Reliability of single-lead electrocardiogram interpretation to detect atrial fibrillation: insights from the SAFER feasibility study.

AIMS: Single-lead electrocardiograms (ECGs) can be recorded using widely available devices such as smartwatches and handheld ECG recorders. Such devices have been approved for atrial fibrillation (AF) detection. However, little evidence exists on the reliability of single-lead ECG interpretation. We aimed to assess the level of agreement on detection of AF by independent cardiologists interpreting single-lead ECGs and to identify factors influencing agreement. METHODS AND RESULTS: In a population-based AF screening study, adults aged ≥65 years old recorded four single-lead ECGs per day for 1-4 weeks using a handheld ECG recorder. Electrocardiograms showing signs of possible AF were identified by a nurse, aided by an automated algorithm. These were reviewed by two independent cardiologists who assigned participant- and ECG-level diagnoses. Inter-rater reliability of AF diagnosis was calculated using linear weighted Cohen's kappa (κw). Out of 2141 participants and 162 515 ECGs, only 1843 ECGs from 185 participants were reviewed by both cardiologists. Agreement was moderate: κw = 0.48 (95% confidence interval, 0.37-0.58) at participant level and κw = 0.58 (0.53-0.62) at ECG level. At participant level, agreement was associated with the number of adequate-quality ECGs recorded, with higher agreement in participants who recorded at least 67 adequate-quality ECGs. At ECG level, agreement was associated with ECG quality and whether ECGs exhibited algorithm-identified possible AF. CONCLUSION: Inter-rater reliability of AF diagnosis from single-lead ECGs was found to be moderate in older adults. Strategies to improve reliability might include participant and cardiologist training and designing AF detection programmes to obtain sufficient ECGs for reliable diagnoses.

Utilisation and impact of predict prostate on decision-making among clinicians and patients in a specialist tertiary referral centre: A retrospective cohort study.

Background: Patients with intermediate-risk prostate cancer are faced with the decision of whether to undergo radical treatment. Decision-making aids, such as Predict Prostate, can empower both clinicians and patients to make treatment decisions with personalised information, but their impact on multi-disciplinary team (MDT) decision-making and uptake of radical treatment remains unknown. Objective: The objective of this study is to assess the utilisation and utility of Predict Prostate in informing treatment decisions for patients with intermediate-risk prostate cancer. Patients and Methods: A retrospective cohort study was conducted in Cambridge University Hospitals (CUH) of patients referred to the prostate cancer specialist multi-disciplinary team (pcSMDT) and robotic prostatectomy clinic (ROPD) between September 2019 and August 2021 for consideration of radical prostatectomy (RARP). Data on patient characteristics, use of PredictProstate and management decisions were collected from the Epic electronic medical record (EMR) of 839 patients, of whom 386 had intermediate-risk prostate cancer. Results: The use of Predict Prostate at the pcSMDT increased in the second half of the study period (34.5% vs. 23.8%, p < 0.001). The use of Predict Prostate was associated with an increased likelihood of attending ROPD for men with CPG2 prostate cancer (OR = 2.155, 95% CI = 1.158-4.013, p = 0.015) but a reduced likelihood of proceeding with RARP for men with CPG2 (OR = 0.397, 95% CI = 0.209-0.753, p = 0.005) and CPG3 (OR = 0.305, 95% CI = 0.108-0.861, p = 0.025) prostate cancer. Conclusion: Our study showed that the use of Predict Prostate for patients with intermediate-risk prostate cancer is associated with increased attendance at specialist surgical clinic and a reduced chance of undergoing radical prostate surgery.

3D-Printing Applications in Ostomy Device Creation and Complex Intestinal Fistula Management: A Scoping Review.

Background This scoping review aims to provide a summary of the use of three-dimensional (3D) printing in colorectal surgery for the management of complex intestinal fistula and ostomy creation. Methods A systematic database search was conducted of original articles that explored the use of 3D printing in colorectal surgery in EMBASE, MEDLINE, Cochrane database, and Google Scholar, from inception to March 2022. Original articles and case reports that discussed 3D printing in colorectal surgery relating to complex intestinal fistulae and ostomies were identified and analyzed. Results There were 8 articles identified which discussed the use of 3D printing in colorectal surgery, of which 2 discussed ostomy creation, 4 discussed complex fistulae management, and 2 discussed patient models. Conclusion 3D printing has a promising role in terms of management of these conditions and can improve outcomes in terms of recovery, fluid loss, and function with no increase in complications. The use of 3D printing is still in its early stages of development in colorectal surgery. Further research in the form of randomized control trials to improve methodological robustness will reveal its true potential.

Prioritising electrocardiograms for manual review to improve the efficiency of atrial fibrillation screening.

Screening for atrial fibrillation (AF) could reduce the incidence of stroke by identifying undiagnosed AF and prompting anticoagulation. However, screening may involve recording many electrocardiograms (ECGs) from each participant, several of which require manual review which is costly and time-consuming. The aim of this study was to investigate whether the number of ECG reviews could be reduced by using a model to prioritise ECGs for review, whilst still accurately diagnosing AF. A multiple logistic regression model was created to estimate the likelihood of an ECG exhibiting AF based on the mean RR-interval and variability in RR-intervals. It was trained on 1,428 manually labelled ECGs from 144 AF screening programme participants, and evaluated using 11,443 ECGs from 1,521 participants. When using the model to order ECGs for review, the number of reviews for AF participants was reduced by 74% since no further reviews are required after an AF ECG is identified; however, it did not impact the number of reviews in non-AF participants (the vast majority of participants), so the overall number of reviews was reduced by 3% with no missed AF diagnoses. When using the model to also exclude ECGs from review, the overall number of reviews was reduced by 28% with no missed AF diagnoses, and by 53% with only 4% of AF diagnoses missed. In conclusion, the workload can be reduced by using a model to prioritise ECGs for review. Ordering ECGs alone only provides only a moderate reduction in workload. The additional use of a threshold to exclude ECGs from review provides a much greater reduction in workload at the expense of some missed AF diagnoses. Clinical Relevance-This shows the potential benefit of using a model to prioritise electrocardiograms for review in order to reduce the manual workload of AF screening.

Screening for Atrial Fibrillation: Improving Efficiency of Manual Review of Handheld Electrocardiograms †.

Atrial fibrillation (AF) is a common irregular heart rhythm associated with a five-fold increase in stroke risk. It is often not recognised as it can occur intermittently and without symptoms. A promising approach to detect AF is to use a handheld electrocardiogram (ECG) sensor for screening. However, the ECG recordings must be manually reviewed, which is time-consuming and costly. Our aims were to: (i) evaluate the manual review workload; and (ii) evaluate strategies to reduce the workload. In total, 2141 older adults were asked to record their ECG four times per day for 1-4 weeks in the SAFER (Screening for Atrial Fibrillation with ECG to Reduce stroke) Feasibility Study, producing 162,515 recordings. Patients with AF were identified by: (i) an algorithm classifying recordings based on signal quality (high or low) and heart rhythm; (ii) a nurse reviewing recordings to correct algorithm misclassifications; and (iii) two cardiologists independently reviewing recordings from patients with any evidence of rhythm abnormality. It was estimated that 30,165 reviews were required (20,155 by the nurse, and 5005 by each cardiologist). The total number of reviews could be reduced to 24,561 if low-quality recordings were excluded from review; 18,573 by only reviewing ECGs falling under certain pathological classifications; and 18,144 by only reviewing ECGs displaying an irregularly irregular rhythm for the entire recording. The number of AF patients identified would not fall considerably: from 54 to 54, 54 and 53, respectively. In conclusion, simple approaches may help feasibly reduce the manual workload by 38.4% whilst still identifying the same number of patients with undiagnosed, clinically relevant AF.

An unusual arrangement ofaccessory fissures observed in left lung

Anatomical variation of pulmonary fissures and lobes is common, and may be a source of confusion in the interpretation of signs seen on chest imaging. We report a very rare case of three pulmonary fissures in a plastinated specimen of a left lung, producing a unique lobar pattern consisting of four lobes. To our knowledge, this is the first report of three complete fissures dividing the left lung into four distinct lobes. A left minor fissure courses obliquely across the upper lobe, distinguishing the lingula from the rest of the upper lobe while an inferior accessory fissure demarcates the anteromedial basal segment from the other bronchopulmonary segments of the lower lobe . Recognising the existence of such rare variants is crucial for surgeons performing lobectomies or surgical resection of the lungs. It is also of great clinical significance to radiologists interpreting chest radio-graphs and computerised tomography (CT) scans to identify and diagnose lung lesions

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