Impact of COVID-19 pandemic on endoscopic retrograde cholangiopancreatography; a single center experience

Background COVID-19 pandemic has impacted several aspects of health care services worldwide. Our aim was to study its influence on the case volume, success rate and complication rate of ERCP. Method All patients who underwent ERCP one-year before and after applying COVID-19 safety measures at Qena university hospital were included. Data were collected from the patients' records, analyzed and compared. Result A total of 250 patients were subjected to ERCP between April 1, 2019 and March 31, 2021, mean age 52±18. There was 5% increase in case volume after applying COVID-19 safety measures than before (128 vs 122) and the total procedure time was significantly shorter (42 versus 46 minutes, p=0.04). The overall success rate and complication rate showed no significant difference. Procedure success significantly corelated to cannulation attempts and total procedure time in both groups, and serum bilirubin and cannulation time in patients before COVID-19, and ALP in patients after. ERCP related complications significantly correlated with cannulation attempts in both groups, and ALP, INR, cannulation time and total procedure time in patients before COVID-19, and platelets count and amylase after. Two patients were confirmed COVID-19 cases at the time of ERCP, therapeutic targets were achieved in both with smooth post-ERCP recovery. Three out of 9 ERCP team members have caught mild to moderate COVID-19 infection and recovered after receiving proper management. Conclusion Our result showed no negative impact of using COVID-19 safety measures and precautions on the case-volume, indications, overall outcome or complication rate of ERCP.

High-flow nasal cannula therapy in a predominantly African American population with COVID-19 associated acute respiratory failure

Importance

Use of non-invasive respiratory modalities in COVID-19 has the potential to reduce rates of intubation and mortality in severe disease however data regarding the use of high-flow nasal cannula (HFNC) in this population is limited.

Objective

To interrogate clinical and laboratory features of SARS-CoV-2 infection associated with high-flow failure.

Design

We conducted a retrospective cohort study to evaluate characteristics of high-flow therapy use early in the pandemic and interrogate factors associated with respiratory therapy failure.

Setting

Multisite single centre hospital system within the metropolitan Detroit region.

Participants

Patients from within the Detroit Medical Center (n=104, 89% African American) who received HFNC therapy during a COVID-19 admission between March and May of 2020.

Primary outcome

HFNC failure is defined as death or intubation while on therapy.

Results

Therapy failure occurred in 57% of the patient population, factors significantly associated with failure centred around markers of multiorgan failure including hepatic dysfunction/transaminitis (OR=6.1, 95% CI 1.9 to 19.4, p<0.01), kidney injury (OR=7.0, 95% CI 2.7 to 17.8, p<0.01) and coagulation dysfunction (OR=4.5, 95% CI 1.2 to 17.1, p=0.03). Conversely, comorbidities, admission characteristics, early oxygen requirements and evaluation just prior to HFNC therapy initiation were not significantly associated with success or failure of therapy.

Conclusions

In a population disproportionately affected by COVID-19, we present key indicators of likely HFNC failure and highlight a patient population in which aggressive monitoring and intervention are warranted.

United Arab Emirates National Newborn Screening Programme:an evaluation 1998-2000

To evaluate the United Arab Emirate National Newborn Screening Programme we compared coverage, timeliness of programme indicators [age at sampling, recall and treatment initiation, timing of specimen delivery and laboratory results] and specimen quality with international st and ards. Recall rate, sensitivity, specificity, positive predictive values and relative incidence rates for phenylketonuria [PKU] and congenital hypothyroidism [CH] were calculated. Investigations for hypothyroidism included thyroid function studies [T3, T4, fT4 and TSH], technetium-99m thyroid scan when possible and thyroglobulin and thyroid antibodies when indicated. PKU investigations included plasma amino acids and measurement of biopterin defects. In the 6 years before December 2000, 138, 718 neonates were screened. Relative incidences for CH and for classic PKU were 1: 1570 and 1: 20, 050 respectively

Factors Predisposing to Post Dural Puncture Headache in Children

BACKGROUND

Knowledge of the factors that predispose to postdural puncture headache in children may help reduce the occurrence of this complication.

MATERIALS AND METHODS

A retrospective cohort study of children who presented to the study institution between 2010 and 2018 was conducted. Children were divided into 2 groups: those who experienced postdural puncture headache and those who did not. The 2 groups were compared with respect to certain demographic, technical, and personnel-related factors. Only children who had opening pressure documented during the procedure were included in the core study group.

RESULTS

In univariate analysis, children aged ≥10 years, female gender, children with higher body mass index, standard blinded lumbar puncture procedure, use of sedation, higher opening pressure, and presence of pseudotumor cerebri increased the probability of postdural puncture headache. In multivariable logistic regression analysis, presence of pseudotumor cerebri was the only factor that attained statistical significance when the opening pressure was measured and documented.

CONCLUSIONS

The risk factors for postdural puncture headache in a pediatric cohort varied from risk factors that are classically implicated in adults.

Comparison of 5 Rectal Preparation Strategies for Prostate MRI and Impact on Image Quality

PURPOSE

To compare 5 different rectal preparation strategies for prostate MRI.

METHODS

This 5-arm quality-assurance study evaluated 56 patients per arm (280 patients) including: no preparation, clear-fluids diet (CFD) beginning at 00:00 hours on the day of MRI, Fleet®-enema, enema + CFD, enema + CFD + IV-antispasmodic agent. The study was powered to 0.80 with alpha-error of 0.05. Three blinded radiologists independently evaluated T2-Weighted (T2W) and Diffusion Weighed Imaging (DWI) for: rectal diameter (maximal AP diameter), rectal content (stool, fluid, gas), rectal motion, T2W/DWI image quality, T2W image sharpness and DWI susceptibility artifact using 5-point Likert scales. Overall comparisons were performed using analysis of variance (ANOVA) and Kruskal-Wallis, with pair-wise comparisons using paired t-tests and Wilcoxon sign-rank tests.

RESULTS

Rectal diameter and amount of gas were lower in enema compared to non-enema groups (p < 0.001), with smallest diameter and least gas in the enema + CFD + IV-antispasmodic group (p = 0.022-<0.001). T2W image quality and sharpness were highest in the enema + CFD groups (p < 0.001) with no difference comparing enema + CFD with/without IV-antispasmodic (p = 0.064, 0.084). Motion artifact was least in enema + CFD + IV-antispasmodic group compared to all other groups (p < 0.001), followed by the enema + CFD group (p = 0.008-<0.001). DWI image quality was highest (p < 0.001) and DWI susceptibility artifact lowest (p < 0.001) in the enema + CFD groups (p < 0.001) and did not differ comparing enema + CFD with/without anti-spasmodic (p = 0.058-0.202).

CONCLUSIONS

Use of enema + clear-fluids diet before prostate MRI yields the highest T2W and DWI image quality with the least DWI artifact. IV-antispasmodic use reduces motion on T2W but does not improve image quality on T2W or DWI, or lessen DWI artifact compared to enema + clear-fluids diet.

Utility of Quantitative T2-Mapping Compared to Conventional and Advanced Diffusion Weighted Imaging Techniques for Multiparametric Prostate MRI in Men with Hip Prosthesis

BACKGROUND

Diffusion weighted imaging (DWI) is fundamental for prostate cancer (PCa) detection with MRI; however, limited by susceptibility artifact from hip prosthesis.

PURPOSE

To evaluate image quality and ability to detect PCa with quantitative T2-mapping and DWI in men with hip prosthesis undergoing prostate MRI.

STUDY TYPE

Prospective, cross-sectional study.

POPULATION

Thirty consecutive men with hip replacement (18 unilateral, 12 bilateral) undergoing prostate MRI from 2019 to 2021.

FIELD STRENGTH/SEQUENCE

3-T; multiparametric MRI (T2W, DCE-MRI, echo-planar [EPI]-DWI), T2-mapping (Carr-Purcell-Meiboom-Gill), FOCUS-EPI-DWI, PROPELLER-DWI.

ASSESSMENT

Five blinded radiologists independently evaluated MRI image quality using a 5-point Likert scale. PI-RADS v2.1 scores were applied in four interpretation strategies: 1) T2W-FSE+DCE-MRI+EPI-DWI, 2) T2W-FSE+DCE-MRI+EPI-DWI+FOCUS-EPI-DWI, 3) T2W-FSE+DCE-MRI+EPI-DWI+PROPELLER-DWI, 4) T2W-FSE+DCE-MRI+EPI-DWI+T2-maps. Five-point confidence scores were recorded.

STATISTICAL ANALYSIS

ANOVA, Kruskal-Wallis with pair-wise comparisons by Wilcoxon sign-rank, and paired t-tests, P < 0.05 was considered significant. Cohen's Kappa (k) for PI-RADSv2.1 scoring and proportion of correctly classified lesions tabulated for pathology-confirmed cases with 95% confidence intervals (CIs).

RESULTS

For all radiologists, T2-map image quality was significantly higher than EPI-DWI, FOCUS-EPI-DWI, and PROPELLER-DWI and similar (P = 0.146-0.706) or significantly better (for two readers) than T2W-FSE and DCE-MRI. PI-RADS v2.1 agreement improved comparing strategy A (k = 0.46) to strategy B (k = 0.58) to strategy C (k = 0.58) and was highest with strategy D which included T2-maps (k = 1.00). Radiologists' confidence was significantly highest with strategy D. Strategies B and C had similar confidence (P = 0.051-0.063) both significantly outperforming strategy A. Twelve men with 17 lesions had pathology confirmed diagnoses (13 PCa, 4 benign). Strategy D had the highest proportion of correctly classified lesions (76.5-82.4%) with overlapping 95% confidence intervals.

DATA CONCLUSION

T2-mapping may be a valuable adjunct to prostate MRI in men with hip replacement resulting in improved image quality, higher reader confidence, interobserver agreement, and accuracy in PI-RADS scoring.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY STAGE: 2.

In-hospital outcomes of endovascular versus surgical revascularization for chronic total occlusion in peripheral artery disease

BACKGROUND

The outcome of endovascular intervention (EVI) compared vs. surgical revascularization in patients with peripheral artery disease (PAD) due to chronic total occlusion (CTO) is unknown.

METHODS

Using the National Inpatient Sample database between 2007 and 2014, we identified all PAD patients with CTO who had limb revascularization. Multivariate analysis was performed to estimate the odds of in-hospital mortality and adverse outcomes between both groups.

RESULTS

A total of 168,420 patients who had peripheral CTO and underwent limb revascularization were identified. 99,279 underwent EVI, and 69,141 underwent surgical revascularization. The patients who underwent EVI were younger, more likely to be women and African American, and less likely to be white (p < 0.001 for all). EVI was associated with lower in-hospital mortality (1.2% vs 1.7%, adjusted odds ratio [aOR]: 0.54; 95% confidence interval [CI] 0.50-0.59). The EVI group had higher vascular complications, major bleeding, acute kidney injury (AKI), and major amputation compared with surgical revascularization. A subgroup analysis on patients with critical limb ischemia showed lower mortality in the EVI group (1.4% vs. 1.9, aOR 0.56; 95% CI 0.50-0.63). Although there was no difference in the incidence of AKI or major amputation between the two groups, the EVI group had higher vascular complication rates and major bleeding events.

CONCLUSION

EVI in PAD with CTO is associated with lower in-hospital mortality, likely due to the procedure's less-invasive nature; however, it is associated with higher postprocedural complications likely due to the CTO's complexity.

Bosniak Classification version 2019: validation and comparison to original classification in pathologically confirmed cystic masses

OBJECTIVE

To evaluate Bosniak Classification v2019 definitions in pathologically confirmed cystic renal masses.

MATERIALS AND METHODS

Seventy-three cystic (≤ 25% solid) masses with histological confirmation (57 malignant, 16 benign) imaged by CT (N = 28) or CT+MRI (N = 56) between 2009 and 2019 were independently evaluated by three blinded radiologists using Bosniak v2019 and original classifications. Discrepancies were resolved by consensus with a fourth blinded radiologist. Overall class and v2019 features were compared to pathology.

RESULTS

Inter-observer agreement was slightly improved comparing v2019 to Original Bosniak Classification (kappa = 0.26-0.47 versus 0.24-0.34 respectively). v2019 proportion of IIF and III masses (20.5% [15/73, 95% confidence interval (CI) 12.0-31.6%], 38.6% [28/73, 95% CI 27.2-50.5%]) differed from the original classification (6.8% [5/73, 95% CI 2.3-15.3%], 61.6% [45/73, 95% CI 49.5-72.8%]) with overlapping proportion of malignancy in each class. Mean septa number (7 ± 4 [range 1-10]) was not associated with malignancy (p = 0.89). Mean wall and septa thicknesses were 3 ± 3 (1-14) and 3 ± 2 (1-10) mm and higher in malignancies (p = 0.03 and 0.20 respectively). Areas under the receiver-operator-characteristic curve for wall and septa thickness were 0.66 (95% CI 0.54-0.79) and 0.61 (95% CI 0.45-0.78) with an optimal cut point of ≥ 3 mm (sensitivity 33.3%, specificity 86.7% and sensitivity 53%, specificity 73% respectively). Proportion of malignancy occurring in masses with the v2019 features "irregularity" (76.9% [10/13], 95% CI 46.2-94.9%) and "nodule" (89.7% [26/29], 95% CI 72.7-97.8%) overlapped. Angle of "nodule" (p = 0.27) was not associated with malignancy.

CONCLUSION

Bosniak v2019 definitions for wall/septa thickness and protrusions are associated with malignancy. Overall, Bosniak v2019 categorizes a higher proportion of malignant masses in Class IIF with slight improvement in inter-observer agreement.

KEY POINTS

• Considering Bosniak v2019 Class IIF cystic masses with many (≥ 4) smooth and thin septa, there was no association between the number of septa and malignancy (p = 0.89) in this study. • Increased cyst wall and septa thickness are associated with malignancy and a lower threshold of ≥ 3 mm maximized overall diagnostic accuracy compared to ≥ 4 mm threshold proposed for Bosniak v2019 Class 3. • An overlapping proportion of malignant masses is noted in Bosniak v2019 Class 3 masses with "irregularity" (76.9% [10/13], 95% CI 46.2-94.9%) compared to Bosniak v2019 Class 4 masses with "nodule" (89.7% [26/29], 95% CI 72.7-97.8%).

Hashimoto's Encephalopathy: A Rare Cause of Seizure-like Activity

Hashimoto’s encephalopathy is an uncommon disorder that may present with a wide variety of different neurological signs and symptoms that can include acute altered level of consciousness, psychosis, seizures, ataxia, dementia, myoclonus, and stupor. We present a case of a 60-year-old female patient who was admitted to the internal medicine floor for workup for seizures of unknown etiology. Investigations, including a complete blood count, basic metabolic panel, magnetic resonance imaging (MRI) of the brain, cerebrospinal fluid analysis, and NMDA (N-methyl-D-aspartate) receptor encephalitis screen, were all unremarkable. Thyroid-stimulating hormone levels and anti-thyroid peroxidase antibodies were found to be elevated, suggesting an underlying etiology of Hashimoto’s thyroiditis. Treatment with corticosteroids and levothyroxine can lead to resolution of symptoms. This case report is presented to suggest the importance of serological screening for anti-thyroid antibodies in the workup of all patients with unknown causes of encephalopathy along with providing a review of the literature.

A Rare Case of Enterococcus gallinarum-Associated Peritonitis and Literature Review

Peritonitis is a well-known complication seen with peritoneal dialysis. Peritonitis is associated with increased mortality risk and is commonly caused by gram-positive and gram-negative bacteria, but it can also be the result of fungal or viral infections. Therefore, it is imperative to obtain a peritoneal fluid sample to send for cell count with differential, gram stain, and culture prior to starting empiric antibiotic therapy. We report a case of peritoneal dialysis-related peritonitis caused by Enterococcus gallinarum, for which there has only been one other reported case in the medical literature. Our patient was initially placed on vancomycin and cefepime but continued to deteriorate until peritoneal fluid cultures revealed E. gallinarum. Based on sensitivities, the patient was treated with daptomycin and cefazolin, which resolved her peritonitis.

Management of ARDS - What Works and What Does Not

Acute respiratory distress syndrome (ARDS) is a clinically and biologically heterogeneous disorder associated with a variety of disease processes that lead to acute lung injury with increased non-hydrostatic extravascular lung water, reduced compliance, and severe hypoxemia. Despite significant advances, mortality associated with this syndrome remains high. Mechanical ventilation remains the most important aspect of managing patients with ARDS. An in-depth knowledge of lung protective ventilation, optimal PEEP strategies, modes of ventilation and recruitment maneuvers are essential for ventilatory management of ARDS. Although, the management of ARDS is constantly evolving as new studies are published and guidelines being updated; we present a detailed review of the literature including the most up-to-date studies and guidelines in the management of ARDS. We believe this review is particularly helpful in the current times where more than half of the acute care hospitals lack in-house intensivists and the burden of ARDS is at large.

Six-year experience of detection and investigation of possible Middle East Respiratory Syndrome coronavirus cases, England, 2012-2018

OBJECTIVES

Surveillance for Middle East Respiratory Syndrome (MERS) has been undertaken in the UK since September 2012. This study describes the surveillance outcomes in England from 2012 to 2018.

STUDY DESIGN

This was a descriptive study using surveillance data.

METHODS

Local health protection teams in England report possible MERS cases to the National Infection Service with clinical and laboratory data.

RESULTS

A total of 1301 possible MERS cases were identified in the study period. Five cases were laboratory-confirmed MERS. The majority of cases had travelled to Saudi Arabia (56.7%) and United Arab Emirates (25.9%). Fifty-four percent of cases were men and 43.7% were women. The majority of cases (65.1%) were aged 45 years or older. The number of tests increased in the period after Hajj each year. Laboratory-confirmed alternative diagnoses were available for 513 (39.4%) cases; influenza was the most common virus detected (n = 255, 52.4%).

CONCLUSIONS

Our study highlights the importance of differential diagnosis of influenza and other respiratory pathogens and early influenza antiviral treatment.

A European multicentre evaluation of detection and typing methods for human enteroviruses and parechoviruses using RNA transcripts

Polymerase chain reaction (PCR) detection has become the gold standard for diagnosis and typing of enterovirus (EV) and human parechovirus (HPeV) infections. Its effectiveness depends critically on using the appropriate sample types and high assay sensitivity as viral loads in cerebrospinal fluid samples from meningitis and sepsis clinical presentation can be extremely low. This study evaluated the sensitivity and specificity of currently used commercial and in-house diagnostic and typing assays. Accurately quantified RNA transcript controls were distributed to 27 diagnostic and 12 reference laboratories in 17 European countries for blinded testing. Transcripts represented the four human EV species (EV-A71, echovirus 30, coxsackie A virus 21, and EV-D68), HPeV3, and specificity controls. Reported results from 48 in-house and 15 commercial assays showed 98% detection frequencies of high copy (1000 RNA copies/5 µL) transcripts. In-house assays showed significantly greater detection frequencies of the low copy (10 copies/5 µL) EV and HPeV transcripts (81% and 86%, respectively) compared with commercial assays (56%, 50%; P = 7 × 10-5 ). EV-specific PCRs showed low cross-reactivity with human rhinovirus C (3 of 42 tests) and infrequent positivity in the negative control (2 of 63 tests). Most or all high copy EV and HPeV controls were successfully typed (88%, 100%) by reference laboratories, but showed reduced effectiveness for low copy controls (41%, 67%). Stabilized RNA transcripts provide an effective, logistically simple and inexpensive reagent for evaluation of diagnostic assay performance. The study provides reassurance of the performance of the many in-house assay formats used across Europe. However, it identified often substantially reduced sensitivities of commercial assays often used as point-of-care tests.

The Utility of Short-Interval Follow-Up for Baseline High-Risk Screening Breast MRI

OBJECTIVE

Patients with a high lifetime risk of developing breast cancer undergo annual screening magnetic resonance imaging (MRI) starting at age 30. A proportion of these patients are subsequently required to undergo short-interval follow-up MRI 6 months after their baseline examination. The purpose of this study was to evaluate the utility and outcome of these short-interval follow-up examinations in this population.

METHODS

A retrospective review was performed of 523 patients who received their baseline high-risk breast screening MRI at our institution between 2013 and 2017. The proportion of patients who received a short-interval follow-up MRI at 6 months was recorded. The findings at baseline and follow-up MRI were recorded, as well as the outcomes and results of any interventions performed.

RESULTS

Ninety-six (17.6%) patients (age range: 25-67, mean age: 41) received a short-interval follow-up MRI following their baseline screening examination. Indications for follow-up included moderate to marked background parenchymal enhancement, nonmass enhancement, and likely benign enhancing mass. Of the 92 patients, 5 (5.4%) went on to have a biopsy, with none revealing a malignant pathology. The remainder either returned to routine screening (91.3%) or received further imaging in the form of ultrasound or additional follow-up MRI (3.3%).

CONCLUSION

Short-interval follow-up breast MRI in high-risk patients after a baseline screening study with likely benign findings is unlikely to yield clinically significant findings. This retrospective study can be considered a starting point for additional future work looking at the rate, indications, and yield of short-interval follow-up following baseline high-risk screening breast MRI studies.

Numerical and experimental studies of water disinfection in UV reactors

Performance of UV reactors for water disinfection is investigated in this paper. Both experimental and numerical studies are performed on base reactor LP24. Enterobacteria phage MS2 is chosen as the challenge microorganism in the experiments. Experiments are conducted to evaluate the effect of different parameters, i.e. flow rate and UV transmission, on the reactor performance. Simulation is carried out based on the commercial software ANSYS FLUENT with user defined functions (UDFs) implemented. The UDF is programmed to calculate UV dose absorbed by different microorganisms along their flow trajectories. The effect with boundary layer mesh and without boundary layer mesh for LP24 is studied. The results show that the inclusion of boundary layer mesh does not have much effect on the reactor performance in terms of reduction equivalent dose (RED). The numerical results agree well with the experimental measurements, hence validating the numerical model. With this achieved, the numerical model is applied to study other scaled reactors: LP12, LP40, LP60 and LP80. Comparisons show that LP40 has the highest RED and log inactivation among all the reactors while LP80 has the lowest RED and log inactivation.