Initial Chest Radiograph Research Articles

Clinical challenges and management of late presenting congenital diaphragmatic hernia mimicking tension pneumothorax in a child: a case report and review of literatures

BackgroundCongenital diaphragmatic hernia(CDH) is a rare congenital anomaly characterized by herniation of abdominal contents into thoracic cavity through a defect in diaphragm. While commonly diagnosed prenatally or in neonatal period, late-presenting CDH can occur and may mimic other thoracic emergencies such as tension pneumothorax, complicating diagnosis and management.Case presentationA two-year old male black child from Ethiopia presented to the emergency department with sudden onset of acute respiratory distress. Initial clinical assessment and chest radiography suggested a diagnosis of tension pneumothorax due to the presence of significant mediastinal shift and apparent pleural air. Despite insertion of chest tube, the child’s condition did not improve, raising suspicion of alternative diagnosis. Careful observation of initial chest x-ray and subsequent chest ultrasound revealed a left sided congenital diaphragmatic hernia with herniation of stomach and intestine into thoracic cavity compressing the left lung and causing mediastinal shift. After the diagnosis of CDH was confirmed, the child was stabilized and emergent surgical repair performed. Postoperative recovery was uneventful, and the child was discharged with no significant long-term complications.ConclusionThis case underscores the importance of considering CDH in the differential diagnosis of acute respiratory distress in a child. It highlights the diagnostic challenges and potential risks of emergency interventions based on initial misdiagnosis. Even if x -ray looks like typical of tension pneumothorax, it showed giant cystic air filled structure pushing the mediastinal structure to contralateral side with loss of left diaphragmatic outline which raised suspicion of congenital cystic lung mass or congenital diaphragmatic hernia. Advanced imaging and high index of suspicion are crucial for accurate diagnosis and timely management, ultimately improving patient outcomes. Consideration of alternative diagnosis when our initial intervention with insertion of chest tube fail to provide symptom improvement in suspected pneumothorax should raise suspicion of congenital diaphragmatic hernia like in our case.

Endovascular treatment of contained ruptured internal thoracic artery aneurysm mimicking a tumor in a patient with neurofibromatosis type 1: a case report

BackgroundAn internal thoracic artery aneurysm (ITAA) is an exceedingly rare condition, with approximately two-thirds of reported cases being iatrogenic pseudoaneurysms. The remainder are attributed to various causes, including vasculitis, connective tissue disease, and neurofibromatosis type 1 (NF-1). NF-1 is an autosomal dominant disorder characterized by distinct clinical manifestations that occasionally include life-threatening vascular complications. Although NF-1 patients may develop various vascular abnormalities, ruptured ITAA is rarely reported, with only seven published cases.Case presentationA 32-year-old man with NF-1 consulted for a three-day history of persistent left back and upper arm pain. Initial chest radiography indicated left pleural effusion and an opacity at the left lung apex. Computed tomography scan revealed a mass in the left upper mediastinum that was initially suspected to be a tumor. Subsequent contrast-enhanced computed tomography revealed the mass to be a subclavian artery aneurysm. Detailed contrast-enhanced computed tomography with 1-mm slices was performed for surgical planning, identifying the mass as a left ITAA with contained rupture. Given the risk of re-rupture, emergency angiography was performed, which confirmed rupture of the left ITAA without extravasation. The ITAA was successfully treated with multiple microcoils at the proximal and distal ends. The patient had an uneventful recovery and was discharged on the fourth postoperative day.ConclusionsThis case highlights the importance of considering vascular lesions in NF-1 patients who present with pleural effusion. It also emphasizes the challenges in diagnosing ITAA and the effectiveness of thin-slice contrast-enhanced computed tomography scans and endovascular treatment.

Comparison of Clinical Endotracheal Tube Depths with Standard Estimates for the Stabilization of Infants with Congenital Diaphragmatic Hernia.

This study aimed to compare the clinical endotracheal tube (ETT) depth after initial stabilization of infants with congenital diaphragmatic hernia (CDH) to weight and gestational age-based depth estimates. This retrospective analysis included 58 inborn infants with left-sided CDH. We compared a standard anatomic ETT depth calculated from initial chest radiographs and the clinical depth of the ETT after adjustments to predicted depths using weight and gestational age-based estimates. The standard anatomic depth was deeper than age (standard deviation 1.29 ± 1.15 cm, p < 0.001) and weight-based (standard deviation 0.59 ± 0.95 cm, p < 0.001) estimates. The clinical ETT depth was also deeper than age (standard deviation 1.01 ± 0.77 cm, p < 0.001) and weight-based (standard deviation 0.26 ± 0.50 cm, p < 0.001) estimates. Established strategies to predict ETT depth underestimate the ideal depth in infants with left-sided CDH. These data suggest utilizing caution during initial ETT placement based on standard depth estimates for patients with CDH. · CDH patients present unique stabilization challenges.. · Standard ETT depth estimates are too shallow.. · Resuscitation teams should cautiously choose ETT depth..

Metal Pneumonitis from “Non-toxic” Decorative Cake Dust Aspiration: A Case Report

Introduction: Metallic luster dusts are decorative agents for cakes and other confections. While some powders are labeled “non-edible,” they are also marketed as “non-toxic.” We present a case of a child who developed acute metal pneumonitis after accidental aspiration of metallic luster dust. Case Report: A four-year-old presented to the emergency department (ED) in respiratorydistress after attempting to ingest gold decorative metallic luster dust. In the ED she was placed on supplemental oxygen. Her initial chest radiograph (CXR) was unremarkable. Her condition worsened despite high-flow nasal cannula oxygen, and she was intubated. A repeat CXR revealed patchy perihilar and peribronchial opacities. While receiving aggressive ventilatory support, her CXR worsened over the next 48 hours as bilateral interstitial and alveolar opacities progressed, likely representing acute metal pneumonitis with acute respiratory distress syndrome (ARDS). She remained intubated until hospital day (HD) 5, requiring supplemental oxygen until HD 9. She was discharged home on HD 10. A CXR obtained four months later demonstrated increased interstitial markings throughout both lungs with overinflation and subsegmental atelectasis. The patient had persistent dyspnea upon exertion, with pulmonology documenting that her symptoms were likely sequelae from inhalation of the cake luster dust. Conclusion: Non-edible metallic cake dusts are toxic. “Non-edible” labeling does not convey the health risks associated with handling by children, as evidenced by this case of metal pneumonitis with associated ARDS and chronic pulmonary disease. Accordingly, this descriptor should be abandoned for these products, and physicians should be aware of this potential complication.

1011 A Rare Case of Left Sided Hemiparesis Following a Pneumatic Gun-Shot Injury to Left Anterior Chest Wall in a 13-Year-Old Boy

Abstract Introduction Even though pneumatic weapons rarely cause severe direct trauma, pellet embolisation can lead to unexpected, catastrophic events. Case Report A 13-year-old, previously healthy boy was injured by an accidentally fired pneumatic gun, while playing with his twin brother. He sustained a penetrating wound to left anterior chest wall and resultant bleeding was self-limiting. He was hospitalised within 15minutes. On admission, he was hemodynamically stable with normal Respiratory, Cardiovascular and Neurological system findings. Entry wound measuring 5*5 mm was present at 5th intercostal space just left to the sternum. No exit wound was detected. Initial chest radiograph and ultra-sound abdomen and chest were normal. 2D echocardiogram revealed only a very thin layer(3mm) of pericardial effusion. Four hours later, He developed a focal seizure followed by left sided hemiparesis. Urgent NCCT brain and carotid artery duplex showed a high dense pellet in right internal carotid artery at the level of petrous temporal bone and hypo-dense Middle Cerebral Artery (MCA) suggestive of right MCA thrombosis. He was transferred to a tertiary care centre. Interventional radiological and endo-vascular attempts of pellet retrieval have been failed. Ischemic stroke pursued with worsening cerebral oedema; thus decompression craniotomy was performed on day 3. He is currently being rehabilitated in a specialised centre. Conclusions High degree of suspicion should be maintained on the possibility of projectile embolisation, in pneumatic gun-shot injuries, especially in the absence of an exit wound. Extensive early investigations should be performed to localise the projectile and retrieval should be planned.

Right-Sided Bochdalek Hernia Associated with Group B Streptococcal Sepsis in a Preterm Neonate.

We report here a compelling case of a premature female newborn who was originally treated for breathing difficulties that arose a few hours after delivery. The initial chest radiograph showed no abnormalities, and the blood culture detected sepsis caused by group B streptococcus (GBS). The antibiotic treatment was modified accordingly. Later on, she experienced a gradually increasing opacification in the right side of her chest, which did not respond to medical treatment. A subsequent imaging examination conducted a few days later indicated the presence of a hernia in the right side of the diaphragm. The neonate, who was 14 days old, received surgical intervention to fix the abnormality in the diaphragm. The procedure was successful, and there were no complications during the postpartum period. This case report aims to emphasize the distinctive correlation between early-onset GBS sepsis and the postponed occurrence of right-side diaphragmatic hernia.

OA16 Clinical and biochemical improvement following daratumumab therapy for anti-MDA5 antibody positive dermatomyositis with rapidly progressive interstitial lung disease: a case report

Abstract Background/Aims Anti-melanoma differentiation-associated 5 gene autoantibody (anti-MDA5) positive dermatomyositis (DM) with rapidly progressive interstitial lung disease (RP-ILD) represents the most severe and difficult-to-treat form of autoimmune myositis with unfavourable 6-month survival rates despite intensive treatment strategies of combination therapy with glucocorticoids, cyclophosphamide, calcineurin inhibitors, mycophenolate mofetil and rituximab. We describe a case of anti-MDA5 positive DM with RP-ILD that was refractory to intensive combination therapy, requiring courses of rescue plasmapheresis, before eventually responding to intravenous daratumumab. Methods A 30-year-old non-smoking Chinese man who was previously well was hospitalised after 3 weeks of intermittent pyrexia, non-productive cough, lethargy, rashes and myalgia. Examination revealed typical cutaneous changes of dermatomyositis, bilateral mid-to-lower zone inspiratory crepitations in his chest with no proximal muscle weakness or synovitis. Initial investigations demonstrated elevations in creatine kinase, C-reactive protein, erythrocyte sedimentation rate, lactate dehydrogenase, ferritin and neutrophil-to-lymphocyte ratio. Although an initial chest radiograph was normal, CT thorax 4 days later showed non-specific ground-glass opacities with consolidation in both lower lobes. Anti-MDA5 antibodies were strongly positive on EUROLINE Inflammatory Myopathies 16 Ag (IgG) commercial line immunoblot. He was transferred to our centre for further care one week after hospitalisation and was intubated on arrival for type I respiratory failure. He was initiated on combination therapy of intravenous methylprednisolone, intravenous rituximab, hydroxychloroquine, tofacitinib and was also treated with plasmapheresis to remove pathogenic anti-MDA5 antibodies. Although his condition improved initially with successful extubation within one week, the disease remained active in the following months with several admissions for infection-related issues and progression of RP-ILD. Despite various combinations of immunosuppressives and further courses of plasmapheresis, at 6 months post-diagnosis he continued to require a minimum daily prednisolone dose of 45mg (0.625mg/kg/day), remaining positive for anti-MDA5 antibodies on the immunoblot assay, with persistently elevated serum ferritin and transaminases. As such, he was treated with four doses of intravenous daratumumab in an attempt to deplete the long-lasting plasma cells that may be driving the disease. Results Following daratumumab treatment, the anti-MDA5 antibody turned negative on the immunoblot assay with normalisation of ferritin and transaminases, with corresponding improvement in lung function tests and chest radiograph findings. 3 months post-daratumumab, he remains clinically well on hydroxychloroquine, tofacitinib and nintedanib, with successful continuing taper of prednisolone. Conclusion Daratumumab is an anti-CD38 monoclonal antibody licensed for the treatment of multiple myeloma which has been used off-label for other refractory autoimmune conditions such as SLE. It is postulated that besides CD19/20 positive B cells, CD38 positive long-lived autoantibody-secreting plasma cells are essential drivers of chronic inflammation in these autoimmune diseases. In our patient with anti-MDA5 DM and RP-ILD, the use of daratumumab was well-tolerated and led to definite clinical and biochemical improvement. Disclosure L. Koh: None. G. Chai: None. M. Manghani: None. X. Lim: None. B.P.L. Leung: None. C. Chua: None.

Risk Factors for Severe Respiratory Syncytial Virus Infection in Hospitalized Children.

Respiratory syncytial virus (RSV) is a common cause of bronchiolitis and pneumonia in infants and young children. Starting in December 2010, RSV monoclonal antibody (RSV mAb) was endorsed by Taiwan National Health Insurance and given to children with prematurity and/or congenital heart diseases, which are considered high-risk factors for severe RSV diseases. Investigating other important contributing risk factors is warranted. We conducted a cohort study at National Taiwan University Hospital to determine the rate of severe outcomes among children hospitalized due to RSV infection from 2008 to 2018. Adjusted for age, sex and birth cohorts born before and after RSV mAb endorsement, we identified risk factors for severe RSV infection, defined as the requirement of invasive ventilator support. There were 1985 admissions due to RSV infections. Among them, 66 patients (3.3%) had severe RSV infection. The proportion of severe RSV infections decreased significantly after RSV mAb endorsement. Multivariable analysis revealed that age <1.5 months and cardiovascular and congenital/genetic diseases were high-risk underlying conditions. In addition, bacterial coinfections, elevated creatinine levels and initial abnormal chest radiograph findings posed warning signs for severe RSV infection. Children younger than 1.5 months of age with cardiovascular or congenital/genetic diseases were predisposed to severe RSV infection and might benefit from RSV mAb prophylaxis.

Reexpansion pulmonary edema after treatment of primary spontaneous pneumothorax.

A 24-year-old male patient, without further symptoms or comorbidities presented to the emergency room with acute dyspnea after heavy lifting two days before. On auscultation an attenuated vesicular breath was noticed on the right lung. In the initial chest radiograph a right-sided primary spontaneous pneumothorax with minor mediastinal shift was diagnosed. After insertion of a 12-French chest tube the patient's clinical condition deteriorated. The following chest radiograph and computed tomography of the thorax showed a reexpansion pulmonary edema in the right lung. The patient was admitted to the ICU and supportive treatment was initiated. Pulmonary reexpansion edema after drainage of a pneumothorax is a very rare complication with mortality rates reaching up to 20%. The exact pathophysiology remains unknown. Typical Symptoms include dyspnea, hypotension, and tachycardia. To minimize the risk of a pulmonary reexpansion edema, not more than 1200-1800 ml of air should be drained at once and the drainage should be stopped when the patient starts coughing.

Pleuropulmonary blastoma in a child masquerading as massive pleural effusion: A case report

Pleuropulmonary blastoma (PPB) is a rare dysembryonic lung neoplasm of childhood. Its aggressive nature is demonstrated by its large size and metastasis at the time of diagnosis. Here, we present a case of a 5-year-old male with a history of sudden dyspnea who was initially referred to the primary health-care center for emergency medical services. His initial chest radiography showed massive hydropneumothorax in the right pleural cavity, with gross mediastinal displacement. These clinical findings and rapidly decreasing peripheral saturation prompted the emergency team to insert a right-sided intercostal drainage tube. Initially, this step was able to stabilize the condition, but a subsequent computed tomography scan revealed a vast cystic-solid mass in the right hemithorax. After establishing the diagnosis of PPB by means of histopathology and immunohistochemistry, he was operated on urgently for cytoreductive purposes. Despite the initial macroscopic clearance, the mass recurrence occurred after 3 months, contributing to the ultimate fatal outcome for the patient. Due to the cystic-solid nature of type II/III PPB, it could be masquerading as hydropneumothorax in the initial chest X-ray, a misleading yet the sole initial presentation of this rare entity.

A Deep-Learning Model Using Chest Radiographs for Prediction of 30-Day Mortality in Patients With Community-Acquired Pneumonia: Development and External Validation.

Chest radiography is an essential tool for diagnosing community-acquired pneumonia (CAP), although has an uncertain prognostic role in patients with CAP. To develop a deep-learning (DL) model to predict 30-day mortality in patients with CAP using chest radiographs from the time of diagnosis and to validate the model's performance in patients from different time period or institutions. In this retrospective study, a DL model was developed in 7105 patients from one institution from March 2013 to December 2019 (3:1:1 allocation to training, validation, and internal test sets) to predict risk of all-cause mortality within 30 days after CAP diagnosis using patients' initial chest radiograph. The DL model was evaluated in patients diagnosed with CAP during emergency department visits at the same institution as the development cohort from January 2020 to December 2020 [temporal test cohort (n=947)], and from two additional different institutions [external test cohort A (n=467), January 2020 to December 2020; external test cohort B (n=381), March 2019 to October 2021]. AUCs were compared between DL model and CURB-65 score (an established risk prediction tool). The combination of CURB-65 score and DL model was evaluated by a logistic regression model. AUC for predicting 30-day mortality was higher (P<.001) for DL model than CURB-65 score in temporal test set (0.77 vs 0.67); higher AUC for DL model than CURB-65 score was not significant (P>.05) in external test cohort A (0.80 vs 0.73) or external test cohort B (0.80 vs 0.72). In the three cohorts, DL model, in comparison with CURB-65 score, exhibited higher (P<.001) specificity (range, 61-69% vs 44-58%) at the sensitivity achieved by CURB-65 score. Combination of DL model and CURB-65 score, in comparison with CURB-65 score, yielded increase in AUC in temporal test cohort (0.77, P<.001) and external test cohort B (0.80, P=.04), and nonsignificant increase in AUC in external test cohort A (0.80, P=.16). A DL-based model using initial chest radiographs could predict 30-day mortality in patients with CAP with improved performance compared with CURB-65 score. The DL-based model may guide clinical decision-making in management of patients with CAP.

Associating a standardized reporting tool for chest radiographs with clinical complications in pediatric acute chest syndrome.

Acute chest syndrome (ACS) is an important cause of morbidity in sickle cell disease (SCD). A standardized tool for reporting chest radiographs in pediatric SCD patients did not previously exist. To analyze the interobserver agreement among pediatric radiologists' interpretations for pediatric ACS chest radiographs utilizing a standardized reporting tool. We also explored the association of radiographic findings with ACS complications. This was a retrospective cohort study of pediatric ACS admissions from a single institution in 2019. ICD-10 codes identified 127 ACS admissions. Two radiologists independently interpreted the chest radiographs utilizing a standardized reporting tool, a third radiologist adjudicated discrepancies, and κ analysis assessed interobserver agreement. Clinical outcomes were correlated with chest radiograph findings utilizing Pearsons' χ2 , ttests, and Mann-Whitney U tests. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Interobserver agreement was moderate to near-perfect across variables, with κ analysis showing near-perfect agreement for opacity reported in the right upper lobe (0.84), substantial agreement for right lower lobe (0.63), and vertebral bony changes (0.72), with moderate agreement for all other reported variables. On the initial chest radiograph, an opacity located in the left lower lobe (LLL) correlated with pediatricintensive care unit transfer (p = .03). Pleural effusion on the initial chest radiograph had a 3.98 OR (95% CI: 1.35-11.74) of requiring blood products and a 10.67 OR (95%CI: 3.62-31.39) for noninvasive ventilation. The standardized reporting tool showed moderate to near-perfect agreement between radiologists. LLL opacity, and pleural effusion were associated with increased risk of ACS complications.

A pediatric case of portosystemic shunt presenting hypoxemia with brain abscess in an emergency department

Portosystemic shunt is a rare congenital vascular anomaly. The shunt is hard to clinically suspect because its symptoms develop insidiously and affect various systems at different time points. We report a case of an 11-year-old girl who presented with brain abscess and hypoxemia without respiratory distress. No abnormality related to the hypoxemia, such as intracardiac shunt, was found on the initial chest radiograph and echocardiogram. However, computed tomography showed a portosystemic shunt. An intrapulmonary shunt was demonstrated by bubble contrast echocardiography, indicating a grade 2 hepatopulmonary syndrome, a complication of portosystemic shunt. This case describes the diagnostic process of an unusual case presenting neurological abnormalities and hypoxemia without respiratory distress. Portosystemic shunt with hepatopulmonary syndrome should be considered in the differential diagnosis of unexplained hypoxemia.

Use of artificial intelligence in triaging of chest radiographs to reduce radiologists' workload.

To evaluate whether deep learning-based detection algorithms (DLD)-based triaging can reduce outpatient chest radiograph interpretation workload while maintaining noninferior sensitivity. This retrospective study included patients who underwent initial chest radiography at the outpatient clinic between June 1 and June 30, 2017. Readers interpreted radiographs with/without a commercially available DLD that detects nine radiologic findings (atelectasis, calcification, cardiomegaly, consolidation, fibrosis, nodules, pneumothorax, pleural effusion, and pneumoperitoneum). The reading order was determined in a randomized, crossover manner. The radiographs were classified into negative and positive examinations. In a 50% worklist reduction scenario, radiographs were sorted in descending order of probability scores: the lower half was regarded as negative exams, while the remaining were read with DLD by radiologists. The primary analysis evaluated noninferiority in sensitivity between radiologists reading all radiographs and simulating a 50% worklist reduction, with the inferiority margin of 5%. The specificities were compared using McNemar's test. The study included 1964 patients (median age [interquartile range], 55years [40-67years]). The sensitivity was 82.6% (195 of 236; 95% CI: 77.5%, 87.3%) when readers interpreted all chest radiographs without DLD and 83.5% (197 of 236; 95% CI: 78.8%, 88.1%) in the 50% worklist reduction scenario. The difference in sensitivity was 0.8% (95% CI: - 3.8%, 5.5%), establishing noninferiority of 50% worklist reduction (p = 0.01). The specificity increased from 86.7% (1498 of 1728) to 90.4% (1562 of 1728) (p < 0.001) with DLD-based triage. Deep learning-based triaging may substantially reduce workload without lowering sensitivity while improving specificity. Substantial workload reduction without lowering sensitivity was feasible using deep learning-based triaging of outpatient chest radiograph; however, the legal responsibility for incorrect diagnoses based on AI-standalone interpretation remains an issue that should be defined before clinical implementation. • A 50% workload reduction simulation using deep learning-based detection algorithm maintained noninferior sensitivity while improving specificity. • The CT recommendation rate significantly decreased in the disease-negative patients, whereas it slightly increased in the disease-positive group without statistical significance. • In the exploratory analysis, the noninferiority of sensitivity was maintained until 70% of the workload was reduced; the difference in sensitivity was 0%.

THE CONCORDANCE OF BRIXIA AND RALE SCORES IN EVALUATION OF COVID-19 PNEUMONIA PATIENT USING RADIOGRAPHY IN INDONESIA REFERRAL HOSPITAL

The COVID-19 pandemic has put intense pressure on the healthcare systems. As the lung complication of COVID-19, pneumonia can be assessed by chest radiography which can be used to predict the severity of patient deterioration using Brixia and RALE scores. This research aims to assess the Radiologists' agreement on diagnosing pneumonia COVID-19 by RT-PCR in CXR using the Brixia and RALE score at Dr. Sardjito Central General Hospital from May 2020-January 2021. Two separate radiologists scored initial chest radiographs for RALE and Brixia independently. The analysis assessed included a descriptive analysis of demographic data, and Bland-Altman plots were used to visualize intra-observer agreement. A total of 332 samples were 162 men (48.8%) and 170 women (51.2%), with a mean age of 42.37. The ICC of Brixia score (0.855, CI:0.794-0.895) and RALE score (0.756, CI:0.662-0.812). Bland–Altman analysis revealed a bias of 5.08 ± 6.04 (95% limits of agreement of -6.760 and 16.929) for Brixia and RALE scores and significantly correlated (r=0.886 (p0.05)). The average score of Brixia (6.29±4.430) and RALE (11.56±9.997) in men was higher than in women. The agreement of Radiologists in diagnosing pneumonia COVID-19 using Brixia and RALE scores with the Bland Altman curve was significant or reliable.

Thoracic Surgeons' Perspective on the Management of Primary Spontaneous Pneumothorax.

The study aimed to determine the current practice of thoracic surgeons in the management of primary spontaneous pneumothorax in Saudi Arabia and to compare the results with the British Thoracic Society guidelines. This is a questionnaire-based study. The questionnaire included 41 questions and was directed to those involved in the management of primary spontaneous pneumothorax in Saudi Arabia; namely thoracic, cardiac, and general surgeons. It was distributed electronically through email. Out of 47 registered surgeons at the time of the study, 47 responses were obtained with a 100% response rate. Among the participants, 39 were thoracic surgeons. It was noted that all surgeons agreed on ordering an initial chest radiograph and most would order an additional view. Also, approaches varied regarding grading systems used. While 26% of the respondents use the British Thoracic Society grading system, 16% follow the American College of Chest Physicians system, and the rest chose other parameters. The majority of surgeons would choose a chest tube of a size not greater than 28 Fr for initial placement. As for video-assisted thoracoscopic surgery, we noted that 55% of the respondents opted for 3 ports, while 36% would place 2 ports. Primary spontaneous pneumothorax is a common condition managed by thoracic surgeons. Various guidelines were established to guide practice. Our study showed some variability in practice which could result in serious medico-legal consequences and can affect the careers of thoracic surgeons. We hope that our results will shed light upon variabilities to influence proper directed management.

Methods of Visualizing the Results of an Artificial-Intelligence-Based Computer-Aided Detection System for Chest Radiographs: Effect on the Diagnostic Performance of Radiologists.

It is unclear whether the visualization methods for artificial-intelligence-based computer-aided detection (AI-CAD) of chest radiographs influence the accuracy of readers' interpretation. We aimed to evaluate the accuracy of radiologists' interpretations of chest radiographs using different visualization methods for the same AI-CAD. Initial chest radiographs of patients with acute respiratory symptoms were retrospectively collected. A commercialized AI-CAD using three different methods of visualizing was applied: (a) closed-line method, (b) heat map method, and (c) combined method. A reader test was conducted with five trainee radiologists over three interpretation sessions. In each session, the chest radiographs were interpreted using AI-CAD with one of the three visualization methods in random order. Examination-level sensitivity and accuracy, and lesion-level detection rates for clinically significant abnormalities were evaluated for the three visualization methods. The sensitivity (p = 0.007) and accuracy (p = 0.037) of the combined method are significantly higher than that of the closed-line method. Detection rates using the heat map method (p = 0.043) and the combined method (p = 0.004) are significantly higher than those using the closed-line method. The methods for visualizing AI-CAD results for chest radiographs influenced the performance of radiologists' interpretations. Combining the closed-line and heat map methods for visualizing AI-CAD results led to the highest sensitivity and accuracy of radiologists.

Deep Learning Analysis of Chest Radiographs to Triage Patients with Acute Chest Pain Syndrome.

Background Patients presenting to the emergency department (ED) with acute chest pain (ACP) syndrome undergo additional testing to exclude acute coronary syndrome (ACS), pulmonary embolism (PE), or aortic dissection (AD), often yielding negative results. Purpose To assess whether deep learning (DL) analysis of the initial chest radiograph may help triage patients with ACP syndrome more efficiently. Materials and Methods This retrospective study used electronic health records of patients with ACP syndrome at presentation who underwent a combination of chest radiography and additional cardiovascular or pulmonary imaging or stress tests at two hospitals (Massachusetts General Hospital [MGH], Brigham and Women's Hospital [BWH]) between January 2005 and December 2015. A DL model was trained on 23 005 patients from MGH to predict a 30-day composite end point of ACS, PE, AD, and all-cause mortality based on chest radiographs. Area under the receiver operating characteristic curve (AUC) was used to compare performance between models (model 1: age + sex; model 2: model 1 + conventional troponin or d-dimer positivity; model 3: model 2 + DL predictions) in internal and external test sets from MGH and BWH, respectively. Results At MGH, 5750 patients (mean age, 59 years ± 17 [SD]; 3329 men, 2421 women) were evaluated. Model 3, which included DL predictions, significantly improved discrimination of those with the composite outcome compared with models 2 and 1 (AUC, 0.85 [95% CI: 0.84, 0.86] vs 0.76 [95% CI: 0.74, 0.77] vs 0.62 [95% CI: 0.60 0.64], respectively; P < .001 for all). When using a sensitivity threshold of 99%, 14% (813 of 5750) of patients could be deferred from cardiovascular or pulmonary testing for differential diagnosis of ACP syndrome using model 3 compared with 2% (98 of 5750) of patients using model 2 (P < .001). Model 3 maintained its diagnostic performance in different age, sex, race, and ethnicity groups. In external validation at BWH (22 764 patients; mean age, 57 years ± 17; 11 470 women), trends were similar and improved after fine tuning. Conclusion Deep learning analysis of chest radiographs may facilitate more efficient triage of patients with acute chest pain syndrome in the emergency department. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Goo in this issue.

Comparison of outcomes between observation and tube thoracostomy for small traumatic pneumothoraces

BackgroundTraumatic pneumothorax management has evolved to include the use of smaller caliber tube thoracostomy and even observation alone. Data is limited comparing tube thoracostomy to observation for small traumatic pneumothoraces. We aimed to investigate whether observing patients with a small traumatic pneumothorax on initial chest radiograph (CXR) is associated with improved outcomes compared to tube thoracostomy. MethodsWe retrospectively reviewed trauma patients at our level 1 trauma center from January 1, 2016 through December 31, 2020. We included those with a pneumothorax size <30 mm as measured from apex to cupola on initial CXR. We excluded patients with injury severity score ≥ 25, operative requirements, hemothorax, bilateral pneumothoraces, and intensive care unit admission. Patients were grouped by management strategy (observation vs tube thoracostomy). Our primary outcome was length of stay with secondary outcomes of pulmonary infection, failed trial of observation, readmission, and mortality. Results are listed as mean ± standard error of the mean. ResultsOf patients who met criteria, 39 were in the observation group, and 34 were in the tube thoracostomy group. Baseline characteristics were similar between the groups. Average pneumothorax size on CXR was 18 ± 1.0 mm in the observation group and 18 ± 0.84 mm in the tube thoracostomy group (p > 0.99). Average pneumothorax sizes on computed tomography were 25 ± 2.1 and 37 ± 3.9 mm in the observation and tube thoracostomy groups, respectively (p = 0.01). Length of stay in the observation group was significantly shorter than the tube thoracostomy group (3.6 ± 0.33 vs 5.8 ± 0.81 days, p < 0.01). While pneumothorax size on computed tomography was associated with tube thoracostomy, only tube thoracostomy correlated with length of stay on multivariable analysis; pneumothorax size on CXR and computed tomography did not. There were no deaths or readmissions in either cohort. One patient in the observation group required tube thoracostomy after 18 h for worsening subcutaneous emphysema, and one patient in the tube thoracostomy group developed an empyema. ConclusionsSelect patients with small traumatic pneumothoraces on initial chest radiograph who were treated with observation experienced an average length of stay over two days shorter than those treated with tube thoracostomy. Outcomes were otherwise similar between the two groups suggesting that an observation-first strategy may be a superior treatment approach for these patients.

MANAGEMENT GUIDELINES FOR OCCULT PNEUMOTHORAX: TUBE THORACOTOMY OR CONSERVATIVE MANAGEMENT?

Pneumothorax is a commonly encountered problem in the Trauma Bay. The ED management of pneumothorax depends on their etiology, their size, and clinical stability of the patient. The term occult pneumothorax (OP) is a pneumothorax that is not suspected on the basis of clinical examination or initial chest radiography, but is later detected on computed tomography (CT) scan. Some Surgeons favour placement of a ICD tube for patients with OP, while others favour close observation without chest drainage. This study was conducted both to determine the incidence of OP and to describe its current treatment status in the chest trauma population at an Indian tertiary trauma centre