Standard View Research Articles

Sonothrombolysis with microbolus administration of perfluoropropane as point of care therapy for STEMI patients

Abstract Introduction There are still major obstacles to timely revascularisation of STEMI patients even on arrival to PCI capable centers. Delivery of intermittent high mechanical index(MI) pulses during contrast infusion(Sonothrombolysis) has been shown to improve culprit vessel recanalization rates, reduce infarct size and improve myocardial hemodynamics. Purpose Our objective was to see if sonothrombolysis administered with a low dose of echo contrast(2mL) given as successive microboluses resulted in angiographic recanalisation. This is pertinent in our resource limited setup as continuous infusion needs specialised pumps and cost of echo contrast is high. Methods This was a randomised control trial on 100 patients presenting with first STEMI (within a window period of 12 hours, Killips stage I or II) to the Chest Pain Unit(CPU) of our institution. The intervention was sonothrombolysis during successive microboluses of perfluoropropane followed by PPCI. Technique of Sonothombolysis: 1 vial of perfluoropropane(2mL) is agitated and diluted in 20ML normal saline(0.1%w/v). Using a 3 way stop cock, 2mL solution is given while performing echocardiography in standard views. This leads to good chamber opacification for 40-60 beats. Once chamber opacification is adequately achieved (usually within 10 beats), high MI pulses (>1.1 MI) were given repeatedly after low MI imaging shows replenishment of microbubbles in the myocardial segment. Once opacification wanes, then another bolus of 2mL is given and steps repeated. The control group underwent low MI imaging with 0.2mL of perfluoropropane followed by PPCI. Results The trial was halted after recruitment of 57 patients following an interim analysis which showed no significant benefit with sonothrombolysis. Angiographic recanalization of culprit vessel occured in 28% of cases (8vs6, p=0.589). Baseline characteristics were similar across both groups. The time from first medical contact(FMC) to balloon time were similar. The use of Gp IIb/IIIa inhibitors or thrombus aspiration catheters did not differ. Discussion Sonothrombolysis with successive microboluses of perflouropropane is not effective in producing angiographic recanalization in STEMI patients. Our results vary from that of Mathias et al which showed a 48% angiographic recanalization rate. The protocol of giving microboluses as against continuous infusion could have contributed though we looked specifically for microbubble replenishment in myocardial segments before delivering high MI pulses. Secondly the higher prevalence of diabetes, dyslipidemia and multivessel CAD in our population could have contributed to the lack of efficacy. Thirdly the mean window period (time between onset of symptoms to arrival at CPU) was 7±2.31hrs which could have contributed to thrombus organization and resistance to shearing forces produced by microbubble cavitation. Further randomized studies are needed to see the efficacy of sonothrombolysis in other populations.Table 1.Baseline CharacteristicsTable 2.Results

High frame rate speckle tracking echocardiography to visualize the mechanical activation sequence of the left ventricle

Abstract Background Cardiac arrhythmias are a known cause of morbidity and mortality, with catheter ablation being an effective treatment. In order to detect the focal source or the re-entrant circuit of the arrhythmia, i.e. the ablation target, current practice includes performing an electrophysiological study. This technique is invasive, with increased patient related risk and variable success rate. Conversely, echocardiography could be used to determine the correct ablation target. High frame rate (HFR) ultrasound has a temporal resolution adequately high to detect the onset of myocardial deformation and could assist the accurate localisation of the arrhythmia source. Purpose To test whether HFR speckle tracking echocardiography (STE) can be used to create cardiac mechanical activation maps. Methods 18 healthy volunteers (HV) (age 30±6y; 69 %males) and 12 heart failure patients treated with cardiac resynchronisation therapy (CRT) (age 69±10y; 75 %males) were included. All participants were scanned with a research HFR ultrasound scanner (∼849fps) and the 3 standard apical views were acquired. Patients were scanned with CRT on and after turning CRT off, in order to allow intrinsic ventricular conduction. Data from one CRT patient were acquired by temporarily altering the pacing pole of the CRT LV lead. All patients had a left bundle branch block (LBBB) pattern of native activation on the surface ECG. For each view, a manually placed contour was tracked during the cardiac cycle by a custom-made 2D HFR STE algorithm; the contours were divided in a standard 16 segment model and segmental strain rate (SR) curves were computed and used to measure the temporal distance between electrical and mechanical activation (i.e. distance between the beginning of QRS and the first positive to negative zero crossing in the SR curve). Finally, an activation map for each subject was created by placing the extracted timings in the middle of the corresponding segment of a bull’s-eye plot and interpolating values between them. Results Tracking was feasible in 94% of the segments; SR curves showed a physiological pattern (Fig. 1A). For the HV, mechanical activation started from mid anteroseptal (72%) or mid inferoseptal (28%) segment at 23±5ms, spreading to basal posterolateral segment at 49±8ms from the start of QRS, in all but one case, where activation ended at basal inferoseptal segment (Fig. 1B). During CRT off, septal wall was activated 31±9ms and lateral wall 74±20ms after the beginning of QRS (p<0.01) (Fig. 1C), whereas during CRT on, septal wall was activated 41±11ms and lateral wall 38±7ms after the beginning of QRS (p=0.3) (Fig. 1D). Changing the pacing pole of the LV lead in one CRT patient also changed the start of mechanical activation in the lateral wall (Fig. 2). Conclusion Our findings comply with left ventricular activation as described in the literature and show that HFR STE could be a useful tool in defining the ablation target for arrhythmia treatment.

Echocardiography-Based Deep Learning Model to Differentiate Constrictive Pericarditis and Restrictive Cardiomyopathy

BackgroundConstrictive pericarditis (CP) is an uncommon but reversible cause of diastolic heart failure if appropriately identified and treated. However, its diagnosis remains a challenge for clinicians. Artificial intelligence may enhance the identification of CP. ObjectivesThe authors proposed a deep learning approach based on transthoracic echocardiography to differentiate CP from restrictive cardiomyopathy. MethodsPatients with a confirmed diagnosis of CP and cardiac amyloidosis (CA) (as the representative disease of restrictive cardiomyopathy) at Mayo Clinic Rochester from January 2003 to December 2021 were identified to extract baseline demographics. The apical 4-chamber view from transthoracic echocardiography studies was used as input data. The patients were split into a 60:20:20 ratio for training, validation, and held-out test sets of the ResNet50 deep learning model. The model performance (differentiating CP and CA) was evaluated in the test set with the area under the curve. GradCAM was used for model interpretation. ResultsA total of 381 patients were identified, including 184 (48.3%) CP, and 197 (51.7%) CA cases. The mean age was 68.7 ± 11.4 years, and 72.8% were male. ResNet50 had a performance with an area under the curve of 0.97 to differentiate the 2-class classification task (CP vs CA). The GradCAM heatmap showed activation around the ventricular septal area. ConclusionsWith a standard apical 4-chamber view, our artificial intelligence model provides a platform to facilitate the detection of CP, allowing for improved workflow efficiency and prompt referral for more advanced evaluation and intervention of CP.

Abstract 14030: Hemodynamic Metrics Can Be Accurately Assessed by a Non-Invasive Sensor Patch: The Portable Technology for Wireless Cardiomyopathy Tracking (Patchwrk) Study

Background: Echocardiographic timing intervals provide valuable prognostic information in patients with pre-clinical cardiac dysfunction. Diastolic filling time (DFT) can identify left bundle branch block (LBBB) patients at higher risk for cardiomyopathy. The need for specialized equipment limits the utility of echo in longitudinal assessment. Hypothesis: A non-invasive multimodal sensor Sansa patch will enable accurate assessment of hemodynamic parameters such as DFT, ejection time (ET), and pre-ejection period (PEP). Methods: Fifty patients scheduled for clinically indicated echocardiography were prospectively enrolled and had simultaneous application of the Sansa patch at the time of echocardiography. Timing intervals were analyzed using continuous wave (CW), pulsed wave (PW), and tissue Doppler imaging (TDI). Data from the Sansa electrocardiogram (ECG), seismocardiogram (SCG), and phonocardiogram (PCG) were independently analyzed to identify valve openings/closures to estimate DFT, ET and PEP. Agreement between echo and Sansa estimates was assessed using the coefficient of determination (R 2 ) and compared with agreement between different echo views. Results: Forty-six of the 50 patients (92%) had data of sufficient quality for analysis. The mean ejection fraction was 53±8% and 11 patients (24%) had LBBB. By echo, the mean DFT, ET, and PEP were 408±137 milliseconds (ms), 297±35ms, and 107±32ms respectively. Sansa estimates for DFT, ET and PEP were 431±135ms, 286±43ms, and 89±34ms respectively. The R 2 for Sansa DFT compared to echo was 0.85. Comparing TDI and PW estimates of DFT within the same patients demonstrated an R 2 of 0.82. Conclusion: Non-invasive Sansa patch monitoring accurately identified key cardiac timing intervals within the error observed between standard echo views. These measures have prognostic value and monitoring them in the ambulatory setting may allow early cardiomyopathy detection and upstream intervention.

Reasonable standards and exculpating moral ignorance

AbstractIt is widely agreed that ignorance of fact exculpates, but does moral ignorance exculpate? If so, does it exculpate in the same way as non-moral ignorance? In this paper I will argue that on one family of views explaining exculpating non-moral ignorance also explains exculpating moral ignorance. The view can be loosely stated in the following way: ignorance counts as an excuse only if it is not the result of a failure to meet some applicable reasonable epistemic standard—call this the Reasonable Epistemic Standards Thesis and call views that accept some version of this principle reasonable standards views. I argue that any plausible reasonable standards view ought to allow that moral ignorance exculpates, at least sometimes, and defend such views against the charge that they are susceptible to clear counterexamples.

Echocardiographic Evaluation of the Right Heart in Pulmonary Hypertension

Pulmonary hypertension (PH) is characterized by increased right ventricular (RV) afterload, which is accommodated early by dramatic increases in RV contractility to maintain right ventriculoarterial coupling. Related to its tissue biology, characteristics of RV contractility differ from those of the left ventricle (LV). As the RV undergoes adaptation in PH, echocardiographic signs emerge which can help identify PH and can be reassessed to noninvasively prognosticate outcomes in PH. Many of these indices can be calculated from standard echocardiographic views without significant modification to scanning procedures. This review will discuss contemporary diagnosis of PH, highlighting the role of echocardiography in this process. We will describe the differences between the LV and RV, including adaptations of the RV in PH, and how these factors impact echocardiographic assessment. We will conclude with a discussion of specific echocardiographic parameters and describe their role in diagnosis and reassessment. Routine assessment of the right heart improves noninvasive risk stratification in PH, may reduce delays in diagnosis, and ultimately may impact the significant and potentially modifiable disease burden in this patient population.

Assessing the inferential strength of epistemic must

This article presents four experiments that investigate the meaning of English and Italian statements containing the epistemic necessity auxiliary verb must/dovere , a topic of long-standing debate in the philosophical and linguistics literature. Our findings show that the endorsement of such statements in a given scenario depends on the participants’ subjective assessment about whether they are convinced that the conclusion suggested by the scenario is true, independently from their objective assessment of the conclusion’s likelihood. We interpret these findings as suggesting that English and Italian speakers use epistemic necessity verbs to communicate neither conclusions judged to be necessary (contrary to the prediction of the standard modal logical view) nor conclusions judged to be highly probable (contrary to the prediction of recent analyses using probabilistic models) but conclusions whose truth they believe in (as predicted by the analysis of epistemic must as an inferential evidential). We suggest that this evidential meaning of epistemic must/dovere might have arisen in everyday conversation from a reiterated hyperbolic use of the words with their original meaning as epistemic necessity verbs.

Improving the Quality of Fetal Heart Ultrasound Imaging with Multihead Enhanced Self-Attention and Contrastive Learning.

Fetal congenital heart disease (FCHD) is a common, serious birth defect affecting ∼1% of newborns annually. Fetal echocardiography is the most effective and important technique for prenatal FCHD diagnosis. The prerequisites for accurate ultrasound FCHD diagnosis are accurate view recognition and high-quality diagnostic view extraction. However, these manual clinical procedures have drawbacks such as, varying technical capabilities and inefficiency. Therefore, the automatic identification of high-quality multiview fetal heart scan images is highly desirable to improve prenatal diagnosis efficiency and accuracy of FCHD. Here, we present a framework for multiview fetal heart ultrasound image recognition and quality assessment that comprises two parts: a multiview classification and localization network (MCLN) and an improved contrastive learning network (ICLN). In the MCLN, a multihead enhanced self-attention mechanism is applied to construct the classification network and identify six accurate and interpretable views of the fetal heart. In the ICLN, anatomical structure standardization and image clarity are considered. With contrastive learning, the absolute loss, feature relative loss and predicted value relative loss are combined to achieve favorable quality assessment results. Experiments show that the MCLN outperforms other state-of-the-art networks by 1.52-13.61% when determining the F1 score in six standard view recognition tasks, and the ICLN is comparable to the performance of expert cardiologists in the quality assessment of fetal heart ultrasound images, reaching 97% on a test set within 2 points for the four-chamber view task. Thus, our architecture offers great potential in helping cardiologists improve quality control for fetal echocardiographic images in clinical practice.

Are acromiohumeral distance measurements on conventional radiographs reliable? A prospective study of inter-method agreement with ultrasonography, and assessment of observer variability.

This study aims to investigate the reliability of acromiohumeral distance (AHD) measurements using conventional radiographs and to compare non-standardized and standardized radiographs with intra-/interobserver reliability measurements. Between February 2021 and January 2022, a total of 110 shoulders of 55 patients (25 males, 30 females; mean age: 49.7±12.6 years; range, 25 to 77 years) were included. Radiographs were taken in four different positions: primarily shoulder anteroposterior (AP), true AP, standardized true AP, and standardized outlet views. The AHD was measured by three orthopedists. A prospective ultrasonography (US) evaluation was performed by an experienced physiatrist, and the relationship between US and radiographic measurements was evaluated. The intra- and interobserver reliability of radiographic measurements was assessed. On the standardized true AP view measurements, all observers showed a moderate to good agreement with US measurements (intraclass correlation coefficients [ICC]: 0.68-0.75). There was no significant difference between the AHD measurements of the senior orthopedist on standardized true AP and outlet views, and the US measurements. The intraobserver agreement of US measurements was excellent (ICC: 0.98, 95% confidence interval [CI]: 0.98-0.99), and the intraobserver agreement level of measurements on radiographs were good to excellent with a wide range of ICC values (ICC: 0.79-0.97). Interobserver reliability was the highest on the standardized outlet view, with an ICC of 0.91 and 0.88 in two measurement times. Interobserver reliability of other measurements were good with ICC values ranging from 0.82 to 0.88. The AHD measurements on radiographs are compatible with US measurements within up to 2 mm difference if standardization is ensured. Also, measurements on standardized views have a superior consistency with lower standard error of measurement and minimal detectable change values. Therefore, we recommend using standardized true shoulder AP and standardized outlet radiographs in clinical practice and studies, as these are the most accurate in demonstrating true AHD.

Resolving a puzzle about the fixity of the past

Abstract In his 2022 article ‘A puzzle about the fixity of the past’, Lampert argues that standard views concerning knowledge and the semantics of ‘actually’ conflict with a widely held principle concerning the fixity of the past. I show that his attempt to establish the conflict fails, as it rests on the implicit assumption that a past mental state or utterance involving a modal indexical must have the same content across worlds with a shared past, when in fact it must, given its character, differ in content.

The Epigenesis of Germs and Dispositions in Logic and Life: Kant’s System of Pure Reason and His Concept of Race

Abstract In the 1787 Transcendental Deduction of the Categories Kant indicates the only possible ways by which one can account for a necessary agreement of experience with the concepts of its objects (B166), using analogies between modes of explanation and biological theories about the origin of life. He endorses epigenesis as a model for his system of pure reason (B167). This paper examines various interpretive claims about the meaning of this theory of generation and its significance for Kant’s philosophy (Section 1), showing that, after his Critical shift in perspective, in 1775/77 Kant already combined preformed elements and their purposively oriented formation by natural forces (Section 2). Contrary to the standard view, Kant’s theory of race appears to constitute the background to assess Blumenbach’s later (1799/1781) shift to epigenesis after supporting Haller’s preformism (Section 3). In Section 4, I argue that the ground of affinity between epigenesis and formal idealism rests in tracing the first origin of these conformities: external a posteriori climate conditions and predisposed germs and dispositions within the generative power of the human body; and external a posteriori experience and spontaneous a priori concepts of its objects, within pure sensory intuiting and pure thinking. In both cases the external empirical conditions would function as occasioning propelling factors affecting internal pre-established forms of generation.

Desire satisfaction and its discontents

According to a well-established view of desire satisfaction, a desire that p is satisfied iff p obtains. Call this the 'standard view'. The standard view is purely semantic, which means the satisfaction condition of desires is placed in the truth of the embedded proposition that indicates the content of the desire. This paper aims to defend the standard view against two frequently discussed problems: the problem of underspecification and desires conditional on their own persistence. The former holds that the standard view cannot capture the specific ways of desire satisfaction. The latter holds that the standard view does not provide sufficient conditions for the satisfaction of desires conditional on their own persistence. To address the first problem, I will disambiguate different interpretations of desire ascriptions using de re/de dicto distinction. My argument to address the second problem rests on the disambiguation of different senses of satisfaction: semantic and agent.

Research on Cohen’s Marxist View of Equality

Cohen’s Marxist view of equality is formed on the basis of criticizing liberals and classical Marxism. On the one hand, he opposes the equality thought of Rawls and Nozick, and on the other hand, he tries to establish a realistic and standardized Marxist view of equality. In addition, Cohen, while criticizing the arguments of the liberals, also constantly rethinks the classical Marxism on the concept of equality, and reconstructs the Marxist concept of equality to a certain extent. Dialectically speaking, although Cohen’s view of equality differs from the Marxist view of equality, it still plays a vital role in the construction of an equal society and the development of equality thought.

An Objective Evaluation of Cleft Lip Repair Deformities Based on Standardized Photographic Views.

Several assessment systems of the cleft-related facial deformity have been reported in the medical literature. Assessments have been made from direct clinical evaluations, photographs, on-screen digital images, and 3-dimensional imaging. An evaluation method based on standardized photographic views is developed to evaluate the most common postoperative deformities and to detect the responsible factors for occurrence of these deformities and how to avoid them. One hundred forty-five cleft lip cases (105 unilateral and 40 bilateral) were evaluated by using standard sheet and scoring system designed by Operation Smile Inc (Virginia Beach). The scoring system is based on photographic analysis of items including Cupid's bow, nasal symmetry, vermilion contour, white roll continuity, and scar quality. In the unilateral cleft cases, we found 0.4% excellent, 48.57% good, 38% fair, and 2.85% poor cases. For bilateral clef lip cases, we found 27.5% excellent, 47.5% good, 17.5% fair, and 7.5% poor outcomes. The most common postoperative deformities were nasal asymmetry, scar hypertrophy, deformed Cupid's bow, and vermilion contour asymmetry. This objective evaluation system can determine the common cleft lip nasal deformities with detection of the responsible factors. Principles that guide optimum surgical repair have been advocated to avoid the common postoperative deformities. Scar formation is an independent factor that must be managed early and separately to maintain surgical outcomes.

Deep learning assisted measurement of echocardiographic left heart parameters: improvement in interobserver variability and workflow efficiency.

Machine learning techniques designed to recognize views and perform measurements are increasingly used to address the need for automation of the interpretation of echocardiographic images. The current study was designed to determine whether a recently developed and validated deep learning (DL) algorithm for automated measurements of echocardiographic parameters of left heart chamber size and function can improve the reproducibility and shorten the analysis time, compared to the conventional methodology. The DL algorithm trained to identify standard views and provide automated measurements of 20 standard parameters, was applied to images obtained in 12 randomly selected echocardiographic studies. The resultant measurements were reviewed and revised as necessary by 10 independent expert readers. The same readers also performed conventional manual measurements, which were averaged and used as the reference standard for the DL-assisted approach with and without the manual revisions. Inter-reader variability was quantified using coefficients of variation, which together with analysis times, were compared between the conventional reads and the DL-assisted approach. The fully automated DL measurements showed good agreement with the reference technique: Bland-Altman biases 0-14% of the measured values. Manual revisions resulted in only minor improvement in accuracy: biases 0-11%. This DL-assisted approach resulted in a 43% decrease in analysis time and less inter-reader variability than the conventional methodology: 2-3 times smaller coefficients of variation. In conclusion, DL-assisted approach to analysis of echocardiographic images can provide accurate left heart measurements with the added benefits of improved reproducibility and time savings, compared to conventional methodology.

The distal tibiofibular syndesmosis is a reliable landmark for 3° varus tibial resection in total knee arthroplasty: a radiological evaluation on 1296 cases.

The purpose of this study was to evaluate the reproducibility and the accuracy of distal tibiofibular syndesmosis (DTFS) as landmark to perform controlled varus tibial resections during total knee arthroplasty (TKA). The hypothesis was that DTFS can be used to perform an accurate 3° varus tibial cut. A retrospective analysis on a consecutive series of standard weightbearing full-length anteroposterior views of the lower limbs radiographic images was conducted. For each radiograph, the hip-knee-ankle (HKA) angle, the angle between the tibial mechanical axis and the line connecting the centre of the tibial spines and the DTFS (tibiofibular angle, TFA) and the medial proximal tibial angle (MPTA) were calculated. Each measurement was carried out twice by three independent observers, and intra- and inter-observer measurement reliability were assessed using the intraclass correlation coefficient (ICC) analysis. A total of 1296 lower limbs were analysed from a series of 648 weightbearing full-length anteroposterior radiographs. The ICC were > 90% for all measurements. The mean TFA value was 2.94 ± 0.68 (range 2.38-3.51). No differences were detected comparing the mean TFA value on the right and left limb (p = 0.795) as well as comparing the values in male and female patients (p = 0.691). Linear regression analysis did not find statistically significant correlation between TFA and MPTA, or TFA and HKA angles, respectively. The distal tibiofibular syndesmosis is a reliable and easy reproducible radiographic landmark that can be used when planning a 3° varus tibial cut. Future studies are needed to confirm the validity of this method also in clinical settings. IV, retrospective case series.

Substantive Social Metaphysics

Social metaphysics is a source of important philosophical and moral insight. Furthermore, much social metaphysics appears to be substantive. However, some have recently argued that standard views of metaphysics cannot accommodate substantive social metaphysics. In this paper I offer a new diagnosis of this problem and defend a new solution, showing that this problem is an illuminating lens through which to examine the nature and boundaries of metaphysics. This case instantiates a broad, common pattern generated by attempts to align distinctions between realism and anti-realism, mind-independence and mind-dependence, and legitimate and non-legitimate inquiry. I show that the best response is to abandon the association between substantive metaphysics and mind-independence, and I sketch a new definition of substantivity, given in terms of explanatory power, that makes room for substantive social metaphysics while also offering an attractive basis for general metaphysics.

Prejudice, generics, and resistance to evidence

ABSTRACT In his book, Prejudice, Endre Begby offers a novel and engaging account of the epistemology of prejudice which challenges some of the standard assumptions that have so far guided the recent discussion on the topic. One of Begby's central arguments against the standard view of prejudice, according to which a prejudiced person necessarily displays an epistemically culpable resistance to counterevidence, is that, qua stereotype judgments, prejudices can be flexible and rationally maintained upon encountering many disconfirming instances. By expanding on Begby's analysis, I argue that, given the variety of truth conditions for true generic statements, the generic form of stereotype judgements can sometimes make prejudice extremely resistant to encounters with statistical facts about the distribution of the property among members of a certain group. At the same time, I argue that a more careful consideration of the generic form of stereotypes also allows us to recognize that evidence about how many members of the kind instantiate a property is not the only type of evidence which could disconfirm a prejudice. Evidence of no explanatory relation between a kind and a property should also have a direct effect on a prejudicial belief. For this reason, things may not look as dim for the standard view of prejudice in assessing paradigmatic instances of prejudicial beliefs as irrationally resistant to evidence.

Disability after breast cancer surgery: Proposal of linkage between the International Classification of Functioning, Disability and Health and the Grocery Shelving Task Test.

To link the concepts measured by the Grocery Shelving Task Test (GST) to the codes and qualifiers of the activity and participation component of the International Classification of Functioning, Disability and Health (ICF). The linkage was performed by two professionals who applied the 10 standardized binding rules. The linking process was performed through the model of extraction and identification of the concepts that were found in each item of the GST Test. The GST test includes 1 domain of the activity and participation component (d4 mobility). The link with the qualifiers allowed quantifying the impairment of the limitations of activities in the postoperative period, being observed that 21.27% of the sample did not present any problem, 61.70% presented the qualifier "0.1" (mild problem), 8.50% had a moderate problem (qualifier '0.2') and 8.50% had a severe problem (qualifier '0.3'). No complete impairment was observed in any study participant. The linking of the GST to the ICF codes and qualifiers allowed quantifying the functional impairment in the postoperative period of breast cancer, allowing a comprehensive and standardized view, and being a guiding tool for treatment plans.

Hysterosalpingography: a step up for dose reduction

To evaluate the efficiency of last image capture in interpreting a hysterosalpingogram (HSG) when compared to conventional spot views; to confirm its validity in showing pathology; to establish its use as the preferred method; and to decrease the radiation dose to the patient. The study population consisted of women aged ≥18 years. A standard technique was performed including additional five last image capture after each spot view. Every patient had two stacks of images, one with the exposure film and one with the last image capture. The images were interpreted separately (high-dose versus low-dose) and blindly by two radiologists with different levels of training assessing for uterine abnormalities, fallopian tube abnormalities, peritoneal spillage, and incidental findings. Inter-reading variability was calculated using Kohen's kappa. Discrepancies between exposure film and last image capture were detected in only a minority of cases for all variables. Except for the presence of strictures, there was at least substantial agreement between the readers and almost perfect agreement regarding peritoneal spillage and fallopian tube patency, both on exposure film and last image capture. Reduction in radiation dose without compromising the diagnostic efficacy of HSG is mandatory. If the study is of sufficient quality and deemed negative on last image capture, conventional spot view can be avoided. If further detail is required, standard spot views can still be obtained. Using last image capture instead of spot films has the potential to reduce the overall radiation dose by up to 78%.