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4th November 2021
Road traffic accidents are often fatal with data from 2015 compiled by the World Health Organization showing that every year the global number of fatal road traffic accidents is around 1.25 million.1 While several tools such as the Revised Trauma Score2 (RTS) and the Trauma and Injury Severity Score3 have been developed to rate both the severity of a trauma and as a prognostic guide, these scores require calculation via formulas that are too complicated for use in the emergency department (ED) resuscitation room. One potential tool is the qSOFA and this has been used to predict mortality risk in patients both with4 and without infection.5
How well the score might perform in predicting mortality in ED resuscitation rooms is yet to be determined and was the subject of a retrospective study by a team from the Department of Critical Care Medicine, the First Affiliated Hospital of Soochow University, Jiangsu Province, China.6 The qSOFA score ranges from 0 to 3 and has three components: a systolic blood pressure (SBP) of 100mmHg or less, a respiratory rate (RR) of 22/min or greater and altered mentation. Over a three-year period, the team divided patients into two groups: survivors and non-survivors and then four subgroups according to their score. They also used the Glasgow Coma Score (GCS) and used this to calculate the RTS score, which is the sum of the GCS, SBP and RR. The main study endpoint was mortality in the ED resuscitation room and multivariate regression was used to determine the association between qSOFA scores and mortality. In addition, receiver operating characteristic (ROC) curve analysis was used to assess the mortality predictive ability of qSOFA scores.
A total of 1739 patients were included in the analysis, 1695 survivors with a mean age of 51 years (73% male) and 44 non-survivors (mean age 50 years, 77.3% male). In terms of the qSOFA scores, 57.8% had a score of 0, 33.3% scored 1, 8.1% scored 2 and 0.75% scored 3. In addition, the proportion of patients dying increased significantly with qSOFA scores, e.g., 0.60%, 3.38%, 12.06% and 15.38% for qSOFA scores of 0, 1, 2 and 3, respectively (p < 0.001). There was also a significant difference in the mean time spent in the ED (4 vs 13 hrs, survivors vs non-survivors, p < 0.001).
Mortality was significantly associated with qSOFA scores with scores of at least two were associated with a significant increased risk of death. For example, using a qSOFA score as the reference point, a qSOFA score of 2 was associated with a nearly seven-fold increased risk of death (odds ratio, OR = 6.80, 95% CI 1.79–25.90, p = 0.005) and a qSOFA score of 3 with a 24-fold increased risk (OR = 24.42). Using the area under the receiver operating curve (AUC), qSOFA scores had a predictive value for mortality of 0.78 (95% CI 0.72–0.85).
Concluding, the authors stated that the qSOFA score can be used to assess the severity of ED trauma patients and has a good predictive value for mortality.
A venous thromboembolism, which includes both deep vein thrombosis and pulmonary embolism (PE), is the third most common cardiovascular disease with an overall incidence of 100–200 per 100,000 people.1 Moreover, a PE is potentially life-threatening and because the condition lacks a specific set of symptoms, the diagnosis has become heavily reliant on non-invasive imaging. In fact, CT-PA is now recognised as the gold standard for the diagnosis of a PE.2 Left untreated an acute PE has a mortality rate of up to 30% and potentially up to two-thirds of patients with a PE can die within 2 hours of presentation.3 Thus, a prompt diagnosis can have a significant impact on mortality and in fact, some evidence suggests that longer waiting times with an emergency department (ED) are associated with
a greater risk in the short-term, of death and admission to hospital.4 The introduction of a 4-hour target in ED therefore seeks to reduce the time patients spend in the department.
However, the need for a CT-PA scan might increase the overall time spent within the ED and therefore breach the 4-hour target. Although clinical care should not be driven solely by the need to achieve a time-based target, a team from the Department of Radiology, Salmaniya Medical Complex, Bahrain, Saudi Arabia, wondered if there were specific patient or environmental factors which might influence the duration of stay in the ED. They undertook a retrospective analysis focussing on patients presenting with a suspected PE and for whom a CT-PA scan was performed.5 The team sought to identify which, if any, patient or environmental factors were associated with meeting the hospital’s 4-hour target. They collected patient demographic and clinical data as well as the time of presentation and deposition, calculating the length of stay in ED as the difference between these two times. Multivariate logistic regression analysis was used to determine independent factors associated with meeting the 4-hour target.
A total of 232 patients (32.8% male) of whom 80.2% were under 50 years of age, presented at the ED and underwent a CT-PA scan to rule out a PE. Overall, only 14.6% had a PE and a D-dimer assay had been requested for 59.1% of them. The overall median time to deposition from the ED was 5.2 hours and the only clinical factors that were significantly associated a lower time to disposition were the presence of hypoxia (p = 0.04) and an altered level of consciousness (p = 0.01). The time to deposition was longer among those who had a D-dimer test but this difference was not significant (p = 0.43). Overall, patients found to have a PE in the CT-PA scan also had a significantly shorter duration of stay in the ED (p = 0.02). Another factor which influenced the duration of stay was the day on which patients were seen, with those who attended at the weekend having a shorter length of stay (p = 0.01).
In the multivariate regression analysis, only two factors were independently associated with a stay of under four hours. The presence of a positive CT-PA scan (odds ratio, OR = 2.2, 95% CI 1.1–4.8, p = 0.02) and the haemoptysis (OR = 10.4, 95% CI 1.2–90.8, p = 0.03).
Commenting on these findings, the authors noted that while guidelines suggest that a D-dimer test is performed before a CT-PA scan, performing this test only added around 30 minutes to the overall time to deposition. They suggested that although their study had focused only on patients who had a CT-PA scan, clinicians should not be reluctant to request a D-dimer test simply to achieve the time-based target.
They concluded that meeting the 4-hour target was not significantly associated with most patient and environmental factors and that careful clinical assessment prior to a CT-PA scan was needed because a negative scan result may be associated with failure to meet the time-based target.
An increased popularity of bike riding in Canada in 1990 led to a 60% increase in the number of emergency department (ED) visits that were attributable to carelessness or poor bike control.1 Five years later, a report by the US, the Centers for Disease Control and Prevention, noted how nearly 1000 people die from injuries caused by bicycle crashes and that 550,000 people are treated in an ED for bike-related injuries.2 Despite the propensity for accidents, the COVID-19 pandemic led to a boom in sales of bicycles, with a report from the Bicycle Association in the UK noting that between April and June 2020, bicycle sales increased by 63% year-on-year.3
But whether increased sales led to a higher incidence of accidents among children during the pandemic is uncertain and this was the question posed by a team from the Department of Pediatric Emergency Medicine, The Hospital for Sick Children, Toronto, Canada.4 They conducted a cross-sectional study of ED visits to their children’s hospital between March and October 2020 and compared the level of visits with the same time period for two previous years: 2018 and 2019.
The researchers included all patients younger than 18 years of age and who presented at the ED with a bicycle-related injury from pedal bicycles, bicycle trailers and E-Bikes. However, they excluded cases where a pedestrian was injured and motorised bicycle-related injuries (e.g., dirt bikes). Data collected from hospital injury records included demographics, chief complaint, triage acuity at presentation and the use of helmets. Acuity was assessed using the Canadian Emergency Department Triage and Acuity Scale (CTAS), which ranges from 1 (critical) to 5 (non-urgent). Outcomes were classed as “admission to hospital”, “left without being seen” or “discharged home from the ED”. Among those admitted, the researchers further categorised patients as admitted to the floor, requiring immediate surgery or admission to the intensive care unit.
In terms of the number of visits, there were 1215 bike-related visits during the study period; 234 in 2018, 305 in 2019 and 676 in 2020. The mean age of all children was 9.5 years (67% male) and the median CTAS score was 3. The most common injury was a fracture (38.8%) and while this was numerically higher during the COVID-19 period (41.9% vs 37.5%, COVID vs pre-COVID), the difference was not statistically significant but there were significantly more bike injuries per month during the COVID-19 period compared to other times (p = 0.041). A comparison of pre-COVID-19 and COVID-19 time periods also revealed how there was a higher incidence of soft tissue bike-related injuries (28.4% vs 38.6%, p < 0.001). In contrast, there was a lower incidence of lacerations (24.3% vs 19.2%, pre vs COVID-19, p = 0.03) and multi-trauma injuries (4.3% vs 1.3%, pre vs COVID-19, p = 0.001). However, there were no significant differences for severe injuries or any other injury category.
Despite the increased rates of injury, the authors maintained that the benefits of cycling outweighed the risks and concluded that bike-related injuries increased during the pandemic and while soft tissue injuries were the most common reason, there was no difference in severe injuries compared to previous years.
NICE has recommended the use of the combination of two monoclonal antibodies, casirivimab and imdevimab, known as Ronapreve, REGEN-COV or REGEN-COV2, to all patients aged 12 years and hospitalised due to COVID-19. Eligible patients are those who have no detectable COVID-19 antibodies (i.e., are seronegative)1 but the combination therapy should not be given to individuals who are seropositive and those whose COVID-19 serostatus is unknown.
Casirivimab and imdevimab is a neutralising monoclonal antibody combination that binds to two different sites on the COVID-19 spike protein and in doing so, prevents entry of the virus into host cells, thus inhibiting viral replication. The evidence for Ronapreve and which was used by NICE to make its latest recommendations, came from data in the RECOVERY trial undertaken by researchers at Oxford University and the results of the trial are available as a preprint.2 The study enrolled 9785 patients hospitalised with COVID-19 and who were randomised 1:1 to a single dose of intravenous casirivimab (4g) and imdevimab (4g) (n=4839) and compared with a group assigned to usual care (n=4946). Since the trial recruited patients across 127 hospital sites throughout the UK, the definition of usual care varied but included corticosteroids (94%), aspirin (28%), remdesivir (25%), colchicine (23%) and tocilizumab or sarilumab (16%). For the trial, the mean age of participants was 61.9 years (63% male) and 54% were seropositive at the point of randomisation. The primary outcome was 28-day all-cause mortality.
In terms of the primary outcome, overall mortality was not significantly different between those assigned Ronapreve or usual care (relative risk, RR = 0.94, 95% CI 0.87–1.02) and with seropositive individuals (RR = 1.07, 95% CI 0.94–1.22). However, for seronegative patients, there was a significant mortality benefit (RR = 0.82, 95% CI 0.73–0.92).
In addition, there was a reduction in the number of seronegative patients progressing to invasive mechanical ventilation and the median duration of hospital stay was reduced from 17 days (usual care) to 13 days.
Based on the evidence from this single trial, the NICE panel agreed to recommend casirivimab and imdevimab to hospitalised seronegative COVID-19 patients aged 12 and over. A recognised limitation of the RECOVERY trial noted by NICE was that there was a lack of data on different doses of casirivimab and imdevimab, among immunocompromised patients and those who had been vaccinated. An additional problem was that safety outcomes were not collected throughout the study and NICE concluded that the safety profile of the combination is yet to be determined. Despite these limitations, the panel agreed that Ronapreve should be used for all eligible patients.
Simulation-based training improves knowledge retention for those undergoing paediatric resuscitation training. After completion of the American Heart Association Pediatric Advanced Life Support (PALS) programme, it is recommended that recertification should occur every 2 years.1 Despite this recommendation, a systematic review of studies examining retention of adult advanced life support knowledge and skills, found that both knowledge and skills decay 6 months to 1 year after training.2 Furthermore, the incidence of in-hospital cardiopulmonary arrests in paediatric patients is very low, ranging from 0.7% to 3% of all hospital admissions.3 Consequently, the capacity to master these skills through experience in clinical practice is limited. One approach to ensure that the necessary medical knowledge and skills are achieved is through a simulated-based curriculum, and this has been shown to enhance skills for handling medical emergencies.4 However, while this approach improves knowledge, it is less clear whether the technique supports the retention of knowledge.
This led a team from the Department of Pediatrics, University of Chicago, US, to explore the impact on retention of resuscitation skills, 8 months after a PALS course when reinforced by an adjunct simulation-based curriculum, 4 months after the initial PALS course.5 The team undertook a randomised, partially double-blind, controlled trial with first-year paediatric residents, who were blinded to the purpose of the study. To evaluate PALS procedural and cognitive skills, the residents had to complete simulation-based assessments (SBAs) on chest compression, airway management with bag-valve mask ventilation, intraosseous access and code team leadership. For each of the SBAs, a knowledge assessment tool was developed and used by trained raters, who watched video recordings of each resident performing the SBAs. The intervention group participated in SBAs and the simulation-based curriculum at 4 and 8 months after the PALS training, whereas the control group did not undergo the 4-month training session. The primary outcome was the changes in retention skills score at 8 months after the PALS course and assessed by the same raters at each time point.
A total of 24 residents were included and equally matched between the intervention and control groups. After 8 months, the overall mean per cent score for the intervention group on all four SBAs was 0.57 (95% CI 0.55–0.59) and 0.52 (95% CI 0.50–0.54) for the control group and this difference was statistically significant (p = 0.037). However, there was no significant difference between the two groups for each of the four individual SBAs. In addition, the intervention group had greater retention of cognitive knowledge mean scores (0.78 vs 0.68, intervention vs control, p = 0.049). The overall SBAs mean scores for all residents reduced from a mean percent of 0.61 at baseline to 0.55 at 8 months.
The authors commented on how the simulation-based curriculum significantly improved residents’ paediatric resuscitation skills. They concluded that this approach provided a suitable pathway for safeguarding against the decay of resuscitation skills.
One study of US emergency department (ED) paediatric visits for poisoning from prescription opioids, identified 21,928 visits between 2006 and 2012.1 Any cases of poisoning in children under 6 years are generally considered to be unintentional. In a further analysis of unsupervised paediatric medication exposures at emergency departments, prescription opioids were the most common class of medicines involved.2 While there are several publications examining the prevalence of unintentional paediatric opioid exposure, much less attention has been paid to the outcomes associated with these ingestions.
This prompted a team from the Department of Pediatric Emergency Medicine, University of Alabama, US to undertake a retrospective analysis of the data collected by the Regional Poison Control Centre (RPCC), in Alabama, of children aged 0 to 6 years with possible opiate exposure over a three period.3 Using the RPCC database, the team identified cases for all of the major opioid drugs including buprenorphine, codeine, fentanyl, hydrocodone, hydromorphone, methadone and oxycodone. Additional information collected included basic demographics, clinical data, including symptoms and the outcomes if the child was admitted.
A total of 429 charts were identified as meeting the inclusion criteria. The median age of children was 2 years (64% male). Caretakers reported symptoms in 140 (32%) of all cases referred to the ED although the remaining 289 were asymptomatic. There were 113 children referred to the ED by the RPCC service and 122 who presented directly to the department. Therefore 235 were seen at the ED, of which in 152 cases (66%) there was no medical intervention. From a total of 231 opioid exposures, the most common drug was buprenorphine (13%), followed by codeine (8.6%). There were 65 children (28%) who were admitted to hospital, 41 directly from the ED and 24 from an outside facility. Among those admitted, the majority, 28, were 1-year olds. Furthermore, 5 of these children were admitted to intensive care and 28 of the children received naloxone, 3 required multiple doses and 5 a continuous infusion. There were no fatalities although one patient had ingested a significant amount of methadone and required active resuscitation and a naloxone drip. Overall, the median length of hospital stay was one day.
In their conclusion, the authors noted that although 28% of children had required admission to hospital, the outcome was positive for most with only a small number requiring medical intervention, mainly in the form of naloxone.
In emergency departments (EDs), rapid and accurate COVID-19 screening is critical for effective infection control and ensuring timely – and appropriate – delivery of care for patients. With the pandemic relentlessly exerting an unprecedented burden on the healthcare system worldwide, this call for fast identification of COVID-19 at the point of care is more urgent than ever.
Currently, the nasopharyngeal swab RT-PCR test – the gold standard for SARS-CoV-2 testing – has a few limitations, including a long turnaround time (12–24 hours), limited sensitivity and requiring laboratory infrastructure.1 The rapid lateral flow antigen detection test yields results faster, but has other limitations such as poor sensitivity. For example, in a study in Liverpool, the overall sensitivity of the rapid test was only 40.0%, i.e., the test only detected four in 10 people who tested positive by PCR.2 And due to this risk of false results and imprecisions in the manufacturer’s accuracy claims, the US Food and Drug Administration recalled and withdrew the rapid tests from sale in the US in June 2021.3
Because it is vital to make quick decisions about a patient’s care pathway (admission, treatment approach, discharge, etc.) while keeping the hospital environment safe, there is a system-wide operational and safety impact when effectively performing front-door COVID-19 triage in the ED.
The CURIAL algorithm – developed by infectious disease and machine learning experts at Oxford University – is a viable alternative to traditional testing that can successfully rule out COVID-19 within the first hour of a patient’s arrival at an emergency department. The CURIAL AI algorithm uses the data from routine CBCs, urea and electrolyte tests, vital signs, liver function tests, C-reactive protein (CRP) tests and blood gas to predict the probability of a patient testing positive for COVID-19.4
Therefore, to combat the transmission of SARS-CoV-2 while providing high-quality care to patients – all within a reasonable timeframe – CURIAL can be an effective, and faster, solution to triage patients for COVID-19 in the ED setting.
CURIAL developed two models to predict COVID-19 in patients: The ED model (for all patients visiting the ED) and the admissions model (for subsequently admitted patients). The training data, gathered from four teaching hospitals in Oxfordshire, assessed 155,689 adult patients at Oxford University Hospitals between 1 December 2017 and 19 April 2020. When calibrated during training to a sensitivity of 80% – the ED model attained 77.4% sensitivity and 95.7% specificity for identifying COVID-19 patients among all patients presenting to hospital. And correspondingly – with the same calibration – the admissions model achieved 77.4% sensitivity and 94.8% specificity. In terms of negative predictive values (NPVs) – the probability that patients with a negative result truly don’t have COVID-19 – both models achieved high NPVs (>98·5%) across a range of prevalences (≤5%), allowing for a quick and reliable rule-out.
During a real-world evaluation of the CURIAL models over a two-week test period (20 April–6 May 2020) in Oxford University Hospitals’ EDs, CURIAL displayed impressive accuracy. The ED model (3326 patients) achieved 92.3% accuracy (NPV 97.6%), and the admissions model (1715 patients) achieved 92.5% accuracy (NPV 97.7%) in comparison to PCR results.4
To understand which individual features had the most significant influence on model predictions, CURIAL ran a relative feature importance analysis. For both models, eosinophils and basophils had most significant effects on model performance,4 meaning complete blood counts directly impact the CURIAL algorithm’s success.
As effective AI-powered COVID-19 screening relies on time-sensitive and accurate CBC results, the University of Oxford researchers created a version of CURIAL, called CURIAL-Rapide, that leverages only CBC results and vital signs to screen for COVID-19 in patients. Consequently, CURIAL-Rapide creates a new collaborative pathway where point of care CBC analysers – such as Sight Diagnostics’ OLO haematology analyser – are used in conjunction with CURIAL to potentially further expedite the overall screening turnaround time. And when the analyser can provide rapid results with lab-grade accuracy – OLO produces accurate results in approximately ten minutes – it can play a pivotal role in ensuring a safer hospital environment by triaging COVID-19 patients efficiently. For example, by reconfiguring the care pathway and removing the time and logistical constraint of using conventional lab infrastructure, hospitals can create separate areas (hot-labs) for CBC testing before patients enter EDs to reduce operational strain and staff work time while keeping the hospital safe from COVID-19 transmission.
To substantiate this innovative pathway and the CURIAL-Rapide algorithm, the University of Oxford deployed OLO analysers at the John Radcliffe Hospital in February 2021 to power lab-free screening. The study’s interim evaluation was successfully completed, and results will be published soon.
Having accurate CBC results in minutes, from OLO, would help CURIAL-Rapide make predictions even sooner, potentially reducing care delays and supporting infection control within hospitals. Our goal is to get the right treatment to patients sooner by helping rule out COVID at triage for a majority of patients who don’t have the infection. This project shows that artificial intelligence can work with rapid diagnostics to help us select the best care pathways and minimise risks of spreading the infection in hospitals.5
Andrew Soltan, academic clinician and machine learning researcher at Oxford University
Sight OLO haematology analyser streamlines the typical blood staining workflow while maintaining lab-grade accuracy. Through a quick finger prick and the culmination of cutting-edge innovations in physics, optics, sample preparation, and an AI-based computer vision algorithm, the self-contained quantitative multi-parameter analyser can deliver fast and accurate CBC results within minutes in point of care settings.
During a recent study, the accuracy of OLO was compared with the Sysmex XN-1000 System. Samples – covering a broad clinical range for each tested parameter – from 355 males (52%) and 324 females (48%) aged 3 months to 94 years were analysed. The regression analysis results showed a consonance in correlation coefficient and slope, bias and intercept between OLO and Sysmex XN. Therefore, the study concluded that OLO performs with high accuracy for all CBC parameters,6 thus, making OLO the perfect partner to use alongside an AI COVID-19 screening initiative, such as CURIAL.
Learn more about CURIAL’s rapid identification of COVID-19 and CBC results’ role in improving ED patient flow in a Sight Diagnostics CURIAL webinar. Register at www.sightdx.com/events/curial-rapide to watch the full webinar.
8th July 2021
Support for the development of this advertorial was provided by Nanosonics
Patients can be at risk from ultrasound-associated infections when low-level disinfection (LLD) is the standard of care. In order to quantify this risk, Scotland’s National Health Service undertook a retrospective analysis of microbiological and prescription data through linked national health databases. Patient records were examined in the 30-day period following semi-invasive ultrasound probe (SIUP) procedures.
The study analysed almost one million patient journeys that occurred during a six-year period from 2010.1
Of the 982,911 patients followed, 330,500 were gynaecological patients; and 60,698 of these gynaecological patients had undergone a transvaginal (TV) ultrasound procedure. These patients were found to be at a 41% greater risk of infection and a 26% greater risk of needing an antibiotic prescription in the 30 days following their transvaginal ultrasound procedure when compared to gynaecological patients who had not undergone a transvaginal ultrasound.
During the study period, 90.5% of facilities reported that they were performing low level disinfection for transvaginal ultrasound probes. These patients were at a greater risk of infection due to inadequate reprocessing and the study concluded that: “Hence failure to comply with existing guidance on [high-level disinfection] of SIUPs will continue to result in an unacceptable risk of harm to patients .”1
The diverse use of ultrasound probes is now prompting a renewed focus on correct probe reprocessing to ensure patient safety. To ensure best practice standards, decontamination experts and ultrasound users need to work together to reduce the risk of infection that is associated with using ultrasound probes.
Ultrasound procedures are performed in various inpatient and outpatient settings by a wide range of health professionals. This has increased the use of surface probes to guide procedures such as biopsies, cell retrieval, cannulation, catheterisation, injections, ablations, surgical aspirations, and drainages. Across these procedures, the probe has the potential to contact various patient sites – including intact skin, non-intact skin, mucous membranes and sterile tissue. This presents a complex challenge, as contact with these various body sites requires differing levels of disinfection or sterilisation between patient uses. Failure to adequately clean and disinfect medical devices like ultrasound probes between patients poses a serious risk to patient safety.
In 2012, a patient in Wales died from a hepatitis B infection – most likely caused by a failure to appropriately decontaminate a transoesophageal echocardiography probe between patients. As a result of this fatality, a Medical Device Alert was issued by the Medicines and Healthcare Products Regulatory Agency (UK) advising users to appropriately decontaminate all types of reusable ultrasound probes.2
The UK and European guidelines require ultrasound probes that come into contact with mucous membranes and non-intact or broken skin to be high-level disinfected. In particular, automated and validated processes for ultrasound reprocessing are preferred. This is supported by a study relating to manual disinfection methods, which found that only 1.4% of reprocessing systems were fully compliant when using manual methods, compared to 75.4% when using semi-automated disinfection methods.3
The Spaulding classification system4 must be applied before a procedure commences so that information about what tissues or body sites may be contacted is taken into account.
This classification system is a widely adopted disinfection framework for classifying medical devices, based on the degree of infection transmission risk, and requires the following approaches:
It is important to note the difference between cleaning and low-level disinfection. Cleaning is the removal of soil and visible material until the item is clean by visual inspection. Low level disinfection is the elimination of most bacteria, some fungi and some viruses.
A final and important point for consideration is the use of probe covers.
While many ultrasound users and sonographers believe that their transvaginal ultrasound patients are protected from infection risk by using barrier shields and/or condoms, research has shown that up to 13% of condoms fail and up to 5% of commercial covers fail. Probe covers may have microscopic tears or breakages which can allow microorganisms to pass through.5
Ultrasound users should work with their decontamination colleagues to understand the current UK and European guidelines for reprocessing ultrasound probes. There are patient risks associated with ultrasound usage when proper disinfection procedures are not followed, as well as from ancillary products such as contaminated ultrasound gel. While the increased use of ultrasound has brought many benefits for patients, effective education and disinfection protocols are required to minimise the risk of infection.
The trophon® system is designed to reduce the risks of infection transmission through automated high-level disinfection of transvaginal, transrectal and surface probes. With over 25,000 units operating worldwide, 80,000 people each day are protected from the risk of cross-contamination with trophon devices. As a fully enclosed system, trophon2 can be placed at the point of care to integrate with clinical workflows and maintain patient throughput. trophon technology# uses proprietary hydrogen peroxide disinfectant that is sonically activated to create a mist. Free radicals in the mist have oxidative properties enabling the disinfectant to kill bacteria, fungi and viruses. The mist particles are so small that they reach crevices, grooves and imperfections on the probe surface. Nanosonics works collaboratively with probe manufacturers to carry out extensive probe compatibility testing. More than 1000 surface and intracavity probes from all major and many specialist probe manufacturers are approved for use with trophon devices.
# The trophon family includes the trophon EPR and trophon2 devices which share the same core technology of sonically-activated hydrogen peroxide.
Sports-related concussion (SRC) occurs when an external force is transmitted to the head and produces transient neurological symptoms. However, there is increasing evidence that individuals who have experienced repeated SRCs when examined at autopsy, are found to display an accumulation and aggregation of the protein, tau, which helps stabilise neurons combined with persistent neuroinflammation. In addition, traumatic brain injury (TBI) is a chronic disease, which leads to progressive white matter atrophy and persistent inflammation. It is possible therefore that repeated SRC might represent a harbinger of TBI but the evidence for this possible association is based on the findings from autopsies.
Is it possible therefore, wondered a team from the Department of Clinical Sciences, Lund University, Sweden, that imaging of the brains of individuals who have suffered SRCs and those with TBI might reveal similar changes?
The researchers recruited healthy young adults, who served as controls, athletes who had previously experienced SRCs and individuals with moderate-to-severe TBI. For the study, the researchers combined the use of positron emission tomography (PET) and magnetic resonance imaging to view images of the brains of their subjects. On the day of the scans, all participants were assessed using the repeated battery assessment of neurological status (RBANS), which provides a measure of attention, language, memory and visuospatial/constructive skills, i.e., overall cognitive skills with higher scores associated less cognitive impairment. Prior to the PET scans, participants were injected with two biomarkers; the neuroinflammation tracer, [11C]-PK11195, which was used to assess neurofilament-light (NF-L) levels, which is a measure of neuroaxonal damage, and later the tau tracer, [18F]-THK5317 that can assess for tau burden. The MRI scans were performed during PET scanning.
Findings
A total of 9 controls, 12 SRC and 6 TBI participants were recruited with a similar mean age (26 years) with 4 male patients in the control and TBI groups. Among the 12 SRC participants, 8 has been ice hockey players and the others were either footballers or Alpine skiers. Both the TBI and SRC groups had lower RBANS scores compared with controls, 75, 80 and 105.5, respectively (p < 0.05). Free tau levels were lowest in those with a TBI (reflecting greater aggregation) compared to controls and those with SRC (3.4 picog/ml, 4.0 picog/ml and 4.7 picog/ml, respectively). Similarly, the highest levels of NF-L (i.e., greater levels of neuroinflammation) were seen in those with TBI compared with controls and SRC (10, 6 and 8, respectively).
Discussing these findings, the authors outlined how on a group levels, both young athletes and TBI patients had increased levels of tau aggregation and neuroinflammation, even though the imaging had occurred six months, and up to several years, after the last SRC or TBI. They authors suggested that this implied a persistent pathology and thought that the reduced free tau levels might be a consequence of decreased release from damaged neurons.
They concluded that the presence of both increased tau aggregation and neuroinflammation among those with TBI and SRC implied a similar pathology, and that follow-up PET imaging was required to establish whether the observed changes persist over time and if such changes are associated with clinical symptoms.
Citation
Marklund N et al. Tau aggregation and increased neuroinflammation in athletes after sports-related concussions and in traumatic brain injury patients – A PET/ MR study. Neurolmage Clin 2021;30:102665. https://doi.org/10.1016/j.nicl.2021.102665
A 2019 international survey of radiologists revealed a limited knowledge of artificial intelligence (AI) and a genuine fear that the technology would lead to their replacement in the coming years. This fear was in part, found to be driven by a lack of understanding of the role of AI with the result that few expressed a proactive attitude towards the technology. Having identified several factors, a team from the Department of Radiology, University Medical Center, Utrecht, The Netherlands, decided to expand upon their earlier findings and further explore the expectations among radiologists regarding the potential implementation of AI systems, possible barriers to adoption and the perceived need for AI education during their residency training.
The team created a web-based survey that included 39 questions which sought to determine demographics, awareness and existing knowledge of AI, respondents’ expectations of the technology and any hurdles to implementation. The survey was piloted with ten radiologists and then translated into English, French, German, Spanish, Italian, Dutch, Czech, Russian and Turkish and distributed electronically through the Italian, French and Dutch radiology societies, as well as the European Society of Medical Imaging Informatics and via social media.
Findings
A total of 1086 respondents from 54 countries, with a median age of 38 years (65% male) completed the survey. Most of the respondents (83%) were based in Europe although a small number came from Africa (1%), Asia (7%) and North America (6%). Among the respondents, the majority (66%) were radiologists and the remainder either fellows or residents. When asked whether AI would improve diagnostic radiology, the majority (89%) said maybe with only 10% believing that it would. Most respondents (89%) agreed that AI would help to improve diagnostic radiology and the majority (85%) also felt that AI would alter the future of radiologists. With respect to the expected role and benefits of AI in diagnostic radiology, the most frequently cited roles were as a second reader (78%) and workflow optimisation (77%). Interestingly, 47% reported that AI would serve as a partial replacement for radiologists with only 1% think that it would represent a complete replacement.
The potential hurdles to implementation cited included ethical and legal issues (62%), lack of knowledge among relevant stakeholders (56%) and limitations due to digital infrastructure (35%). Additionally, both the high cost of AI software development and the cost of the software itself, were seen as barriers to implementation by 35% and 38% of respondents respectively. Most respondents (79%) also felt that AI education should be incorporated into residency training programmes and this was more likely among older radiologists, although only a minority (23%) thought that imaging informatics and AI should become a radiology subspeciality. In addition, three-quarters (75%) of respondents stated that they were planning on learning about AI.
In discussing these findings, the authors noted how the many (82%) respondents expected that AI would cause a significant change to the profession within ten years but on a positive note, most felt that AI systems could serve as a second reader and assist with workflow optimisation within departments. They concluded that the data suggested how there was broad support across the radiologist community for the incorporation of AI into residency programmes while, at the same time, recognising that legal/ethical issues together with digital infrastructure constraints were an overlooked challenge.
Citation
Huisman M et al. An international survey on AI in radiology in 1041 radiologists and radiology residents’ part 2: expectations, hurdles to implementation, and education. Eur Radiol 2021. https://doi.org/10.1007/s00330-021-07782-4
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