Exposure

I was exposed last March 8, 2020. In a meeting, there were two who had recent travel to Malaysia. At that time, Malaysia was not in the list of “high risk” destinations, not until 2 days after our meeting. One of them was asymptomatic, the other rapidly deteriorated by the second week and was intubated. Thankfully, she has now pulled through and is on her way to full recovery. As many of us in that meeting (10 of 14) started having symptoms, 2 of whom believed it was “asthma,” for the rest it had to be COVID19. At that time, however, we did not qualify for testing, test kits were few, and we were just all on home quarantine. None of us who had symptoms were tested, except for the one severe case that was admitted.

My Symptoms

I had dry cough that was prolonged for about two weeks, had a one day malaise and tiredness, but had no sense of smell or taste for about a week, and a few sporadic episodes of diarrhea. I needed to be persistent, I was persistent. I was bothering and texting Dr. Karl Henson, every so often, and watched the Department of Health’s guidelines on testing almost daily. Finally, especially after our index case had deteriorated, I was finally told, that I could already be tested. My nasopharyngeal and oropharyngeal swabs were taken on day 11 from my onset of symptoms, or day 14 from my exposure. My real time-reverse transcription polymerase chain reactive (RT-PCR) test came back negative 3 days later.

Believe It or Not

Trained as a physician, I knew that not all tests were a 100% accurate. None of existing tests are a 100% sensitive. We base diagnosis and management on clinical history and presentation, more than just “treating a test result.” I felt I was a “false negative” — I was tested too late, or I had recovered by the time my swabs were taken, or the test was simply incorrect. When I had the opportunity to be tested for antibodies specific against COVID19, I had myself tested.

Thanks to Dr. Minguita Padilla who had access to test kits and graciously performed the rapid antibody test on me. I turned IgG positive, implying that as I had suspected, I indeed had a prior COVID19 infection. [IgG is short for immunoglobulin-G, antibodies that form after you have recovered from an infection in the past].

Processing

I had mixed emotions. I felt fear: I could have turned for the worse too. I was not ready. My son was not ready. Is anyone really ready? There was relief, somehow, I survived the ordeal and now have antibodies to fight the disease. Then there was this deep sense of responsibility: if my antibodies will help someone get well, I needed to donate my plasma.

Donating Plasma

I was initially rejected as a donor. Most centers doing plasmapheresis required a positive RT-PCR test, that will turn negative at least twice. I only had an RT-PCR test done once, that turned out negative and did not meet the usual criteria. I nagged Dr. Karl to give me my results from the Destura test kit, maybe that turned out positive. I was initially “rejected” too at the University of the Philippines-Philippine General Hospital, being the first potential donor that did not have an RT-PCR test that was positive. I told them about the parallel testing on the UP-NIH test kit for validation, and hope they could gain access to it.

It was Dr. Jonas del Rosario who rechecked parameters for donation. There was a third parameter –a “positive result for anti-SARS-CoV-2 IgG antibody-based test done on recovery.” Yey! I absolved Dr. Karl, God bless him for all the work he does, he needed a break from me!

After at least 28 days of no symptoms, on April 20, 2020, I finally donated convalescent plasma (that yellow-orange fluid component you see inside the bag) at the University of the Philippines College of Medicine, Paz Mendoza Building Room 108 in the hope that it can help someone fighting COVID19 who was not as lucky as I was. Room 108 brought back all good memories…I was a student again of health informatics in this room at fifty. I learned new skills here. This time, however, the feeling was even better. I can donate every two weeks, at most twelve times in a year, God-willing I hope I can fulfill that responsibility.

Why donate?

I could not be at the frontlines. This was the only way I could think of to give back. I owe it to all of you staying in your houses, to all of you donating and finding ways to help our frontliners, frontliners on the streets, residents, fellows, teachers, mentors and colleagues, and other health care workers at the hospital frontlines, some of whom had paid dearly for this with their own lives.

SARS-CoV2, the virus responsible for COVID19 will be beaten. The heart and soul of mankind will win. Our task is daunting, but #WeHealasONE and #WeWinasOne.

This week’s task for #MI227, Clinical and Laboratory Information Systems for #MSHI required us to find an article describing the adoption or use of an EMR system, a CPOE system, a medication administration system, a telemedicine system, a telehealth system, a PHR, or other clinical or laboratory information system or application, discuss its key points, lessons learned and how this can relate to the Philippines. I chose

Automated retinal image analysis for diabetic retinopathy in telemedicine by Sim et al, published online in Curr Diab Rep (2015) 15:14. https://www.researchgate.net/publication/272518326_Automated_Retinal_Image_Analysis_for_Diabetic_Retinopathy_in_Telemedicine

Key points:

The article by Sim et al discusses how an automation process analysis can negate the heavy reliance of current telemedicine practices on specially trained retinal image graders, thereby improving the delivery of diabetes eye care, expediting diagnosis and facilitating referral to a treatment facility. In addition, the potential of such a system integrating with the electronic medical record permits a more accurate analysis and prognostication of the disease.

The need for early diagnosis (and necessary intervention) is diabetic retinopathy is recognized as a major factor in reducing blindness due to this pathology. In England and Wales where systematic population based screening is in place, diabetic retinopathy is no longer the leading cause of blindness. Yet, even in the developed countries, such as the US for example, access to eye care is only 60-90%, and is presumably much lower elsewhere. The ARIA potentially can distribute quality eye care or screening to virtually anywhere, with the software providing automated image analysis algorithms.

It is the need for “trained personnel for image reading and grading a large volume of retinal images” that the ARIA addresses, making the reading process less dependent on humans. Human readers, however, will continually be required for quality control, arbitration, and interpretation of atypical retinal images. The ARIA is envisioned to be linked to a patient’s electronic medical record.

ARIA was developed to perform computer algorithms capable of computer-aided detection (CADe) and computer-aided diagnosis (CADx). ARIA addressed two issues: image quality assessment and image analysis. Image quality assessment required that pre-processing improve on factors affecting image quality such as brightness, contrast, signal/noise ratio, and/or determining image clarity by assessing vessels around the macula. Image analysis begins with initial segmentation or the identification and localization of normal anatomy so that the “normal” is excluded from image analysis of what is pathologic (microaneurysms, exudates, hemorrhage, beading, neovascularization). The challenge encountered with such a system was how ARIA could deal with distractors such as retinal capillaries, choroidal vessels, and reflection artifacts.

ARIA systems currently deployed in telemedicine and screening programs include the iGradingM, The Triad Network, Iowa Detection Program (IDx-DR), RetmarkerDR, and Retinalyze System.

Future development of ARIA algorithms require a set of images used for calibration and “training” where human labeled sample images are used to teach the computer to remember such an image and its reading. Two public datasets are available for such use, the Methods for Evaluating Segmentation and Indexing techniques Dedicated to Retinal Ophthalmology (MESSIDOR) and Retinopathy Online Challege (ROC). More could be made available if only regulatory and proprietary barriers could be breached.

Lessons Learned

Telemedicine programs done right, can fill a void by exponentially increasing the capabilities of performing early screening and detection (with computer-aided detection and diagnosis in the case of ARIA), virtually eliminating boundaries. To quote the article by Sim et al “telemedicine programs for diabetic retinopathy should include:

1. Remote, reliable, cost effective image acquisition system
2. An image reading center
3. A clinical recording center that:
4. communicates results to physicians and patients
5. facilitates appointments for follow-up assessments
6. facilitates appointments for treatment
7. IT and technical support
8. Administrative support
9. Trained personnel for image reading and grading a large volume of retinal images”
10. Telemedicine concerns should address ethical and patient privacy issues.

Telemedicine diagnosis is still continually evolving and changing and requires research, validation, revalidation, improvement in software, image capture, and image sharing. Human intervention still cannot be fully removed as human readers will continually be required for quality control, arbitration, and interpretation of atypical retinal images.

Finally, collaboration is required at different levels:

• National health authorities, commercial companies, and the medical profession
• Large repositories of real-life datasets for expert-annotated images
• International agreement on performance criteria and evaluation and validationparameters
• Involvement of primary care providers

What this means for the Philippines

In the Philippines, there remains a heavy reliance of screening on trained specialists in Retina, a human resource that is concentrated in the urban areas such as the National Capital Region and wanting in the provinces and outskirts of the metropolis and most especially in the remote areas. Using telemedicine partially solves the problem as reading centers are staffed by these trained Retina specialists. Specialists staff reading centers and commit to evaluating photographs within a predetermined time. This minimizes the cost of unneccessary travel to urban centers, and includes the primary care physician in diabetes care. We are at this stage.

Automating the process of reading can exponentially increase the number that can be screened, in real time. Readings can be provided to the health care team, almost immediately after a patient performs the test. This frees up the the retina specialist to deal more with patients for counseling, education, performings lasers, or surgeries.

We have problems to deal with, the infamous slow internet connection precludes real time image transfer. Patient privacy issues remain a concern. Multilevel collaboration, interhospital collaboration, data sharing are still wanting. Diabetic Retinopathy ranks among the leading cause of vision impairment in the Pacific. (ref 2) The World Health Organization estimates that 15% of blindness is due to diabetic retinopathy or glaucoma in the Western Pacific region. If telemedicine can take off, if screening can exponentially increase, and intervention introduced early, this number can drastically reduce a significant cause of blindness.

References:

1. Sim DA, Keane PA, Tufail A, et al. Automated Retinal Image Analysis for Diabetic Retinopathy in Telemedicine. Curr Diab Rep (2015) 15: 14 https://www.researchgate.net/publication/272518326_Automated_Retinal_Image_Analysis_for_Diabetic_Retinopathy_in_Telemedicine Accessed January 28, 2016.

2. Keefe JE, Konyama K, Taylor HR. Visiion Impairment in the Pacific Region. Br J Ophthalmology 2002: 86(6). 605-610. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1771168/ Accessed January 28, 2016.

3. World Health Organization. Vision 2020 report. http://www.who.int/blindness/Vision2020_report.pdf Accessed January 28, 2016.

Telemedicine and the Facebook platform seem to be tempting bed fellows, but there are many reasons why physicians, who swore to protect our patient’s privacy, need to step back and rethink, if not condemn this as an option for telemedicine.

http://efocalpoint.pao.org.ph/v6n2/index.php?route=pavblog/blog&id=31