et al. with the exception of a pre-symptomatic phase. 7 CT findings begin as single or multifocal ground-glass opacities, pulmonary nodules, or air bronchograms, which progress with development of interlobular septal thickening and crazy paving, before regression in both size and density at the end of the second week of infection. Opacities often have extensive distribution, typically bilaterally, but also seen unilaterally, with occasional round morphology or reversed-halo or atoll sign. 5 In the dissipation phase, there may be continued patchy consolidative opacities in addition to reticular "strip-like" opacities, bronchial wall thickening, and interlobular septal thickening. 1,8 The characteristic ultrasound findings (bilateral and multilobar B-lines, subpleural consolidates, irregular pleural line, and decreased blood flow 3,4,9 ) have been shown to be highly consistent with CT findings 3,4 and can be expected to develop over a similar timeline. During the first few days of symptom presentation, scattered unilateral or bilateral multilobar B-lines can be visualised. 3,9 As the disease progresses from the end of week 1 through week 2, development of alveolar interstitial syndrome with diffuse, bilateral B-lines can occur in addition to an irregular pleural line with punctate defects and formation of subpleural consolidations with visible air bronchograms. Lastly, after the end of week 2 during convalescence, there can be an expected regression of prior findings with re-emergence of A-lines. 9 A summary of findings is listed in Table 1.Although the literature remains limited, there is still a clear benefit for clinicians to be familiar with ultrasound findings and their progression in COVID-19 patients. It may be particularly useful in helping emergency personnel to triage and diagnose suspected patients, 4 but also for monitoring progression of the disease throughout hospitalisation. Additionally, it offers substantial benefits in comparison to CT imaging, including portability, lower cost, reduced radiation, and ease of sterilisation. Physicians are encouraged to be familiar with and to utilise lung ultrasound in the management of COVID-19 patients.
To compare the prognostic value and reproducibility of visual versus AI-assisted analysis of lung involvement on submillisievert low-dose chest CT in COVID-19 patients. Materials and Methods: This was a HIPAA-compliant, institutional review board-approved retrospective study. From March 15 to June 1, 2020, 250 RT-PCR confirmed COVID-19 patients were studied with low-dose chest CT at admission. Visual and AI-assisted analysis of lung involvement was performed by using a semi-quantitative CT score and a quantitative percentage of lung involvement. Adverse outcome was defined as intensive care unit (ICU) admission or death. Cox regression analysis, Kaplan-Meier curves, and cross-validated receiver operating characteristic curve with area under the curve (AUROC) analysis was performed to compare model performance. Intraclass correlation coefficients (ICCs) and Bland-Altman analysis was used to assess intra-and interreader reproducibility. Results: Adverse outcome occurred in 39 patients (11 deaths, 28 ICU admissions). AUC values from AI-assisted analysis were significantly higher than those from visual analysis for both semiquantitative CT scores and percentages of lung involvement (all P<0.001). Intrareader and interreader agreement rates were significantly higher for AI-assisted analysis than visual analysis (all ICC 0.960 versus 0.885). AI-assisted variability for quantitative percentage of lung involvement was 17.2% (coefficient of variation) versus 34.7% for visual analysis. The sample size to detect a 5% change in lung involvement with 90% power and an error of 0.05 was 250 patients with AI-assisted analysis and 1014 patients with visual analysis. Conclusion: AI-assisted analysis of lung involvement on submillisievert low-dose chest CT outperformed conventional visual analysis in predicting outcome in COVID-19 patients while I n p r e s s 3 reducing CT variability. Lung involvement on chest CT could be used as a reliable metric in future clinical trials.
Immune checkpoint inhibition has improved the clinical outcomes for numerous patients with cancer. However, the downside is a whole new spectrum of immune-related adverse events. We report a 68-year-old man with a history of nonsmall cell lung cancer presenting with a spontaneous corneal perforation in the right eye after 22 cycles of pembrolizumab. In addition, a chronic central nonhealing epithelial defect developed after performing a penetrating keratoplasty. Treatment with autologous serum drops resulted in complete healing of the corneal ulcer, where other conventional therapies had no effect. One month after reinitiating pembrolizumab therapy, our patient presented again with a corneal perforation in the fellow eye. This case describes relapsing sterile ulcerations associated with pembrolizumab use and presents an unexpected cure.
In the past decade, the approach to patients with metastatic non-small-cell lung cancer has relied on chemotherapy and on targeted agents for molecularly selected subgroups of patients. Recent work has introduced immunotherapy as another area of progress, and likely as a new treatment paradigm in the near future. While the large Phase III studies with cancer vaccination with the current technologies remain at present disappointing, the immunomodulation strategies with immune checkpoint inhibitors have delivered remarkable results in expanded Phase I studies and are now intensively studied in large Phase III studies. This review summarizes the past decade of immunotherapy for non-small-cell lung cancer, gives an updated overview of trials in this field, and the context of future development in this exciting field.
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