Diagnosis of Acute Aortic Syndrome in the Emergency Department (DAShED) study: an observational cohort study of people attending the emergency department with symptoms consistent with acute aortic syndrome.

BACKGROUND: The diagnosis of acute aortic syndrome (AAS) is commonly delayed or missed in the ED. We describe characteristics of ED attendances with symptoms potentially associated with AAS, diagnostic performance of clinical decision tools (CDTs) and physicians and yield of CT aorta angiogram (CTA). METHODS: This was a multicentre observational cohort study of adults attending 27 UK EDs between 26 September 2022 and 30 November 2022, with potential AAS symptoms: chest, back or abdominal pain, syncope or symptoms related to malperfusion. Patients were preferably identified prospectively, but retrospective recruitment was also permitted. Anonymised, routinely collected patient data including components of CDTs, was abstracted. Clinicians treating prospectively identified patients were asked to record their perceived likelihood of AAS, prior to any confirmatory testing. Reference standard was radiological or operative confirmation of AAS. 30-day electronic patient record follow-up evaluated whether a subsequent diagnosis of AAS had been made and mortality. RESULTS: 5548 patients presented, with a median age of 55 years (IQR 37-72; n=5539). 14 (0.3%; n=5353) had confirmed AAS. 10/1046 (1.0%) patients in whom the ED clinician thought AAS was possible had AAS. 5/147 (3.4%) patients in whom AAS was considered the most likely diagnosis had AAS. 2/3319 (0.06%) patients in whom AAS was considered not possible did have AAS. 540 (10%; n=5446) patients underwent CT, of which 407 were CTA (7%). 30-day follow-up did not reveal any missed AAS diagnoses. AUROC (area under the receiver operating characteristic) curve for ED clinician AAS likelihood rating was 0.958 (95% CI 0.933 to 0.983, n=4006) and for individual CDTs were: Aortic Dissection Detection Risk Score (ADD-RS) 0.674 (95% CI 0.508 to 0.839, n=4989), AORTAs 0.689 (95% CI 0.527 to 0.852, n=5132), Canadian 0.818 (95% CI 0.686 to 0.951, n=5180) and Sheffield 0.628 (95% CI 0.467 to 0.788, n=5092). CONCLUSION: Only 0.3% of patients presenting with potential AAS symptoms had AAS but 7% underwent CTA. CDTs incorporating clinician gestalt appear to be most promising, but further prospective work is needed, including evaluation of the role of D-dimer. TRIAL REGISTRATION NUMBER: NCT05582967; NCT05582967.

Kienböck Disease and Carpal Coalitions: A Potential Correlation.

Kienböck disease, or lunate avascular necrosis, can lead to chronic wrist pain and instability. Its etiology appears to be multifactorial including variations in adjacent anatomical structures, interrupted blood supply, and trauma. Capitate-hamate fusion is the second most commonly diagnosed carpal coalition and not treated unless symptomatic. Coalitions may alter the wrist mechanics depending on their extent. No prior reports have associated Kienböck disease with capitate-hamate coalition. We present 2 cases with congenital capitate-hamate fusion and lunate AVN.

Mercury bioaccessiblity in freshwater fish species from northern Canada.

Indigenous communities in northern Canada rely on locally harvested traditional foods, including fish, which provides them with nutritional, cultural, and social benefits. However, mercury exposure from fish consumption can pose a health risk for populations that consume large amounts of fish with elevated mercury concentrations. The bioaccessiblity of mercury in the tissue of northern Canadian freshwater fish is not yet known. To address this, samples from five commonly consumed freshwater fish species (Lake Trout, Northern Pike, Walleye, Lake Whitefish, and Burbot) caught from lakes in the Northwest Territories and Yukon, Canada were examined. Total mercury concentrations, fatty acid composition, and total mercury bioaccessibility differed significantly among fish species and lakes. Mean total mercury bioaccessibility using an in vitro gastrointestinal model ranged between 56 % and 96 % in muscle tissue across fish species and waterbodies examined and was 39 % in liver tissue from Burbot. Mean total mercury bioaccessibility was much lower (range: 38 % to 42 %) for a subset of samples run through only the gastric phase of the digestion model. Total mercury bioaccessibility was significantly lower (on average 40 % lower) in a subset of samples that were pan-fried in water. Thus, although cooking increased total mercury concentrations in pan-fried fish samples (likely due to moisture loss), bioaccessible concentrations of total mercury were lower (on average 32 % lower). Results from this study contribute to addressing a large knowledge gap in the literature regarding bioaccessibility of total mercury in northern freshwater fish species. To the best of our knowledge, this is the first study to examine mercury bioaccessibility in raw and cooked liver samples from freshwater fish. It also adds to the growing literature indicating that mercury bioaccessibility varies among fish species, locations, and cooking/preparation methods.