A potential link between mortality, D-dimer values and a prothrombotic syndrome has been reported in patients with COVID-19 infection. The National Institute for Public Health of the Netherlands asked a group of Radiology and Vascular Medicine experts to provide guidance for the imaging workup and treatment of these important complications. This report summarizes evidence for thromboembolic disease, potential diagnostic and preventive actions as well as recommendations for patients with COVID-19 infection.

iffuse idiopathic skeletal hyperostosis (DISH) is a condition characterized by the formation of new bone along the anterolateral spinal column (1). The lower thoracic spine is most frequently affected, and ossifications of peripheral entheses are also frequently present in DISH (1,2). The prevalence of DISH varies between 2.9% and 42.0%, depending on the criteria used, demographic background, and presence of associated factors (3-6). Risk factors for developing DISH are older age, metabolic derangement (hypertension, obesity, diabetes mellitus), and cardiovascular disease (1,4). The pathogenesis of DISH is unknown (1). The three criteria established by Resnick and Niwayama are the criteria most frequently used for the diagnosis of DISH and include bridging of four adjacent vertebral bodies by newly formed bone, without severe loss of the intervertebral disk height and without degeneration of the apophyseal and sacroiliac joints (3,7). The Resnick and Niwayama criteria were designed so as to include only "definite" cases of DISH in their study, excluding other spinal pathologies such as ankylosing spondylitis (7). As a consequence, the threshold criteria for DISH are high and therefore possibly reflect a late or even end stage of DISH (3). Longitudinal research on the natural course of DISH has exposed a process of slow, ongoing formation of new bone (8-10). Over time, the number of affected vertebral body segments increases

ObjectiveTo evaluate and improve the interobserver agreement for the CT-based diagnosis of diffuse idiopathic skeletal hyperostosis (DISH).MethodsSix hundred participants of the CT arm of a lung cancer screening trial were randomly divided into two groups. The first 300 CTs were scored by five observers for the presence of DISH based on the original Resnick criteria for radiographs. After analysis of the data a consensus meeting was organised and the criteria were slightly modified regarding the definition of ‘contiguous’, the definition of ‘flowing ossifications’ and the viewing plane and window level. Subsequently, the second set of 300 CTs was scored by the same observers. κ ≥ 0.61 was considered good agreement.ResultsThe 600 male participants were on average 63.5 (SD 5.3) years old and had smoked on average 38.0 pack-years. In the first round κ values ranged from 0.32 to 0.74 and 7 out of 10 values were below 0.61. After the consensus meeting the interobserver agreement ranged from 0.51 to 0.86 and 3 out of 10 values were below 0.61. The agreement improved significantly.ConclusionsThis is the first study that reports interobserver agreement for the diagnosis of DISH on chest CT, showing mostly good agreement for modified Resnick criteria.Key Points• DISH is diagnosed on fluoroscopic and radiographic examinations using Resnick criteria • Evaluation of DISH on chest CT was modestly reproducible with the Resnick criteria • A consensus meeting and Resnick criteria modification improved inter-rater reliability for DISH • Reproducible CT criteria for DISH aids research into this poorly understood entity

idiopathic skeletal hyperostosis (DISH) is a common incidental finding on medical imaging and often thought to be benign.• Subjects with DISH have more CAC as a reflection of coronary atherosclerosis.• DISH is usually observed as an incidental finding on imaging and may be an important finding to stimulate assessment of occult cardiovascular disease.

A potential link between mortality, D-dimer values and a prothrombotic syndrome has been reported in COVID-19 patients. The National Institute for Public Health of the Netherlands published a report for guidance on diagnosis, prevention and treatment of thromboembolic complications in COVID-19 with a new vascular disease concept. The analysis of all available current medical, laboratory and imaging data on COVID-19 confirms that symptoms and diagnostic tests can not be explained by impaired pulmonary ventilation. Further imaging and pathological investigations confirm that the COVID-19 syndrome is explained by perfusion disturbances first in the lung, but consecutively in all organs of the body. Damage of the microvasculature by SARS 1 and SARS 2 (COVID-19) viruses causes microthrombotic changes in the pulmonary capillaries and organs leading to macrothrombosis and emboli. Therefore anticoagulant profylaxis, close lab and CT imaging monitoring and early anticoagulant therapy are indicated.

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