Rethinking international financing for health to better respond to future pandemics.

International financing for health has been high on the political and global health agenda since COVID-19. The recent launch of the Pandemic Fund represents the first consolidated effort of the international community to mobilise additional voluntary financial resources for the purpose of strengthening global efforts in pandemic prevention, preparedness and response (PPR). Against such a dynamic landscape, building on recent critiques and new policy proposals, we propose a new generation of more equitable, effective and coordinated financing arrangements for pandemic PPR and for global health and development more broadly: lessons that could be applied in the ongoing endeavour of the Pandemic Fund. We also explore the principles of Global Public Investment and consider their potential to achieve greater inclusiveness in governance, diversity in financing, and transparency and performance in operations. The Pandemic Fund could become the first example of a global health initiative based on innovative concepts. It needs to be broad based, more flexible, leverage a great variety of funding sources and join forces with multiple stakeholders to maximise the impact.

Crystal Diseases of the Spine.

Gout, calcium pyrophosphate deposition disease, and apatite calcifications, the three main crystal disorders, may involve the spine. These disorders can be completely asymptomatic or associated with various clinical symptoms, such as acute flares and more chronic manifestations. This article presents the typical and more unusual imaging features encountered in these disorders.

Addressing the challenges restoring clinical services during the COVID-19 pandemic by harnessing the alignment of clinical and management leadership: an example from a large colorectal service.

BACKGROUND: The COVID-19 pandemic has posed the greatest operational challenge to the English National Health Service since its inception. Elective surgical services have struggled due to the need to protect both staff and patients from viral exposure, and perioperative COVID-19 infection has been associated with significant excess mortality. INTERVENTIONS: In this brief report, we describe how through necessity, it has provided an opportunity to redesign services for the benefit of both patients and organisations, with attendant improvement in activity compared with prepandemic metrics. We present the experience of a large district general hospital, using the department of colorectal surgery as a case study, in responding to the pandemic by restoring services and achieving improved short-term outcomes and processes in newly redesignated facilities. CONCLUSIONS: These reorganised surgical services represent a 'silver lining' of the pandemic. Clinician-led service restructuring, with positive engagement with staff at all levels, has not only addressed backlogs of urgent elective patients in a safe environment, but has also led to patient benefits and high levels of patient and staff satisfaction.

Minimally invasive removal of deep contraceptive implants under continuous ultrasound guidance is effective, quick, and safe.

OBJECTIVES: The aim of this study was to assess the feasibility, performance, and complications of a non-surgical, minimally-invasive procedure of deep contraceptive implant removal under continuous ultrasound guidance. METHODS: The ultrasound-guided procedure consisted of local anesthesia using lidocaine chlorhydrate 1% (10 mg/mL) with a 21-G needle, followed by hydrodissection using NaCl 0.9% (9 mg/mL) and implant extraction using a Hartmann grasping microforceps. The parameters studied were the implant localization, success and complication rates, pain throughout the intervention, volumes of lidocaïne and NaCl used, duration of the procedure, and size of the incision. Between November 2019 and January 2021, 45 patients were referred to the musculoskeletal radiology department for ultrasound-guided removal of a deep contraceptive implant and were all retrospectively included. RESULTS: All implants were successfully removed en bloc (100%). The mean incision size was 2.7 ± 0.5 mm. The mean duration of the extraction procedure was 7.7 ± 6.3 min. There were no major complications (infection, nerve, or vessel damage). As a minor complication, 21 patients (46.7%) reported a benign superficial skin ecchymosis at the puncture site, spontaneously regressing in less than 1 week. The procedure was very well-tolerated, with low pain rating throughout (1.0 ± 1.5/10 during implant extraction). CONCLUSIONS: Minimally invasive removal of deep contraceptive implants under continuous ultrasound guidance alone is feasible, effective, and safe. In the present cohort, all implants were successfully removed, whatever the location, with short procedural time, small incision size, low pain levels, and no significant complications. This procedure could become a gold standard in this indication. KEY POINTS: • Minimally invasive removal of deep contraceptive implants under continuous ultrasound guidance alone is feasible, which led to a success rate of 100% whatever the location (even close to neurovascular structures), with only a small skin incision (2.7 ± 0.5 mm). • The procedure was safe, quick, without any major complications, and very well tolerated in terms of pain. • This minimally invasive ultrasound-guided procedure could become the future gold standard for the removal of deep contraceptive implants, as an alternative to surgical extraction, even for implants in difficult locations such as subfascial ones or those close to neurovascular structures.

Clinical course and cost assessment of infants with a first episode of acute bronchiolitis presenting to the emergency department: Data from the GUERANDE clinical trial.

INTRODUCTION: Bronchiolitis is the leading cause of hospitalization for infants but its economic burden is not well documented. Our objective was to describe the clinical evolution and to assess the 1-month cost of a first episode of acute bronchiolitis presenting to the emergency department (ED). METHODS: Our study was an epidemiologic analysis and a cost study of the cohort drawn from the clinical trial GUERANDE, conducted in 24 French pediatric EDs. Infants of 6 weeks to 12 months of age presenting at pediatric EDs with a first episode of bronchiolitis were eligible. The costs considered were collected from a societal viewpoint, according to the recommendations of the French National Health Authority. RESULTS: A total of 777 infants were included with a median age of 4 months. A total of 57% were hospitalized during the month following the first consultation in the ED, including 28 (3.6%) in an intensive care unit. The mean length of stay was 4.2 days (SD = 3.7). The average time to relief of all symptoms was 13 days (SD = 7). Average total cost per patient was €1919 (95% confidence interval: 1756-2138) from a societal perspective, mostly due to hospitalization cost. The estimated annual cost of bronchiolitis in infants was evaluated to be between €160 and €273 million in France. DISCUSSION: Bronchiolitis represent a high cost for the health care system and broadly for society, with hospitalizations costs being the main cost driver. Thus significant investments should be made to develop innovative therapies, to reduce the number of hospitalizations and length of stay.

Correction to: National dose reference levels in computed tomography-guided interventional procedures-a proposal.

The original version of this article, published on 02 May 2020, unfortunately contained a mistake.

National dose reference levels in computed tomography-guided interventional procedures-a proposal.

OBJECTIVES: To establish national reference levels (RLs) in interventional procedures under CT guidance as required by the 2013/59/Euratom European Directive. METHODS: Seventeen categories of interventional procedures in thoracic, abdominopelvic, and osteoarticular specialties (percutaneous infiltration, vertebroplasty, biopsy, drainage, tumor destruction) were analyzed. Total dose length product (DLP), number of helical acquisitions (NH), and total DLP for helical, sequential, or fluoroscopic acquisitions were recorded for 10 to 20 patients per procedure at each center. RLs were calculated as the 3rd quartiles of the distributions and target values for optimization process (TVOs) as the median. RLs and TVOs were compared with previously published studies. RESULTS: Results on 5001 procedures from 49 centers confirmed the great variability in patient dose for the same category of procedures. RLs were proposed for the DLPs and NHs in the seventeen categories. RLs in terms of DLP and NH were 375 mGy.cm and 2 NH for spinal or peri-spinal infiltration, 1630 mGy.cm and 3 NH for vertebroplasty, 845 mGy.cm and 4 NH for biopsy, 1950 mGy.cm and 8 NH for destruction of tumors, and 1090 mGy.cm and 5 NH for drainage. DLP and NH increased with the complexity of procedures. CONCLUSIONS: This study was the first nationwide multicentric survey to propose RLs for interventional procedures under CT guidance. Heterogeneity of practice in centers were found with different levels of patient doses for the same procedure. The proposed RLs will allow imaging departments to benchmark their practice with others and optimize their protocols. KEY POINTS: • National reference levels are proposed for 17 categories of interventional procedures under CT guidance. • Reference levels are useful for benchmarking practices and optimizing protocols. • Reference levels are proposed for dose length product and the number of helical acquisitions.

Minimally-invasive fully ultrasound-guided removal of nonpalpable single-rod contraceptive implant: Case report and technical description.

A 38 year-old patient had a nonpalpable subfascial single-rod contraceptive implant close to major neurovascular structures. We removed the implant through a 3 mm incision using local anesthesia, hydrodissection and a grasping micro-forceps under continuous real-time ultrasound guidance.

Effect of Nebulized Hypertonic Saline Treatment in Emergency Departments on the Hospitalization Rate for Acute Bronchiolitis: A Randomized Clinical Trial.

Importance: Acute bronchiolitis is the leading cause of hospitalization among infants. Previous studies, underpowered to examine hospital admission, have found a limited benefit of nebulized hypertonic saline (HS) treatment in the pediatric emergency department (ED). Objective: To examine whether HS nebulization treatment would decrease the hospital admission rate among infants with a first episode of acute bronchiolitis. Design, Setting, and Participants: The Efficacy of 3% Hypertonic Saline in Acute Viral Bronchiolitis (GUERANDE) study was a multicenter, double-blind randomized clinical trial on 2 parallel groups conducted during 2 bronchiolitis seasons (October through March) from October 15, 2012, through April 15, 2014, at 24 French pediatric EDs. Among the 2445 infants (6 weeks to 12 months of age) assessed for inclusion, 777 with a first episode of acute bronchiolitis with respiratory distress and no chronic medical condition were included. Interventions: Two 20-minute nebulization treatments of 4 mL of HS, 3%, or 4 mL of normal saline (NS), 0.9%, given 20 minutes apart. Main Outcomes and Measures: Hospital admission rate in the 24 hours after enrollment. Results: Of the 777 infants included in the study (median age, 3 months; interquartile range, 2-5 months; 468 [60.2%] male), 385 (49.5%) were randomized to the HS group and 387 (49.8%) to the NS group (5 patients did not receive treatment). By 24 hours, 185 of 385 infants (48.1%) in the HS group were admitted compared with 202 of 387 infants (52.2%) in the NS group. The risk difference for hospitalizations was not significant according to the mixed-effects regression model (adjusted risk difference, -3.2%; 95% CI, -8.7% to 2.2%; P = .25). The mean (SD) Respiratory Distress Assessment Instrument score improvement was greater in the HS group (-3.1 [3.2]) than in the NS group (-2.4 [3.3]) (adjusted difference, -0.7; 95% CI, -1.2 to -0.2; P = .006) and similarly for the Respiratory Assessment Change Score. Mild adverse events, such as worsening of cough, occurred more frequently among children in the HS group (35 of 392 [8.9%]) than among those in the NS group (15 of 384 [3.9%]) (risk difference, 5.0%; 95% CI, 1.6%-8.4%; P = .005), with no serious adverse events. Conclusions and Relevance: Nebulized HS treatment did not significantly reduce the rate of hospital admissions among infants with a first episode of acute moderate to severe bronchiolitis who were admitted to the pediatric ED relative to NS, but mild adverse events were more frequent in the HS group. Trial Registration: clinicaltrials.gov Identifier: NCT01777347.

Impact of iterative reconstruction on the diagnosis of acute pulmonary embolism (PE) on reduced-dose chest CT angiograms.

PURPOSE: To evaluate the impact of iterative reconstruction on the detectability of clots. METHODS AND MATERIALS: Fifty-three patients were enrolled in a study comparing reduced-dose and full-dose images, available from the same dual-source data set. From each acquisition, three series of images were generated: (1) full-dose images (from both tubes), reconstructed with filtered back projection (FBP) (group 1; standard of reference), (2) reduced-dose images (from tube A only; 60 % dose reduction) reconstructed with FBP (group 2) and iterative reconstruction (SAFIRE) (group 3). RESULTS: In group 1 (mean DLP: 264.6 mGy.cm), (1) PE was diagnosed in 8 patients (15 %) with 82 clots in the central (n = 5), segmental (n = 39) and subsegmental (n = 38) arteries and (2) mean level of noise was 30.56 ± 5.07. In group 2 (mean DLP: 105.8 mGy.cm), a significant increase in noise (44.56 ± 6.24; p < 0.0001) (1) hampered detection of PE in one patient and (2) altered detection of peripheral clots (12 false-negative and 2 false-positive results). In group 3, image noise was not significantly different from that in group 1 (p = 0.1525; effect size: 0.2683), with a similar detection of PE compared to group 1 (p = 1). CONCLUSION: Reconstruction of reduced-dose images (60 % dose reduction) with SAFIRE provided image quality and diagnostic value comparable to those of full-dose FBP images. KEY POINTS: • Iterative reconstruction does not alter the detection of endoluminal clots. • Iterative reconstruction allows dose reduction in the context of acute PE. • Iterative reconstruction allows radiologists to approach the prospects of submilliSievert CT.

Pediatric chest CT at 70 kVp: a feasibility study in 129 children.

BACKGROUND: Before introducing 70-kVp settings in the low-kilovoltage strategies for pediatric examinations, it was mandatory to demonstrate, at similar dose levels, an equivalence of image quality at 70 kVp and 80 kVp. OBJECTIVE: To assess image quality of chest CT examinations acquired at 70 kVp in comparison with standard scanning at 80 kVp. MATERIALS AND METHODS: We prospectively evaluated 129 children with a 70-kVp scanning protocol (group 1). All scanning parameters were kept similar to those usually selected for pediatric standard 80-kVp protocols, except the milliamperage increased by a factor of 1.6 to maintain comparable radiation dose. Image quality of group 1 examinations was compared to that of a paired population scanned at 80 kVp (group 2). The noninferiority hypothesis was fixed at 10% of the mean level of image noise. RESULTS: There was no significant difference in the mean dose length product (DLP) and the volume computed tomography dose index (CTDIvol) between the groups (DLP: 20.5 ± 5.8 mGy.cm [group 1] vs. 19.7 ± 7.6 mGy.cm [group 2]; P = 0.06) (CTDIvol: 0.8 ± 0.1 mGy [group 1] vs. 0.8 ± 0.18 mGy [group 2]; P = 0.94). The mean of differences in image noise between group 1 and group 2 examinations was -1.38 (-2.59; -0.18), verifying the noninferiority hypothesis. Subjective image quality did not significantly differ between group 1 and group 2 examinations (P = 0.18). CONCLUSION: At equivalent radiation dose levels, 70-kVp protocols provide similar image quality to that achievable at 80 kVp.

Clinical evaluation of automatic tube voltage selection in chest CT angiography.

OBJECTIVE: To evaluate the clinical impact of automatic tube voltage selection on chest CT angiography (CTA). METHODS: Ninety-three patients were prospectively evaluated with a CT protocol aimed at comparing two successive CTAs acquired under similar technical conditions except for the kV selection: (1) the initial CTA was systematically obtained at 120 kVp and 90 ref mAs; (2) the follow-up CTA was obtained with an automatic selection of the kilovoltage (Care KV; Siemens Healthcare) for optimised CTA. RESULTS: At follow-up, 90 patients (97 %) underwent CTA with reduced tube voltage, 100 kV (n = 26; 28 %) and 80 kV (n = 64; 69 %), resulting in a significant dose-length-product reduction (follow-up: 87.27; initial: 141.88 mGy.cm; P < 0.0001; mean dose reduction: 38.5 %) and a significant increase in the CNR at follow-up (follow-up: 11.5 ± 3.5 HU; initial: 10.9 ± 3.7 HU; P = 0.03). The increase in objective image noise at follow-up (follow-up: 23.2 ± 6.7 HU vs. 17.8 ± 5.1 HU; P < 0.0001) did not alter the diagnostic value of images. CONCLUSION: Automatic tube voltage selection reduced the radiation dose delivered during chest CT angiograms by 38.5 % while improving the contrast-to-noise ratio of the examinations. KEY POINTS: • As low a dose as possible must be used for CT angiography. • Automatic tube voltage selection permits reduced patient exposure. • Lowering the kVp enables increased intravascular attenuation. • Automatic tube voltage selection does not compromise the overall image quality.