AVASCULAR NECROSIS OF THE FEMORAL HEAD – NOT TO BE OVERLOOKED SEQUELA AFTER COVID 19 INFECTION

BackgroundCOVID 19 infection could lead to different sequelae in survivors, known as post-COVID or long COVID 19 syndromes. Some of them are thought to be due to the thrombophylic changes observed in COVID 19 infection, but some are thought to be caused by the administrated (especially high dose) corticosteroid treatment. Avascular necrosis of the femoral head (AVNFH) is a multifactorial disease which leads to compromised vascular supply, ischemia and finally necrosis of the femoral head. As corticosteroids usage and thrombophylic states are among the main known risk factors for the development AVNFH [1], it could be presumed that the frequency of this disease will increase with the COVID 19 pandemic. The exact corticosteroid dose needed for the development of AVNFH is not clear, but it has been stated that a higher daily dose and a larger total cumulative dose increase substantially the risk for the development of osteonecrosis [2].ObjectivesTo describe in detail the characteristics of AVNFH diagnosed in patients after COVID 19 infection.MethodsThe study was done in a tertiary university rheumatological clinic. Data was extracted from the records of patients who have been referred to the clinic because of hip pain between June and December 2022. Inclusion criteria were: - a new onset of uni-or bilateral hip pain that started after a documented COVID 19 infection;and an MRI scan of the hip joints showing osteonecrosis of one or both femoral heads. Exclusion criteria were the presence of hip pain prior to the COVID 19 infection, anamnesis of traumatic injuries of the hips or pelvis, personal history of hypercoagulable states.ResultsNine patients (4 women and 5 men) with an average age 59.1 years (range 38-72) were included in the study. Four patients had been diagnosed with bilateral and five – with unilateral AVNFH, thus 13 hip joints were analysed in total (8 left and 5 right sided). The mean time lap between the COVID 19 infection and the start of the hip pain was 26.2 weeks (range 10-48 weeks). All patients had limited and painful movement in their symptomatic hip(s), especially internal rotation and four of the patients had also elevated CRP levels (mean 11.7 mg/L). The stage of the AVNFH was evaluated according to the Ficat-Arlet classification (0-IV stage). In four hips the AVNFH was stage I, five hips were classified as stage II and the remaining four joints - as stage III. All symptomatic hip joints exhibited effusion/synovitis on both ultrasound examination and the corresponding MRI scan. It should be noted that the presence of hip effusion was found to be related with a worse prognosis in AVNFH [1]. In three patients the amount of the effusion required arthrocentesis and fluid aspiration. The analysis of the joint fluid was consistent with a degenerative disease (i.e., low WBC count with predominant lymphocytes and no crystals). All patients included in our study had received corticosteroids during their COVID19 infection, while 6 of the patients had also been hospitalized due to more severe disease. According to the patients' documentation, the mean cumulative dose of the received corticosteroids was 936.2 mg prednisolone equivalent per patient (range 187-2272 mg).ConclusionAVNFH must not be overlooked in a new onset hip pain after COVID 19 infection. Our results show that corticosteroids administrated during the infection and the presence of hip joint effusion on ultrasound are especially suggestive for the development of osteonecrosis, as they were registered in all of our patients. The presence of these two factors necessitates patient referral for an MRI scan of the hips, in order that AVNFH be detected timely.References[1]Petek D, Hannouche D, Suva D. Osteonecrosis of the femoral head: pathophysiology and current concepts of treatment. EFORT Open Rev. 2019 Mar 15;4(3):85-97.[2]Kerachian MA, Séguin C, Harvey EJ. Glucocorticoids in osteonecrosis of the femoral head: a new understanding of the mechanisms of action. J Steroid Biochem Mol Biol. 2009 Apr;114(3-5):121-8.Acknowledgements:NIL.Disclosur of InterestsPLAMEN TODOROV Speakers bureau: speaker at national level for AbbVie, Novartis and UCB, Lily Mekenyan: None declared, Anastas Batalov Speakers bureau: Speaker at national level for AbbVie, Novartis, Pfizer, Stada, Elly Lilly.

TELEDIDACTIC MUSCULOSKELETAL ULTRASOUND COURSE AND COMPARISON WITH CONVENTIONAL ON-CAMPUS TRAINING – INTERIM ANALYSIS OF THE TELMUS STUDY

BackgroundMusculoskeletal ultrasound (MSUS) is increasingly gaining importance as an imaging tool in rheumatology. Most training programs currently address resident doctors. However, several studies have demonstrated that teaching MSUS to medical students improves their palpation skills and understanding of musculoskeletal anatomy. With the development of portable ultrasound devices, MSUS education is lately getting more flexible and location-independent. In addition, the COVID-19 pandemic raised awareness of telemedicine training as a powerful tool to ensure the teaching of practical skills under pandemic conditions.ObjectivesThe purpose of our study is to establish a telemedical MSUS course for medical students and to compare its effectiveness with a conventional on-campus course as a world-wide pilot study. In doing so, we aim to expand student educational opportunities in MSUS using innovative teaching options while ensuring quality maintenance of teaching.MethodsThirty medical students were randomized to either a virtual group being delivered only telemedicine instructions, or an on-campus cohort receiving the course in a conventional format. Each student was provided with a handheld ultrasound device. Prior to the start of the course, the students' skills were assessed with an Objective Clinical Structured Examination (OSCE). During the course, a DEGUM-III-certified course instructor taught the basic physics of ultrasound and standard sections of the MUDE ultrasound protocol[1]. In order to quantify the students' learning progress, a second OSCE was carried out after completion of the course. [1].ResultsAt the time of this analysis, data collection within the on-campus course has already been completed, whereas the virtual course is still ongoing. While the average score of the students in the PRE-course OSCE was 21,02% (SD ±6,78), the students were able to achieve an average of 90% (SD ±6,81) in the POST-course OSCE after the intervention.ConclusionWith the results obtained so far, it can be shown that an innovative course concept with hand-held ultrasound devices, originally developed for dermatologists to improve the detection of psoriatic arthritis, can be used very well in student teaching without major modifications and leads to a significant increase in MSUS skills among medical students. The TELMUS study thereby offers a successful example of extending an existing course concept to student teaching and thus promoting the next generation of rheumatologists.Reference[1]Grobelski J, Recker F, Wilsmann- Theis D, et al. Etablierung und Validierung eines didaktischen muskuloskelettalen Ultraschallkurses für Dermatologen unter Verwendung eines innovativen Hand-Ultraschallsystems – die MUDE-Studie (Muskuloskelettaler Ultraschall für Dermatologen). J Deutsche Derma Gesell 2021;19:1753–60. doi:10.1111/ddg.14614_gFigure 1.Acknowledgements:NIL.Disclosure of InterestsNone Declared.

THE CURRENT SITUATION OF MUSCULOSKELETAL ULTRASOUND EDUCATION - A SYSTEMATIC LITERATURE REVIEW

BackgroundThe use of musculoskeletal ultrasound improves patient care by increasing diagnostic and therapeutic safety. With its growing application and increasing evidence of its value, the demand for standardized training in musculoskeletal ultrasonography (MSUS) rises rapidly.ObjectivesIn this systematic literature review, we aim to provide a general overview of the various aspects of musculoskeletal ultrasound education worldwide, including target groups, teaching staff, didactic methods, and course formats, as well as to reflect on existing problems and future opportunities. No restrictions were made regarding the educational level of the course recipients nor the specialization of the course instructors.MethodsIn our methodological approach, we followed the PRISMA statement for reporting systematic reviews and meta-analyses of studies[1]. In January 2022, the databases Embase, PubMed, and Google Scholar were considered with all publications to date and were filtered for relevant publications using previously defined keywords. Title and were then screened independently by two authors for inclusion using relevant study characteristics determined in advance according to the PICO scheme[1]. Finally relevant information was filtered from the full text version of the sixty-seven included publications.ResultsThe range of training programs has increased greatly in recent years, primarily aiming at residents in rheumatology, radiology and physical medicine and rehabilitation. However, MSUS is also receiving more attention as a training tool for medical students. Due to the COVID pandemic, didactic approaches using distance learning via simulators and handheld devices have gained additional importance. Given the existing lack of sufficient equipment and trained teaching staff, those approaches should continue to be explored post-pandemic. Another still existing problem is the low international comparability of MSUS training and competency assessment. Therefore, several international institutions, including the European League Against Rheumatism (EULAR) and the Pan-American League of Associations for Rheumatology (PANLAR) have proposed guidelines for training curricula to promote standardized ultrasound training.ConclusionThere is a broad consensus that the development of standardized curricula improves training and facilitates the implementation of new training centers. The development of alternative teaching methods incorporating e-learning, peer teaching, and distance learning on mobile ultrasound devices and the determination of international guidelines could facilitate overcoming the remaining major obstacles still to be passed.Reference[1]Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009;339:b2700. doi:10.1136/bmj.b2700Acknowledgements:NIL.Disclosure of InterestsNone Declared.

CHALLENGES FOR PATIENTS WITH RMD'S IN BULGARIA DURING THE COVID-19 PANDEMIC

BackgroundThe Covid-19 pandemic has put patients with rheumatic diseases in front of a number of obstacles that had to be solved together with Bulgarian rheumatologists. The lockdowns and restrictive measures have made it difficult for people with rheumatic diseases to have access to timely hospital and pre-hospital care. A number of digital solutions have been implemented to address these issues.ObjectivesTo highlight the problems that patients with rheumatic diseases had during the Covid-19 pandemic;access to rheumatologists and the effectiveness of hospital and pre-hospital care during the pandemic, access to treatment, changes of treatment;communication between physicians and patients, the impact of the pandemic on work, social contacts, hobbies.MethodsAn anonymous survey was conducted online and by telephone. The survey was developed by Medical university, Plovdiv, University hospital "Kaspela”:, Plovdiv, Bulgarian Association for Musculoskeletal Ultrasound, Bulgarian organization for people with rheumatic diseases;Association for patients with autoimmune diseases.Number of participants: 1205 patients with RMD's.Age range: 18-82ResultsFace to face meetings with doctors have been limited during the pandemic.Visits to the rheumatologist's office are significantly reduced and phone, email, text messaging, online consultations were preferred as communication channels.Before the pandemic, 76% of respondents most often communicated with their physicians by visiting their practice, during the pandemic their relative share decreased to 46%, with a significant difference of 30%Phone consultations: patients using this type of communication increasing from 38% before the pandemic to 56% during the pandemic, a significant difference of 18%The percentage of patients who communicated via text or email rises from 10% to 17 %.It has become apparent that Digital transformation is needed and patients and physicians should work together to achieve it and to be established in Bulgaria.245 patients reported a change in their treatment. Of these: (30%) reduced the dose of their medications, 119 (49%) increased the dose and the remaining 55 (21%) stopped their therapy.From the responses of the respondents, it is clear that 71% have not experienced a change in their work during the COVID-19 pandemic, 17% have worked from home.From the responses of the respondents, it is clear that 71% have not experienced a change in their work during the COVID-19 pandemic, 17% have worked from home, 4% have been fired, 3% have left their jobs due to the risk of their health and 5% left their jobs for other reasons.ConclusionThe Covid-19 pandemic has shown that the digital transformation in rheumatology care can be an efficient alternative to some of the services offered to patients with rheumatic diseases in Bulgaria (especially secondary examinations and therapy monitoring examinations). The results of the conducted survey could be used to support digitization in healthcare in Bulgaria.Very important was the collaboration between the patient organizations and the Bulgarian Association for Musculoskeletal Ultrasound, Medical University, Plovdiv and the rheumatologists from University hospital "Kaspela” Plovdiv.References[1]Gianfrancesco M, Hyrich KL, Al-Adely S, et al. Characteristics associated with hospitalisation for COVID-19 in people with rheumatic disease: data from the COVID-19 Global Rheumatology Alliance physician-reported registry. Ann Rheum Dis 2020;79: 859–66.[2]Monti S, Balduzzi S, Delvino P, Bellis E, Quadrelli VS, Montecucco C. Clinical course of COVID-19 in a series of patients with chronic arthritis treated with immunosuppressive targeted therapies. Ann Rheum Dis 2020;79: 667–68.[3]Dejaco, C.;Alunno, A.;Bijlsma, J.W.;Boonen, A.;Combe, B.;Finckh, A.;Machado, P.M.;Padjen, I.;Sivera, F.;Stamm, T.A.;et al. Influence of COVID-19 pandemic on decisions for the management of people with inflammatory rheumatic and musculoskeletal diseases: A survey among EULAR countries. Ann. Rheum. Dis. 2020AcknowledgementsBul arian organization for people with rheumatic diseases.Association for patients with autoimmune diseases.Bulgarian Association for Musculoskeletal Ultrasound.Disclosure of InterestsNone Declared.

Recent advances in the effect of ultrasound on the binding of protein−polyphenol complexes in foodstuff

Foodstuff is a complex system that consists of a variety of nutrients. Protein is the basis of human life and health, which is made up of amino acids combined in different proportional orders. Polyphenols are a class of small molecule active substances with strong pro-life health effects. It has been found that protein and polyphenols can be combined by covalent and non-covalent interactions to form complex delivery carriers. The interaction between the two can effectively improve the physiological activities of proteins and enhance the bio-accessibility of polyphenols. With the maturation of ultrasound technology, several studies have shown that ultrasound can promote the production of protein−polyphenol complexes. To promote the study of protein–polyphenol interactions in foodstuff by ultrasound technology, the preparation methods of protein−polyphenol complexes, the effects of ultrasound on complex generation, and analytical methods were systematically summarized based on an extensive literature review, and further research directions were proposed. It provides the reference for the ultrasound study of protein−polyphenol complexes.

IDDF2023-ABS-0005 Hepatocellular carcinoma (HCC) treatment experience using smart fusion in dialysis patients

BackgroundApproximately 700 dialysis patients are seen at our hospital. Among them are patients with HCC that develop viral hepatitis. Advances in ultrasound systems have improved the accuracy of HCC treatment and diagnosis. This time, we had the opportunity to use microwaves for dialysis patients using Smart Fusion and needle navigation installed in APLIOi800 so that we will report it.MethodsTen dialysis patients were treated from January 2018 to February 2023. An Emprint (Covidien, USA) antenna was used for treatment. Canon APLIOi800(Canon, Tochigi, Japan) was used. The built-in function is Smart Fusion. This method can display ultrasound imaging and volume data from other modalities, such as CT and MRI, in association with positional information using a magnetic sensor. Needle navigation has a function that can confirm the position of the needle. It is possible to treat even when the tumor is overprinted and the visualization is poor due to bubbles. Informed consent was obtained from all patients and the treatment was performed.ResultsIt was possible to visualize all tumors. In this study, CT images were used in 0 cases, and MRI was used in 1 Case. No serious side effects occurred after treatment.ConclusionsUsing this method, it was thought that dialysis patients could be safely and accurately treated.

REAL WORLD EXPERIENCE OF MODERATE DISEASE ACTIVITY STATE (MDAS) RA PATIENTS OVER 4-YEAR FOLLOW-UP

BackgroundIn recent years despite improved therapies for RA, there is an increased awareness of persistent pain in people with RA. Before the pandemic we assessed a large group of patients with RA with comprehensive joint ultrasound (US) and for presence of fibromyalgia (FM) meeting 2010 ACR diagnostic criteria. When combinations of synovitis and/or FM were made we noted 4 groups of patients. As well as some with only FM, we also noted a group we believe had peripheral non-inflammatory pain, a new concept in RA. Here we investigate if these different groups change over time in our T2T routine care pathway.ObjectivesTo assess the progress and outcomes patients with RA with different well defined pain states during 4 years of follow up including the COVID19 pandemic.MethodsThe TITRATE-ULTRASOUND patient cohort categorised patients with RA into 4 groups depending on the presence or absence FM and the presence or absence of power doppler synovitis (PD, defined as positive PD signal in ≥2 joints in a 44 joint US). We identified 72 patients with active RA (DAS28 3.2 – 5.1) from this cohort with sufficient clinical data during the study period and collected the following data on each follow up encounter: visit type, treatment changes and disease activity measures. In the COVID19 pandemic follow up visits were largely virtual without the ability to collect physician assessed disease activity scores. Progress assessment was performed as to whether the patient had improved, no change or worse with a numerical value of +1, 0 and -1 at each visit to calculate a score tracking patient progress during the pandemic. Statistical analysis was performed using 1-way ANOVA to assess for difference between the 4 groups.Results72 patients with were assigned into the following categories: FM-PD-, 12 (peripheral pain group);FM-PD+,18;FM+PD-, 29;FM+PD+, 13. Table 1 shows baseline characteristics of the 4 groups and reveals no significant difference by ANOVA between the 4 groups in total visits, face to face visits, telephone visits, tender joint count, treatment escalations, steroid prescriptions, csDMARD prescriptions, and progress score. Biologic prescriptions did vary significantly between the groups (p = 0.009).Table 1.FM-PD- (n=12)FM-PD+ (n=18)FM+PD- (n=29)FM+PD+ (n=13)ANOVA p-valueFemale (n, %)10 (83%)13 (72%)24 (83%)13 (92%)CCP+ve (n, %)4 (33%)12 (67%)14 (48%)6 (46%)Disease duration (years) (mean, SEM)11.04 (2.676)16.19 (2.889)12.29 (1.709)16.23 (3.340)On csDMARD (n, %)11 (92%)15 (83%)24 (83%)10 (77%)On bDMARD (n, %)4 (33%)5 (28%)7 (24%)8 (61.5%)Baseline DAS28 (mean, SEM)4.412 (0.1641)4.344 (0.1177)4.192 (0.08910)4.366 (0.1461)Total visits (mean, SEM)11.67 (2.647)10.50 (2.031)8.724 (1.039)8.308 (1.407)0.533F2F visits (mean, SEM)7.909 (2.164)7.944 (1.924)5.793 (1.033)5.769 (1.311)0.5959Telephone visits (mean, SEM)4.417 (1.474)2.556 (0.3154)2.931 (0.3327)2.538 (0.6162)0.2268Tender joint count (mean, SEM)3.604 (1.101)3.506 (0.6177)5.376 (0.6899)4.603 (1.246)0.3179Treatment escalations (mean, SEM)2.917 (1.062)3.722 (1.028)2.000 (0.5526)1.615 (0.6257)0.2671Steroid prescriptions (mean, SEM)1.833 (0.7160)1.611 (0.5310)1.000 (0.3908)0.7692 (0.5329)0.503csDMARD prescriptions (mean, SEM)0.7500 (0.3046)0.7778 (0.2070)0.5185 (0.1634)0.3636 (0.2787)0.5789Biologic prescriptions (mean, SEM)0.3333 (0.2247)1.778 (0.6291)0.3793 (0.1257)0.3077 (0.2371)0.009Progress score (mean, SEM)-1.167 (1.461)0.6111 (0.3889)-0.1379 (0.2366)0.4615 (0.6265)0.2579ConclusionOver the follow-up period we show the management of RA patients without active power doppler synovitis or fibromyalgia did not differ significantly from other categories of patients. Similar numbers of visits, treatment escalations, csDMARDs and corticosteroid prescriptions were observed. This illustrates how it can be difficult to define the specific causes of disease activity without access to US. Despite similar management strategies, FM-PD- patients tended towards worse progress scores, suggesting a potential unmet need in such patients.REFERENCES:NIL.Acknowledgements:NIL.Disclosure of In erestsMark Gibson: None declared, Nadia Ladha Hassan: None declared, L Bruce Kirkham Speakers bureau: Abbvie, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, UCB, Consultant of: Abbvie, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, UCB, Grant/research support from: Eli Lilly.

E-LEARNING AND PRACTICAL PERFORMANCE IN MUSCULOSKELETAL ULTRASOUND - A MULTICENTER RANDOMIZED STUDY

BackgroundThe COVID-19 pandemic has forced a change in the teaching approach when educating physicians. Several training programs have been digitally transformed, including complex procedures such as ultrasound [1]. Recent studies have suggested the possibilities for practicing theoretical and practical ultrasound skills using online platforms, e.g., e-learning [2]. Even though the effect of e-learning on theoretical knowledge is unquestionable, the impact on practical skills is unknown. Thus, it is essential to examine the effect of e-learning on the development of practical skills.ObjectivesTo examine the effect of pre-course e-learning on residents' practical performance in musculoskeletal ultrasound (MSUS). Moreover, to examine the effect of pre-course e-learning on residents' satisfaction with the following face-to-face MSUS course.MethodsWe designed a multi-center randomized controlled study following the CONSORT statement. Residents with no or little MSUS experience were randomized to either an e-learning group or a traditional group. One week before a 2-day face-to-face MSUS course, the e-learning group received access to an interactive platform consisting of online lectures, assignments, and practical instruction videos aligned with the content of the following course. The traditional group only received standard pre-course information (program, venue, and time). All participants performed a pre- and post-course practical MSUS examination and were assessed by two individual raters, blinded to the group allocation, using the validated Objective Structured Assessment of Ultrasound skills (OSAUS) tool. Finally, the participants filled out a subjective satisfaction questionnaire, the Intrinsic Motivation Inventory (IMI).ResultsTwenty-eight participants completed the study. There were no statistically significant differences in the pre- or post-course practical MSUS performance between the e-learning group and the traditional group;the mean pre-course OSAUS score (±SD) in the e-learning group was 5.4±3.7 compared to 5.2±2.4 in the traditional group, p=0.8, whereas the post-course OSAUS score in the e-learning group was 11.1±2.8 compared to 10.9±2.4 in the traditional group, p=0.8 (Figure 1). There was a significant difference between the mean pre- and post-course scores (p<0.001) for both groups. The OSAUS assessment tool demonstrated excellent inter-rater reliability (ICC=0.84). There were no significant differences between the groups regarding their subjective satisfaction with the course measured by the IMI score.ConclusionWe found no significant impact of pre-course e-learning on novices' acquisition of practical MSUS skills or on trainees' satisfaction with the course. Hands-on training is of utmost importance and improves MSUS performance significantly. The OSAUS assessment tool is an applicable tool for the assessment of trainees' MSUS competences and demonstrated excellent interrater reliability.References[1]Strobel D et al. Ultraschall Med 2022;43:428-434.[2]Kan TL et al. Adv Med Educ Pract 2015;6:171-175AcknowledgementsWe would like to express our appreciation to the residents, healthy volunteers, and raters who donated their time to participate in this study. Moreover, the authors thank Søren Grimstrup for statistical assistance. We would like to thank the TOYOTA foundation for financial support for the purchase of an ultrasound machine.Disclosure of InterestsNone Declared.

Development of an acquisition system to monitoring asynchronous tele-ultrasound for lung patients

Lung ultrasound imaging allows the detection and evaluation of the lung damage generated by COVID-19. However, several infrastructure and logistical limitations prevent them from being carried out in isolated and remote areas. In this work, a system for the acquisition of medical images through asynchronous tele-ultrasounds was developed. The system is based on a graphical user interface, which records the three video cameras, the ultrasound image and the accelerometer simultaneously. The interface was developed according to the Volume Sweep Imaging acquisition protocol. The translational and rotational movement of the transducer are tracked and monitored by the accelerometer and the position of the transducer is obtained from the images acquired by the three video cameras. The results show a correct functioning of the system overall, being viable to be implemented for data acquisition and calculation of error, although in order to validate the error calculation there is still more research to be done. © 2023 SPIE.

One stop vein clinic

Team involved are:Vascular surgery department in collaboration with the radiology department.Kent and Canterbury hospitalEast Kent University Foundation TrustIn the current practice under the vascular clinic, a patient with venous disease must pass through a journey of 3 steps.An outpatient appointment initially for clinical examination and evaluation of stage of his venous disease,Referral to radiographer for a duplex ultrasound scan (to rule out thrombosis and clarify the level of the disease)Further appointment with surgeon for receiving their final diagnosis and being listed for treatment.This unfortunately, has cause an unacceptable considerable delay in providing our service and treating those patients. The delay between referral to diagnosis exceeded more than 8 months. The main reasons were:Shortage of radiographersCOVID backlogTime consumed between these 3 appointmentsAssessment of issue and analysis of its causesWe analysed the factors of the cause of the delay in management of patients with venous diseases and it showed that the main reason for delay is delay in ultrasound scan, (the second step in the patient journey to gain the diagnosis).-We faced a period when our only radiographer resigned and we stayed without radiographers in the department for several months until the management were able to recruit a new radiographer. This of course has created a huge impact on our service.Of course the covid has impacted badly on our service. As we cancelled all the patient appointments with venous diseases and concentrated in life or limb threatening conditions only.-The inherited pathway has an element in delay as well as the time consumed between these 3 appointments may exceed several months.ImpactThe project is to merge all the three appointments in only one appointment where the patient will be examined and have the ultrasound in same setting. Thus, the patient will be able to have the outcome immediately in the same session without delay.The main problem , is that there's no enough radiographers to join the vascular surgeons in their clinic to carry on the scan simultaneously. Hence, the idea came to light, that the scan should be done by the vascular surgeons themselves.InterventionThis project helped me to act as a leader and express the ideas without fear and come out of my comfort zone.-We have been taught by the eclips team, To be a good leader , you have to start with your self.Thus, when I started this project, I had to learn the ultrasound skills and collaborate with the radiology department to ease the steps for the rest of the vascular team who would like to follow my steps and gain the ultrasound skill.Involvement of stakeholders, such as patients, carers or family members:The stakeholders areThe patientsFor the patient benefit, being assessed in one clinic, is believed to reduce the stress of awaiting diagnosis for such problem, in addition to some other merits like less time off work for patients, and less transportation cost.The vascular surgeons.The ultrasound is a cornerstone in the modern vascular era, and learning the skills for this tool will in fact benefit the surgeons in their daily work as they can scan the patient themselves particularly in case of emergency.The radiographers and radiology department.It is believed that scanning the patient by the vascular surgeons for the venous diseases will reduce the pressure on the radiology department for a huge list of patients awaiting scan .The management–Saving administration resources, by reducing the clinic cost and reducing the number of clinics.–Reduce the need for hiring locum radiographers or out of hours shifts to reduce the number of patients awaiting their venous scan.–To achieve the 18 months NHS timeframe between referral to diagnosis.–Cost effective measure to use the resources which is already present (portable ultrasounds) without need to buy a new machine or use another room for the scanning.Key MessagesThe main message is that there's a lot of brilliant ideas to improve the service in NHS. Giving us the chance to express these ideas is amazing. All appreciation to eclips team who helped us to start such projects.When I started describing my idea to my line manager, I was astonished that he was completing my words as if he was reading my mind. His support was outstanding and he eased the project steps to me.I hope my project will come to light and to be implemented in other sites as in my opinion, it will help plenty of patients who are struggling to manage their venous disease because of unaccepted delay , unfortunately a lot of them have no choice but to go the private sector which is extremely expensive.Lessons learntMy retrospective audit is still ongoing.There are 2 elements in my project.The first one is subjective, as I had to start with my self.I had a very limited ultrasound experience. So, I have done some search until I found a good centre for ultrasound course for vascular diseases. I applied and had my basic ultrasound skills.The challenge is how to apply this knowledge to the patients where I'm not yet confident to give a report. So, the collaboration with the radiology department was started and they were extremely helpful and supportive as they were kindly supported us with one of the best radiologist consultant to supervise me until I feel confident to do the scan independently. This step took around 2 months until is has been successful.-The second element is objective. As collecting the data during the working hours with busy rota is challenging.Measurement of improvementTo measure the effect of our improvement.We looked at the numbers of patients awaiting venous scan before starting the project (February 2022),. the number was around 230 patients.I managed to share my experience to my colleagues and one of them was interested and joined me. we as 2 speciality vascular surgeon in a half day once weekly clinic , were able to complete a venous scan of 105 patients (almost 50% of the number) in just 6 months.-Currently , we are running an audit to assess the time difference before and after the implementation of the project and hopefully, the data will come to light soon.Strategy for improvementThe timeline for the project is 6 month, which have been completed successfully as myself and the other vascular surgeon are able to perform the venous scan independently.The data is analysed at the moment and will soon be published.

You Can Do Hard Things

Can we move forward with the procedure? I work in the healthcare system myself and I deliver bad news every day. The staff quickly realized I worked in healthcare and that I was faculty at the university medical center. John was given a new badge and explicit instructions not to wander the hospital floors. When I stood, it felt like nothing was holding my insides in and I felt a huge rush of blood leave my body.

Finding Peace Through Recurrent Loss

No attempt at building defenses could shield from the uncertainty that crept in when the first ultrasound showed a length shorter than expected without convincing cardiac activity. Fellow clinicians provided unsubstantiated and non-evidence based medical advice about waiting for multiple cycles prior to trying again, despite my age and likely dwindling ovarian reserve. (While I acknowledge imperfections, I thought I was maintaining a decently well-balanced life raising a thriving toddler despite working as a palliative care provider amid a global pandemic.) I felt disillusioned leaving these medical appointments, embarrassed for my own profession, and alone without medical providers who I could trust to guide me.

Diary of a Family Physician

My first patient is a 13-year-old boy with abdominal pain. He had a fever of 102.6°F (39.0°C) last night and is in significant distress this morning. He has no appetite and has not vomited. He has not had a bowel movement for three days. On examination, he has right lower quadrant tenderness but no rebound. I direct him to the ED with concern for appendicitis.

Determination of Particulate Matter in Dental Clinics: The Effectiveness of Different Air Purifiers and the Central Ventilation System

The purpose of this study was to measure the number and concentration of airborne particulates occurring in a dental clinic while performing dental procedures, with and without the simultaneous use of air purifier systems and a central ventilation system. The initial background concentrations of airborne particulates recorded during dental procedures, i.e., grinding of natural teeth and metals, without the use of air purifier systems, and with closed windows, reduced by 68% for ΡΜ10, 77% for ΡΜ2.5, and 81% for ΡΜ1 when the same procedures were carried out with the simultaneous use of air purifying systems. In addition, measurements taken during patient treatment showed that an operating central ventilation system contributes to the reduction of airborne particles by a significant 94% for ΡΜ10, 94% for ΡΜ2.5, and 88% for ΡΜ1 compared to dental procedures performed without the simultaneous use of air purifiers. Air purifying systems were also observed to contribute to the further reduction of airborne particulates when dental procedures were performed in combination with an operating central ventilation system. The majority of particles captured had diameters of 0.25-0.30 μm, 0.5 μm, and 1.0-4.0 μm, while particles with diameters of >5.0 μm were the least commonly observed in all experiments. Finally, a statistically significant difference between concentrations of particulate matter was recorded during dental procedures carried out with and without the simultaneous operation of air purifiers and central ventilation system increasing the risk of SARS-CoV-2 virus contamination in dental clinics due to the aerosols emitted by the use of common dental instruments during standard treatments.

Artifact Detection in Lung Ultrasound: An Analytical Approach

Lung ultrasound is used to detect various artifacts in the lungs that support the diagnosis of different conditions. There is ongoing research to support the automatic detection of such artifacts using machine learning. We propose a solution that uses analytical computer vision methods to detect two types of lung artifacts, namely A- and B-lines. We evaluate the proposed approach on the POCUS dataset and data acquired from a hospital. We show that by using the Fourier transform, we can analyze lung ultrasound images in real-time and classify videos with an accuracy above 70%. We also evaluate the method's applicability for segmentation, showcasing its high success rate for B-lines (89% accuracy) and its shortcomings for A-line detection. We then propose a hybrid solution that uses a combination of neural networks and analytical methods to increase accuracy in horizontal line detection, emphasizing the pleura.

Skin-to-deltoid-muscle distance at three recommended sites for intramuscular vaccination in a population with obesity: an observational study

The study also explored i) the associations between skin-to-deltoid-muscle distance across the three recommended sites with sex, body mass index (BMI), and arm circumference, and ii) the proportion of participants with a skin-to-deltoid-muscle distance >20 millimetres (mm), in whom the standard 25mm needle length would not ensure deposition of vaccine within the deltoid muscle. method: When choosing the required needle length to achieve intramuscular vaccination in obese vaccine recipients, consideration needs to be given to the injection site location, sex, BMI and/or arm circumference, as these factors all influence the skin-to-deltoid-muscle distance. Published data report that a standard needle length (25mm) is suitable for most people with a body mass index (BMI) <25 kilograms [kg]/m2.48 However, progressively higher BMIs increase the likelihood of requiring a longer-than-standard needle length for deltoid intramuscular injection.810 Worldwide, immunisation guidelines vary in their instructions on how to choose the correct needle length based on BMI and body weight, or contain non-specific terms such as "larger arms".1113 An accurate measurement of BMI for a vaccine recipient is not always readily available and the interpretation of arm size is subjective, resulting in an increased risk of inappropriate needle length choice and subcutaneous vaccine delivery. An observational study of a SARS-CoV-2 mRNA vaccine, administered with needles of different lengths at the discretion of the vaccinator, did not demonstrate a difference in immunogenicity between those vaccinated with a needle of sufficient versus insufficient length to achieve intramuscular deposition of vaccine.14 However, there is evidence that intramuscular injection results in significantly better immune response compared to subcutaneous delivery of influenza and hepatitis B vaccines.15 Further, there is high-grade evidence that subcutaneous administration of different vaccine types (adjuvanted, live virus and non-adjuvanted) is associated with increased local side effects including abscess and granuloma formation, compared to intramuscular delivery.15" The location of the deltoid intramuscular injection site is defined variably between countries based on anatomical landmarks (Figure 1).

Masking morality in the making: how China's anti-epidemic promotional videos present facemask as a techno-moral mediator

The spread of Covid-19 has made facemask a critical artifact for people all over the world. Mediating between (non-)wearers and their environment, facemask makes people aware of a set of morally relevant distinctions and sometimes forces decisions on them. In fact, the semiotics of "facemask in use” largely shapes the parameters for human practice and experience in the epidemic. Drawing on the techno-moral mediation concept [Verbeek, 2008. "Obstetric Ultrasound and the Technological Mediation of Morality: A Postphenomenological Analysis.” Human Studies 31 (1): 11–26], we explore how anti-epidemic promotional videos released by Chinese authorities build facemask-related narratives in the Covid-19 epidemic. Findings reveal that "facemask in use” links people's "smaller love” for family to a "bigger love” for Chinese people in general;transforms an individual to member of a large group of commoner-turned-protectors;or marks the military's loyalty and obedience to the Party-State, which makes possible the "Chinese speed” in saving lives. We add to extant literature by unraveling an entanglement between the moralization of facemask-wearing and China's traditional values, social institutions and media newsroom culture about disaster coverage. This scrutiny into the "face-masking morality in the making” implies that the power to frame the cultural significance of facemask induces an alternative mode of techno-moral change, which may outlast the epidemic itself.

COVITALE 2020 from eastern Indian population: imageologists perspective, a learning curve

BackgroundHigh-resolution computed tomography (HRCT) chest becomes a valuable diagnostic tool for identifying patients infected with Coronavirus Disease 2019 (COVID-19) in the early stage, where patients may be asymptomatic or with non-specific pulmonary symptoms. An early diagnosis of COVID-19 is of utmost importance, so that patients can be isolated and treated in time, eventually preventing spread of the disease, improving the prognosis and reducing the mortality. In this paper, we have highlighted our radiological experience of dealing with the pandemic crisis of 2020 through the study of HRCT thorax, lung ultrasonography, chest X-rays and artificial intelligence (AI).ResultsResults of CT thorax analysis have been given in detail. We had also compared CT severity score (CTSS) with clinical and laboratory parameters. Correlation of CTSS with SpO2 values and comorbidities was also studied. We also analysed manual CTSS with the CTSS scored calculated by the AI software.ConclusionsCTSS and use of COVID-19 Reporting and Data System (CORADS) result in accuracy and uniform percolation of information among the clinicians. Bed-side X-rays and ultrasonography have played a role where the patients could not be shifted for CT scan. The possibility of predicting impending or progression of hypoxia was not possible when SpO2 mapping was correlated with the CTSS. AI was alternatively tried with available software (CT pneumonia analysis) which was not so appropriate considering the imaging patterns in the bulk of atypical category.

Severe Acute Pancreatitis Associated with Weil's Disease

Leptospirosis is an emerging zoonosis of worldwide importance. Its distribution is closely linked to hydrometric conditions. It is characterized by a wide clinical range, from the subclinical form, or one with few symptoms;which resolves spontaneously, to the multi-visceral form, known as icterrohemorrhagic disease or Weil's disease, with a lethal risk. All organs can be affected but with variable frequency. Pancreatic involvement is not well documented. We describe a 45-year-old man with Weil's disease associated with acute necrotizing pancreatitis. The evolution was favorable but required a three-week stay in the intensive care unit.

Electrochemical Sensing Platform Based on Renewable Carbon Modified with Antimony Nanoparticles for Methylparaben Detection in Personal Care Products

This paper describes for the first time the surface modification of glassy carbon (GC) electrodes with bamboo-based renewable carbon (RC) and antimony nanoparticles (SbNPs) for the determination of methylparaben (MePa) in personal care products (PCPs). The synthesized RC-SbNP material was successfully characterized by scanning electron microcopy, energy-dispersive X-ray spectroscopy and cyclic voltammetry. The proposed sensor was applied in the detection of MePa using the optimized parameters by differential pulse voltammetry (DPV). The analytical range for detection of MePa was 0.2 to 9.0 µmol L−1, with limits of detection and quantification of 0.05 µmol L−1 and 0.16 µmol L−1, respectively. The determination of MePa in real PCP samples was performed using the proposed GC/RC-SbNP sensor by DPV and UV-vis spectrophotometry as comparative methodology. The use of RC-SbNP material for the development of electrochemical sensors brings a fresh approach to low-cost devices for MePa analysis.