was longer for participants in group 1 than those in group two (27 days [IQR, 26] vs 15 days [IQR, 8], P < .001). With regard to treatment, participants in group one were more likely to receive glucocorticosteroids (53% [21 of twoscore] vs twenty% [fifteen of 74], P = .01) and noninvasive mechanical ventilation (45% [18 of 40] vs 8.1% [half-dozen of 74], P < .001) than participants in group 2.

Comparison of Tiptop Laboratory Findings

After correction for multiple comparisons (Table two), the laboratory findings showed significantly college peak levels of hypersensitive C-reactive protein (median, 80 mg/L [IQR, 124] vs 26 mg/L [IQR, 76], P = .03) and d-dimer (median, 8.7 mg/Fifty [IQR, 33] vs 1.0 mg/50 [IQR, ane.five], P < .001) in group 1 than in group 2.

Table 2: Comparison of Peak Laboratory Findings between Groups

Comparison of Initial CT Findings and Scores

The initial CT scans were obtained a mean of 17 days ± 11 after the onset of symptoms, with no difference betwixt the two groups (19 days ± 11 for group 1 vs 16 days ± 11 for group 2; P > .99) (Table 3). The overall median total CT score was xv (IQR, 9). Afterwards correction for multiple comparisons, participants in group 1 had significantly higher scores for full lesions (median, 20 [IQR, five.5] vs 13 [IQR, 7]; P < .001) and GGO (median, 16 [IQR, ten] vs 10 [IQR, 8]; P = .02) than participants in grouping 2 (Tabular array 3). Thickening of the adjacent pleura was more than common in grouping 1 than in group 2 (55% [22 of 40 participants] vs 24% [xviii of 74 participants], P = .02) (Fig 2).

Table 3: Comparison of Initial CT Findings and Scores between Groups

Factors Associated with Fibrotic-Like Changes in the Lung

The multivariable analysis identified an historic period of older than 50 years (odds ratio [OR]: 8.five; 95% CI: 1.9, 38; P = .01), middle rate greater than 100 beats per infinitesimal at admission (OR: 5.6; 95% CI: ane.1, 29; P = .04), hospital stay of 17 days or more (OR: five.5; 95% CI: ane.5, 21; P = .01), ARDS (OR: 13; 95% CI: 3.3, 55; P < .001), noninvasive mechanical ventilation (OR: 6.3; 95% CI: 1.iii, thirty; P = .02), and full CT score of 18 or greater on initial CT scans (OR: four.2; 95% CI: 1.2, 14; P = .02) as independent predictors of fibrotic-like changes in the lung (Tabular array 4).

Table 4: Univariable and Multivariable Analysis of Predictors of Fibrotic-Like Changes in the Lung in Survivors of Severe Coronavirus Affliction 2019

Scores for Fibrotic-Like Changes

According to the Spearman correlation analysis (Table E1 [online]), the score for fibrotic-like changes was correlated with age (r = 0.32, P < .001), middle charge per unit at admission (r = 0.24, P = .01), hospital stay (r = 0.49, P < .001), ARDS (r = 0.57, P < .001), elevation hypersensitive C-reactive protein level (r = 0.37, P < .001), peak d-dimer level (r = 0.59, P < .001), noninvasive mechanical ventilation (r = 0.49, P < .001), total CT score (r = 0.47, P < .001), and CT score for GGO (r = 0.38, P < .001). In all participants, the CT score for fibrotic-like changes at half dozen-month follow-upwardly CT was significantly increased from that at initial CT (median, 0 [range, 0–iv; IQR, 0] vs 0 [range, 0–eighteen; IQR, iv]; P < .001) (Tabular array E2 [online]). In improver, the median score for fibrotic-like changes in participants in grouping i at half-dozen-month follow-up CT was 6 (range, 2–18; IQR, 5).

Comparing of CT Findings and Scores between Initial and Follow-up Scans

A significant decrease in the CT scores for full lesions (P < .001), GGO (P < .001), and consolidation (P < .001) was observed in all participants (Table E2 [online]). Compared with the initial CT scans, follow-up scans had a significantly higher frequency of nodules or masses (1.8% [ii of 114] vs 17% [xix of 114], P < .001), interlobar pleural traction (seven.nine% [nine of 144] vs 17% [nineteen of 114], P = .04) (Fig 6), pulmonary atelectasis (3.v% [four of 114] vs xi% [13 of 114], P = .02) (Fig E1 [online]), and bronchiectasis (vii.0% [eight of 114] vs 24% [27 of 114], P < .001), whereas pleural effusion was completely resorbed (half-dozen.1% [7 of 114] vs 0% [0 of 114], P = .01).

Effigy 6: Series sparse-section CT scans in a 52-year-old man with severe coronavirus disease 2019 pneumonia. A, Axial CT scan obtained on day 8 later symptom onset shows multiple ground-glass opacities bilaterally, with a slight traction of the right interlobar pleural (arrow). B, C, Scans obtained on days 79 and 149, respectively, show continuous assimilation of previous opacifications, with the progression of interlobar pleural traction.

Figure 6:

Time Points of Occurrence of Fibrotic-Like Changes or Complete Resolution

In group 1 (participants who exhibited fibrotic-like lung changes), two of the forty participants (5%) showed the fibrotic-similar changes on initial CT scans. Fibrotic-like changes were seen on follow-upwards scans in 16 of the 37 participants (43%) who presented for 3-calendar month follow-up and 22 of the twoscore participants (55%) who presented for 6-month follow-upwardly. In group 2, of the 43 participants (58%) who demonstrated complete resolution of CT abnormalities, 20 of the 34 participants (59%) who presented for follow-upwardly showed resolution at iii months, and the remaining 23 of 43 (53%) showed resolution at the half-dozen-calendar month follow-up (Table E3 [online]).

Follow-upward Findings

At vi-calendar month follow-upwards (Table E4 [online]), seven of the 114 participants (six.1%) were yet reporting dry out cough, 11 (ten%) had expectoration, and 16 (xiv%) experienced slight dyspnea on exertion. Participants in group 1 with fibrotic-like changes in the lung more commonly experienced dry out cough (P = .03) than participants in group 2. Of the 104 participants who underwent pulmonary function testing, 27 (26%) presented with aberrant pulmonary diffusion (DLco <fourscore% predicted), with participants in group one more than often presenting with improvidence abnormalities than those in grouping ii (50% [18 of 36] vs 13% [nine of 68], respectively; P < .001).

Discussion

In our study, 40 of 114 participants (35%) who recovered from severe coronavirus disease 2019 pneumonia developed fibrotic-like changes in the lung within 6 months; in this grouping, most of the fibrotic-like changes (22 of 40 [55%]) manifested at six-month follow-up CT. Using multivariable analysis, we establish that age older than 50 years (odds ratio [OR]: 8.5; 95% CI: one.9, 38; P = .01), centre rate greater than 100 beats per minute at admission (OR: 5.vi; 95% CI: ane.one, 29; P = .04), infirmary stay of 17 days or more (OR: 5.5; 95% CI: 1.five, 21; P = .01), acute respiratory distress syndrome (OR: xiii; 95% CI: iii.three, 55; P < .001), noninvasive mechanical ventilation (OR: vi.three; 95% CI: one.3, xxx; P = .02), and a total chest CT score of eighteen or greater on initial CT scans (OR: 4.ii; 95% CI: one.ii, 14; P = .02) were independent predictors of the subsequent evolution of fibrotic-like changes in the lung after 6-month follow-up.

Participants with fibrotic-similar changes in the lung showed a college frequency of ARDS (25 of forty [63%]), which was also a predictor of fibrotic-like changes. Previous studies (23,24) have demonstrated that a substantial proportion of patients who survive ARDS may develop progressive fibrotic-like changes on CT scans. Nevertheless, it remains uncertain whether the fibrotic-similar changes observed in this study represent true fibrotic lung disease (eg, at pathologic examination or longer-term follow-upward CT). Whether or not these fibrotic-like changes, found at vi months, reflect permanent change in the lung remains to be investigated. Additionally, in our written report, the high frequency of noninvasive mechanical ventilation is another take chances cistron for the development of fibrotic-like changes at vi months. On the basis of previously published data (24), mechanical ventilation is strongly related to fibrotic-like changes observed after ARDS. Likewise, the fibrotic-like changes in the lung in our patients may also be associated with ventilator-induced lung injury. The laboratory results also demonstrated college d-dimer and hypersensitive C-reactive protein levels in patients with pulmonary fibrotic-like changes. Emerging prove of coagulopathy and an overexuberant inflammatory response has been reported in patients with severe COVID-19 (25,26); these findings are associated with affliction severity and may also lead to greater damage to the pulmonary parenchyma.

We establish that a higher CT score (≥xviii) at the initial CT examination was an independent prognostic factor for the presence of fibrotic-like changes at the six-month follow-up test. According to a previous study on idiopathic pulmonary fibrosis (27), CT score is correlated with the degree of pulmonary fibrosis in pathologic specimens. Moreover, a recent publication revealed an clan between a CT score of 18 or greater and an increased mortality take chances in patients with COVID-xix (22). Therefore, a greater extent of lung injury in the astute phase may be associated with a college mortality rate and more severe pulmonary sequelae in survivors. In addition, the correlations of scores for fibrotic-similar changes with the aforementioned take a chance factors were also confirmed in our study.

At six-month follow-upwards, a few patients notwithstanding reported ongoing respiratory symptoms, and 26% of patients had pulmonary improvidence abnormalities, which more than frequently occurred in patients with fibrotic-like changes. Thus, both structural and functional lung impairments may simultaneously occur in patients who survive severe COVID-nineteen pneumonia. Pregnant decreases in CT scores for total lesions, GGO, and consolidation were observed at follow-up CT compared with the initial CT. Although the predominant CT pattern at follow-upward CT was notwithstanding GGO, the densities had visually decreased, which might follow the "tinted" sign (ten) or "melting sugar" sign (28), defined as an imaging advent of increased extension of the GGO or consolidation and decreased attenuation. Two studies (ten,28) reported an increased extension of the GGO or consolidation and a decreased attenuation at follow-upwards CT of COVID-xix pneumonia, which may indicate the gradual regression of the inflammation and re-expansion of the alveoli. GGO in the acute phase of COVID-19 pneumonia may correspond the inflammatory infiltrates, edema, or hemorrhaging (2,3). Moreover, increased d-dimer levels in the astute stage were associated with pulmonary embolism in patients with COVID-19, which might also account for GGO appearance on the chest CT scans (29,30); however, CT pulmonary angiography was not routinely performed in our patients to analyze this betoken. The pathophysiology underlying GGO in the convalescent phase of COVID-xix pneumonia and the correlation with fibrosis is worthy of farther investigation.

Our study has several limitations. Start, sample size was small-scale, and follow-upward was conducted for merely half dozen months. Patients with fibrotic-like changes crave longer follow-up to determine whether the fibrotic-like changes are permanent, progressive, or reversible. 2d, the extent of fibrotic-similar changes in the lung was not quantified with a computer-based analysis as described in previous research (31). Withal, we have supplied the semiquantitative scores for the fibrotic-like changes, which were shown to exist correlated with the caste of pulmonary fibrosis in pathologic specimens. Third, inter- and intrareader comparison of CT grading was not performed. Fourth, the number of years of smoking was not evaluated in the present study. Fifth, 62 of 114 participants (54%) had a section thickness of 5 mm on the initial scan, in which case subtle findings may be occult or disregarded. Nonetheless, all follow-upwardly CT scans were obtained with thin sections of one mm to assess lung abnormalities. Finally, the lack of a histologic correlation is a limitation. Further studies are warranted to explore whether fibrotic-like changes on CT scans represent true pathologic fibrosis.

In summary, follow-up CT scans obtained within 6 months of illness onset showed fibrotic-like changes in the lung in more than one-third of patients who survived astringent coronavirus illness 2019 pneumonia. These patients were older and had more astringent illness during the acute phase. Even so, the long-term lung sequelae of these CT findings are notwithstanding largely unknown. This report serves every bit a ground for new, prospective, large-scale, long-term investigations analyzing these loftier-risk patients.

Disclosures of Conflicts of Interest: X.H. disclosed no relevant relationships. Y.F. disclosed no relevant relationships. O.A. disclosed no relevant relationships. N.L. disclosed no relevant relationships. Ten.J. disclosed no relevant relationships. M.Y. disclosed no relevant relationships. Y.L. disclosed no relevant relationships. Y.C. disclosed no relevant relationships. J.Chiliad. disclosed no relevant relationships. H.West. disclosed no relevant relationships. H.Due south. disclosed no relevant relationships.

Acknowledgments

We thank all colleagues for helping usa during the current report and all the selfless volunteers who participated in the study. We highly capeesh Hongwei Jiang, PhD (Epidemiology & Biostatistics, Huazhong Academy of Science and Technology), for his assistance in statistical analysis. Nosotros are also very grateful to the many members of the frontline medical staff for their selfless and heroic dedication in the face of this outbreak, despite the potential threat to their own lives and the lives of their families.

Author Contributions

Writer contributions: Guarantors of integrity of entire study, X.H., Y.F., Northward.L., 10.J., M.Y., Y.L., Y.C., J.G., H.South.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; approval of concluding version of submitted manuscript, all authors; agrees to ensure any questions related to the work are appropriately resolved, all authors; literature enquiry, X.H., Y.F., O.A., X.J., Y.Fifty., Y.C., J.G., H.S.; clinical studies, Ten.H., Y.F., O.A., 10.J., One thousand.Y., Y.L., Y.C., J.G., H.S.; experimental studies, X.H., Y.F., X.J., Y.50., Y.C., J.G., H.S.; statistical assay, X.H., Y.F., N.L., X.J., M.Y., Y.Fifty., Y.C., J.G., H.S.; and manuscript editing, X.H., Y.F., O.A., X.J., Y.50., Y.C., J.M., H.Due west., H.Southward.

* X.H. and Y.F. contributed equally to this piece of work.

Supported by the National Natural Science Foundation of China (grant 82071921), Zhejiang Academy special scientific research fund for COVID-19 prevention and control, and Fundamental Research Funds for the Central Universities (grant 2020kfyXGYJ019).

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Received: July xviii 2020
Revision requested: Aug 24 2020
Revision received: Nov 19 2020
Accustomed: Nov 23 2020
Published online: Jan 26 2021
Published in print: Apr 2021

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Source: https://pubs.rsna.org/doi/full/10.1148/radiol.2021203153

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