Prevalence of Extraintestinal Manifestations in Inflammatory Bowel Disease: A Systematic Review and Meta-analysis.

BACKGROUND: Inflammatory bowel disease (IBD) is a multisystem disease impacting various body systems including musculoskeletal, ocular, skin, hepatobiliary, pulmonary, cardiac, and haematological systems. The extraintestinal manifestations of IBD are frequent, common in both ulcerative colitis (UC) and Crohn's disease (CD), and impact the morbidity and mortality of patients. METHODS: The Embase, Embase classic, and PubMed databases were searched between January 1979 and December 2021. A random effects model was performed to find the pooled prevalence of joint, ocular, and skin extraintestinal manifestations of UC and CD. RESULTS: Fifty-two studies were included that reported on 352 454 patients. The prevalence of at least 1 joint, ocular, or skin extraintestinal manifestation in all IBD, UC, and CD was 24%, 27%, and 35% respectively. The prevalence between UC and CD were similar for pyoderma gangrenosum and axial joint manifestations. Ocular manifestations were found to be more common in CD than in UC. Peripheral joint manifestations and erythema nodosum were found to be more common in CD than UC. DISCUSSION: To our knowledge, this is the first meta-analysis that reports on the prevalence of at least 1 joint, ocular, or skin extraintestinal manifestation in IBD. Our results are largely consistent with figures and statements quoted in the literature. However, our findings are based on significantly larger cohort sizes. Thus, our results have the potential to better power studies and more accurately counsel patients.

The prevalence of joint, ocular, or skin extraintestinal manifestations in IBD, UC, and CD was 24%, 27%, and 35% respectively. Ocular manifestations were more common in CD. Peripheral joint manifestations and erythema nodosum were more common in CD.

An atypical cause of chest pain.

Congenital coronary artery anomalies are of major significance in clinical cardiology and cardiac surgery due to their association with myocardial ischaemia and sudden death. Having a multidisciplinary approach in managing complex congenital conditions and including patients in the management decisions is essential for good doctor-patient relationship. Here within, we describe a complex coronary artery fistula leading to myocardial steal.

Successful Surgical Treatment of a Rare Case of Acute Isolated Right Ventricle Wall Rupture Caused by Distal Circumflex Coronary Artery Occlusion

Abstract We describe a rare case of isolated right ventricular inferior free-wall rupture and cardiogenic shock caused by occlusion of the distal left circumflex coronary artery. Our case highlights the central role of transthoracic echocardiography in identifying unexpected conditions that can guide management - in our case involving early surgical intervention, thus leading to favourable patient outcomes.

An unusual case of concurrent Kounis syndrome and prolonged QT in a young patient.

Allergic reactions related to drug use is a common entity presenting often from minor urticaria to life-threatening anaphylactoid reactions. A common but easily overlooked diagnosis, Kounis syndrome, is an established hypersensitivity coronary disorder induced by drugs, foods, environmental factors, and coronary stents that can present in the same way as non-allergy-induced acute coronary syndrome. Here within, we present a unique case of dual presentation of Kounis syndrome and prolonged QTc in a young patient after a single dose of Domperidone and Lansoprazole.

The diagnostic certainty levels of junior clinicians: A retrospective cohort study.

BACKGROUND: Clinical decision-making is influenced by many factors, including clinicians' perceptions of the certainty around what is the best course of action to pursue. OBJECTIVE: To characterise the documentation of working diagnoses and the associated level of real-time certainty expressed by clinicians and to gauge patient opinion about the importance of research into clinician decision certainty. METHOD: This was a single-centre retrospective cohort study of non-consultant grade clinicians and their assessments of patients admitted from the emergency department between 01 March 2019 and 31 March 2019. De-identified electronic health record proformas were extracted that included the type of diagnosis documented and the certainty adjective used. Patient opinion was canvassed from a focus group. RESULTS: During the study period, 850 clerking proformas were analysed; 420 presented a single diagnosis, while 430 presented multiple diagnoses. Of the 420 single diagnoses, 67 (16%) were documented as either a symptom or physical sign and 16 (4%) were laboratory-result-defined diagnoses. No uncertainty was expressed in 309 (74%) of the diagnoses. Of 430 multiple diagnoses, uncertainty was expressed in 346 (80%) compared to 84 (20%) in which no uncertainty was expressed. The patient focus group were unanimous in their support of this research. CONCLUSION: The documentation of working diagnoses is highly variable among non-consultant grade clinicians. In nearly three quarters of assessments with single diagnoses, no element of uncertainty was implied or quantified. More uncertainty was expressed in multiple diagnoses than single diagnoses. IMPLICATIONS: Increased standardisation of documentation will help future studies to better analyse and quantify diagnostic certainty in both single and multiple working diagnoses. This could lead to subsequent examination of their association with important process or clinical outcome measures.

Successful Surgical Treatment of a Rare Case of Acute Isolated Right Ventricle Wall Rupture Caused by Distal Circumflex Coronary Artery Occlusion.

We describe a rare case of isolated right ventricular inferior free-wall rupture and cardiogenic shock caused by occlusion of the distal left circumflex coronary artery. Our case highlights the central role of transthoracic echocardiography in identifying unexpected conditions that can guide management - in our case involving early surgical intervention, thus leading to favourable patient outcomes.

Prevalence of pouchitis in both ulcerative colitis and familial adenomatous polyposis: A systematic review and meta-analysis.

AIM: Pouchitis is a clinically significant complication of ileal pouch-anal anastomosis with its prevalence varying in the literature. Pouchitis is thought to occur more commonly in patients with ulcerative colitis (UC) than in patients with familial adenomatous polyposis (FAP). We conducted a systematic review with meta-analysis of all published literature to report the prevalence of pouchitis in all pouch patients as well as specifically in UC and FAP. We also investigated the prevalence of acute and chronic pouchitis in UC and FAP. METHODS: A meta-analysis was conducted by searching the Embase, Embase Classic and PubMed databases between 1978 and 2021 exploring the prevalence of pouchitis in UC and FAP. We then performed a random effects model in order to find the pooled prevalence of pouchitis and used odds ratios to report differences in the prevalence of pouchitis in UC and FAP. RESULTS: Fifty-nine full papers and conference abstracts were included in the meta-analysis comprising 18 117 patients with UC and 860 with FAP. The prevalence of pouchitis in UC was 0.32 (95% CI 0.27-0.37) and in FAP was found to be 0.06 (95% CI 0.03-0.15). The odds ratio of pouchitis in UC patients compared with FAP patients was 4.95 (95% CI 3.17-7.72, P < 0.0001). CONCLUSIONS: Our findings support the consensus that the prevalence of pouchitis is higher in UC than in FAP. More significantly our findings suggest that the true prevalence of pouchitis is higher than commonly reported in the literature. This literature may help counsel patients prior to undergoing restorative proctocolectomy.

The public's attitude towards doctors' use of Twitter and perceived professionalism: an exploratory study.

INTRODUCTION: Medical professionals use social media to interact with other healthcare professionals, discuss medical issues and promote healthcare information. These platforms have tremendous power to promote healthcare messages but also have potential to damage the profession if used inappropriately. It is currently unknown how others perceive medical doctors' Twitter activity and, therefore, we conducted an online survey exploring these views. METHODS: We used a Google Forms questionnaire consisting of 21 questions, which we distributed on Twitter, exploring doctors', patients', the public's and other healthcare professionals' views of doctors' Twitter activities. We investigated factors that were associated with mistrust by univariate and multivariate analysis. RESULTS: Seven-hundred and twenty-six respondents completed the survey. By univariate analysis, a higher proportion of non-doctors reported witnessing unprofessional behaviour and potential breaches of patient confidentiality compared with doctors (p<0.01). In addition, a significantly higher proportion of non-doctors felt that doctors' Twitter accounts should be monitored by both their employer and regulator when compared with doctors. By multivariate analysis, the main predictor of mistrust in the profession were those that had previously witnessed unprofessional behaviour (odds ratio 2.70; 95% confidence interval 2.08-3.33; p<0.01). CONCLUSION: There are discrepancies in how doctors and non-doctors view Twitter activity and significant mistrust in the profession was brought about by doctors' Twitter activity. To help limit this, adherence to current guidelines set out by the General Medical Council and British Medical Association is vital and doctors should be cautious about how their Twitter activity is professionally perceived by others before posting.

Advanced deep learning methodology for accurate, real-time segmentation of high-resolution intravascular ultrasound images.

AIMS: The aim of this study is to develop and validate a deep learning (DL) methodology capable of automated and accurate segmentation of intravascular ultrasound (IVUS) image sequences in real-time. METHODS AND RESULTS: IVUS segmentation was performed by two experts who manually annotated the external elastic membrane (EEM) and lumen borders in the end-diastolic frames of 197 IVUS sequences portraying the native coronary arteries of 65 patients. The IVUS sequences of 177 randomly-selected vessels were used to train and optimise a novel DL model for the segmentation of IVUS images. Validation of the developed methodology was performed in 20 vessels using the estimations of two expert analysts as the reference standard. The mean difference for the EEM, lumen and plaque area between the DL-methodology and the analysts was ≤0.23mm2 (standard deviation ≤0.85mm2), while the Hausdorff and mean distance differences for the EEM and lumen borders was ≤0.19 mm (standard deviation≤0.17 mm). The agreement between DL and experts was similar to experts' agreement (Williams Index ranges: 0.754-1.061) with similar results in frames portraying calcific plaques or side branches. CONCLUSIONS: The developed DL-methodology appears accurate and capable of segmenting high-resolution real-world IVUS datasets. These features are expected to facilitate its broad adoption and enhance the applications of IVUS in clinical practice and research.

An Unusual Cause of Gastrointestinal Perforation in an Adolescent Patient With Beta-Thalassemia on Deferasirox and SARS-CoV-2 Infection.

Chelation therapy is recognized as a safe and effective treatment option in patients with beta-thalassemia with iron overload. We report an 18-year-old male with acute abdomen and gastrointestinal bleeding with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection secondary to gastric perforation due to chelation therapy. This patient had a prolonged intensive care stay with complications of SARS-CoV-2 and a small bowel obstruction post-surgery that resolved after conservative management. Given the acute presentation, chelation therapy use and concomitant SARS-CoV-2 infection, clinicians should keep an open mind on the differential diagnosis of acute abdomen in patients with beta-thalassemia.

A deep learning methodology for the automated detection of end-diastolic frames in intravascular ultrasound images.

Coronary luminal dimensions change during the cardiac cycle. However, contemporary volumetric intravascular ultrasound (IVUS) analysis is performed in non-gated images as existing methods to acquire gated or to retrospectively gate IVUS images have failed to dominate in research. We developed a novel deep learning (DL)-methodology for end-diastolic frame detection in IVUS and compared its efficacy against expert analysts and a previously established methodology using electrocardiographic (ECG)-estimations as reference standard. Near-infrared spectroscopy-IVUS (NIRS-IVUS) data were prospectively acquired from 20 coronary arteries and co-registered with the concurrent ECG-signal to identify end-diastolic frames. A DL-methodology which takes advantage of changes in intensity of corresponding pixels in consecutive NIRS-IVUS frames and consists of a network model designed in a bidirectional gated-recurrent-unit (Bi-GRU) structure was trained to detect end-diastolic frames. The efficacy of the DL-methodology in identifying end-diastolic frames was compared with two expert analysts and a conventional image-based (CIB)-methodology that relies on detecting vessel movement to estimate phases of the cardiac cycle. A window of ± 100 ms from the ECG estimations was used to define accurate end-diastolic frames detection. The ECG-signal identified 3,167 end-diastolic frames. The mean difference between DL and ECG estimations was 3 ± 112 ms while the mean differences between the 1st-analyst and ECG, 2nd-analyst and ECG and CIB-methodology and ECG were 86 ± 192 ms, 78 ± 183 ms and 59 ± 207 ms, respectively. The DL-methodology was able to accurately detect 80.4%, while the two analysts and the CIB-methodology detected 39.0%, 43.4% and 42.8% of end-diastolic frames, respectively (P < 0.05). The DL-methodology can identify NIRS-IVUS end-diastolic frames accurately and should be preferred over expert analysts and CIB-methodologies, which have limited efficacy.

Diagnostic accuracy of quantitative flow ratio (QFR) and vessel fractional flow reserve (vFFR) estimated retrospectively by conventional radiation saving X-ray angiography.

BACKGROUND: Angiography derived FFR reveals good performance in assessing intermediate coronary stenosis. However, its performance under contemporary low X-ray frame and pulse rate settings is unknown. We aim to validate the feasibility and performance of quantitative flow ratio (QFR) and vessel fractional flow reserve (vFFR) under such angiograms. METHODS: This was an observational, retrospective, single center cohort study. 134 vessels in 102 patients, with angiograms acquired under 7.5fps and 7pps mode, were enrolled. QFR (fQFR and cQFR) and vFFR were validated with FFR as the gold standard. A conventional manual and a newly developed algorithmic exclusion method (M and A group) were both evaluated for identification of poor-quality angiograms. RESULTS: Good agreement between QFR/vFFR and FFR were observed in both M and A group, except for vFFR in the M group. The correlation coefficients between fQFR/cQFR/vFFR and FFR were 0.6242, 0.5888, 0.4089 in the M group, with rvFFR significantly lower than rfQFR (p = 0.0303), and 0.7055, 0.6793, 0.5664 in the A group, respectively. AUCs of detecting lesions with FFR ≤ 0.80 were 0.852 (95% CI 0.722-0.913), 0.858 (95% CI 0.778-0.917), 0.682 (95% CI 0.586-0.768), for fQFR/cQFR/vFFR in the M group, while vFFR performed poorer than fQFR (p = 0.0063) and cQFR (p = 0.0054). AUCs were 0.898 (95% CI 0.811-0.945), 0.892 (95% CI 0.803-0.949), 0.843 (95% CI 0.746-0.914) for fQFR/cQFR/vFFR in the A group. AUCvFFR was significantly higher in the A group than that in the M group (p = 0.0399). CONCLUSIONS: QFR/vFFR assessment is feasible under 7.5fps and 7pps angiography, where cQFR showed no advantage compared to fQFR. Our newly developed algorithmic exclusion method could be a better method of selecting angiograms with adequate quality for angiography derived FFR assessment.

Should interventional radiology gain speciality status within the royal college of radiologists?

Interventional Radiology (IR) medicine's best kept secret will revolutionise healthcare like never before. The legacy Charles Dotter left behind not only showcases IR's pursuit of innovative and complex techniques in order to provide better treatment options for patients, it also sparked an opportunity for radiologists to use their imagination and creativity to develop IR into a speciality catering for the 21st century. By utilising imaging as well as clinical and minimal invasive surgical knowledge IRs are able to play an integral role in caring for patients in nearly all specialities.Over the past few decades, the absence of radiology in the leadership management arena has allowed other specialities to perpetuate turf wars and utilise techniques developed by IR. A concerted effort is required by the wider radiology community to address the problems faced by IR and to recognise its true potential as a speciality to further improve patient care.

Computerised Methodologies for Non-Invasive Angiography-Derived Fractional Flow Reserve Assessment: A Critical Review.

Fractional flow reserve is the gold standard for assessing the haemodynamic significance of intermediate coronary artery stenoses. Cumulative evidence has shown that FFR-guided revascularisation reduces stent implantations and improves patient outcomes. However, despite the wealth of evidence and guideline recommendations, its use in clinical practice remains minimal. Patient and technical limitations of FFR as well as the need for intracoronary instrumentation, use of adenosine, and increased costs have limited FFR's applicability in clinical practice. Over the last decade, several angiography-derived FFR software packages have been developed which do not require intracoronary pressure assessment with a guidewire or need for administration of hyperaemic agents. At present, there are 3 commercially available software packages and several other non-commercial technologies that have been described in the literature. These technologies have been validated against invasive FFR showing good accuracy and correlation. However, the methodology behind these solutions is different-some algorithms are based on solving the governing equations of fluid dynamics such as the Navier-Stokes equation while others have opted for a more simplified mathematical formula approach. The aim of this review is to critically appraise the methodology behind all the known angiography-derived FFR technologies highlighting the key differences and limitations.

The Evolution of Data Fusion Methodologies Developed to Reconstruct Coronary Artery Geometry From Intravascular Imaging and Coronary Angiography Data: A Comprehensive Review.

Understanding the mechanisms that regulate atherosclerotic plaque formation and evolution is a crucial step for developing treatment strategies that will prevent plaque progression and reduce cardiovascular events. Advances in signal processing and the miniaturization of medical devices have enabled the design of multimodality intravascular imaging catheters that allow complete and detailed assessment of plaque morphology and biology. However, a significant limitation of these novel imaging catheters is that they provide two-dimensional (2D) visualization of the lumen and vessel wall and thus they cannot portray vessel geometry and 3D lesion architecture. To address this limitation computer-based methodologies and user-friendly software have been developed. These are able to off-line process and fuse intravascular imaging data with X-ray or computed tomography coronary angiography (CTCA) to reconstruct coronary artery anatomy. The aim of this review article is to summarize the evolution in the field of coronary artery modeling; we thus present the first methodologies that were developed to model vessel geometry, highlight the modifications introduced in revised methods to overcome the limitations of the first approaches and discuss the challenges that need to be addressed, so these techniques can have broad application in clinical practice and research.

Diagnostic flow-chart to identify bowel involvement in patients with stage IIIC-IV ovarian cancer: Can laparoscopy improve the accuracy of CT scan?

OBJECTIVE: This study investigates the diagnostic power of CT scan combined with exploratory laparoscopy (EXL) at identifying large bowel involvement in patients with stage IIIC-IV primary Epithelial Ovarian Cancer (EOC) by comparing with the macroscopic surgical findings at laparotomy. METHODS: All patients with FIGO Stage IIIC-IV EOC who had Visceral Peritoneal Debulking (VPD) were included in the study. Results of CT scan, EXL and laparotomy (LPT) with regards to the bowel involvement were prospectively recorded in an ad hoc study form. Setting LPT findings as the gold standard, positive and negative predictive value (PPV/NPV), sensitivity, specificity and accuracy of CT and EXL were calculated. In addition, the diagnostic power of the combination CT scan + EXL was investigated. RESULTS: Ninety-four out of 177 patients (53.2%) had a bowel resection during VPD. CT-scan alone had sensitivity, specificity, PPV, NPV and accuracy of 56.7%, 72.4%, 70.8%, 58.5% and 63.8% respectively. EXL alone 84.4%, 93.8%, 93.8%, 84.3%, 88.8%. CT combined with EXL detected bowel involvement with a sensitivity, specificity, PPV, NPV and accuracy of 87.5%, 70.4%, 77.8%, 82.6% and 79.6% and respectively. The combined tests showed a statistically significant improvement vs. CT scan alone (p < 0001) in sensitivity, NPV and accuracy, with non-significant difference in specificity and PPV. CONCLUSIONS: CT-scan alone shows a limited diagnostic power at detecting large bowel involvement in patients with stage IIIC-IV EOC. The combination of CT scan with EXL increases the diagnostic power and enables to appropriately plan the bowel resection and consent the patients.