 So, we are from Manipal Hospital, Dwarka. We're going to talk about coronavirus and how it affects respiratory system. Then we are going to discuss the serial radiative features of coronavirus infection. And then also, we are going to have some questions about microbiological aspects of coronavirus and how to diagnose and manage the infection control. So, as we all know, coronavirus is a large family of viruses that cause illness ranging from common cold to more severe diseases. Because earlier in the form of March and SARS, but since 2019, it has been called COVID-19 because it was discovered in 19 as a new strain of re-existing virus. It is an RNA virus which generally resembles SARS virus, but it has almost 96% genetic resemblance to that origin coronavirus which had been existing before. And resemblance to coronavirus seen in pangolins. So, these exotic animals, they were supposed to be the vector for this virus and because of this mutation, it has started from Wuhan. How does coronavirus spreads is mainly through a rocket infection and people get infection by touching these objects or surfaces. And that is the reason it should be, it is important for us to stay about one meter away from these patients. Can COVID be, apart from person who has got no symptoms, that is actually true because although the risk of catching COVID from someone with no symptoms is very low, but still, since many people have only mild symptoms and at least severe diseases, it is possible that we can get infection and viral infection from someone who is just called mild cough and is not actually hurting anyone. There are clinical symptoms which are very classical of any viral infection. It usually happens from 2 to 40 days after exposure. With mild to severe respiratory areas, fever and diabetes, dry cough and shortness of breath are a form of this particular disease along with body ache and nausea and sometimes dry knee. Both the 80% recover spontaneously from these symptoms and they do not need any special treatment like all other viral infections. But in severe cases which are almost as in 2%, we require hospitalization because of pneumonia, SARS, kidney failure or death. Diagnosis is mainly upon epidemiological history. If you have history of travel to particular places and clinical manifestations. And then the detection by IDVC at Dr. Naveen from microbiologist will talk about that in a while and radiology section is to be taken by Dr. Bera. Then we will be seeing how we can diagnose COVID infection based on these tests. Cough symptoms are almost similar to flu and cold but there are certain differences in coronavirus infection compared to flu and cold. Dry cough and fever is quite common in both the flu and COVID but it is less common in common cold whereas runny nose and so forth is more common in seasonal cold which we have along with body aches and sneezes. There are certain high risk populations like elderly, diabetic and chronic smokers or those with underlying disease. Healthcare workers in particular have got a very high viral load because of the long duration of exposure to the viral infections per se. And also there is a cardio respiratory illness because this virus does affect the cardiac condition. Almost 55% of doctors or medical workers they get infection from healthcare facility only. There is something called a cytokine storm or hyperhypoxia which is the main cause of death in coronavirus infection which is ARDS because it triggers a moderate attack by the immune system to the body. The mechanism is still unclear and the patient initially appears very comfortable although very severely intoxicated. Treatment is still supportive care and very frequent. Proxychloroquine is one which has been motleyed along with empty virals although the benefits are unclear as of now. And there are large number of times that are underway and vaccine is also located. Hydroxychloroquine basically was proven to be efficacious based on one study which came from China about 62 patients. Where hydroxychloroquine showed that there was a significant production in body temperature once there were these patients. And there were improvement radiologically also. So that is the reason but large scale screen can be basically just immediate. A trial of Nupida war and return of aid failed in severe COVID patients and it did not significantly accelerate clinical improvement. And the studies are still underway to see the complete efficacy. A few slides about how to manage your abilities in case we have coronavirus patients. You should have a strict appointment system, a limited number of patients. You should be a master in patient and relatives. And I think other than that we will talk about infection control policies in the case of infection. Similarly inside doctor's armor we need to have a proper PPE and we need to minimize paperwork as much as possible. So I think now we will just take some questions and start with a few major questions about the micro-virage aspect of coronavirus infection. So what could be the mode of transmission of SARS-CoV-2 virus and is there any change in understanding that this virus could be airborne? And can this virus be controlled? Hi, good afternoon. Thank you Dr. Puneet for such giving a white picture of the micro-coronavirus pathology and also management. Relates to the pertinent questions related to diagnosed and this is the commonly been asked to us is what's the mode of transmission? As you know the primary mode of transmission is a droplet and it can be transmitted to the direct contact. And when we talk about droplet transmission it means when we're coughing and sneezing then the particles which comes out which is more than 5 micron in size and in that the virus will be there. And also if the patient is infected and the surrounding environment is contaminated so through the 4 mites contact which we call it. So and normally this droplet transmission is considered that to be in the range of one meter of a patient who has a person I can say infected and in the coughing and sneezing. So that's the common mode of transmission which been considered in case of the SARS-CoV-2 virus. But obviously on and off we get kind of a noise that could be airborne or not. And there is one publication where there has shown that in the experimental condition the virus can remain for 3 hours in the environment and they have found it to be positive. But till now it's airborne transmission has been documented only in aerosol generating procedure where droplet scoping is where you are prone to aerosol containing SARS-CoV-2 virus if the person is infected. Other than that even if it's an experimental condition where they are talking about where if they found the virus in the environment finding just RNA the virus doesn't mean the virus is transmissible. So till now the based on information the virus is still considered to be droplet transmissible virus and aerosol transmission is probable but not been proven till now you know as such in a normal condition. So now coming to the second part of the first question which is can it be transmitted by the other route other than the respiratory route. There is one report of intestine you know that because this virus has got a presentation is different than respiratory in symptoms also patients do present with you know. Exactly. And in one publication they have found that you know the virus has been isolated from the stool specimen. But again you know the persistence and everything has not been studied. It's a new virus still we are learning about this but till now there is no documented you know report of any FICO or transmission at this moment. Yes this virus can be isolated from the stool based on the report available. So I will just interject in between to the audience who are listening to us that they can just post their questions on chat box if there are additional questions related to coronavirus. Just in connection with this how effective is the mask in which particular mask is more important for the end of the airborne transmission or for the remote transmission. Absolutely I mean this is a very important question and always being you know. And as WTO and CDC recommends and various other bodies also recommend that for the routine practice if you're just dealing with you know the routine care to pull a good quality. I will always say good quality to pull a surgical mask is sufficient prevent drop in transmission. But again you know like in a in a high risk area where you are there's you know particularly in the respiratory and since we are still learning there is a probability we don't know. I mean N95 mask could be a reasonable option I can say the good options to have gone for to prevent airborne transmission. So yes but again now the contingency is also in questions and the supply is also a big challenge at this moment. In that situation basically the message is that N95 may not be required for every case. Absolutely. So we can just give it for airborne transmission or by risk. By risk. Yes. And otherwise it's a typical mask. So the next question is what we all know that PCR, RT-PCR is the principle standard of diagnosis. So what are the questions which clinicians should take before sending such samples? And what are the challenges? Absolutely. Because at the moment you know this is the primary mode of diagnosis. So most important is to send adequate sample because the first thing you know in you know any microbiological diagnosis is that good quality sample improved the yield of the virus or any organism. So safety of the healthcare worker is very important when you're collecting the samples and the good quality samples. And I say good quality means you know it should be the nose and throat salt combined at this moment. Though I will come to the next questions regarding the sensitivity of different samples. So primary patients if it's you know it's presenting to us you know early you know early days of the symptoms then nose and throat salt is a good sample. Good you know this basically setting is good. Absolutely. Absolutely. And the thing is we are talking about nose so nasal swab then it should be basically collected from the you know the at least from the nasal before or you can go inside of you know at least because this virus is attached to the epithelial cells. So that should be there you know. Is it one swab from one nostril and one from another? You need to take two or you can take similar one from here. I think similar one can be taken from both. From both you know. Yeah. And then you're talking about throat salt then obviously the difference. So when you take from both some people say that it has to be taken from tongue. So is it for base of tongue or it is back of the throat? I think back of the throat is a signal that instead of pushing a fragile wall which they can reach to but again with the diagonality. So some people take it from tongue signal. That is a sample which is to be taken from. Among all these samples what will be sensitivity of the full samples and how we should be low risk. Yeah. That is a very good question because we do know we listen while we hear about that you know this ugly sample was negative then it turned out to be positive or you know that kind of. So yes at the moment you know I can just put in this one slide is there which I have you know there's one good publications where they have shown sensitivity of sensitivity. Very good. Okay. Just a second. Yeah. Let's see. There's a good publications in I mean I'm not even sure the you know the. Yeah. So it's a in Java is published in March and they have shown sensitivity based on the you know different samples. So if you see that barn has got 93% positivity. Over on. And you know the commonly collected sample is no nasal saw which has got you know sensitivity of 63%. And combined is a nasal saw has got you know because it's so well known as 32%. So that's very combined. Then the sensitivity of 70% around you can say sensitivity of combined nose and so on. Is there any blood test for it? Yes, we do have blood test available. And again you know we do have all this this antibody testing which is not the antibody testing. I mean the blood culture or the body culture is it being done routinely for these? While the culture is still limited for the trashy for the what do you say? Academic centers. Academic centers and the research lab because you know it's a new virus and should not be cultured in a routine lab where the viral cultures are available. So blood definitely they have isolated. This can be yes. So you can say the blood it is quite low. The challenge with actually. I think this one you know the ball becomes significant because if the patient develops pneumonia and you know that's it. In that stations you may have nose and full form negative. You know so less less commonly. So in that situations you can negative still cleanly suspected patients sick enough. And it went later in those situations while can be taken. Yes, and what is the role of antibody testing? Because we heard that it was coming initially. Eliza based antibody testing was happening but then it was drawn by ICMR because that's a skill. Yeah. What is the current status and what is the logic behind? Yeah. I think you know. Any virus when it infects is just you know it's basically generating immune response in the body and body mounting immune response in term of earlier as IGA and IGM and IGG. But again, you know how much these antibodies are mounted in the person and it's and it differs from different viruses. Some would have a good quality of antibody in the blood detective detectable by detectable by the different assays available. Particularly this you know in SARS-CoV-2 infections that as they which are developed, I can say of moderate. Yeah, we know moderate. You can say accuracy at this moment and still there's the rapid test which has been designed. It also differs with the different manufacturers and how and the different platforms where it is being used. So the rapid test which are some of them has got a productivity issues and they are not going to be more causing false cost. So these challenges are still there and you know it's getting worked upon. So hopefully in the future we'll have a good quality essay which will have a better sensitivity and specialty and can be introduced as a routine test. In a patient who presented late in the. As I understand, they are point of care. There are point of care blood tests. There are Eliza based tests also, but it's still there. There are rapid tests for nasal swab also. Still in experimental stage but not available as a routine diagnostic test at this moment. Because going forward it may be possibly be required for airlines for. Absolutely. Absolutely. There's a lot of work going on to have a point of care test which can detect antigen in the nose in a respiratory sample. And what is the way forward to improve diagnostic accuracy for all the tests we can do? Yeah, I think that's a very good question because we understand all the essay has got limitations and none of the essay can be 100% sensitive in a specific. It's a new virus. We are always been in situations to rule out as much we can. So the way forward will be to have a combined test as a molecular test as well as antibody test available so that whoever, you know, like the PCR is negative. Then we can do that. We can do the antibody test would quality antibody test combined with helping come up picking up as much early infection possible. So that's a way forward. Yeah. And I think just follow few questions about how to take prevention of the control of infection, particularly those who are next thing, maybe having their own opinions or maybe starting their opinions at home or clinics. So what basic precautions they should take to prevent spread of infection and disinfection of the opinions. Yeah, I think it's very important. I think it's really to know that this virus is going to stay with us forward. You have to live with this virus. It's not going to go away. You know, it's obviously if you see the mode of transmission is your reposal surfaces. So that has to be protected. Triple S surgical mask. If you're more, you know, trying to be more cautious, you can wear an identify mask if it's available. There are many, you know, the guidance is coming out for reuse. But how much effective they are at this moment is very difficult question to answer. But can we reuse so mask and hand hygiene, frequent hand hygiene, taking care of your eyes. And, you know, I think that's looking here should be frequent cleaning of the area to prevent virus to be present on the, you know, on the surfaces. Our physicians who are running their activities at clinic. So what kind of solution? One person sodium apocryte freshly prepared is the ideal solutions. How frequently should it be? I think every three to four hours will be a good way to move forward at this moment. And another question people when you bring the answers, whether fumigation is required or whether it is useful or if required, how frequently should we use it? Absolutely. You know, this question always been asked and the fumigation is one thing which is not really required in a, you know, any clinical area. More recent guidance always discourage fumigations because it just gives you a false sense of satisfaction. Fumigation has very limited indications. If there is any new area or you can say new, you know, or any engineering has been done in those situations. So if your routine fumigation has no terminal cleaning, tunnel cleaning involves cleaning off all the surfaces, including, you know, your chairs, furniture, door handles, wall, you know, that's, that's a thing we need to be done rather than fumigation. All right. Thank you so much. Yes, sir. My regularity is different on your positivity. Now that I can say, oh, what is the positive rate of sensitivity? Sensitivity overall, sensitivity of PCR test is overall, if we say, because it's all different from our time of infection type of sample taken. And, you know, how the PCR is being performed, different PCR performs differently. Overall, it can say 70 to 80 percent. 70 to 80 percent. This also depends on the value of what is fine. Absolutely. There are a lot of factors. The MSC repeated in the city, in a suspected cases, in the case of DL, there is a situation where the city is indicated. This is one of the conditions I am asking. Secondly, you can say about the decision to the room. I don't have a percentage in the area. In my department, I have a lower percentage in the area. A lot of cases are coming along with the mandates. They may include the asymptomatic cases. I think the last question is for all those people who are running their individual activities, come to the more or less same. Frequent cleaning of all the areas with any disinfectant. You know, freshly prepared sodium apocrylate is a good one. There are quaternary ammonium compounds, which is widely available. So, cleaning of the area every three to four hours is a good way to prevent infections. Hand hygiene is more important. If you just, you know, because of your hand, we should definitely not transmit other than, you know, the respiratory route. So, that's what the respiratory secretions, direct respiratory secretions are talking about. So, here is hand hygiene, frequent cleaning of the area of furnitures and all the surfaces will be the way of preventing addicts. Doing addicts can come. Why ask? Because it's our moral responsibility to avoid transmission. Yes, absolutely. We are not going to, you know, we have hand hygiene. What about the heavy visitors who are sitting there? We are talking about regulations. So, for instance, very, very, very much. So, distancing has to be there. And also, when you are coming, that's why you protect all the mucosal surfaces, the respiratory route and hand hygiene and decondamnation. And I think one more question is about my CT rooms and ultrasound. They are the global rooms. Any positive patients coming to see once they exhale the virus, they are supposed to get lost somewhere and supposed to cause a central rare virus. Next slide. After positive patients, your CTs can run the sound to the CT that will help you to recover. So, after on the surface, the room may be given, at least ultrasound will spray, followed by one or two lockdowns are passing there in case of death. So, that is my idea. Because in a pandemic, every patient is assumed to be positive unless you want other patients. And the best thing is to run masks for your patients. Yeah, health care is present. For both of them, the mask is mandatory. And for CTs, we have to do this, we have to think about this. Not to avoid. I have known also, even with the healthy new years, we have to go to the department. So, I think now, we are going to talk about Chastivitis and coronavirus diseases. And Dr. Bhaira, our head doctor. Thank you, Puneet. Thank you. For initial part of the coronavirus disease. Now I'll take up the imaging parts. Apart from that, I think I'll go very basic about how to run the disease process in my department. As well as questions. As well as various imaging findings, particular X-ray and CT very frequently used. And their efficacy, followed by few images, some critical images where you don't expect coronavirus disease, still they are there. So, topic of Chastivitis in coronavirus disease. Coronavirus disease is a pandemic disease started in December 2019 at 1. And now with worldwide spread. It is an airborne highly contagious disease. COVID-19 has very high mortality and morbidity rate. Extremes of air, less than 10 years, about 65 hours, have the more hundred to do. Strict preventing measures are required to avoid infection or to contain the disease process. COVID-19 positive patients can spread disease to staff as well as healthy patients and visitors in the radiology department. Radiology workers frequently come in contact with patients and can contract infection unknowingly from undetected COVID patients. As symptomatic staff with COVID-19 infection can spread to non-infective patients or healthy visitors in the radiology department as well as fellow workers unknowingly. The imaging rooms like CT scan, ultrasound rooms, X-ray rooms can harbor viruses for hours a day due to poor ventilation and may serve as sanctuary for the virus. These are the drawbacks of the radiology department. What are the preventing measures we should take? Strict presence training prior to radiological investigation. That's why we have to see that for somebody who has fever and cough, possibly we should not deal with this as a suspect COVID-19 in our pandemic situations. Strict social distancing for staff and patients. Strict hand sterilization by staff before and after assumption of patients. Strict and effective utilization of available masks or PPE for staff as well as patients as applicable. Strict drain to be followed by examining patients. We all have strict drain in our ultrasound CT as well as by doing auto X-ray in the ward with suspected patients. Proper sterilization or sanitation of requirements and examination rooms after examination of COVID-19 or suspected COVID-19 patients. These are the various preventive measures we have to avoid disease contamination. Just imaging COVID patients, effective imaging tools are X-ray CT scan and ultrasound. X-ray is most widely available and frequently used imaging tool. Easy to operate and does not require radiology to perform and images can be instantly seen with digital format. Similar said CT scans, not imaging tool for initial evaluation of COVID patients. Provide excellent depiction of pathological reasons even in its very early stage. Real problem like in-person mobilization and sanitation of equipment and equipment rooms. Ultra sound of chest, an effective tool for initial imaging as well as subsequent follow up but a very much operator dependent tool with individual skill in chest imaging. Correlation of chest, this is one of the largest report in March this year. Various X-ray findings in patient with confirmed COVID. It was a retrospective observational study of largest series published in March 2020. Total number of 36 patients, sample type patient with urgent care or emergency department with confirmed COVID-19. Total number of COVID-19 SS study with 636 normal X-ray 371, 58.93%. They reported as a normal patient in early stage abnormal X-ray to 65, 51.7%. And severity was mild in 195, 30.7% was in milder form. Moderate is 65, 10.2% and severe form was only 5% 0.8%. These are the presentation 636 cases. Various X-ray findings in these cases. Interest changes 151, 23.7% patients presented. Interest in life, septal thickening. Bumper bus cure, prominent Bumper bus cure markings like other linear shadows. Ground glass opacities for what you said GGOs 5120, 18.9%. Lower-loop location 215, 33.8% of the patients had a lower-loop dominance. Bilateral location 193, 20.9%, bilateral infiltration. Multi-focusing 150, 24.2%. Infusion and lymphadenopathy are uncommon in these cases. CT scan COVID, this is ICRI guidelines and documentation. Subfrater case, not recommended except RT-PCR negative with strong SPF contact with COVID-19% and having clinical interviews. So if it is positive, not required, if the negative PCR test still you are suspecting clinically, then only CT scan is recommended. Moving case, CT should be used sparingly and reserved for hospitalized patients with specific clinical indication like organising pneumonia versus ARDS. CT should not be used to screen COVID-19% as fast-line test to diagnose COVID-19. This is the recommendation of ICMR. Further, CT does not get diagnostic value. Positive results can only be believed if the previous probability of the disease is high. Using CT for diagnosis is not known to provide clinical welcome and could lead to fall security if results are negative. If COVID-19 suspected patients should be isolated, pending confirmation with PCR test multiple times or until quarantine has lost. CT scan do not change this. 50 findings in COVID-19% up to 50% of patients with COVID-19 infection may have normal CT scan. Within 0 to 2 days after onset of few leg symptoms from COVID-19. Ground loss of acetyl and concentration with or without vascular enlargement, interloval of septal thickening and air conchogram sign are common CT patients of COVID-19% GGO forms the major barcode of 50 to 75% of the findings. Crazy plug-in and concentration are the dominant CT findings peaking around 9 to 13 days followed by slow clearing. This is the last finding. Chest x-ray in CT to charge of COVID-19. The classical findings is ground loss of acetyl and concentration, crazy plug-in and reverse helosine. They have got peripheral, multi-cooled, bi-lateral, low-low-domain. The probable findings are bronchocentric, peripheral concentration, less of GGO or reverse helo. Indeterminate. Confidence level is less than 70%. Not so classical findings. Some changes but not sure. But not normal. Barely done x-ray. These are the various causes. Here we are not sure your level is less than 70%. And non-COVID, there is 70% confidence for alternative diagnosis like lower pneumonia, effusion, pneumothorax, pulmonary edema. These are here. You are not suspecting COVID and normal. No findings. But COVID-19 is not excluded in normal. 50% they come with a non-covidic stage. However, imaging does not make the diagnosis of disease. It defines the extent of disease and may suggest alternate diagnosis. Full role of CTs came in COVID, tribe of patients. Not suggest of COVID-19 infection. Just people say it is not suggestive. But then 50% are normal. So it is very tricky one. That's why not at the present scenario don't recommend. It is possible or most likely COVID-19 infection. Yes, there is something possible. That's what we say changes. You can say these are COVID to determine severity of the disease. Yes, follow on. Whether it is increasing or decreasing. Whether it is regressing or increasing. Predicting or worsening. Prediction of improvement. And problems about some time. Like strong clinical substance is present with negative artificial test. In cases where still it is your destiny but your theory is suspecting that CT is indicating. Decision to use CT for trial depends on many considerations like chances for spread of infection. If you think it must be done, it must be done. Operational cost. Availability of coronal CT. Like what if the infusion that can have a CT scan affected to a particular coronal infection. You can even if you are not worried. Otherwise the only one is if we get room infected to our operation of hospital. Very high. Once you do the coronal procedure, you have to keep the room at a small amount before doing for next patient. Assessment of severity is stored in coronal. This is a great question. A very big question. Anything depends on the treatment depends on the severity. Roughly severity is assessed by calculating the percentage of lung involvement. CT gives better visual impression of segmental involvement and their assessment. Based on the percentage of lung involvement, severity score is graded into mild, moderate, moderate, severe and severe forms. Mild is less than 25% involvement, moderate less than 50%. Moderately severe less than 75% and above 75% severe form. Based on the X-ray, there will be rough measurement, severity score is assessed by generally involvement. We have divided the line into 6 zones. Right side upper will be lower, left upper will be lower. So 6 zones. So mild form will only 1 zone in moderate. 1 for localised. Moderate is 2 to 3 zones and severe is more than 4 zones. We have the X-ray, very rough estimation. Now let me see the various X-rays. 2 similar X-rays looks alike. But one is normal. One is simple you see. One here this small ground glass opposite. It's a very milder form of DG process. Now we have a case here. This is the initial X-ray. This person was wounded here. Completely white out. Extensive bilateral involvement. Gradually regressing. Second you see. Epical is almost clear. This is the third. This is the last one. Almost uppermost here. It's a case we had only 2 positive cases and followed in one month. This is the patient again. Look at normal chest. Imature radiovisual may miss this one. Small one and ground glass nodule. One CT is showing a peripheral nodule. Central you see. Like we can say. Reverse heliocytes sometimes you find but it's a very dense one. This is a positive case. These images are taken open. Radio gradient because we don't have that much of cases. Only for the same purposes. The case again having. Comorbidity factors. X-ray. See the peripheral sapper wall. Upper zone. Lower zone. X-ray. CT is there is extensive ground glass. And even. There's consolidation. Violetary mostly positive. This is a positive case. This is a. Absolutely multifocal. Multiple peripheral ground glass of acidity. There is a ground glass of acidity. Superimposed by linear opacities. That is interlopular septum. A crazy moving pattern. This is a very classical finding for. Coronavirus. This is another case. There is a peripheral sub-ural ground glass of acidity. This is a soft opacities. Very classical findings. This is an extensive bilateral. Sub-ural, peripheral ground glass of acidity. With some peripheral vascular and central also. These are all of it. Classical positive cases. This is a case. Very difficult to say. There is a very high layer of acidity. Violetary. Classical. But he has got some linear. Ground glass of acidity. This is a positive case. This would be very difficult to say. By that it is coronal. But this was a coronal positive case. This is another case. Very, very interesting. There is a dense constellation. There is a constellation. Light, low-arison cities can dense. Just above the fissure. So, classically. These are not classified as coronal. But then it is coronal positive. Ultimately it is positive secondary infection. They are in this presence. So difficult presence to predict from city whether these are coronal or not. This is another thing. Ground glass of acidity. Very broad. All around. Very saggy pattern. Not very classical pattern. Here is also a peripheral or very subtle ground glass of acidity. All over. In the cell stage nobody will say. I will say this is a hypersensitonemia pattern. But this is a positive. So these are the three exceptional cases. You have to think about this. This is a case. Now what is the latest development we have in the city? Cover coating of the affected areas. That gives you better visual impression about how much it is involved. And now there are also likely some software are there to calculate the total volume of the lung. Plus, what is the volume that affected it is. So can we calculate possibly involvement. These are the coming. I don't have this facility. This is a 3D image of the entire lung with the area of involvement. This I do. I have a facility this minimum intensity present 3D images and you can show you the involvement like that. This is the latest involvement development with artificial intelligence possibly in the coming days. We will be able to automatically see the selective the lung. Let's talk about the thoracic ultrasound. We don't have any experience. Only our limited experience thoracic ultrasound is plural to desperation. You have to configure some and you suffer a loss for that. You are not being diagnosed to take ultrasound for the lung. But here she is an effective meaningful for evaluation of lung as well as plural space, but highly operated dependent. It is a highly versatile tool without any radiation hazard to patients or operators and can be mobilized and care side is very important part. Lung ultrasound gives results that are similar to HRCT and superior to standard chest x-ray for evaluation of pneumonia and for ARDS with added advantages of use at the point of care. ESG may be helpful in the evaluation of critically ill COVID-19 patients and the subsequent follower. We have to develop this technique. Our dedicated regulars have to work on this. These are the few images. These are linear lines, whatever you can see the B line we say. These are the subject of perimocular linear capacity, septal thickening. These are the plural to the demonic consume. These are the way you can see the lung ultrasound images are taken from the books of mine. So thank you for listening to me about very radiological aspects. Thank you very much.