Effects of a computerised diagnostic decision support tool on diagnostic quality in emergency departments: study protocol of the DDx-BRO multicentre cluster randomised cross-over trial.

INTRODUCTION: Computerised diagnostic decision support systems (CDDS) suggesting differential diagnoses to physicians aim to improve clinical reasoning and diagnostic quality. However, controlled clinical trials investigating their effectiveness and safety are absent and the consequences of its use in clinical practice are unknown. We aim to investigate the effect of CDDS use in the emergency department (ED) on diagnostic quality, workflow, resource consumption and patient outcomes. METHODS AND ANALYSIS: This is a multicentre, outcome assessor and patient-blinded, cluster-randomised, multiperiod crossover superiority trial. A validated differential diagnosis generator will be implemented in four EDs and randomly allocated to a sequence of six alternating intervention and control periods. During intervention periods, the treating ED physician will be asked to consult the CDDS at least once during diagnostic workup. During control periods, physicians will not have access to the CDDS and diagnostic workup will follow usual clinical care. Key inclusion criteria will be patients' presentation to the ED with either fever, abdominal pain, syncope or a non-specific complaint as chief complaint. The primary outcome is a binary diagnostic quality risk score composed of presence of an unscheduled medical care after discharge, change in diagnosis or death during time of follow-up or an unexpected upscale in care within 24 hours after hospital admission. Time of follow-up is 14 days. At least 1184 patients will be included. Secondary outcomes include length of hospital stay, diagnostics and data regarding CDDS usage, physicians' confidence calibration and diagnostic workflow. Statistical analysis will use general linear mixed modelling methods. ETHICS AND DISSEMINATION: Approved by the cantonal ethics committee of canton Berne (2022-D0002) and Swissmedic, the Swiss national regulatory authority on medical devices. Study results will be disseminated through peer-reviewed journals, open repositories and the network of investigators and the expert and patients advisory board. TRIAL REGISTRATION NUMBER: NCT05346523.

Tuberculosis and Migration: A Challenge for Medical Staff and Public Health.

A high number of asylum seekers enter Switzerland every year. They often originate from countries with a high TB prevalence. Our patient from Somalia presented with 2 lipoma-like tumors with pain on palpation on his left chest wall but no symptoms including coughing, fever, night-sweats, or loss of weight. CT scan then showed diffuse infiltrations of his lung and multiple abscesses on his left chest wall. Therefore contagious tuberculosis (TB) was suspected and the patient was put in isolation. In the follow-up the diagnosis of open TB was proofed with bronchial secretion and EBUS-guided biopsy that showed acid-fast rods. This particular case shows how difficult the identification of patients with open TB can be, especially if there are no respiratory or systemic symptoms. Therefore awareness of possible infectious disease is paramount for ED Doctors treating patients from countries with high prevalence. Early and strict isolation measures can help to reduce risk of contagion among staff and patients.

Stable coronary artery disease: prognostic value of myocardial perfusion SPECT in relation to coronary calcium scoring--long-term follow-up.

PURPOSE: To evaluate the incremental prognostic value of coronary artery calcification (CAC) scoring over single photon emission computed tomographic (SPECT) myocardial perfusion imaging in long-term prognosis and survival of patients with stable coronary artery disease (CAD). MATERIALS AND METHODS: All patients provided written informed consent to undergo CAC scoring according to a protocol that was approved by the local clinical institutional review board. Over a median follow-up time of 5.4 years, 260 patients with stable CAD were followed up for severe cardiac events (cardiac death or nonfatal myocardial infarction). CAC scanning and SPECT myocardial perfusion imaging were performed at enrollment. Patients were stratified on the basis of well-established cutoff points for CAC score, summed stress score (SSS), and summed rest score (SRS). Kaplan-Meier survival curves and the Cox proportional hazards model were used. RESULTS: CAC score and SRS were identified as the only independent predictors of event-free survival. Patients with perfusion abnormalities at rest (SRS > or = 2), a CAC score greater than 400, or severe perfusion abnormalities under stress (SSS > or = 13) were identified as having significantly increased risk for subsequent severe cardiac events (P = .023, .0095, and .007, respectively). In addition, a CAC score greater than 400 offered incremental prognostic value over the scintigraphic scores alone (P = .028 with an SSS > 8; P = .008 with an SRS > or = 2). CONCLUSION: CAC score and SRS were identified as independent predictors of severe cardiac events during long-term follow-up of patients with known CAD. CAC scores imparted superior risk stratification information as compared with SPECT myocardial perfusion imaging results alone.