Recent Submissions

  • Management of Lung Nodules and Lung Cancer Screening During the COVID-19 Pandemic: CHEST Expert Panel Report

    Mazzone, P.J.; Gould, M.K.; White, C.S. (Elsevier Inc, 2020)
    Background: The risks from potential exposure to coronavirus disease 2019 (COVID-19), and resource reallocation that has occurred to combat the pandemic, have altered the balance of benefits and harms that informed current (pre-COVID-19) guideline recommendations for lung cancer screening and lung nodule evaluation. Consensus statements were developed to guide clinicians managing lung cancer screening programs and patients with lung nodules during the COVID-19 pandemic. Methods: An expert panel of 24 members, including pulmonologists (n = 17), thoracic radiologists (n = 5), and thoracic surgeons (n = 2), was formed. The panel was provided with an overview of current evidence, summarized by recent guidelines related to lung cancer screening and lung nodule evaluation. The panel was convened by video teleconference to discuss and then vote on statements related to 12 common clinical scenarios. A predefined threshold of 70% of panel members voting agree or strongly agree was used to determine if there was a consensus for each statement. Items that may influence decisions were listed as notes to be considered for each scenario. Results: Twelve statements related to baseline and annual lung cancer screening (n = 2), surveillance of a previously detected lung nodule (n = 5), evaluation of intermediate and high-risk lung nodules (n = 4), and management of clinical stage I non-small cell lung cancer (n = 1) were developed and modified. All 12 statements were confirmed as consensus statements according to the voting results. The consensus statements provide guidance about situations in which it was believed to be appropriate to delay screening, defer surveillance imaging of lung nodules, and minimize nonurgent interventions during the evaluation of lung nodules and stage I non-small cell lung cancer. Conclusions: There was consensus that during the COVID-19 pandemic, it is appropriate to defer enrollment in lung cancer screening and modify the evaluation of lung nodules due to the added risks from potential exposure and the need for resource reallocation. There are multiple local, regional, and patient-related factors that should be considered when applying these statements to individual patient care.
  • Management of Lung Nodules and Lung Cancer Screening During the COVID-19 Pandemic: CHEST Expert Panel Report

    Mazzone, P.J.; Gould, M.K.; White, C.S. (Elsevier Inc, 2020)
    Background: The risks from potential exposure to coronavirus disease 2019 (COVID-19), and resource reallocation that has occurred to combat the pandemic, have altered the balance of benefits and harms that informed current (pre-COVID-19) guideline recommendations for lung cancer screening and lung nodule evaluation. Consensus statements were developed to guide clinicians managing lung cancer screening programs and patients with lung nodules during the COVID-19 pandemic. Methods: An expert panel of 24 members, including pulmonologists (n = 17), thoracic radiologists (n = 5), and thoracic surgeons (n = 2), was formed. The panel was provided with an overview of current evidence, summarized by recent guidelines related to lung cancer screening and lung nodule evaluation. The panel was convened by video teleconference to discuss and then vote on statements related to 12 common clinical scenarios. A predefined threshold of 70% of panel members voting agree or strongly agree was used to determine if there was a consensus for each statement. Items that may influence decisions were listed as notes to be considered for each scenario. Results: Twelve statements related to baseline and annual lung cancer screening (n = 2), surveillance of a previously detected lung nodule (n = 5), evaluation of intermediate and high-risk lung nodules (n = 4), and management of clinical stage I non-small cell lung cancer (n = 1) were developed and modified. All 12 statements were confirmed as consensus statements according to the voting results. The consensus statements provide guidance about situations in which it was believed to be appropriate to delay screening, defer surveillance imaging of lung nodules, and minimize nonurgent interventions during the evaluation of lung nodules and stage I non-small cell lung cancer. Conclusions: There was consensus that during the COVID-19 pandemic, it is appropriate to defer enrollment in lung cancer screening and modify the evaluation of lung nodules due to the added risks from potential exposure and the need for resource reallocation. There are multiple local, regional, and patient-related factors that should be considered when applying these statements to individual patient care.
  • Respiratory Protection Considerations for Healthcare Workers During the COVID-19 Pandemic

    Friese, C.R.; Veenema, T.G.; Chang, J.C. (Mary Ann Liebert, 2020)
    The COVID-19 pandemic has resulted in a surge of patients that exceeds available human and physical resources in many settings, triggering the implementation of crisis standards of care. High-quality respiratory protection is essential to reduce exposure among healthcare workers, yet dire shortages of personal protective equipment in the United States threaten the health and safety of this essential workforce. In the context of rapidly changing conditions and incomplete data, this article outlines 3 important strategies to improve healthcare workers' respiratory protection. At a minimum, healthcare workers delivering care to patients with confirmed or suspected COVID-19 should wear N95 respirators and full-face shields. Several mechanisms exist to boost and protect the supply of N95 respirators, including rigorous decontamination protocols, invoking the Defense Production Act, expanded use of reusable elastomeric respirators, and repurposing industrial N95 respirators. Finally, homemade facial coverings do not protect healthcare workers and should be avoided. These strategies, coupled with longer-term strategies of investments in protective equipment research, infrastructure, and data systems, provide a framework to protect healthcare workers immediately and enhance preparedness efforts for future pandemics.
  • Radiation therapy considerations during the COVID-19 Pandemic: Literature review and expert opinions

    Mohindra, P.; Buckey, C.R.; Chen, S. (American Institute of Physics, 2020)
  • The Surge after the Surge: Cardiac Surgery post-COVID-19

    Salenger, R.; Etchill, E.W.; Gammie, J.S. (Elsevier, Inc., 2020)
    BACKGROUND: The COVID-19 pandemic has dramatically reduced adult cardiac surgery case volumes as institutions and surgeons curtail non-urgent operations. There will be a progressive increase in deferred cases during the pandemic that will require completion within a limited time frame once restrictions ease. We investigated the impact of various levels of increased post-pandemic hospital operating capacity on the time to clear the backlog of deferred cases. METHODS: We collected data from four cardiac surgery programs across two health systems. We recorded case rates at baseline and during the COVID-19 pandemic. We created a mathematical model to quantify the cumulative surgical backlog based on the projected pandemic duration. We then used our model to predict the time required to clear the backlog depending on the level of increased operating capacity. RESULTS: Cardiac surgery volumes fell to 54% of baseline after restrictions were implemented. Assuming a service restoration date of either June 1 or July 1, we calculated the need to perform 216% or 263% of monthly baseline volume, respectively, to clear the backlog in one month. The actual duration required to clear the backlog is highly dependent on hospital capacity in the post-COVID time period, and ranges from one to eight months depending on when services are restored and degree of increased capacity. CONCLUSIONS: Cardiac surgical operating capacity during the COVID-19 recovery period will have a dramatic impact on the time to clear the deferred cases backlog. Inadequate operating capacity may cause substantial delays and increase morbidity and mortality. If only pre-pandemic capacity is available, the backlog will never clear.
  • Inpatient Teledermatology During the COVID-19 Pandemic

    Rismiller, K.; Cartron, A.M.; Trinidad, J.C.L. (Taylor & Francis, 2020)
  • CT Scans Obtained for Nonpulmonary Indications: Associated Respiratory Findings of COVID-19

    Hossain, R.; Lazarus, M.S.; Roudenko, A.; Dako, F.; Mehta, V.; Alis, J.; Zalta, B.; Lei, B.; Haramati, L.B.; White, C.S. (Radiological Society of North America, 2020)
    Background: Atypical manifestations of COVID-19 are being encountered as the pandemic unfolds, leading to non-chest CT scans that may uncover unsuspected pulmonary disease. Purpose: To investigate patients with primary non-respiratory symptoms who underwent abdomen/pelvis or cervical spine/neck CT with unsuspected findings highly suspicious for pulmonary COVID-19. Materials and Methods: This retrospective study from March 10, 2020 to April 6, 2020 involved three institutions, two in a region considered a hotspot (area of high prevalence) for COVID-19. Patients without known COVID-19 were included who presented to the emergency room (ER) with primary non-respiratory [gastrointestinal (GI) or neurological] symptoms, had lung parenchymal findings suspicious for COVID-19 on a non-chest CT but no concurrent chest CT and had COVID-19 testing in the ER. Group 1 patients had RT PCR obtained pre-CT read (COVID-19 suspected on presentation); Group 2 had RT PCR obtained post-CT read (COVID-19 not suspected). Presentation and imaging findings were compared and outcomes were evaluated. Descriptive statistics and Fisher exact tests were used for analysis. Results: Group 1 comprised 62 patients [31 men, 31 women, mean age 67(SD ±17) years] and group 2 comprised 57 patients [28 men, 29 women, mean age 63(SD ± 16) years). Cough and fever were more common in group 1 (37/62, 60%, 29/62, 47%) than group 2 (9/57, 16%, 12/57, 21%) respectively, with no significant difference in the remaining symptoms. There were 101 abdomen/pelvis and 18 cervical spine/neck CTs. In Group 1, non-chest CT findings provided the initial evidence of COVID-19 related pneumonia in 32/62 (52%); for Group 2, it was 44/57 (77%). Overall, the most common CT findings were ground glass opacity (114/119, 96%) and consolidation (47/119,40%). 29/119 (24%) patients required major interventions (vasopressor medication or intubation) and 27/119 (23%) died. Patients who underwent cervical spine/neck CT had worse outcomes than those with abdominal/pelvic CT (p =0.01). Conclusion: In a substantial percentage of patients with primary non-respiratory symptoms who underwent non-chest CT, the CT provided the first evidence of COVID-19 related pneumonia.
  • The imperative for universal healthcare to curtail the COVID-19 outbreak in the USA

    Galvani, A.P.; Parpia, A.S.; Fitzpatrick, M.C. (Lancet Publishing Group, 2020)
    The COVID-19 outbreak in the United States is growing steeply and spreading widely. As of March 26, national incidence surpassed every other country, and as of April 28 has reported over a million cases. The COVID-19 crisis is exposing the systemic frailties in our healthcare system. More than 78 million people in America do not have access to adequate health insurance [1]. Given that health insurance in the US is typically provided by employers, millions more are at risk of losing their healthcare coverage as unemployment surges. Here we discuss how the pervasive healthcare insecurity in the US hampers control of COVID-19. Further, we argue that universal healthcare would alleviate the cost barriers that are impeding control of this pandemic.
  • Management of Acute Myocardial Infarction During the COVID-19 Pandemic

    Mahmud, E.; Dauerman, H.L.; Mattu, A. (John Wiley and Sons Inc., 2020)
    The worldwide pandemic caused by the novel acute respiratory syndrome coronavirus 2 (SARS-CoV2) has resulted in a new and lethal disease termed coronavirus disease 2019 (COVID-19). Although there is an association between cardiovascular disease and COVID-19, the majority of patients who need cardiovascular care for the management of ischemic heart disease may not be infected with COVID-19. The objective of this document is to provide recommendations for a systematic approach for the care of patients with an acute myocardial infarction (AMI) during the COVID-19 pandemic. There is a recognition of two major challenges in providing recommendations for AMI care in the COVID-19 era. Cardiovascular manifestations of COVID-19 are complex with patients presenting with AMI, myocarditis simulating a ST-elevation MI presentation, stress cardiomyopathy, non-ischemic cardiomyopathy, coronary spasm, or nonspecific myocardial injury and the prevalence of COVID-19 disease in the US population remains unknown with risk of asymptomatic spread. This document addresses the care of these patients focusing on 1) the varied clinical presentations; 2) appropriate personal protection equipment (PPE) for health care workers; 3) role of the Emergency Department, Emergency Medical System and the Cardiac Catheterization Laboratory; and 4) Regional STEMI systems of care. During the COVID-19 pandemic, primary PCI remains the standard of care for STEMI patients at PCI capable hospitals when it can be provided in a timely fashion, with an expert team outfitted with PPE in a dedicated CCL room. A fibrinolysis-based strategy may be entertained at non-PCI capable referral hospitals or in specific situations where primary PCI cannot be executed or is not deemed the best option.
  • Emerging SARS-CoV-2 mutation hot spots include a novel RNA-dependent-RNA polymerase variant

    Pachetti, M.; Benedetti, F.; Gallo, R.C. (Springer Nature, 2020)
    BACKGROUND: SARS-CoV-2 is a RNA coronavirus responsible for the pandemic of the Severe Acute Respiratory Syndrome (COVID-19). RNA viruses are characterized by a high mutation rate, up to a million times higher than that of their hosts. Virus mutagenic capability depends upon several factors, including the fidelity of viral enzymes that replicate nucleic acids, as SARS-CoV-2 RNA dependent RNA polymerase (RdRp). Mutation rate drives viral evolution and genome variability, thereby enabling viruses to escape host immunity and to develop drug resistance. METHODS: We analyzed 220 genomic sequences from the GISAID database derived from patients infected by SARS-CoV-2 worldwide from December 2019 to mid-March 2020. SARS-CoV-2 reference genome was obtained from the GenBank database. Genomes alignment was performed using Clustal Omega. Mann-Whitney and Fisher-Exact tests were used to assess statistical significance. RESULTS: We characterized 8 novel recurrent mutations of SARS-CoV-2, located at positions 1397, 2891, 14408, 17746, 17857, 18060, 23403 and 28881. Mutations in 2891, 3036, 14408, 23403 and 28881 positions are predominantly observed in Europe, whereas those located at positions 17746, 17857 and 18060 are exclusively present in North America. We noticed for the first time a silent mutation in RdRp gene in England (UK) on February 9th, 2020 while a different mutation in RdRp changing its amino acid composition emerged on February 20th, 2020 in Italy (Lombardy). Viruses with RdRp mutation have a median of 3 point mutations [range: 2-5], otherwise they have a median of 1 mutation [range: 0-3] (p value?<?0.001). CONCLUSIONS: These findings suggest that the virus is evolving and European, North American and Asian strains might coexist, each of them characterized by a different mutation pattern. The contribution of the mutated RdRp to this phenomenon needs to be investigated. To date, several drugs targeting RdRp enzymes are being employed for SARS-CoV-2 infection treatment. Some of them have a predicted binding moiety in a SARS-CoV-2 RdRp hydrophobic cleft, which is adjacent to the 14408 mutation we identified. Consequently, it is important to study and characterize SARS-CoV-2 RdRp mutation in order to assess possible drug-resistance viral phenotypes. It is also important to recognize whether the presence of some mutations might correlate with different SARS-CoV-2 mortality rates.
  • Chest CT and Coronavirus Disease (COVID-19): A Critical Review of the Literature to Date

    Raptis, C.A.; Hammer, M.M.; Jeudy, J. (American Roentgen Ray Society, 2020)
    OBJECTIVE. Coronavirus disease (COVID-19) is a global pandemic. Studies in the radiology literature have suggested that CT might be sufficiently sensitive and specific in diagnosing COVID-19 when used in lieu of a reverse transcription-polymerase chain reaction test; however, this suggestion runs counter to current society guidelines. The purpose of this article is to critically review some of the most frequently cited studies on the use of CT for detecting COVID-19. CONCLUSION. To date, the radiology literature on COVID-19 has consisted of limited retrospective studies that do not substantiate the use of CT as a diagnostic test for COVID-19.
  • Editorial. COVID-19 and spinal surgery

    Ghogawala, Z.; Kurpad, S.; Sansur, C.A. (American Association of Neurological Surgeons, 2020)
  • The Impact of COVID-19 on Radiation Oncology Clinics and Patients With Cancer in the United States

    Rivera, A.; Ohri, N.; Miller, R. (Elsevier Inc, 2020)
    Patients with cancer are known to be at an increased risk for community-acquired respiratory viruses, such as influenza, because of their frequently observed immunocompromised state.5 The spread of SARS-CoV-2 is of particular concern in this vulnerable population, given the higher case fatality rate seen in Wuhan and the potentially increased severity of the disease course with COVID-19.
  • Projecting hospital utilization during the COVID-19 outbreaks in the United States

    Moghadas, S.M.; Shoukat, A.; Fitzpatrick, M.C. (National Academy of Sciences, 2020)
    In the wake of community coronavirus disease 2019 (COVID-19) transmission in the United States, there is a growing public health concern regarding the adequacy of resources to treat infected cases. Hospital beds, intensive care units (ICUs), and ventilators are vital for the treatment of patients with severe illness. To project the timing of the outbreak peak and the number of ICU beds required at peak, we simulated a COVID-19 outbreak parameterized with the US population demographics. In scenario analyses, we varied the delay from symptom onset to self-isolation, the proportion of symptomatic individuals practicing self-isolation, and the basic reproduction number R0. Without self-isolation, when R0 = 2.5, treatment of critically ill individuals at the outbreak peak would require 3.8 times more ICU beds than exist in the United States. Self-isolation by 20% of cases 24 h after symptom onset would delay and flatten the outbreak trajectory, reducing the number of ICU beds needed at the peak by 48.4% (interquartile range 46.4-50.3%), although still exceeding existing capacity. When R0 = 2, twice as many ICU beds would be required at the peak of outbreak in the absence of self-isolation. In this scenario, the proportional impact of self-isolation within 24 h on reducing the peak number of ICU beds is substantially higher at 73.5% (interquartile range 71.4-75.3%). Our estimates underscore the inadequacy of critical care capacity to handle the burgeoning outbreak. Policies that encourage self-isolation, such as paid sick leave, may delay the epidemic peak, giving a window of time that could facilitate emergency mobilization to expand hospital capacity.
  • Insights from nanomedicine into chloroquine efficacy against COVID-19

    Hu, T.Y.; Frieman, M.; Wolfram, J. (32203437, 2020)
    Recent multicentre clinical trials and cell culture studies suggest that the 70-year-old malaria drug, chloroquine, may potentially display therapeutic efficacy against COVID-19 (corona virus disease 2019), a rapidly spreading viral infection that can cause pneumonia-induced death in approximately 2.5% of infected individuals. Based on the preliminary clinical trial findings, chloroquine has been included in federal guidelines for treatment of COVID-19 in the People’s Republic of China. However, caution should be exercised when making premature interpretations, as clinical trials are still ongoing and interim trial data have not yet been made available. Given the current lack of an approved and effective vaccine for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus causing COVID-19, it is important to evaluate potential prophylactic and/or therapeutic effects of drugs that are clinically approved for other indications. Chloroquine and its derivative, hydroxychloroquine, have a long history as safe and inexpensive drugs for use as prophylactic measures in malaria-endemic regions and as daily treatments for autoimmune diseases with the most common side effect being eye damage after long-term use. Although previous studies have revealed that chloroquine has therapeutic activity against viruses5, including human coronavirus OC43 in animal models and SARS-CoV in cell culture studies, anti-viral mechanisms of chloroquine remain speculative. Chloroquine has been used in the field of nanomedicine for the investigation of nanoparticle uptake in cells, and, therefore, insights from synthetic nanoparticle interactions with cells in the presence of chloroquine may reveal mechanisms that are active at early stages prior to viral replication. Specifically, nanomedicine studies may provide clues on chloroquine-induced alterations of SARS-CoV-2 cellular uptake.
  • Projecting the demand for ventilators at the peak of the COVID-19 outbreak in the USA

    Wells, C.R.; Fitzpatrick, M.C.; Sah, P. (Lancet Publishing Group, 2020)
    The coronavirus disease 2019 (COVID-19) pandemic has been straining health-care systems worldwide. For countries still in the early phase of an outbreak, there is concern regarding insufficient supply of intensive care unit (ICU) beds and ventilators to handle the impending surge in critically ill patients. To inform pandemic preparations, we projected the number of ventilators that will be required in the USA at the peak of the COVID-19 outbreak.
  • Review of Emerging Pharmacotherapy for the Treatment of Coronavirus Disease 2019

    Barlow, A.; Landolf, K.M.; Yeung, S.Y.A.; Heavner, J.J.; Claassen, C.W.; Heavner, M.S. (Wiley-Blackwell, 2020)
    The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) has evolved into an emergent global pandemic. Coronavirus disease 2019 (COVID‐19) can manifest on a spectrum of illness from mild disease to severe respiratory failure requiring intensive care unit (ICU) admission. As the incidence continues to rise at a rapid pace, critical care teams are faced with challenging treatment decisions. There is currently no widely accepted standard of care in the pharmacological management of patients with COVID‐19. Urgent identification of potential treatment strategies is a priority. Therapies include novel agents available in clinical trials or through compassionate use, and other drugs, repurposed antiviral and immune modulating therapies. Many have demonstrated in vitro or in vivo potential against other viruses that are similar to SARS‐CoV‐2. Critically ill patients with COVID‐19 have additional considerations related to adjustments for organ impairment and renal replacement therapies, complex lists of concurrent medications, limitations with drug administration and compatibility, and unique toxicities that should be evaluated when utilizing these therapies. The purpose of this review is to summarize practical considerations for pharmacotherapy in patients with COVID‐19, with the intent of serving as a resource for health care providers at the forefront of clinical care during this pandemic.

View more