Bridging the gap with Pando

The Pando app is UK based and part of the NHS Clinical Communication Procurement Framework, which is designed to provide continuity of care with virtual patient management (https://www.bad.org.uk/healthcare-professionals/covid-19/re mote-dermatology-guidance), and drive tech-enabled connectivity across the National Health Service (NHS). This has also been used in the British Army to help defence medical staff connect with and seek advice from their colleagues in the UK while in the field (www.hellopando.com). Lack of on-site medical illustration, the COVID-19 pandemic and plastic surgeons operating in a NHS-funded private setting with no access to Picture Archiving and Communication System (PACS) in our Trust prompted use of the Pando app to capture prebiopsy pictures, avoid wrong-site surgery and improve interdepartmental communication. We present our multidisciplinary quality improvement project, involving dermatology and plastic surgery, evaluating the use of the Pando app from September to December 2020, mostly from 2-week-wait skin cancer clinics. All dermatology and plastic surgery colleagues downloaded the Pando app to their mobile phones and created a group entitled 'Dermatology/Plastics' to share their patient photos with identity labels. Patient photos could also be emailed to the clinicians' NHS email addresses - all done with patient consent. We evaluated our project with pre-and post-Pando feedback questionnaires. In the pre-Pando questionnaires, the majority of 14 colleagues involved were concerned with the varying quality of photos emailed by patients, the time lag in photos being uploaded to PACS and any likelihood of compromising patient safety. With post-Pando questionnaires, the majority found the app to be user-friendly, that the photographs taken were of superior quality, that there were no reported concerns with patient consent and they preferred using the app to the previous pathway. Comments suggested the Pando app to be invaluable for site recognition in patients with cognitive impairment, multiple lesions, difficult-to-see areas, medicolegal, educational and audit purposes, and local cancer multidisciplinary discussions. The drawbacks were the lack of seamless connection between the app and PACS, the inability to search for pictures in the app with patient identification and lack of access to previously shared pictures for new users. Despite some limitations, the Pando app has immensely improved patient safety and proved to be invaluable for our joint dermatology and plastic surgery interactions. However, there is an unmet need for a system with the ability to instantly transfer pictures to PACS and patient electronic records, to improve things further.

Natural evolution of COVID19 pneumonia radiological findings

Introduction: COVID19 pneumonias' outpatient follow up is mainly based on chest Xrays at 4 weeks post hospital discharge. The natural evolution of radiological findings on chest CT imaging between the time of diagnosis and at 4 weeks' post discharge remains vague. Aim(s): To review the natural evolution of CT radiological findings of COVID19 pneumonia Material(s) and Method(s): We prospectively reviewed patients in our postCOVID19 outpatient clinic at 4 weeks following hospital discharge. All patients were previously admitted due to COVID19 pneumonia. Thorough review of all medical records and the Picture Archiving and Communication System (PACS) followed. Result(s): 237 patients attended their first outpatient appointment at 4 weeks post discharge (11.2020-12.2021) (103 males, 134 females, mean age 54 years). 94.9% presented with HRCT as per local protocol and 5,1% presented with CXR due to concerns about radiation exposure. 72% (162/237) presented solely ground glass opacities (GGO) in HRCT versus a subsolid combination pattern in their HRCTs on hospital admission. 12,4% (28/237) presented with a combination of GGOs and traction bronchiectasis, the latter being novel findings. A mere 1,77% (4/237) had new onset pulmonary fibrosis while only 15,5% (35/237) had a normal chest CT scan. Conclusion(s): COVID19 pneumonia does not resolve radiologically within 4 weeks following hospital discharge. Although solid components seem to resolve within this timeframe, GGOs persist and are accompanied by bronchiectasis as a new finding.

Head and neck imaging manifestations in COVID-19: collective experience of 17 months during 2nd wave of the pandemic

Background: COVID-19 is well known to result in pulmonary and multiple extra-pulmonary manifestations. Among them, head and neck manifestations were commonly recognized in the 2nd wave of the pandemic. With the growing global COVID-19 burden, imaging is of utmost importance in diagnosing the disease and its related complications. The study aims to enumerate the various head and neck manifestations and their complications in COVID-19. Additionally, in sinusitis patients, the invasion was correlated with the neutrophil-lymphocyte ratio (NLR). Result(s): A cross-sectional observational study in which total of 78 COVID-19 cases that underwent head and neck imaging were retrospectively evaluated. The cohort included 52 males (66.7%) and 26 females (33.3%) with a mean age of 46.19 years (median = 49.0, SD = 16.47). The various head and neck manifestations included non invasive rhinosinusitis (n = 48), invasive sinusitis and its complications (n = 25), nasal septal abscess (n = 1), dacryoadenitis (n = 1), pre-septal and post-septal orbital cellulitis and its complications (n = 13), otitis media, mastoiditis and its complications (n = 6), parotitis (n = 2), neck vessel thrombosis (n = 2) and cervical lymphadenopathy (n = 3). An increase in the invasive nature of sinusitis was demonstrated among patients with comorbidities and elevated NLR. Conclusion(s): Early diagnosis and management of head and neck manifestations of COVID-19 are aided by prompt imaging. It is imperative that we are armed with the knowledge of various head and neck manifestations and how they may bear semblance to other pathologies for us to ensure COVID as a differential, especially in the background of known infection. Copyright © 2023, The Author(s).

Correlation between Chest CT Severity Scores and Clinical Parameters in Patients with COVID-19 Pneumonia: A Comparative Study between 1st and 2nd Wave

Aim and objective: To correlate a chest CT score in COVID-19 pneumonia with clinical severity and inflammatory biomarkers and overall patient's outcome. Materials and methods: In this retrospective single-center analysis, we collected data of 200 patients admitted to Fortis hospital during the peaks of the two waves of the COVID-19 pandemic. Data for 1st wave were collected between July and September 2020 (100 patients) and 2nd wave from March to April 2021 (100 patients). We collected clinical and laboratory data for analysis, derived from the electronic medical record system for the above durations. Only symptomatic patients within 10 days of onset of symptoms who had CT imaging done at admission were included in the study. A team of experienced radiologists analysed the images to determine the CT severity score based on the extent of lobar involvement. Each lung lobe was visually scored from 0-5, 0-no involvement, 1: <5% involvement, 2: 5-25% involvement;3: 26-50% involvement;4: 51-75% involvement;5: >75% involvement. The total CT score was the sum of individual lobar scores ranging from 0 (no involvement) to 25 (maximum involvement). The results of the chest HRCT images were collected and evaluated using the picture archiving and communication systems (PACS). Patient's chest CT score, P/F ratio, O2 requirement, and need for ventilatory support and mortality were compared. Descriptive statistics of patients demographics, clinical, and laboratory results were reported as numbers and relative frequencies. Frequencies of CT scores were calculated and compared with other clinical variables. The Pearson correlation coefficient test was used for correlations, considering p < 0.05 statistically significant. Results: Our study highlights the clinical implication of initial CT findings as a prognostic indicator in patients with COVID-19. In terms of demographic distribution median age was 57.5 and 58 years, respectively, and both the waves had a median male predominance of 65%. Wave 1 had more patients with lower CT scores and higher P/F ratio, whereas wave 2 had a significant lower P/F ratio for the same CT scores as compared to wave 1, especially at higher CT scores. CT score of >18/25 is associated with increased probability of ventilatory requirement and hence increased mortality in both the waves which was found to be statistically significant with p = 0.005. Also, higher CT scores were found to be positively correlated with lymphopenia, increased serum CRP, d-dimer, and ferritin levels. Conclusion: Chest CT imaging has played an important role in monitoring disease progression and predicting prognosis during the COVID-19 pandemic. They can be pivotal in assisting clinicians in diagnosing the severity, predicting the outcomes and most of all, in the management plan for the concerned patient. In our analysis of one of the largest single-centre studies conducted during the two waves of the COVID-19 pandemic in India, CT severity score was directly proportional with inflammatory lab markers, length of hospital stays, and oxygen requirement in patients with COVID-19 infection. CT Chest score of >18/25 on admission is associated with poor prognosis and increased mortality.

The prevalence of pulmonary embolism among COVID-19 patients underwent CT pulmonary angiography

Background Pulmonary embolism (PE) is a common and fatal complication of COVID-19 infection. COVID-19's main clinical manifestations are not only pneumonia but also coagulation disorders. This study evaluates the prevalence of pulmonary embolism at CT pulmonary angiography (CTA) for positive coronavirus patients as well as the factors associated with PE severity. Materials and methods This is a retrospective cross-sectional study that was conducted at King Faisal Medical Complex (KFMC) in Taif city of Saudi Arabia from June 2020 to June 2021. Data was collected from the picture archiving and communication system (PACs) for a total of 445 positive patients who underwent CT pulmonary angiography and analyzed using SPSS. Results The mean age and gender of the male were 57.3 ± 15.8 years and 64.5%, respectively. The prevalence of pulmonary embolism at CTA among patients with COVID-19 was found to be 8.1%. Bilateral segmental and bilateral subsegmental pulmonary embolism were found to be the most common sites for PE (16.7% for each). Furthermore, shortness of breath (SOB) was found to be the most common reported symptom among the respondents. Lastly, shortness of breath, chest pain, loss of taste or smell, D-dimer, and cardiac troponin were found to be significantly associated with PE (P-value = < 0.001, <0.001, 0.001, <0.001 and 0.037 respectively). Conclusion Present results show that the prevalence of pulmonary embolism among COVID19 patients with CT Pulmonary Angiography at KFMC is relatively low (8.1%) and most of the patients were from the ICU department. Early detection and treatment of COVID-19 patients with PE and APE complications are critical for lowering the mortality rate.

Upskirt exposure: The effectiveness of lead skirts to protect the urologist during seated endoscopic stone surgery

Introduction & Objectives: The use of intra-operative image intensifier (II) has increased in urological practice as the mainstay of stone surgery is performed endoscopically. Here we examine the radiation exposure to the groin of the urologist performed endoscopic stone surgery. Our primary aim was to assess whether urologists are exposed to potentially avoidable radiation exposure in the seated position when using vest and skirt lead protection. We hypothesize that the level of exposure is negligible and should not influence surgeon decision on seated versus standing or on lead apron versus skirt and vest combination protective wear. Methods: We conducted a prospective, multicentre study across all public hospitals in the Hunter New England Area Health Network offering Holmium:YAG laser lithotripsy. Routinely, servicing a very large population base, the number of laser lithotripsy cases are quite high however during our research period the coronavirus pandemic diminished the number of elective cases performed. Because of this, we included a total of 50 cases in this study. Small multidimensional-reading dosimeters were worn on the medial aspect of both upper thighs of the urologist under the lead skirt as well as a third dosimeter worn on the outside of the lead protective skirt. All cases were performed with the II in an under-couch position and all cases included were either ureteroscopy or pyeloscopy with laser destruction of urinary stones. In one centre, all surgery was performed by a consultant urologist whilst in another it was all performed by a registrar. Screening time and total dose delivered were prospectively collected using the local network picture archiving and communication system (PACS). This data was analysed by an onsite physicist and collated. After calculating mean and median radiation dose exposures for each dosimeter and grouping those worn under the skirt, comparison was made between dosimeters worn under skirt versus over skirt and Results: Lead gowns reduced radiation dose exposure by 87% (p = <0.01);99% on the side opposite the II and by 76% on the same side of the II (p = 0.2). Mean total dose area product was 88.9 GyCm2 with a mean screening time of 80 seconds per case (range 12-311 seconds). Conclusions: These results support the hypothesis that there is no significant exposure risk in a seated position with vest and skirt combination lead protective wear. An unexpected result was the difference in exposure between the side closest versus furthest away from the image intensifier.

SUSTAINING MULTIDISCIPLINARY CARE OF CHILDREN WITH CENTRAL NERVOUS SYSTEM TUMORS DURING THE COVID-19 PANDEMIC

INTRODUCTION: A multidisciplinary team (MDT) approach is essential for quality cancer care. Since 2019, we have conducted regular MDT meetings to discuss pediatric patients with central nervous system (CNS) tumors at the Philippine General Hospital. Because of COVID-19, an abrupt transition from in-person to virtual meetings became necessary. METHODS: We reviewed the proceedings of MDT meetings for pediatric CNS tumors from March 2020-December 2021. We identified the strategies and adaptations of our pediatric neuro-oncology group, and outlined recommendations for other institutions in low- and middle-income countries. RESULTS: Our pediatric neuro-oncology group conducted 18 virtual MDT meetings during the study period. Meetings were scheduled every last Tuesday of the month, with pediatric oncologists, neurologists, neurosurgeons, radiation oncologists, radiologists, and neuropathologists regularly attending. We invited other specialists as needed. In total, we had 135 case discussions for 79 unique patients, or about 8 patients per meeting. These included both inpatients (74%) and outpatients (26%). Ten patients received prior treatment elsewhere. At the time of the meeting, 86% were postoperative, 8% were preoperative, and 6% did not require surgery. Most (60%) had malignant CNS tumors and 15% had disseminated/leptomeningeal disease. Histopathologic diagnosis was obtained for 62 patients (79%). Concerns addressed were: formulating a treatment plan (88%), surveillance strategy (10%), and diagnostic workup (5%). DISCUSSION: Several factors contributed to the ease of online transition: (1) motivated care providers including a patient navigator, (2) fixed schedule, (3) institutional Zoom account for securing data privacy, and (4) availability of picture archiving and communication system (PACS) for neuroimaging. Challenges included: (1) delays due to internet connectivity, (2) Zoom fatigue and online distractions, and (3) risk for miscommunication or misunderstanding. Commitment of the entire neuro-oncology team is essential to ensure the delivery of best possible care for pediatric patients with CNS tumors.

Serum LDH: a potential surrogate to chest radiograph in pediatric Covid-19 patients to reduce radiation exposure

Background: Chest radiographs are frequently used to evaluate pediatric patients with COVID-19 infection during the current pandemic. Despite the minimal radiation dose associated with chest radiography, children are far more sensitive to ionizing radiation's carcinogenic effects than adults. This study aimed to examine whether serum biochemical markers could be potentially used as a surrogate for imaging findings to reduce radiation exposure. Methods: The retrospective posthoc analysis of 187 pediatric patients who underwent initial chest radiographs and serum biochemical parameters on the first day of emergency department admission. The cohort was separated into two groups according to whether or not the initial chest radiograph revealed evidence of pneumonia. Spearman's rank correlation was used to connect serum biochemical markers with observations on chest radiographs. The Student's t-test was employed for normally distributed data, and for non-normally distributed data, the Mann–Whitney U test was used. A simple binary logistic regression was used to determine the importance of LDH in predicting chest radiographs. The discriminating ability of LDH in predicting chest radiographs was determined using receiver operating characteristics (ROC) analysis. The cut-off value was determined using Youden's test. Interobserver agreement was quantified using the Cohen k coefficient. Results: 187 chest radiographs from 187 individual pediatric patients (95 boys and 92 girls;mean age ± SD, 10.1 ± 6.0 years;range, nine months–18 years) were evaluated. The first group has 103 patients who did not have pneumonia on chest radiographs, while the second group contains 84 patients who had evidence of pneumonia on chest radiographs. GGO, GGO with consolidation, consolidation, and peri-bronchial thickening were deemed radiographic evidence of pneumonia in group 2 patients. Individuals in group 2 with radiological indications of pneumonia had significantly higher LDH levels (p = 0.001) than patients in group 1. The Spearman's rank correlation coefficient between LDH and chest radiography score is 0.425, showing a significant link. With a p-value of < 0.001, the simple binary logistic regression analysis result validated the relevance of LDH in predicting chest radiography. An abnormal chest radiograph was related to LDH > 200.50 U/L (AUC = 0.75), according to the ROC method. Interobserver agreement between the two reviewers was almost perfect for chest radiography results in both groups (k = 0.96, p = 0.001). Conclusion: This study results show that, compared to other biochemical indicators, LDH has an 80.6% sensitivity and a 62% specificity for predicting abnormal chest radiographs in a pediatric patient with confirmed COVID-19 infection. It also emphasizes that biochemical measures, rather than chest radiological imaging, can detect the pathogenic response to COVID-19 infection in the chest earlier. As a result, we hypothesized LDH levels might be potentially used instead of chest radiography in children with COVID-19, reducing radiation exposure.

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.

Is Fatty Liver Associated with Increased Mortality and Morbidity in Coronavirus Disease 2019 (COVID-19) Pneumonia?

Background: Fatty liver has been shown to be associated with severe COVID-19 disease without any impact on mortality. This is based on heterogenous criteria for defining both fatty liver as well as the severity parameters. This study aimed to study the impact of fatty liver on the mortality and severity of disease in patients with COVID-19 pneumonia. Methods: In a case control study design, patients with COVID-19 pneumonia (COVID-19 computed tomography severity index [CTSI] on high-resolution computed tomography chest of ≥1) with fatty liver (defined as liver to spleen attenuation index ≤5 on noncontrast computed tomography cuts of upper abdomen) were compared with those without fatty liver. The primary outcome measure was in-hospital mortality, and the secondary outcome measures were CTSI score, need for intensive care unit (ICU) care, need for ventilatory support, duration of ICU stay, and duration of hospital stay. Results: Of 446 patients with COVID-19 pneumonia, 289 (64.7%)admitted to Max Hospital, Saket, India, between January 1, 2021, and October 30, 2021, had fatty liver. Fifty-nine of 446 patients died during the index admission. In-hospital mortality was not different between patients with fatty liver (38 [13.24%]) or without fatty liver (21 [13.81%]). COVID-19 CTSI score was found to be significantly higher among patients who had fatty liver (13.40 [5.16] vs 11.81 [5.50]; P = 0.003). There was no difference in the requirement of ICU (94 [32%] vs 62 [39.49%]; P = 0.752), requirement of ventilatory support (27 [9.34%] vs 14 [8.91%]; P = 0.385), duration of ICU stay (8.29 [6.87] vs 7.07 [5.71] days; P = 0.208), and duration of hospital stay (10.10 [7.14] vs 10.69 [8.13] days; P = 0.430) between the groups with fatty liver or no fatty liver. Similarly, no difference was found in primary or secondary outcomes measure between the group with severe fatty liver vs mild/moderate or no fatty liver. High total leucocyte count and Fibrosis-4 (FIB-4) index were independently associated with mortality. Conclusions: Fatty liver may not be associated with increased mortality or clinical morbidity in patients who have COVID-19 pneumonia.

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.

Digital radiograph rejection analysis during "Coronavirus disease 2019 (COVID-19) pandemic" in a tertiary care public sector hospital in Khyber Pakhtunkhwa Province of Pakistan.

BACKGROUND: Evaluation of X-ray reject analysis is an important quality parameter in diagnostic facility. The aim of this study was to find out the radiograph rejection and its causes during the coronavirus disease 2019 (COVID-19) pandemics as there was fear of coronavirus disease infection among the technical staff from the incoming patients in a busy, high volume public sector tertiary care hospital. MATERIALS AND METHOD: This descriptive study was conducted at Radiology Department, Lady Reading Hospital, Peshawar from August to November, 2020. The rejected radiographs and their causes were analyzed. RESULTS: A total of 15,000 X-ray procedures were conducted during study period out of which 2550 cases were repeated making the total rejection 17%. Rejection in male and female were 74.3 and 25.7%, respectively, while rejection in adults was (80.1%) and (19.9%) in pediatric age group of the total rejection. The main cause of rejection was positioning (30.5%) followed by artifacts (22.4%), motion (12.1%), improper collimation (10%), wrong labeling (8.4%), exposure errors (6.9%), detector errors (3.7%), machine faults (2.8%), re-request from referring physician (1.7%), and PACS issues (1.5%). In terms of body anatomical parts, the highest rejection was observed in extremities (44.1%), followed by chest radiography (23.3%), spine (11.4%), abdomen (6.4%), skull (5.9%), pelvis (4.7%), KUB (3.7%), and neck (0.6%), respectively. CONCLUSION: Radiograph rejection is common problem in every diagnostic facility but significant reduction can be achieved by implementing rejection analysis as basic quality indicator, and conducting technologist/s specific training programs for their knowledge and skill enhancement.

Risk of in-hospital death associated with Covid-19 lung consolidations on chest computed tomography - A novel translational approach using a radiation oncology contour software.

PURPOSE: To determine whether the percentage of lung involvement at the initial chest computed tomography (CT) is related to the subsequent risk of in-hospital death in patients with coronavirus disease-2019 (Covid-19). MATERIALS AND METHODS: Using a cohort of 154 laboratory-confirmed Covid-19 pneumonia cases that underwent chest CT between February and April 2020, we performed a volumetric analysis of the lung opacities. The impact of relative lung involvement on outcomes was evaluated using multivariate logistic regression. The primary endpoint was the in-hospital mortality rate. The secondary endpoint was major adverse hospitalization events (intensive care unit admission, use of mechanical ventilation, or death). RESULTS: The median age of the patients was 65 years: 50.6 % were male, and 36.4 % had a history of smoking. The median relative lung involvement was 28.8 % (interquartile range 9.5-50.3). The overall in-hospital mortality rate was 16.2 %. Thirty-six (26.3 %) patients were intubated. After adjusting for significant clinical factors, there was a 3.6 % increase in the chance of in-hospital mortality (OR 1.036; 95 % confidence interval, 1.010-1.063; P = 0.007) and a 2.5 % increase in major adverse hospital events (OR 1.025; 95 % confidence interval, 1.009-1.042; P = 0.002) per percentage unit of lung involvement. Advanced age (P = 0.013), DNR/DNI status at admission (P < 0.001) and smoking (P = 0.008) also increased in-hospital mortality. Older (P = 0.032) and male patients (P = 0.026) had an increased probability of major adverse hospitalization events. CONCLUSIONS: Among patients hospitalized with Covid-19, more lung consolidation on chest CT increases the risk of in-hospital death, independently of confounding clinical factors.