The system, called the Sectra Digital Pathology Solution, lets HSS pathologists scan and upload slides into a single repository where others in the care team — from orthopedic surgeons and radiologists to rheumatologists and endocrinologists — can view them, along with radiologic images that also are housed in the system. This facilitates access for specialists from across HSS to share and discuss tissue samples in real time, making care more efficient and improving clinicians’ ability to diagnose and treat their patients. Additionally, HSS clinicians and others in the care team can review the digital slides individually, simultaneously or slides shared by other hospitals to consult on complex cases.

“HSS is the first hospital in the United States to have successfully integrated a high-resolution digital scanner [Leica] with the pathology Laboratory Information System [Epic/Beaker] and the enterprise-wide PACS [Sectra] in a way that allows pathologists to use digital images for primary diagnosis,” said Thomas W. Bauer, MD, PhD, pathologist-in-chief at HSS, who led the digital pathology initiative.

Allowing surgeons, radiologists, and other physicians to view high-resolution digital images of scanned microscope slides can significantly improve patient care, Dr. Bauer said. “Access to digital pathology images, side by side with radiology images on the same enterprise-wide PACS, enables correlation between different types of studies and promotes efficient discussion about complicated cases.”

In addition, instantly viewing digital images from previous procedures will be much easier than retrieving old microscope slides from long-term storage for re-review, he added.

“The implications of the move to digital pathology are significant for patients everywhere,” Dr. Bauer said. For example, because HSS pathologists are experts in musculoskeletal pathology, they frequently receive cases for consultation from other hospitals.

“Receiving digital images electronically from hospitals with their own scanners will facilitate consultative review, and has the potential to greatly reduce turnaround time,” he added.

“Digital pathology is the natural next step in the digital transformation of healthcare,” said Douglas N. Mintz, MD, a radiologist at HSS who specializes in musculoskeletal imaging and who was instrumental in developing the platform with Dr. Bauer. “We can compare what we see on an image with what was seen on biopsy. It also facilitates the correlation between radiology and pathology, which is particularly important in the diagnosis and treatment of musculoskeletal neoplasms.”

Array of High-Tech Tools

“The scanned images are extremely high quality and, when used in combination with the Leica scanner and Sectra viewer, are considered by the FDA to be equivalent to conventional microscopy for making a primary diagnosis,” explained Dr. Bauer.

HSS, ranked #1 in the world for Orthopedics by Newsweek and has been ranked #1 in the United States for orthopedics for 11 consecutive years by U.S. News & World Report, began its digital pathology initiative in 2017, and started working with Sectra technology in 2018, when it was still in the development phase. Initially, the goal was to use the system in a limited fashion, for particularly challenging cases in which clinicians had questions about pathology reports. But the COVID-19 pandemic prompted the FDA to grant the company emergency use authorization for its imaging platform, allowing HSS to speed up its transition to digital pathology.

"It is gratifying to see our vision of Integrated Diagnostics come to fruition after a long software development and integration journey," said Inderpal Kohli, assistant vice president, IT Clinical Applications at HSS. In addition to other benefits, the solution offers HSS clinicians a familiar user interface and workflows, enabling ease of use and broader adoption across the enterprise.

Beyond patient care, digital pathology will also have an immediate impact on student and resident education, both at HSS, where the technology already is being used to help trainees, and elsewhere.

“We and other hospitals anticipate incorporating digital pathology into a variety of educational conferences available online, in which residents and fellows learn from more senior faculty by reviewing digital images,” Dr. Bauer said. “As other hospitals convert their systems to digital imaging, they will be able to better take advantage of the expertise of the faculty at HSS and other centers of excellence, thereby promoting physician education and improving the care of patients around the world.”

HSS is the world’s largest academic medical center specialized in musculoskeletal health, spanning orthopedics, rheumatology and related disciplines. The HSS Research Institute maintains 20 laboratories dedicated to solving debilitating orthopedic and rheumatic conditions such as arthritis, bone and soft tissue injuries, autoimmune diseases, and musculoskeletal pain and deformities. There, more than 300 dedicated personnel focus on tissue repair, improving surgical outcomes, autoimmunity and inflammation, genomics, new treatments, and precision medicine.

“HSS has a long history of contributing to the collective base of clinical and basic science knowledge and finding healthcare solutions for complex conditions,” said Louis A. Shapiro, President and CEO, HSS. “We’re proud that through the joint efforts of our institution and philanthropic support, we will have the ability to make a strong impact on this growing and vital area of research.”

“As experts in inflammatory disorders and in the development of interventions for overactive immune responses, the clinicians and researchers at HSS are well-positioned to investigate many of the adverse effects of COVID-19,” says Lionel B. Ivashkiv, MD, Chief Scientific Officer at the HSS Research Institute. “This includes studying the causes of these adverse effects as well as how to prevent and treat them.”What follows are descriptions of the first group of funded projects in basic/translational research:

Activation of pDCs by SARS-CoV-2 and Its Impact on Macrophage Response

Principal Investigator: Franck Barrat, PhD

Co-Investigator: Marie-Dominique Ah Kioon, PhD

This project will study cell types that are responsible for cytokine storm syndrome — the hyperactive immune response seen in people with COVID-19 — by looking at how certain immune cells are activated by SARS-CoV-2. Research in mice infected with SARS-CoV, a coronavirus similar to the one that causes COVID-19, has suggested that plasmacytoid dendritic cell precursors (pDCs) are key to the immune response to infection. These pDCs activate macrophages, which in turn secrete cytokines. In the SARS-CoV research, depletion of pDCs appeared to protect the mice from lethal lung injury. Using blood samples from donors, the investigators will study the pathway by which pDCs activate macrophages and look at ways to therapeutically block that process.

Inhibiting RNA Polymerase II Transcription Complexes in Macrophages to Target COVID-19–Associated Cytokine Storm

Principal Investigator: Inez Rogatsky, PhD

Co-Investigators: Steven Josefowicz, PhD, and Robert P. Fisher, MD, PhD

This pilot project will dissect the role of macrophages in SARS-CoV-2-induced acute respiratory distress syndrome (ARDS), the main driver of COVID-19-associated mortality. We will test small-molecule inhibitors of RNA Polymerase II (Pol II) transcription complexes for their ability to modulate type I interferon and inflammatory pathways in monocytes/macrophages. This research will be done using cultured macrophages as well as donor blood and blood from COVID-19 patients.

Mechanisms of Cytokine Storm in Patients with COVID-19

Principal Investigator: Mary K. Crow, MD

Co-Investigators: Mikhail Olferiev, MD, and Lionel B. Ivashkiv, MD

The objectives of this study are to describe the process of the cytokine storm in people with COVID-19 and to identify biologic predictors of a favorable outcome in patients with severe cases of the disease. The project aims to characterize immune cell populations seen in COVID-19 patients who experience cytokine storm and compare them to those patients who do not, to compare the immune response before and after patients are given the anti-inflammatory drug anakinra, and to identify measures that suggest patients are more likely to decline and eventually require mechanical ventilation. The research will employ blood samples from HSS patients who are being treated for COVID-19 at New York–Presbyterian Hospital and who meet certain other qualifications.

What follows are descriptions of the first group of funded projects in the areas of clinical and health outcomes research:

Response to and Recovery from TKA in Patients with Antibodies to SARS-CoV-2

Principal Investigator: Miguel Otero, PhD

Co-Investigators: Meghan Kirksey, MD, PhD, and Peter K. Sculco, MD

It is unknown if people who have been exposed to COVID-19 may be at higher risk of experiencing an abnormal immune response following surgery, resulting in poor outcomes. This study will evaluate the response to and recovery from total knee arthroplasty (TKA) in people who have antibodies to COVID-19 — a marker of exposure. This study will include both patients who have COVID-19 antibodies and those who don’t, to act as controls. Patients will be followed for six weeks after surgery and evaluated for the presence of certain immune markers in the blood, as well as symptoms of inflammation including pain and stiffness in the joint.

SARS-CoV-2 Exposure and the Role of Vitamin D Among Hospital Employees

Principal Investigator: Emily M. Stein, MD, MS

Co-Investigators: Theresa T. Lu, MD, PhD; Andy O. Miller, MD; Jeri Nieves, PhD; and Alana Serota, MD

It is unknown if people with vitamin D deficiency may be more likely to become infected with COVID-19. This study will investigate vitamin D status and associated immune markers as risk factors for COVID-19 infection in a cohort of healthcare workers. Healthcare workers are at higher risk of contracting COVID-19 than the general population, making them a good group to study. Vitamin D is critical for immune function and is known to be protective against respiratory-tract infection and tuberculosis. This prospective, observational study will follow healthcare workers at HSS and at other healthcare facilities for one year, to determine whether levels of vitamin D and certain immune cells in the blood make someone more susceptible to COVID-19 infection.

Association of Immunomodulatory Medication Use and Social Determinants of Health with COVID-19 Infection in Systemic Rheumatic Disease Patients in New York City

Principal Investigator: Medha Barbhaiya, MD, MPH

Co-Investigators from HSS: Lisa Mandl, MD, MPH; Catherine MacLean, MD, PhD; Vinicius Antao, MD, PhD; Jane Salmon, MD; and Mayu Sasaki, MPH

Other Co-Investigators: Candace Feldman, MD, MPH (of Brigham and Women’s Hospital); Debra D’Angelo, MS (of Weill Cornell Medicine)

Using data from the INSIGHT Clinical Research Network, a central repository containing longitudinal electronic health data for residents of New York City, investigators will assemble a cohort of patients being treated with immunomodulatory medications for rheumatic disease. This patient population will then be used to study the effect of these medications on COVID-19 incidence and outcomes. Retrospective data will be used to evaluate the incidence and severity of COVID-19 in these patients. Patients will also be studied prospectively to determine whether there’s a relationship between COVID-19 infection and future rheumatic disease as well as to study connections between infection and future psycho-social issues.

Assessment of Surgical Outcomes in the COVID-19 Pandemic Era

Principal Investigator: Andy O. Miller, MD

Co-Investigators: Scott A. Rodeo, MD, and Mark Fontana, PhD

Investigators will implement a patient registry to evaluate how COVID-19 affects outcomes and complication rates after orthopedic surgery. This registry, along with COVID-19 screening procedures, will provide the tools to address specific research questions. Among these questions are determining the incidence of current and prior infection among the HSS surgical population, the clinical features associated with current and prior infections in this patient population, and whether COVID-19 status affects short-term complication rates.

What follows is a description of an integrated multidisciplinary study being undertaken jointly by the Adult Reconstruction and Joint Replacement (ARJR) Perioperative Research Group, Anesthesiology and Rheumatology:

Prediction and Prevention of Postoperative Blood Clots in COVID-19 Patients

Principal Investigators: Friedrich Boettner, MD; Kethy M. Jules-Elysee, MD; Lisa A. Mandl, MD, MPH

Co-Investigators: ARJR surgeons: Alejandro Gonzalez Della Valle, MD; Jason Blevins, MD; David J. Mayman, MD; Peter K. Sculco, MD; Geoffrey H. Westrich, MD and Thomas P. Sculco, MD

Medicine/Rheumatology: Medha Barbhaiya, MD, MPH; Doruk Erkan, MD, MPH; Deanna Jannat-Khah, DrPH

Pathology: Thomas W. Bauer, MD, PhD

Anesthesiology: Stavros G. Memtsoudis, MD, PhD, MBA; Alexandra Sideris, PhD

ARJR: Amethia Joseph, MHA; Ethan Krell, MS

Weill Cornell Medicine: Raymond David Pastore, MD

Recent literature suggests that one of the major complications seen in people with COVID-19 is thrombosis (the formation of blood clots) due to endothelial dysfunction, persistent inflammation and potentially antiphospholipid antibodies. As elective surgeries resume, those with prior exposure to SARS-CoV-2 will inevitably present for treatment, and some may have perioperative management considerations related to their risk of deep-vein thrombosis. This project will use, a noninvasive device that can determine clotting risks, to investigate whether people who have had COVID-19 have a more dysfunctional endothelium preoperatively and at 24 hours after surgery. The investigators will measure antiphospholipid antibodies and inflammatory markers, and evaluate the prevalence of asymptomatic post-operative deep-vein thrombosis in people who undergo TKR and have SARS-CoV-2 antibodies.

COVID-19 Translational Research Core at HSS

Principal Investigator: Theresa Lu, MD, PhD

Co-Investigators: Jessica Andrés-Bergós, PhD; Miguel Otero, PhD and Emily M. Stein, MD, MS

The COVID-19 Translational Research Core (TRC) was designed to fill critical gaps in the resources needed to promote the broad range of COVID-19–related clinical and translational research at HSS. The TRC will provide consultation on the design and implementation of COVID-19 research in the areas of orthopedics, rheumatology and metabolic bone disease; support for a COVID-19 biobank; and technical expertise and facilities required for clinical and translational researchers working on COVID-19–related projects. The TRC staff will help to acquire, house, and track biospecimens from investigator-initiated COVID-19–related research studies.

“The pathology team at HSS was thrilled to partner with Sectra on this initiative to integrate pathology and radiology diagnostics,” said Thomas Bauer, MD, PhD, Pathologist-in-Chief at HSS. “We believe this advancement will enhance the care we provide our surgical patients, which is what we strive for every day.”

Pathologists select slides of interest and scan them into the patient file. A microscope icon informs users that digital pathology images exist side-by-side with the radiology images. Physician users will then be able to navigate and zoom the whole slide images. HSS installed Sectra PACS for radiology in 2010 and added its specialty orthopedic modules in 2018.

“We are excited to see the benefits HSS will experience by incorporating digital pathology into their workflow. The ability for radiologists, pathologists, and surgeons to easily access both the radiology and pathology images should be a game-changer for patient care, especially in complex cancer cases,” says Mikael Anden, President of Sectra, Inc.

Sectra’s digital pathology solution received FDA clearance last week, read more here >>.

Epic and Beaker are registered trademarks of Epic Systems Corporation. 

About Sectra Imaging IT Solutions

With more than 30 years of innovation and approaching 2,000 installations worldwide, Sectra is a leading global provider of imaging IT solutions that support healthcare in achieving patient-centric care. Sectra offers an enterprise imaging solution comprising PACS for imaging-intense departments (radiology, pathology, cardiology, orthopedics), VNA, and share and collaborate solutions. Read more about Sectra and why Sectra PACS is “Best in KLAS” at https://medical.sectra.com/.