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Luo JC, Zhang YJ, Niu Y, Luo MH, Sun F, Tu GW, Chen Z, Zhou SY, Gu GR, Cheng XF, Zhao YW, Zhou WT, Luo Z. Development and external validation of a novel modality for rapid recognition of aortic dissection based on peripheral pulse oximetry waveforms. Med Phys 2024. [PMID: 39269979 DOI: 10.1002/mp.17405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 08/02/2024] [Accepted: 08/20/2024] [Indexed: 09/15/2024] Open
Abstract
BACKGROUND Aortic dissection (AD) is a life-threatening cardiovascular emergency that is often misdiagnosed as other chest pain conditions. Physiologically, AD may cause abnormalities in peripheral blood flow, which can be detected using pulse oximetry waveforms. PURPOSE This study aimed to assess the feasibility of identifying AD based on pulse oximetry waveforms and to highlight the key waveform features that play a crucial role in this diagnostic method. METHODS This prospective study employed high-risk chest pain cohorts from two emergency departments. The initial cohort was enriched with AD patients (n = 258, 47% AD) for model development, while the second cohort consisted of chest pain patients awaiting angiography (n = 71, 25% AD) and was used for external validation. Pulse oximetry waveforms from the four extremities were collected for each patient. After data preprocessing, a recognition model based on the random forest algorithm was trained using patients' gender, age, and waveform difference features extracted from the pulse oximetry waveforms. The performance of the model was evaluated using receiver operating characteristic (ROC) curve analysis and decision curve analysis (DCA). The importance of features was also assessed using Shapley Value and Gini importance. RESULTS The model demonstrated strong performance in identifying AD in both the training and external validation sets. In the training set, the model achieved an area under the ROC curve of 0.979 (95% CI: 0.961-0.990), sensitivity of 0.918 (95% CI: 0.873-0.955), specificity of 0.949 (95% CI: 0.912-0.985), and accuracy of 0.933 (95% CI: 0.904-0.959). In the external validation set, the model attained an area under the ROC curve of 0.855 (95% CI: 0.720-0.965), sensitivity of 0.889 (95% CI: 0.722-1.000), specificity of 0.698 (95% CI: 0.566-0.812), and accuracy of 0.794 (95% CI: 0.672-0.878). Decision curve analysis (DCA) further showed that the model provided a substantial net benefit for identifying AD. The median mean and median variance of the four limbs' signals were the most influential features in the recognition model. CONCLUSIONS This study demonstrated the feasibility and strong performance of identifying AD based on peripheral pulse oximetry waveforms in high-risk chest pain populations in the emergency setting. The findings also provided valuable insights for future human fluid dynamics simulations to elucidate the impact of AD on blood flow in greater detail.
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Affiliation(s)
- Jing-Chao Luo
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi-Jie Zhang
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ying Niu
- Shanghai Center for Mathematical Sciences, Fudan University, Shanghai, China
| | - Ming-Hao Luo
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Medical College, Fudan University, Shanghai, China
| | - Feng Sun
- Department of Emergency Medicine, Jiangsu Province Hospital, Nanjing, China
| | - Guo-Wei Tu
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhao Chen
- School of Data Science, Fudan University, Shanghai, China
| | - Si-Ying Zhou
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Rong Gu
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xu-Feng Cheng
- Department of Emergency Medicine, Jiangsu Province Hospital, Nanjing, China
| | - Yu-Wei Zhao
- Shanghai Center for Mathematical Sciences, Fudan University, Shanghai, China
- Department of Financial and Actuarial Mathematics, Xi'an Jiaotong-Liverpool University, Suzhou, China
| | - Wan-Ting Zhou
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhe Luo
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai, China
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2
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Rudolph J, Huemmer C, Preuhs A, Buizza G, Hoppe BF, Dinkel J, Koliogiannis V, Fink N, Goller SS, Schwarze V, Mansour N, Schmidt VF, Fischer M, Jörgens M, Ben Khaled N, Liebig T, Ricke J, Rueckel J, Sabel BO. Nonradiology Health Care Professionals Significantly Benefit From AI Assistance in Emergency-Related Chest Radiography Interpretation. Chest 2024; 166:157-170. [PMID: 38295950 PMCID: PMC11251081 DOI: 10.1016/j.chest.2024.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/23/2024] [Accepted: 01/23/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Chest radiographs (CXRs) are still of crucial importance in primary diagnostics, but their interpretation poses difficulties at times. RESEARCH QUESTION Can a convolutional neural network-based artificial intelligence (AI) system that interprets CXRs add value in an emergency unit setting? STUDY DESIGN AND METHODS A total of 563 CXRs acquired in the emergency unit of a major university hospital were retrospectively assessed twice by three board-certified radiologists, three radiology residents, and three emergency unit-experienced nonradiology residents (NRRs). They used a two-step reading process: (1) without AI support; and (2) with AI support providing additional images with AI overlays. Suspicion of four suspected pathologies (pleural effusion, pneumothorax, consolidations suspicious for pneumonia, and nodules) was reported on a five-point confidence scale. Confidence scores of the board-certified radiologists were converted into four binary reference standards of different sensitivities. Performance by radiology residents and NRRs without AI support/with AI support were statistically compared by using receiver-operating characteristics (ROCs), Youden statistics, and operating point metrics derived from fitted ROC curves. RESULTS NRRs could significantly improve performance, sensitivity, and accuracy with AI support in all four pathologies tested. In the most sensitive reference standard (reference standard IV), NRR consensus improved the area under the ROC curve (mean, 95% CI) in the detection of the time-critical pathology pneumothorax from 0.846 (0.785-0.907) without AI support to 0.974 (0.947-1.000) with AI support (P < .001), which represented a gain of 30% in sensitivity and 2% in accuracy (while maintaining an optimized specificity). The most pronounced effect was observed in nodule detection, with NRR with AI support improving sensitivity by 53% and accuracy by 7% (area under the ROC curve without AI support, 0.723 [0.661-0.785]; with AI support, 0.890 [0.848-0.931]; P < .001). Radiology residents had smaller, mostly nonsignificant gains in performance, sensitivity, and accuracy with AI support. INTERPRETATION We found that in an emergency unit setting without 24/7 radiology coverage, the presented AI solution features an excellent clinical support tool to nonradiologists, similar to a second reader, and allows for a more accurate primary diagnosis and thus earlier therapy initiation.
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Affiliation(s)
- Jan Rudolph
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany.
| | - Christian Huemmer
- XP Technology and Innovation, Siemens Healthcare GmbH, Forchheim, Germany
| | - Alexander Preuhs
- XP Technology and Innovation, Siemens Healthcare GmbH, Forchheim, Germany
| | - Giulia Buizza
- XP Technology and Innovation, Siemens Healthcare GmbH, Forchheim, Germany
| | - Boj F Hoppe
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Julien Dinkel
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany; Comprehensive Pneumology Center, German Center for Lung Research, Munich, Germany; Department of Radiology, Asklepios Fachklinik München, Gauting, Germany
| | | | - Nicola Fink
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Sophia S Goller
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Vincent Schwarze
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Nabeel Mansour
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Vanessa F Schmidt
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Maximilian Fischer
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Maximilian Jörgens
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Najib Ben Khaled
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Thomas Liebig
- Institute of Neuroradiology, University Hospital, LMU Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Johannes Rueckel
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany; Institute of Neuroradiology, University Hospital, LMU Munich, Munich, Germany
| | - Bastian O Sabel
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
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3
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Abdelhameed AA, Choudhary S, Khoudir MA. Extensive Type A Aortic Arterial Dissection Presenting With Stroke Symptoms: A Case Report. Cureus 2024; 16:e55564. [PMID: 38576638 PMCID: PMC10993097 DOI: 10.7759/cureus.55564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2024] [Indexed: 04/06/2024] Open
Abstract
Aortic dissection (AD) is a rare but often lethal condition if not properly and urgently treated. Most often, patients arrive with acute hemodynamic instability and ripping chest agony. The patient's life depends critically on a correct diagnosis made as soon as possible. We describe a 60-year-old man who arrived at the emergency room with symptoms of a brain stroke, including poor consciousness, left-sided weakness, and speech disturbance associated with hemodynamic instability, and chest pain. Thoracic aortic arch dissection was observed on CT angiography (CTA). In addition, CTA revealed that the dissection extends proximally into the left common carotid artery, left subclavian artery, brachiocephalic trunk, and right common carotid artery and distally to the left common iliac artery, coupled with significant stenosis of the left common iliac artery. Proper management of blood pressure (BP) parameters is life-saving for the patient. Since our hospital did not offer cardiothoracic surgery services, the patient was transferred to a different institution, where he received medical care immediately from an expert team and had surgery.
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4
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Cevhertas MK, Baykan O, Saglam C, Akay S, Unverdi BP, Adibelli ZH. The diagnostic performance and utility of chest XR in relation to chest CT in nontraumatic respiratory emergency patients. Niger J Clin Pract 2023; 26:438-446. [PMID: 37203108 DOI: 10.4103/njcp.njcp_458_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Background and Aim This study aimed to determine the diagnostic performance and utility of chest radiography in relation to chest computed tomography (CT) in nontraumatic respiratory emergency patients. Patients and Methods Patients presenting to the emergency department with respiratory complaints due to nontraumatic pathologies and who had consecutive chest XR and chest CT assessments with an interval of fewer than 6 hours were enrolled in the study (n = 561). Results The two methods were determined to be consistent with moderate agreement in detecting pleural effusion (κ = 0.576, P < 0.001), pneumothorax (κ = 0.567, P < 0.001), increased cardiothoracic ratio (κ =0.472, P < 0.001), and pneumonic consolidation (κ = 0.465, P < 0.001). The consistency rate was significantly higher in patients aged <40 years (95.5% in ≤30 years and 90.9% in 31-40 years) as compared to older patients (81.8%, 68.2%, and 72.7% in 41-60 years, 61-80 years, and >80 years, respectively; P < 0.001 for each). The consistency rate was also higher for posteroanterior (PA) chest XR views than for anteroposterior (AP) chest XR views (72.7% vs. 68.2%, P = 0.005) and for high- and moderate-quality chest XR views than for poor-quality views (72.7% and 77.3% vs. 70.5%, P = 0.001). Conclusion The consistency between the chest XR and CT was more likely in patients aged <40 years and for PA and moderate-to-high quality chest XR views, as compared to older patients and AP and poor-quality views, respectively. We suggest that an upright position PA chest X-ray with high imaging quality may be the first choice, especially in patients aged <40 years admitted to the emergency department with respiratory symptoms.
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Affiliation(s)
- M K Cevhertas
- Clinic of Emergency Medicine, Buca Seyfi Demirsoy Training and Research Hospital, İzmir, Turkey
| | - O Baykan
- Clinic of Emergency Medicine, Ataturk Training and Research Hospital, Balikesir, Turkey
| | - C Saglam
- Clinic of Emergency Medicine, Health Sciences University, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - S Akay
- Clinic of Emergency Medicine, Health Sciences University, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - B P Unverdi
- Clinic of Radiology, Health Sciences University, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Z H Adibelli
- Clinic of Radiology, Health Sciences University, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
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Rudolph J, Schachtner B, Fink N, Koliogiannis V, Schwarze V, Goller S, Trappmann L, Hoppe BF, Mansour N, Fischer M, Ben Khaled N, Jörgens M, Dinkel J, Kunz WG, Ricke J, Ingrisch M, Sabel BO, Rueckel J. Clinically focused multi-cohort benchmarking as a tool for external validation of artificial intelligence algorithm performance in basic chest radiography analysis. Sci Rep 2022; 12:12764. [PMID: 35896763 PMCID: PMC9329327 DOI: 10.1038/s41598-022-16514-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 07/11/2022] [Indexed: 01/08/2023] Open
Abstract
Artificial intelligence (AI) algorithms evaluating [supine] chest radiographs ([S]CXRs) have remarkably increased in number recently. Since training and validation are often performed on subsets of the same overall dataset, external validation is mandatory to reproduce results and reveal potential training errors. We applied a multicohort benchmarking to the publicly accessible (S)CXR analyzing AI algorithm CheXNet, comprising three clinically relevant study cohorts which differ in patient positioning ([S]CXRs), the applied reference standards (CT-/[S]CXR-based) and the possibility to also compare algorithm classification with different medical experts’ reading performance. The study cohorts include [1] a cohort, characterized by 563 CXRs acquired in the emergency unit that were evaluated by 9 readers (radiologists and non-radiologists) in terms of 4 common pathologies, [2] a collection of 6,248 SCXRs annotated by radiologists in terms of pneumothorax presence, its size and presence of inserted thoracic tube material which allowed for subgroup and confounding bias analysis and [3] a cohort consisting of 166 patients with SCXRs that were evaluated by radiologists for underlying causes of basal lung opacities, all of those cases having been correlated to a timely acquired computed tomography scan (SCXR and CT within < 90 min). CheXNet non-significantly exceeded the radiology resident (RR) consensus in the detection of suspicious lung nodules (cohort [1], AUC AI/RR: 0.851/0.839, p = 0.793) and the radiological readers in the detection of basal pneumonia (cohort [3], AUC AI/reader consensus: 0.825/0.782, p = 0.390) and basal pleural effusion (cohort [3], AUC AI/reader consensus: 0.762/0.710, p = 0.336) in SCXR, partly with AUC values higher than originally published (“Nodule”: 0.780, “Infiltration”: 0.735, “Effusion”: 0.864). The classifier “Infiltration” turned out to be very dependent on patient positioning (best in CXR, worst in SCXR). The pneumothorax SCXR cohort [2] revealed poor algorithm performance in CXRs without inserted thoracic material and in the detection of small pneumothoraces, which can be explained by a known systematic confounding error in the algorithm training process. The benefit of clinically relevant external validation is demonstrated by the differences in algorithm performance as compared to the original publication. Our multi-cohort benchmarking finally enables the consideration of confounders, different reference standards and patient positioning as well as the AI performance comparison with differentially qualified medical readers.
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Affiliation(s)
- Jan Rudolph
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Balthasar Schachtner
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.,Comprehensive Pneumology Center, German Center for Lung Research, Munich, Germany
| | - Nicola Fink
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.,Comprehensive Pneumology Center, German Center for Lung Research, Munich, Germany
| | - Vanessa Koliogiannis
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Vincent Schwarze
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Sophia Goller
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Lena Trappmann
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Boj F Hoppe
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Nabeel Mansour
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Maximilian Fischer
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Najib Ben Khaled
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Maximilian Jörgens
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Julien Dinkel
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.,Comprehensive Pneumology Center, German Center for Lung Research, Munich, Germany.,Department of Radiology, Asklepios Fachklinik München, Gauting, Germany
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Michael Ingrisch
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Bastian O Sabel
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Johannes Rueckel
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.,Institute of Neuroradiology, University Hospital, LMU Munich, Munich, Germany
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6
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Landa E, Javaid S, Campos F, Vigandt E, Hussaini M. Incidental Finding of an Extensive Type B Aortic Dissection Extending to the Iliac Arteries. Cureus 2022; 14:e22655. [PMID: 35371679 PMCID: PMC8963726 DOI: 10.7759/cureus.22655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 11/12/2022] Open
Abstract
An aortic dissection is a life-threatening event that requires urgent evaluation. A dissection is defined as a tear in the innermost layer of the aortic wall forming a true and false lumen. This is normally diagnosed with a CT with contrast when clinical suspicion is present. Deciding whether urgent surgical intervention is required is key, as it may determine the survival of the patient. The treatment of type A aortic dissection involves emergent open-heart surgery. Medical treatment and clinical follow-up are recommended for uncomplicated type B dissections. In this report, we present a case of an extensive type B aortic dissection in an asymptomatic patient who required immediate surgical intervention.
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7
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Roohafza H, Bagherieh S, Feizi A, Khani A, Yavari N, Saneian P, Teimouri Z, Sadeghi M. How is type D personality associated with the major psychological outcomes in noncardiac chest pain patients? Personal Ment Health 2022; 16:70-78. [PMID: 34505402 DOI: 10.1002/pmh.1527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/25/2021] [Accepted: 08/09/2021] [Indexed: 11/10/2022]
Abstract
Noncardiac chest pain (NCCP) may lead many problems on the health-care system. Having type D personality has been shown to adversely affect NCCP patients. This study aimed to determine the psychological comorbidities that type D personality is associated with, in patients with NCCP. The participants of this cross-sectional study were 360 patients diagnosed with NCCP. Patients filled out questionnaires about sociodemographic, behavioral, and clinical factors (severity of pain, somatization, cardiac anxiety, fear of body sensations, depression, and type D personality). Type D personality was more prevalent among female (p < 0.005), and those people having this personality showed lower sleep quality (p = 0.001) and sexual life satisfaction (p < 0.001) and more likely to be smoker (p < 0.001). Type D personality is strongly associated with fear of body sensations (β = 5.92, SE = 1.95, p = 0.003), pain intensity (β = 3.53, SE = 0.98, p < 0.001), depression (β = 2.91, SE = 0.62, p < 0.001), and somatization (β = 1.75, SE = 0.55, p < 0.001). Type D personality and major psychological comorbidities were strongly associated. Physicians should consider that having type D personality can be linked to NCCP in an effort to help patients receive effective psychological consultations.
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Affiliation(s)
- Hamidreza Roohafza
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sara Bagherieh
- Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Awat Feizi
- Department of Biostatistics and Epidemiology, School of Health and Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azam Khani
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Niloufar Yavari
- Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Parsa Saneian
- Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Teimouri
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Masoumeh Sadeghi
- Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
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8
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Stowell JT, Walker CM, Chung JH, Bang TJ, Carter BW, Christensen JD, Donnelly EF, Hanna TN, Hobbs SB, Johnson BD, Kandathil A, Lo BM, Madan R, Majercik S, Moore WH, Kanne JP. ACR Appropriateness Criteria® Nontraumatic Chest Wall Pain. J Am Coll Radiol 2021; 18:S394-S405. [PMID: 34794596 DOI: 10.1016/j.jacr.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 10/19/2022]
Abstract
Chest pain is a common reason that patients may present for evaluation in both ambulatory and emergency department settings, and is often of musculoskeletal origin in the former. Chest wall syndrome collectively describes the various entities that can contribute to chest wall pain of musculoskeletal origin and may affect any chest wall structure. Various imaging modalities may be employed for the diagnosis of nontraumatic chest wall conditions, each with variable utility depending on the clinical scenario. We review the evidence for or against use of various imaging modalities for the diagnosis of nontraumatic chest wall pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | | | - Jonathan H Chung
- Panel Chair; and Vice-Chair, Quality and Section Chief, Chest Imaging, Department of Radiology, University of Chicago, Chicago, Illinois
| | - Tami J Bang
- Co-Director, Cardiothoracic Imaging Fellowship Committee, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; Co-Chair, membership committee, NASCI; and Membership committee, ad-hoc online content committee, STR
| | - Brett W Carter
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jared D Christensen
- Vice-Chair, Department of Radiology, Duke University Medical Center, Durham, North Carolina; and Chair, Lung-RADS
| | - Edwin F Donnelly
- Chief, Thoracic Imaging, Ohio State University, Columbus, Ohio; Co-Chair Physics Module Committee, RSNA
| | - Tarek N Hanna
- Associate Director, Emergency and Trauma Imaging, Emory University, Atlanta, Georgia; and Director-at-Large, American Society of Emergency Radiology
| | - Stephen B Hobbs
- Vice-Chair, Informatics and Integrated Clinical Operations and Division Chief, Cardiovascular and Thoracic Radiology, University of Kentucky, Lexington, Kentucky
| | | | | | - Bruce M Lo
- Sentara Norfolk General/Eastern Virginia Medical School, Norfolk, Virginia; and Board Member, American College of Emergency Physicians
| | - Rachna Madan
- Associate Fellowship Director, Division of Thoracic Imaging, Brigham & Women's Hospital, Boston, Massachusetts
| | - Sarah Majercik
- Vice-Chair, Surgery for Research and Director, Trauma Research, Intermountain Medical Center, Salt Lake City, Utah; and American Association for the Surgery of Trauma
| | - William H Moore
- Associate Chair, Clinical Informatics and Chief, Thoracic Imaging, New York University Langone Medical Center, New York, New York
| | - Jeffrey P Kanne
- Specialty Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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9
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Hsieh CC, Zeng AB, Chen CH, Jhou ZY, Wang CH, Yang YL, Hsieh FC, Lin JK, Yeh JY, Huang CC. A practical biphasic contrast media injection protocol strongly enhances the aorta and pulmonary artery simultaneously using a single CT angiography scan. BMC Med Imaging 2021; 21:160. [PMID: 34717585 PMCID: PMC8557493 DOI: 10.1186/s12880-021-00691-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 10/19/2021] [Indexed: 11/10/2022] Open
Abstract
Background Enhancement profiles of the pulmonary artery (PA) and aorta differ when using computed tomography (CT) angiography. Our aim was to determine the optimal CT protocol for a one-time CT scan that assesses both blood vessels. Methods We prospectively enrolled 101 cases of CT angiography in patients with suspected pulmonary embolism or aortic dissection from our center between 2018 and 2020. We also retrospectively collected the data of 40 patients who underwent traditional two-time CT scans between 2015 and 2018. Patients were divided into four groups: test bolus (TB) I, TB II, bolus-tracking (BT) I, and BT II. The enhancement of the PA and aorta, and the radiation doses used in the four groups were collected. Those who underwent two-time scans were classified into the traditional PA or aorta scan groups. Data were compared between the BT and traditional groups. Results The aortic enhancement was highest in BT II (294.78 ± 64.48 HU) followed BT I (285.18 ± 64.99 HU), TB II (186.58 ± 57.53 HU), and TB I (173.62 ± 69.70 HU). The radiation dose used was lowest in BT I (11.85 ± 5.55 mSv) and BT II (9.07 ± 3.44 mSv) compared with that used in the traditional groups (20.07 ± 7.78 mSv) and accounted for half of the traditional group (45.17–59.02%). The aortic enhancement was also highest in BT II (294.78 ± 64.48 HU) followed by BT I (285.18 ± 64.99 HU) when compared with that in the traditional aorta scan group (234.95 ± 94.18 HU). Conclusion Our CT protocol with a BT technique allows for a lower radiation dose and better image quality of the PA and aorta than those obtained using traditional CT scans. Trial registration: NCT04832633, retrospectively registered in April 2021 to the clinical trial registry.
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Affiliation(s)
- Cheng-Chih Hsieh
- Department of Radiology, MacKay Memorial Hospital, No.92, Sec.2, Zhongshan North Rd., Taipei, 10449, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.,Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
| | - An-Bang Zeng
- Department of Radiology, MacKay Memorial Hospital, No.92, Sec.2, Zhongshan North Rd., Taipei, 10449, Taiwan.,Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
| | - Chia-Hung Chen
- Department of Radiology, MacKay Memorial Hospital, No.92, Sec.2, Zhongshan North Rd., Taipei, 10449, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.,Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
| | - Zong-Yi Jhou
- Department of Radiology, MacKay Memorial Hospital, No.92, Sec.2, Zhongshan North Rd., Taipei, 10449, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.,Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
| | - Chih-Hsin Wang
- Department of Radiology, MacKay Memorial Hospital, No.92, Sec.2, Zhongshan North Rd., Taipei, 10449, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.,Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
| | - Ya-Ling Yang
- Department of Radiology, MacKay Memorial Hospital, No.92, Sec.2, Zhongshan North Rd., Taipei, 10449, Taiwan
| | - Feng-Chuan Hsieh
- Department of Radiology, MacKay Memorial Hospital, No.92, Sec.2, Zhongshan North Rd., Taipei, 10449, Taiwan
| | - Jing-Kai Lin
- Department of Radiology, MacKay Memorial Hospital, No.92, Sec.2, Zhongshan North Rd., Taipei, 10449, Taiwan
| | - Ju-Yen Yeh
- Department of Radiology, MacKay Memorial Hospital, No.92, Sec.2, Zhongshan North Rd., Taipei, 10449, Taiwan
| | - Chun-Chao Huang
- Department of Radiology, MacKay Memorial Hospital, No.92, Sec.2, Zhongshan North Rd., Taipei, 10449, Taiwan. .,Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.
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10
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Tien M, Ku A, Martinez-Acero N, Zvara J, Sun EC, Cheung AT. The Penn Classification Predicts Hospital Mortality in Acute Stanford Type A and Type B Aortic Dissections. J Cardiothorac Vasc Anesth 2020; 34:867-873. [PMID: 31558394 PMCID: PMC7684762 DOI: 10.1053/j.jvca.2019.08.036] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 08/15/2019] [Accepted: 08/18/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Mortality in acute aortic dissection varies depending on anatomic location, extent, and associated complications. The Stanford classification guides surgical versus medical management. The Penn classification stratifies mortality risk in patients with Stanford type A aortic dissections undergoing surgery. The objective of the present study was to determine whether the Penn classification can predict hospital mortality in patients with acute Stanford type A and type B aortic dissections undergoing surgical or medical management. DESIGN Retrospective, observational study. SETTING Tertiary care, university hospital. PARTICIPANTS Patients with acute aortic dissection between January 2008 and December 2017. INTERVENTIONS Examination of hospital mortality after surgical or medical management. MEASUREMENTS AND MAIN RESULTS Three hundred fifty-two patients had confirmed dissections (186 type A, 166 type B). The overall mortality was 18.8% for type A and 13.3% for type B. Penn class A patients with type A or type B dissections undergoing surgical repair had the lowest mortality (both 3.1%). Penn class B, C, or B+C patients with type A dissections and Penn class B+C patients with type B dissections undergoing medical management had the greatest incidence of mortality (50.0%-57.1%). All others had intermediate mortality (6.7%-39.3%). Logistic regression analysis demonstrated that Penn class B, C, and B+C patients had a greater odds of mortality and predicted mortality than did Penn class A patients. CONCLUSIONS The Penn classification predicts hospital mortality in patients with acute Stanford type A or type B aortic dissections undergoing surgical or medical management. Early endovascular repair may confer lower risk of mortality in patients with type B dissections presenting without ischemia.
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Affiliation(s)
- Michael Tien
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Andrew Ku
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Natalia Martinez-Acero
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jessica Zvara
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Eric C Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Albert T Cheung
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA.
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Ullah W, Khanal S, Sattar Z, Roomi S, Ahmad A, Sarwar U, Ghani AR. "Singultus" uncloaking potentially fatal vascular dissections. J Community Hosp Intern Med Perspect 2019; 9:282-284. [PMID: 31258876 PMCID: PMC6586111 DOI: 10.1080/20009666.2019.1622379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/13/2019] [Indexed: 10/26/2022] Open
Abstract
Aortic dissection (AD) is a serious condition in which the intimal layer of aorta tears and blood surges in between the intimal and medial layers of aorta causing it to separate (dissect). It usually presents with excruciating pain radiating to the back. Here we present a unique presentation of AD where an old-aged Caucasian male presented with a chronic history of intractable hiccups. His computed tomography (CAT scan) revealed the dissection of the descending thoracic aorta. He was managed conservatively and was discharged home in stable condition. The purpose of this report is to highlight this unusual presentation of AD and unmask the possible etiology of hiccups in such cases.
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Affiliation(s)
- Waqas Ullah
- Internal Medicine, Abington-Jefferson Health, Abington, USA
| | - Shristi Khanal
- Internal Medicine, Abington-Jefferson Health, Abington, USA
| | - Zeeshan Sattar
- Internal Medicine, SUNY Downstate Medical Center, Brooklyn, USA,CONTACT Zeeshan Sattar Internal Medicine, SUNY Downstate Medical Center, Brooklyn, USA
| | - Sohaib Roomi
- Internal Medicine, Abington-Jefferson Health, Abington, USA
| | - Asrar Ahmad
- Internal Medicine, Abington-Jefferson Health, Abington, USA
| | - Usman Sarwar
- Internal Medicine, Abington-Jefferson Health, Abington, USA
| | - Ali Raza Ghani
- Internal Medicine, Abington-Jefferson Health, Abington, USA
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12
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Extracardiac findings on coronary computed tomography angiography in patients without significant coronary artery disease. Eur Radiol 2018; 29:1714-1723. [PMID: 30255246 DOI: 10.1007/s00330-018-5688-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/09/2018] [Accepted: 07/30/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To analyse extracardiac findings in patients without significant coronary artery disease (CAD) in general and in symptomatic patients in particular. METHODS We searched the Radiology Information System database for coronary computed tomography angiographies (CTA) performed from 2000-2014 and retrospectively enrolled 3,898 patients without significant CAD (coronary stenosis < 50%) in CTA. In 2,330 symptomatic patients, we analysed the spectrum of extracardiac findings and identified pathologies potentially explaining chest pain. Finally, we investigated variables affecting the number of extracardiac findings detected in CTA. RESULTS Overall extracardiac findings were found in 1,177 patients (30.2%; 95%CI, 28.8-31.7%). 94 patients (2.4%; 95%CI, 2.0-2.9%) had extracardiac findings with a recommendation for follow-up, sixteen patients (0.4%; 95%CI, 0.3-0.7%) had incidental urgent, and another three patients (0.1%; 95%CI, 0.1-0.2%) had incidental malignant extracardiac findings. 185 of 2,330 symptomatic patients (7.9%; 95%CI, 6.9-9.1%) revealed extracardiac findings potentially explaining chest pain after exclusion of significant CAD. The number of extracardiac findings increased significantly with patient age (p < 0.001) and the cumulative experience of the CT reader (p < 0.001). CONCLUSION 30.2% of patients undergoing CTA for exclusion of CAD had ECF, and 7.9% of symptomatic patients without significant CAD on their examination had findings that could potentially explain their symptoms. KEY POINTS • Of patients undergoing CTA, 2.8% have relevant incidental extracardiac findings. • CTA could identify the differential diagnosis of chest pain when excluding significant CAD. • Patient age and reader's professional experience influence the number of detected ECFs.
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Ha YR, Toh HC. Clinically integrated multi-organ point-of-care ultrasound for undifferentiated respiratory difficulty, chest pain, or shock: a critical analytic review. J Intensive Care 2016; 4:54. [PMID: 27529030 PMCID: PMC4983789 DOI: 10.1186/s40560-016-0172-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 07/12/2016] [Indexed: 12/16/2022] Open
Abstract
Rapid and accurate diagnosis and treatment are paramount in the management of the critically ill. Critical care ultrasound has been widely used as an adjunct to standard clinical examination, an invaluable extension of physical examination to guide clinical decision-making at bedside. Recently, there is growing interest in the use of multi-organ point-of-care ultrasound (MOPOCUS) for the management of the critically ill, especially in the early phase of resuscitation. This article will review the role and utility of symptom-based and sign-oriented MOPOCUS in patients with undifferentiated respiratory difficulty, chest pain, or shock and how it can be performed in a timely, effective, and efficient manner.
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Affiliation(s)
- Young-Rock Ha
- Emergency Department, Bundang Jesaeng Hospital, 20 Seohyeon-ro 180beongil, Bundang-gu, Seongnam-si, Gyeonggi-do South Korea
| | - Hong-Chuen Toh
- Acute and Emergency Care Centre, Khoo Teck Puat Hospital, 90 Yishun Central, S768828 Singapore, Singapore
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14
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Raff GL, Chinnaiyan KM, Cury RC, Garcia MT, Hecht HS, Hollander JE, O'Neil B, Taylor AJ, Hoffmann U. SCCT guidelines on the use of coronary computed tomographic angiography for patients presenting with acute chest pain to the emergency department: A Report of the Society of Cardiovascular Computed Tomography Guidelines Committee. J Cardiovasc Comput Tomogr 2014; 8:254-71. [DOI: 10.1016/j.jcct.2014.06.002] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 06/04/2014] [Indexed: 02/06/2023]
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