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Coronavirus Will Strain Radiology, Chest CT



MARCH 20, 2020 — The coronavirus pandemic will strain many healthcare sectors, including radiology. Radiologists have been conscripted to the front line because COVID-19 has signatures on chest CT befitting of viruses that damage lungs. But CT can be normal in early illness, and after each potentially infected patient is scanned, the machine must be completely disinfected. Therefore, CT isn’t recommended to screen for COVID-19.

Of course, CT will still be used in patients with acute respiratory symptoms, some of whom may have coronavirus infection. How should radiologists report findings suggestive of COVID-19 in patients imaged for other conditions? The answer isn’t straightforward and needs careful thought.

When present, the findings of COVID-19 on CT — notably peripheral ground-glass opacities — are sensitive but not specific for coronavirus; other pneumonias resemble COVID-19, particularly viral and Pneumocystis jirovecii pneumonia, cryptogenic organizing pneumonia, and acute lung injury from drug toxicity, hypersensitivity, and autoimmune diseases, to name a few pathologies. This means that false-positive errors don’t occur so much from falsely labeling healthy people with COVID-19 infection but rather from falsely attributing COVID-19 in ill patients with other acute respiratory pathologies — ie, misattribution.

Radiologists thus face a familiar dilemma, choosing between overcalling or undercalling, and both errors are costly. If radiologists omit COVID-19 infection in their reports when they see suggestive findings, and patients are actually infected, they won’t be appropriately isolated and could infect others. If radiologists call COVID-19 infection when they see suggestive findings, and patients aren’t infected, wrong protocols will be activated and they may not be treated for the condition they actually have, not to mention that the CT scanner will be unnecessarily nonoperational until decontaminated.

Furthermore, with constrained resources, attention on patients who don’t have coronavirus will divert attention from those who do.

One approach is for radiologists to report what they see and let clinicians decide how to use that information. The problem is that radiologists’ comments will influence how clinicians think and act; similarly, how clinicians think and what they might do with the information affects what radiologists say.

Image interpretation is not an island; it’s a complex archipelago.

Many radiologists throw responsibility back to clinicians with disclaimers such as “clinically correlate” or “pneumonia can’t be excluded,” a universally unhelpful practice that should unequivocally be abandoned during this pandemic.

A few steps may reduce undercalling and overcalling. First, radiologists should be familiar with the spectrum of findings of COVID-19 on chest CT and also recognize its most characteristic findings. Second, COVID-19 should only be mentioned after radiologists speak with clinicians and all agree that coronavirus infection is possible. Radiologists should express their confidence of COVID-19 infection on chest CT and grade their confidence as low, intermediate, or high. Clinicians should express the pretest probability of COVID-19 infection. Combining information from radiologists and clinicians will improve CT’s accuracy.

A joint effort prevents the burden of diagnosis falling on one side. The diagnosis of coronavirus should be confirmed with RT-PCR, though precautions should commence, including disinfecting the CT.

Some patients at higher risk for mortality from COVID-19 also are likely to have acute respiratory pathology that resembles COVID-19 on chest CT, such as those with chronic heart or lung disease, the elderly, oncology patients, posttransplant patients, and others with immunosuppression. Diagnosis is hard in these groups because misattribution in either direction is harmful.

We recommend a triangulation approach here. A second radiologist should look at the images and answer two questions: How characteristic are the CT findings of non-coronavirus respiratory pathology? How likely are the clinical features of non-coronavirus respiratory pathology?

Radiologists are better at answering “Could it be COVID-19?” than “Is it COVID-19?” A consensus, multidisciplinary approach will give us an idea of the pretest probability of COVID-19, conditional probability of CT, and posttest probability of COVID-19; such numbers aren’t reliably available for a new disease with unknown and changing prevalence.

We discourage using CT to rule out multiple pathologies at once, such as pulmonary embolus (PE), dissection, and COVID-19 infection. Such quests may increase false negatives and false positives because radiologists, when looking for multiple pathologies without knowing which is more likely, can miss what’s important and amplify what isn’t.

Furthermore, PE CTs are often obtained at the end of tidal breathing, which increases lung density that mimics diffuse ground glass opacities that can be mistaken for COVID-19 infection.

CT is often used to exclude a second acute pathology in patients with known acute respiratory disease, such as superimposed pneumonia in patients with acute pulmonary edema. We strongly discourage using chest CT to exclude “superimposed COVID-19” in patients with other acute respiratory pathologies such as pulmonary edema, because of their resemblance. The quest to exclude “superimposed COVID-19” is forlorn because the answer will always be, “Yes, superimposed COVID-19 infection is possible.”

Positive COVID-19 CT cases should be collected in a central databank to develop algorithms, using machine learning, to improve CT’s specificity and to reduce misattribution.

Although CT should be used judiciously, its use may increase if diagnostic uncertainty increases during the pandemic. The demand on resources from CT isn’t just the scan itself but downstream follow-up of incidental findings (incidentalomas) such as thyroid nodules, which are overwhelmingly likely to be harmless. In times of coronavirus, pursuit of incidentalomas could divert resources from higher-impact endeavors.

To reduce the incidentaloma burden, radiologists should limit what’s seen and see only what’s clinically most relevant. In the COVID-19 chest CT protocol, the field-of-view should be restricted to avoid the thyroid and adrenals, and thick slices should be created to avoid small nodules. The changes will reduce both the number of images radiologists view — typically 1000 per study — and the radiation exposure.

Our culture of seeking abnormalities with all our visual might, summed up by the ethos to “find, measure, and document anything and everything, no matter how small or clinically significant,” should temporarily change. This will require a deliberate effort because our search pattern has evolved to seeking trees rather than seeing forests. Amnesty from litigation during the pandemic for missed incidentalomas that cause future harm will encourage radiologists to focus on what will harm the patient in the next 20 hours rather than what might harm the patient in 20 years. Professional organizations should say in no uncertain terms that the search for, and documentation of, incidentalomas is ill advised during the pandemic.

Other habits that should be suspended include ordering daily portable chest radiographs in the intensive care unit in stable intubated patients, in-patient malignancy workups, and frequent surveillance of aneurysms and cancer. Some would argue that these practices should be discontinued permanently, but that diminishes the significance of the moment, so we ask that they be suspended only until the pandemic ends.

Thrift can boost capacity. It will take a village to achieve thrift.

Saurabh Jha, MBBS, MRCS, Associate Professor of Radiology, University of Pennsylvania; Staff Physician, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania

Scott A. Simpson, DO, MS, Assistant Professor of Clinical Radiology; Associate Program Director, Department of Radiology, University of Pennsylvania, Philadelphia


©2020 WebMD, LLC. All Rights Reserved.


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What’s the Evidence They Are Protective?



By Dennis Thompson
HealthDay Reporter

FRIDAY, April 3, 2020 (HealthDay News) — The Trump Administration is expected to announce guidelines that will recommend many Americans wear face masks when out in public, to curb transmission of the novel coronavirus.

The recommendation will apply to those living in hard-hit areas only, and it is not mandatory, the Associated Press reported.

Experts say there’s emerging — but still inconclusive — evidence that such a practice might help “flatten the curve” of COVID-19’s spread.

On Thursday, President Donald Trump announced that his administration was “coming out with regulations” on mask use, but no one will force individuals to do so.

“If people want to wear them, they can,” he said.

To save scarce N95 masks and surgical masks for front-line health care workers, many experts believe that cheaper versions or do-it-yourself cloth masks might be a good alternative for everyday use. Trump has said that even scarves wrapped over the mouth and nose might work.

Thursday’s announcement from the White House runs counter to COVID-19 public health guidelines in place over the past two months. Those guidelines opposed healthy folks wearing face masks in public.

That was due to concerns that cloth masks might increase a persons’s risk of infection if not worn properly or washed regularly, explained Dr. Luis Ostrosky, an infectious disease specialist with Memorial Hermann-Texas Medical Center in Houston.

“We know the virus can live on surfaces up to three days. The more porous and moist the surface, the longer it can live there,” Ostrosky said. “We don’t like cloth masks because they tend to get very moist and pull germs in, not only virus, but bacteria.”

Officials also didn’t want people to use surgical masks or respirators, given that hospitals face critically short supplies of these valuable protective devices.

But recently, U.S. Surgeon General Dr. Jerome Adams has asked the U.S. Centers for Disease Control and Prevention to investigate whether this recommendation should change, based on the spread of COVID-19 by people who have not developed any symptoms.

Although there’s not a lot of scientific evidence, there’s a growing consensus that DIY cloth masks might help protect people in crowded or poorly ventilated areas such as subways, elevators or grocery stores, said Ravina Kullar, an infectious diseases researcher with Expert Stewardship Inc. in Newport Beach, Calif.

“It goes both ways. It’s to protect other people if you’re asymptomatic, and it’s to protect yourself if someone is out there coughing and their droplet falls on you,” Kullar said.

People who are in high-risk groups — the elderly, immunocompromised or chronically ill — also might want to wear a DIY cloth mask for added protection, Kullar said.

The COVID-19 coronavirus is probably three times as infectious as the flu, CDC Director Dr. Robert Redfield noted in a Monday interview with an NPR station in Atlanta. He believes that some infected people are likely transmitting the virus as many as two days before showing symptoms.

Further, there’s a possibility that the novel coronavirus could be spread by simple conversation or breathing, and not just by sneezing or coughing, according to a letter issued Wednesday by the U.S. National Academies of Science.

Still, the evidence on that is far from solid.

“It’s unclear if aerosolized droplets from casual conversation or simply breathing — from even 6 feet away — could place others at risk of contracting COVID-19,” said Dr. Robert Glatter, emergency physician at Lenox Hill Hospital in New York City. However, he said, “since we can’t definitively exclude this possibility, wearing a face covering might be advisable at this time.

“That said, we should reserve surgical face masks for health care workers on the front lines of this crisis,” Glatter continued.

Kullar urges people to donate any store-bought surgical face masks or respirators to local hospitals in desperate need.

And, most importantly, folks who choose to wear a DIY mask must not let lapse other healthy habits that protect against infection, Kullar added.

Even with the mask, you should still practice social distancing, regularly wash your hands, and avoid touching your face, Kullar said.

“In the beginning, my stance was, I don’t think it’s a good idea because I fear that social distancing will lapse and then people will start touching their face more because it gives a false sense of security,” Kullar said. “They think they’re protected with this mask, and they don’t need to physically distance themselves anymore, and that’s not true.”

For its part, the World Health Organization is standing by its recommendation that people not wear face masks unless they are sick with COVID-19 for precisely that reason.

“There is no specific evidence to suggest that the wearing of masks by the mass population has any potential benefit,” Dr. Mike Ryan, executive director of the WHO health emergencies program, said at a media briefing in Geneva on Monday. “In fact, there’s some evidence to suggest the opposite in the misuse of wearing a mask properly or fitting it properly.”

Individual countries haven’t toed this line. For example, Japan has announced that it plans to provide two washable face masks to 50 million households.

The best-performing DIY face mask design involves two layers of high-quality heavyweight “quilter’s cotton” with a thread count of 180 or more, according to a new study by Wake Forest Baptist Health.

Other cloth with an especially tight weave and thicker thread like batiks also do well, as does a double-layer mask with a simple cotton outer later and an inner layer of flannel, the Wake Forest researchers said.

Single-layer masks or double-layer designs using low-quality lightweight cotton do not work as well to filter airborne particles, the researchers said.

People who choose to wear a mask should refrain from touching it while worn, particularly with hands that haven’t been washed, Ostrosky said.

They should wash the mask after each use, and refrain from either placing it on surfaces that might not be clean or in a storage bag or container that could be contaminated, Ostrosky said.

“There’s no clear evidence that may be guiding the discussion,” Ostrosky said. “It’s really a personal choice. If you’re going to do it, it should be done correctly or it could be detrimental to your health.”

Also keep in mind you don’t need to wear the mask when you’re out at a park or walking through your neighborhood, as long as you’re practicing social distancing.

“The risk of transmission from simple breathing or conversation is much less of an issue outside in the environment with more efficient circulation from wind currents,” Glatter said. “It’s more of a concern in poorly ventilated or closed spaces indoors.”

Copyright © 2020 HealthDay. All rights reserved.


SOURCES: Luis Ostrosky, M.D., infectious disease specialist, Memorial Hermann-Texas Medical Center, Houston; Ravina Kullar, Pharm.D., M.P.H., infectious diseases researcher and epidemiologist, Expert Stewardship Inc., Newport Beach, Calif.; Robert Glatter, M.D., emergency physician, Lenox Hill Hospital, New York City


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Rashmika Mandanna Latest Workout Live Chat With Fitness trainer | Rashmika workout | Filmylooks



Watch Rashmika Mandanna Latest Workout Live Chat With Fitness trainer | Rashmika workout | Filmylooks

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Key Drugs Join PPEs on List of Front-Line Shortages



What your doctor is reading on

APRIL 02, 2020 — First it was a critical shortage of personal protective equipment. Then pleas for more ventilators to sustain patients with COVID-19 and providers to care for them. Now, multiple sources are reporting deepening shortages of the drugs needed to help ventilate patients and keep them sedated.

Shortages are already evident for albuterol; neuromuscular blockers and sedatives, including fentanyl, midazolam, and propofol; and vasopressors for septic shock, even as orders increase exponentially.

The rates at which hospitals traditionally had been able to fill orders for ventilator-associated drugs was 95%, Dan Kistner, PharmD, told Medscape Medical News

“These classes of drugs have dropped to 60 or 70% in the last month alone,” said Kistner, senior vice president for pharmacy solutions at Vizient, a group purchasing organization that negotiates medicine contracts for about 3000 hospitals and healthcare facilities in the US.

“Every day it’s dropping 2 or 3 additional percent,” he continued.

Demand “Unprecedented”

The demand is simply “unprecedented,” he said, adding that the shortages are piling up even after elective surgeries have been put on hold.

A California nurse’s tweet in a nationwide thread of tweets under #WeNeedMeds poignantly described the consequences of severe shortages of some of these drugs. “Please do not put me on a vent if you can’t keep me sedated,” she writes. “I understand the alternative is death.”

Esther Choo, MD, MPH, an emergency physician at Oregon Health &  Science University in Portland, tweeted: “Those ventilators can’t really be used without a similarly vast supply of coupled medications to get people *on* the vents — and keep them on humanely. Hospitals are already experiencing shortages, before we even hit disease apex.”

15 Drugs at or Near Short Supply

Healthcare improvement company Premier, based in Charlotte, North Carolina, this week released a report that found 15 drugs used for COVID-19 care are in shortage or close to being in short supply at the same time demand is skyrocketing, particularly in New York.

Their data differ slightly from Vizient’s but still show increasing numbers of orders going unfilled.


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