Review of X-ray and computed tomography scan findings with a promising role of point of care ultrasound in COVID-19 pandemic

As healthcare professionals continue to combat the coronavirus disease 2019 (COVID-19) infection worldwide, there is an increasing interest in the role of imaging and the relevance of various modalities. Since imaging not only helps assess the disease at the time of diagnosis but also aids evaluation of response to management, it is critical to examine the role of different modalities currently in use, such as baseline X-rays and computed tomography scans carefully. In this article, we will draw attention to the critical findings for the radiologist. Further, we will look at point of care ultrasound, an increasingly a popular tool in diagnostic medicine, as a component of COVID-19 management.     

COVID-19 and venous thromboembolism: Known and unknown for imaging decisions

As we continue to fight against the current coronavirus disease-2019 (COVID-19) pandemic, healthcare professionals across the globe are trying to answer questions surrounding how to best help patients with the up-to-date available science while awaiting the development of new therapies and mass vaccination. Since early in the pandemic, studies indicated a heightened risk of venous thromboembolism (VTE) in COVID-19 infected patients. There have been differing expert opinions about how to assess pretest probability of VTE in this patient population. This has been partly due to the high prevalence of respiratory failure in this patient population and the use of D-dimer as a prognostic test which is also frequently elevated in patients with COVID-19 in absence of VTE. Some experts have argued for an approach similar to usual care with testing if clinical suspicion is high enough. Some have argued for more routine screening at different points of care. Others have even suggested empiric therapeutic anti-coagulation in moderate to severely ill COVID-19 patients. In the following article, we review and summarize the most current literature in hopes of assisting clinicians in decision making and guidance for when to be concerned for VTE in COVID-19 patients. We also discuss research gaps and share pathways currently being used within our institution.     

Comments on "Review of the role of diagnostic modalities and imaging findings in the COVID-19 pandemic"

The present letter to the editor corresponds to the article entitled “Comprehensive literature review on the radiographic findings, imaging modalities, and the role of radiology in the coronavirus disease 2019 (COVID-19) pandemic” by Pal et al, published in World J Radiol. 2021; 13(9): 258-282. With zero to unknown prevalence, COVID-19 has created a heterogeneous and unforeseen situation across the world. Healthcare providers encountered new challenges in image interpretation, characterization, and prognostication of the disease. Pal et al delineated the radiological findings, which would guide the radiologists to identify the early signs of severe infection.     

Multimodality imaging in COVID-19 patients: A key role from diagnosis to prognosis

The integrated clinical, laboratory and ultrasound approach is essential for the diagnosis, evaluation and monitoring of the patient's therapy in coronavirus disease 2019 pneumonia. The ideal imaging approach in this context is not yet well defined. Chest X-ray is characterized by low sensitivity in identifying earlier lung changes. The "bedside" pulmonary ultrasound has an undeniable series of advantages in the patient at high infectious risk and can provide incremental data in the respiratory intensive care for the serial control of the individual patient as well as for the home delivery of the stabilized subjects. Pulmonary computed tomography shows high sensitivity but should not be routinely performed in all patients, because in the first 48 h it can be absolutely negative and in the late phase the imaging findings may not change the therapeutic approach. Echocardiography should be limited to patients with hemodynamic instability to assess ventricular function and pulmonary pressures.     

Diagnostic accuracy of thoracic imaging modalities for the detection of COVID-19

The ongoing coronavirus disease 2019 (COVID-19) pandemic continues to present diagnostic challenges. The use of thoracic radiography has been studied as a method to improve the diagnostic accuracy of COVID-19. The ‘Living’ Cochrane Systematic Review on the diagnostic accuracy of imaging tests for COVID-19 is continuously updated as new information becomes available for study. In the most recent version, published in March 2021, a meta-analysis was done to determine the pooled sensitivity and specificity of chest X-ray (CXR) and lung ultrasound (LUS) for the diagnosis of COVID-19. CXR gave a sensitivity of 80.6% (95%CI: 69.1-88.6) and a specificity of 71.5% (95%CI: 59.8-80.8). LUS gave a sensitivity rate of 86.4% (95%CI: 72.7-93.9) and specificity of 54.6% (95%CI: 35.3-72.6). These results differed from the findings reported in the recent article in this journal where they cited the previous versions of the study in which a meta-analysis for CXR and LUS could not be performed. Additionally, the article states that COVID-19 could not be distinguished, using chest computed tomography (CT), from other respiratory diseases. However, the latest review version identifies chest CT as having a specificity of 80.0% (95%CI: 74.9-84.3), which is much higher than the previous version which indicated a specificity of 61.1% (95%CI: 42.3-77.1). Therefore, CXR, chest CT and LUS have the potential to be used in conjunction with other methods in the diagnosis of COVID-19.     

Incremental value of thoracic ultrasound in intensive care units: Indications,uses, and applications

Emergency physicians are required to care for unstable patients with life-threatening conditions, and thus must make decisions that are both quick and precise about unclear clinical situations. There is increasing consensus in favor of using ultrasound as a real-time bedside clinical tool for clinicians in emergency settings alongside the irreplaceable use of historical and physical examinations. B-mode sonography is an old technology that was first proposed for medical applications more than 50 years ago. Its application in the diagnosis of thoracic diseases has always been considered limited, due to the presence of air in the lung and the presence of the bones of the thoracic cage, which prevent the progression of the ultrasound beam. However, the close relationship between air and water in the lungs causes a variety of artifacts on ultrasounds. At the bedside, thoracic ultrasound is based primarily on the analysis of these artifacts, with the aim of improving accuracy and safety in the diagnosis and therapy of the various varieties of pulmonary pathologic diseases which are predominantly “water-rich” or “air-rich”. The indications, contraindications, advantages, disadvantages, and techniques of thoracic ultrasound and its related procedures are analyzed in the present review.     

Knowledge,attitude, and practice of forensic practitioners during COVID-19 pandemic in Arab countries

COVID-19 pandemic burdens forensic practice worldwide. The experience of crisis management is a lesson learned that guides future preparedness for similar casualties. Thus, the present study takes an in-depth look at the knowledge, attitude, and practice of forensic practitioners during the COVID-19 pandemic in the Arab world. A comprehensive questionnaire was adopted in compliance with optimum international standards for the management of deaths during the pandemic. The survey was electronically distributed in 13 Arab countries. The responses were received from 29 forensic practitioners from 11 countries. Total median knowledge, attitude, and practice scores of respondents constituted 37.9%, 74%, and 36.8% of optimum scores respectively. Regarding knowledge, better scores are related to risk assessment and routes of exposure to Coronavirus, whereas, least scores were related to ventilation and negative pressure system. Most of the participants had a positive attitude, 85.2% were concerned about proper management of COVID-19 deaths, and 77.8% trusted the decisions of their teams. Considering practice, better scores are related to forensic staff competence, whereas, least scores were related to the implementation of ideal safety measures. Participants described the management process as useful (52%), reliable (35%), high quality (21%), and cost-effective (17%), however, they expressed challenges as staff infection, limited resources, and infrastructure issues. This survey guides readjusting of procedures and future preparedness for similar disasters in the Arab world. This research adopted a questionnaire that could be used in initial and periodic assessments in any medicolegal institute worldwide. Also, it could support infrastructure projects and disaster management plans.     

Unilateral Lymphadenopathy After COVID-19 Vaccination: A Practical Management Plan for Radiologists Across Specialties

Reports are rising of patients with unilateral axillary lymphadenopathy, visible on diverse imaging examinations, after recent coronavirus disease 2019 vaccination. With less than 10% of the US population fully vaccinated, we can prepare now for informed care of patients imaged after recent vaccination. The authors recommend documenting vaccination information (date[s] of vaccination[s], injection site [left or right, arm or thigh], type of vaccine) on intake forms and having this information available to the radiologist at the time of examination interpretation. These recommendations are based on three key factors: the timing and location of the vaccine injection, clinical context, and imaging findings. The authors report isolated unilateral axillary lymphadenopathy (i.e., no imaging findings outside of visible lymphadenopathy), which is ipsilateral to recent (prior 6 weeks) vaccination, as benign with no further imaging indicated. Clinical management is recommended, with ultrasound if clinical concern persists 6 weeks after the final vaccination dose. In the clinical setting to stage a recent cancer diagnosis or assess response to therapy, the authors encourage prompt recommended imaging and vaccination (possibly in the thigh or contralateral arm according to the location of the known cancer). Management in this clinical context of a current cancer diagnosis is tailored to the specific case, ideally with consultation between the oncology treatment team and the radiologist. The aim of these recommendations is to (1) reduce patient anxiety, provider burden, and costs of unnecessary evaluation of enlarged nodes in the setting of recent vaccination and (2) avoid further delays in vaccinations and recommended imaging for best patient care during the pandemic.     

Imaging volumes during COVID-19: A Victorian health service experience

BACKGROUNDThe World Health Organisation declared the coronavirus disease 2019 (COVID-19) a pandemic on March 11, 2020. While globally, the relative caseload has been high, Australia’s has been relatively low. During the pandemic, radiology services have seen significant changes in workflow across modalities and a reduction in imaging volumes. AIMTo investigate differences in modality imaging volumes during the COVID-19 pandemic across a large Victorian public health network.METHODSA retrospective analysis from January 2019 to December 2020 compared imaging volumes across two periods corresponding to the pandemic’s first and second waves. Weekly volumes across patient class, modality and mobile imaging were summed for periods: wave 1 (weeks 11 to 16 for 2019; weeks 63 to 68 for 2020) and wave 2 (weeks 28 to 43 for 2019; weeks 80 to 95 for 2020). Microsoft Power Business Intelligence linked to the radiology information system was used to mine all completed examinations.RESULTSSummed weekly data during the pandemic’s first wave showed the greatest decrease of 29.8% in adult outpatient imaging volumes and 46.3% in paediatric emergency department imaging volumes. Adult nuclear medicine demonstrated the greatest decrease of 37.1% for the same period. Paediatric nuclear medicine showed the greatest decrease of 47.8%, with angiography increasing by 50%. The pandemic’s second wave demonstrated the greatest decrease of 23.5% in adult outpatient imaging volumes, with an increase of 18.2% in inpatient imaging volumes. The greatest decrease was 28.5% in paediatric emergency department imaging volumes. Nuclear medicine showed the greatest decrease of 37.1% for the same period. Paediatric nuclear medicine showed the greatest decrease of 36.7%. Mobile imaging utilisation increased between 57.8% and 135.1% during the first and second waves. A strong correlation was observed between mobile and non-mobile imaging in the emergency setting (Spearman’s correlation coefficient = -0.743, P = 0.000). No correlation was observed in the inpatient setting (Spearman’s correlation coefficient = -0.059, P = 0.554).CONCLUSIONNuclear medicine was most impacted, while computed tomography and angiography were the least affected by the pandemic. The impact was less during the pandemic’s second wave. Mobile imaging shows continuous growth during both waves.     

Brachytherapy care during the COVID-19 pandemic: Practice statement from a cancer center in Wuhan,China

PurposeCOVID-19 broke out in late 2019 and rapidly spread around the world and became a pandemic. This highly contagious disease affects routine health care services and patients with cancer who are susceptible to it. Delivering brachytherapy on time is critical for patients with cancer to get better prognosis. The purpose of this study is to present workflow and standard for radiation centers to deliver brachytherapy and avoid cross-infection during the COVID-19 pandemic.Methods and MaterialsThis study combined previous literature and guidelines of precaution with clinical experience in the COVID-19 pandemic.ResultsA workflow covering patients' screening, health care workers’ precaution, training, and other aspects of the whole brachytherapy procedure was established.ConclusionsFrom the reopening of radiation center to mid-May in 2020, there is no hospital infection of COVID-19 in patients or health care workers. This recommendation is effective and helpful to other cancer centers.     

A novel use for routine CBCT imaging during radiotherapy to detect COVID-19

IntroductionThoracic CT is a useful tool in the early diagnosis of patients with COVID-19. Typical appearances include patchy ground glass shadowing. Thoracic radiotherapy uses daily cone beam CT imaging (CBCT) to check for changes in patient positioning and anatomy prior to treatment through a qualitative assessment of lung appearance by radiographers. Observation of changes related to COVID-19 infection during this process may facilitate earlier testing improving patient management and staff protection.MethodsA tool was developed to create overview reports for all CBCTs for each patient throughout their treatment. Reports contain coronal maximum intensity projection (MIP's) of all CBCTs and plots of lung density over time. A single therapeutic radiographer undertook a blinded off-line audit that reviewed 150 patient datasets for tool optimisation in which medical notes were compared to image findings. This cohort included 75 patients treated during the pandemic and 75 patients treated between 2014 and 2017. The process was repeated retrospectively on a subset of the 285 thoracic radiotherapy patients treated between January–June 2020 to assess the efficiency of the tool and process.ResultsThree patients in the n = 150 optimisation cohort had confirmed COVID-19 infections during their radiotherapy. Two of these were detected by the reported image assessment process. The third case was not detected on CBCT due to minimal density changes in the visible part of the lungs.Within the retrospective cohort four patients had confirmed COVID-19 based on RT-PCR tests, three of which were retrospectively detected by the reported process.ConclusionThe preliminary results indicate that the presence of COVID-19 can be detected on CBCT by therapeutic radiographers.Implications for practiceThis process has now been extended to clinical service with daily assessments of all thoracic CBCTs. Changes noted are referred for oncologist review.     

Organization of a radiotherapy service during the COVID-19 epidemic: Experience of Regional Center of Oncology of Agadir,Morocco

This study proposes organization of the activity of a radiotherapy service during the pandemic COVID-19 period. Reliable circuits for staff as well as for patients are installed and treatment protocols are adapted to the current COVID-19 situation. Several scenarios are proposed to deal with any subsequent pandemic situation.     

Pre and retroperitoneal necrotizing fasciitis after COVID-19 infection: A case report

Necrotizing fasciitis is a serious infection that originates in the subcutaneous tissues. We present a case of 52 years old male patient who developed preperitoneal and retroperitoneal necrotizing fasciitis 2 weeks after the start of Coronavirus-19 infection. Preoperative abdominal computed tomography with intravenous and oral contrast revealed pre and retroperitoneal spread of air loculi with turbid fluid patches within necrotic tissues. After surgical excision of the lesion, histopathological and microbiological examinations of the samples revealed necrotizing fasciitis. This is the first report of preperitoneal and retroperitoneal necrotizing fasciitis after Coronavirus-19 infection in 52 years old male with no history of trauma or immunocompromised condition. Coronavirus-19 infection may increase the liability of patients to develop overwhelming infection and it may also delay the patient presentation causing serious health-related emergencies. The findings of necrotizing fasciitis on clinical grounds or imaging studies can help in diagnosis as well as the surgical intervention and appropriate antibiotics can highly impact the prognosis and survival of the patient.     

Acute ischemic stroke after first dose of inactivated COVID-19 vaccine: A case report

The acute cerebral ischemia induced by the COVID-19 vaccine is one of the side effects. We report the first case of a patient who suffered from a neurological deficit mimicking a stroke after receiving his 1st dose of the inactivated COVID-19 vaccine BIBP (Sinopharm) and who mainly developed cerebral venous thrombosis. Our reported case is a 36-year-old man who was admitted to our intensive care unit 2 days after his first injection dose of the inactivated COVID-19 vaccine BIBP (Sinopharm). He presented a numbness in his left arm and legs with headaches 24 hours after the vaccine injection. In the second day, he had asymmetry of the face which was aggravated by the installation of disturbance of consciousness and a state of agitation. His vital signs were normal. A brain CT scan without injection was done showing a right deep parietal ischemic stroke. The treatment was initiated by aspirin. cerebral MRI showed a very extensive stroke ischemic in the superficial and deep right parietal territory with the onset of hemorrhagic rearrangement of the right basal ganglia, magnetic resonance imaging angiography of the supra-aortic trunks was normal. The patient gradually improved and was discharged after 15 days of his stay in the intensive care unit. The installation of ischemic stroke reported in our young patient after receiving his first dose of inactivated COVID-19 vaccine BIBP; could be a new immune response to the vaccine.     

Radiological review of rhinocerebral mucormycosis cases during the COVID-19 Pandemic: A single-center experience

Mucormycosis is caused by the fungi belonging to the order Mucorales and class Zygomycetes. The incidence of mucormycosis has increased with the onset of the severe acute respiratory syndrome coronavirus 2 infections leading to the coronavirus disease 2019 (COVID-19) pandemic. This rise is attributed to the use of immunosuppressive medication to treat COVID-19 infections. Authors have retrospectively collected data of our cases of mucormycosis diagnosed from April 2020 to April 2021 at our institute. A total of 20 patients with rhinocerebral mucormycosis were studied. Most of the study subjects were male patients (90%) and were of the age group 41-50 years. Most patients in the review had comorbidities (85%) with diabetes being the most common comorbidity. Para nasal sinuses were involved in all the cases. Involvement of the neck spaces was present in 60% of the cases. Involvement of the central nervous system was present in 80% of the cases. Orbital involvement was present in 90% of the cases. The authors reviewed the various imaging findings of mucormycosis on computed tomography and magnetic resonance imaging in this article.     

Recommendations for risk stratified use of cardiac computed tomography for congenital heart disease during the COVID-19 pandemic

The impact of the coronavirus disease (COVID-19) pandemic in the United States and around the world has required significant changes to medical practice. Amidst the rapidly evolving public health emergency, hospital centers have been required to postpone elective procedures, preserve personal protective equipment (PPE), practice social distancing and limit staff exposures. Patients with congenital heart disease (CHD) often need urgent evaluation, most commonly for preprocedural evaluation. We have stratified the most common indications for cardiac computed tomography (CCT) imaging in patients with CHD to help guide care for these patients during the COVID-19 pandemic including considerations for reopening.