Generalizable diagnosis of chest radiographs through attention-guided decomposition of images utilizing self-consistency loss.

BACKGROUND: Chest X-ray (CXR) is one of the most commonly performed imaging tests worldwide. Due to its wide usage, there is a growing need for automated and generalizable methods to accurately diagnose these images. Traditional methods for chest X-ray analysis often struggle with generalization across diverse datasets due to variations in imaging protocols, patient demographics, and the presence of overlapping anatomical structures. Therefore, there is a significant demand for advanced diagnostic tools that can consistently identify abnormalities across different patient populations and imaging settings. We propose a method that can provide a generalizable diagnosis of chest X-ray. METHOD: Our method utilizes an attention-guided decomposer network (ADSC) to extract disease maps from chest X-ray images. The ADSC employs one encoder and multiple decoders, incorporating a novel self-consistency loss to ensure consistent functionality across its modules. The attention-guided encoder captures salient features of abnormalities, while three distinct decoders generate a normal synthesized image, a disease map, and a reconstructed input image, respectively. A discriminator differentiates the real and the synthesized normal chest X-rays, enhancing the quality of generated images. The disease map along with the original chest X-ray image are fed to a DenseNet-121 classifier modified for multi-class classification of the input X-ray. RESULTS: Experimental results on multiple publicly available datasets demonstrate the effectiveness of our approach. For multi-class classification, we achieve up to a 3% improvement in AUROC score for certain abnormalities compared to the existing methods. For binary classification (normal versus abnormal), our method surpasses existing approaches across various datasets. In terms of generalizability, we train our model on one dataset and tested it on multiple datasets. The standard deviation of AUROC scores for different test datasets is calculated to measure the variability of performance across datasets. Our model exhibits superior generalization across datasets from diverse sources. CONCLUSIONS: Our model shows promising results for the generalizable diagnosis of chest X-rays. The impacts of using the attention mechanism and the self-consistency loss in our method are evident from the results. In the future, we plan to incorporate Explainable AI techniques to provide explanations for model decisions. Additionally, we aim to design data augmentation techniques to reduce class imbalance in our model.

Methodological evaluation of systematic reviews based on the use of artificial intelligence systems in chest radiography.

INTRODUCTION: In recent years, systems that use artificial intelligence (AI) in medical imaging have been developed, such as the interpretation of chest X-ray to rule out pathology. This has produced an increase in systematic reviews (SR) published on this topic. This article aims to evaluate the methodological quality of SRs that use AI for the diagnosis of thoracic pathology by simple chest X-ray. MATERIAL AND METHODS: SRs evaluating the use of AI systems for the automatic reading of chest X-ray were selected. Searches were conducted (from inception to May 2022): PubMed, EMBASE, and the Cochrane Database of Systematic Reviews. Two investigators selected the reviews. From each SR, general, methodological and transparency characteristics were extracted. The PRISMA statement for diagnostic tests (PRISMA-DTA) and AMSTAR-2 were used. A narrative synthesis of the evidence was performed. Protocol registry: Open Science Framework: https://osf.io/4b6u2/. RESULTS: After applying the inclusion and exclusion criteria, 7 SRs were selected (mean of 36 included studies per review). All the included SRs evaluated "deep learning" systems in which chest X-ray was used for the diagnosis of infectious diseases. Only 2 (29%) SRs indicated the existence of a review protocol. None of the SRs specified the design of the included studies or provided a list of excluded studies with their justification. Six (86%) SRs mentioned the use of PRISMA or one of its extensions. The risk of bias assessment was performed in 4 (57%) SRs. One (14%) SR included studies with some validation of AI techniques. Five (71%) SRs presented results in favour of the diagnostic capacity of the intervention. All SRs were rated "critically low" following AMSTAR-2 criteria. CONCLUSIONS: The methodological quality of SRs that use AI systems in chest radiography can be improved. The lack of compliance in some items of the tools used means that the SRs published in this field must be interpreted with caution.

Malignant Pleural Effusion: A Multidisciplinary Approach.

Malignant pleural effusion (MPE) has become an increasingly prevalent complication in oncological patients, negatively impacting their quality of life and casting a shadow over their prognosis. Owing to the pathophysiological mechanisms involved and the heterogeneous nature of the underlying disease, this entity is both a diagnostic and therapeutic challenge. Advances in the understanding of MPE have led to a shift in the treatment paradigm towards a more personalized approach. This article provides a comprehensive review and update on the pathophysiology of MPE and describes the diagnostic tools and the latest advances in the treatment of this complex clinical entity.

El derrame pleural maligno (DPM) se ha convertido en una complicación cada vez más prevalente en los pacientes oncológicos, empeorando la calidad de vida y ensombreciendo el pronóstico de los mismos. Debido a los mecanismos fisiopatológicos involucrados y a la naturaleza heterogénea de la enfermedad subyacente, esta entidad representa un desafío diagnóstico y terapéutico. Los avances en la comprensión del DPM han originado un cambio en el paradigma del tratamiento hacia un enfoque más personalizado. Este artículo proporciona una revisión exhaustiva y una actualización sobre la fisiopatología del DPM, y describe las herramientas diagnósticas y los últimos avances en el tratamiento de esta compleja entidad clínica.

Challenges and Successes in Introducing Coronary CT Angiography in an Emergency Medicine-Run Observation Unit.

This study was designed to analyze the departmental changes in transitioning the Emergency Department (ED)-run Observation Medicine Unit's routine noninvasive cardiac evaluation from the traditional standard-of-care procedures to coronary computed tomography angiography (CCTA).  While the routine use of CCTA for the evaluation of chest pain has been deemed feasible and safe, provider confidence appears apprehensive, and ordering patterns appear reluctant to change.  We conducted a retrospective analysis of data from two risk-matched cohorts of ED patients who presented with symptoms suggestive of acute coronary syndrome (ACS) but without ischemic electrocardiogram (ECG) changes or positive troponin. Endpoints included length of stay, major adverse cardiovascular event (MACE) rates at 28 days, recidivism rate, and downstream findings on coronary catheterization.  The adoption of CCTA led to a significant reduction in the length of stay for patients in the ED-run Observation Medicine Unit. Provider and nursing education initiatives were crucial in overcoming initial resistance and improving the implementation of CCTA. Post-education, there was a marked increase in the volume of CCTA performed and a decrease in the length of stay, enhancing overall departmental throughput.  The results suggest that CCTA offers a reliable and efficient diagnostic alternative to traditional noninvasive tests, with high diagnostic accuracy contributing to faster decision-making and reduced need for invasive procedures. Continuous education for providers and nursing staff was essential to ensure adherence to the new protocol and improve clinical outcomes.  Transitioning to CCTA for routine noninvasive cardiac evaluation in the ED-run Observation Medicine Unit demonstrated significant efficiency and diagnostic accuracy benefits. Successful implementation requires targeted educational efforts to ensure competency and confidence among healthcare providers. The findings support the integration of CCTA into standard clinical practice for the evaluation of chest pain in the emergency setting, with future research needed to validate these results in broader patient populations and assess long-term outcomes.

French practice of emergency resuscitative thoracotomy. A study based on the Traumabase Registry.

AIM OF THE STUDY: Emergency resuscitative thoracotomy (ERT) has been described as a potentially life-saving procedure for trauma patients who have been admitted in refractory shock or with recent loss of sign of life (SOL). This nationwide registry analysis aimed to describe the French practice of ERT. PATIENTS AND METHODS: From 2015 to 2021, all severe trauma patients who underwent ERT were extracted from the TraumaBase→ registry. Demographic data, prehospital management and in-hospital outcomes were recorded to evaluate predictors of success-to rescue after ERT at 24-hour and 28-day. RESULTS: Only 10/26 Trauma centers have an effective practice of ERT, three of them perform more than 1 ERT/year. Sixty-six patients (74% male, 49/66) with a median age of 37 y/o [26-51], mostly with blunt trauma (52%, 35/66) were managed with ERT. The median pre-hospital time was 64mins [45-89]. At admission, the median injury severity score was 35 [25-48], and 51% (16/30) of patients have lost SOL. ERT was associated with a massive transfusion protocol including 8 RBCs [6-13], 6 FFPs [4-10], and 0 PCs [0-1] in the first 6h. The overall success-to-rescue after ERT at 24-h and 28-d were 27% and 15%, respectively. In case of refractory shock after penetrating trauma, survival was 64% at 24-hours and 47% at 28-days. CONCLUSIONS: ERT integrated into the trauma protocol remains a life-saving procedure that appears to be underutilized in France, despite significant success-to-rescue observed by trained teams for selected patients.

Assessing the diagnostic utility of serum tumor markers for lung cancer detection in patients with interstitial pneumonia.

BACKGROUND: The prevalence of lung cancer among individuals afflicted with interstitial pneumonia (IP) stands at approximately 20%. The early detection of lung cancer via chest computed tomography (CT) surveillance proves challenging in IP patients. Our investigation sought to identify a potential biomarker capable of providing early indications of the presence of lung tumors in such patients. MATERIALS AND METHODS: We examined the attributes of serum tumor markers, imaging characteristics, and histological findings in individuals diagnosed with IP, both with and without concurrent lung cancer. RESULTS: 106 patients diagnosed with IP were included in the study, comprising 36 individuals with concurrent lung cancer and 70 patients solely diagnosed with IP. Serum concentrations of CEA and CA12-5 were notably elevated in IP patients with lung cancer, compared to those with IP alone. Logistic regression analyses revealed that, in comparison to IP patients within the first quartile of CEA levels, the relative risk of developing lung cancer associated with IP escalated by 4.0-fold, 3.1-fold, 11.0-fold, and 13.3-fold in the second, third, fourth, and fifth quartiles, respectively. Upon controlling for gender and age, statistical significance in risk was observed solely for the fourth and fifth quartiles. Receiver operating characteristic (ROC) curve analysis conducted in patients diagnosed with ILD-CA identified a CEA cutoff point of 6.9 ng/mL, demonstrating sensitivities of 61.1% and specificities of 78.5%. The area under the curve was calculated as 0.7(95% CI: 0.63-0.81). CONCLUSION: The serum levels of CEA were notably elevated in IP patients with concurrent lung cancer in contrast to those who were just suffering from IP. The heightened serum CEA levels correlate with an escalated risk of cancer occurrence among IP patients, suggesting that serum CEA levels could potentially serve as an indicative marker for the presence of cancer in IP patients.

Impact of routine bedside lung ultrasound implementation on chest x-ray requests for mechanically ventilated children: a before-after uncontrolled quality improvement project.

Lung imaging techniques are crucial for managing ventilated patients in pediatric intensive care units (PICUs). Bedside chest x-ray has limitations such as low sensitivity and radiation exposure risks. Recently, lung ultrasound has emerged as a promising technology offering advantages such as real-time monitoring and radiation-free imaging. However, the integration of lung ultrasound into clinical practice raises questions about its impact on chest x-ray prescriptions. This study aims to assess whether implementing lung ultrasound reduces reliance on chest x-rays for ventilated pediatric patients in the PICU. This before-and-after uncontrolled quality improvement project was conducted from January 2022 to December 2023 in a referral PICU. The study included three phases: retrospective evaluation, learning phase, and prospective evaluation. Patients aged under 14 years, intubated, and ventilated for ≤ 30 days were included. Lung ultrasound was performed using a standardized protocol, and chest x-rays were conducted as per clinical indications. During the study period, 430 patients were admitted to the PICU, with 142 requiring mechanical ventilation. Implementation of routine bedside lung ultrasound led to a 39% reduction in chest x-ray requests (p < 0.001). Additionally, there was a significant decrease in irradiation exposure and a 27% reduction in costs associated with chest x-rays.Conclusion: Routine bedside lung ultrasound is a valuable tool in the modern PICU, it reduces the number of chest x-rays, with reduced radiation exposure and a potential cost savings. What is known: • Bedside chest x-ray is the main imaging study in ventilated pediatric patients • Chest x-ray is a valuable tool in pediatric critical care but it is associated with irradiation exposure What is new: • Implementation of bedside lung ultrasound in pediatric critical care unites reduces the chest x-rays requests and therefore patient-irradiation.

Complications of chest wall around malignant tumors: differences based on reconstruction strategy.

BACKGROUND: Malignant chest wall tumors need to be excised with wide resection to ensure tumor free margins, and the reconstruction method should be selected according to the depth and dimensions of the tumor. Vascularized tissue is needed to cover the superficial soft tissue defect or bone tissue defect. This study evaluated differences in complications according to reconstruction strategy. METHODS: Forty-five patients with 52 operations for resection of malignant tumors in the chest wall were retrospectively reviewed. Patients were categorized as having superficial tumors, comprising Group A with simple closure for small soft tissue defects and Group B with flap coverage for wide soft tissue defects, or deep tumors, comprising Group C with full-thickness resection with or without mesh reconstruction and Group D with full-thickness resection covered by flap with or without polymethyl methacrylate. Complications were evaluated for the 52 operations based on reconstruction strategy then risk factors for surgical and respiratory complications were elucidated. RESULTS: Total local recurrence-free survival rates in 45 patients who received first operation were 83.9% at 5 years and 70.6% at 10 years. The surgical complication rate was 11.5% (6/52), occurring only in cases with deep tumors, predominantly from Group D. Operations needing chest wall reconstruction (p = 0.0016) and flap transfer (p = 0.0112) were significantly associated with the incidence of complications. Operations involving complications showed significantly larger tumors, wider areas of bony chest wall resection and greater volumes of bleeding (p < 0.005). Flap transfer was the only significant predictor identified from multivariate analysis (OR: 10.8, 95%CI: 1.05-111; p = 0.0456). The respiratory complication rate was 13.5% (7/52), occurring with superficial and deep tumors, particularly Groups B and D. Flap transfer was significantly associated with the incidence of respiratory complications (p < 0.0005). Cases in the group with respiratory complications were older, more frequently had a history of smoking, had lower FEV1.0% and had a wider area of skin resected compared to cases in the group without respiratory complications (p < 0.05). Preoperative FEV1.0% was the only significant predictor identified from multivariate analysis (OR: 0.814, 95%CI: 0.693-0.957; p = 0.0126). CONCLUSIONS: Surgical complications were more frequent in Group D and after operations involving flap transfer. Severe preoperative FEV1.0% was associated with respiratory complications even in cases of superficial tumors with flap transfer.

Assessing the human factors involved in chest compression with superimposed sustained inflation during neonatal and paediatric resuscitation: A randomized crossover study.

Background: A new cardiopulmonary resuscitation technique, chest compressions with sustained inflation (CC + SI) might be an alternative to both the neonatal [3:1compressions to ventilations (3:1C:V)] and paediatric [chest compression with asynchronous ventilation (CCaV)] approaches. The human factors associated with this technique are unknown. We aimed to compare the physical, cognitive, and team-based human factors for CC + SI to standard CPR (3:1C:V or CCaV). Methods: Randomized crossover simulation study including 40 participants on 20 two-person teams. Workload [National Aeronautics and Space Administration Task Load Index (NASA-TLX)], crisis resource management skills (CRM) [Ottawa Global Rating Scale (OGRS)], and debrief analysis were compared. Results: There was no difference in paired NASA-TLX scores for any dimension between the CC + SI and standard, adjusting for CPR order. There was no difference in CRM scores for CC + SI compared to standard. Participants were less familiar with CC + SI although many found it simpler to perform, better for transitions/switching roles, and better for communication. Conclusions: The human factors are no more physically or cognitively demanding with CC + SI compared to standard CPR (NASA-TLX and participant debrief) and team performance was no different with CC + SI compared to standard CPR (OGRS score).

Pulmonary Embolism Presenting As Shoulder and Back Pain: A Case Report.

Pulmonary embolism (PE) is a common but life-threatening condition, and diagnosis can be challenging. Diagnosis is even more difficult in those patients with atypical presentations such as the absence of pleuritic chest pain, dyspnoea, tachycardia, or symptoms of deep vein thrombosis. We have delineated shoulder and back pain as an atypical sign of PE. However, the significant amount of misdiagnosis highlights the importance of other rare symptoms of this potentially fatal disease. Therefore, eliciting these rare presenting symptoms can significantly reduce morbidity and mortality. Here, we report the case of a patient who, 13 days after a laparoscopic Nissen fundoplication, presented to the emergency department (ED) with left shoulder and left-sided pleuritic back pain. She was managed in the resuscitation area in the ED and was subsequently diagnosed with a left-sided PE. Her care was taken over by the medical team, and she continued her recovery in the acute medical unit.

A robust ensemble deep learning framework for accurate diagnoses of tuberculosis from chest radiographs.

Introduction: Tuberculosis (TB) stands as a paramount global health concern, contributing significantly to worldwide mortality rates. Effective containment of TB requires deployment of cost-efficient screening method with limited resources. To enhance the precision of resource allocation in the global fight against TB, this research proposed chest X-ray radiography (CXR) based machine learning screening algorithms with optimization, benchmarking and tuning for the best TB subclassification tasks for clinical application. Methods: This investigation delves into the development and evaluation of a robust ensemble deep learning framework, comprising 43 distinct models, tailored for the identification of active TB cases and the categorization of their clinical subtypes. The proposed framework is essentially an ensemble model with multiple feature extractors and one of three fusion strategies-voting, attention-based, or concatenation methods-in the fusion stage before a final classification. The comprised de-identified dataset contains records of 915 active TB patients alongside 1,276 healthy controls with subtype-specific information. Thus, the realizations of our framework are capable for diagnosis with subclass identification. The subclass tags include: secondary tuberculosis/tuberculous pleurisy; non-cavity/cavity; secondary tuberculosis only/secondary tuberculosis and tuberculous pleurisy; tuberculous pleurisy only/secondary tuberculosis and tuberculous pleurisy. Results: Based on the dataset and model selection and tuning, ensemble models show their capability with self-correction capability of subclass identification with rendering robust clinical predictions. The best double-CNN-extractor model with concatenation/attention fusion strategies may potentially be the successful model for subclass tasks in real application. With visualization techniques, in-depth analysis of the ensemble model's performance across different fusion strategies are verified. Discussion: The findings underscore the potential of such ensemble approaches in augmenting TB diagnostics with subclassification. Even with limited dataset, the self-correction within the ensemble models still guarantees the accuracies to some level for potential clinical decision-making processes in TB management. Ultimately, this study shows a direction for better TB screening in the future TB response strategy.

Radiological Features of Extramedullary Hematopoiesis in a Young Male With Beta-Thalassemia: A Case Report.

The formation of the blood elements and their maturation is called hematopoiesis. In adults, this typically takes place in the bone marrow of vertebrae, ribs, and long bones. In contrast, during fetal development, the primary sites of hematopoiesis are the spleen, liver, and the yolk sac. This process of hematopoiesis, when it occurs in sites other than the bone marrow, is called the extramedullary hematopoiesis (EMH). Extramedullary hematopoiesis usually happens in patients with blood disorders like sickle cell disease and thalassemia, where there is failure of hematopoiesis in the primary sites. Here, we present a young male with beta-thalassemia who presented with shortness of breath and palpitations for one month. This manuscript discusses the imaging findings of the EMH in our patient.

A Case Report of Type B Aortic Dissection With Ruptured False Lumen.

Aortic dissection is a critical condition characterized by an intimal tear in the aortic wall, leading to the formation of a false lumen. We present a case of a 54-year-old male with chronic type B aortic dissection and hypertension who presented with acute tearing left back pain. Initial evaluation revealed elevated blood pressure and subtle laboratory abnormalities. Imaging confirmed a Stanford type B aortic dissection with an intramural hematoma and contained rupture of the false lumen. Despite initial stabilization efforts, the patient deteriorated rapidly and succumbed. This case highlights the critical importance of early diagnosis.

Use of a novel configuration of ports for patients needing intermittent long-term apheresis.

PURPOSE: In patients with a need for frequent but intermittent apheresis, vascular access can prove challenging. We describe the migration of the use of a Vortex LP dual lumen port (Angiodynamics, Latham, NY) to one Powerflow and one ClearVUE power injectable port (Becton Dickinson, Franklin Lakes, NJ) in a series of patients undergoing intermittent apheresis. MATERIALS AND METHODS: All patients had a need for long-term intermittent apheresis. Eight had double lumen Vortex port (pre) and were exchanged for one Powerflow port and one conventional subcutaneous venous port with 90° needle entry (post) while 12 did not have any port in place and received the same configuration. IRB approval was granted. We recorded the treatment time, flow rate, and tissue plasminogen activator (tPA) use for five treatment sessions after placement. When available, we compared five treatments with the Vortex port and the new configuration. RESULTS: The mean treatment time is reduced with the new configuration (P = 0.0033). The predicted mean treatment time, adjusting for gender, race, BMI and age and accounting for correlations within a patient is 91.18 min pre and 77.96 min post. The flow rate is higher with the new configuration (P < 0.0001). The predicted mean flow rate in mL/min is 61.59 for the Vortex port and 71.89 for the new configuration. tPA use was eliminated in the population converted from Vortex ports and had a 48% reduction when compared to all other configurations in the study. CONCLUSION: The introduction of a novel device configuration of venous access ports for intermittent apheresis resulted in higher flow rates and less total time for treatment. Use of tPA was greatly reduced. These results suggest that the new configuration could result in less expense for the hospital and better throughput in a busy pheresis practice. Clinical trial registration with ClinicalTrials.gov: NCT04846374.

Effect of posture on the position of the subcutaneous implantable defibrillator.

BACKGROUND: The PRAETORIAN score is developed as an alternative for defibrillation testing (DFT) post subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation, and assess three aspects of implant position on a bidirectional chest X-ray. The score is validated on a standard standing chest X-ray with arms elevated in the lateral view. OBJECTIVE: We aim to evaluate the effect of different anatomical positions on the PRAETORIAN score. METHODS: Thirty S-ICD patients underwent standard posterior-anterior (PA) and lateral chest X-rays, including additional lateral views in two positions: standing with arms down and supine with arms alongside the body. PRAETORIAN score and weighted kappa coefficient were calculated for each position. RESULTS: In 8 out of 30 patients the PRAETORIAN score was ≥90 in standard position. The agreement in PRAETORIAN score was substantial (κ=0.677) for the position with the arms down and fair (κ =0.399) for the supine position. In 10 patients (33%) with the arms down the PRAETORIAN score decreased, of whom 4 changed to a lower risk category. In 16 patients (53%) the PRAETORIAN score decreased in supine position, of whom 7 changed to a lower risk category of which one patient changed from high to low risk. CONCLUSION: A supine or arms-down position during chest X-rays can result in lower PRAETORIAN scores and underestimation of associated risk on DFT failure. This emphasizes the importance of correct anatomical positioning ('arms up') during chest X-rays when using the PRAETORIAN score.

The analgesic effects of combined bilateral parasternal block and serratus anterior plane block for coronary artery bypass grafting surgery.

BACKGROUND: Severe pain occurs after cardiac surgery in the sternum and chest tubes sites. Although analgesia targeting the sternum is often prioritized, the analgesia of the drain site is sometimes overlooked. This study of patients undergoing coronary artery bypass grafting (CABG) aimed to provide optimized analgesia for both the sternum and the chest tubes area by combining parasternal block (PSB) and serratus anterior plane block (SAPB). METHODS: Ethics committee approval (E.Kurul-E2-24-6176, 07/02/2024) was received for the study. Then, the trial was registered on www. CLINICALTRIALS: gov ( https://clinicaltrials.gov/ ) under the identifier NCT05427955 on 17/03/2024. Twenty patients between the ages of 18-80, with ASA physical status classification II-III, undergoing coronary artery bypass grafting CABG with sternotomy, were included. While the patients were under general anesthesia, PSB was performed through the second and fourth intercostal spaces, and SAPB was performed over the sixth rib. The primary outcome was VAS (Visual Analog Scale) during the first 12 h after extubation. The secondary outcomes were intraoperative remifentanil consumption and block-related side effects. RESULTS: The average age of the patients was 64 years. Five patients were female, and 15 were male. For the sternum area, only one patient had resting VAS scores of 4, while the VAS scores for resting for the other patients were below 4. For chest tubes area, only two patients had resting VAS scores of 4 or above, while the resting VAS scores for the other patients were below 4. The patients' intraoperative remifentanil consumption averaged 2.05 mg. No side effects related to analgesic protocol were observed in any of the patients. CONCLUSIONS: In this preliminary study where PSB and SAPB were combined in patients undergoing CABG, effective analgesia was achieved for the sternum and chest tubes area.

Risk scores and coronary artery disease in patients with suspected acute coronary syndrome and intermediate cardiac troponin concentrations.

BACKGROUND: Guidelines recommend the use of risk scores to select patients for further investigation after myocardial infarction has been ruled out but their utility to identify those with coronary artery disease is uncertain. METHODS: In a prospective cohort study, patients with intermediate high-sensitivity cardiac troponin I concentrations (5 ng/L to sex-specific 99th percentile) in whom myocardial infarction was ruled out were enrolled and underwent coronary CT angiography (CCTA) after hospital discharge. History, ECG, Age, Risk factors, Troponin (HEART), Emergency Department Assessment of Chest Pain Score (EDACS), Global Registry of Acute Coronary Event (GRACE), Thrombolysis In Myocardial Infarction (TIMI), Systematic COronary Risk Evaluation 2 and Pooled Cohort Equation risk scores were calculated and the odds ratio (OR) and diagnostic performance for obstructive coronary artery disease were determined using established thresholds. RESULTS: Of 167 patients enrolled (64±12 years, 28% female), 29.9% (50/167) had obstructive coronary artery disease. The odds of having obstructive disease were increased for all scores with the lowest and highest increase observed for an EDACS score ≥16 (OR 2.2 (1.1-4.6)) and a TIMI risk score ≥1 (OR 12.9 (3.0-56.0)), respectively. The positive predictive value (PPV) was low for all scores but was highest for a GRACE score >88 identifying 39% as high risk with a PPV of 41.9% (30.4-54.2%). The negative predictive value (NPV) varied from 77.3% to 95.2% but was highest for a TIMI score of 0 identifying 26% as low risk with an NPV of 95.2% (87.2-100%). CONCLUSIONS: In patients with intermediate cardiac troponin concentrations in whom myocardial infarction has been excluded, clinical risk scores can help identify patients with and without coronary artery disease, although the performance of established risk thresholds is suboptimal for utilisation in clinical practice. TRIAL REGISTRATION NUMBER: NCT04549805.

Síndrome de la costilla deslizante en la edad pediátrica. Serie de casos / Slipping rib syndrome in childhood. A case series

Entre las causas de dolor torácico, la costilla deslizante presenta baja prevalencia, antecedentes traumáticos y manejo controvertido. Este síndrome merece ser incluido en el diagnóstico diferencial de causas de dolor torácico en niños. Al no asociarse a traumatismos previos y la deformidad de cartílagos, nos induce a pensar en una alteración en el desarrollo costal, al margen de la etiología traumática típica en adultos. Se presenta una serie de pacientes pediátricos intervenidos por costilla deslizante en un centro de referencia entre 2001 y 2022. Se incluyeron nueve pacientes, con un rango de edades de 11 a 16 años. Solo dos casos describen traumatismo previo. Todos presentan un inicio súbito de dolor toracoabdominal intenso. Los pacientes fueron intervenidos mediante resección abierta de cartílagos costales afectos, con resolución del dolor.

Among the causes of chest pain, slipping rib has a low prevalence, usually with a history of trauma, and its management is controversial. Slipping rib syndrome should be included in the differential diagnosis of causes of chest pain in children. When not associated with previous trauma and cartilage deformity, it is necessary to consider an alteration in rib development, regardless of the typical traumatic etiology in adults. Here we describe a series of pediatric patients with slipping rib seen at a referral hospital between 2001 and 2022. Nine patients aged 11 to 16 years were included. Only 2 had a history of trauma. All patients described a sudden onset of severe thoracic abdominal pain. The patients underwent open resection of the affected costal cartilages, with resolution of pain.

Improving lung point-of-care ultrasound (POCUS) training and accreditation - a multidisciplinary, multi-centre and multi-pronged approach to development and delivery using the action learning process.

BACKGROUND: Point-of-Care Ultrasound (POCUS) consists of a range of increasingly important imaging modalities across a variety of specialties. Despite a variety of accreditation pathways available in the UK, lung POCUS training remains difficult to deliver and accreditation rates remain suboptimal. We describe a multidisciplinary, multi-centre, and multi-pronged approach to lung POCUS education within a region. METHODS: A survey was conducted in a region. From these results, bottlenecks were identified for improvement. We utilised key stages in an established accreditation pathway, and the Action Learning process. Analysing participant feedback, consensus amongst the team, regional educational needs, and leveraging the expertise within the faculty, we implemented several solutions which were multidisciplinary, multi-centre, and multi-pronged. We also set up a database across several accreditation pathways to facilitate supervision and assessment of rotational trainees. RESULTS: Utilising the Action Learning process, we implemented several improvements at elements of the lung ultrasound accreditation pathways. An initial regional survey identified key barriers to accreditation: lack of courses (52%), lack of mentors (93%), and difficulty arranging directly supervised scans (73%). A multidisciplinary team of trainers was assembled. Regular courses were organised and altered based on feedback and anecdotal educational needs within the region. Courses were set up to also facilitate continuing professional development and exchange of knowledge and ideas amongst trainers. The barrier of supervision was removed through the organisation of regular supervision sessions, facilitating up to fifty scans per half day per trainer. We collected feedback from courses and optimised them. Remote mentoring platforms were utilised to encourage asynchronous supervision. A database of trainers was collated to facilitate triggered assessments. These approaches promoted a conducive environment and a commitment to learning. Repeat survey results support this. CONCLUSION: Lung ultrasound accreditation remains a complex educational training pathway. Utilising an education framework, recruiting a multidisciplinary team, ensuring a multi-pronged approach, and fostering a commitment to learning can improve accreditation success.

Spontaneous coronary artery dissection in the context of tamoxifen; Is there any correlation?

Key Clinical Message: Clinicians should consider spontaneous coronary artery dissection in middle-aged women presenting with acute coronary syndromes and a history of tamoxifen use, to ensure timely diagnosis, and appropriate management strategies. Abstract: Spontaneous coronary artery dissection (SCAD) is characterized by a non-iatrogenic, nontraumatic separation of the coronary artery wall, contributing to acute coronary syndromes (ACS), and sudden cardiac death. SCAD predominantly affects the left anterior descending artery (LAD) and is frequently observed in middle-aged women. This condition has been associated with cancer treatment and exogenous hormones exposure. The diagnostic gold standard remains coronary angiography, management strategies include conservative measures, percutaneous coronary intervention (PCI), and coronary artery bypass graft surgery (CABG). We describe a case of a 54-year-old woman with breast cancer and a history of tamoxifen use, presenting with SCAD in the posterolateral branch (PLB) originating from the left circumflex artery (LCX), and right coronary artery (RCA) and managed conservatively.