Prospective RandOmised Trial of Emergency Cardiac Computerised Tomography (PROTECCT).

OBJECTIVE: Many patients presenting with suspected acute coronary syndrome (ACS) have high-sensitivity cardiac troponin (hs-cTn) concentrations between rule-in and rule-out thresholds and hence need serial testing, which is time consuming. The Prospective RandOmised Trial of Emergency Cardiac Computerised Tomography (PROTECCT) assessed the utility of coronary CT angiography (CCTA) in patients with suspected ACS, non-ischaemic ECG and intermediate initial hs-cTn concentration. METHODS: Patients were randomised to CCTA-guided management versus standard of care (SOC). The primary outcome was hospital length of stay (LOS). Secondary outcomes included cost of in-hospital stay and major adverse cardiac events (MACE) at 12 months of follow-up. Data are mean (SD); for LOS harmonic means, IQRs are shown. RESULTS: 250 (aged 55 (14) years, 25% women) patients were randomised. Harmonic mean (IQR) LOS was 7.53 (6.0-9.6) hours in the CCTA arm and 8.14 (6.3-9.8) hours in the SOC arm (p=0.13). Inpatient cost was £1285 (£2216) and £1108 (£3573), respectively, p=0.68. LOS was shorter in the CCTA group in patients with <25% stenosis, compared with SOC; 6.6 (5.6-7.8) hours vs 7.5 (6.1-9.4) hours, respectively; p=0.021. More referrals for cardiology outpatient clinic review and cardiac CT-related outpatient referrals occurred in the SOC arm (p=0.01). 12-month MACE rates were similar between the two arms (7 (5.6%) in the CCTA arm and 8 (6.5%) in the SOC arm-log-rank p=0.78). CONCLUSIONS: CCTA did not lead to reduced hospital LOS or cost, largely because these outcomes were influenced by the detection of ≥25% grade stenosis in a proportion of patients. TRIAL REGISTRATION NUMBER: NCT03583320.

Differences in Perspectives of Medical Device Adverse Events: Observational Results in Training Program Using Virtual Cases.

BACKGROUND: Medical device adverse event reporting is an essential activity for mitigating device-related risks. Reporting of adverse events can be done by anyone like healthcare workers, patients, and others. However, for an individual to determine the reporting, he or she should recognize the current situation as an adverse event. The objective of this report is to share observed individual differences in the perception of a medical device adverse event, which may affect the judgment and the reporting of adverse events. METHODS: We trained twenty-three participants from twelve Asia-Pacific Economic Cooperation (APEC) member economies about international guidelines for medical device vigilance. We developed and used six virtual cases and six questions. We divided participants into six groups and compared their opinions. We also surveyed the country's opinion to investigate the beginning point of 'patient use'. The phases of 'patient use' are divided into: 1) inspecting, 2) preparing, and 3) applying medical device. RESULTS: As for the question on the beginning point of 'patient use,' 28.6%, 35.7%, and 35.7% of participants provided answers regarding the first, second, and third phases, respectively. In training for applying international guidelines to virtual cases, only one of the six questions reached a consensus between the two groups in all six virtual cases. For the other five questions, different judgments were given in at least two groups. CONCLUSION: From training courses using virtual cases, we found that there was no consensus on 'patient use' point of view of medical devices. There was a significant difference in applying definitions of adverse events written in guidelines regarding the medical device associated incidents. Our results point out that international harmonization effort is needed not only to harmonize differences in regulations between countries but also to overcome diversity in perspectives existing at the site of medical device use.

Chronic cough: a herald symptom of thoracic aortic aneurysm in a patient with a bicuspid aortic valve.

Chronic cough has a wide differential, of which thoracic aortic aneurysm is a rare but potentially devastating cause. We present a patient with previous aortic valve replacement for a bicuspid valve who had been suffering from a chronic cough for 8 months and who developed subsequent voice hoarseness. This had been initially managed in the community with trials of steroid inhalers, steroid nasal sprays and proton pump inhibitors to no avail. He was referred to cardiology and chest clinics. An urgent CT aortogram was requested given his widened mediastinum on chest radiograph, cardiac history of bicuspid valve and symptoms. This revealed a large aneurysm of the thoracic aorta with chronic dissection that required urgent operative intervention. His cough resolved 6 weeks postoperatively. The purpose of this report is to highlight thoracic aortic aneurysms as a potential rare differential for chronic cough and as a complication of patients with bicuspid aortic valves.

Pleomorphic adenoma of the nasopharyngeal mucosal space with locally aggressive appearance (2010: 11b).

Pleomorphic adenoma arising from submucosal minor salivary gland tissue in the head and neck is well described in the published literature. Where associated bone changes are present, benign-appearing bone remodelling is the rule, reflecting the slow growth of this benign tumour. Aggressive-appearing bone destruction was observed in this case. This atypical appearance has not been widely described.

Delayed ileal perforation secondary to traumatic stricture presenting as pyrexia of unknown origin.

Traumatic small bowel strictures secondary to blunt abdominal trauma are extremely rare, with few cases reported. Delayed ileal perforation as a result of a traumatic ileal stricture remains, to the best of our knowledge, unreported. We herein report a case of a 28-year-old polytrauma patient admitted following a high speed road traffic accident who developed abdominal pain, distension and vomiting. Despite serial computerized tomography (CT) scanning, the diagnosis remained unclear until eight weeks into his admission by which time he had developed pyrexia. A fourth CT scan at this time revealed a collection in the right iliac fossa suggestive of possible appendicitis. Subsequent laparotomy, however, revealed an ileal stricture with upstream small bowel dilatation and perforation into a chronic abscess cavity. The appendix was normal. The patient underwent resection of the strictured segment and end ileostomy. Our case highlights the potential pitfalls in managing polytrauma patients who develop abdominal symptoms and in particular, traumatic small bowel strictures. We would like to highlight the limitations of CT in making this diagnosis and the importance of having a high index of clinical suspicion, particularly in the presence of distracting injuries.