Automated calculation of the right ventricle to left ventricle ratio on CT for the risk stratification of patients with acute pulmonary embolism.

OBJECTIVES: To assess the feasibility and reliability of the use of artificial intelligence post-processing to calculate the RV:LV diameter ratio on computed tomography pulmonary angiography (CTPA) and to investigate its prognostic value in patients with acute PE. METHODS: Single-centre, retrospective study of 101 consecutive patients with CTPA-proven acute PE. RV and LV volumes were segmented on 1-mm contrast-enhanced axial slices and maximal ventricular diameters were derived for RV:LV ratio using automated post-processing software (IMBIO LLC, USA) and compared to manual analysis in two observers, via intraclass coefficient correlation analysis. Each CTPA report was analysed for mention of the RV:LV ratio and compared to the automated RV:LV ratio. Thirty-day all-cause mortality post-CTPA was recorded. RESULTS: Automated RV:LV analysis was feasible in 87% (n = 88). RV:LV ratios ranged from 0.67 to 2.43, with 64% (n = 65) > 1.0. There was very strong agreement between manual and automated RV:LV ratios (ICC = 0.83, 0.77-0.88). The use of automated analysis led to a change in risk stratification in 45% of patients (n = 40). The AUC of the automated measurement for the prediction of all-cause 30-day mortality was 0.77 (95% CI: 0.62-0.99). CONCLUSION: The RV:LV ratio on CTPA can be reliably measured automatically in the majority of real-world cases of acute PE, with perfect reproducibility. The routine use of this automated analysis in clinical practice would add important prognostic information in patients with acute PE. KEY POINTS: • Automated calculation of the right ventricle to left ventricle ratio was feasible in the majority of patients and demonstrated perfect intraobserver variability. • Automated analysis would have added important prognostic information and altered risk stratification in the majority of patients. • The optimal cut-off value for the automated right ventricle to left ventricle ratio was 1.18, with a sensitivity of 100% and specificity of 54% for the prediction of 30-day mortality.

Fulminant immune-mediated necrotising myopathy (IMNM) mimicking myocardial infarction with non-obstructive coronary arteries (MINOCA).

A 74-year-old man, with inflammatory arthritis, recently commenced on adalimumab, presented with a 4-week history of left-sided chest pain, malaise and shortness of breath. Admission ECG showed age-indeterminate left bundle branch block. Troponin T was 4444 ng/L (normal range <15 ng/L) and acute coronary syndrome treatment was commenced. Catheter angiogram revealed mild-burden non-obstructive coronary disease. Cardiac magnetic resonance (CMR) was performed to refine the differential diagnosis and demonstrated no myocardial oedema or late gadolinium enhancement. Extracardiac review highlighted oedema and enhancement of the left shoulder girdle muscles consistent with acute myositis. Creatine kinase was subsequently measured and significantly elevated at 7386 IU/L (normal range 30-200 IU/L in men). Electrophoresis clarified that this was of predominantly skeletal muscle origin. Myositis protocol MRI revealed florid skeletal muscle oedema. The MR findings, together with positive anti-Scl-70 antibodies, suggested fulminant immune-mediated necrotising myopathy presenting as a rare mimic of myocardial infarction with non-obstructive coronary arteries, diagnosed by careful extracardiac CMR review.

Radiology teaching for interns: Experiences, current practice and suggestions for improvement.

INTRODUCTION: Junior doctors are typically responsible for requesting and interpreting diagnostic imaging studies. European studies have highlighted the paucity of radiology teaching leading to junior doctors feeling underprepared for clinical practice involving radiology. There is a lack of published data on the experiences of Australian medical students and junior doctors. This study aimed to describe the experiences of interns in Western Australia to establish whether they felt prepared for clinical practice by the radiology teaching they received at medical school and beyond. METHODS: This cross-sectional observational study involved a needs analysis questionnaire. The study population included all interns currently employed by Fiona Stanley Hospital (n = 121). RESULTS: Radiology teaching at medical school was reportedly mostly informal and infrequent. More than half felt this was inadequate (52%). Current teaching was also reportedly infrequent and 31% reported receiving no radiology teaching in their current rotation. The interns reported requesting high volumes of diagnostic imaging with 66% reporting requesting imaging once a day or more frequently. The overwhelming majority stated their clinical practice would benefit from additional teaching in radiology (98%). CONCLUSION: This study has demonstrated a paucity of radiology teaching provided to interns in a large Australian teaching hospital. As they request and interpret high volumes of diagnostic imaging, skills in this domain are paramount in the provision of safe, effective and timely patient care. The results are being used in the design and implementation of a high-quality radiology teaching programme to improve junior doctors' skill and develop the radiologist-clinical referrer interface.