Determining Typical Patient Effective Dose Levels Using a Dose Monitoring System for Optimization Studies: Application to Dental Cone Beam Ct Imaging

Purpose: To use a dose monitoring system for determining typical patient effective dose levels for optimization studies of x-ray exposures, with a focus on dental cone beam CT (CBCT) imaging. Material(s) and Method(s): A dose monitoring system (DOSE, Qaelum NV, Belgium) was used to collect radiation exposure data (i.e. the recorded Dose Area Product (DAP) value in dGy.cm2, Field Of View (FOV) selection in cm2, and the system operation mode), as well as the patient age for 5163 dental CBCT examinations performed in the university hospital of Leuven from January to December 2019, just prior to the Covid-19 pandemic. Examinations were performed on a 3D Accuitomo 170 (Morita, Japan) and a VGi EVO (NewTom, Italy) CBCT system. The extracted DAP values were corrected with an experimentally determined correction factor obtained during annual quality control tests. For each CBCT system, effective dose conversion factors (CFs) as a function of DAP and patient age were calculated and implemented in DOSE. CFs were determined for the following age groups: 4-6y, 7-11y, 12-14y, and >=15y. For the effective dose calculations, patient data was, for each system, further classified based on the selected FOV and operation mode. The FOV size was categorized into small (<=40 cm2), medium (>40 cm2 and <=100 cm2), or large (>100 cm2). Result(s): For the standard operation mode, average effective doses on the 3D Accuitomo 170 system as a function of age group were, from young to old: 77.7-300, 54.4-210, 39.9-154, 35.1-136 Sv, and for the VGi EVO system: 60.5-117, 12.1-97, 9.54-69.9, 9.26-61.5 Sv. For both systems, a decreasing trend in the effective dose with increasing age was observed. For each age group, the doses increased with increasing FOV size. The selected operation mode also influenced the dose to the patient (e.g. for the high-resolution mode on the VGi EVO system, 1.5-4 times higher effective doses were observed compared to the standard mode). The effective dose levels on the NewTom VGi evo system were significantly lower than on the 3D Accuitomo 170. For the VGi EVO system, the most frequently used system in clinical practice, the total radiation burden from the examinations was 0.22 manSv. Conclusion(s): This was one of the first studies providing a complete 1 year overview of dental CBCT effective doses in a university hospital dental department. The results could be used for optimization studies and/or to situate the exposures in comparison to multislice CT or panoramic examinations.Copyright © 2023 Southern Society for Clinical Investigation.

A Case of Periradicular Surgery: Apicoectomy and Obturation of the Apex

Introduction: The purpose of the current case is to give a detail description on an incidence of a traumatized upper left central incisor with symptomatic periapical periodontitis which was root treated. Descriptions: The apical portion of the tooth had a large apical lesion with external root resorption that end up with an open apex due to the loss of tooth cementum, dentine and adjacent hard tissue. The tooth was endodontically retreated, and the apical region was treated surgically with apical curettage and retrograde Mineral Trioxide Aggregate filling (MTA). Result(s): The affected tooth was considered successful both functionally and aesthetically during a 12-month follow-up. Conclusion(s): Apicoectomy and retrograde filling with MTA is a viable option in case of treating traumatized tooth with large peri-apical lesion and open apex.Copyright © 2023 Japan University of Health Sciences & Japan International Cultural Exchange Foundation.

Are COVID-19 Lungs Recruitable-yes!!! If Done the Right Way

Aim and objective: To find out whether the COVID-19 affected ARDS lungs are recruitable with the combined use of 1. Transpulmonary pressure monitoring (to limit the stress);2. End expiratory lung volume measurement (to limit strain);3. Electrical impedance tomography;4. Compliance (to diagnose overdistension) and the increase in the SpO2 as a marker of clinical recruitment. Materials and methods: Retrospective data from charts and progress sheets were collected from 27 patients admitted to the ICU (between February 2021 and June 2021) with PaO2/FiO2 ratio <150 with a diagnosis of acute respiratory distress syndrome. Data acquisition: As a protocol, the esophageal pressure was monitored using the polyfunctional nasogastric tube (Nutrivent). The end-expiratory volume was measured using the Carescape R860 (Carescape R860;GE Healthcare) by the nitrogen multiple breath wash-out/ wash-in (EELV) at a PEEP of 5. Electrical impedance tomography measurements were performed using the PulmoVista 500. We performed a recruitment maneuver using the staircase maneuver. Statistics: Categorical variables are presented as frequency and percentage (%) and continuous variables are presented as mean and standard deviation. Comparison between pre- and post-recruitable was tested using t-test, while repeated-measures ANOVA was used to test follow-ups like 2 hours and 4 hours. Statistical significance is assumed at a value of p < 0.05. Results: As per the results of our study we found that almost 2/3rd (66.7%) of the COVID ARDS lungs were recruitable safely. The average plateau pressure (cm of H2O), mean compliance, FRC, and SPO2 were noted before the attempt at recruitment and after recruitment. After conducting the staircase manoeuvre, the plateau pressure remained at 25.56 with a standard deviation of 3.641. However, the mean compliance rose to 31.926 with a standard deviation of 10.099. Post recruitment there was a marked rise of FRC to 1581.778 with a standard deviation of 311.049 mL. Pre recruitment means SPO2 was 83.6% with a standard deviation of 3.9%. Post recruitment at 2 hours the SPO2 had reached 91.1% with a standard deviation of 5.4% and remained the same at 91.9% with a standard deviation of 7.5%. Among the 27 patients' clinical recruitment was seen in 18 patients (66.7%). As per the results of our study, we found that almost 2/3rd (66.7% or 18/27 pts) of the COVID ARDS lungs were recruitable safely (rise in SPO2 maintained at 2 and 4 hours along with the absence of overdistension as seen on EIT with an increase in FRC and compliance). Conclusion: As per the results of our study almost 2/3rd of COVID-19 patients were recruitable. This is the first Indian study to comprehensively study recruitment in COVID-19. ARDS pts with the best available techniques. This study shows that majority of COVID-19 lungs may be recruitable in the earlier stage of the illness (within the first week of ARDS) and thus warrant a trial of a safe monitored recruitment strategy.

The impact of COVID-19 on the performance of the Rapid Access Lung Clinic: The Cork/Kerry experience

Background: The COVID-19 pandemic has contributed to lower hospital admissions and higher mortalities associated with chronic conditions such as cancer and cardiovascular diseases. The Rapid Access Lung Clinic (RALC), established in 2009 for immediate assessment of individuals at risk of lung cancer, has experienced reduced functioning particularly during the pandemic peaks in Ireland. Therefore, we undertook a retrospective chart review of the 2019-2021 referrals and attendances at the Cork University Hospital (CUH) RALC to determine the impact of COVID-19 on this pathway. Methods: The medical charts of patients referred to CUH RALC from 03/2019 to 02/2020 (period I), and from 03/ 2020 to 02/2021 (period II), were reviewed after ethical approval was obtained. Clinicodemographic characteristics including age, sex, and hometown were extracted. Average time to acquire the first CT scan, consultation at RALC, and receiving a diagnosis of cancer were calculated using the date of referral and compared between periods I and II using the t-test. Frequency and the stages of cancer diagnosis in periods I and II were compared using a Chi-squared test. Progression-free and overall survivals were measured from diagnosis date until 09/2020 for period I and 09/2021 for period II. Results: Of the 1192 medical charts reviewed;687 patients in period I and 505 patients in period II were referred to RALC;indicating a 26.5% reduction in the number of referrals during the first year of the pandemic. Average monthly referrals (p = 0.008) and reviews (p = 0.017) were significantly lower in period II compared to period I and corresponded with the COVID-19 peaks in 04/2020 and 01/2021 in Ireland. However, no significant difference was seen in the length of time from referral to review at RALC (p = 0.11). There were 33% fewer post-referral CT scans performed (p = 0.032) and shorter wait times from referral to CT scan in period II (p = 0.001). The frequency of cancers detected did not differ between periods I and II. While there was no difference in the wait times from referral to diagnosis between periods, patients ultimately diagnosed with lung cancer in period II received surgery sooner than patients in period I (p = 0.024). Progression-free and overall survivals for patients diagnosed with lung cancer were comparable between periods I and II. Conclusions: Contrary to our hypothesis, we have shown that the COVID-19 pandemic had minimal impact on the performance of RALC. Shorter wait times for CT scan and surgery during the pandemic account for fewer hospital referrals and availability of CT scanner. Fewer referrals to RALC in period II may relate to the fewer patients attending their general practitioner (GP) and/or GPs raising the thresholds for referrals to RALC during the pandemic. Ultimately, a national evaluation will be required to fully determine the impact of this pandemic on lung cancer diagnosis, management, and outcomes in Ireland.

Sensitivity and specificity of RT PCR and HRCT Thorax for Confirmed Diagnosis ofCOVID-19

Introduction:TheCOVID-19pandemichasrepeatedlyhittheplanetwithawaveofinfection.Clinicians are attempting to defend public health care ethics. Asymptomatic COVID-19 casesgounrecorded,andthemajorityofthemisolatethemselves.Significantradiologicalabnormalit ies have been discovered in RT-PCR positive asymptomatic COVID-19 cases,accordingto studies. Objective:Thegoalofthiscross-sectionalstudyistoevaluateasymptomaticRT-PCRpositivepatients'chest CT findingsin oneof India's COVID-designatedinstitutions in a tertiary care centre in Bihar. Methods: In three months, we did HRCT chest of diverse (200 patient case study) proved andprobableinstances of COVID-19 infection. All patients are underwent HRCT chest by multislice (128 slice) Toshiba CT scan (Aquilion) or 16 slice Toshiba CT scan. The following CT parameters were used: collimation 5mm;slice thickness, 0.5- 2.5 mm;reconstruction interval, 2.5 mm;table speed 13.5 mm per rotation;150 -250 mA effective current;tube potential 120kVp;and matrix size, 512 x 512. the patient was examined in supine position with both arms extended above the head. All CT chest were taken in caudocranial direction, covering entire chest from diaphragmatic dome up to lung apex, without intravenous contrast administration. The image finally send to PACS for reporting. Results: Positive HRCT chest results were detected in 196 of 200 scanned individuals withclinical complaints and suspicion, indicating clinical-radiological association and an accuracyof 98 percent. Based on positive RT-PCR data, the sensitivity of chest CT in suggestingCOVID-19was98.6%(146/148patients).90percent(18/20)ofpatientswithnegativeRTPCRresultsandsigni ficantclinicalsuspicionhadpositivechestCTfindings. Conclusion:InlaboratorynegativeRT-PCRcaseswithstrongclinicalsuspicionofCOVID-19infection,HRCTchestisparticularly sensitive and accurate in detecting up lung parenchymal abnormalities, as well asin all symptomatic patients whose RT-PCR was not done. In patients with a strong clinicalsuspicion,HRCTcanbeexceedinglysensitive,cost-effective,andtimeeffective.HRCT outperformsRTPCRintermsofprovidingimmediateresults,measuringdiseaseseverity,andprognosisprediction. InallpatientswithclinicalsymptomsandsuspicionofCOVIDinfection,regardlessoflaboratoryRTPCRstatus,werecommendHRCTchestforidentificationofearlyparenchymalabnormalities and determining diseaseseverity.

Advantages of Positron Emission Tomography/Computed Tomography Over Conventional Computed Tomography in Evaluation of Lymphoma

Background: Lymphoma is one of the most common primary malignancies of the hematopoietic system. Lymphoid neoplasms are classified into Hodgkin’s and Non-Hodgkin’s lymphoma. Non-Hodgkin lymphoma accounts for about 5% of all cases of malignancies, It is less predictable than Hodgkin lymphoma and more liable for extra-nodal spread. Males are slightly more affected than females with higher incidence in white population. B-cell lymphomas have higher incidence in adults while T-cell lymphomas have higher incidence in children. With many imaging modalities that can describe the morphological changes in lymph nodes, it’s almost exclusive for the PET/CT to describe the biological changes in those lymph nodes through their uptake of FDG which has a great value in determining whether those lymph nodes are affected or not, which in turn will play an important role in treatment & management plan. What gives PET/CT scan the upper hand is that it acts on the biological level of the cells which permit early discovering of the affected lymph nodes, much earlier than standard C.T or MRI scan.

CT severity score: an imaging biomarker to estimate the severity of COVID-19 pneumonia in vaccinated and non-vaccinated population

Background: In India, two vaccines received emergent use authorization, namely Covishield (a brand of the Oxford—Astra Zeneca vaccine manufactured by the Serum institute of India) and Covaxin (developed by Bharat Biotech) against COVID-19 disease. Chest CT is an objective way to assess the extent of pulmonary parenchymal involvement. This study aims to estimate the disease severity and outcome due to COVID-19 among vaccinated and non-vaccinated symptomatic patients and compare the same in Covishield versus Covaxin recipients using CT severity score. Results: A total of 306 patients were retrospectively evaluated. The mean age was 62.56 ± 8.9 years, and males [n-208 (67.97%)] were commonly affected. Of 306 patients, 143 were non-vaccinated (47%), 124 were partially vaccinated (40%), and 39 were completely vaccinated (13%). CT severity scores were reduced in both Covishield and Covaxin recipients in comparison with the non-vaccinated group [χ2 (2) = 16.32, p < 0.001]. There is a reduction in LOS among the vaccinated group, predominantly among the Covishield recipients. Conclusion: Vaccination confers protection from severe SARS-CoV2 infection and is associated with an overall reduction in mortality.

Parotid Abscess in A Case of Acute Lymphoblastic Leukemia

Parotid gland enlargement as a presenting manifestation of acute lymphoblastic leukemia (ALL) is very rare, even though it has been reported in acute myeloid leukemia. Here we present a case of parotid abscess in a case of ALL in the presence of Dengue.

Radiological manifestations and complications of lung and brain in Egyptian COVID-19 patients

Background: Coronavirus disease COVID-19 is a viral illness, currently affecting millions of people worldwide. Pneumonia is the most common extreme presentation of COVID-19 infection, manifesting by fever, dry cough, difficulty of breathing or shortness of breath and mainly ground-glass infiltrates in radiological images. Chest computed tomography (CT) has a potential role in the diagnosis, detection of complications and prognostication of coronavirus disease COVID-19. In addition to severe respiratory manifestations, there are a wide range of neurological manifestations ranging from nonspecific symptoms to necrotizing encephalopathies and stroke. Our study aimed to review lung and neurological manifestations in recent and post-COVID-19 Egyptian patients and to be familiar with magnetic resonance imaging (MRI) findings of Neuro-COVID patients. Results: The present study included eighty COVID-19 patients with age ranged from 28 to 78 years (mean age 57.84 + 12.58 years) who were 54 males (mean age 56.64 + 12.50) and 26 females (mean age 48.65 + 14.24). All our patients were with recent or previous history of COVID-19 infection and subjected to careful history taking, thorough clinical examination, routine laboratory investigations and CT examination. The reported lung manifestations included normal lung shadows, ground-glass opacifications (GGOs), consolidations, reticulation, reticulation and GGOs (crazy paving) and fibrotic-like changes. Out of eighty COVID-19 patients, twenty showed neurological manifestations ranging from nonspecific symptoms to necrotizing encephalopathies and stroke. Patients with neurological manifestation were in addition to CT submitted to magnetic resonance imaging (MRI) as appropriate. MRI done to neuro-COVID patients showed that 8/20 (40%) had no abnormalities and 12/20 (60%) had abnormalities. The most common abnormalities are infarction, major or lacunar infarction, followed by acute disseminated encephalomyelitis (ADEM), posterior reversible encephalopathy syndrome (PRES) and meningoencephalitis. Conclusion: Old age patients, especially males, were more affected than females. Lung manifestations are common in COVID-19 patients than neurological manifestations. The presence of fibrotic changes in the lung could predict severe COVID-19 affection and bad prognosis. There might be an association between appearance of neurological manifestations and poor outcome in COVID-19 patients.

Correlation between chest CT severity scoring system with oxygen saturation and laboratory inflammatory markers in adult patients with COVID-19 infection

Background: COVID-19 pneumonia is responsible for the latest pandemics. Chest computed tomography (CT) scan is known to be an essential tool for diagnosis of COVID-19. In this research, the relationship between on-admission chest CT severity score, capillary blood oxygen saturation level, and laboratory inflammatory markers results in patients with SARS-COV-2 pneumonia was investigated. Methods: This prospective analytical study was conducted in COVID-19 isolation unit, Zagazig University Hospitals, from 1st to end of April 2021. Adult patients with COVID-19 infection were included. Chest CT scan was performed for all patients, and CT severity score was computed. The initial capillary oxygen saturation was also assessed at the time of admission. The information was gathered and analyzed. Results: A total number of 305 COVID-19 patients were involved in the study with the following data: age, gender, presence of co morbidities, capillary blood oxygen saturation, laboratory tests including absolute lymphocytic count, CRP, D-dimer and ferritin levels, as well as chest CT severity score. Based on chest CT severity score, we found that 110 cases (36.1%) were mild, 163 cases (53.4%) were moderate, and 32 cases (10.5%) were severe, with significant male predominance among moderate and severe cases. The initial measurements of blood oxygen saturation values revealed that mean blood oxygen saturation was 95.6% among mild to moderate cases and 85.4% among severe cases. Furthermore, there was a high statistically significant negative correlation between chest CT severity score and absolute lymphocytic count of studied cases, while there was a statistically significant positive correlation with D-dimer, CRP and ferritin levels. Conclusions: CT scans can help clinicians in developing a management strategy and serve as a predictor of illness severity and possible outcomes. In individuals with COVID-19 infection, the severity of a chest CT scan is positively correlated to inflammatory markers and oxygen demand.

Submillisievert CT chest for COVID-19 patients in a rural hospital with limited resources

Background: This is a secondary analysis of prospectively acquired data approved by the hospital institutional board committee. We performed a retrospective chart review of 463 patients who underwent a CT Chest for suspected COVID-19 infection between April 1st, 2020, and March 31st, 2021. Patients were grouped based on the CT chest obtained protocol: ultra-low dose or full dose. The likelihood of suspicion of COVID-19 infection was classified on a Likert scale based on the probability of pulmonary involvement. For each group, the sensitivity and specificity of CT were compared to nasopharyngeal swab as standard of reference. The median dose length product and duration of apnea were compared between both groups using two-tailed Mann–Whitney U test. The aim of this study is to share our experience of reducing radiation dose in COVID-19 patients by using an ultra-low dose CT chest protocol on a 16 row multidetector CT scan in a hospital with limited resources. Results: Two hundred sixty-nine patients underwent a full dose CT and 194 patients an ultra-low dose CT. In the former group, the median dose length product was 341.11 mGy*cm [Interquartile range (IQR), 239.1–443.2] and the median duration of apnea was 13.29 s [IQR, 10.85–15.73]. In the latter group, the median dose length product was 30.8 mGy*cm [IQR, 28.9–32.7] and median duration of apnea was 8.27 s [IQR, 7.69–8.85]. The sensitivity of the ultra-low dose CT was 91.2% and that of the full dose was 94%. Conclusion: A 90% reduction in estimated dose and 38% reduction in apnea duration could be achieved using an ultra-low dose CT chest protocol on a 16-row MDCT without significant loss in the sensitivity of CT to detect COVID-related parenchymal involvement.

Diagnostic value of FDG-PET/CT in fever of unknown origin

Background: Fever of unknown origin (FUO) is a challenging clinical problem in medicine that needs collaboration of various diagnostic techniques to establish the accurate diagnosis. We evaluated the diagnostic performance of 18F-FDG PET/CT in patients who presented themselves with FUO. Our study included 40 patients with FUO who underwent PET/CT examination and their results were compared to the results of laboratory, histopathological, microbiological investigations and/or response to therapy. Results: The final diagnosis included malignancy in 20 patients (50%), infectious causes in 7 patients (17.5%) and non-infectious inflammatory causes in 6 patients (15%). Fever resolved without diagnosis in 4 patients (10%), while no definite diagnosis was reached in 3 patients (7%). PET/CT successfully contributed to diagnosis of 35 out of 40 patients with diagnostic accuracy of 87.5%. The sensitivity, specificity, positive predictive value and negative predictive value of PET/CT in our study were 93.5%, 66.7%, 90.6% and 75%, respectively. Conclusion: PET/CT is a useful tool to investigate and diagnose the cause of FUO. It provides information that can guide the treatment strategy of the patients.

Correlation between the initial CT chest findings and short-term prognosis in Egyptian patients with COVID-19 pneumonia

Background: The recent pandemic of COVID‐19 has thrown the world into chaos due to its high rate of transmissions. This study aimed to highlight the encountered CT findings in 910 patients with COVID-19 pneumonia in Egypt including the mean severity score and also correlation between the initial CT finding and the short-term prognosis in 320 patients. Results: All patients had confirmed COVID-19 infection. Non-contrast CT chest was performed for all cases;in addition, the correlation between each CT finding and disease severity or the short-term prognosis was reported. The mean age was higher for patients with unfavorable prognosis (P < 0.01). The patchy pattern was the most common, found in 532/910 patients (58.4%), the nodular pattern was the least common 123/910 (13.5%). The diffuse pattern was reported in 124 (13.6%). The ground glass density was the most common reported density in the study 512/910 (56.2%). The crazy pavement sign was reported more frequently in patients required hospitalization or ICU and was reported in 53 (56.9%) of patients required hospitalization and in 29 (40.2%) patients needed ICU, and it was reported in 11 (39.2%) deceased patients. Air bronchogram was reported more frequently in patients with poor prognosis than patients with good prognosis (16/100;26% Vs 12/220;5.4%). The mean CT severity score for patients with poor prognosis was 15.2. The mean CT severity score for patients with good prognosis 8.7., with statistically significant difference (P = 0.001). Conclusion: Our results confirm the important role of the initial CT findings in the prediction of clinical outcome and short-term prognosis. Some signs like subpleural lines, halo sign, reversed halo sign and nodular shape of the lesions predict mild disease and favorable prognosis. The crazy paving sign, dense vessel sign, consolidation, diffuse shape and high severity score predict more severe disease and probably warrant early hospitalization. The high severity score is most important in prediction of unfavorable prognosis. The nodular shape of the lesions is the most important predictor of good prognosis.

Accidental diagnosis of significant coronary artery disease by cardiac CT scan to rule out left atrial appendage thrombus in patients with atrial fibrillation during COVID19 pandemic

Introduction The exclusion of left atrial appendage (LAA) thrombus prior to urgent electrical cardioversion (DCCV) for atrial fibrillation (AF) is traditionally performed by transesophageal echocardiography (TEE). During the COVID19 pandemic, TEE was replaced by cardiac CT (CCT) due to its high aerosol generating property, which in addition to assessing the anatomy of the heart, can also be used to evaluate the coronary arteries at the same time. Methods In our retrospective study, we evaluated the cardiac CT scans of patients undergoing DCCV in our institution between January 1, 2020 and February 28, 2021 for coronary artery disease (CAD). The scans were performed by a GE Revolution 256-slice CT scanner. Results CCT scans were performed in 32 patients to rule out LAA thrombus (24 male;8 female;age: 61.8 ± 11.2 years;BMI: 29.2 ± 4.4;heart rate: 79.2 ± 24.4 1/min;CHA2DS2VASc score: 2.4 ± 1.5). The mean radiation exposure of the scans was DLP: 356.3 ± 130.1 mGy-cm;effective dose: 5.0 ±1.8 mSv, Ca-score: 361.4 ± 883.0. In 4 equivocal cases TEE was also performed with negative results. No CAD was confirmed in 7 cases, mild CAD in 14 patients. CCT was not diagnostic only in 4 cases. Significant (moderate or severe) CAD was detected in 7 cases, invasive coronary angiography (ICA) was also performed in 5 cases. In 2 cases significant one-vessel disease, in 2 other cases borderline (FFR: 0.81 and 0.84) stenosis and in 1 case only mild CAD was diagnosed by ICA. Conclusions: CCT scans performed by our 256-slice CT scanner for AF can identify patients, who require further invasive or invasive and functional coronary artery assessment with satisfactory accuracy. In terms of coronary artery disease, the non-diagnostic scan rate was low, despite the presence of arrhythmia, suboptimal heart rate and higher than usual Ca-score.

'One stop colorectal cancer and radiological staging' (OSCARS) pathway reduces time from referral to diagnosis

Purpose/Background: To investigate the effectiveness of a one-stop colorectal cancer (CRC) staging pathway using faecal immunochemical test (FIT) as stratification tool. Methods/Interventions: The OSCARS pathway, which uses FIT as a triage tool to identify 'high risk' patients, was formally introduced in March 2020 in our Hospital Trust. A major driving force for this was to deal with the increased pressures on diagnostic services resulting from the COVID-19 pandemic. 2 week wait colorectal cancer referrals deemed appropriate to proceed to diagnostic testing prior to a clinic review ('straight to test') who had a FIT > 100 μg Hb/g faeces were allocated to the OSCARS pathway. This involved a single hospital visit during which they would have an endoscopy, a staging CT or completion CT colonography if needed, and be assessed and counseled by a colorectal cancer surgeon. Notes of all patents referred with suspected colorectal cancer between 01/01/2020 and 16/03/2021 (prior to the introduction of the pathway) and 16/03/2021 and 31/07/2021 (post introduction of the pathway) were reviewed to evaluate outcomes of the pathway. Time from referral to investigations, histological diagnosis and discussion at multidisciplinary team (MDT) meeting was compared before and after the introduction of the OSCARS pathway. Results/Outcomes: There were a total of 748 patients referred with suspected colorectal cancer in the pre-OSCARS group and 1194 in the OSCARS group. of those who were referred with an increased FIT, 43 (8.0%) and 86 (7.9%) were diagnosed with colorectal cancer (CRC) respectively. CRC diagnoses established on a 'straight to test' pathway increased from 69.8% in pre-OSCARS to 86.0% in the OSCARS groups, likely due to better stratification to a 'straight to test' pathway through the use of FIT. Despite the COVID-19 pandemic coinciding with the introduction of the OSCARS pathway, time for 'referral to first investigation' and 'referral to endoscopy' were similar between the groups (13 vs 12 days, p = 0.511 and 13 vs 13, p = 0.988). All patients diagnosed with cancer in the OSCARS group had staging CT scan on the same day (as opposed to 4 days pre-OSCARS, p = 0.002) but the difference in time for 'endoscopy to MRI' (8 vs 5 days, p0.271) or 'endoscopy to histopathology (4 vs 5 days, p = 0.236) did not change significantly. Time for 'endoscopy to MDT' was significantly reduced from 14.5 to 9 days (p = 0.019). Conclusion/Discussion: Time from referral to diagnostic test on 'straight to test' pathway remained unchanged in our Trust despite COVID-19 pandemic as a result of stringent stratification using FIT. Time from 'endoscopy to MDT' was significantly reduced with introduction of the OSCARS pathway due to same day access to CT scanner. It is likely that this section of the 2ww pathway would further be reduced with improved access to MRI and histopathology reporting services. Although OSCARS pathway reduces the number of hospital visits, its effect on patients' experience needs to be formally assessed.

CT Scan Finding Characteristics of Confirmed Covid-19 Patients Based on Clinical Symptom Onset Patterns

Chest computed tomography (CT) scan is one of the main modalities to detect COVID-19 infection. Several CT scan findings are the hallmark to rapidly detect suspected COVID-19 infection, therefore timely treatment could be administered. This study aims to describe chest CT scan findings of confirmed COVID-19 patients based on clinical symptom onset patterns. This study is a descriptive study with a retrospective design in confirmed COVID-19 patients. Data regarding characteristics of chest CT scan findings and the patient’s history including clinical symptoms onset were collected. There were 123 subjects in this study. The study data were categorized into modified clinical symptom onset patterns which were early, progressive, peak, absorption, and advanced phases. Most of male (57%) and female (43%) patients that were admitted to the hospital were in absorption phase of the disease with fever, cough, and dyspnea as the most prevalent symptoms. Chest CT scan findings of absorption phase included GGO (ground glass opacity) in 28 patients (76%), crazy paving pattern in 18 patients (49%), consolidation in 22 patients (59%), and fibrosis in 31 patients (84%). Chest CT scan findings of confirmed COVID-19 patients vary depending on the phase of the disease. Risk factors and secondary bacterial infection may contribute to long-term persistence of symptoms.

BREATH HOLDING TIME AND OXYGEN SATURATION IN COVID AFFECTED NURSING STUDENTS-A COMPARATIVE STUDY

Objective: The present study is based on a novel approach of validated breath-holding technique and efficiency of SpO2 in the adverse COVID-19 outcomes and comparison with normal subjects. Methods: It is a prospective observational study conducted in residential/private nursing colleges, St. Luke’s School and College of Nursing and Smt. Vijaya Luke’s College of Nursing, Visakhapatnam during the period July 2021. Fifty-three student nurses affected with mild COVID-19, 35 student nurses affected with moderate COVID-19, aged 18–23 years were enrolled after taking thorough history about COVID-19 that is after 2 months of complete recovery. They were classified based on the symptom history in which the subjects without symptoms or mild symptoms were taken as mildly affected, whereas subjects with severe symptoms with mild fluctuations in SpO2 who didn’t require hospitalization were classified as moderately affected. The study included 109 normal control cases who are never affected with COVID-19 viral infection. In all the subjects, the oxygen saturation was measured using pulse oxymeter and their Breath holding times were also measured using standard protocols. Results: The mean value of BHT was significantly reduced from normal 16.7339±3.4 to 12.8571±5.1 (p<0.05) in moderate cases. When oxygen saturation levels were compared before and after the breath holding in normal, mild and moderate cases the results were significant. However, when the oxygen saturation levels were compared between normal and mild COVID-19 cases the values were insignificant (p=0.4) and at the same time when the oxygen saturation levels were compared between normal and moderate COVID-19 cases the values were significant (p=0.0001). Conclusion: According to the findings, breath-holding does not need greater energy expenditure or cardiac output, and it eliminates walking and the related contamination of bystanders as occurring with pulse oximeter. Breath holding time is a determinant of respiratory capacity, when used as parameter helps in assessing the progression of lung injury, it gives an idea about respiratory fitness especially in this COVID era. Breath holding time and fluctuations in SpO2 when used conjointly we can assess degree of lung damage so that further treatment such as the continuity of medication, practicing of breathing exercises with or without medical treatment can be planned. This simple non-invasive tool can be used for the self-assessment of improvement in post-Covid patients. Future validation studies validate this hypothesis, measurement of these basic, innovative surrogates requires minimum inventory (i.e., a means to record oximetry and a timing device) and could feasibly provide a useful way to evaluate risks of future deterioration under under-resourced conditions.

Step-by-step surveillance in children with multisystem inflammatory syndrome associated with COVID-19 infection: proposal of a cardiologic follow-up

Introduction: Multisystem Inflammatory Syndrome Associated with COVID-19 Infection (MIS-C) shows many matches with children with Kawasaki disease (KD) and most children with MIS-C have incomplete or complete KD-like phenotype. In these patients cardiologic involvement mimics KD, showing, however, a higher incidence of severe acute manifestations. Objectives: In children with MIS-C and clinical findings related to heart disease, ECG and echocardiography are the first-line imaging. Until now, there are no international guidelines on the management of these patients. We suggest to take inspiration from the recommendations for KD for the significant phenotypic overlap between MIS-C and KD. Methods: We propose a step-by-step cardiologic imaging follow-up: - in all the patients, we recommend ECG and echocardiography at the diagnosis, at the worsening of the clinical and/or blood chemist parameters (CRP, ESR, ferritin;proBNP, troponin, D-Dimer), at any change of treatment supported by clinical worsening, at 8, 30, 45, 60, 90, 180 days since the diagnosis. The time-table may be changed in consideration of the outcome of the patient. -In patients with coronary artery dilatation (CAL), documented by echocardiography, it is advisable to follow-up them, since the diagnosis, with ECG, echocardiography, D-dimer, pro-BNP, troponin. -If CAL are oversized with z-score >- 2,5, according to age and body surface or increase during the follow-up: -it is recommended to perform Coronary Computed Tomography (CT) (CCA) or Cardiac Magnetic Resonance Angiography (CMRA). In fact, echocardiography cannot visualize the whole coronary artery vessels. Results: Both allow visualization of coronary artery aneurysms, vessels thickening, myocardial perfusion defects, permitting risk stratification and handing treatment decisions. CMRA is the first choice, because it is a radiation-free imaging method. It can evaluate the entire coronary artery system and provides details on myocardial function ischemia (detecting areas of inducible myocardial ischemia with pharmacological stress), infarction, inflammation, fibrosis. However, the new generation Multidetector Single -Source CT scanners and Dual Source Ct scanner allow a fast heart CT study with low radiation dose and reduce the need for sedation. CMR is less suitable because it is a lengthy examination and very often requires general anesthesia. If echocardiography demonstrates myocardial dysfunction or valve regurgitation at admission or during hospitalization, we suggest performing CMR. There is no consensus on the right timing. Conclusion: We suggest performing CMR during the acute or subacute phase: it is a step of the relieve in the cardiologic diagnosis to assess ventricular function and myocardial active injuries (oedema, hyperemia, ischemia, necrosis) and to repeat the imaging at the discharge in patients with the first pathological CMR, to evaluate fibrosis by myocardial delayed enhancement. CMR at the discharge is suggested also in cases with the first CMR normal, who showed a worsening of the echocardiographic parameters, the relieve of newinsurance valvulitis, persistent arrhythmia. At 3-6 months since the patient showed the remission, the CMR must be repeated to avoid any fibrotic lesions.

Prognostic impact of CT severity score in childhood cancer with SARS-CoV-2

Background: CT chest severity score (CTSS) is a semi-quantitative measure done to correlate the severity of the pulmonary involvement on the CT with the severity of the disease. The objectives of this study are to describe chest CT criteria and CTSS of the COVID-19 infection in pediatric oncology patients, to find a cut-off value of CTSS that can differentiate mild COVID-19 cases that can be managed at home and moderate to severe cases that need hospital care. A retrospective cohort study was conducted on 64 pediatric oncology patients with confirmed COVID-19 infection between 1 April and 30 November 2020. They were classified clinically into mild, moderate, and severe groups. CT findings were evaluated for lung involvement and CTSS was calculated and range from 0 (clear lung) to 20 (all lung lobes were affected). Results: Overall, 89% of patients had hematological malignancies and 92% were under active oncology treatment. The main CT findings were ground-glass opacity (70%) and consolidation patches (62.5%). In total, 85% of patients had bilateral lung involvement, ROC curve showed that the area under the curve of CTSS for diagnosing severe type was 0.842 (95% CI 0.737–0.948). The CTSS cut-off of 6.5 had 90.9% sensitivity and 69% specificity, with 41.7% positive predictive value (PPV) and 96.9% negative predictive value (NPV). According to the Kaplan–Meier analysis, mortality risk was higher in patients with CT score > 7 than in those with CTSS < 7. Conclusion: Pediatric oncology patients, especially those with hematological malignancies, are more vulnerable to COVID-19 infection. Chest CT severity score > 6.5 (about 35% lung involvement) can be used as a predictor of the need for hospitalization.