Influence of Body Mass Index on Radiation Exposure Across Imaging Modalities in the Evaluation of Chest Pain.

BACKGROUND: Essential to a patient-centered approach to imaging individuals with chest pain is knowledge of differences in radiation effective dose across imaging modalities. Body mass index (BMI) is an important and underappreciated predictor of effective dose. This study evaluated the impact of BMI on estimated radiation exposure across imaging modalities. METHODS AND RESULTS: This was a retrospective analysis of patients with concern for cardiac ischemia undergoing positron emission tomography (PET)/computed tomography (CT), cadmium zinc telluride single-photon emission CT (SPECT) myocardial perfusion imaging, or coronary CT angiography (CCTA) using state-of-the-art imaging modalities and optimal radiation-sparing protocols. Radiation exposure was calculated across BMI categories based on established cardiac imaging-specific conversion factors. Among 9046 patients (mean±SD age, 64.3±13.1 years; 55% men; mean±SD BMI, 30.6±6.9 kg/m2), 4787 were imaged with PET/CT, 3092 were imaged with SPECT/CT, and 1167 were imaged with CCTA. Median (interquartile range) radiation effective doses were 4.4 (3.9-4.9) mSv for PET/CT, 4.9 (4.0-6.3) mSv for SPECT/CT, and 6.9 (4.0-11.2) mSv for CCTA. Patients at a BMI <20 kg/m2 had similar radiation effective dose with all 3 imaging modalities, whereas those with BMI ≥20 kg/m2 had the lowest effective dose with PET/CT. Radiation effective dose and variability increased dramatically with CCTA as BMI increased, and was 10 times higher in patients with BMI >45 kg/m2 compared with <20 kg/m2 (median, 26.9 versus 2.6 mSv). After multivariable adjustment, PET/CT offered the lowest effective dose, followed by SPECT/CT, and then CCTA (P<0.001). CONCLUSIONS: Although median radiation exposure is modest across state-of-the-art PET/CT, SPECT/CT, and CCTA systems using optimal radiation-sparing protocols, there are significant variations across modalities based on BMI. These data are important for making patient-centered decisions for ischemic testing.

A 25-Year-Old Man with a History of Substance Abuse Presenting with Pneumomediastinum Due to Methamphetamine Vapor Inhalation.

BACKGROUND There has been an increase in the use of inhalation methods to abuse drugs, including freebasing crack cocaine (alkaloid) and inhaling methamphetamine vapor. This report is of a 25-year-old man with a history of substance abuse presenting with pneumomediastinum due to methamphetamine vapor inhalation. Acute pneumomediastinum is an extremely rare complication of methamphetamine use. CASE REPORT A 25-year-old man was treated for polysubstance abuse following 9 days of methamphetamine abuse. EKG did not show any ST &T change. D-dimer was normal, at 0.4 mg/L, so we did not do further work-up for pulmonary embolism. His chest pain worsened in the Emergency Department (ED), and a physical exam demonstrated crepitation of the posterior neck, trapezius, and right scapula. A portable chest X-ray revealed subcutaneous air over the right scapular region, in addition to pneumomediastinum. The urine drug screen test was positive for methamphetamine. A chest CT was ordered, which showed a moderate-volume pneumomediastinum with soft-tissue air tracking into the lower neck and along the right chest wall. The patient underwent an esophagogram, which showed no air leak, and Boerhaave's syndrome was ruled out. His symptoms improved and he did not require any surgical intervention. CONCLUSIONS Considering the higher rates of illicit substance use, especially methamphetamine, it is important to pay attention to the associated pathologies and to keep spontaneous pneumomediastinum on the list of differentials for patients using methamphetamine, particularly those who inhale it, which can cause pneumomediastinum, even without Boerhaave's syndrome.

ChatGPT provides inconsistent risk-stratification of patients with atraumatic chest pain.

BACKGROUND: ChatGPT-4 is a large language model with promising healthcare applications. However, its ability to analyze complex clinical data and provide consistent results is poorly known. Compared to validated tools, this study evaluated ChatGPT-4's risk stratification of simulated patients with acute nontraumatic chest pain. METHODS: Three datasets of simulated case studies were created: one based on the TIMI score variables, another on HEART score variables, and a third comprising 44 randomized variables related to non-traumatic chest pain presentations. ChatGPT-4 independently scored each dataset five times. Its risk scores were compared to calculated TIMI and HEART scores. A model trained on 44 clinical variables was evaluated for consistency. RESULTS: ChatGPT-4 showed a high correlation with TIMI and HEART scores (r = 0.898 and 0.928, respectively), but the distribution of individual risk assessments was broad. ChatGPT-4 gave a different risk 45-48% of the time for a fixed TIMI or HEART score. On the 44-variable model, a majority of the five ChatGPT-4 models agreed on a diagnosis category only 56% of the time, and risk scores were poorly correlated (r = 0.605). CONCLUSION: While ChatGPT-4 correlates closely with established risk stratification tools regarding mean scores, its inconsistency when presented with identical patient data on separate occasions raises concerns about its reliability. The findings suggest that while large language models like ChatGPT-4 hold promise for healthcare applications, further refinement and customization are necessary, particularly in the clinical risk assessment of atraumatic chest pain patients.

Chest pain in pediatric patients in the emergency department- Presentation, risk factors and outcomes-A systematic review and meta-analysis.

OBJECTIVE: This study aimed to assess and determine the presentation, risk factors, and outcomes of pediatric patients who were admitted for cardiac-related chest pain. BACKGROUND: Although chest pain is common in children, most cases are due to non-cardiac etiology. The risk of misdiagnosis and the pressure of potentially adverse outcomes can lead to unnecessary diagnostic testing and overall poorer patient experiences. Additionally, this can lead to a depletion of resources that could be better allocated towards patients who are truly suffering from cardiac-related pathology. METHODS: This review was conducted per PRISMA guidelines. This systematic review used several databases including MEDLINE, Embase, Scopus, and Web of Science to obtain its articles for review. RESULTS: A total of 6,520 articles were identified, and 11 articles were included in the study. 2.5% of our study population was found to have cardiac-related chest pain (prevalence = 0.025, 95% CI [0.013, 0.038]). The most commonly reported location of pain was retrosternal chest pain. 97.5% of the study population had a non-cardiac cause of chest pain, with musculoskeletal pain being identified as the most common cause (prevalence = 0.357, 95% CI [0.202, 0.512]), followed by idiopathic (prevalence = 0.352, 95% CI [0.258, 0.446]) and then gastrointestinal causes (prevalence = 0.053, 95% CI [0.039, 0.067]). CONCLUSIONS: The overwhelming majority of pediatric chest pain cases stem from benign origins. This comprehensive analysis found musculoskeletal pain as the predominant culprit behind chest discomfort in children. Scrutinizing our study cohort revealed that retrosternal chest pain stands as the unequivocal epicenter of this affliction. Thorough evaluation of pediatric patients manifesting with chest pain is paramount for the delivery of unparalleled care, especially in the context of potential cardiac risks in the emergency department.

Factors Influencing Time to First Medical Contact in Patients with Acute ST-Segment Elevation Myocardial Infarction: A Retrospective Analysis.

BACKGROUND Exploring the factors that impact the time from symptom onset to first medical contact (S2FMC) is crucial for improving outcomes in elderly patients diagnosed with acute ST-segment elevation myocardial infarction (STEMI). This study conducted a retrospective analysis on 282 patients who underwent emergency percutaneous coronary intervention (PCI) or percutaneous transluminal coronary angioplasty (PTCA) in Guangzhou City District to identify significant factors affecting S2FMC. MATERIAL AND METHODS A retrospective analysis was conducted on 282 patients with STEMI who underwent emergency percutaneous coronary intervention (PCI). Descriptive statistics, univariate and multivariate Cox regression analyses were used to identify significant factors affecting S2FMC. Additionally, interactions between risk factors were examined using multivariate logistic regression and the structural equation model (SEM). RESULTS Age (HR=0.984, 95% CI: 0.975-0.993), nature of chest pain (HR=2.561, 95% CI: 1.900-3.458), admission mode (HR=1.805, 95% CI: 1.358-2.400), and vascular characteristics (HR=1.246, 95% CI: 1.069-1.451) were independent influencing factors for S2FMC. Persistent chest tightness/pain, EMS admission, and vascular characteristics (RCADL or LCADL) played a protective role in S2FMC. Among the influencing factors, vascular characteristics (OR=1.072, 95% CI: 1.008-1.141) had an independent effect on the nature of chest pain. Meanwhile, the nature of chest pain (OR=1.148, 95% CI: 1.015-1.298) was an independent influencing factor in the admission mode. CONCLUSIONS Patients with persistent chest tightness/pain, EMS admission, and vascular characteristics (RCADL or LCADL) experienced shorter S2FMC and higher compliance rate (S2FMC ≤180 min). At the same time, age and other vascular features played an inverse role. This study proposes enhancing follow-up and monitoring measures, and shows the consequences of intermittent chest pain should not be disregarded.

Critical Assessment of the Management of Unstable Angina in a Specialized Cardiology Emergency Room. / Avaliação Crítica do Manejo da Angina Instável em Pronto-Socorro Terciário de Cardiologia.

BACKGROUND: The management of unstable angina (UA) presents a challenge due to its subjective diagnosis and limited representation in randomized clinical trials that inform current practices. OBJECTIVES: This study aims to identify key factors associated with the indication for invasive versus non-invasive stratification in this population and to evaluate factors associated with stratification test results. METHODS: This retrospective cohort study included patients hospitalized with UA over a consecutive 20-month period. To assess factors associated with stratification strategies, patients were divided into invasive stratification (coronary angiography) and non-invasive stratification (other methods) groups. For the analysis of factors related to changes in stratification tests, patients were categorized into groups with or without obstructive coronary artery disease (CAD) or ischemia, as per the results of the requested tests. Comparisons between groups and multiple logistic regression analyses were performed, with statistical significance set at a 5% level. RESULTS: A total of 729 patients were included, with a median age of 63 years and a predominance of males (64.6%). Factors associated with invasive stratification included smoking (p = 0.001); type of chest pain (p < 0.001); "crescendo" pain (p = 0.006); TIMI score (p = 0.006); HEART score (p = 0.011). In multivariate analysis, current smokers (OR 2.23, 95% CI 1.13-4.8), former smokers (OR 2.19, 95% CI 1.39-3.53), and type A chest pain (OR 3.39, 95% CI 1.93-6.66) were independently associated. Factors associated with obstructive CAD or ischemia included length of hospital stay (p < 0.001); male gender (p = 0.032); effort-induced pain (p = 0.037); Diamond-Forrester score (p = 0.026); TIMI score (p = 0.001). In multivariate analysis, only chest pain (type B chest pain: OR 0.6, 95% CI 0.38-0.93, p = 0.026) and previous CAD (OR 1.42, 95% CI 1.01-2.0, p = 0.048) were independently associated. CONCLUSION: The type of chest pain plays a crucial role not only in the diagnosis of UA but also in determining the appropriate treatment. Our results highlight the importance of incorporating pain characteristics into prognostic scores endorsed by guidelines to optimize UA management.

FUNDAMENTO: O manejo da angina instável (AI) é um desafio devido ao seu diagnóstico subjetivo e à sua escassa representação em ensaios clínicos randomizados que determinem as práticas atuais. OBJETIVOS: O objetivo deste estudo é identificar os principais fatores associados à indicação de estratificação invasiva ou não nessa população e avaliar os fatores associados às alterações nos exames de estratificação. MÉTODOS: Coorte retrospectiva de pacientes internados por AI, em um período de 20 meses consecutivos. Para avaliar os fatores associados à estratégia de estratificação, os pacientes foram divididos em estratificação invasiva (cinecoronariografia) e não invasiva (demais métodos). Para análise de fatores relacionados às alterações nos exames de estratificação, os pacientes foram divididos em grupos com ou sem doença arterial coronariana (DAC) obstrutiva ou isquemia, conforme resultados dos exames solicitados. Foram realizadas comparações entre grupos e análise de regressão logística múltipla, com significância estatística definida em um nível de 5%. RESULTADOS: 729 pacientes foram incluídos, com mediana de idade de 63 anos e predomínio do sexo masculino (64,6%). Estiveram associados à estratificação invasiva: tabagismo (p = 0,001); tipo de dor torácica (p < 0,001); dor "em crescendo" (p = 0,006); escore TIMI (p = 0,006); escore HEART (p = 0,011). Na análise multivariada, tabagistas (OR 2,23, IC 95% 1,13-4,8), ex-tabagistas (OR 2,19, IC 1,39-3,53) e dor torácica tipo A (OR 3,39, IC 95% 1,93-6,66) estiveram associados de forma independente. Estiveram associados à DAC obstrutiva ou isquemia: tempo de internação hospitalar (p < 0,001); sexo masculino (p = 0,032); dor desencadeada por esforço (p = 0,037); Diamond-Forrester (p = 0,026); escore TIMI (p = 0,001). Na análise multivariada, apenas dor torácica (dor torácica tipo B: OR 0,6, IC 95% 0,38-0,93, p = 0,026) e DAC prévia (OR 1,42, IC 95% 1,01-2,0, p = 0,048) estiveram associadas de maneira independente. CONCLUSÕES: O tipo de dor torácica desempenha um papel crucial não apenas no diagnóstico da AI, mas também na definição do tratamento adequado. Nossos resultados destacam a importância de incorporar características da dor aos escores prognósticos endossados pelas diretrizes, para otimização do manejo da AI.

Pneumopericardium in a child - "halo sign" on chest x-ray: A Case Report.

A 5 year old boy with acute ly mphoblastic leukaemia on chemotherapy presented with chest pain and vomiting for two days after an elective procedure under general anaesthesia. H is ches t x-ray was remarkabl e for a promin ent halo sign, an air gap surrounding the he art indicat ing a large pneumope ricardium. Alth ough the pneu mo pericardium could not be appre ciated on an echocardiogram, the child developed clinical sig ns of cardiac t amponade. Attem pts to evacu ate the pneumopericardium were unsuccessful leading to death.

Severe acute respiratory syndrome coronavirus 2 infection rate among pediatric patients with respiratory symptoms.

BACKGROUND: The incidence of coronavirus disease 2019 (COVID-19) in children has been increasing worldwide since the onset of the pandemic. This study examined the risk factors and characteristics of COVID-19 among pediatric patients compared to other respiratory viral infections. METHODS: This was a prospective cross-sectional study. Patients aged 0-18 years presenting with respiratory symptoms from October 2020 to December 2021 were included. Demographic and clinical data were reviewed. RESULTS: In total, 738 pediatric patients were enrolled. Of these, 48.5% had COVID-19, and 41.3% were infected with another respiratory virus. The COVID-19 incidence increased from 0.5% during the original strain outbreak (October 2020 to March 2021) to 56.5% and 73.4% during the alpha (April to June 2021) and delta (July to December 2021) periods, respectively. Children aged 6-18 years, being female, obesity, exposure to household members with COVID-19, and the delta period were risk factors for COVID-19. Being aged 1-5 years, obesity, shortness of breath, productive cough, and chest pain were associated with COVID-19 pneumonia. Children aged 5-18 years, underlying neurological disease, a history of COVID-19 pneumonia, and the delta period were associated with long COVID. CONCLUSIONS: Pediatric COVID-19 patients presenting with respiratory symptoms who are obese or have been exposed to household members with COVID-19 should be tested for COVID-19. COVID-19 patients who are obese, younger than five years old, or who present with shortness of breath, productive cough, or chest pain should be evaluated for pneumonia. COVID-19 patients with a history of COVID-19 pneumonia or underlying neurological disease should receive follow-up for long COVID.

Age and healthy lifestyle behavior's disparities and similarities on knowledge of myocardial infarction symptoms and risk factors among public and outpatients in a resource-limited setting, cross-sectional study in greater Gaborone, Botswana.

OBJECTIVES: In this cross-sectional study from Botswana, we investigated knowledge of myocardial infarction (MI) symptoms and risk factors among the general public and outpatients with MI risk factors based on age and lifestyle behaviors, in addition to assessing associations with sociodemographic and MI risk factors. METHOD: Open-ended questionnaires about 8 MI symptoms and 10 risk factors, were administered by research assistants to a representative selection of outpatients (n = 525) and the public (n = 2248). Weight and height were measured in all participants and BMI was calculated. Knowledge scores were compared between the two groups. We examined whether sociodemographic and MI risk factors had impact on the scores. Analyses were further adjusted for lifestyle behavior (smoking status, dietary status and physical activities). RESULTS: The valid response rate was 97.9% comprising 97.8% for the public (n = 2199) and 98.1% for outpatients (n = 515). Public respondents (35.2 ± 12.3 years) were younger than outpatients (38.5 ± 12.6 years). The public comprised 56.9% females while outpatients 54.6%. In general, outpatients had higher knowledge of MI symptoms than the public, with mean scores ± SD of 3.49 ± 2.84 vs 2.80 ± 2.54. Outpatients also had higher knowledge score of MI risk factors than the public, with mean scores, 5.33 ± 3.22 vs 3.82 ± 3.07. For MI symptoms, outpatients were more aware than the public for chest pains among all ages, for arm pain/ numbness, neck/ jaw pain radiating to/ from chest, and feeling sick or looking pallor on the skin among those aged 35-49 years. Among both the public and outpatients, lower knowledge of both MI symptoms and risk factors was associated with primary education, not residing/working together, history of hypertension, no history of heart disease/stroke, and obesity. There were similarities and disparities on MI knowledge among respondents with various numbers of healthy lifestyle behaviours. CONCLUSION: Results call for urgent educational campaigns on awareness and knowledge of MI and using strategies based on age and lifestyle behavior.

[Sudden Chest Pain due to Early Bioprosthetic Valve Dysfunction:Report of a Case].

We report a case of bioprosthetic valve dysfunction and acute aortic valve regurgitation. The case was a 75-year-old female who had sudden onset chest pain. ST-segment depression in several leads on electrocardiogram( ECG) suggested acute coronary syndrome. Coronary angiography showed no significant stenosis in coronary arteries. Transesophageal echocardiography revealed severe aortic regurgitation, suggesting that angina was caused by myocardial ischemia associated with acute aortic regurgitation. She was diagnosed as having bioprosthetic valve dysfunction, and underwent redo aortic valve replacement. One leaflet of the bioprosthetic valve was torn along the stent post and caused bioprosthetic valve dysfunction. Failed bioprosthetic valve was removed and replaced by a mechanical valve.

[Surgical Therapy of Slipping Rib Syndrome].

We have operated on two cases of slipped ribs syndrome( SRS). Both patients were men in their 40s with a history of right thoracic trauma who were referred to us because of unexplained lower thoracic pain. The left rib was positive for hooking maneuver (lift test), and dynamic ultrasonography showed narrowing of the intercostal space, which led to the diagnosis of SRS. in the first case, the tip of the ninth rib cartilage was excised, and the ninth and tenth rib cartilages were sutured and fixed with No.2 fiber wire in two places with Z sutures. In the second case, the tip of the ninth rib cartilage was excised, the eighth and ninth ribs and the ninth and tenth ribs were fixed with No.2 fiber wire with Z sutures as in the first case, and a 0.7 mm thick poly-L-lactide (PLLA) plate was added between the eighth and tenth rib cartilages. In both cases, the postoperative course was good and the pain disappeared. SRS should be recognized as a disease and surgical treatment should be used as therapy.

[Multiple pulmonary nodules with cavity formation].

A 64-year-old female patient was admitted to Beijing Chao-Yang Hospital on February 21, 2023 because of right-sided chest pain for more than 4 years and left-sided chest pain for more than 9 months. She had a past medical history of previous tuberculosis and rheumatoid arthritis. A chest CT in October 2018 revealed multiple pulmonary nodules. A CT-guided biopsy showed no tumors, and adenosine deaminase levels in the pleural effusion were elevated, suggesting a high likelihood of tuberculosis. As a result, anti-tuberculosis treatment was initiated in March 2019. In December 2019, she underwent a right lower lobe resection due to localized hydropneumothorax on the right side. Postoperative pathology unveiled granulomatous inflammation with necrosis. A chest CT in May 2020 showed a significant increase in nodules and cavities. In January 2023, a diagnosis of cryptococcal pneumonia was considered, and she was prescribed oral fluconazole. Finally, the diagnosis of pulmonary rheumatoid nodules was confirmed after a pathological consultation of the postoperative specimen. After one month of treatment with oral prednisone and mycophenolate mofetil, a follow-up chest CT showed improvement. It was recommended that she continue with her current treatment and undergo regular chest CT scans.

Increased Angio-Derived Index of Microcirculatory Resistance Within a Timeframe of 30-60 days After COVID-19 Infection.

BACKGROUND AND OBJECTIVES: Chest pain is a relatively long-term symptom that commonly occurs in patients who have contracted COVID-19. The reasons for these symptoms remain unclear, with coronary microvascular dysfunction (CMD) emerging as a potential factor. This study aimed to assess the presence of CMD in these patients by measuring the angio-derived index of microcirculatory resistance (AMR). METHODS: In this cross-sectional case-control study, patients who had chest pain and a history of COVID-19 infection within the preceding 30 to 60 days were included. The control subjects were patients without COVID-19. Demographic, clinical, and echocardiographic data were recorded. Angiographic images were collected for AMR analysis through an angioplus quantitative flow ratio measurement system. Propensity score matching (PSM) was performed to match the two groups. Multivariate logistic regression was used to examine the association between COVID-19 incidence and the increase in AMR (AMR > 285 mmHg*s/m) after correction for other confounders. RESULTS: After PSM, there were 58 patients in each group (the mean age was 66.3 ± 9.04 years, and 55.2% were men). The average time between the onset of COVID-19 infection and patient presentation at the hospital for coronary angiography was 41 ± 9.5 days. Moreover, there was no significant difference in the quantitative flow ratio between the two groups. Patients with COVID-19 had a greater mean AMR (295 vs. 266, p = 0.002). Multivariate logistic regression analysis revealed that COVID-19 (OR = 3.32, 95% CI = 1.50-7.60, p = 0.004) was significantly associated with an increase in AMR. CONCLUSIONS: Long-term COVID-19 patients who experience chest pain without evidence of myocardial ischemia exhibit an increase in AMR, and CMD may be one of the reasons for this increase. COVID-19 is an independent risk factor for an increase in AMR.