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      Suboptimal Quality and High Risk of Bias in Diagnostic Test Accuracy Studies on Chest Radiography and Computed Tomography in the Acute Setting of the COVID-19 Pandemic: A Systematic Review

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          Abstract

          Purpose

          Chest imaging techniques have been implemented for screening and diagnosis of COVID-19 patients, based on experience with other viral pneumonias and a handful of COVID-19 diagnostic test accuracy (DTA) studies. We performed a systematic review to synthesize the literature on DTA of chest radiography (CXR), computed tomography (CT) and ultrasound for diagnosis of COVID-19 in suspected patients in hospital setting and evaluated the extent of suboptimal reporting and risk-of-bias.

          Methods

          A systematic search was performed (April 26, 2020) in Embase, Pubmed and Cochrane to identify CXR, CT or ultrasound studies in adult patients with suspected COVID-19, using RT-PCR or clinical consensus as reference standard. 2x2 contingency tables were reconstructed and test sensitivity, specificity, positive predictive values (PPV) and negative predictive values (NPV) re-calculated. Reporting quality was evaluated by adherence to STARD and risk-of-bias by QUADAS-2.

          Results

          Thirteen studies were eligible (CT=12, CXR=1, US=0). Re-calculated CT sensitivity and specificity ranged between 0.57-0.97 and 0.37-0.94, respectively, PPV and NPV between 0.59-0.92 and 0.57-0.96, respectively. On average studies complied with only 35% of the STARD-guideline items. No study scored low risk-of-bias for all QUADAS-2 domains (patient selection, index test, reference test, flow and timing). High risk-of-bias in ≥one domain was scored in 10/13 studies (77%).

          Conclusion

          Reported CT test accuracy for COVID-19 diagnosis varies substantially. Validity and generalizability of these findings is complicated by poor adherence to reporting guidelines and high risk-of-bias, which are most likely due to the need for urgent publication of findings in the first months of the COVID-19 pandemic.

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          Most cited references30

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          Detection of SARS-CoV-2 in Different Types of Clinical Specimens

          This study describes results of PCR and viral RNA testing for SARS-CoV-2 in bronchoalveolar fluid, sputum, feces, blood, and urine specimens from patients with COVID-19 infection in China to identify possible means of non-respiratory transmission.
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            CT Imaging Features of 2019 Novel Coronavirus (2019-nCoV)

            In this retrospective case series, chest CT scans of 21 symptomatic patients from China infected with the 2019 novel coronavirus (2019-nCoV) were reviewed, with emphasis on identifying and characterizing the most common findings. Typical CT findings included bilateral pulmonary parenchymal ground-glass and consolidative pulmonary opacities, sometimes with a rounded morphology and a peripheral lung distribution. Notably, lung cavitation, discrete pulmonary nodules, pleural effusions, and lymphadenopathy were absent. Follow-up imaging in a subset of patients during the study time window often demonstrated mild or moderate progression of disease, as manifested by increasing extent and density of lung opacities. © RSNA, 2020
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              Performance of radiologists in differentiating COVID-19 from viral pneumonia on chest CT

              Background Despite its high sensitivity in diagnosing COVID-19 in a screening population, chest CT appearances of COVID 19 pneumonia are thought to be non-specific. Purpose To assess the performance of United States (U.S.) and Chinese radiologists in differentiating COVID-19 from viral pneumonia on chest CT. Methods A total of 219 patients with both positive COVID-19 by RT-PCR and abnormal chest CT findings were retrospectively identified from 7 Chinese hospitals in Hunan Providence, China from January 6 to February 20, 2020. A total of 205 patients with positive Respiratory Pathogen Panel for viral pneumonia and CT findings consistent with or highly suspicious for pneumonia by original radiology interpretation within 7 days of each other were identified from Rhode Island Hospital in Providence, RI. Three Chinese radiologists blindly reviewed all chest CTs (n=424) to differentiate COVID-19 from viral pneumonia. A sample of 58 age-matched cases was randomly selected and evaluated by 4 U.S. radiologists in a similar fashion. Different CT features were recorded and compared between the two groups. Results For all chest CTs, three Chinese radiologists correctly differentiated COVID-19 from non-COVID-19 pneumonia 83% (350/424), 80% (338/424), and 60% (255/424) of the time, respectively. The seven radiologists had sensitivities of 80%, 67%, 97%, 93%, 83%, 73% and 70% and specificities of 100%, 93%, 7%, 100%, 93%, 93%, 100%. Compared to non-COVID-19 pneumonia, COVID-19 pneumonia was more likely to have a peripheral distribution (80% vs. 57%, p<0.001), ground-glass opacity (91% vs. 68%, p<0.001), fine reticular opacity (56% vs. 22%, p<0.001), and vascular thickening (59% vs. 22%, p<0.001), but less likely to have a central+peripheral distribution (14.% vs. 35%, p<0.001), pleural effusion (4.1 vs. 39%, p<0.001) and lymphadenopathy (2.7% vs. 10.2%, p<0.001). Conclusion Radiologists in China and the United States distinguished COVID-19 from viral pneumonia on chest CT with high specificity but moderate sensitivity. A translation of this abstract in Farsi is available in the supplement. - ترجمه چکیده این مقاله به فارسی، در ضمیمه موجود است.
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                Author and article information

                Contributors
                Journal
                Radiol Cardiothorac Imaging
                Radiol Cardiothorac Imaging
                cardiothoracic
                Radiology. Cardiothoracic Imaging
                Radiological Society of North America
                2638-6135
                30 July 2020
                : 2
                : 4
                : e200342
                Affiliations
                [1]Departments of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands (D.S., R.W.V.H., A.F.V.D.H., P.A.D.J., H.M.V.), Imaging Division University Medical Center Utrecht, Utrecht, The Netherlands (H.M.V.)
                Author notes
                Address correspondence to D.S. (E-mail: d.sucha@ 123456umcutrecht.nl ).
                Author information
                https://orcid.org/0000-0003-2331-7169
                https://orcid.org/0000-0002-6084-0656
                https://orcid.org/0000-0003-1218-0865
                https://orcid.org/0000-0003-4840-6854
                https://orcid.org/0000-0001-9480-1623
                Article
                200342
                10.1148/ryct.2020200342
                7393956
                31dd9a3c-15c1-4b13-83d9-780e2a546102
                2020 by the Radiological Society of North America, Inc.

                This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.

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