First-line Diagnostic Tool Research Articles

From CT to artificial intelligence for complex assessment of plaque-associated risk.

The recent technological developments in the field of cardiac imaging have established coronary computed tomography angiography (CCTA) as a first-line diagnostic tool in patients with suspected coronary artery disease (CAD). CCTA offers robust information on the overall coronary circulation and luminal stenosis, also providing the ability to assess the composition, morphology, and vulnerability of atherosclerotic plaques. In addition, the perivascular adipose tissue (PVAT) has recently emerged as a marker of increased cardiovascular risk. The addition of PVAT quantification to standard CCTA imaging may provide the ability to extract information on local inflammation, for an individualized approach in coronary risk stratification. The development of image post-processing tools over the past several years allowed CCTA to provide a significant amount of data that can be incorporated into machine learning (ML) applications. ML algorithms that use radiomic features extracted from CCTA are still at an early stage. However, the recent development of artificial intelligence will probably bring major changes in the way we integrate clinical, biological, and imaging information, for a complex risk stratification and individualized therapeutic decision making in patients with CAD. This review aims to present the current evidence on the complex role of CCTA in the detection and quantification of vulnerable plaques and the associated coronary inflammation, also describing the most recent developments in the radiomics-based machine learning approach for complex assessment of plaque-associated risk.

In women with chronic or subclinical endometritis is hysteroscopy suitable for setting the diagnosis? A systematic review.

The role of hysteroscopy in cases of chronic or subclinical endometritis remains uncertain. Reevaluating the clinical relevance of diagnostic hysteroscopic in these cases will improve the level of case in women's health worldwide. The objective of this systematic review was to assess the suitability of hysteroscopy in detecting and diagnosing female patients with chronic or subclinical endometritis, as a first-line diagnostic tool. For this systematic review, five major search engines PubMed, Embase, MEDLINE, Google Scholar, as well as ResearchGate were searched using MeSH (medical subject headings) without language or year restrictions up to November 2019. All types of scientific papers were taken into consideration, with a priority to randomized control trials enrolling women with chronic or subclinical endometritis and compared with standard diagnostic tools such as histology or immunohistochemistry, in order to ensure the efficacy of the method. Risk of bias was assessed using the recommended Cochrane Collaboration criteria. In order to gather more information and data, we have decided to include all the scientific evidence regardless of study design. Data collection and analysis were performed according to PRISMA protocol. Hysteroscopy is an important diagnostic tool in cases of endometritis when accompanied by endometrial samples assessment techniques. In cases of high suspicion endometritis facilitates greater diagnostic accuracy. Hysteroscopy facilitates also the assessment of antibiotic administration efficacy in cases of confirmed endometritis. Micropolyposis, stromal edema or congestion, diffuse or focal hyperemia are the dominant hysteroscopic features that are considered by most studies as suggestive of chronic or subclinical endometritis. The heterogeneity of the included studies presents a high risk of bias as assessed according to Cochrane Collaboration criteria. Hysteroscopy is not suitable as a first-line diagnostic tool in cases of chronic or subclinical endometritis. Further randomized controlled trials need to be conducted in order to define the role of hysteroscopy as a first-line diagnostic tool in cases of chronic or subclinical endometritis.

Stab wound of the superficial femoral artery early diagnosed by point-of-care Doppler ultrasound

BackgroundTraumatic vascular injury of the limbs has the potential to cause substantial patient morbidity and mortality, and therefore, early recognition and treatment are crucial to improve outcomes. While patients with hard signs of arterial injury mandate for an immediate surgical intervention, patients presenting with soft signs of arterial injury need further diagnostic evaluation.Case presentationA 24-year-old male was admitted to the emergency department after suffering a stab wound in the anterolateral aspect of his left upper thigh. Entry wound measures approximately 3 cm × 0.7 cm; no exit wound was observed. On examination of the injured limb, the thigh was swollen and painful. Skin color was mildly pale and skin temperature was slightly diminished in his leg; leg numbness was also pointed out by the patient. Common femoral artery pulse was normal, while distal pulses were diminished. Point-of-care Doppler ultrasound (DUS) showed a subfascial hematoma in the thigh, which filled on color Doppler, corresponding to a pseudoaneurysm. On spectral Doppler, signs of distal low blood supply were noted. The patient was immediately transferred to the operating room where a 1-cm laceration was found in the anterior aspect of the superficial femoral artery. The involved artery was successfully repaired and distal flow was reestablished, as assessed by clinical examination, pulse palpation and DUS.ConclusionsBased on its several advantages, DUS should be considered as the first-line diagnostic tool in the diagnostic workup of patients with soft signs of arterial injury.

Randomized Clinical Trial of First-Line Genome Sequencing in Pediatric White Matter Disorders.

Genome sequencing (GS) is promising for unsolved leukodystrophies, but its efficacy has not been prospectively studied. A prospective time-delayed crossover design trial of GS to assess the efficacy of GS as a first-line diagnostic tool for genetic white matter disorders took place between December 1, 2015 and September 27, 2017. Patients were randomized to receive GS immediately with concurrent standard of care (SoC) testing, or to receive SoC testing for 4 months followed by GS. Thirty-four individuals were assessed at interim review. The genetic origin of 2 patient's leukoencephalopathy was resolved before randomization. Nine patients were stratified to the immediate intervention group and 23 patients to the delayed-GS arm. The efficacy of GS was significant relative to SoC in the immediate (5/9 [56%] vs 0/9 [0%]; Wild-Seber, p < 0.005) and delayed (control) arms (14/23 [61%] vs 5/23 [22%]; Wild-Seber, p < 0.005). The time to diagnosis was significantly shorter in the immediate-GS group (log-rank test, p = 0.04). The overall diagnostic efficacy of combined GS and SoC approaches was 26 of 34 (76.5%, 95% confidence interval = 58.8-89.3%) in <4 months, greater than historical norms of <50% over 5 years. Owing to loss of clinical equipoise, the trial design was altered to a single-arm observational study. In this study, first-line GS provided earlier and greater diagnostic efficacy in white matter disorders. We provide an evidence-based diagnostic testing algorithm to enable appropriate clinical GS utilization in this population. ANN NEUROL 2020;88:264-273.

Su1271 TRANSESOPHAGEAL EUS-GUIDED CORE BIOPSY OF LUNG MASSES USING 22G FRANSEEN-TIP NEEDLE- INITIAL EXPERIENCE

EUS is well established modality for evaluation and sampling of solid and cystic lesions in the abdominal cavity and for screening patients with lung cancer for mediastinal lymph node metastasis. The utility of EUS- guided transesophageal core biopsy of lung tumors has been rarely investigated. Most prior reported cases were performed with fine-needle aspiration or with smaller caliber FNB- needles. To evaluate the diagnostic utility and safety of transesophageal EUS-guided core biopsy of pulmonary tumors using 22G Franseen-tip needle. Data was collected retrospectively from January 2019 to October 2019. All the patients had pulmonary masses close to or abutting the esophagus, detected on CT-scan. They were referred for EUS- guided biopsy after failure of bronchoscopy to establish tissue diagnosis or judged as unsuitable for bronchoscopy due to the location. Patients underwent endoscopic ultrasound with a linear scope (Fujifilm EG-580UT) and fine needle biopsy using 22G Acquire needle (Boston Scientific Corp.). The obtained material was assessed visually by the endoscopist without onsite cytologist. Eleven patients (7 men, 4 women) underwent EUS-guided transesophageal core biopsy of lung masses during the study period. The procedure yielded tissue for histologic diagnosis in 100% of patients. Immunohistochemical analysis was possible in all cases. Non-small-cell lung cancer was proven in seven patients, small-cell lung cancer in two, metastatic lung disease in one and mesothelioma in one. No complication was encountered during the first 48 hours and after 30 days follow-up.(Table 1) EUS- guided core biopsy of lung masses using 22G Franseen-tip needle is safe and established histologic diagnosis in all patients in this study. In cases of accessible lesions this procedure could be discussed as first-line diagnostic tool.

SAT0256 THE ROLE OF FAST-TRACK ULTRASOUND IN PREVENTING EARLY COMPLICATIONS AND RELAPSES IN GIANT CELL ARTERITIS

Background:Giant Cell Arteritis (GCA) is the most common form of primary systemic vasculitis, mainly affecting adults over 50 years old. Permanent visual loss (PVL) is one of the most feared complications, occurring in about 20% of cases, typically prior to initiation of high-dose glucocorticoid (GC) therapy. Color-duplex sonography (CDS) of temporal arteries (TAs) and large vessels (LVs) is recognized as a first-line diagnostic tool for patients with suspected GCA. A fast track approach (FTA), incorporating CDS has been associated to a significant reduction of PVL in two retrospective studies1,2.Objectives:To assess the impact of FTA on PVL and risk of relapses during follow-up compared to conventional care prior to the introduction of the FTA in our rheumatology clinic.Methods:Patients with new-onset GCA evaluated in our department from January 1998 to September 2019 were included in the study. The FTA approach for GCA was implemented since October 2016. The diagnosis of GCA was based on positive TAs and/or LVs CDS and/or a positive TA biopsy and clinical signs and symptoms of GCA. All patients were clinically examined by the same rheumatologist who performed the CDS. PVL was defined as total visual impairment in one or both eyes. Data on baseline clinical features and later outcomes were collected.Results:153 patients were included: 115 females (75.2%), mean age at diagnosis 71.6±8.2 years. Of these, 112 patients (73%) were evaluated conventionally and 41 (27%) with FTA. Patients in the FTA group were older (P=0.0002), presented more frequently with polymyalgia rheumatica symptoms, weight loss, jaw or tongue claudication and scalp tenderness (P&lt;0.05 for all comparisons). The median duration of follow-up in the FTA group was shorter compared with the conventional group (1.5 vs 5.8 years). PVL occurred in 22 (19.6%) patients in the conventional group compared to 5 patient (12.2%) in the FTA, leading to a reduction of 37.9% in the relative risk of PVL with the FTA approach. Cumulative incidence of relapses and time to first relapse did not change after FTA introduction (P&gt;0.05) (Fig. 1).Conclusion:The application of a FTA in GCA resulted in a significant reduction of PVL. However, the relapse rate did not seem to be influenced by the FTA, highlighting the need to implement further management strategies, besides earlier diagnosis and prompt initiation of GC, that would impact the course of the disease during long-term follow-up

Medical Student Ultrasound Education, a WFUMB Position Paper, Part II. A consensus statement of ultrasound societies.

Ultrasound is becoming a fundamental first-line diagnostic tool for most medical specialties and an innovative tool to teach anatomy, physiology and pathophysiology to undergraduate and graduate students. However, availability of structured training programs during medical school is lagging behind and many physicians still acquire all their ultrasound skills during postgraduate training.There is wide variation in medical student ultrasound education worldwide. Sharing successful educational strategies from early adopter medical schools and learning from leading education programs should advance the integration of ultrasound into the university medical school curricula. In this overview, we present current approaches and suggestions by ultrasound societies concerning medical student educa-tion throughout the world. Based on these examples, we formulate a consensus statement with suggestions on how to integrate ultrasound teaching into the preclinical and clinical medical curricula.

A systematic review of chest imaging findings in COVID-19.

Chest computed tomography (CT) is frequently used in diagnosing coronavirus disease 2019 (COVID-19) for detecting abnormal changes in the lungs and monitoring disease progression during the treatment process. Furthermore, CT imaging appearances are correlated with patients presenting with different clinical scenarios, such as early versus advanced stages, asymptomatic versus symptomatic patients, and severe versus nonsevere situations. However, its role as a screening and diagnostic tool in COVID-19 remains to be clarified. This article provides a systematic review and meta-analysis of the current literature on chest CT imaging findings with the aim of highlighting the contribution and judicious use of CT in the diagnosis of COVID-19. A search of PubMed/Medline, Web of Science, ScienceDirect, Google Scholar and Scopus was performed to identify studies reporting chest imaging findings in COVID-19. Chest imaging abnormalities associated with COVID-19 were extracted from the eligible studies and diagnostic value of CT in detecting these abnormal changes was compared between studies consisting of both COVID-19 and non-COVID-19 patients. A random-effects model was used to perform meta-analysis for calculation of pooled mean values and 95% confidence intervals (95% CI) of abnormal imaging findings. Fifty-five studies met the selection criteria and were included in the analysis. Pulmonary lesions more often involved bilateral lungs (78%, 95% CI: 45-100%) and were more likely to have a peripheral (65.35%, 95% CI: 25.93-100%) and peripheral plus central distribution (31.12%, 95% CI: 1.96-74.07%), but less likely to have a central distribution (3.57%, 95% CI: 0.99-9.80%). Ground glass opacities (GGO) (58.05%, 95% CI: 16.67-100%), consolidation (44.18%, 95% CI: 1.61-71.46%) and GGO plus consolidation (52.99%, 95% CI: 19.05-76.79%) were the most common findings reported in 94.5% (52/55) of the studies, followed by air bronchogram (42.50%, 95% CI: 7.78-80.39%), linear opacities (41.29%, 95% CI: 7.44-65.06%), crazy-paving pattern (23.57%, 95% CI: 3.13-91.67%) and interlobular septal thickening (22.91%, 95% CI: 0.90-80.49%). CT has low specificity in differentiating pneumonia-related lung changes due to significant overlap between COVID-19 and non-COVID-19 patients with no significant differences in most of the imaging findings between these two groups (P>0.05). Furthermore, normal CT (13.31%, 95% CI: 0.74-38.36%) was reported in 26 (47.3%) studies. Despite widespread use of CT in the diagnosis of COVID-19 patients based on the current literature, CT findings are not pathognomonic as it lacks specificity in differentiating imaging appearances caused by different types of pneumonia. Further, there is a relatively high percentage of normal CT scans. Use of CT as a first-line diagnostic or screening tool in COVID-19 is not recommended.

First-line exome sequencing in Palestinian and Israeli Arabs with neurological disorders is efficient and facilitates disease gene discovery

A high rate of consanguinity leads to a high prevalence of autosomal recessive disorders in inbred populations. One example of inbred populations is the Arab communities in Israel and the Palestinian Authority. In the Palestinian Authority in particular, due to limited access to specialized medical care, most patients do not receive a genetic diagnosis and can therefore neither receive genetic counseling nor possibly specific treatment. We used whole-exome sequencing as a first-line diagnostic tool in 83 Palestinian and Israeli Arab families with suspected neurogenetic disorders and were able to establish a probable genetic diagnosis in 51% of the families (42 families). Pathogenic, likely pathogenic or highly suggestive candidate variants were found in the following genes extending and refining the mutational and phenotypic spectrum of these rare disorders: ACO2, ADAT3, ALS2, AMPD2, APTX, B4GALNT1, CAPN1, CLCN1, CNTNAP1, DNAJC6, GAMT, GPT2, KCNQ2, KIF11, LCA5, MCOLN1, MECP2, MFN2, MTMR2, NT5C2, NTRK1, PEX1, POLR3A, PRICKLE1, PRKN, PRX, SCAPER, SEPSECS, SGCG, SLC25A15, SPG11, SYNJ1, TMCO1, and TSEN54. Further, this cohort has proven to be ideal for prioritization of new disease genes. Two separately published candidate genes (WWOX and PAX7) were identified in this study. Analyzing the runs of homozygosity (ROHs) derived from the Exome sequencing data as a marker for the rate of inbreeding, revealed significantly longer ROHs in the included families compared with a German control cohort. The total length of ROHs correlated with the detection rate of recessive disease-causing variants. Identification of the disease-causing gene led to new therapeutic options in four families.

Saliva as a first-line diagnostic tool: A spectral challenge for identification of cancer biomarkers

Abstract The paper concentrates on the role of saliva in the early diagnosis of salivary gland tumor. Due to the still not fully understood etiology of head and neck cancer, the fundamental objective of this study is to find tumor markers of salivary gland tumor progression. This work demonstrates the feasibility of Attenuated Total Reflection Fourier Transform Infrared spectroscopy (ATR-FTIR) to track spectral variations between saliva samples derived from healthy volunteers and from salivary gland tumor (tumor mixus, TM) patients. Furthermore, a Real-Time Polymerase Chain Reaction (RT-PCR) has been used to detect a selected genes expression associated with neoplasm changes. The obtained results imply that spectral signals attributed to the amide I/II (secondary structure of protein), carbohydrates and inorganic phosphates oscillations are the most sensitive to alterations associated with the salivary gland cancer progression. Several spectroscopic biomarkers have been indicated as potential predictors of salivary gland tumor development. Additionally, the RT-PCR results reveal the increased level of Bcl-2 factor in salivary gland tumor patients' samples which may be related to inhibition of apoptosis process and increasing uncontrolled cell proliferation. Such combination of physico-chemical methods is a unique approach towards better understanding the tumor's etiology and early diagnosis problem. Based on the promising findings presented in this article, it could be concluded that saliva fluid has a great potential to be used as a first-line diagnostic tool in patients with suspicion of salivary gland tumor.

Methods Used by General Practitioners to Interpret Chest Radiographs at District Hospitals in the City of Tshwane, South Africa

IntroductionA chest radiograph is one of the first-line diagnostic tools for general practitioners (GPs) to diagnose, monitor treatment, and predict the outcomes of diseases. In district hospitals, after clinical examination, GPs refer patients for imaging in the X-ray department. Radiologists specialize in interpretation of radiographs and provide a gold standard radiologist report to help diagnose support and influence patient management. A shortage of radiologists restricts continuity in radiology services and causes a delay in diagnosis, compromising the overall quality of service to patients. GPs are mandated to perform image interpretation on all chest radiographs taken at district hospitals and they sometimes request assistance from radiographers. AimThe aim of this study was to explore methods used by GPs to interpret chest radiographs at district hospitals in the City of Tshwane, in South Africa. MethodsA qualitative, exploratory, and descriptive case study method of inquiry, with convenience sampling was used. Under discussion, the case studies were reconstructed in terms of themes. Recurring themes in these case studies were expounded and linked within the literature. ResultsResults obtained from a sample of 15 participants showed that GPs used a free global search to scan radiographs without a preconceived orderly pattern. Their only training on image interpretation occurred during undergraduate education and training. ConclusionsIt was concluded that the methods used by GPs for interpretations of chest radiographs were not systematic in approach, resulting in omission in identifying abnormalities in some structures of the chest/thoracic region. The researcher recommends that all GPs need continuous in-house training to acquire the knowledge of the systematic method of evaluating chest radiographs.

Multidrug Resistant Mycobacterium tuberculosis Among Military and Civilian Personnel seen at a Tertiary Military Hospital, Manila, Philippines (2015-2018).

About one third of the world population is estimated to be infected with Mycobacterium tuberculosis (MTB), and this proportion is expected to be higher in countries with a high tuberculosis (TB) burden. The Philippines is both a high tuberculosis burden and a high multidrug resistant tuberculosis (MDR-TB) burden country. Though TB has been extensively described in the civilian population, there is limited data on TB in the military population. The objectives are: (1) To determine MTB/MDR-TB prevalence among military and civilian patients in the Philippines presenting with clinically suspected TB in a tertiary military hospital and (2) To determine performance of direct sputum smear microscopy (DSSM) using Ziehl-Neelsen (ZN) staining compared to Xpert MTB/RIF real-time reverse transcriptase polymerase chain reaction. Sputum samples were obtained from patients, clinically suspected with TB, and/or with TB associated signs/symptoms. Sputum specimens were tested using DSSM with ZN staining and Xpert MTB/RIF assay (Cepheid, Sunnyvale, California) and patient demographic and clinical data were collected. From March 2015 to December 2018, a total of 795 (173 military personnel [164 active duty and 9 retired]; 618 civilians; and 4 with no data on military/civilian status) patients with TB associated symptoms or clinically suspected with TB were tested. Overall, MTB prevalence was 81/795 (10%). MTB prevalence among active duty and retired military personnel were 27/164 (16%) and 4/9 (44%), respectively while MTB prevalence for civilian patients was 50/618 (8%) (p value=0.0003; OR=2.48 [95% C.I. 1.5-4]). Among active and retired military personnel who tested positive for MTB, rifampin resistance was 4/27 (15%) and 1/4 (25%), respectively, while rifampin resistance for civilian patients was 9/50 (18%) (p value=1; OR=0.88 [95% C.I. 0.26-2.90]). For active duty military personnel, average MTB prevalence (based on Xpert MTB/RIF) covering years 2015-2018 was 21% and ranged from 13% to 35%, while average rifampin resistance among MTB positive active duty military personnel was 15% and ranged from 0% to 25%. Overall sensitivity and specificity of DSSM compared to Xpert MTB/RIF were 70% and 96%, respectively. Positive and negative predictive values of DSSM to accurately categorize MTB in symptomatic cases (with Xpert MTB/RIF as "true positive" reference) were 74% and 95%, respectively. Performance of DSSM varied according to MTB load detected by Xpert MTB/RIF with increasing DSSM sensitivity observed as the MTB load detected by Xpert MTB/RIF increased (p=0.02). This report describes high MTB and MDR-TB prevalence rates among symptomatic military patients with military personnel having higher odds of MTB infection compared to the civilian patients in the study. Since DSSM (ZN) sensitivity greatly varied depending on MTB load, the Xpert MTB/RIF should be used as a first-line diagnostic tool to identify MTB and detect rifampin resistance among presumptive TB cases instead of DSSM (ZN) microscopy.

P1275 In-hospital outcome of patients with infective endocarditis: is echocardiography enough?

Abstract Background Despite improvements in medical and surgical therapy, infective endocarditis (IE) remains a deadly disease. Echocardiography is the first-line diagnostic tool. However, data regarding its role in the prognostic assessment of in-hospital clinical outcome of IE are scarce. Purpose We sought to assess the role of echocardiography to predict the in-hospital outcome in a large cohort of patients diagnosed with definite IE and its association with clinical presentation and microorganisms. Methods We retrospectively included patients from two centers between 2006 and 2018. Transthoracic and transesophageal echocardiography were performed in all patients. The clinical endpoints were in-hospital death, embolic events (cerebrovascular and non-cerebrovascular), shock (septic shock and cardiogenic shock) and cardiac surgery. Results 183 patients with definite IE (age 68.9 ± 14.2 years old, 68.9% male) were evaluated. Ninety three (50.8%) patients had aortic valve IE and 81 (44.3%) patients presented with mitral valve IE. Twenty three patients had multivalvular IE. The in-hospital mortality rate was 22.4%. Sixty patients (32.8%) had embolic events and 42 (23%) patients developed shock during hospitalization. Surgery was performed in 103 (56.3%) patients. Mitral valve IE on echocardiography was an independent predictor of in-hospital mortality (p = 0.038, OR 0.38, 95% CI 0.15 – 0.94) and aortic valve IE on echocardiography was an independent predictor of embolic events (p = 0.018, OR 0.36, 95% 0.16-0.84). The presence of a new cardiac murmur upon admission was predictive for the need of cardiac surgery (p = 0.042, OR 0.51, 95% CI 0.22- 1.09) and correlated with the severity of valvular regurgitation identified by echocardiography (p = 0.024). Methicillin resistant Staphylococcus aureus (MRSA) as the causative microorganism was an independent predictor for in - hospital mortality and for the development of shock during hospitalization (p = 0.010, OR 0.13 95% CI 0.30 - 0.62 and p = 0.027, OR 6.11, 95% CI 1.22 – 30.37, respectively). No correlation was found between MRSA and echocardiographic parameters. Conclusion Mitral valve IE was an independent predictor of in - hospital mortality. Furthermore, aortic valve IE was an independent predictor of embolic events. The presence of a new cardiac murmur was predictive for the need of cardiac surgery and correlated with the severity of valvular regurgitation by echocardiography. Our findings suggest that a thorough physical examination upon admission is required in combination with a comprehensive echocardiographic exam for early identification of patients with IE at high - risk for in-hospital death and complications.

Our Closed Pleural Biopsy Results in Our Patients With Pleural Effusion

Objective: We retrospectively analyzed patients who underwent closed pleural biopsy for diagnostic purposes among our patients who were followed up in our clinic for the last 5 years due to pleural effusion. Material and Method: Of the 155 patients who underwent closed pleural biopsy in our clinic between January 2015 and January 2020, 125 patients whom we could contact were included in the study. Postero anterior lung (PAAG) radiographs and lateral chest radiographs were examined. Pleural fluid amount according to the PAAG graph; It was defined as minimal (fluid that closes the costophrenic angle and does not erase the entire diaphragm), medium (fluid covering less than 2/3 of the hilus) and massive (fluid covering more than 2/3 of the hemithorax). Results: When the complaints of our cases were evaluated. The most common complaint was the shortness of breath with 35 (28%) people, while 24 (19.2%) people had cough and 21 (16.8%) chest pain, respectively. A statistically significant difference was observed in the complaints of the patients in terms of the amount of dyspnea and fluid (p = 0.04). When the biopsy pathology results of our patients were examined, 43 (34.4%) patients were malignant, 29 (23.2%) patients had nonspecific inflammation, 28 (22.4%) patients had chronic inflammation and 25 (20%) patients had granulomatous inflammation. Conclusion: Considering its low cost, easy use in experienced hands, and low complication rates, and its applicability with local anesthesia, closed pleural biopsy should always be considered as a first-line diagnostic tool in the diagnosis of exudative pleural effusion.

Ulnar neuropathy at the elbow: Reappraisal of the wrist-upper arm latency difference between ulnar and median nerves

ObjectivesTo evaluate the sensitivity and specificity of the latency difference (DLat) between ulnar and median nerves of the arm after stimulation at the wrist; one of the easiest techniques proposed for recognizing ulnar neuropathy at the elbow (UNE). As latency difference is not a standardized technique, we set up a multicenter study to recruit large numbers of normal subjects and patients with UNE or generalized neuropathy. MethodsSix centers participated in the study with data obtained from three groups of participants, controls (CTRLs), patients with UNE and patients with generalized neuropathy (GNP).We first verified the anatomical superposition of the ulnar and median nerves in cadaver examination. The optimal recording site for these two nerves was found to be 10 cm above the medial epicondyle. We then standardized the position of the arm with full extension of the elbow and stimulated first the median and then the ulnar nerves at the wrist. CTRLs were examined on both arms at two consecutive visits. ResultsWe recorded 32 idiopathic UNE cases, 44 GNP patients and 62 controls.We demonstrated that a DLat cut-off value of 0.69 ms brings a sensitivity of 0.86 and specificity of 0.89 to discriminate CTRLs from UNE. We also validated that intra-examiner reproducibility was good. ConclusionWe report a lower normal value for DLat than reported in several non-standardized studies and CTRL and UNE groups have clearly separated DLat values. SignificanceDue to its high sensitivity, our standardized technique could be used as a first-line diagnostic tool when UNE is suspected.

Spontaneous coronary artery dissection: update 2019.

Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction (MI) in women with few or no conventional cardiovascular risk factors. Lack of awareness about this condition among healthcare providers had led to significant underdiagnosis and misdiagnosis in this relatively young patient population. The current review summarizes the contemporary data on cause, management strategies and outcomes of SCAD. SCAD is not as rare as previously thought, accounting for up to 4% of all acute coronary syndromes. It is frequently linked with predisposing factors, such as fibromuscular dysplasia or other vasculopathies, and is often triggered by physical or emotional stress. Due to more fragile vessel architecture, coronary angiography as the first-line diagnostic tool should be performed meticulously to avoid iatrogenic dissection. Intravascular imaging may be required if angiographic findings are uncertain. Unless patients have high-risk features such as ongoing ischemia, recurrent chest pains, left main artery dissection, ventricular arrhythmias, or hemodynamic instability, a conservative treatment strategy is favored over revascularization. Close monitoring is essential after a SCAD-event as recurrent cardiovascular events post-SCAD are frequent.

Sonographic Differential Diagnosis in Deep Infiltrating Endometriosis: The Bowel.

Up to one-third of fertile-age women with severe endometriosis suffer from colonic involvement. Transvaginal ultrasonography has become a first-line diagnostic tool for the study of the pelvis and more specifically for the diagnosis of pelvic endometriosis. Accuracy of pelvic ultrasound for deep endometriosis increases with operator experience, but the difficulties in the differential diagnosis with diseases that can afflict the bowel tract remain a challenge. We reviewed noteworthy cases referred for secondary level diagnosis suspected of bowel endometriosis in which the subsequent ultrasound led to an alternative diagnosis. This case series aims to highlight awareness for both experts and less-experienced operators the possible differential diagnoses of bowel lesions that initially resemble endometriosis.

Value of coarse needle biopsy in thyroid nodules as first-line diagnostic tool

Objective:By retrospectively analyzing the results of ultrasound guided coarse needle biopsy（CNB） of thyroid nodules based on large samples, so as to evaluate its diagnostic value as first-line diagnostic tool for thyroid nodules. Method:From October 2015 to November 2017, a total of 508 nodules were studied from 474 patients who underwent CNB in general surgery department of tianjin first central hospital. The nondiagnostic rate, inconclusive rate, unnecessary surgery rate and complication rate of thyroid nodules diagnosed by CNB were calculated. The accuracy, sensitivity, specificity, positive predictive value and negative predictive value of CNB in thyroid cancer diagnosis were analyzed. The correlation between inconclusive diagnostic results and ultrasonic findings like echogenicity, composition, margin, calcification type, blood supply and nodule size was analyzed. Result:The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of CNB diagnosis were 97.27%, 99.17%, 99.07%, 99.45% and 99.36%, respectively. However, the nondiagnostic rate, the inconclusive rate, the conclusive rate and the unnecessary surgery rate of thyroid nodules diagnosed by CNB were 2.95%, 7.09%, 92.92% and 1.86%, respectively. Conclusion:Ultrasound guided coarse needle biopsy might be safe and reliable for the diagnosis of thyroid nodules, with relatively stable diagnostic effect. It is not only of high diagnostic value but also can significantly reduce diagnostic surgery. Therefore, CNB could be the preferred examinational method for nodules with suspicious ultrasonic findings.

Using Chinese Body Constitution Concepts and Measurable Variables for Assessing Risk of Coronary Artery Disease.

Background Identifying patients with high risk of coronary artery disease (CAD) is often difficult in outpatient clinic settings. This study aimed to explore if the measurement of body constitution can be adopted to predict the risk of CAD diagnosis. The objective of this study is to conduct a prospective observational study and a case-control study to answer the research question. Study Design Part 1 (prospective observational study): a total of 143 patients with chest pain and admitted to receive cardiac catheterization were enrolled, and 108 of them were diagnosed with CAD. Part 2 (case-control study): the above 108 CAD patients and 476 healthy controls matched by age and gender from the participants of Taiwan Biobank were adopted for comparison. Main Outcome Measures The body constitution of both patients and healthy controls were measured by the Body Constitution Questionnaire (BCQ). Each one received scores of Yang-Xu (Yang-deficiency), Yin-Xu (Yin-deficiency), and Stasis. These 3 scores together with demographic characteristics and CAD risk factors were used in the logistic multiple regression model to predict the risk of CAD. Results (Part 1) No difference was found between the scores of Yang-Xu, Yin-Xu, and Stasis between the patients with and without CAD. (Part 2) The scores of Yang-Xu, Yin-Xu, and Stasis of the CAD patients were significant higher those of the healthy controls. Yang-Xu and Stasis scores were obtained with age, BMI, and hypertension in the model with prediction rate 89.0%. The area under receiver operating characteristic curve of this model was 0.896. Conclusions This study is the first to apply Chinese body constitution concepts and measurable variables to assess the risk of having CAD of the patients with chest pain prior to receiving cardiac catheterization. The higher scores of Yang-Xu and Stasis were found to be risk factors. Our results revealed that BCQ has the potential to be a first-line diagnostic tool for patients with chest pain to facilitate early recognition and diagnosis of CAD.

Development and validation of a pen side test for Rift Valley fever.

BackgroundRift Valley fever (RVF) is one of the main vector borne zoonotic diseases that affects a wide range of ruminants and human beings in Africa and the Arabian Peninsula. A rapid and specific test for RVF diagnosis at the site of a suspected outbreak is crucial for the implementation of control measures.Methodology/Principal findingsA first-line lateral flow immunochromatographic strip test (LFT) was developed for the detection of the nucleoprotein (N) of the RVF virus (RVFV). Its diagnostic performance characteristics were evaluated using reference stocks isolates recovered from different hosts and in geographic regions mimicking clinical specimens and from known RVF negative serum samples. A high level of diagnostic accuracy (DSe (35/35), DSp (167/169)) was observed, including the absence of cross-reactivity with viruses belonging to different genera.Conclusion/SignificanceThe fact no specialized reagents and laboratory equipment are needed, make this assay a valuable, first-line diagnostic tool in resource-poor diagnostic territories for on-site RVFV detection, however the staff require training.