Initial X-ray Research Articles

Clinical outcomes of traumatic pneumothoraces undergoing conservative management following detection by prehospital physicians

ObjectiveTo describe the clinical and transport characteristics of patients diagnosed with a suspected traumatic pneumothorax and managed conservatively by prehospital medical teams including secondary deterioration during transfer and the subsequent rate of in-hospital tube thoracostomy. MethodsRetrospective observational study of all adult trauma patients diagnosed with a suspected pneumothorax on ultrasound and managed conservatively by their treating prehospital medical team between 2018 and 2020. Descriptive analysis was performed comparing patients who did and did not receive in-hospital tube thoracostomy. ResultsIn total, 181 patients were diagnosed with suspected traumatic pneumothoraces on prehospital ultrasound of which 75 (41.4%) were managed conservatively by their treating medical team whilst 106 (58.6%) underwent pleural decompression. There were no recorded cases of emergent pleural decompression required in transit. Of the 75 conservatively managed patients, 42 (56%) had an intercostal catheter (ICC) placed within four hours of hospital arrival and another nine (17.6%) had an ICC placed between four- and 24-hours post-hospital arrival. There was no significant difference in prehospital clinical characteristics between patients who did and did not receive an in-hospital ICC. The detection of a pneumothorax on the initial chest x-ray and larger pneumothorax volume visualised on computed tomography imaging were significantly more common in patients receiving in-hospital ICCs. Aviation factors including flight altitude and duration of flight were not associated with subsequent in-hospital tube thoracostomy. ConclusionPrehospital medical teams can safely identify patients who have a traumatic pneumothorax and can be transported to hospital without pleural decompression. Patient characteristics at the time of hospital arrival combined with the size of pneumothorax identified on imaging appear most likely to influence subsequent urgent in-hospital tube thoracostomy placement.

Development of a new radiographic score for the follow-up of calcific tendinopathy of the rotator cuff.

The aim of this study was to evaluate the psychometric properties of a new x-ray scoring system for calcific tendinopathy of the rotator cuff (CTRC). This is a post-hoc analysis of the CALCECHO trial. All patients received an ultrasound-guided puncture and lavage of their calcification. Clinical data and x-rays from baseline and follow-up visits at 7 days (D7), 3 months (M3) and 12 months (M12) were used. The scoring system was based on the reduction in size and density of the calcification compared to the initial x-ray (0 = no change; 1 = decrease of less than 50%; 2 = decrease of between 50 and 90%; 3 = decrease of more than 90%; 4 = complete disappearance). Inter-observer and intra-observer reliability were established between 3 independent investigators (2 experts and one junior) using weighted Kappa calculation. Construct validity was assessed as well as predictive validity and sensitivity to change. Between the two experts, inter-reader reliability was at 0.677, 0.744 and 0.656 at D7, M3 and M12 respectively. Intra-reader reliability was between 0.577 and 0.836 for the two expert readers and between 0.519 and 0.697 for the junior reader. Our score was correlated with shoulder pain and function at M3 and M12 and the score at M3 was predictive of the clinical outcome at M12. Finally, sensitivity to change was 0.8. Our new score presented good psychometric properties and was correlated with clinical data. It could be useful in the follow-up of patients treated for CTRC.

Deep learning approach for early prediction of COVID-19 mortality using chest X-ray and electronic health records

BackgroundAn artificial-intelligence (AI) model for predicting the prognosis or mortality of coronavirus disease 2019 (COVID-19) patients will allow efficient allocation of limited medical resources. We developed an early mortality prediction ensemble model for COVID-19 using AI models with initial chest X-ray and electronic health record (EHR) data.ResultsWe used convolutional neural network (CNN) models (Inception-ResNet-V2 and EfficientNet) for chest X-ray analysis and multilayer perceptron (MLP), Extreme Gradient Boosting (XGBoost), and random forest (RF) models for EHR data analysis. The Gradient-weighted Class Activation Mapping and Shapley Additive Explanations (SHAP) methods were used to determine the effects of these features on COVID-19. We developed an ensemble model (Area under the receiver operating characteristic curve of 0.8698) using a soft voting method with weight differences for CNN, XGBoost, MLP, and RF models. To resolve the data imbalance, we conducted F1-score optimization by adjusting the cutoff values to optimize the model performance (F1 score of 0.77).ConclusionsOur study is meaningful in that we developed an early mortality prediction model using only the initial chest X-ray and EHR data of COVID-19 patients. Early prediction of the clinical courses of patients is helpful for not only treatment but also bed management. Our results confirmed the performance improvement of the ensemble model achieved by combining AI models. Through the SHAP method, laboratory tests that indicate the factors affecting COVID-19 mortality were discovered, highlighting the importance of these tests in managing COVID-19 patients.

Cryptococcus neoformans osteomyelitis of the tibia: a case report and review of the literature

IntroductionOsteomyelitis is a bone inflammation that can be related to various infectious agents. As with any other type of inflammation, the prevailing symptoms and signs may include redness, swelling, pain, and heat. Fungal osteomyelitis is rare and usually found in immune-compromised patients.Case presentationA non-human immunodeficiency virus immunocompromised Greek female patient, 82 years old, visited the emergency department due to a 3 day pain located mainly over the left tibia’s anterior surface, accompanied by swelling and redness. There was also a subcutaneous lesion of her left breast. Medical history revealed that the patient had an unmasked close contact with pigeons, a main host of the disease. Initial x-ray imaging showed an osteolytic area in the upper third of the tibial diaphysis. The patient was admitted and underwent a computed tomography-guided biopsy. The specimen revealed a Cryptococcus neoformans infection of the bone and the breast. She was treated with 400 mg fluconazole twice a day for 3 weeks while in hospital and 200 mg twice a day upon discharge for 9 months. After that, she underwent surgical debridement because of lasting local irritation. She was closely monitored in our outpatient office, and in her last visit, 1 year after the initial admission, inflammatory signs had regressed vastly.ConclusionsTo our knowledge, this is the ninth cryptococcal osteomyelitis of the tibia to be recorded since 1974, and the most unusual finding was the bifocal nature of the infection, affecting both the tibia and the breast.

Appropriate Imaging Modalities in the Emergency Department for Assessment of Renal Stones

Introduction:Urolithiasis prevalence is approximately 15-20%, the third most common urological presentation to emergency departments (ED). In the ED, renal stones are usually diagnosed by clinical presentation, but imaging modalities play a role in confirmation and exclusion of hydronephrosis. 85% of stones are calcium oxalate/calcium phosphate, which are radio opaque, and 15% are radiolucent uric acid or cysteine stones. Non-contrast CT scans have 95% and 97% sensitivity and specificity rates, while x-rays have 57% and 76% respectively. In Wexford General Hospital, radiology prefers plain film x-rays prior to CT scans in assessing kidney stones.Method:The aim of this study was to assess the sensitivity of x-rays in patients undergoing low dose non-contrast CT for kidney stones and to apply this information to clinical practice. A retrospective audit was conducted using NIMIS/PACS from December 1, 2021-March 31,2022. All patients who underwent CT KUBS for evaluation of renal stones were included, and CT KUB findings were compared with initial x-ray findings.Results:A CT KUB was performed on 56 patients to assess renal stones, and 29 patients had renal stones. Among 29 patients, 21 had x-rays and CT scans performed, and 12 had x-ray findings that indicated renal stones, indicating 57% sensitivity. The study found 36 patients had x-rays for renal stones, but no CT scan was scheduled for 15 patients who might have undiagnosed radiolucent stones.Conclusion:Radiological imaging plays a central role in the management of suspected renal stones. CT KUB is a useful tool for evaluating patients with radio-opaque kidney stones as well as detecting radiolucent stones and renal pathologies that can be missed with plain radiographs. Low-dose CT KUB is recommended as a first-line investigation for renal stone patients to reduce radiation risks and unnecessary abdominal x-rays while assisting clinicians in accurately diagnosing patients and excluding other possible causes.

Aluminyum fosfit zehirlenmesi

Letter to Editor
 
 
 
 Aluminum phosphide poisoning
 
 
 Dear Editor,
 
 Aluminum phosphide, is a fumigant with high insecticide power in all life stages of insects, which is harmful in stored products.
 It is in the form of tablets or granules and is highlylethal and has no antidote.
 It inhibits the enyzme of cytochrome oxidase. Complications may develop as a result of inhaling phosphine gas or oral intake. Respiratory, circulatory, gastrointestinal tract andnervous system, kidney and liver may be affected. Shock, ARDS, aspration pnomony, anemia, metabolic acidosis, electrolytic disorder, coma, hipoxy, hemorrhage, pericardide are poorprognosis criterion. Leukopenia indicates severe toxicity. The lethal dose is 0.15-0.5 g and death is inevitableeven when buying 3-5 tablets
 Arrhythmia is responsible for death in the first 24 hours.The mortality rate varies between 37-100%.Treatment consists entirely of supportive treatment. (liquid, dopamine, oxygen, mechanical ventilation, gastric washing, activated charcoal,bicarbonate, hemodialysis)We aimed to present the case that developedsystemic complications in follow-up but wedischarged with healing as a result of appropriatefollow-up and treatment.
 CASE
 A 16-year old female patient was rushed to theemergency room two hours ago for drinking morethan she 
 knew the amount of the drug containing aluminum phosphide for suicidal purposes.
 When the patient arrived, his general condition wasmoderate, conscious, pale sweaty appearance and Tachypnea, BREATHING:26/min, TA:60/40mmhg,Pulse:135/min,,fever:37 degree systemic examination showed no abnormalities.
 Initial blood values, ECG and chest x-ray were normal.
 
 The patient was followed up in the emergency department. 1000ml serum physiological started
 In order to reduce the formation of phosphine gas(with alkalısm), oral bicarbonate was started. 
 Ta:100/70mmHg in the 2nd hour of follow-up andchest pain developed.
 The first TROPONIN I value was:0.02(0-0.06 ng/ml). In echocardiography, ejection fraction wasdetermined 57%. In the blood gas, PH was 7.32 and there was metabolic acidosis. Her acidosis level improved in the 6th hour of the follow up. The control TROPONİN value was 0.21. Asetilsalisilik acid started at 100 mg. At the 12th hour white blood cell (4-11 k/ml) decreased from 12000 to 4000.However no abnormality was detected in other hemogram values.
 
 At the 20th hour ,her chest pain gone and her troponin values increased up to 1.45.No ECG change detected.Her acidose improved and lokopenia not seen.The patient’s control , liver and kidney function tests and ECHO were normal.No abnormality was detected in the follow ups , polyclinic controls and laboratory values on the third day of the hospitalization. The patient was discharged from the hospital with suggestions.
 
 Aluminum phosphide is an extremely mortal toxic substance.During the follow ups unwanted complications can develop. Merely satisfactory results can be achieved with valid , timely and appropriate supportive treatments

Value of Thoracic CT in Blunt Trauma Patients With High Glasgow Coma Scale and Low Injury Severity Scale.

To determine the value of ordering a routine chest CT (CCT) in patients with blunt trauma presenting to the emergency department with a high GCS and low ISS, we retrospectively collected patient data including CT scan results, when physical examination and initial chest X-ray were normal in the trauma bay area. A retrospective data collection of 901 consecutive blunt trauma patients seen in the ED between 2017 and 2019 was analyzed. Data included physical examination, age, gender, current use of anticoagulation therapy, comorbid conditions, as well as the result of radiologic images, hospital length of stay, surgical intervention, and mortality. The patients were divided into two groups: group one (patients with negative physical examination; chest x-ray and CT) and group 2 (negative physical examination, positive or negative chest x-ray, and positive CT). Statistical analysis was performed using student's t-test and chi-square test. Of the 901 patients there were 489 (54%) males and 412 (46%) females with a mean age of 56 years. There were 461 patients who had a physical examination, chest x-ray, abdominal and CCT done. Group one included 442 (96%) patients, with negative physical examination, negative chest X-ray and CT scan. In group 2, 19 (4%) patients who had positive CT and or chest x-ray. Both groups were similar in GCS and ISS. Of the 19 patients, sixteen patients had a positive CCT, and thirteen of those had a positive chest x-ray. In the three patients who had negative physical examination and chest x-ray, the CT findings included one with a nondisplaced 10th rib fracture and two patients with osteoporotic compression fractures of dorsal vertebrae. The rate of both chest x-ray and CCT being positive among a group of screened patients was 16% (3/19) and the rate of a negative chest x-ray but positive CT was 16% (3/19). The odds ratio between the two outcomes was one. In blunt trauma patients presenting to the ED with a high GCS and low ISS score, when initial physical examination and chest x-ray are negative, routine CCT is of little value.

Mycobacterium genavense splenitis in a pet rabbit (Oryctolagus cuniculus) presented for fracture

Mycobacteriosis is an uncommon infection that has been sporadically described among wild, farmed and pet rabbits. To date, only one case of Mycobacterium genavense infection has been reported in a dwarf rabbit presenting with granulomatous pneumonia. This new case report describes granulomatous splenitis caused by M. genavense in a pet rabbit brought in for lameness caused by a femoral fracture. The initial blood test, X-ray, abdominal ultrasound, and bone marrow and spleen cytology results were consistent with a diagnosis of a metastatic giant-cell tumour. The rabbit underwent successful femoral osteosynthesis, and six months later, following the occurrence of a second spontaneous fracture and a worsening of overall health, the patient was euthanised. The postmortem histological examination showed severe granulomatous splenitis caused by acid-fast bacilli identified as M. genavense by real-time PCR analysis. The route of infection remains unknown, yet the lack of pulmonary involvement likely rules out airborne transmission. M. genavense infection, although rarely described in pet rabbits, appears to be an emerging pathogen and should be included among the differential diagnoses for pneumonia and splenomegaly.

VIRTUAL FRACTURE CLINIC TRIAGE AND SELECTIVE USE OF MRI: A HYBRID MODEL FOR MANAGING SUSPECTED SCAPHOID FRACTURES

In current practice in the UK there are three main approaches to investigating suspected scaphoid fractures not seen on initial plain film x-rays.Early MRI of all casesReview all cases in clinic at two weeks with repeat x-raysHybrid model. Virtual Fracture Clinic (VFC) triage to reduce those who are seen in clinic at two weeks by:Organising early MRI for those with high-risk presentation.Discharging those with an alternative more likely diagnosis.Our unit uses the VFC model. We aimed to evaluate its efficiency, safety, clinical outcomes and economic viability.All patients attending the emergency department with either a confirmed or suspected scaphoid fracture between March and December 2020 were included (n=305). Of these 297 were referred to the VFC: 33 had a confirmed fracture on x-ray and 264 had a suspected fracture.Of the suspected fractures reviewed in VFC 14% had an MRI organised directly owing to a high-risk presentation, 79% were brought for fracture clinic review and 17% discharged with an alternative diagnosis such as osteoarthritis.Of those subsequently reviewed in fracture clinic at two weeks: 9% were treated as scaphoid fractures (based on clinical suspicion and repeat x-rays), 17% had MRI or CT imaging organised, 5% did not attend and 69% were discharged.Overall, 17% of cases initially triaged, had further imaging – 41 MRIs and 5 CTs. MRI detected: 5% scaphoid fracture, 17% other fracture, 24% bone contusion, complete ligament tear 10%, partial ligament tear 39% and normal study 10%. The results of MRI minimally affected management. 3 patients were taken out of plaster early, 1 patient was immobilized who was not previously and no patients underwent operative management.In the following 12-month period one patient re-presented with a hand or wrist issue.This approach avoided 218 MRIs, equating to £24000 and 109 hours of scanner time.VFC triage and selective use of MRI scanning is a safe, efficient and cost-effective method for the management suspected scaphoid fractures. This can be implemented in units without the resource to MRI all suspected scaphoid fractures from the emergency department.

First-day computed tomography: does it has a role in the assessment of patients with inhalation lung injury?

BackgroundInhalation lung injury occurs in almost one-third of all serious burns and is responsible for a considerable proportion of burn patient fatalities each year. History of closed space fire or unconsciousness at the accident site, occurrence of pharyngeal or facial burns, hoarseness, and wheezing, and laboratory tests that include blood gas abnormalities or Carboxyhemoglobin levels in blood ˃ 10% are used to diagnose inhalation lung injury. It is also characterized by radiological findings of alveolar or interstitial edema, atelectasis, and/or consolidations, as well as the presence of erythema with laryngeal or tracheal edema in the bronchoscope.ObjectivesTo study the diagnostic and prognostic efficacy of radiologist score and bronchial wall thickening as radiological CT findings in inhalation lung injury.MethodsThis prospective case–control study included 48 patients with inhalation lung injury (ILI) as a case group and 10 patients without ILI were selected as the control group, all recruited from the burn and plastic department. Within the first 12 h of suspected ILI, a fiberoptic bronchoscope was done to confirm the diagnosis. An initial chest X-ray was done followed by computed tomography through which the radiologist score (RADS) together with bronchial wall thickening (BWT) was done.ResultsDuration of ventilation was higher in cases than in controls (8.50 ± 3.94 vs 3.25 ± 0.50). The hospital duration was higher in cases than in controls (13.6 ± 4.68 vs9.50 ± 4.52). The BWT was 2.12 ± 0.66 (mean ± SD) in the ILI group while the control group was 1.32 ± 0.48 (mean ± SD). Correlating between baseline PaO2 and RADS score and BWT, it was found that there was a highly significant negative correlation between PaO2 and RADS score and BWT among inhalation lung injury patients (P value 0.001). The sensitivity of BWT in the detection of the need for mechanical ventilation was 83% at a cut-off point of 1.65. Its specificity was 78% and accuracy 75%.ConclusionCT done within 24 h of burn patients has a good role in the diagnosis and management of ILI from the burn.

A Young Skier with Leg Pain

BackgroundProximal tibiofibular joint (PTFJ) dislocation is a rare injury that can disrupt the proximal tibia-fibula joint. The abnormalities in knee x-ray imaging can be subtle and difficult to detect, requiring careful assessment. This rare cause of lateral knee pain requires a high level of suspicion for diagnosis. Treatment is closed reduction; unstable PTFJ dislocations often require surgical intervention. Case ReportA 17-year-old young man presented to the emergency department (ED) with right lateral knee pain and difficulty walking after colliding with another skier 2 days prior. The examination showed right lateral ecchymosis and tenderness over the lateral proximal fibula. He remained neurovascularly intact with a full passive and active range of motion. X-ray studies were obtained. The patient was referred by his outpatient orthopedic surgeon after the initial knee x-ray study was concerning for PTFJ dislocation and unsuccessful reduction. In the ED, the patient underwent moderate sedation and successful orthopedic-guided reduction via medial force on the lateral fibular head, while hyper-flexing the knee and holding the foot dorsiflexed and everted. Post-reduction radiographs showed improved proximal tibiofibular alignment without fracture. Why Should an Emergency Physician Be Aware of This?PTFJ dislocation is a rare injury that can be missed easily and requires a high level of suspicion when presented with an acute traumatic knee pain. Closed reduction of PTFJ dislocation can be achieved in the ED and early identification can prevent long-term sequelae.

Marginal Bone Level and Biomechanical Behavior of Titanium-Indexed Abutment Base of Conical Connection Used for Single Ceramic Crowns on Morse-Taper Implant: A Clinical Retrospective Study.

The goal of this retrospective clinical study was to evaluate the behavior of Morse-taper indexed abutments by analyzing the marginal bone level (MBL) after at least 12 months of function. Patients rehabilitated with single ceramic crowns between May 2015 and December 2020 received single Morse-taper connection implants (DuoCone implant) with two-piece straight abutment baseT used for at least 12 months, presenting periapical radiograph immediately after crown installation were enrolled. The position of the rehabilitated tooth and arch (maxilla or mandible), crown installation period, implant dimensions, abutment transmucosal height, installation site (immediate implant placement or healed area), associated with bone regeneration, immediate provisionalization, and complications after installation of the final crown were analyzed. The initial and final MBL was evaluated by comparing the initial and final X-rays. The level of significance was α = 0.05. Seventy-five patients (49 women and 26 men) enrolled had a mean period of evaluation of 22.7 ± 6.2 months. Thirty-one implant-abutment (IA) sets had between 12-18 months, 34 between 19-24 months, and 44 between 25-33 months. Only one patient failed due to an abutment fracture after 25 months of function. Fifty-eight implants were placed in the maxilla (53.2%) and 51 in the mandible (46.8%). Seventy-four implants were installed in healed sites (67.9%), and 35 were in fresh socket sites (32.1%). Thirty-two out of these 35 implants placed in fresh sockets had the gap filled with bone graft particles. Twenty-six implants received immediate provisionalization. The average MBL was -0.67 ± 0.65 mm in mesial and -0.70 ± 0.63 mm in distal (p = 0.5072). The most important finding was the statistically significant difference comparing the values obtained for MBL between the abutments with different transmucosal height portions, which were better for abutments with heights greater than 2.5 mm. Regarding the abutments' diameter, 58 had 3.5 mm (53.2%) and 51 had 4.5 mm (46.8%). There was no statistical difference between them, with the following means and standard deviation, respectively, -0.57 ± 0.53 mm (mesial) and -0.66 ± 0.50 mm (distal), and -0.78 ± 0.75 mm (mesial) and -0.746 ± 0.76 mm (distal). Regarding the implant dimensions, 24 implants were 3.5 mm (22%), and 85 implants (78%) had 4.0 mm. In length, 51 implants had 9 mm (46.8%), 25 had 11 mm (22.9%), and 33 implants were 13 mm (30.3%). There was no statistical difference between the abutment diameters (p > 0.05). Within the limitations of this study, it was possible to conclude that better behavior and lesser marginal bone loss were observed when using abutment heights greater than 2.5 mm of transmucosal portion and when placed implants with 13 mm length. Furthermore, this type of abutment showed a little incidence of failures within the period analyzed in our study.

Description and evaluation of cocaine body-packers management in French Guiana (2016–2019)

IntroductionFrench Guiana is a hub for drugs trafficking between South America and Europe. In Corpore transport, or Body-packing, is one of the options favored. In 2018, 577 people were arrested for smuggling cocaine from French Guiana to mainland France. The objective of this study was to update the epidemiological data and to evaluate the overall management of body-packers. MethodsA monocentric retrospective and observational study included patients admitted to the emergency department of the Cayenne General Hospital from January 1st, 2016 to December 31st, 2019 after ingestion of cocaine pellets. ResultsDuring the period, 668 people were referred to Cayenne hospital's emergency department by for suspected body-packing. Two hundred nineteen were excluded due to the absence of cocaine pellets in the initial X-ray or because they were carrying cannabis pellets. The mean age was 25.2 years with a sex ratio of 2.21 males per female. Among them, 13.7% of cases were complicated without endangering the vital prognosis. The mean number of pellets was similar between the population with and without complications (respectively 54.1 [50.9–57.4] and 57.8 [48.9–66.6], p = 0.22). The presence of cocaine in the urine was not significantly associated with the risk of complications (OR = 0.5, [95%CI = 0.1–1.8], p = 0.23). Compared to the CT-scanner which has the highest diagnostic accuracy (Se 100%, Sp 94%), the sensitivity of the Abdominal X-ray was 44%. ConclusionThis study showed that complications were rare, most of which were digestive stagnation requiring endoscopy. Given the low rate of complications and their low severity the average duration of hospitalization was relatively short. The type 3, micro-industrial quality packaging, almost exclusively used in body-packing in French Guiana, seems to be the main factor in this reduction of complications. This observation suggests possible adaptations of the current protocol for body-packers monitoring.

A Retrospective Study of Missed Fractures and Injuries in Orthopedics

Introduction: Common Orthopedics injuries may result in long-term disability when they are treated lately. Simple fractures may require surgeries when they are missed and neglected. Most musculoskeletal injuries are seen in emergencies, some injuries may be missed when life-threatening conditions require attention, especially in poly-trauma patients. Certain injuries are difficult to recognize and some fractures may not visible in initial x-rays. A high index of suspicion is required to diagnose such cases. Methods: We conduct a retrospective study in which missed fractures, dislocations, and injuries were diagnosed and noted by consultant Orthopaedic surgeons from 2013 to 2022. Results: There were 76 missed diagnosed cases noted from 2013 to 2022. The patient’s ages range from 2 years to 63 years. Altogether 42(55.3%) were missed fractures, 23 (30.3%) were missed dislocations, and 11(14.5%) were tendon and ligament injuries cases. The common reason for the error was related to radiological error found in 62 (81.6%) cases. Misreading of X-rays was seen in 22 (28.9%) cases, poor quality x-rays in 17 (22.4%) cases, improper x- rays in 10 (13.2%) cases, and failure to order for x-rays in 16 (21.1%) cases. Conclusions: Good history and clinical examinations are essential. Proper x-rays should be taken and poor-quality x- rays should not be accepted but repeated. Most injuries missed on radiographs are not difficult to diagnose. Re-evaluation of patients should be done in an emergency, and with poly-trauma patients.

Risk Factors of Hospital-Acquired Pneumonia Among Hospitalized Patients With Cardiac Diseases.

Background To our knowledge, no studies have been done in Saudi Arabia to determine the risk factors of hospital-acquired pneumonia (HAP) among hospitalized cardiac patients. This study aimed to assess these risk factors. Methods A retrospective study was done at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia. Five hundred hospitalized patients diagnosed with pre-existing cardiovascular disease (CVD) were included. A checklist was used to collect data about patients' demographic characteristics; BMI; smoking and alcohol abuse; type of cardiac disease; other chronic diseases; exposure to immunosuppressives; chemotherapyand radiotherapy in the last six months; glucocorticoiduse; application of ventilator; initial, follow-up chest X-ray results; pneumonia vaccination status; nasogastric tube use; general anesthesia received; use of loop diuretics; presence of pulmonary diseases; levels of WBC, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP); results of blood and respiratory cultures; number of hospitalizations and intensive care unit (ICU) admissions in the last six months; and Richmond Agitation and Sedation Scale (RASS) score. Results The prevalence of pneumonia was 7%. Females; patients with autoimmune diseaseswho were exposed to immunosuppressives or glucocorticoids; those with an initial or second abnormal chest X-ray; patients who used nasogastric tube, had pulmonary disease, and had high levels of WBC, ESR, or CRP; and patients hospitalized for more than two times had a significantly higher percentage of having pneumonia. Abnormal second chest X-ray, high ESR, and more than two times of hospitalization within the last six months were the risk factors of pneumonia on multivariate logistic regression analysis. Conclusion Better prevention and intervention programs are needed to assess the risk factors of pneumonia among admitted cardiac patients.

Patient-specific finite element modeling of scoliotic curve progression using region-specific stress-modulated vertebral growth

PurposeThis study describes the creation of patient-specific (PS) osteo-ligamentous finite element (FE) models of the spine, ribcage, and pelvis, simulation of up to three years of region-specific, stress-modulated growth, and validation of simulated curve progression with patient clinical angle measurements. Research Question: Does the inclusion of region-specific, stress-modulated vertebral growth, in addition to scaling based on age, weight, skeletal maturity, and spine flexibility allow for clinically accurate scoliotic curve progression prediction in patient-specific FE models of the spine, ribcage, and pelvis?MethodsFrontal, lateral, and lateral bending X-Rays of five AIS patients were obtained for approximately three-year timespans. PS-FE models were generated by morphing a normative template FE model with landmark points obtained from patient X-rays at the initial X-ray timepoint. Vertebral growth behavior and response to stress, as well as model material properties were made patient-specific based on several prognostic factors. Spine curvature angles from the PS–FE models were compared to the corresponding X-ray measurements.ResultsAverage FE model errors were 6.3 ± 4.6°, 12.2 ± 6.6°, 8.9 ± 7.7°, and 5.3 ± 3.4° for thoracic Cobb, lumbar Cobb, kyphosis, and lordosis angles, respectively. Average error in prediction of vertebral wedging at the apex and adjacent levels was 3.2 ± 2.2°. Vertebral column stress ranged from 0.11 MPa in tension to 0.79 MPa in compression.ConclusionIntegration of region-specific stress-modulated growth, as well as adjustment of growth and material properties based on patient-specific data yielded clinically useful prediction accuracy while maintaining physiological stress magnitudes. This framework can be further developed for PS surgical simulation.

Accuracy of the radiological protocols in detecting scaphoid fractures, a retrospective study

Early and accurate diagnosis of scaphoid fractures is vital for improving patient outcomes. However, there is no international agreement on the optimal imaging examination for diagnosing suspected scaphoid fractures. This study aimed to assess the different imaging examinations of scaphoid fractures at three major hospitals in Najran, Saudi Arabia. Radiological strategies for imaging suspected scaphoid fracture were determined using a short cross-sectional survey. The accuracy of the different imaging techniques was compared, and the number of patients with a scaphoid fracture who underwent examination at these hospitals in the past year preceding the start of this study was also investigated. The results showed that plain x-ray was the first line of imaging examination for suspected scaphoid fracture at the three hospitals. When the initial plain x-ray could not rule out scaphoid fracture, a repeated x-ray (10–14 days) was used as second-line imaging in two hospitals, while computed tomography (CT) was used as a third line of imaging. In the third hospital, CT scan was used as the second line of imaging, while magnetic resonance imaging (MRI) was used as the third line of imaging. A total of 112 patients sustained scaphoid fractures in the three hospitals. Initial plain x-ray was able to diagnose 72% of all cases as the first imaging line. Repeated x-ray identified 60% of the fractures that were not detected on the initial plain radiograph, while CT scans identified 88% of the fractures that were not detected on the first plain radiograph. Repeated plain x-rays maybe not be the ideal second-line imaging for scaphoid fracture. The ability of the CT scan to detect scaphoid fracture at an early stage was evident (p = 0.001). Altogether, these results indicate the important role of CT scan in diagnosing scaphoid fracture at an early stage. More studies are warranted to improve the national guidelines for the radiological investigation of scaphoid fractures.

Reconstruction of posterior dislocation of the sternoclavicular joint with nonabsorbable No. 5 ethibond sutures

Posterior sternoclavicular joint dislocation (PSCJD) is rare. It is usually due to contact sports or trauma and is often associated with multiple life-threatening complications. We report a case of a Kabaddi player (an Indian contact sport) who was pushed by an opponent and fell on his right shoulder. The patient complained of right shoulder pain and visible deformity over the right sternal area. After initial X-rays, the right posterior dislocation of the sternoclavicular joint was confirmed with computed tomography scan. After the attempts of closed reduction failed, open reduction and internal fixation were done with a double loop of No. 5 ethibond sutures. Excellent results can be achieved in PSCJD using open reduction and reconstruction techniques with double-stranded 5.0 ethibond nonabsorbable sutures.

Kontuzija i perforacija tankog creva usled retke tupe traume abdomena

Introduction: Small bowel injuries are rare, accounting for only 1% - 5% of injuries following blunt abdominal trauma, while small bowel perforation has been reported in 0.3% of patients. Delays in early diagnosis or misdiagnosis significantly contribute to the mortality and morbidity associated with small bowel injuries. Blunt abdominal trauma poses a diagnostic challenge, with focused assessment using sonography in trauma and computed tomography abdomen becoming invaluable methods for diagnosis, integrated into management guidelines. Case Report: We present a case of jejunal perforation and contusion resulting from blunt abdominal injury due to a fall onto a fence. The initial chest X-ray did not reveal any traumatic injuries or sub diaphragmatic free gas. Computed tomography of the abdomen and small pelvis revealed free fluid in the peritoneal cavity and thickening of the jejunal wall, corroborated by abdominal ultrasound. Surgical intervention confirmed a diagnosis of small jejunal perforation. Conclusion: Given the minimal and often clinically undetectable signs in patients with blunt abdominal trauma, timely and accurate imaging diagnostics and prompt surgical intervention significantly reduce the morbidity and mortality associated with these injuries.

Extensive subcutaneous emphysema with pneumothorax in COVID-19

Subcutaneous emphysema is the infiltration of air in the subcutaneous tissues. There are multiple causes of subcutaneous emphysema that can occur, for example, due to surgery, infection, barotrauma, trauma, or spontaneous. In a patient with respiratory failure on mechanical ventilation especially in severe Acute respiratory distress syndrome (ARDS), positive pressure ventilation may lead to subcutaneous emphysema. During positive pressure ventilation, small mucosal injury in the trachea or the bronchi leads air to escape out of the airways. The air then travels along the endovascular bundle into the mediastinum and then follows the facial planes into the neck and subcutaneous tissue of the chest. Positive pressure ventilation may also lead to a pneumothorax due to barotrauma or volutrauma. The subsequent injury to the parietal pleura causes air to leak into the subcutaneous tissue of the chest. This is a 71-year-old female with a history of type 2 diabetes, hypertension, and obesity, who was admitted for acute hypoxic respiratory failure secondary to COVID-19. In the emergency room (ER) her oxygen saturation was 75% on room air, and she was started on supplemental oxygen. Laboratory workup revealed a normal complete blood, count and complete metabolic panel, c-reactive protein (CRP) was elevated at 13.5 mg/dL and COVID-19 polymerase chain reaction (PCR) was positive. Initial chest X-ray was also normal with very mild right lower lobe infiltrate. On hospital day 10, she was intubated for worsening respiratory failure. Seven (7) days post-intubation, chest X-ray (A) revealed significant subcutaneous emphysema (blue arrows). A computed tomography (CT) scan of the chest (B) was obtained which revealed a left pneumothorax (red arrow) with significant subcutaneous emphysema.