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This study compared the prognostic value of quantified thoracic artery calcium (TAC) including aortic arch on chest CT and coronary artery calcium (CAC) score on ECG-gated cardiac CT.MethodsA total of 2412 participants who underwent both chest CT and ECG-gated cardiac CT at the same period were included in the Multi-Ethnic Study of Atherosclerosis Exam 5. All participants were monitored for incident atherosclerotic cardiovascular disease (ASCVD) events. TAC is defined as calcification in the ascending aorta, aortic arch and descending aorta on chest CT. The quantification of TAC was measured using the Agatston method. Time-dependent receiver-operating characteristic (ROC) curves were used to compare the prognostic value of TAC and CAC scores.ResultsParticipants were 69±9 years of age and 47% were male. The Spearman correlation between TAC and CAC scores was 0.46 (p

Study design: Retrospective cohort study. Purpose: To explore the complications and risk factors for total resection (TR) of primary thoracic and lumbar spinal tumors over the past decade at our institution. Methods: Patients meeting inclusion criteria (primary spinal tumors, thoracic or lumbar location, TR at our center) were included. Demographic characteristics, surgical data, perioperative complications and management results were reviewed. Patients were stratified by tumor site, the number of excised segments, and recurrence status to elucidate distinctive characteristics. Results: The cohort comprised 103 patients, with a mean age of 35.8 years. On average, 1.83 vertebral segments were resected per patient. Perioperative complications were substantial, totaling 166 events, with 71 classified as major and 95 as minor, yielding an average of 1.61 complications per patient. No perioperative deaths occurred, but 79 patients (76.7%) experienced at least one complication. Multiple vertebral sections correlated with a higher complication rate (P = 0.031), and lumbar surgeries exhibited elevated risks of large vascular injury (P = 0.001), neurological deterioration, and cerebrospinal fluid leakage compared to thoracic cases. Conversely, thoracic spinal procedures showed a higher rate of pleural effusion (P = 0.004). Binary logistics stepwise regression identified multi-segmental resection as the independent risk factor for major perioperative complications. Conclusions: TR of primary spinal tumors is associated with a high perioperative complication rate, although most events have a favorable prognosis. Complication characteristics vary based on the surgical site, number of excised segments, and surgical history. A nuanced preoperative evaluating approach considering patient age, surgical segments, and extent of resection is crucial. [ABSTRACT FROM AUTHOR]

Background: The thoracic corpectomy is a well-described technique for the surgical treatment of vertebral column fractures with spinal canal compromise. Traditionally, the posterolateral approach to this procedure required the removal of the approach side rib in order to introduce the corpectomy cage. This rib removal, however, has been identified as a major contributor to post-operative morbidity. Rib-sparing techniques have been shown to be beneficial in minimizing post-operative morbidity in non-spinal surgeries. Herein, we present a previously undescribed technique of a rib-sparing thoracic corpectomy that avoids sequalae of rib resection with assistance from an ultrasonic bone scalpel (UBS). Methods: A retrospective chart review was conducted on patients having undergone this thoracic corpectomy technique. Data on patient age at operation, indication for surgery, number of corpectomies per case, estimated blood loss (EBL), operative time (OT), intra-operative complications, and post-operative length of stay (LOS) were collected and analyzed. A pictorial step-by-step guide was created to highlight the advantages of an entirely posterior rib-sparing unilateral transpedicular technique for thoracic corpectomy. Results: A total of 36 corpectomies were performed on 32 patients between August 2015 and March 2023. Patients ages ranged from 17 to 85 years (mean = 63). The most common indication was oncological (n = 22, 69%), followed by degenerative/traumatic deformity (n = 7, 22%), and infection (n = 3, 9%). For the cases for which data was accessible, mean EBL was 853 cc and mean OT was 178 min. The average post-operative LOS was 6.5 days. Conclusion: The described surgical approach makes it possible to create a transpedicular corridor with no costectomy for implantation of an expandable titanium cage and anterior column reconstruction. The use of the UBS in this approach is critical as it minimizes bony removal and avoids sequelae of rib resection. The described technique has the potential to circumvent post-costectomy pain, thereby expediting post-operative recovery after thoracic corpectomy. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the prevalence, type, site and breed predisposition of thoracic congenital vertebral malformations (CVM) in neurologically normal brachycephalic 'screw‐tail' dog breeds. Study Design: Retrospective case series. Animals: Neurologically normal French Bulldogs (n = 63), British Bulldogs (n = 42), Boston Terriers (n = 4) and Pugs (n = 86) presenting for brachycephalic obstructive airway syndrome treatment. Methods: Either a plain computer tomography scan of the thorax or lateral and dorso‐ventral digital radiographs of the thoracic vertebral column of each dog were assessed for any vertebral malformations and classed according to the Modified McMaster vertebral abnormality classification scheme proposed by Guiterrez et al. Results: The prevalence of dogs with one or more abnormal vertebrae was 96.82% in French Bulldogs, 90.47% in British Bulldogs, and 76.74% in Pugs. Pugs had significantly lower instances of CVMs than French Bulldogs. The four Boston Terriers all had vertebral malformations, but the results were not considered to be statistically significant due to their small sample size. In French Bulldogs and British Bulldogs, ventral hypoplasia (Type 3) occurred at greater rates than all other types, followed by ventral and median hypoplasia (Types 7) and symmetrical hypoplasia (Type 8). In Pugs, symmetrical hypoplasia (Type 8) was the most common and then ventral hypoplasia (Type 3). The most affected vertebrae were T6–T9 in Pugs and T5–T10 in French Bulldogs and British Bulldogs. Conclusions: The majority of neurologically normal brachycephalic 'screw‐tail' dogs assessed in this paper possessed one or more congenital thoracic vertebral malformations. Dogs with vertebral malformations were found to be more likely to have more than one affected vertebra. Sex had no effect on the prevalence of CVM. Clinical Relevance: A substantial number of neurologically normal brachycephalic 'screw‐tail' dogs suffer from congenital vertebral malformations. Thus, the need for selective breeding programmes to eliminate this hereditary condition is crucial. [ABSTRACT FROM AUTHOR]

Epithelioid inflammatory myofibroblastic sarcoma (EIMS) is a rare subtype of inflammatory myofibroblastic tumor, characterized to be an aggressive disease with high frequency of ALK rearrangement, rapid recurrence, and poor prognosis. Primary EIMS of thoracic origin is rarely observed. Herein, we described a case of 28-year-old female developed primary EIMS in the anterior mediastinum with hepatic metastasis. The EIMS displayed sheet-like growth of epithelioid and spindle cells with enlarged nuclei, abundant and eosinophilic cytoplasm, and infiltration of inflammatory cells. Immunohistochemical staining revealed positive expression of ALK in the nuclear membrane, and ALK rearrangement was identified by polymerase chain reaction assay. Alectinib showed partial response, and achieved a meaningful survival benefit for four months. Based on this case report and literature review, ALK inhibitor reveals promising activity on the rare but aggressive EIMS. Awareness of EIMS in thoracic disease and its clinicopathological features is essential to avoid erroneous diagnosis. [ABSTRACT FROM AUTHOR]

Thoracic vertebral fractures within homes are pivotal public health concerns due to their associated morbidity and significant healthcare expenditures. This study aims to dissect the intricate epidemiology of these injuries, integrating comprehensive risk factors beyond conventional demographics and location analyses. Utilizing a decade of data (2013–2022) from the National Electronic Injury Surveillance System, this study examines thoracic vertebral fractures across age and gender in household settings. Inclusion criteria targeted specific thoracic spine-related terms, analyzing fractures by location (e.g., kitchen, stairs) and associated products. Data processing employed R programming, with statistical analysis focusing on descriptive statistics and multivariate logistic regression, to identify fracture patterns and assess gender differences in fracture risks through Adjusted Odds Ratios (AORs). Analysis of 46,371 thoracic vertebral fractures identified stairs as the primary site (26.81%), with subsequent frequent locations being bedrooms (18.52%), living rooms (17.88%), and kitchens (16.29%). Gender-specific risk analysis revealed females had a higher likelihood of fractures on stairs (AOR = 1.24, 95% CI: 1.16–1.37, P < 0.001) and in bedrooms (AOR = 1.13, 95% CI: 1.09–1.54, P < 0.001). The most affected age group was 51–60, showcasing the multifaceted nature of risk factors beyond mere location. This study transcends prior insights by detailing the influence of various factors, including socioeconomic status and lifestyle, on fracture risk. It emphasizes the complexity of household fractures, highlighting gender and age as pivotal but not exclusive risk determinants. By offering a comprehensive analysis that incorporates a wide array of risk factors, this study advances the understanding of thoracic vertebral fractures in residential environments. It underscores the necessity for targeted preventive measures that are cognizant of the multifactorial nature of these injuries, paving the way for improved safety interventions and public health policies. [ABSTRACT FROM AUTHOR]

Thoracic cytology can be challenging due to limited procured material or overlapping morphology between benign and malignant entities. In such cases, expert consultation might be sought. This study aimed to characterize all pulmonary and pleural cytology consult cases submitted to our practice and provide recommendations on approaching difficult cases. All thoracic (pulmonary and pleural) cytology cases submitted for expert consultation to the University of Michigan (MLabs) from 2013 to mid-2022 were reviewed. Cases where cytology was only part of a hematopathology or surgical pathology consult were excluded. Patient demographics, specimen location, procedure performed, referring diagnosis, and our diagnoses were recorded for each case. Diagnoses were categorized according to the Papanicolaou Society of Cytopathology recommendations for pulmonary and effusion cytology. Discordant diagnoses were stratified as major or minor. Data was analyzed using chi-square analysis and logistic models. We received 784 thoracic cytology consult cases, including 530 exfoliative samples and 307 fine-needle aspirations. The most common anatomic locations sampled were the bronchial wall (n = 194, 23%), lung nodule (n = 322, 38%), and pleura (n = 296, 35%). 413 cases had a diagnostic discrepancy (48.3%), with 274 (66%) minor and 139 (34%) major discrepancies. By location, pleural effusion specimens had the highest probability of a discrepant diagnosis (P = 0.003). By specimen type, fine-needle aspiration samples were more likely to have a discrepant diagnosis (P = 0.09), approaching significance. Nearly half of the thoracic cytology cases submitted for expert second opinion had diagnostic discrepancies. Consequently, consulting a tertiary medical care center with cytopathology expertise for challenging thoracic cytology diagnoses is beneficial. [ABSTRACT FROM AUTHOR]

Abstract Study design Retrospective cohort study. Purpose To explore the complications and risk factors for total resection (TR) of primary thoracic and lumbar spinal tumors over the past decade at our institution. Methods Patients meeting inclusion criteria (primary spinal tumors, thoracic or lumbar location, TR at our center) were included. Demographic characteristics, surgical data, perioperative complications and management results were reviewed. Patients were stratified by tumor site, the number of excised segments, and recurrence status to elucidate distinctive characteristics. Results The cohort comprised 103 patients, with a mean age of 35.8 years. On average, 1.83 vertebral segments were resected per patient. Perioperative complications were substantial, totaling 166 events, with 71 classified as major and 95 as minor, yielding an average of 1.61 complications per patient. No perioperative deaths occurred, but 79 patients (76.7%) experienced at least one complication. Multiple vertebral sections correlated with a higher complication rate (P = 0.031), and lumbar surgeries exhibited elevated risks of large vascular injury (P = 0.001), neurological deterioration, and cerebrospinal fluid leakage compared to thoracic cases. Conversely, thoracic spinal procedures showed a higher rate of pleural effusion (P = 0.004). Binary logistics stepwise regression identified multi-segmental resection as the independent risk factor for major perioperative complications. Conclusions TR of primary spinal tumors is associated with a high perioperative complication rate, although most events have a favorable prognosis. Complication characteristics vary based on the surgical site, number of excised segments, and surgical history. A nuanced preoperative evaluating approach considering patient age, surgical segments, and extent of resection is crucial.

Abstract Background The thoracic corpectomy is a well-described technique for the surgical treatment of vertebral column fractures with spinal canal compromise. Traditionally, the posterolateral approach to this procedure required the removal of the approach side rib in order to introduce the corpectomy cage. This rib removal, however, has been identified as a major contributor to post-operative morbidity. Rib-sparing techniques have been shown to be beneficial in minimizing post-operative morbidity in non-spinal surgeries. Herein, we present a previously undescribed technique of a rib-sparing thoracic corpectomy that avoids sequalae of rib resection with assistance from an ultrasonic bone scalpel (UBS). Methods A retrospective chart review was conducted on patients having undergone this thoracic corpectomy technique. Data on patient age at operation, indication for surgery, number of corpectomies per case, estimated blood loss (EBL), operative time (OT), intra-operative complications, and post-operative length of stay (LOS) were collected and analyzed. A pictorial step-by-step guide was created to highlight the advantages of an entirely posterior rib-sparing unilateral transpedicular technique for thoracic corpectomy. Results A total of 36 corpectomies were performed on 32 patients between August 2015 and March 2023. Patients ages ranged from 17 to 85 years (mean = 63). The most common indication was oncological (n = 22, 69%), followed by degenerative/traumatic deformity (n = 7, 22%), and infection (n = 3, 9%). For the cases for which data was accessible, mean EBL was 853 cc and mean OT was 178 min. The average post-operative LOS was 6.5 days. Conclusion The described surgical approach makes it possible to create a transpedicular corridor with no costectomy for implantation of an expandable titanium cage and anterior column reconstruction. The use of the UBS in this approach is critical as it minimizes bony removal and avoids sequelae of rib resection. The described technique has the potential to circumvent post-costectomy pain, thereby expediting post-operative recovery after thoracic corpectomy.

Abstract Epithelioid inflammatory myofibroblastic sarcoma (EIMS) is a rare subtype of inflammatory myofibroblastic tumor, characterized to be an aggressive disease with high frequency of ALK rearrangement, rapid recurrence, and poor prognosis. Primary EIMS of thoracic origin is rarely observed. Herein, we described a case of 28-year-old female developed primary EIMS in the anterior mediastinum with hepatic metastasis. The EIMS displayed sheet-like growth of epithelioid and spindle cells with enlarged nuclei, abundant and eosinophilic cytoplasm, and infiltration of inflammatory cells. Immunohistochemical staining revealed positive expression of ALK in the nuclear membrane, and ALK rearrangement was identified by polymerase chain reaction assay. Alectinib showed partial response, and achieved a meaningful survival benefit for four months. Based on this case report and literature review, ALK inhibitor reveals promising activity on the rare but aggressive EIMS. Awareness of EIMS in thoracic disease and its clinicopathological features is essential to avoid erroneous diagnosis.

Abstract Predicting outcomes in pulmonary tuberculosis is challenging despite effective treatments. This study aimed to identify factors influencing treatment success and culture conversion, focusing on artificial intelligence (AI)-based chest X-ray analysis and Xpert MTB/RIF assay cycle threshold (Ct) values. In this retrospective study across six South Korean referral centers (January 1 to December 31, 2019), we included adults with rifampicin-susceptible pulmonary tuberculosis confirmed by Xpert assay from sputum samples. We analyzed patient characteristics, AI-based tuberculosis extent scores from chest X-rays, and Xpert Ct values. Of 230 patients, 206 (89.6%) achieved treatment success. The median age was 61 years, predominantly male (76.1%). AI-based radiographic tuberculosis extent scores (median 7.5) significantly correlated with treatment success (odds ratio [OR] 0.938, 95% confidence interval [CI] 0.895–0.983) and culture conversion at 8 weeks (liquid medium: OR 0.911, 95% CI 0.853–0.973; solid medium: OR 0.910, 95% CI 0.850–0.973). Sputum smear positivity was 49.6%, with a median Ct of 26.2. However, Ct values did not significantly correlate with major treatment outcomes. AI-based radiographic scoring at diagnosis is a significant predictor of treatment success and culture conversion in pulmonary tuberculosis, underscoring its potential in personalized patient management.

Patients with thoracic metastatic epidural spinal cord compression (MESCC) often undergo extensive surgical decompression to avoid functional decline. Though limited in scope, scales including the revised cardiac risk index (RCRI) are used to stratify surgical risk to predict perioperative morbidity. This study uses the 5-item modified frailty index (mFI-5) to predict outcomes following transpedicular decompression/fusion for high-grade MESCC. A retrospective chart review was conducted on patients who underwent transpedicular decompression and fusion for MESCC (baseline demographics, spinal instability neoplastic score, preoperative and postoperative Bilsky scores, primary cancer type, and RCRI). Primary outcomes included length of stay (LOS), intraoperative estimated blood loss, readmission/reoperation within 90 days of index surgery, 90-day mortality, and posthospitalization disposition. One hundred twenty-seven patients were included in our study. Ninety percent of patients' lesions were Bilsky 2 or greater. Increasing frailty, measured by mFI-5, was a significant predictor of increased LOS (P < 0.01) and 90-day mortality (P < 0.05). Multivariate analysis adjusting for sex, body mass index , and age still showed statistical significance (P < 0.05). MFI-5 was not a significant predictor of readmission/reoperation within 90 days or estimated blood loss. Age – not mFI-5 or RCRI – was a significant predictor for posthospitalization nonhome disposition (P = 0.001). The mFI-5 can serve as a useful predictor of outcomes after transpedicular decompression and fusion for thoracic MESCC as it can account for the patient's frailty. Our study demonstrated the mFI-5 as a predictor of LOS and 90-day mortality. These results provide a background to both understanding and integrating frailty into decision-making in MESCC. [ABSTRACT FROM AUTHOR]

• Cervical and thoracic VBQ scores are distinct from Hounsfield Unit and DEXA values. • Patient age, ethnicity, sex, or BMI do not influence cervical and thoracic VBQ. • VBQ does not appear to serve as a direct surrogate indicator of HU or DEXA scores. • This study is the first to compare VBQ to established Hounsfield and DEXA scores. Further optimization of the validated vertebral bone quality (VBQ) score using magnetic resonance imaging (MRI) may expand its clinical utility for bone mineral density (BMD) assessment. This study evaluated the correlations among cervical and thoracic VBQ scores, the validated Hounsfield Unit (HU) measured on computed tomography (CT), and dual-energy x-ray absorptiometry (DEXA) values. We retrieved the medical and radiographic records of 165 patients who underwent synchronous MRI of the cervical and thoracic spine, as well as DEXA and CT imaging of the spine obtained within 1 year of each other between 2015 and 2022. Radiographic data consisted of the MRI-based cervical and thoracic VBQ scores, CT-based HU, and DEXA T-scores of the spine and hip. Patient age, sex, body mass index (BMI), and ethnicity were also obtained. Mean cervical and thoracic VBQ scores were 3.99 ± 1.68 and 3.82 ± 2.11, respectively. Mean HU and DEXA T-scores of the spine and hip were 135.75 ± 60.36, −1.01 ± 1.15, and −0.47 ± 2.27. All correlations among VBQ, HU, and DEXA were insignificant except for weak correlations between cervical and thoracic VBQ, and cervical VBQ and HU. No correlations were observed between radiographic scores and patient age or BMI. No differences based on ethnicity or sex were observed with respect to cervical or thoracic VBQ, HU, or DEXA. Cervical and thoracic VBQ scores are distinct from Hounsfield Unit and DEXA values. VBQ scoring in the cervical and thoracic spine is not influenced by patient age, ethnicity, sex, or BMI. [ABSTRACT FROM AUTHOR]

Objective: Rare disease Background: Cerebrovascular occlusion is a critical health concern associated with strokes, a leading cause of mortality worldwide. Large vessel occlusion, constituting a significant portion of acute ischemic strokes, presents serious patient outcomes. Occlusions involving multiple extracranial vessels are rare but pose challenges in early detection due to potential absence of overt symptoms. Case Report: A 65-year-old man with a significant smoking history and no prior history of hypertension or cardiovascular disease presented with recurrent generalized tonic seizures occurring 4 to 5 times daily. Despite normal neurological examinations, neck sonography indicated potential obstruction in the carotid and vertebral arteries. Conventional angiography revealed mild coronary artery plaques but complete occlusion of all cranial branches originating from the aorta, alongside porcelain aorta. Neck CT angiography confirmed complete occlusion of the supra-aortic branches of the aorta and absence of the right internal carotid artery, with evidence of proximal occlusion of the left internal carotid artery. Medical management without surgical intervention was pursued due to the patient's stable condition. He was discharged with a medication regimen including antiplatelet therapy and statins. Four-month follow-up showed significant symptom improvement, with minimal changes in brain blood flow circulation noted on CT. Conclusions: This case underscores the brain's remarkable adaptive capacity in withstanding severe vascular challenges. The rarity of multiple extracranial vessel occlusions and presence of porcelain aorta further complicated the case. Utilizing advanced imaging techniques and personalized treatment approaches are crucial in managing complex vascular conditions. Ongoing research and careful monitoring are essential to advance understanding and management in such cases. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Spontaneous spinal epidural hematoma (SSEH) rarely occurs. Without early diagnosis, SSEH can lead to the acute onset of neurologic deficits. We report the case of a 65‐year‐old male with diabetes mellitus who was admitted to our emergency department with a chief complaint of sharp and severe pain in the left scapula and behind the sternum. He was misdiagnosed with cardiovascular disease until the onset of progressive bilateral paraplegia and lower limb numbness. Magnetic resonance imaging revealed a ventral thoracic SSEH. Surgical treatment to remove epidural hematoma and laminectomy for decompression were performed. Except for urine retention, bilateral lower limb paraplegia and numbness were alleviated postoperatively. Due to the high risk of poor neurological outcomes without treatment or with delayed intervention, timely surgical evacuation of the hematoma and hemostasis are recommended to ensure favorable neurological outcomes. [ABSTRACT FROM AUTHOR]

Introduction: MRI-guided radiotherapy (MRgRT) allows for direct motion management and real-time radiation treatment plan adaptation. We report our institutional experience using low strength 0.35T MRgRT for thoracic malignancies, and evaluate changes in treatment duty cycle between first and final MRgRT fractions. Methods: All patients with intrathoracic tumors treated with MRgRT were included. The primary reason for MRgRT (adjacent organ at risk [OAR] vs. motion management [MM] vs. other) was recorded. Tumor location was classified as central (within 2cm of tracheobronchial tree) vs. non-central, and further classified by the Expanded HILUS grouping. Gross tumor volume (GTV) motion, planning target volume expansions, dose/fractionation, treatment plan time, and total delivery time were extracted from the treatment planning system. Treatment plan time was defined as the time for beam delivery, including multileaf collimator (MLC) motion, and gantry rotation. Treatment delivery time was defined as the time from beam on to completion of treatment, including treatment plan time and patient respiratory breath holds. Duty cycle was calculated as treatment plan time/treatment delivery time. Duty cycles were compared between first and final fraction using a two-sample t-test. Results: Twenty-seven patients with thoracic tumors (16 non-small cell lung cancer and 11 thoracic metastases) were treated with MRgRT between 12/2021 and 06/2023. Fifteen patients received MRgRT due to OAR and 11 patients received MRgRT for motion management. 11 patients had central tumors and all were treated with MRgRT due to OAR risk. The median dose/fractionation was 50 Gy/5 fractions. For patients treated due to OAR (n=15), 80% had at least 1 adapted fraction during their course of radiotherapy. There was no plan adaptation for patients treated due to motion management (n=11). Mean GTV motion was significantly higher for patients treated due to motion management compared to OAR (16.1mm vs. 6.5mm, p=0.011). Mean duty cycle for fraction 1 was 54.2% compared to 62.1% with final fraction (p=0.004). Mean fraction 1 duty cycle was higher for patients treated due to OAR compared to patients treated for MM (61% vs. 45.0%, p=0.012). Discussion: Duty cycle improved from first fraction to final fraction possibly due to patient familiarity with treatment. Duty cycle was improved for patients treated due to OAR risk, likely due to more central location and thus decreased target motion. [ABSTRACT FROM AUTHOR]

Predicting outcomes in pulmonary tuberculosis is challenging despite effective treatments. This study aimed to identify factors influencing treatment success and culture conversion, focusing on artificial intelligence (AI)-based chest X-ray analysis and Xpert MTB/RIF assay cycle threshold (Ct) values. In this retrospective study across six South Korean referral centers (January 1 to December 31, 2019), we included adults with rifampicin-susceptible pulmonary tuberculosis confirmed by Xpert assay from sputum samples. We analyzed patient characteristics, AI-based tuberculosis extent scores from chest X-rays, and Xpert Ct values. Of 230 patients, 206 (89.6%) achieved treatment success. The median age was 61 years, predominantly male (76.1%). AI-based radiographic tuberculosis extent scores (median 7.5) significantly correlated with treatment success (odds ratio [OR] 0.938, 95% confidence interval [CI] 0.895–0.983) and culture conversion at 8 weeks (liquid medium: OR 0.911, 95% CI 0.853–0.973; solid medium: OR 0.910, 95% CI 0.850–0.973). Sputum smear positivity was 49.6%, with a median Ct of 26.2. However, Ct values did not significantly correlate with major treatment outcomes. AI-based radiographic scoring at diagnosis is a significant predictor of treatment success and culture conversion in pulmonary tuberculosis, underscoring its potential in personalized patient management. [ABSTRACT FROM AUTHOR]

The aim of this study was to establish international consensus regarding the use of spinal manipulation and mobilisation among infants, children, and adolescents among expert international physiotherapists. Twenty-six international expert physiotherapists in manual therapy and paediatrics voluntarily participated in a 3-Round Delphi survey to reach a consensus via direct electronic mail solicitation using Qualtrics®. Consensus was defined a-priori as ≥75% agreement on all items with the same ranking of agreement or disagreement. Round 1 identified impairments and conditions where spinal mobilisation and manipulation might be utilised. In Rounds 2 and 3, panelists agreed or disagreed using a 4-point Likert scale. Eleven physiotherapists from seven countries representing five continents completed all three Delphi rounds. Consensus regarding spinal mobilisation or manipulation included: Manipulation is not recommended: (1) for infants across all conditions, impairments, and spinal levels; and (2) for children and adolescents across most conditions and spinal levels. Manipulation may be recommended for adolescents to treat spinal region-specific joint hypomobility (thoracic, lumbar), and pain (thoracic). Mobilisation may be recommended for children and adolescents with hypomobility, joint pain, muscle/myofascial pain, or stiffness at all spinal levels. Consensus revealed spinal manipulation should not be performed on infants regardless of condition, impairment, or spinal level. Additionally, the panel agreed that manipulation may be recommended only for adolescents to treat joint pain and joint hypomobility (limited to thoracic and/or lumbar levels). Spinal mobilisation may be recommended for joint hypomobility, joint pain, muscle/myofascial pain, and muscle/myofascial stiffness at all spinal levels among children and adolescents. [ABSTRACT FROM AUTHOR]

To identify factors and barriers, which affect the utilisation of spinal manipulation and mobilisation among infants, children, and adolescents. Twenty-six international expert physiotherapists in manual therapy and paediatrics were invited to participate in a Delphi investigation using QualtricsⓇ. In Round-1 physiotherapists selected from a list of factors and barriers affecting their decision to use spinal manipulation and mobilisation in the paediatric population and had opportunity to add to the list. Round-2 asked respondents to select as many factors and barriers that they agreed with, resulting in a frequency count. The subset of responses to questions around barriers and facilitators are the focus of this study. Twelve physiotherapists completed both rounds of the survey. Medical diagnosis, mechanism of injury, patient presentation, tolerance to handling, and therapist's knowledge of techniques were the dominant deciding factors to use spinal manipulation and mobilisation among infants, children, and adolescents across spinal levels. More than 90% of the respondents selected manipulation as inappropriate among infants as their top barrier. Additional dominant barriers to using spinal manipulation among infants and children identified by ≥ 75% of the respondents included fear of injuring the patient, fear of litigation, lack of communication, lack of evidence, lack of guardian consent, and precision of the examination to inform clinical reasoning. This international survey provides much needed insight regarding the factors and barriers physiotherapists should consider when contemplating the utilisation of spinal mobilisation and manipulation in the paediatric population. [ABSTRACT FROM AUTHOR]

Study Design: Literature Review. Objective: Myelopathy affecting the thoracic spinal cord can arise secondary to several aetiologies which have similar presentation and management. Consequently, there are many uncertainties in this area, including optimal terminology and definitions. Recent collaborative cervical spinal research has led to the proposal and subsequent community adoption of the name degenerative cervical myelopathy(DCM), which has facilitated the establishment of internationally-agreed research priorities for DCM. We put forward the case for the introduction of the term degenerative thoracic myelopathy(DTM) and degenerative spinal myelopathy(DSM) as an umbrella term for both DCM and DTM. Methods: Following PRISMA guidelines, a systematic literature search was performed to identify degenerative thoracic myelopathy literature in Embase and MEDLINE. Results: Conditions encompassed within DTM include thoracic spondylotic myelopathy, ossification of the posterior longitudinal ligament, ossification of the ligamentum flavum, calcification of ligaments, hypertrophy of ligaments, degenerative disc disease, thoracic osteoarthritis, intervertebral disc herniation, and posterior osteophytosis. The classic presentation includes girdle pain, gait disturbance, leg weakness, sensory disturbance, and bladder or bowel dysfunction, often with associated back pain. Surgical management is typically favoured with post-surgical outcomes dependent on many factors, including the causative pathology, and presence of additional stenosis. Conclusion: The clinical entities encompassed by the term DTM are interrelated, can manifest concurrently, and present similarly. Building on the consensus adoption of DCM in the cervical spine and the recent proposal of degenerative cervical radiculopathy(DCR), extending this common nomenclature framework to the terms degenerative spinal myelopathy and degenerative thoracic myelopathy will help improve recognition and communication. [ABSTRACT FROM AUTHOR]

Background: Transbronchial microwave ablation in treating lung nodules is gaining popularity. However, microwave ablation in subpleural lung nodules raised concerns about pleural-based complications due to the proximity between the pleura and the ablation zone. Methods: Patients who underwent transbronchial microwave ablation between March 2019 and November 2022 were included in this analysis. The lung nodules were categorized into the subpleural group—less than 5 mm distance to the nearest pleural surface; the deep nodule group—larger or equal to 5 mm distance to the nearest pleural surface. A review of the safety profile of subpleural lung nodule ablation was conducted. Results: Eighty-two lung nodules (n = 82) from 77 patients were treated. The mean nodule size was 14.2 ± 5.50 mm. The technical success rate was 100%. The mean procedural time was 133 min. No statistically significant differences were detected in the complication rate and the length of stay between the subpleural and deep nodule groups. Complications occured in 21 nodules (25.6%). No minor pneumothorax was reported. Total five cases of pneumothorax required drainage were observed (6.06% in subpleural nodules [ n = 2] vs. 6.12% in deep nodules [ n = 3], p = 0.991). Total seven cases of pleuritic chest pain were observed (12.1% in subpleural nodules [ n = 4] vs. 6.12% in deep nodules [ n = 3], p = 0.340). Conclusions: This single-center retrospective analysis found no significant difference in the safety outcomes between subpleural and nonsubpleural lung nodule ablation. The overall rate of complications was low in the cohort. This demonstrated that transbronchial microwave was feasible and safe for most lung nodules. [ABSTRACT FROM AUTHOR]

The current understanding of the genetic determinants of thoracic aortic aneurysms and dissections (TAAD) has largely been informed through studies of rare, Mendelian forms of disease. Here, we conducted a genome-wide association study (GWAS) of TAAD, testing ~25 million DNA sequence variants in 8,626 participants with and 453,043 participants without TAAD in the Million Veteran Program, with replication in an independent sample of 4,459 individuals with and 512,463 without TAAD from six cohorts. We identified 21 TAAD risk loci, 17 of which have not been previously reported. We leverage multiple downstream analytic methods to identify causal TAAD risk genes and cell types and provide human genetic evidence that TAAD is a non-atherosclerotic aortic disorder distinct from other forms of vascular disease. Our results demonstrate that the genetic architecture of TAAD mirrors that of other complex traits and that it is not solely inherited through protein-altering variants of large effect size.

Venous thoracic outlet syndrome commonly results in arm swelling and pain as the subclavian vein is obstructed within the thoracic inlet. We report the use of ferumoxytol-enhanced contrast MRI in the diagnosis of venous thoracic outlet syndrome in a male adolescent. In this patient who presented with right upper extremity thrombosis, ferumoxytol-enhanced MRI of the chest was able to show both chronic subclavian vein thromboses and dynamic occlusion of the subclavian veins with arm abduction consistent with Paget-Schroetter syndrome.

ObjectivesRapid diameter growth is a criterion for ascending thoracic aortic aneurysm repair; however, there are sparse data on aneurysm elongation rate. The purpose of this study was to assess aortic elongation rates in nonsyndromic, nonsurgical aneurysms to understand length dynamics and correlate with aortic diameter over time.MethodsPatients with

BACKGROUND: As the largest conduit vessel, the aorta is responsible for the conversion of phasic systolic inflow from ventricular ejection into more continuous peripheral blood delivery. Systolic distention and diastolic recoil conserve energy and are enabled by the specialized composition of the aortic extracellular matrix. Aortic distensibility decreases with age and vascular disease. OBJECTIVES: In this study, we sought to discover epidemiologic correlates and genetic determinants of aortic distensibility and strain. METHODS: We trained a deep learning model to quantify thoracic aortic area throughout the cardiac cycle from cardiac magnetic resonance images and calculated aortic distensibility and strain in 42,342 UK Biobank participants. RESULTS: Descending aortic distensibility was inversely associated with future incidence of cardiovascular diseases, such as stroke (HR: 0.59 per SD; P = 0.00031). The heritabilities of aortic distensibility and strain were 22% to 25% and 30% to 33%, respectively. Common variant analyses identified 12 and 26 loci for ascending and 11 and 21 loci for descending aortic distensibility and strain, respectively. Of the newly identified loci, 22 were not significantly associated with thoracic aortic diameter. Nearby genes were involved in elastogenesis and atherosclerosis. Aortic strain and distensibility polygenic scores had modest effect sizes for predicting cardiovascular outcomes (delaying or accelerating disease onset by 2%-18% per SD change in scores) and remained statistically significant predictors after accounting for aortic diameter polygenic scores. CONCLUSIONS: Genetic determinants of aortic function influence risk for stroke and coronary artery disease and may lead to novel targets for medical intervention.

Introduction and Objective: Thoracic disc calcification is a radiological finding which may be incidental or diagnosed in patients presenting with myelopathy due to spinal cord compression. We performed a study to analyze the imaging patterns of calcified thoracic discs (CTDs). Patients and Methods: A retrospective review of the spinal and radiology database of a tertiary referral orthopedic hospital was conducted for the incidence of CTDs between 2007 and 2020. Patients’ demographics and radiological findings were recorded. The relationship between disc size, morphology, spinal cord compression, and management was assessed. Results: Fifty-one cases of CTDs were identified. The mean size of CTD was 806.2 mm3 (range: 144–2340). The most common level of disc calcification was T9–T10 (24%) in 12 patients. Thoracic disc calcifications in our series commonly involved disc “protrusion” in 67% (34 patients), followed by “mushroom” type in 31% (16 patients) and “extrusion” in 2% (1 patient). 37% (19 patients) had spinal cord compression with 12% (6 patients) undergoing surgical interventions. There was no statistically significant difference in the mean sizes of CTD between the groups with and without spinal cord compression (P = 0.566, independent sample t-test). Patients with “mushroom” type calcification were more likely to have surgical intervention (P = 0.01, Fisher’s exact test). Conclusion: Thoracic disc calcifications, while common, can still be underdiagnosed till late myelopathic deterioration. Care of the elderly physicians, spinal surgeons, and radiologists need to be aware of them to guide diagnosis and management. Our study demonstrates that disc morphology plays a vital role in myelopathic presentation and therefore determines the need for surgical intervention instead of the absolute size of disc calcification.

Penetrating traumatic aortic injury (PTAI) is increasing in prevalence given the rise in firearm violence in the United States and is associated with significant morbidity and mortality. These injuries often result in hemorrhagic shock, with patients presenting in extremis or pulseless, traditionally requiring open approaches for repair. A rare but potentially devastating complication of firearm-related PTAI is bullet embolization. This case report describes the successful resuscitation and endovascular treatment of a patient with a firearm-induced PTAI complicated by acute limb ischemia secondary to bullet arterial embolization to the common femoral artery requiring arteriotomy for bullet removal.

We describe the curation, annotation methodology, and characteristics of the dataset used in an artificial intelligence challenge for detection and localization of COVID-19 on chest radiographs. The chest radiographs were annotated by an international group of radiologists into four mutually exclusive categories, including typical, indeterminate, and atypical appearance for COVID-19, or negative for pneumonia, adapted from previously published guidelines, and bounding boxes were placed on airspace opacities. This dataset and respective annotations are available to researchers for academic and noncommercial use.

ObjectivePrevious reports of rod fracture (RF) in adult spinal deformity are limited by heterogeneous cohorts, low follow-up rates, and relatively short follow-up durations. Since the majority of RFs present > 2 years after surgery, true occurrence and revision rates remain unclear. The objectives of this study were to better understand the risk factors for RF and assess its occurrence and revision rates following primary thoracolumbar fusions to the sacrum/pelvis for adult symptomatic lumbar scoliosis (ASLS) in a prospective series with long-term follow-up.MethodsPatient records were obtained from the Adult Symptomatic Lumbar Scoliosis-1 (ASLS-1) database, an NIH-sponsored multicenter, prospective study. Inclusion criteria were as follows: patients aged 40-80 years undergoing primary surgeries for ASLS (Cobb angle ≥ 30° and Oswestry Disability Index ≥ 20 or Scoliosis Research Society-22r ≤ 4.0 in pain, function, and/or self-image) with instrumented fusion of ≥ 7 levels that included the sacrum/pelvis. Patients with and without RF were compared to assess risk factors for RF and revision surgery.ResultsInclusion criteria were met by 160 patients (median age 62 years, IQR 55.7-67.9 years). At a median follow-up of 5.1 years (IQR 3.8-6.6 years), there were 92 RFs in 62 patients (38.8%). The median time to RF was 3.0 years (IQR 1.9-4.54 years), and 73% occurred > 2 years following surgery. Based on Kaplan-Meier analyses, estimated RF rates at 2, 4, 5, and 8 years after surgery were 11%, 24%, 35%, and 49%, respectively. Baseline radiographic, clinical, and demographic characteristics were similar between patients with and without RF. In Cox regression models, greater postoperative pelvic tilt (HR 1.895, 95% CI 1.196-3.002, p = 0.0065) and greater estimated blood loss (HR 1.02, 95% CI 1.005-1.036, p = 0.0088) were associated with increased risk of RF. Thirty-eight patients (61% of all RFs) underwent revision surgery. Bilateral RF was predictive of revision surgery (HR 3.52, 95% CI 1.8-6.9, p = 0.0002), while patients with unilateral nondisplaced RFs were less likely to require revision (HR 0.39, 95% CI 0.18-0.84, p = 0.016).ConclusionsThis study provides what is to the authors' knowledge the highest-quality data to date on RF rates following ASLS surgery. At a median follow-up of 5.1 years, 38.8% of patients had at least one RF. Estimated RF rates at 2, 4, 5, and 8 years after surgery were 11%, 24%, 35%, and 49%, respectively. Greater estimated blood loss and postoperative pelvic tilt were significant risk factors for RF. These findings emphasize the importance of long-term follow-up to realize the true prevalence and cumulative incidence of RF.

Background: Lung cancer is the second most diagnosed cancer and the leading cause of cancer deaths worldwide. Surgical lung resection is the best treatment modality in the early stages of lung cancer as well as in some locally advanced cases. Postoperative air leak is one of the most common complications after pulmonary resection with incidence ranging between 20 and 33%. The majority of air leaks seal, within 5 days after surgery, on their own by conservative management. However, at least 5% of patients still have prolonged air coming out from the residual lung at discharge. This report describes the management of a thin lady with right lung cancer who underwent a right lower lobectomy and then suffered from a delayed air leak 7 weeks after surgery and required extensive thoracic and general surgery collaboration. Case presentation: A 72-year-old heavy smoker female patient diagnosed with stage I lung cancer underwent right robotic-assisted thoracoscopic surgery converted to thoracotomy because of a fused fissure, right lower lobectomy, and mediastinal lymphadenectomy presented with delayed air leak 49 days after surgery. VATS decortication and mechanical pleurodesis were done 2 weeks after unsuccessful conservative treatment. Still, the lung failed to expand four weeks later so the patient was sent to surgery; she is underweight (BMI of 18) with not many options for a big flap to fill the chest cavity empty space. Accordingly; the decision was to use multiple pedicle flaps; omentum, intercostal muscle, and serratus anterior muscle to cover the bronchopleural fistulas and fill the pleural space in addition to mechanical and chemical pleurodesis. Full expansion of the lung was obtained. The patient was discharged on Post-Operative day 5 without remnant pneumothorax. Conclusions: Air leaks After lobectomy usually presents directly postoperatively; various management options are available ranging from conservative and minimally invasive to major operative treatment. We presented what we believe was unusual delayed bronchopleural fistula post-lobectomy in a thin lady which demonstrates clearly how a delayed air leak was detected and how collaborative efforts were crucial for delivering high-quality, safe, and patient-centered care till treated and complete recovery. [ABSTRACT FROM AUTHOR]

The Canadian Association of Radiologists (CAR) Thoracic Expert Panel consists of radiologists, respirologists, emergency and family physicians, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 24 clinical/diagnostic scenarios, a rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 30 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop 48 recommendation statements across the 24 scenarios. This guideline presents the methods of development and the referral recommendations for screening/asymptomatic individuals, non-specific chest pain, hospital admission for non-thoracic conditions, long-term care admission, routine pre-operative imaging, post-interventional chest procedure, upper respiratory tract infection, acute exacerbation of asthma, acute exacerbation of chronic obstructive pulmonary disease, suspect pneumonia, pneumonia follow-up, immunosuppressed patient with respiratory symptoms/febrile neutropenia, chronic cough, suspected pneumothorax (non-traumatic), clinically suspected pleural effusion, hemoptysis, chronic dyspnea of non-cardiovascular origin, suspected interstitial lung disease, incidental lung nodule, suspected mediastinal lesion, suspected mediastinal lymphadenopathy, and elevated diaphragm on chest radiograph. [ABSTRACT FROM AUTHOR]

Significant acute postoperative pain remains prevalent among patients who undergo truncal surgery and is associated with increased morbidity, prolonged patient recovery, and increased healthcare costs. The provision of high-quality postoperative analgesia is an important component of postoperative care, particularly within enhanced recovery programmes. Regional anaesthetic techniques have become increasingly prevalent within multimodal analgesic regimens and the widespread adoption of ultrasonography has facilitated the development of novel fascial plane blocks. The number of described fascial plane blocks has increased significantly over the past decade, leading to a burgeoning area of clinical investigation. Their applications are increasing, and truncal fascial plane blocks are increasingly recommended as part of procedure-specific guidelines. Some fascial plane blocks have been shown to be more efficacious than others, with favourable side-effect profiles compared with neuraxial analgesia, and are increasingly utilised in breast, thoracic, and other truncal surgery. However, use of these blocks is debated in regional anaesthesia circles because of limitations in our understanding of their mechanisms of action. This narrative review evaluates available evidence for the analgesic efficacy of the most commonly practised fascial plane blocks in breast, thoracic, and abdominal truncal surgery, in particular their efficacy compared with systemic analgesia, alternative blocks, and neuraxial techniques. We also highlight areas where investigations are ongoing and suggest priorities for original investigations. [ABSTRACT FROM AUTHOR]

Background Tube thoracostomy (TT) allows for the drainage of air or fluid from the pleural space. We aimed to describe the indications, management, and outcomes of patients managed with TT at AIC Litein Hospital in Southwestern Kenya. Methods This prospective study was undertaken between November 2020 and August 2022. All consecutive patients with TT were included. Data were collected on demographics, presentation, indications for TT, management, and outcome. Ethical approval was obtained from the Institutional Ethics and Research Committee. Results The study included 39 (33 male, 6 female) patients who had a mean age of 35 years (range 3-75) and 45 TTs placed for a median duration of 6 days (1-26). Hemopneumothorax (n=19), empyema thoracis (n=8), and pneumothorax (n=7) were the most common indications for TT. Trauma was noted in 28 cases presenting as assault (n=17), road traffic collision (n=8), fall (n=1), and barotrauma (n=1). Preadmission traumatic injuries led to four deaths, while fourteen (35.9%) patients developed TT-related complications, with three requiring TT replacement. Conclusions In this series, TT was mainly indicated for hemopneumothorax, empyema thoracis, and pneumothorax. [ABSTRACT FROM AUTHOR]

To determine the effects of thoracic stiffness on mechanical stress in the lumbar spine during motion. To evaluate the effect of preoperative thoracic flexibility, stiff and flexible spine models were created by changing the material properties of ligaments and discs in the thoracic spine. Total laminectomy was performed at L4/5 in stiff and flexible models. A biomechanical investigation and finite element analysis were performed preoperatively and postoperatively. A hybrid loading condition was applied, and the range of motion (ROM) at each segment and maximum stress in the discs and pars interarticularis were computed. In the preoperative model with the stiff thoracic spine, lumbar disc stress, lumbar ROM, and pars interarticularis stress at L5 increased. In contrast, as the thoracic spine became more flexible, lumbar disc stress, lumbar ROM, and pars interarticularis stress at L5 decreased. All L4/5 laminectomy models had increased instability and ROM at L4/5. To evaluate the effect of thoracic flexibility on the lumbar spine, differences between the stiff and flexible thoracic spine were examined: Differences in ROM and intervertebral disc stress at L4/5 in flexion between the stiff and flexible thoracic spine were respectively 0.7° and 0.0179 MPa preoperatively and 1.5° and 0.0367 MPa in the L4/5 laminectomy model. Biomechanically, disc stress and pars interarticularis stress decrease in the flexible thoracic spine. Flexibility of the thoracic spine reduces lumbar spine loading and could help to prevent stress-related disorders. [ABSTRACT FROM AUTHOR]

Purpose: To describe the complications and the outcome of patients with achondroplasia undergoing thoracolumbar spinal surgery. Methods: Retrospective analysis of prospectively collected data of all patients with achondroplasia undergoing surgery within the years 1992–2021 at the thoracic and/or lumbar spine. The outcome was measured by analyzing the surgical complications and revisions. The patient-rated outcome was assessed with the COMI score from 2005 onwards. Results: A total of 15 patients were included in this study undergoing a total of 31 surgeries at 79 thoracolumbar levels. 12/31 surgeries had intraoperative complications consisting of 11 dural tears and one excessive intraoperative bleeding. 4/18 revision surgeries were conducted due to post-decompression hyperkyphosis. The COMI score decreased from 7.5 IQR 1.4 (range 7.1–9.8) preoperatively to 5.3 IQR 4.1 (2.5–7.5) after 2 years (p = 0.046). Conclusion: Patients with achondroplasia, the most common skeletal dysplasia condition with short-limb dwarfism, are burdened with a congenitally narrow spinal canal and are commonly in need of spinal surgery. However, surgery in these patients is often associated with complications, namely dural tears and post-decompression kyphosis. Despite these complications, patients benefit from surgical treatment at a follow-up of 2 years after surgery. [ABSTRACT FROM AUTHOR]

Introduction and Objective: Thoracic disc calcification is a radiological finding which may be incidental or diagnosed in patients presenting with myelopathy due to spinal cord compression. We performed a study to analyze the imaging patterns of calcified thoracic discs (CTDs). Patients and Methods: A retrospective review of the spinal and radiology database of a tertiary referral orthopedic hospital was conducted for the incidence of CTDs between 2007 and 2020. Patients' demographics and radiological findings were recorded. The relationship between disc size, morphology, spinal cord compression, and management was assessed. Results: Fifty-one cases of CTDs were identified. The mean size of CTD was 806.2 mm3 (range: 144-2340). The most common level of disc calcification was T9-T10 (24%) in 12 patients. Thoracic disc calcifications in our series commonly involved disc "protrusion" in 67% (34 patients), followed by "mushroom" type in 31% (16 patients) and "extrusion" in 2% (1 patient). 37% (19 patients) had spinal cord compression with 12% (6 patients) undergoing surgical interventions. There was no statistically significant difference in the mean sizes of CTD between the groups with and without spinal cord compression (P = 0.566, independent sample t-test). Patients with "mushroom" type calcification were more likely to have surgical intervention (P = 0.01, Fisher's exact test). Conclusion: Thoracic disc calcifications, while common, can still be underdiagnosed till late myelopathic deterioration. Care of the elderly physicians, spinal surgeons, and radiologists need to be aware of them to guide diagnosis and management. Our study demonstrates that disc morphology plays a vital role in myelopathic presentation and therefore determines the need for surgical intervention instead of the absolute size of disc calcification. [ABSTRACT FROM AUTHOR]

Background: Blunt thoracic aortic injury (BTAI) is associated with a high mortality and is the second most common cause of death from trauma. The approach to major trauma, imaging technology and advancement in endovascular therapy have revolutionised the management of BTAI. Endovascular therapy has now become the gold standard technique replacing surgery with its high mortality and morbidity in unstable patients. We aim to assess the outcomes following management of BTAI. Method: This is a retrospective study of all patients with BTAI between 1 January 2010 and 1 January 2022. Data were obtained from electronic health records. The grading of BTAI severity was done based on the Society of Vascular Surgery (SVS) Criteria. Results: Fifty patients were included in the study analysis. The most common cause of BTAI was due to high-speed motor vehicle accidents (MVA) (36 patients, 72%). Grade 1 and grade 3 BTAI injuries were mostly encountered in 40% and 30% of the study cohort, respectively. Twenty-three patients (46%) underwent thoracic endovascular aortic repair (TEVAR). There was no secondary aortic re-intervention, conversion to open surgery or aortic-related deaths at 30 days or at most recent follow-up. Conclusion: Management of BTAI in our centre compares well with currently published studies. Long-term studies are warranted to guide clinicians in areas of controversy in BTAI management. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort study. Objectives: To determine if standing pre-discharge radiographs can predict the development of junctional complications. Materials and methods: Adult spinal deformity patients who underwent fusion of the lumbar spine (≥5 levels, LIV pelvis) were included. All patients underwent full-length standing radiographs before hospital discharge. Outcomes of interest included 2-year radiographic PJK and proximal junctional failure (PJF). Patients were stratified into 3 exclusive groups: No PJK, PJK, and PJF. Chi-square automatic interaction detection (CHAID) decision tree analysis was utilized to identify pre-discharge proximal junctional angle (PJA) thresholds associated with increased risk of PJK or PJF. Results: The 117 study patients had a mean age 65.8 ± 8.5, BMI 27.2 ± 4.9, PI-LL 23.3 ± 17.4, TPA 27.2 ± 11.5. Sample was stratified into 64 (54.7%) No PJK, 39 (33.3%) PJK, 14 (12.0%) PJF. No differences were detected between cohorts in discharge alignment, preop-discharge change, or offset from age-adjusted alignment targets (P >.005). Decision tree analysis showed that the first branch point depended on the UIV, as most patients with an UT UIV did not develop PJK or PJF (no PJK, 67.4%). For patients with an LT UIV, a second branch point occurred based on the ΔPJA. 89.5% of LT patients with a ΔPJA < 4.3° were free of radiographic PJK and PJF. The third branch point occurred based on the PJA at discharge. Thus, the highest risk group was comprised of ΔPJA ≥4.3° and PJA > 15.5°, as 57.1% of developed PJF and 28.6% PJK. Conclusion: Most patients with a lower thoracic UIV, preop-discharge ΔPJA ≥4.3°, and discharge PJA > 15.5° develop PJF. [ABSTRACT FROM AUTHOR]

Objective: Congenital defects/diseases Background: The VACTEREL association is an acronym that includes vertebral malformations (V), anal atresia (A), cardiac defects (C), tracheoesophageal fistula (TE), renal defects (R), and limb malformations (L). The aortic arch is the section between the ascending aorta and the descending aorta, where some variants have been described, such as the right aortic arch and bovine aortic arch, among others. A rare presentation in the Natsis classification is the "type X" where a bovine aortic arch and anomalous origin of the left vertebral artery are present. Several structural cardiac malformations have been described in the VACTEREL association. Still, there is no bovine arch or an anomalous left vertebral artery. Case Report: Our patient was a 3-year-old boy with a diagnosis of VACTEREL association (type III esophageal atresia, congenital hip dislocation, scoliosis, bilateral clubfoot, and grade IV biliary ureteral reflux). Echocardiographic findings showed changes in the aortic arch, and angiotomography and magnetic resonance angiography showed a bovine aortic arch and an anomalous left vertebral artery. At the time of diagnosis, there were no clinical manifestations or complications due to the anomalous origin of the left vertebral artery. Conclusions: This is the first description of a bovine type X arch according to the Natsis classification in a VACTEREL association. In general, knowledge of the anatomical variants of the aortic arch and the origin and course of the vertebral arteries is of great clinical and interventional importance, mainly because of the risk of cerebral ischemia. [ABSTRACT FROM AUTHOR]

Background: There are few reports on the associations between lymph node (LN) status, determined by preoperative 18F‐fluorodeoxyglucose‐positron emission tomography (FDG‐PET), and prognosis in patients with locally advanced esophageal squamous cell carcinoma (ESCC) who underwent esophagectomy post‐neoadjuvant chemotherapy (NCT). Additionally, details on the diagnostic performance of LN metastasis determination based on pathological examination versus FDG‐PET have not been reported. In this study, we aimed to evaluate the associations among LN status using FDG‐PET, LN status based on pathological examination, and prognosis in patients with locally advanced ESCC who underwent esophagectomy post‐NCT. Methods: We reviewed the data of 124 consecutive patients with ESCC who underwent esophagectomy with R0 resection post‐NCT between December 2008 and August 2022 and were evaluated pre‐ and post‐NCT using FDG‐PET. The associations among LN status using FDG‐PET, LN status based on pathological examination, and prognosis were assessed. Results: Station‐by‐station analysis of PET‐positive LNs pre‐ and post‐NCT correlated significantly with pathological LN metastases (sensitivity, specificity, and accuracy pre‐ and post‐NCT: 51.6%, 96.0%, and 92.1%; and 28.2%, 99.5%, and 93.1%, respectively; both p < 0.0001). Using univariate and multivariate analyses, LN status determined using PET post‐NCT was a significant independent predictor of both recurrence‐free survival and overall survival. Conclusion: The LN status assessed using FDG‐PET post‐NCT was significantly associated with the pathological LN status and prognosis in patients with ESCC who underwent esophagectomy post‐NCT. Therefore, FDG‐PET is a useful diagnostic tool for preoperatively predicting pathological LN metastasis and survival in these patients and could provide valuable information for selecting individualized treatment strategies. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES In this cohort study, we aimed to assess the 1-year clinical outcomes of using the E-vita Open NEO™ hybrid prosthesis for total arch replacement with frozen elephant trunk (FET) to repair extensive aortic pathologies. METHODS We reviewed individuals who underwent thoracic aortic surgery between April 2021 and March 2023 from the Gangnam Severance Aortic Registry. Exclusion criteria included ascending aortic replacement, 1 or 2 partial arch replacement, descending aortic replacement and total arch replacement without an FET. Finally, all consecutive patients who underwent total arch replacement and FET with E-vita Open NEO for aortic arch pathologies between April 2021 and March 2023 were included in this cohort study. The patients were divided into 3 groups based on their pathology: acute aortic dissection, chronic aortic dissection and thoracic aortic aneurysm. The primary end point was in-hospital mortality. The secondary end points during the postoperative period comprised stroke, spinal cord injury and redo sternotomy for bleeding. Additionally, the secondary end points during the follow-up period included the 1-year survival rate, 1-year freedom from all aortic procedures and 1-year freedom from unplanned aortic interventions. RESULTS The study included 167 patients in total: 92 patients (55.1%) with acute aortic dissection, 20 patients (12.0%) with chronic aortic dissection and 55 patients (32.9%) with thoracic aortic aneurysm. The in-hospital mortality was 1.8% (n  = 3). Strokes occurred in 1.8% (n  = 3) of the patients, spinal cord injury in 1.8% (n  = 3) and redo sternotomy for bleeding was performed in 3.0% (n  = 5). There were no significant differences between the pathological groups. The median follow-up period (quartile 1–quartile 3) was 198 (37–373) days, with 1-year survival rates of 95.9%. At 1 year, the freedom from all aortic procedures and unplanned aortic interventions were 90.3% and 92.0%, respectively. CONCLUSIONS The 1-year clinical outcomes of total arch replacement with FET using the E-vita Open NEO were favourable. Long-term follow-up is required to evaluate the durability of the FET. [ABSTRACT FROM AUTHOR]

Background Lung cancer is one of the most common types of cancer in the United Kingdom. It is often diagnosed late. The 5-year survival rate for lung cancer is below 10%. Early diagnosis may improve survival. Software that has an artificial intelligence-developed algorithm might be useful in assisting with the identification of suspected lung cancer. Objectives This review sought to identify evidence on adjunct artificial intelligence software for analysing chest X-rays for suspected lung cancer, and to develop a conceptual cost-effectiveness model to inform discussion of what would be required to develop a fully executable cost-effectiveness model for future economic evaluation. Data sources The data sources were MEDLINE All, EMBASE, Cochrane Database of Systematic Reviews, Cochrane CENTRAL, Epistemonikos, ACM Digital Library, World Health Organization International Clinical Trials Registry Platform, clinical experts, Tufts Cost-Effectiveness Analysis Registry, company submissions and clinical experts. Searches were conducted from 25 November 2022 to 18 January 2023. Methods Rapid evidence synthesis methods were employed. Data from companies were scrutinised. The eligibility criteria were (1) primary care populations referred for chest X-ray due to symptoms suggestive of lung cancer or reasons unrelated to lung cancer; (2) study designs that compared radiology specialist assessing chest X-ray with adjunct artificial intelligence software versus radiology specialists alone and (3) outcomes relating to test accuracy, practical implications of using artificial intelligence software and patient-related outcomes. A conceptual decision-analytic model was developed to inform a potential full cost-effectiveness evaluation of adjunct artificial intelligence software for analysing chest X-ray images to identify suspected lung cancer. Results None of the studies identified in the searches or submitted by the companies met the inclusion criteria of the review. Contextual information from six studies that did not meet the inclusion criteria provided some evidence that sensitivity for lung cancer detection (but not nodule detection) might be higher when chest X-rays are interpreted by radiology specialists in combination with artificial intelligence software than when they are interpreted by radiology specialists alone. No significant differences were observed for specificity, positive predictive value or number of cancers detected. None of the six studies provided evidence on the clinical effectiveness of adjunct artificial intelligence software. The conceptual model highlighted a paucity of input data along the course of the diagnostic pathway and identified key assumptions required for evidence linkage. Limitations This review employed rapid evidence synthesis methods. This included only one reviewer conducting all elements of the review, and targeted searches that were conducted in English only. No eligible studies were identified. Conclusions There is currently no evidence applicable to this review on the use of adjunct artificial intelligence software for the detection of suspected lung cancer on chest X-ray in either people referred from primary care with symptoms of lung cancer or people referred from primary care for other reasons. Future work Future research is required to understand the accuracy of adjunct artificial intelligence software to detect lung nodules and cancers, as well as its impact on clinical decision-making and patient outcomes. Research generating key input parameters for the conceptual model will enable refinement of the model structure, and conversion to a full working model, to analyse the cost-effectiveness of artificial intelligence software for this indication. Study registration This study is registered as PROSPERO CRD42023384164. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR135755) and is published in full in Health Technology Assessment; Vol. 28, No. 50. See the NIHR Funding and Awards website for further award information. Plain language summary Lung cancer is one of the most common types of cancer in the United Kingdom. Early diagnosis may improve survival, as lung cancer is often diagnosed late. Chest X-rays can be used to identify features of lung cancer. There can be delays in getting X-rays, and sometimes features of lung cancer are not seen on them. Artificial intelligence software may help by finding features of cancer on chest X-rays and highlighting them. A radiologist will look at the X-rays and information from the software. There is a lack of information about how lung cancer diagnosis could change if artificial intelligence software is used and what the costs may be to the National Health Service. This project looked at the use of artificial intelligence software in the detection of lung cancer in people referred from primary care. Software companies were invited to provide evidence. There were no studies that looked at this topic among people from primary care. We summarised the closest evidence we could find instead. All of this had flaws, so we could not tell if the results were accurate or helpful to this review. It was not clear if artificial intelligence helped to find cancers or improve people’s health. We made a theoretical model to discuss the best way to assess if artificial intelligence software might be cost-effective in detecting lung cancer and what evidence would be needed to do this in a fully working model. Costs and alternative pricing models provided by five companies were used to calculate the cost of adding artificial intelligence software to review chest X-rays in people referred from their general practitioner, for the first 5 years, based on one National Health Service trust. Future studies are needed to identify the impact of adjunct artificial intelligence on test accuracy, clinical decision-making and patient outcomes (e.g. mortality and morbidity). Scientific summary Background Lung cancer occurs when abnormal cells multiply in an uncontrolled way to form a tumour in the lung. It is one of the most common types of cancer in the UK, and each year over 43,000 new cases are diagnosed. In the early stages of the disease, people usually do not have symptoms, which means that lung cancer is often diagnosed late. The 5-year survival rate for lung cancer is low, at below 10%. Early diagnosis may improve survival. The National Institute for Health and Care Excellence (NICE) has identified software that has an artificial intelligence (AI)-developed algorithm (referred to hereafter as AI software) as potentially useful in assisting with the identification of suspected lung cancer. AI combines computer science and data sets to enable problem-solving. Machine learning and deep learning are subfields of AI. They comprise AI algorithms that seek to create expert systems to make predictions or classifications based on data input. This assessment covers the use of AI software as an adjunct to an appropriate radiology specialist to assist in the identification of suspected lung cancer on chest X-rays (CXRs). AI technologies subject to this assessment are standalone software platforms developed with deep-learning algorithms to interpret CXRs. The algorithms are fixed but updated periodically. The AI software automatically interprets radiology images from the CXR to identify abnormalities or suspected abnormalities. The abnormalities detected and the methods of flagging the location and type of abnormalities differ between different AI technologies. For example, a CXR may be flagged as suspected lung cancer when a lung nodule, lung mass or hilar enlargement, or a combination of these, is identified. A technology may classify CXRs into those with and without a nodule, or it may identify several different abnormalities or lung diseases. Objectives The overall aim of this early value assessment (EVA) is to identify evidence on adjunct AI software for analysing CXRs for suspected lung cancer and identify evidence gaps to help direct data collection and further research. A conceptual modelling process was undertaken to inform discussion of what would be required to develop a fully executable cost-effectiveness model for future economic evaluation. The assessment is not intended to replace the need for a full assessment (Diagnostic Assessment Report) or to provide sufficient detail or synthesis to enable a recommendation to be made about whether AI software can be implemented in clinical practice at the present time. There are two populations of interest in this EVA: (1) people referred from primary care for a CXR because they have symptoms suggestive of lung cancer (symptomatic population) and (2) people referred from primary care for a CXR for reasons unrelated to lung cancer (incidental population). Based on the scope produced by NICE, we defined the following questions to inform future assessment on the benefits, harms and costs of adjunct AI for analysing on CXRs for suspected lung cancer compared with human reader alone in these populations: What is the test accuracy and test failure rate of adjunct AI software to detect lung cancer on CXRs? What are the practical implications of adjunct AI to detect lung cancer on CXRs? What is the clinical effectiveness of adjunct AI software applied to CXRs? What are the cost and resource use considerations relating to use of adjunct AI to detect lung cancer? What would a health economic model to estimate the cost-effectiveness of adjunct AI to detect lung cancer look like? Methods Data sources MEDLINE All (via Ovid), EMBASE (via Ovid), Cochrane Database of Systematic Reviews (via Wiley), Cochrane CENTRAL (via Wiley), Epistemonikos, ACM Digital Library, World Health Organization International Clinical Trials Registry Platform, clinical experts, and company submissions. Eligibility criteria Population: people referred for CXR from primary care because they have symptoms suggestive of lung cancer, and people referred for CXR from primary care for reasons unrelated to lung cancer. Intervention: radiology specialist with adjunct AI Comparator: radiology specialist without adjunct AI Outcomes: test accuracy, patient management, clinical effectiveness. Study selection, data extraction and assessment of risks of bias Titles and abstracts of all identified records were screened by one reviewer against the review eligibility criteria, with a random 20% screened by a second reviewer. Full texts of records considered potentially relevant by either reviewer were retrieved and assessed for inclusion by one reviewer. A random 20% sample were assessed independently by a second reviewer, with any disagreements resolved by consensus or discussion with a third reviewer. We planned to extract data into a piloted form, assess risk of bias and synthesise data using methods described in the research protocol; however, no studies met the inclusion criteria. Post hoc methods were determined following discussions with NICE to select and summarise the closest available evidence to the review inclusion criteria. Studies were selected that assessed eligible AI software in conjunction with radiologists compared with radiologists alone but in which the referral status and symptomatic status of the population was unclear. Data were extracted by one reviewer, with a random 20% checked by a second reviewer. Results were summarised narratively, and key biases were noted. Data synthesis A narrative data synthesis was performed. Modelling The conceptual modelling process explored both the structure and evidence requirements for parameter inputs, for future model development. An iterative approach was taken to facilitate the identification of cost outcomes, potential value drivers of AI software for this indication and evidence linkage requirements for longer-term outcomes, where time allowed. Costs associated with implementing AI software were also considered. Information to inform the conceptual model was obtained from a variety of sources including a literature review, current clinical guidelines, discussion with specialist clinical experts and the companies submitting evidence on AI software. Given the time available, the diagnostic component of the model was the primary focus of the health economics aspect of the report. Priority was given to the following considerations: input parameters to populate the model – including consideration of the type of evidence required, sources available and gaps in the evidence relevant outcome measures to compare the cost-effectiveness and clinical effectiveness of AI software in the detection of lung cancer identification of potential value drivers of the model – with recommendations of how these can be measured for inclusion in a cost-effectiveness model. Results Test accuracy, practical implications and clinical effectiveness No studies met the inclusion criteria of the review. Two ongoing studies with unclear eligibility were identified. In the absence of available evidence, we summarised data from six studies that had unclear populations but included a comparison of CXRs read by readers with and without the use of commercial AI software. Statistical comparisons were not undertaken in most of the studies, but there was some evidence that sensitivity might be higher among specialist radiologist with AI than among specialist radiologist without AI. This finding was not consistent between studies, however. No significant differences were observed for specificity, positive predictive value or number of cancers detected. None of the studies provided evidence on the clinical effectiveness of adjunct AI software. The summarised studies were small retrospective studies with important methodological limitations, and their generalisability to the UK population is unclear. Conclusions There is currently no evidence applicable to this review on the use of adjunct AI software for the detection of suspected lung cancer on CXRs in either people referred from primary care with symptoms of lung cancer or people referred from primary care for other reasons. Implications for service provision Lung cancer pathways are complex and contain many routes to diagnosis. Although national guidance and timelines for diagnosis exist, practice varies widely throughout radiology departments and lung cancer teams both within and across NHS trusts. With many ways to achieve these targets, changes in any area of the diagnostic pathway may have a significant impact elsewhere. There is some evidence for the impact of CXR results on the diagnostic pathway when performed without AI assistance, as is current practice. This is limited, and it is difficult to compare results because of the different study designs used and the different outcomes reported. There is no published evidence to link measures of progression through the diagnostic pathways with long-term outcomes such as stage at diagnosis and survival. There is currently no applicable evidence to show the impact of the addition of AI software to CXR review on the diagnosis of lung cancer. There may be multiple ways AI software could change measures along this pathway. These could include improved accuracy of lung cancer detection, directing patients along the quickest pathway to diagnosis, quicker report turnaround time to achieve earlier confirmatory testing, or prioritisation of cases for review including those without lung cancer who can be discharged more quickly and free up staff time and resources. AI software may also have a negative impact on pathways by increasing the number of benign lung nodules detected and increasing the number of patients who undergo a computed tomography scan that they might not have needed. This would be detrimental to the patients, with increased exposure to radiation and anxiety due to a positive CXR result, and has cost and resource use implications for the department. With a lack of evidence on AI software, the impact on service provision is unknown and may have significant implications in terms of progression through diagnostic pathways, resource use, costs and patient outcomes. Study registration This study is registered as PROSPERO CRD42023384164. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR135755) and is published in full in Health Technology Assessment; Vol. 28, No. 50. See the NIHR Funding and Awards website for further award information.

We present a case of a 42-year-old man with DiGeorge syndrome and congenital cardiac anomalies including a type B interrupted aortic arch who had previously undergone two bypasses between the ascending and descending thoracic aorta in childhood. He was found to have a 7.4-cm pseudoaneurysm of the descending thoracic aorta with the left subclavian artery arising from the aneurysm. The patient was treated with a single stage hybrid repair including left common carotid to subclavian bypass followed by thoracic endovascular aortic aneurysm repair.