The potential roles of nuclear medicine in the evaluationof long haulers from the COVID-19 pandemic

Introduction: Although most studies on the symptomatology associated with the coronavirus disease 2019(COVID-19) have been focused on the clinical presentations of hospitalized patients in acute settings, an increasingnumber of reports show a rise in “COVID-19 long haulers”-patients who continue to experience or developpersistent symptoms weeks or months after recovering from initial illness. Over 66-87% of COVID-19 patientsreported at least one persistent symptom related to the disease, the most common of which includes: fatigue,cough, dyspnea, anosmia, headaches, arthralgia, and chest pain. These lingering symptoms affect those whoexperienced mild as well as moderate or severe COVID-19 both as inpatients and outpatients. The field of NuclearMedicine offers non-invasive tests that has the potential to help monitor and evaluate COVID-19 long haulers. Methods: We discuss the role of Nuclear Medicine in evaluating COVID-19 long-haulers by presenting the relevanttechniques available in the field. We describe potential applications of these tests to provide both anatomic andfunctional evaluation with the potential to identify medical issues in the long-haulers. Results: COVID-19 has been shown to be a disease that affects multiple organ systems in a variety of ways.Infection and inflammation due to COVID-19 can damage several organs, most notably the lungs, heart, andkidneys. In examining injuries in the lungs, the use of 18F-FDG PET not only highlights the ground-glass opacitiesand lung consolidations consistent with CT findings of COVID-19 patients, but also shows increased 18F-FDGuptake in specific infected areas such as the lymph nodes, allowing us to detect and accurately map the location ofinfection and inflammation. On the other hand, myocardial injury due to COVID-19 can be observed by myocardialperfusion scintigraphy. This is especially useful when assessing microcirculation and coronary flow reserve for riskstratification and therapeutic planning. Finally, due to the high incidence of acute kidney injuries and subsequentrenal complications among COVID-19 patients, the use of renal scintigraphy with Tc-99m MAG-3 and DMSA mayhelp identify renal injuries and scarring. Conclusion: Diagnostic procedures in Nuclear Medicine such as PET/CTand body scintigraphy has the potential to allow us to detect, monitor and evaluate COVID-19 disease complicationsand related organ damage in long-haulers. When utilized in conjunction to other imaging techniques, NuclearMedicine can help provide additional anatomic and functional information to evaluate issues in COVID-19 longhaulers.

“Out of sight”: Nuclear medicine, eye strain andteleradiology during the COVID-19 pandemic

Objectives: Digital eye strain (DES) or computer vision syndrome is a term used to describe a constellation ofvisual problems arising from prolonged digital screen exposure. Radiologists have long been vulnerable to thisoccupational hazard given the extended hours spent behind digital screens reviewing images. Given that excellentvisual acuity is perhaps the most important requirement a nuclear physician must possess in order to effectivelyanalyze images, it is important to shed light on this growing health concern, particularly during the COVID-19pandemic. Methods: During the COVID-19 pandemic imaging became even more crucial in diagnosing and managing clinicalconditions. Due to the high risk of exposure, shortages in personal-protective equipment and increasing healthcareburnout, the amount of time providers spent obtaining histories and examining patients decreased significantly.Consequently, imaging became central in helping clinicians in reaching diagnoses and tailoring patient treatmentplans accordingly. In 2020, imaging in the emergency department setting increased to 42% from 39% in 2019, whereas inpatient imaging increased from 24% to 33% in 2020. The unpredictability of the COVID disease courseresulted in more emergent imaging being ordered by clinicians, which put additional strain on radiologists toincrease turnaround time to help provide answers. Results: There has also been a shift towards Teleradiology during the COVID-19 pandemic with more nuclearmedicine physicians and radiologists working remotely or from home. Although telemedicine has helped decreaserisk of COVID 19 exposure, it has resulted in fewer in person interactions with consultants, as well as with radiologyresidents at academic institutions. Conclusions: Utilizing videoconferencing services has become the new norm and has resulted in increased digitalscreen time. During these unprecedented times, nuclear medicine physicians and radiologists should be morecognizant of DES and focus on measures to help mitigate its potential long-term effects such as by taking frequentbreaks, using appropriate lighting, adjusting image settings and utilizing artificial tears.

“no hard feelings”: Empathy training for nuclearmedicine technologists: A review and methods ofimprovement during the COVID-19 pandemic

Objectives: Empathy is the capacity of an individual to understand and share the feelings, emotions, or experiencesof another person and to observe that person's perspective. In a professional setting, particularly in health caredepartments during the COVID-19 pandemic, empathy becomes a necessary tool in the care of patients. During theCOVID-19 pandemic, a new wave of stress, anxiety and fear has been experienced by all patients, which posesnew challenges for health care professionals who work closely with patients on a daily basis. Here, we discuss theimportance of empathy training of nuclear medicine technologists, and how we can better improve the experienceand care of our patients through methods which implement empathy in the nuclear medicine department. Methods: There are three components of empathy: cognitive, affective and behavioral. Cognitive refers to the abilityto view the perspective of others;in other words, putting oneself in another's shoes. The affective component refers to experiencing the feelings of others. The behavioral component involves communication to reflect understandingof another's feelings;therefore, it must be perceived that one person understands another in a meaningful way. Inempathy training, not all components are necessary to master in order to express empathy. Empathy can still beexperienced by patients even if only one of the components are met. Empathy training is effective and can beenhanced through didactic training and experiential techniques, whereby the student gains insight and educationabout empathy through lectures on empathy theories, followed by experience, whether simulated or in the form of agame. Skill training is another effective method, whereby students are given a list of skills to learn, the skills aremodeled for the students, and finally the students practice performing such skills. Results: Nuclear medicine technologists should actively practice empathy in the workplace, which involves theaction of active listening, framing, reflecting back to the patient, identifying emotions, and looking for feedback.Patients who interact with empathetic medical professionals feel understood, respected, and validated. Thispromotes patient satisfaction, enhances the quantity and quality of clinical data, improves adherence, and fostersbetter relationships. Conclusions: Empathy training is an essential and necessary component to the training ofhealth care professionals, especially in light of the COVID-19 pandemic. Patients are scared and anxious, and usingempathy training to our advantage may help alleviate these fears in our patients during such a difficult time. Byimplementing empathy training techniques, technologists will be better able to make patients comfortable and lessenfears during imaging.

“Better late than never”: Methods of dealing with no-shows in nuclear medicine during the COVID-19pandemic

Objectives: In scheduling, “no-shows” are patients who make appointments, but neither keep nor cancel them. No-shows in the nuclear medicine department lead to waste of valuable resources, revenue and staffing;all which costtime and money, regardless if patients show up or not. During the COVID-19 pandemic, hospitals havedemonstrated a profound lack of appointment adherence, leading to even more waste of resources. Here, wediscuss methods of dealing with no-show patients to reduce anxieties around the virus and to promote adherence toappointments. Methods: Fear is a natural biological defense mechanism used to deal with threats acutely. When chronic, this canbecome disproportionate and unbeneficial to the health of the organism. During the COVID-19 pandemic, fear hasbeen shown to perpetuate anxiety and stress in healthy patients, while intensifying symptoms in less healthy patients. This fear has also decreased appointment adherence, which negatively impacts the nuclear medicinedepartment. Thus, it becomes important to understand our patients and their fears, beliefs, or reasons for notkeeping their appointments, if we seek to reduce the no-show rate. One particular method we may use is thehuman-centered design method, which consists of patient interviews and qualitative research to better understandhuman behavior in order to develop innovative ways to combat problems we may face. By collecting information onwhy patients do not attend their appointments, we may be able to understand, and thus formulate creative ways toimprove compliance tailored to our communities. Another useful method can be retrospective and qualitative datacollection of patients who “no-show” in the electronic health record. By compiling the patients who no-show andidentifying psychosocial factors, we may be better able to identify obstacles to care and develop ways to combatthem in ways that are tailored to the patient. Overall, a humanistic approach to our patients might prove beneficial inthe long run if our aim is to reduce no-shows going forward. Results: Common fears of patients during the COVID-19 pandemic have been due to misinformation and lack ofeducation about the virus, skewed information from the media, the fear of death from the virus, and hospitals beingthought of as infectious reservoirs for the virus. Through patient interviews, data collection, and examining theelectronic health record of our patients, we can design flyers, informational pamphlets, advertisements or posterswhich seek to target these populations and distribute information to them in order to reduce their anxieties. Inaddition, by identifying obstacles to care, we can develop methods that remove or lessen these burdens so that ourpatients have improved access to the care they need. Conclusions: Through use of humanistic methods and data collection to understand our patients fears, we arebetter able to appreciate their motives, particularly their reasons for appointment non-adherence. This way, we canhelp our patients quell those fears, and promote the importance of keeping appointments so that we maximize boththeir care and the use of resources in the nuclear medicine department.

“Day or Night”: The sundown syndrome andperformance of nuclear medicine studies during the COVID-19 pandemic

Objectives: Sundown syndrome, or sundowning, is a state of confusion occurring in the late afternoon andcontinues into the night. Sundowning can cause a variety of behaviors such as confusion, anxiety, aggression,agitation, and hallucinations. Sundown syndrome commonly occurs in patients with dementia, in inpatient elderlyfacilities and hospitals. This project seeks to identify the effects of sundowning on nuclear medicine studies,especially during the COVID-19 pandemic. Methods: Elderly patients with dementia can experience sundown syndrome when their daily routines are distorted.Sundowning in elderly patients can be avoided by maintaining a consistent daily schedule and routine. Anappropriate schedule to prevent sundowning may include getting the patient out of bed, walking, regular mealintervals, frequent reorientations, and regular patient to staff interactions. During the COVID-19 pandemic, patient-staff interactions have been limited which alters a patient's daily schedule, thus potentiating sundown syndrome.Elderly patients can undergo nuclear medicine studies at varying times during the day or night. The irregular timingof nuclear medicine studies can exacerbate and potentiate sundowning in elderly patients with dementia. Even priorto the pandemic, the performance of nuclear studies can be affected by sundowning, especially ones that are longand requiring the patient's cooperation. Anxious, agitated, and disoriented patients with sundown syndrome canmake the practice of nuclear medicine studies challenging and effect the potential efficacy of the study. Results: Nuclear medicine plays an important role in the care of elderly patients. Sundown syndrome in specificpatient populations may present as a challenge during nuclear medicine scans, therefore limiting the performance,diagnosis and efficacy of potential studies. We review the ways sundown syndrome occurs in the hospital during theCOVID-19 pandemic, prior to the pandemic and present methods to manage these challenges. Conclusions: Nuclear medicine provides important diagnostic information in the health of elderly patients. Wediscuss the implications of elderly patients with sundown syndrome and identify the challenges nuclear medicinephysicians and technologists face with sundowning patients in the practice of nuclear medicine, especially duringCOVID-19. We explore methods to prevent sundowning to ensure the best performance of nuclear medicine studiesin elderly patients. Bibliography Graff-Radford J. Sundowning: Tips for dealing with late-day confusion. Mayo Clinic.https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/expert-answers/sundowning/faq-20058511.Published April 23, 2019. White J. Avoid 'sundowning' in elderly hospital patients.https://www.healthcarebusinesstech.com/sundowning-elderly-patients/. Published November 18, 2020.