Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection

Diagnosis of orthopaedic prosthesis infections with radionuclide techniques; clinical application of various imaging methods

Abstract A variety of radiopharmaceuticals and imaging techniques are currently available for scintigraphic imaging of infections. However, comparisons on the clinical value of such techniques have been limited, especially in prosthesis infections. This series included 138 cases with suspected prosthesis infections – 94 in hip and 44 in knee prostheses of patients whose final diagnoses were based on clinical, operative and microbiological findings, and who underwent three-phase bone, 99mTc -leukocyte and 99mTc-ciprofloxacin imaging in the Department of Clinical Chemistry, Oulu University Hospital and in the Laboratory, L?nsi-Pohja Central Hospital, during the years from 1993 to 2001. The normal arterial and soft-tissue phase images of three-phase bone imaging practically excluded infection in hip prostheses, whereas these techniques frequently yielded false positive findings in patients with knee prostheses, resulting in specificity of 23% or less. In combined 99mTc-leukocyte/bone imaging, diagnostic accuracy was 80–86% at two- to four-hour images and 87–98% at 24-hour images. The 99mTc-ciprofloxacin images showed unspecific accumulation of tracer in the one-hour and four-hour images, which disappeared in the 24-hour images in most hip and knee prostheses. 99mTc-ciprofloxacin imaging yielded almost as good diagnostic accuracy as combined 99mTc-leukocyte/bone imaging. In conclusion, in suspected hip prosthesis infections, normal findings in three-phase bone imaging exclude infection, whereas abnormal results in the arterial and soft-tissue phases should be confirmed with 99mTc-leukocyte imaging using 24-hour images. Contrary-wise, in suspected knee prosthesis infections, 99mTc-leukocyte imaging with 24-hour images is the first-line examination, and abnormal results in 24-hour images should be confirmed by using 99mTc-bone-metabolic imaging. 99mTc-ciprofloxacin yielded almost equally good results as 99mTc-leukocyte/bone-metabolic imaging, but unfortunately, the tracer is not commercially available, although it has been patented

Discriminating infection from sterile inflammation: can radiolabelled antibiotics solve the problem?

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A large retrospective single-centre study to define the best image acquisition protocols and interpretation criteria for white blood cell scintigraphy with Tc-99m-HMPAO-labelled leucocytes in musculoskeletal infections

<p>The diagnosis of infection is often based on clinical, pathological and microbiological results. However, these investigations lack specificity. White blood cell (WBC) scintigraphy is considered the gold standard nuclear imaging technique for diagnosing infections in bone and soft tissues (except spondylodiscitis). However, image acquisition and interpretation criteria differ amongst centres throughout the world, leading to differences in reported results. The aim of this study was to identify the most accurate WBC scintigraphy acquisition and interpretation protocols for diagnosis of bone and soft tissue infections.</p><p>Included in this retrospective study were 297 patients with suspected bone or soft tissue infection who underwent WBC scintigraphy with Tc-99m-HMPAO-labelled leucocytes between 2009 and 2012. Sensitivity, specificity, accuracy, and positive and negative predictive values of WBC scintigraphy were determined for two different dual time point acquisition protocols (fixed-time acquisition and time decay-corrected acquisition) and five image interpretation methods (visual and semiquantitative with four different reference regions of interest). Final diagnosis was based on pathological and microbiological reports, and when these were not available, on clinical follow-up of at least 6 months.</p><p>The best acquisition protocol was 4 h and 20 - 24 h dual time-point acquisition with time decay-corrected acquisition. When using this acquisition protocol, visual qualitative interpretation led to a sensitivity of 85.1 %, a specificity of 97.1 %, a diagnostic accuracy of 94.5 %, a positive predictive value of 88.8 % and a negative predictive value of 95.9 %. For semiquantitative analysis, the best results were found when lesion-to-reference ratios were calculated with the contralateral side as the reference tissue, except for osteomyelitis and infected osteosynthesis, for which the contralateral bone marrow was found to be the best reference tissue. Results of the semiquantitative analyses per se were not better than for visual analysis. In the optimal analysis protocol, scans are first visually evaluated, and if this gives equivocal results, semiquantitative analysis is performed. This strategy resulted in an improved sensitivity of 97.9 %, a specificity of 91.8 % and a diagnostic accuracy of 93.1 %.</p><p>WBC scintigraphy for bone and soft-tissue infection is best performed using a dual acquisition protocol at 4 h and at 20-24 h after injection, in which the acquisition time of the scans is corrected for decay. In most patients, visual analysis is sufficient and leads to high diagnostic accuracy. When interpretation by visual analysis is inconclusive, semiquantitative analysis adds accuracy. Based on our results, we propose a flow chart for analysing WBC scintigraphy in musculoskeletal infections.</p>

Musculoskeletal Imaging Update: Current Applications of Advanced Imaging Techniques to Evaluate the Early and Long-Term Complications of Patients with Orthopedic Implants

Technical advances in imaging have increased their applicability to diagnosing conditions of the musculoskeletal system, especially in the postoperative setting, where traditionally metallic artifacts have hindered evaluation. Advances in computed tomography (CT), magnetic resonance (MR) imaging, ultrasound, and nuclear medicine have resulted in improved overall image quality. Specific modifications of imaging parameters, especially in CT and MRI, have improved the radiologist's ability to diagnose potential hardware complications such as loosening and osteolysis. Sonography can evaluate the periprosthetic soft tissues and enables both diagnostic information and therapeutic treatment at the same sitting. Lastly, diagnostic scintigraphic applications such as positron emission tomography (PET) have increased specificity in diagnosing potential infection in the arthroplasty setting. This review discusses some of the current applications of CT, MRI, ultrasound, and nuclear medicine in evaluating the postoperative orthopedic patient, concentrating on the appropriate imaging evaluation for the painful arthroplasty patient