Unnecessary Invasive Testing Research Articles

The Clinical Lens: It is time to start using the right test for febrile young infants

Abstract Fever among infants in the first months of life is a common clinical conundrum facing all clinicians who treat children. Most well-appearing febrile young infants have viral illnesses. However, it is critical to identify those at risk of invasive bacterial infections, specifically bacteremia and bacterial meningitis. Clinicians must balance the risks of missing these infections against the harms of over-investigation. Procalcitonin testing is currently the best diagnostic test available to help guide management, and the Canadian Paediatric Society Position Statement on the management of febrile young infants recommends procalcitonin-based risk stratification. However, in many clinical settings, procalcitonin is either unavailable or has a turnaround time that is too long to aid decision-making. Clinicians who care for febrile young infants must have rapid access to procalcitonin results to provide best-evidence, guideline-adherent care. The wider availability of this test is essential to reduce unnecessary invasive testing, hospitalizations, and antibiotic exposure and could reduce system-wide resource utilization.

Diagnostic Performance of Fractional Flow Reserve Derived From Coronary CT Angiography: The ACCURATE-CT Study

BackgroundAccuFFRct (ArteryFlow Technology) is a novel noninvasive method for calculating fractional flow reserve (FFR) from coronary computed tomography angiography (CCTA). The accuracy of AccuFFRct has not been adequately assessed. ObjectivesThis study sought to evaluate the diagnostic performance of AccuFFRct in detecting lesion-specific ischemia. MethodsThis prospective study enrolled 339 patients with 404 vessels. CCTA-derived FFR was calculated using an on-site computational fluid dynamics–based method and compared with invasive FFR. The performance of AccuFFRct was comprehensively analyzed in all lesions and subgroups, including “gray zone” lesions, various lesion classifications, clinical presentations, stenosis severities, and lesion locations. ResultsUsing FFR ≤0.80 as a reference standard, the overall diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for AccuFFRct were 90.6% (95% CI: 87.3%-93.3%), 90.9% (95% CI: 85.1%-94.9%), 90.4% (95% CI: 86.1%-93.8%), 85.3% (95% CI: 79.8%-89.5%), and 94.2% (95% CI: 90.8%-96.4%), respectively. Good correlation and agreement were found between the computed AccuFFRct and measured FFR. AccuFFRct showed superior discrimination ability to CCTA (AUC: 0.93 [95% CI: 0.89-0.95] vs 0.77 [95% CI: 0.72-0.81]; P < 0.001) and quantitative coronary angiography (AUC: 0.93 [95% CI: 0.89-0.95] vs 0.89 [95% CI: 0.85-0.92]; P = 0.048) for identifying functionally significant stenosis. Notably, AccuFFRct maintained high diagnostic accuracy across the spectrum of lesion classifications, clinical presentations, stenosis severities, lesion locations, and in the “gray zone”. Furthermore, in the cohort with ≥70% stenosis, AccuFFRct could significantly reduce the rate of un-necessary invasive tests (33.1% vs 6.6%; P < 0.001). ConclusionsThe study confirms the potential of AccuFFRct as a noninvasive alternative to invasive FFR for detecting ischemia in coronary artery disease and to risk stratify patients. The results highlight AccuFFRct’s robust diagnostic ability across a wide range of lesion classifications, clinical presentations, stenosis severities, lesion locations, and in the “gray zone”. (Diagnostic Performance of Fractional Flow Reserve Derived From Coronary CT Angiography [ACCURATE-CT]; NCT04426396)

Abstract PO1-07-12: Inverse modeling with surface temperature accurately detects the presence of breast cancer

Abstract Breast cancer affects over 250,000 women in the United States every year. Patient outcomes including overall survival significantly decline with large sized tumors and nodal involvement on initial presentation. The introduction of mammogram screening has been instrumental in the early detection of cancer. However, it has lower sensitivity in dense breast tissue and limited specificity which leads to unnecessary additional invasive testing. Several methods such as magnetic resonance imaging (MRI), computed tomography (CT) and ultrasound imaging are used as adjunctive methods. However, there is still a need for cost-effective techniques without additional radiation exposure for breast cancer screening for use with mammography. We propose an adjunctive screening method using surface temperature measurements and inverse breast modeling for early detection of breath cancer. Methods: We enrolled patients who presented with mammogram detected breast tumors that were confirmed to be cancerous lesions by biopsy. We used prone position steady state infrared imaging of bilateral breasts to measure surface temperatures and multi-view MRI images to create patient specific 3D breast models. The inverse technique applies Levenberg-Marquard algorithms (LMA) and utilizes commercial software for thermal transport modeling. The inverse technique predicts a heat generation map normalized for baseline surface temperatures to localize the presence of an underlying tumor. Results: A total of 25 breast tumors (diameter range from 5 to 27 mm) from 24 patients were included in the analysis with a median patient age of 67 years. One patient had bilateral breast tumors. Mammogram data showed inclusion of mixed breast tissue composition including dense and extremely dense breast tissue. LMA accurately detected the tumor in all 25 patients with maximum absolute errors of 7 mm in location of the tumor in the breast and 1.78 mm in diameter. The accuracy of detection was not affected by tumor histology which included invasive ductal and lobular carcinomas, ductal and lobular carcinoma in-situ and atypical ductal hyperplasia. No heat sensitive tumors were detected in the 23 contralateral breasts which acted as internal negative controls. Conclusion: Infrared temperature profiles and inverse modeling successfully detected malignant breast tumors with no missed tumors or false positive results and could be used as adjunctive screening along with mammography, especially in patients with dense breast tissue. Citation Format: Nithya Sritharan, Carlos Gutierrez, Isaac Perez-Raya, Jose-Luis Gonzalez-Hernandez, Alyssa Owens, Donnette Dabydeen, Lori Medeiros, Satish Kandlikar, Pradyumna Phatak. Inverse modeling with surface temperature accurately detects the presence of breast cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-07-12.

The suffering is expensive: comparison of therapeutic costs between palliative care and dysthanasia patient

Objectives: Several studies highlight benefits of palliative care for patients with lifethreatening illnesses, especially in terms of pain control and improving life quality. However, there is still research gap, particularly in the Brazilian context, regarding its ability to reduce costs associated with unnecessary invasive tests and procedures often invested in dysthanasia patients, thereby relieving the burden on the healthcare system. Given this scenario, the objective was to determine whether there is a significant difference in healthcare costs between cancer patients receiving palliative care and those in dysthanasia. Method: Documentary research, analyzing 94 medical records of patients who died from cancer in a hospital, divided into two groups: 47 in palliative care and 47 in dysthanasia. The groups had their average costs compared by surveying all tests and procedures recorded in the last 30 days of each patient’s life, with values scored based on the price table of the Unified Health System (Sistema Único de Saúde). Results: Patients receiving curative care in dysthanasia incurred an average cost of 2,316.92 Brazilian Reais (SD = 3,146.60) for tests and procedures in the last 30 days of life. Patients in palliative care had an average cost of 945.40 Brazilian Reais (SD = 2,508.01). There is a statistically significant difference in the invested values between patients in palliative care and those in dysthanasia (U = 620.00; Z = -4.334; p &lt; 0.001). Conclusions: Implementing palliative care can be considered an effective strategy for reducing hospital costs, leading to significant savings within the healthcare system.

Diagnostic approach to penetrating neck trauma: What you need to know.

Diagnostic evaluation of penetrating neck trauma has evolved considerably over the last several decades. The contemporary approach to these injuries is based primarily on clinical signs of injury and multidetector computed tomographic angiography. The neck is evaluated as a unit, rather than relying on the surface anatomy zones in which external injuries are seen to guide the workup of internal injuries. This "no-zone" approach safely spares many patients from negative explorations and unnecessary invasive tests. The purpose of this review is to describe an evidence-based approach to the diagnostic evaluation of penetrating neck trauma, including indications for adjunctive testing beyond physical examination and multidetector computed tomographic angiography. Literature Synthesis and Expert Opinion; Level V.

Diagnostic accuracy of intravoxel incoherent motion (IVIM) and dynamic contrast-enhanced (DCE) MRI to differentiate benign from malignant breast lesions: A systematic review and meta-analysis

PurposeMagnetic resonance imaging (MRI) can reduce the need for unnecessary invasive diagnostic tests by nearly half. In this meta-analysis, we investigated the diagnostic accuracy of intravoxel incoherent motion modeling (IVIM) and dynamic contrast-enhanced (DCE) MRI in differentiating benign from malignant breast lesions. MethodWe systematically searched PubMed, EMBASE, and Scopus. We included English articles reporting diagnostic accuracy for both sequences in differentiating benign from malignant breast lesions. Articles were assessed by quality assessment of diagnostic accuracy studies-2 (QUADAS-2) questionnaire. We used a bivariate effects model for standardized mean difference (SMD) analysis and diagnostic test accuracy analysis. ResultsTen studies with 537 patients and 707 (435 malignant and 272 benign) lesions were included. The D, f, Ktrans, and Kep mean values significantly differ between benign and malignant lesions. The pooled sensitivity (95 % confidence interval) and specificity were 86.2 % (77.9 %–91.7 %) and 70.3 % (56.5 %–81.1 %) for IVIM, and 93.8 % (85.3 %–97.5 %) and 68.1 % (52.7 %–80.4 %) for DCE, respectively. Combined IVIM and DCE depicted the highest area under the curve of 0.94, with a sensitivity and specificity of 91.8 % (82.8 %–96.3 %) and 87.6 % (73.8 %–94.7 %), respectively. ConclusionsCombined IVIM and DCE had the highest diagnostic accuracy, and multiparametric MRI may help reduce unnecessary benign breast biopsy.

Childhood Outcomes in Children with and without Cardiac Echogenic Foci: An Electronic Birth Cohort Study in Wales, UK.

There is uncertainty about outcomes associated with cardiac echogenic foci (CEF) seen at the midtrimester ultrasound scan because of limited population-based follow-up data. This can lead to unnecessary invasive testing and significant parental anxiety. We analysed data from a cohort study, The Welsh Study of Mothers and Babies, to examine whether children with CEF had more adverse outcomes during childhood compared with children without CEF. Children born between 1 January 2009 and 31 December 2011 were followed until 31 January 2018, migration out of Wales, or death. The primary outcome was cardiac hospital admissions, defined a priori by an expert steering group. Secondary outcomes included congenital cardiac anomalies, and hospital admissions for other causes. There was no evidence of an association between isolated CEF and cardiac hospital admissions (hazard ratio 0.87, 95% confidence interval [CI] 0.33-2.25, p value 0.768), or with congenital cardiac anomalies. There was a small increased risk of a respiratory admission with isolated CEF (hazard ratio 1.27, 95% CI 1.04-1.54, p value 0.020). Further research is needed on features of CEF, such as location or number, to fully understand the clinical significance of these findings.

Clinical Manifestation of Cytomegalovirus-Associated Protein-Losing Enteropathy in Children.

In children, CMV-associated protein-losing enteropathy (PLE) is characterised by a benign course and spontaneous healing but can lead to generalised oedema. Poorly defined, it is diagnosed after unnecessary invasive tests. Children with CMV-associated PLE between 2009 and 2019 in two French hospitals are retrospectively described. Clinical and biological signs, CMV identification, endoscopy and histological findings, disease management and course are analysed. CMV-associated PLE is proven in 21 immunocompetent and 22 immunosuppressed patients, with ages consistent with primo-infection and reactivation, respectively. The digestive symptoms prevail in immunocompetent children, mainly with vomiting (85.7% versus 50%, CI [1.2; 39.2], p = 0.02). Immunocompetent patients show more oedema (61.9% versus 4.5%, CI [3.6; 1502.4], p < 0.001), linked to more severe hypoalbuminemia (21.2 g/L [17.6-25.7] versus 29.6 g/L [24.9-33.9], p = 0.01). A severe course is observed in 23.8% of the immunocompetent patients and 54.5% of the immunosuppressed ones (p = 0.06). Evidence of CMV infection based on non-invasive methods is found on 88.9% of immunocompetent and 95.5% of immunosuppressed patients (p = 0.58), while endoscopy was performed on 95.2% and 100% of them, respectively (p = 0.48), without any therapeutic change. Thus, CMV-associated PLE should be suspected in children with generalised oedema. Not as benign as previously described, it can be confirmed using non-invasive tests.

Discrimination Between Pre- and Postcapillary Pulmonary Hypertension Using Platelet RNA.

Background Appropriate treatment of pulmonary hypertension (PH) is critically dependent on accurate discrimination between pre- and postcapillary PH. However, clinical discrimination is challenging and frequently requires a right heart catheterization. Existing risk scores to detect postcapillary PH have suboptimal discriminatory strength. We have previously shown that platelet-derived RNA profiles may have diagnostic value for PH detection. Here, we hypothesize that platelet-derived RNAs can be employed to select unique biomarker panels for the discrimination between pre- and postcapillary PH. Methods and Results Blood platelet RNA from whole blood was isolated and sequenced from 50 patients with precapillary PH (with different PH subtypes) as well as 50 patients with postcapillary PH. RNA panels were calculated by ANOVA statistics, and classifications were performed using a support vector machine algorithm, supported by particle swarm optimization. We identified in total 4279 different RNAs in blood platelets from patients with pre- and postcapillary PH. A particle swarm optimization-selected RNA panel of 1618 distinctive RNAs with differential levels together with a trained support vector machine algorithm accurately discriminated patients with precapillary PH from patients with postcapillary PH with 100% sensitivity, 60% specificity, 80% accuracy, and 0.95 (95% CI, 0.86-1.00) area under the curve in the independent validation series (n=20). Conclusions This proof-of-concept study demonstrates that particle swarm optimization/support vector machine-enhanced classification of platelet RNA panels may be able to discriminate precapillary PH from postcapillary PH. This research provides a foundation for the development of a blood test with a high negative predictive value that would improve early diagnosis of precapillary PH and prevents unnecessary invasive testing in patients with postcapillary PH.

Providing recurrence risk counselling for parents after diagnosis of a serious genetic condition caused by an apparently de novo mutation in their child: a qualitative investigation of the PREGCARE strategy with UK clinical genetics practitioners

BackgroundDiagnosis of a child with a genetic condition leads to parents asking whether there is a risk the condition could occur again with future pregnancies. If the cause is identified...

A Better Understanding of Pediatric Autoimmune Pancreatitis: Over 13 Years of Experience.

Pediatric autoimmune pancreatitis (P-AIP) is an uncommon disease whose diagnosis requires strong clinical suspicion. Late diagnosis increases morbidity. We aimed to compare the usefulness of the 2011 International Consensus Diagnostic Criteria (ICDC) for Autoimmune Pancreatitis with the 2018 INSPPIRE (INternational Study Group of Pediatric Pancreatitis: In search for a cuRE) criteria. We retrospectively analyzed demographics and clinical, laboratory, radiological, and histological findings at diagnosis and during long-term follow-up in children diagnosed with AIP in 2 tertiary hospitals between 2008 and 2021. We included 11 patients [6 girls; median age at diagnosis, 12.5 (range 2.8-15.7) years]. The most common symptom was abdominal pain. Pancreatic enzymes were elevated in 10 patients, and serum immunoglobulin G4 was elevated in 1. Magnetic resonance imaging showed enlargement of the pancreatic head in 10 patients and general pancreatic enlargement in 1. Pancreatic and papilla tissue were obtained from 9 patients. All patients received corticosteroids (prednisolone), and 4 also received azathioprine. According to the ICDC, all patients were classified as probable or non-otherwise specified AIP. According to INSPPIRE criteria, all patients were classified as AIP. Using the INSPPIRE criteria would have avoided biopsies in 6 patients who responded well to corticosteroids. The INSPPIRE criteria are useful. Using the ICDC in pediatric patients can delay diagnosis and result in unnecessary invasive tests.

Improving lung cancer diagnosis with cancer, fungal, and imaging biomarkers

ObjectiveIndeterminate pulmonary nodules (IPNs) represent a significant diagnostic burden in health care. We aimed to compare a combination clinical prediction model (Mayo Clinic model), fungal (histoplasmosis serology), imaging (computed tomography [CT] radiomics), and cancer (high-sensitivity cytokeratin fraction 21; hsCYFRA 21-1) biomarker approach to a validated prediction model in diagnosing lung cancer. MethodsA prospective specimen collection, retrospective blinded evaluation study was performed in 3 independent cohorts with 6- to 30-mm IPNs (n = 281). Serum histoplasmosis immunoglobulin G and immunoglobulin M antibodies and hsCYFRA 21-1 levels were measured and a validated CT radiomic score was calculated. Multivariable logistic regression models were estimated with Mayo Clinic model variables, histoplasmosis antibody levels, CT radiomic score, and hsCYFRA 21-1. Diagnostic performance of the combination model was compared with that of the Mayo Clinic model. Bias-corrected clinical net reclassification index (cNRI) was used to estimate the clinical utility of a combination biomarker approach. ResultsA total of 281 patients were included (111 from a histoplasmosis-endemic region). The combination biomarker model including the Mayo Clinic model score, histoplasmosis antibody levels, radiomics, and hsCYFRA 21-1 level showed improved diagnostic accuracy for IPNs compared with the Mayo Clinic model alone with an area under the receiver operating characteristics curve of 0.80 (95% CI, 0.76-0.84) versus 0.72 (95% CI, 0.66-0.78). Use of this combination model correctly reclassified intermediate risk IPNs into low- or high-risk category (cNRI benign = 0.11 and cNRI malignant = 0.16). ConclusionsThe addition of cancer, fungal, and imaging biomarkers improves the diagnostic accuracy for IPNs. Integrating a combination biomarker approach into the diagnostic algorithm of IPNs might decrease unnecessary invasive testing of benign nodules and reduce time to diagnosis for cancer.

Evaluation of the Advantages of Myocardial Blood Flow Index in the Diagnosis of Chronic Obstructive Coronary Artery Disease Versus Coronary Computed Tomography Angiography: A Feasibility Study

Background: There is a hidden relationship between the degree of coronary artery stenosis and downstream myocardial remodeling. The mutual influence in myocardial ischemia and myocardial remodeling provides an index for quantifying the myocardial blood flow based on the principles of physics. Objectives: This study aimed to evaluate the advantages of myocardial blood flow index (MBFI) in the diagnosis of chronic obstructive coronary artery disease (CAD). Patients and Methods: The data of 68 patients (39 males; mean age: 57.0 ± 10.20 years) with suspected CAD were analyzed retrospectively, including the imaging findings of coronary computed tomography angiography (CCTA) and invasive coronary angiography (ICA) within one week. The MBFI was also calculated for the patients. After determining the optimal cut-off value based on ICA (stenosis ≥ 70%) as the gold standard test, the diagnostic performance of MBFI and CCTA was compared. The diagnostic accuracy was examined by the receiver operating characteristic (ROC) curve. For statistical analysis, chi-square test was performed to analyze influence data, and a P-value less than 0.05 was considered statistically significant. Results: In 68 cases evaluated in this study, the average scan dose of CCTA was 3.02 ± 1.15 millisievert (mSv). There were 28 cases with stenosis ≥ 70%. The optimal cutoff value of MBFI and CCTA was 0.111 and 70%, respectively. Also, the area under the curve (AUC) for MBFI and CCTA was 0.857 and 0.621 (Z = 2.091, P = 0.0365), respectively. The sensitivity, specificity, positive predictive value, and negative predictive value were 92.31%, 92.86%, 88.89%, and 95.12% for MBFI and 61.54%, 78.57%, 64.00%, and 76.74% for CCTA, respectively. The diagnostic accuracy was also estimated at 92.65% for MBFI and 72.06% for CCTA (χ2 = 9.844, P = 0.0017). Conclusion: In this study, MBFI performed better than CCTA in identifying lesions with stenosis ≥ 70%. A lower MBFI indicated the need for an upcoming active intervention, while a higher MBFI suggested avoiding unnecessary invasive testing.

Development and Validation of a Risk Assessment Model for Pulmonary Nodules Using Plasma Proteins and Clinical Factors

Deficiencies in risk assessment for patients with pulmonary nodules (PNs) contribute to unnecessary invasive testing and delays in diagnosis. What is the accuracy of a novel PN risk model that includes plasma proteins and clinical factors? How does the accuracy compare with that of an established risk model? Based on technology using magnetic nanosensors, assays were developed with seven plasma proteins. In a training cohort (n= 429), machine learning approaches were used to identify an optimal algorithm that subsequently was evaluated in a validation cohort (n= 489), and its performance was compared with the Mayo Clinic model. In the training set, we identified a support vector machine algorithm that included the seven plasma proteins and six clinical factors that demonstrated an area under the receiver operating characteristic curve of 0.87 and met other selection criteria. The resulting risk reclassification model (RRM) was used to recategorize patients with a pretest risk of between 10%and 84%, and its performance was assessed across five risk strata (low,≤ 10%; moderate, 10%-34%; intermediate, 35%-70%; high, 71%-84%; very high, > 85%). Stratification by the RRM decreased the proportion of intermediate-risk patients from 26.7%to 10.8%(P< .001) and increased the low-risk and high-risk strata from 16.8%to 21.9%(P< .001) and from 3.7%to 12.1%(P< .001), respectively. Among patients classified as low risk by the RRM and Mayo Clinic model, the corresponding true-negative to false-negative ratios were 16.8 and 19.5, respectively. Among patients classified as very high risk by the RRM and Mayo Clinic model, the corresponding true-positive to false-positive ratios were 28.5 and 17.0, respectively. Compared with the Mayo Clinic model, the RRM provided higher specificity at the low-risk threshold and higher sensitivity at the very high-risk threshold. The RRM accurately reclassified some patients into low-risk and very high-risk categories, suggesting the potential to improve PN risk assessment.

(Digital Presentation) Rapid and Oxygen-Insensitive Electrochemical Immunoassay for Detection and Staging of Prostate Cancer

Prostate cancer (PCa) is the most common cancer among men diagnosed worldwide. The conventional non-invasive test for detection and staging of prostate cancer include prostate specific antigen (PSA) test which often can give false positives and is unable to distinguish between aggressive and indolent stages of PCa. This results in doing unnecessary invasive tests like digital rectal examination (DRE), biopsy etc., which only gives further anxiety to patients. Here we describe a rapid and oxygen-insensitive microfluidic immunoassay for on-line capture and precise detection of potential prostate cancer protein biomarkers. Measurement of a panel of biomarkers will help in not only diagnosing the PCa precisely but may also help in staging the cancer.The microfluidic system includes protein capture from serum using a sandwich ELISA arrangement and signal-transducing poly-horseradish peroxidase (poly-HRP) enzyme labels on an 8-electrode screen-printed carbon array. A major challenge in using these screen-printed electrode arrays is the estimation of the electrochemical surface area (ECSA) of electrodes because the current signal is proportional to ECSA and variability in the electrode surface areas generate variability in the corresponding currents. We show that normalization of electrode responses having different surface areas can be achieved using in-situ experimental methods and that the normalization methods can improve the precision of the immunoassay. Another challenge in electrochemical immunoassay systems is the interference of oxygen using the mediator hydroquinone1. A range of osmium polypyridyl complexes were studied to find the best mediator that is not affected by oxygen.Using an optimized mediator and a simple method to estimate carbon electrode surface area, immunoassays can be designed with improved detection characteristics.(1) Dhanapala, L.; Jones, A. L.; Czarnecki, P.; Rusling, J. F. Sub-Zeptomole Detection of Biomarker Proteins Using a Microfluidic Immunoarray with Nanostructured Sensors. Anal. Chem. 2020, 92 (12), 8021–8025. ttps://doi.org/10.1021/acs.analchem.0c01507.

S2646 Role of Point-of-Care Ultrasound in Diagnosis of Upper GI Bleed Secondary to Aorto-Esophageal Fistula

Introduction: Aorto-esophageal fistula (AEF) is a rare etiology of upper gastrointestinal bleed (UGIB) with a high mortality rate. In patients with vascular pathology or aortic aneurysms presenting with hematemesis and Chiari’s triad (midthoracic pain, sentinel arterial hemorrhage and exsanguination after symptom-free interval), there should be high suspicion for AEF as mortality is high even with timely diagnosis and surgical intervention. Diagnostic endoscopy, aortography, or thoracic computed tomography angiography (CTA) are current standards of care but may be unobtainable in emergent cases. Here, we report a case of UGIB in which bedside Point-of-Care Ultrasound (POCUS) facilitated prompt diagnosis of AEF. Case Description/Methods: A 75-year-old male with history of diabetes, uncontrolled hypertension and abdominal aortic aneurysm presented with large volume hematemesis resulting in two episodes of PEA arrests. ROSC was achieved with aggressive hemodynamic support. Gastroenterology was consulted, but the patient was deemed too unstable for endoscopy. Octreotide and pantoprazole drips were initiated. Placement of a Blakemore tube was attempted. POCUS demonstrated descending aortic intraluminal flap consistent with aortic dissection. After stabilization, CTA was pursued which showed descending thoracic aortic aneurysm with penetrating ulcer and active extravasation into the subcarinal mediastinum. Vascular surgery was urgently consulted but the patient became increasingly unstable and ultimately expired. Discussion: AEF is a rare cause of UGIB that should be suspected in patients with large volume hematemesis, chest pain, hemodynamic compromise. Index of suspicion should be high in patients with a history of aortic aneurysm, esophageal malignancy, ingestion of foreign body or recent esophageal surgery. Temporization, rapid diagnosis, and surgical intervention are critical, but guideline directed diagnostic modalities are limited in hemodynamically unstable patients. Here, POCUS allowed prompt diagnosis several hours before the patient was stable enough for CTA. This case demonstrates that POCUS has a diagnostic role in massive UGIB in patients with a high pretest probability of vascular pathology and may limit unnecessary invasive testing in select patients who are unlikely to benefit from endoscopy. Further research is needed to determine the diagnostic role of POCUS in UGIB, but it should be considered in patients with high suspicion for AEF (Figure).Figure 1.: (A) POCUS showing descending aortic intraluminal flap consistent with aortic dissection. (B) CTA showing descending aortic aneurysm with penetrating ulcer resulting in hematoma of the subcarinal mediastinum.

Role of biomarkers in lung nodule evaluation.

Worldwide, lung cancer is the leading cause of cancer mortality. Much of this mortality is thought to be secondary to detection in later stages, where treatment options and survivability are limited. The goals of lung nodule evaluation are to expedite the diagnosis and treatment of patients with malignant nodules and to minimize unnecessary diagnostic procedures in those with benign nodules. However, the differentiation between benign and malignant has been challenging and is further complicated by the benefits of early diagnosis competing with potential morbidity of invasive diagnostic procedures. Biomarkers have the potential to improve estimates of pretest probability of malignancy in pulmonary nodules, especially in the intermediate-risk subgroup. Four biomarkers have undergone extensive validation and are available for clinical use, and we will discuss each in this review. The application of biomarkers to lung cancer risk assessment has the potential to improve cancer probability assessments, which in turn can reduce unnecessary invasive testing and/or reduce delays in diagnosis and treatment.

Is Low-value Testing Before Low-risk Hand Surgery Associated With Increased Downstream Healthcare Use and Reimbursements? A National Claims Database Analysis.

Minor hand procedures can often be completed in the office without any laboratory testing. Preoperative screening tests before minor hand procedures are unnecessary and considered low value because they can lead to preventable invasive confirmatory tests and/or procedures. Prior studies have shown that low-value testing before low-risk hand surgery is still common, yet little is known about their downstream effects and associated costs. Assessing these downstream events can elucidate the consequences of obtaining a low-value test and inform context-specific interventions to reduce their use. (1) Among healthy adults undergoing low-risk hand surgery, are patients who receive a preoperative low-value test more likely to have subsequent diagnostic tests and procedures than those who do not receive a low-value test? (2) What is the increased 90-day reimbursement associated with subsequent diagnostic tests and procedures in patients who received a low-value test compared with those who did not? In this retrospective, comparative study using a large national database, we queried a large health insurance provider's administrative claims data to identify adult patients undergoing low-risk hand surgery (carpal tunnel release, trigger finger release, Dupuytren fasciectomy, de Quervain release, thumb carpometacarpal arthroplasty, wrist ganglion cyst, or mass excision) between 2011 and 2017. This database was selected for its ability to track patient claims longitudinally with direct provision of reimbursement data in a large, geographically diverse patient population. Patients who received at least one preoperative low-value test, including complete blood count, basic metabolic panel, electrocardiogram, chest radiography, pulmonary function test, and urinalysis within the 30-day preoperative period, were matched with propensity scores to those who did not. Among the 73,112 patients who met our inclusion criteria (mean age 57 ± 14 years; 68% [49,847] were women), 27% (19,453) received at least one preoperative low-value test and were propensity score-matched to those who did not. Multivariable regression analyses were performed to assess the frequency and reimbursements of subsequent diagnostic tests and procedures in the 90 days after surgery while controlling for potentially confounding variables such as age, sex, comorbidities, and baseline healthcare use. When controlling for covariates such as age, sex, comorbidities, and baseline healthcare use, patients in the low-value test cohort had an adjusted odds ratio of 1.57 (95% confidence interval [CI] 1.50 to 1.64; p < 0.001) for a postoperative use event (a downstream diagnostic test or procedure) compared with those who did not have a low-value test. The median (IQR) per-patient reimbursements associated with downstream utilization events in patients who received a low-value test was USD 231.97 (64.37 to 1138.84), and those who did not receive a low-value test had a median of USD 191.52 (57.1 to 899.42) (adjusted difference when controlling for covariates: USD 217.27 per patient [95% CI 59.51 to 375.03]; p = 0.007). After adjusting for inflation, total additional reimbursements for patients in the low-value test cohort increased annually. Low-value tests generate downstream tests and procedures that are known to provide minimal benefit to healthy patients and may expose patients to potential harms associated with subsequent, unnecessary invasive tests and procedures in response to false positives. Nevertheless, low-value testing remains common and the rising trend in low-value test-associated spending demonstrates the need for multicomponent interventions that target change at both the payer and health system level. Such interventions should disincentivize the initial low-value test and the cascade that may follow. Future work to identify the barriers and facilitators to reduce low-value testing in hand surgery can inform the development and revision of deimplementation strategies. Level III, therapeutic study.

Assessment of clinical conditions associated with Mondor disease.

Mondor disease is superficial thrombophlebitis of the thoracoabdominal wall, mid-upper arm, and penis. Although it is usually a benign disease requiring no specific treatment, little is known about this disease owing to its rarity. The aim of this retrospective observational study was to investigate the epidemiology and prognosis of Mondor disease. We conducted a single-center observational study of patients with Mondor disease. Patients who received a diagnosis of Mondor disease between 2015 and 2020 were analyzed. The patients' medical records were manually reviewed to obtain the following variables: date of diagnosis, patient's age, sex, department of diagnosing physicians, underlying diseases, medications, surgery, and time until resolution of the lesion. We also reviewed the 1-year mortality, 1-year occurrence of malignancy, and recurrence of Mondor disease. 20 patients were included in the study. The age of the patients ranged from 7 to 83 years, with a median of 47.5 years. Most of the patients presented with thoracoabdominal wall lesions. The underlying conditions included skin diseases, surgical procedures, breast cancer, smoking, and collagenous diseases, although more than half of the patients did not have plausible predisposing factors. About three-quarters of the patients saw a spontaneous resolution of the lesions within 4 weeks without medical or surgical treatments. Considering the good prognosis of this disease, it is essential to avoid unnecessary invasive tests or treatment once the diagnosis is confirmed.

A Houttuynia cordata-based Chinese herbal formula improved symptoms of allergic rhinitis during the COVID-19 pandemic.

The symptoms of coronavirus disease 2019 (COVID-19) such as hyposmia, rhinorrhea, nasal obstruction, and cough are similar to those of chronic allergic rhinitis (AR). Such symptoms can easily lead AR patients to unnecessary anxiety, misdiagnosis, and invasive diagnostic tests in the COVID-19 pandemic. Interleukin-6 (IL-6) is an important mediator for chronic AR and plays a crucial role in the inflammation of COVID-19. Houttuynia cordata (HC) has been shown to reduce nasal congestion and swelling by suppressing the activation of IL-6 and is used to fight COVID-19. A novel HC-based Chinese herbal formula, Zheng-Yi-Fang (ZYF), was developed to test effects on nasal symptoms of patients with AR in the COVID-19 pandemic. Participants aged between 20 and 60 years with at least a 2-year history of moderate to severe perennial AR were enrolled. Eligible participants were randomly allocated to either the intervention group (taking ZYF) or the control group (using regular western medicine) for 4 weeks. The Chinese version of the Rhinosinusitis Outcome Measures was used to evaluate impacts on quality of life and nasal symptoms of participants with AR. In addition, the effect of ZYF on lipopolysaccharide (LPS)-induced IL-6 was investigated. Participants with AR taking ZYF improved their symptoms of nasal obstruction, nasal secretion, hyposmia, and postnasal drip in comparison with those of the control group. Meanwhile, ZYF exhibited inhibition of IL-6 secretion in the LPS-induced inflammatory model. ZYF has potential effects to relieve nasal symptoms for AR during the COVID-19 pandemic.