Evaluation of the impact of artificial intelligence-assisted image interpretation on the diagnostic performance of clinicians in identifying pneumothoraces on plain chest X-ray: a multi-case multi-reader study.

BACKGROUND: Artificial intelligence (AI)-assisted image interpretation is a fast-developing area of clinical innovation. Most research to date has focused on the performance of AI-assisted algorithms in comparison with that of radiologists rather than evaluating the algorithms' impact on the clinicians who often undertake initial image interpretation in routine clinical practice. This study assessed the impact of AI-assisted image interpretation on the diagnostic performance of frontline acute care clinicians for the detection of pneumothoraces (PTX). METHODS: A multicentre blinded multi-case multi-reader study was conducted between October 2021 and January 2022. The online study recruited 18 clinician readers from six different clinical specialties, with differing levels of seniority, across four English hospitals. The study included 395 plain CXR images, 189 positive for PTX and 206 negative. The reference standard was the consensus opinion of two thoracic radiologists with a third acting as arbitrator. General Electric Healthcare Critical Care Suite (GEHC CCS) PTX algorithm was applied to the final dataset. Readers individually interpreted the dataset without AI assistance, recording the presence or absence of a PTX and a confidence rating. Following a 'washout' period, this process was repeated including the AI output. RESULTS: Analysis of the performance of the algorithm for detecting or ruling out a PTX revealed an overall AUROC of 0.939. Overall reader sensitivity increased by 11.4% (95% CI 4.8, 18.0, p=0.002) from 66.8% (95% CI 57.3, 76.2) unaided to 78.1% aided (95% CI 72.2, 84.0, p=0.002), specificity 93.9% (95% CI 90.9, 97.0) without AI to 95.8% (95% CI 93.7, 97.9, p=0.247). The junior reader subgroup showed the largest improvement at 21.7% (95% CI 10.9, 32.6), increasing from 56.0% (95% CI 37.7, 74.3) to 77.7% (95% CI 65.8, 89.7, p<0.01). CONCLUSION: The study indicates that AI-assisted image interpretation significantly enhances the diagnostic accuracy of clinicians in detecting PTX, particularly benefiting less experienced practitioners. While overall interpretation time remained unchanged, the use of AI improved diagnostic confidence and sensitivity, especially among junior clinicians. These findings underscore the potential of AI to support less skilled clinicians in acute care settings.

Surgical treatment of symptomatic pineal cysts without hydrocephalus-meta-analysis of the published literature.

BACKGROUND: To examine published data and assess evidence relating to safety and efficacy of surgical management of symptomatic pineal cysts without hydrocephalus (nhSPC), we performed a systematic review of the literature and meta-analysis. METHODS: Following the PRISMA guidelines, we searched Pubmed and SCOPUS for all reports with the query 'Pineal Cyst' AND 'Surgery' as of March 2021, without constraints on study design, publication year or status (PROSPERO_CRD:42,021,242,517). Assessment of 1537 hits identified 26 reports that met inclusion and exclusion criteria. RESULTS: All 26 input studies were either case reports or single-centre retrospective cohorts. The majority of outcome data were derived from routine physician-recorded notes. A total of 294 patients with surgically managed nhSPC were identified. Demographics: Mean age was 29 (range: 4-63) with 77% females. Mean cyst size was 15 mm (5-35). Supracerebellar-infratentorial approach was adopted in 90% of cases, occipital-transtentorial in 9%, and was not reported in 1%. Most patients were managed by cyst resection (96%), and the remainder by fenestration. Mean post-operative follow-up was 35 months (0-228). PRESENTATION: Headache was the commonest symptom (87%), followed by visual (54%), nausea/vomit (34%) and vertigo/dizziness (31%). Other symptoms included focal neurology (25%), sleep disturbance (17%), cognitive impairment (16%), loss of consciousness (11%), gait disturbance (11%), fatigue (10%), 'psychiatric' (2%) and seizures (1%). Mean number of symptoms reported at presentation was 3 (0-9). OUTCOMES: Improvement rate was 93% (to minimise reporting bias only consecutive cases from cohort studies were considered, N = 280) and was independent of presentation. Predictors of better outcomes were large cyst size (OR = 5.76; 95% CI: 1.74-19.02) and resection over fenestration (OR = 12.64; 3.07-52.01). Age predicted worse outcomes (OR = 0.95; 0.91-0.99). Overall complication rate was 17% and this was independent of any patient characteristics. Complications with long-term consequences occurred in 10 cases (3.6%): visual disturbance (3), chronic incisional pain (2), sensory disturbance (1), fatigue (1), cervicalgia (1), cerebellar stroke (1) and mortality due to myocardial infarction (1). CONCLUSIONS: Although the results support the role of surgery in the management of nhSPCs, they have to be interpreted with a great deal of caution as the current evidence is limited, consisting only of case reports and retrospective surgical series. Inherent to such studies are inhomogeneity and incompleteness of data, selection bias and bias related to assessment of outcome carried out by the treating surgeon in the majority of cases. Prospective studies with patient-reported and objective outcome assessment are needed to provide higher level of evidence.

Which factors influence the decision to transfer patients with traumatic brain injury to a neurosurgery unit in a major trauma network?

Objectives: Within the pan London Major Trauma System many patients with minor or non-life threatening traumatic brain injury (TBI) remain at their local hospital and are not transferred to a major trauma centre (MTC). Our aim was to identify factors that influence the decision to transfer patients with TBI to a neurosurgical centre.Methods: This is a single centre prospective cohort study of all patients with TBI referred to our neurosurgery unit from regional acute hospitals over a 4-month period (Sept 2016-Jan 2017). Our primary outcome was transferred to a neurosurgical centre. We identified the following factors that may predict decision to transfer: patient demographics, transfer distance, antithrombotic therapy and severity of TBI based on initial Glasgow Coma Scale (GCS) and Marshall CT score. A multivariable logistic regression analysis was performed.Results: A total of 339 patients were referred from regional hospitals with TBI and of these, 53 (15.6%) were transferred to our hospital. The mean age of patients referred was 70.6 years, 62.5% were men and 43% on antithrombotic drugs. Eighty-six percent of patients had mild TBI (GCS 13-15) on initial assessment and 79% had a Marshall CT score of 2. The adjusted analysis revealed only higher age, higher Marshall Score, the presence of chronic subdural haematoma (CSDH), the presence of contusion(s) and fracture(s) predicted transfer (p<.05). Subgroup analysis consistently showed a higher Marshall score predicted transfer (p<.05).Conclusions: In our cohort higher Marshall score consistently predicted transfer to our neurosurgical centre. Presenting GCS, transfer distance and antithrombotic therapy did not influence decision to transfer.

Undergraduate neurosurgical conferences - what role do they play?

INTRODUCTION: Undergraduate student conferences provide networking opportunities for students interested in exploring a speciality. The ability to meet with like-minded students, engage with senior clinicians and experience the practical side of a speciality are valuable in shaping the career trajectory of undergraduates. We report our experience of developing a national undergraduate neurosurgery conference - a combined project between the medical students of King's College London School of Medicine and the neurosurgery department at King's College Hospital NHS Foundation Trust. DESIGN: Evaluation of conference design and student feedback. METHODS: The conference was organised by medical students with support from a neurosurgical unit. Senior clinicians and trainees helped design practical workshops and a focused programme. Questionnaires were distributed before and after the conference to assess the quality of content and impact of the conference on students. RESULTS: Prior to the conference, 80.7% of respondents stated they were interested in a career in neurosurgery. After the conference the figure rose to 88.9%. The percentage of students who felt they understood what a career in neurosurgery involves increased from 38.6% to 92.1% of respondents. 39.0% of participants had no neurosurgery exposure prior to the conference. 91.9% of participants agreed or strongly agreed they would be more confident engaging with a neurosurgical department following the conference. All participants agreed (29.0%) or strongly agreed (71.0%) that they would recommend this conference to a colleague. CONCLUSIONS: Student conferences are a valuable method of increasing exposure to a career in neurosurgery. They serve a great purpose in demystifying the specialty and guiding those with an interest through the steps required to enter and progress.

Surgical Strategies in Reoperation of the Proximal Aorta and Arch for Patients with Previous Frozen Elephant Trunk.

Background: The frozen elephant trunk (FET) technique is increasingly utilized for aortic arch replacement in cases of aortic dissections and aneurysms. This rise in usage has led to more patients needing redo aortic surgeries due to progression of existing conditions, FET-related complications, or new valvular/coronary diseases. This article aims to evaluate surgical techniques to minimize risks during these reoperations, including a case study of a complex redo surgery. Methods: A comprehensive examination of surgical strategies was conducted, focusing on preoperative preparation, cannulation site identification, cerebral and cardiac protective measures, and pitfalls to avoid. The importance of adapting to the modified anatomical landscape post-FET is emphasized. A detailed case study of a patient undergoing complex redo FET surgery is included. Results: The article identified key surgical strategies for reoperation in patients with prior FET, highlighting the importance of meticulous preoperative planning and execution. Techniques to minimize risks include detailed imaging for planning, strategic cannulation for optimal perfusion, multidisciplinary approaches as well as careful fail-safe measures. The case study demonstrates the practical application of these strategies in a high-risk scenario. The evidence underscores the necessity for individualized patient management and the development of standardized protocols. Conclusions: The FET technique, while effective for initial aortic arch repairs, often necessitates complex reoperations. Adopting advanced surgical strategies and multidisciplinary planning can significantly mitigate risks associated with these procedures. Future research should focus on refining these techniques and establishing standardized protocols to improve patient outcomes.

The Surgical Treatment of Infective Endocarditis: A Comprehensive Review.

Infective endocarditis (IE) is a severe cardiac complication with high mortality rates, especially when surgical intervention is delayed or absent. This review addresses the expanding role of surgery in managing IE, focusing on the variation in surgical treatment rates, the impact of patient demographics, and the effectiveness of different surgical approaches. Despite varying global data, a notable increase in surgical interventions for IE is evident, with over 50% of patients undergoing surgery in tertiary centres. This review synthesizes information from focused literature searches up to July 2023, covering preoperative to postoperative considerations and surgical strategies for IE. Key preoperative concerns include accurate diagnosis, appropriate antimicrobial treatment, and the timing of surgery, which is particularly crucial for patients with heart failure or at risk of embolism. Surgical approaches vary based on valve involvement, with mitral valve repair showing promising outcomes compared to replacement. Aortic valve surgery, traditionally favouring replacement, now includes repair as a viable option. Emerging techniques such as sutureless valves and aortic homografts are explored, highlighting their potential advantages in specific IE cases. The review also delves into high-risk groups like intravenous drug users and the elderly, emphasizing the need for tailored surgical strategies. With an increasing number of patients presenting with prosthetic valve endocarditis and device-related IE, the review underscores the importance of comprehensive management strategies encompassing surgical and medical interventions. Overall, this review provides a comprehensive overview of current evidence in the surgical management of IE, highlighting the necessity of a multidisciplinary approach and ongoing research to optimize patient outcomes.

Sarcopenia Adversely Affects Outcomes following Cardiac Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: Sarcopenia is a degenerative condition characterised by the loss of skeletal muscle mass and strength. Its impact on cardiac surgery outcomes remains poorly investigated. This meta-analysis aims to provide a comprehensive synthesis of the available evidence to determine the effect of sarcopenia on cardiac surgery outcomes. METHODS: A systematic review and meta-analysis followed PRISMA guidelines from inception to April 2023 in EMBASE, MEDLINE, Cochrane database, and Google Scholar. Twelve studies involving 2717 patients undergoing cardiac surgery were included. Primary outcomes were early and late mortality; secondary outcomes included surgical time, infection rates, and functional outcomes. Statistical analyses were performed using appropriate methods. RESULTS: Sarcopenic patients (906 patients) had a significantly higher risk of early mortality (OR: 2.40, 95% CI: 1.44 to 3.99, p = 0.0007) and late mortality (OR: 2.65, 95% CI: 1.57 to 4.48, p = 0.0003) compared to non-sarcopenic patients (1811 patients). There were no significant differences in overall surgical time or infection rates. However, sarcopenic patients had longer ICU stays, higher rates of renal dialysis, care home discharge, and longer intubation times. CONCLUSION: Sarcopenia significantly increases the risk of early and late mortality following cardiac surgery, and sarcopenic patients also experience poorer functional outcomes.

Subtype switching in breast cancer brain metastases: a multicenter analysis.

BACKGROUND: Breast cancer (BC) brain metastases (BM) can have discordant hormonal or human epidermal growth factor receptor 2 (HER2) expression compared with corresponding primary tumors. This study aimed to describe incidence, predictors, and survival outcomes of discordant receptors and associated subtype switching in BM. METHODS: BCBM patients seen at 4 tertiary institutions who had undergone BM resection or biopsy were included. Surgical pathology reports were retrospectively assessed to determine discordance between the primary tumor and the BCBM. In discordant cases, expression in extracranial metastases was also assessed. RESULTS: In BM from 219 patients, prevalence of any discordance was 36.3%; receptor-specific discordance was 16.7% for estrogen, 25.2% for progesterone, and 10.4% for HER2. Because estrogen and progesterone were considered together for hormonal status, 50 (22.8%) patients switched subtype as a result; 20 of these switches were HER2 based. Baseline subtype predicted switching, which occurred in up to 37.5% of primary HR+ patients. Moreover, 14.8% of initially HER2-negative patients gained HER2 in the BM. Most (63.6%) discordant patients with extracranial metastases also had discordance between BM and extracranial subtype. Loss of receptor expression was generally associated with worse survival, which appeared to be driven by estrogen loss (hazard ratio = 1.80, P = 0.03). Patients gaining HER2 status (n = 8) showed a nonsignificant tendency toward improved survival (hazard ratio = 0.64, P = 0.17). CONCLUSIONS: In this multicenter study, we report incidence and predictors of subtype switching, the risk of which varies considerably by baseline subtype. Switches can have clinical implications for prognosis and treatment choice.

Factors Influencing Medical Student Interest in a Career in Neurosurgery.

BACKGROUND: Exposure to neurosurgery at the undergraduate level is an important factor in determining future interest in and applications to the specialty. Given the high competition for training posts, this exposure is also becoming an almost essential addition to an applicant's portfolio. We organized a neurosurgical conference aimed at undergraduate medical students. The aim of this study was to determine factors attracting and deterring students from the specialty before and after the conference. METHODS: Responses were collected prospectively from students attending a national neurosurgical conference organized by medical students with support from the local neurosurgical unit. Questionnaires were distributed before and after the conference examining students' perceptions of a career in neurosurgery using free-text responses. RESULTS: Poor lifestyle or work-life balance was the most important factor deterring students from a career in the specialty both before (29.7%) and after (60%) the conference. The most important factor attracting students to the specialty before the conference was the practical (surgical approaches and techniques) aspect (21.9%). After the conference, the most important attracting factor was the rewarding nature of the specialty (18.9%). CONCLUSIONS: The most notable factor deterring students from a career in neurosurgery was work-life balance. Other deterring factors were much less prevalent following the conference. Understanding how exposure to neurosurgery influences students' perceptions is important for developing future initiatives to prevent misconceptions and allow students to make informed choices as well as encourage the right candidates to apply.

In vivo biocompatibility and pacing function study of silver ion-based antimicrobial surface technology applied to cardiac pacemakers.

INTRODUCTION: Evidence suggests that the rate of cardiovascular implantable electronic device (CIED) infections is increasing more rapidly than the rates of CIED implantation and is associated with considerable mortality, morbidity and health economic impact. Antimicrobial surface treatments are being developed for CIEDs to reduce the risk of postimplantation infection within the subcutaneous implant pocket. METHODS AND ANALYSIS: The feasibility of processing cardiac pacemakers with the Agluna antimicrobial silver ion surface technology and in vivo biocompatibility were evaluated. Antimicrobially processed (n=6) and control pacemakers (n=6) were implanted into subcutaneous pockets and connected to a part of the sacrospinalis muscle using an ovine model for 12 weeks. Pacemaker function was monitored preimplantation and postimplantation. RESULTS: Neither local infection nor systemic toxicity were detected in antimicrobial or control devices, and surrounding tissues showed no abnormal pathology or over-reactivity. Semiquantitative scores of membrane formation, cellular orientation and vascularity were applied over five regions of the pacemaker capsule and average scores compared. Results showed no significant difference between antimicrobially processed and control pacemakers. Silver analysis of whole blood at 7 days found that levels were a maximum of 10 parts per billion (ppb) for one sample, more typically ≤2 ppb, compared with <<2 ppb for preimplantation levels, well below reported toxic levels. CONCLUSIONS: There was no evidence of adverse or abnormal pathology in tissue surrounding antimicrobially processed pacemakers, or deleterious effect on basic pacing capabilities and parameters at 12 weeks. This proof of concept study provides evidence of basic biocompatibility and feasibility of applying this silver ion-based antimicrobial surface to a titanium pacemaker surface.