A Review of the Issues Associated with Imaging and Treating Patients with a Larger Body Habitus

Purpose: Obesity is generally reported as having a significant impact on healthcare practice and systems, although there is also growing recognition that pervasive weight stigma can affect access to healthcare and/or cause negative health effects. Imaging and treating patients with a larger body habitus is one of the many practice considerations for medical radiation science professionals (MRSPs). There are known technical and patient care considerations including size and weight equipment limitations in medical imaging and radiation therapy departments as well as considerations of imaging dose and treatment reproducibility for patients of a larger size. Communication and patient care also needs to be tailored to this patient population. This scoping review sought to answer the question: How has imaging and treating patients with a larger body habitus been defined, classified, and understood in the Medical Radiation Sciences literature? Methods A scoping study is typically carried out to examine the extent, range, and nature of research activity for a specific topic or question. For this study, a scoping review of English language peer-reviewed papers published from 2011 to 2021 was performed using the PRISMA framework. Four independent reviewers with content and methodological expertise selected papers with the initial inclusion criteria: english language, human subjects, obese, bariatric, fat, medical imaging, medical radiation technology, radiation therapy and radiography. An iterative process was utilized that included searching the literature, refining the search strategy, and reviewing articles for study inclusion. Result(s): The initial search identified 8809 articles. The review was carried out with the literature review and screening software 'Covidience'. Of the articles included, preliminary qualitative content analysis revealed three major themes. The majority of papers looked at imaging and/or dose (e.g. radiation exposure, image quality, artifacts and treatment position considerations) as well as equipment and environment (e.g. table load limits, aperture sizes, immobilization devices and positioning). Fewer papers discussed patient care (e.g. communication, perception and attitudes, practitioner bias and the need for appropriate education). Many of the radiography and radiation therapy specific papers were reviews and commentaries rather than research studies and lacked robust evidence. Data analysis is ongoing with a projected completion time of April 2022. Result(s): A growing number of studies about patients with a larger body habitus have been published in the last few years with both practical and patient care implications. Preliminary qualitative content analysis revealed the major themes in the MRSP literature consist of equipment and technical considerations. In addition, it seems likely that further investigation from the patient care perspective would reveal practice insights to inform future research, practice and policy and improve care for this patient population. Copyright © 2022

Building a Student Community: A Virtual Otolaryngology Summer Program

Introduction: The COVID-19 pandemic had far-reaching effects on medical education. Innovations in virtual education attempted to fill the gaps. In our department, a summer virtual medical student program was developed, run, and evaluated. Method(s): Summer evening sessions lasting 1.5 hours were run over Zoom for medical students across the country in 2020 and 2021;11 sessions were run in 2020 and 8 in 2021. Advertising was done via social media and with emails to program directors and ear, nose, throat (ENT) interest groups. Topics were determined by volunteer attendings, residents, and participants located throughout the United States. Postcourse evaluations were used to improve the course. Result(s): Fourteen attendings and 12 residents/fellows from 11 otolaryngology programs presented. A total of 204 students participated;33 (16%) were local students, and 118 (56%) were fourth-year students. In 2020, 14 students made presentations, and 32 did in 2021. About 25 students typically attended each session. Of the participants, 72.7% registered in preparation of their ENT subinternships, 47.3% for the chance to present themselves, 45.5% for curiosity, 36.4% for career exploration, and 18.2% on advisement of a mentor. At the end of the session, 69.1% were most interested in general ENT, 54.5% in pediatric ENT, and 49% in laryngology or head and neck surgery. Students were most interested in learning about the residency application process (mean 9.3/10) and how to be successful during clinical rotations (mean 9.2/10) and in clinical exam maneuvers (mean 9.2/10). Conclusion(s): A virtual noncredit evening course about clinical otolaryngology can attract medical student participation and is a viable way of introducing students to our specialty.

Utility of the Pediatric Smell Wheel in Children During the COVID-19 Pandemic

Introduction: Measuring pediatric odor detection in a COVID-19-impacted context is important. Our goal was to determine whether the Pediatric Smell Wheel (PSW) can be used effectively in this clinical setting. Method(s): Consecutive patients at a pediatric otolaryngology clinic who were aged 5-17 years were recruited. Demographics including gender, race, use of nasal topical medications, previous nasal surgery, and previous COVID-19 infection were collected. Each child performed a test of their sense of smell using the PSW (Sensonics International) under direct supervision, and scores were compared. Result(s): Forty-three children were included;mean age was 9.1 years (95% CI, 8.0-10.1);19 (44.2%) were female and 24 (55.8%) male. Thirteen (30.2%) used nasal sprays, 10 (23.2%) had undergone adenoidectomy, and 4 (9.3%) had other nasal surgery. Twenty (46.5%) had a previous COVID-19 infection. Mean and median PSW score out of 11 was 7 (95% CI, 6.4-7.7), ranging from 2 to 10. There was no significant difference in scores based on age, gender, race, use of nasal topicals, previous nasal surgery, or previous COVID-19 infection. Children were able to perform the task as directed. Percentage correct for each odorant on the PSW ranged from 86% for identifying the onion scent to 27.9% for identifying the popcorn scent. Cronbach alpha was 0.54, and deleting any individual item did not improve it above 0.57, indicating low internal consistency of the PSW. Conclusion(s): During the COVID-19 pandemic, children performed more poorly identifying odors on the PSW than previously reported. The reliability of the PSW may not be adequate in today's context.

DIFFERENTIALLY EXPRESSED IMMUNOLOGICAL GENES in MILD and SEVERE CASES of COVID-19

Background: Coronavirus disease 2019 (COVID19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has varied clinical presentations from mild subclinical to severe disease with high mortality. Our aim was to determine whether examining immune-related gene expression early in infection could predict progression to severe disease. Methods: In subjects of the All Ireland Infectious Diseases Cohort study, we analysed expression of 579 genes with the NanoString nCounter Immunology panel in peripheral blood mononuclear cells in those with confirmed SARS-CoV-2 infection collected within 5 days of symptom onset and matched SARS-CoV-2 negative controls with respiratory infection. Subsequent maximum COVID19 disease severity was classified as mild or severe. Read counts were normalized using panel housekeeping genes. Expression changes in severity groups were estimated against control baseline. Results: Between April and July of 2020, we recruited 120 subjects, 62 with COVID19 and 58 controls, with average age 59 y.o. (IQR 34-88), 66% males and 69% Caucasian ethnicity. Maximal disease severity was used to separate COVID19 cases into mild (n=31) and severe (n=31). We identified 20 significantly deregulated genes between those with COVID19 and controls (;log2 fold;>0.5, p<0.05, Benjamin-Yekutieli p-adjustment). Function of 12 of these genes related to cytokine signaling, 9 upregulated genes to type I interferon signaling (MX1, IRF7, IFITM1, IFI35, STAT2, IRF4, PML, BST2, STAT1), while 7 downregulated genes mapped to innate immune function (IRF7, ICAM2, SERPING1, IFI16, BST2, FCER1A, PTK2). Expression in the severe group showed downregulation of FCER1A (innate immunity regulation), IL1B and TNF (inflammatory cytokines), and PTGS2 (inflammatory mediator) and greater upregulation of TNFSF4 (cytokine signaling) and PTK2 (innate immunity). Mild cases presented higher upregulation of IFIT2 (type I interferon signaling). Conclusion: Observed early downregulation of regulators and mediators of inflammation in those who developed severe COVID19, suggested dysregulation of inflammation. Specifically, IFIT2 upregulation in mild cases and FCER1A downregulation in severe cases, points to early differences in host responses centered on deregulation of the interferon and inflammation responses. Whether these patterns reflect delayed interferon involvement in pathways to control the infection and contribute to pathological inflammation and cytokine storms observed in severe COVID19 requires further research.

Echocardiographic assessment of strain and associations with markers of clinical severity in multisystem inflammatory syndrome in children (MIS-c) associated with covid-19

Introduction: Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 can cause cardiovascular dysfunction. We aimed to determine if strain abnormalities persist in MISC patients 3-10 weeks post-discharge, and whether acute markers of clinical severity are associated with lower strain at subacute follow-up. Methods: We performed a retrospective cohort study of MIS-C patients admitted at a single center from 3/2020-3/2021. Demographic and clinical variables during hospitalization were obtained. Global longitudinal strain (GLS), 4-chamber longitudinal strain (4C-LS), mid-papillary circumferential strain (CS), and left atrial strain (LAS) at 3-10 week follow-up were compared to age matched controls (n=10). Bivariate analyses were performed using Spearman rank correlation and twosample t-test or Wilcoxon rank sum test. Results: Sixty MIS-C patients were identified (age 8.9 +/-4 years, 35/60 male, 39% Hispanic, 29% African American). Hypotension (65%), ICU admission (57%), and inotropic support (45%) were common;7% received mechanical ventilation. No deaths or need for ECMO were reported. Median length of stay (LOS) was 7 days. LVEF was <55% in 28% during hospitalization (median 57% [52-61]) and 6% at follow-up (median 65% [61-67]). Peak NT-proBNP (median 5321 pg/ml [IQR 1712, 17400]) and peak CRP (median 17 mg/dl [12, 22]) were significantly associated with hypotension, ICU admission, and total ICU days. Forty-five patients had available follow-up imaging for strain. CS (mean-26.0 vs-28.6;p=0.009) and LAS (mean-34.5 vs-51.2;p=0.001) were lower in MIS-C vs controls, but not GLS or 4C-LS. Lower CS (-24.2 +/-3.1 vs-26.7 +/-2.7;p=0.04) and lower 4C-LS (-19.1 +/-1.9 vs-21.2 +/-3.3;p=0.04) were associated with abnormal EF (<55%) during acute illness. CS was lower in those admitted to ICU (-25.1 +/-2.6 vs-27.5 +/-2.9;p=0.03). Peak CRP correlated with lower CS (r=-0.41, p=0.03) and GLS (r=-0.55, p=0.01) at follow-up. Conclusions: MIS-C patients show abnormal strain during subacute follow-up despite improvement in EF. Lower CS, GLS, and 4C-LS were associated with in-hospital markers of clinical severity. This data may allow for identification of at-risk MIS-C patients and help guide outpatient cardiology follow-up.

Genomic evidence of SARS-CoV-2 reinfection in Ireland

Presentation A 40-year-old healthcare worker (HCW) presented with cough, headache, sore throat, fatigue and myalgia seven months after primary infection with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Symptoms were milder and recovery was faster on the second episode. Diagnosis Reinfection with phylogenetically distinct SARS-CoV-2 was confirmed by whole-genome sequencing (WGS). Treatment Management involved symptomatic treatment and self-isolation. Discussion The incidence of SARS-CoV-2 reinfection is not well characterised. Infection control precautions may still be required in healthcare facilities, even in previously infected and possibly in vaccinated individuals while SARS-CoV-2 remains in circulation. Further research on the nature and duration of immunity is required to inform public health and infection control policy.

Tracking the international spread of SARS-CoV-2 lineages B.1.1.7 and B.1.351/501Y-V2

Late in 2020, two genetically-distinct clusters of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with mutations of biological concern were reported, one in the United Kingdom and one in South Africa. Using a combination of data from routine surveillance, genomic sequencing and international travel we track the international dispersal of lineages B.1.1.7 and B.1.351 (variant 501Y-V2). We account for potential biases in genomic surveillance efforts by including passenger volumes from location of where the lineage was first reported, London and South Africa respectively. Using the software tool grinch (global report investigating novel coronavirus haplotypes), we track the international spread of lineages of concern with automated daily reports, Further, we have built a custom tracking website (cov-lineages.org/global_report.html) which hosts this daily report and will continue to include novel SARS-CoV-2 lineages of concern as they are detected.

Benzos. when beers does not apply: Managing terminal delirium

Background: Terminal delirium (TD) occurs in up to 88% of patients at the end of life. Hyperactive TD requires an individualized management approach, which may include using a long-acting benzodiazepine. This medication can aggravate delirium;however, in the appropriate patient, with close interprofessional collaboration and if congruent with goals of care, it may provide net benefit. Case: An 85-year-old lady with dementia, macular degeneration, and failed spinal stenosis surgery requiring wheelchair use, presented from an assisted living facility with agitation and elopement attempt. She had multiple delirium episodes in the past year precipitated by separation from her husband and social isolation due to COVID-19. Infectious workup was negative. CT brain showed volume loss and severe chronic microangiopathic changes. During her hospitalization, she was screaming, restless, impulsive, combative, anxious, paranoid regarding her husband having extramarital affairs, and required restraints. Her behaviors made care provision very challenging. Trazodone and olanzapine were started and titrated, and home pregabalin and sertraline were continued. She still received frequent IM/IV antipsychotics as PO medications were not administered on a consistent schedule due to fluctuating emotional distress. Her family was routinely updated, and ultimately decided on a comfort care approach. Due to persistent agitation despite maximal doses of olanzapine, scheduled twice daily clonazepam was trialed given its long acting properties, in addition to morphine. There was finally a marked reduction in her emotional distress. She eventually passed peacefully. Discussion: Given the scarcity of evidence to guide the optimal management of TD, its treatment should be tailored to each patient. Beers Criteria recommends against benzodiazepines because of potential worsened delirium. However, if comfort is the treatment goal, TD patients with severe agitation refractory to behavioral approaches and multiple classes of medications including antipsychotics may be trialed on long acting benzodiazepines to achieve proportionate sedation and alleviate suffering. Our patient's distress was not ameliorated by multiple treatments over weeks, but she became comfortable after we scheduled clonazepam. Conclusion: Deviation from conventional geriatric treatment paradigms, including using long-acting benzodiazepines, might be required to treat hyperactive TD in a patient-centered manner.

COM-PACE: Compliance-Aware Cloud Application Engineering Using Blockchain

The COVID19 Pandemic has highlighted our dependence on online services (from government, e-commerce/retail, and entertainment), often hosted over external cloud computing infrastructure. The users of these services interact with a web interface rather than the larger distributed service provisioning chain that can involve an interlinked group of providers. The data and identity of users are often provided to service provider who may share it (or have automatic sharing agreement) with backend services (such as advertising and analytics). We propose the development of compliance-aware cloud application engineering, which is able to improve transparency of personal data use-particularly with reference to the European GDPR regulation. Key compliance operations and the perceived implementation challenges for the realization of these operations in current cloud infrastructure are outlined. © 1997-2012 IEEE.