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OBJECTIVE In 2004, government-funded routine eye exams were discontinued for individuals aged 20-64 years in Ontario. We assessed whether this policy change reduced the rate of new glaucoma diagnoses. DESIGN Cohort-based time-series analysis. PARTICIPANTS Ontarians aged 20+ years in 2000-2014. METHODS Province-wide physician billing data were analyzed using segmented regression analysis. New glaucoma diagnoses were defined as the first glaucoma diagnostic billing code submitted by an ophthalmologist or optometrist among Ontarians who did not visit an ophthalmologist or an optometrist in the year prior to the study year. RESULTS Post- versus pre-2004, the rate of new glaucoma billings was reduced in all age groups: -2.7‰ (p < 0.0001) in the age group 20-39 years, -8.2‰ (p < 0.0001) in the age group 40-64 years (p < 0.0001), and -2.1‰ (p = 0.0003) in the age group 65+ years. This corresponds to a decreased number of individuals with a new glaucoma billing after 2004 versus before 2004: -8,800 (p < 0.001) in the age group 20-39 years, -32,234 (p < 0.0001) in the age group 40-64 years, and -3,255 (p = 0.0012) in the age group 65+ years. Reduced rates of new glaucoma diagnostic billings were seen in males, females and rural and urban residents among policy-affected and policy-unaffected age groups. Ontarians living in the wealthiest neighbourhood areas also had a significantly reduced rate after versus before 2004: -2.7‰ (p < 0.0001) for the age group 20-39 years, -9.0‰ (p < 0.0001) for the age group 40-64 years, and -2.3‰ (p < 0.001) for the age group 65+ years. CONCLUSIONS Discontinuation of government-funding for routine eye exams was associated with a significantly reduced rate of new glaucoma diagnostic billings irrespective of sociodemographics. More research is needed to understand the reduced glaucoma billings in unaffected seniors and those living in the wealthiest neighbourhood areas.

A 69-year-old man with dementia presented to our hospital with fever and left back pain. He was diagnosed with acute pyelonephritis based on microscopy and CT findings indicating bacteriuria and elevated fat density around the right kidney, respectively. Three days post admission, the diagnosis of a urinary tract infection was queried and the patient was re-examined. Marked tenderness was observed in the left buttock; contrast CT scan was subsequently performed and a left piriformis abscess was diagnosed. This diagnostic delay occurred due to a communication error—the referral letter to the radiologist stated ‘fever and back pain’—and the physician’s hyposkillia; hence, differential diagnoses were not considered. Physicians can reduce the frequency of related errors by conducting proper physical examinations and not relying on imaging findings alone. Furthermore, to ensure accurate diagnoses, the comments to the radiologist should be clear and detailed when requesting diagnostic imaging.

Unconscious biases may influence clinical decision making, leading to diagnostic error. Anchoring bias occurs when a physician relies too heavily on the initial data received. We present a 57-year-old man with a 3-year history of unexplained right thigh pain who was referred to a physiatry clinic for suggestions on managing presumed non-organic pain. The patient had previously been assessed by numerous specialists and had undergone several imaging investigations, with no identifiable cause for his pain. Physical examination was challenging and there were several ‘yellow flags’ on history. A thorough reconsideration of the possible diagnoses led to the discovery of hip synovial osteochondromatosis as the cause for his symptoms. Over-reliance on the referral information may have led to this diagnosis being missed. In patients with unexplained pain, it is important to be aware of anchoring bias in order to avoid missing rare diagnoses.

We describe here an interesting case of a 7-day-old male infant brought with parental concerns of inability to extend both knees. Clinical evaluation revealed dysplastic fingernails, bilateral abnormal patellae, triangular lunules in conjunction with pathognomic iliac horns on pelvic radiographs suggesting the possibility of nail-patella syndrome (NPS). Other competing diagnoses with similar phenotypic features were considered and sequentially excluded. A definitive diagnosis was established by the identification of the principal mutation at the LMX1B gene locus of chromosome 9. NPS is seldom diagnosed in neonates due to the heterogeneity of clinical presentations as well as the subtlety of clinical clues in this population. NPS is a dominantly inherited disorder that is predominantly familial in origin and thus carries important implications for the prenatal diagnosis of future pregnancies as well as pre-emptive surveillance of nephropathy in the index child.

Rationale and Objectives We evaluated the availability of cytological diagnosis with outer cannula washing solution (C-OCWS) as a clinical diagnostic tool for computed tomography (CT)-guided needle biopsy. Materials and Methods We retrospectively assessed 109 consecutive patients (71 males, 38 females; median age 68 years), who underwent CT-guided needle biopsy. In all patients, the specimens sampled by the inner needle were used for histological diagnosis, and those taken from the outer cannula were rinsed with 0.9% saline solution: outer cannula washing solution for cytological diagnosis. The accuracy of C-OCWS in addition to histological diagnosis were compared with that of histological diagnosis alone. We used binary logistic regression analysis to determine the variables associated with diagnostic accuracy for malignancy and lesion characteristics. Results The C-OCWS method precisely diagnosed 7 (6.4%) malignant lesions (i.e., effective cases) in the 109 patients characterized as “negative for malignancy” via histological diagnosis alone. The accuracy of the combination of C-OCWS and histological diagnoses was significantly higher than that of histological diagnosis alone (0.95 vs. 0.89, respectively; p = 0.023). Multivariate logistic regression analysis showed that increasing only a marginal ratio (failure rate for proper position of biopsy needle within the tumor) was independently associated with a high rate of effective cases (p = 0.003). Conclusion C-OCWS may be helpful for improving the quality of CT-guided needle biopsy, and is a simple method that may not necessarily increase the patients’ physical burden.

BACKGROUND: Clinicians make a medical diagnosis by recognizing diagnostic possibilities, often using memories of prior examples. These memories, called exemplars, reflect specific symptom combinations in individual patients, yet most clinical studies report how symptoms aggregate in populations. We studied how symptoms of acute myocardial infarction combine in individuals as symptom phenotypes and how symptom phenotypes are distributed in women and men. METHODS: In this analysis of the SILVER-AMI Study, we studied 3041 patients (1346 women and 1645 men) ≥75 years old with acute myocardial infarction. Each patient had a standardized in-person interview during the acute myocardial infarction admission to document the presenting symptoms, which enabled a thorough examination of symptom combinations in individuals. Specific symptom combinations defined symptom phenotypes and distributions of symptom phenotypes were compared in women and men using Monte Carlo permutation testing and repeated subsampling. RESULTS: There were 1469 unique symptom phenotypes in the entire SILVER-AMI cohort of acute myocardial infarction patients. There were 831 unique symptom phenotypes in women, as compared with 819 in men, which was highly significant, given the larger number of men than women in the study (p

Ultrasonography (US) is the primary imaging modality for the evaluation of pediatric scrotal disease. The ability to obtain exceptional anatomical detail and testicular perfusion information without ionizing radiation makes it the essential tool for evaluating scrotal pain and palpable masses. Challenges arise in both the performance and interpretation of scrotal US in the child. Optimizing imaging parameters and recognizing key differentiating US features help minimize misinterpretations that can lead to poor patient outcomes. Key pearls and pitfalls in pediatric scrotal ultrasound methods and diagnoses are reviewed. Knowledge of what is normal for the various ages of childhood from neonate through adolescence is necessary for accurate US analysis. Imaging evaluation of key causes of the acute painful scrotum including testicular appendage torsion, epididymitis, and testicular torsion are discussed. Sonographic features for the diagnosis of benign and malignant scrotal masses, microlithiasis, and cryptorchidism are reviewed.

Purpose Most patients with ankle arthrosis have a history of ankle fracture. Evaluation of malleolar fractures solely on X-ray may be insufficient to identify many pathologies that potentially contribute to ankle arthrosis, with a consequent poor prognosis. We investigated the pathologies that may be overlooked in malleolar fractures evaluated solely on plain X-ray. Methods During 2012–2019, 65,479 patients attended our Emergency Department, of which 6508 complained of an ankle joint problem. X-rays indicated a fracture in 454 of these patients. Patients with isolated, simple fracture of the lateral or medial malleolus, or talus, or a history of surgery to this area were excluded; finally, 67 patients were enrolled (31 males, 36 females; mean age: 51,2 years (range: 9–83 years). Patients underwent X-ray imaging of both ankles in anterio-posterior, lateral, and Mortise views, as well as CT scans. Three independent observers with varied experience in diagnostic imaging (orthopaedic resident, experienced orthopaedic surgeon, and musculoskeletal radiologist) evaluated X-ray images blinded to CT scans. Their diagnoses were subsequently compared with CT findings. Results Modeling results indicated that about 40% [95% CI: 32%, 50%] of pathologies may be overlooked based on X-ray evaluation, regardless of evaluator experience. The most frequently overlooked injuries were: Tillaux fracture, Pillon fracture, loose bodies and syndesmosis injury. All of that missed pathologies required dedicated treatment and could be easily missed with standard surgical approach. Conclusion Evaluation of malleolar fractures by X-ray only inevitably results in overlooking of many pathologies, despite the clinician’s experience. Routine CT scan can help to improve the accuracy of diagnosis, and thereby reduce the risk of ankle osteoarthrosis.

Background Brugada syndrome is a major cause of sudden cardiac death in young people with a distinctive electrocardiogram (ECG) feature. We aimed to develop a deep learning-enabled ECG model for automatic screening Brugada syndrome to identify these patients at an early time, thus allowing for life-saving therapy. Methods A total of 276 ECGs with a type 1 Brugada ECG pattern (276 type 1 Brugada ECGs and another randomly retrieved 276 non-Brugada type ECGs for one to one allocation) were extracted from the hospital-based ECG database for a two-stage analysis with a deep learning model. After trained network for identifying right bundle branch block pattern, we transferred the first-stage learning to the second task to diagnose the type 1 Brugada ECG pattern. The diagnostic performance of the deep learning model was compared to that of board-certified practicing cardiologists. The model was further validated in the independent ECG dataset, collected from the hospitals in Taiwan and Japan. Results The diagnoses by the deep learning model (AUC: 0.96, sensitivity: 88.4%, specificity: 89.1%) were highly consistent with the standard diagnoses (Kappa coefficient: 0.78). However, the diagnoses by the cardiologists were significantly different from the standard diagnoses, with only moderate consistency (Kappa coefficient: 0.63). In the independent ECG cohort, the deep learning model still reached a satisfactory diagnostic performance (AUC 0.89, sensitivity: 86.0%, specificity: 90.0%). Conclusions We presented the first deep learning-enabled ECG model for diagnosing Brugada syndrome, which appears to be a robust screening tool with a diagnostic potential rivaling trained physicians.

Background Contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) can be used for the differential diagnosis of pancreatic lesions by evaluating microvascular circulation and patterns of contrast enhancement. However, routine use of CEH-EUS is limited by its high cost, the lack of contrast agent availability and the absence of expertise with this technique. Directional eFLOW (D-eFLOW) (Aloka Co., Ltd., Tokyo, Japan) was introduced as a new high-definition modality that detects blood flow in microvessels. Because it uses built-in functions, it entails no additional cost and reduces time for examination. The present study compared the usefulness of D-eFLOW and CEH-EUS for differential diagnosis of pancreatic and peripancreatic lesions. Methods This retrospective study analyzed 130 patients who underwent EUS and D-eFLOW examinations from January 2016 to March 2020 to evaluate pancreatic and peripancreatic masses. Results All 130 patients underwent D-eFLOW and CEH-EUS examinations. Histological diagnoses were confirmed in 130 patients by EUS-FNA and/or surgery. D-eFLOW and CEH-EUS showed good correlation in evaluating the vascularity of pancreatic and peripancreatic tumors (Fisher's exact test, p Conclusions In evaluating the characteristics of tumorous lesions, vascularity detected by D-eFLOW showed good correlation with enhancement patterns of CEH-EUS. D-eFLOW can be considered a good alternative to CEH-EUS in diagnosing pancreatic and peripancreatic masses.

AIM To evaluate the detection of acute aortic syndrome (AAS) and the prevalence of alternative diagnoses that may explain the presentation or require follow-up. MATERIALS AND METHODS This was a retrospective, blinded re-evaluation of consecutive electrocardiography (ECG)-gated computed tomography (CT) aortic studies by a cardiovascular radiologist performed between September 2019 and May 2020 in a tertiary-referral cardiothoracic centre. RESULTS There were 118 identified examinations, six examinations were excluded leaving 112 (mean age = 61 ± 17; 56% male). Three cases of AAS were present (prevalence 2.7%); only one was reported on initial review. There were no false-positive diagnoses of AAS. The heart was mentioned in 79 (70.5%) reports and 73 (65.2%) of reviews revealed a total of 114 new observations; 111 (97.4%) of these were cardiovascular with 44/112 (39.3%) patients potentially having a significant previously unsuspected cardiovascular diagnosis. CONCLUSION The implementation of national clinical guidance to increase testing and improve image quality led to a series of challenges. The real value of ECG-gated CT may lie in detecting other diseases that mimic AAS. With the additional workload, increased subspecialty expertise is required but there needs to be a willingness to learn with an adequate support infrastructure.

Objective Clinical diagnoses of asthma and reactive airway disease (RAD) in young children are subjective. We examined how often children were diagnosed with asthma versus RAD, and whether preventive care and 2-year clinical outcomes differed based on initial diagnosis. Methods We conducted a retrospective cohort analysis of children (2–7 years) from a university-based general pediatrics practice who had been diagnosed with RAD or asthma. We performed adjusted comparisons between groups for time until subsequent asthma-related care. We also compared delivery of asthma-related healthcare services, corticosteroid and controller prescriptions, and action plans within 2 years of index diagnosis, using bivariate and regression analyses. Results Four hundred three children were included (64% male, 67% Black, 25% Hispanic). RAD was diagnosed in 62% of index visits, and was more likely than asthma to be diagnosed in emergency settings. In the full sample, the time between index visit and subsequent asthma care did not differ between groups, after adjustment for index location. For subjects with complete 24-month follow-up (N = 300), no between-group differences were found in adjusted analyses. Most children with RAD received action plans and controller medications only after a subsequent asthma diagnosis, on average, 9 months after their index visit. Conclusions RAD diagnoses were linked to delayed delivery of preventive care measures, but within 2 years of initial diagnosis, clinical outcomes for those diagnosed with RAD and asthma did not differ. To facilitate clear communication and timely treatment, a prompt diagnosis of asthma, rather than RAD, should be considered for children with asthma symptoms.

Summary Background Skin adnexal tumours (SATs) comprise a diverse range of neoplasms, which are difficult to diagnose clinically. They present in paediatric and adult populations, and may be indicative of an underlying genetic syndrome. There is a lack of recent data on the presentation of these tumours in clinical practice in European populations. Objectives To characterize the clinical and pathological features of SATs received at a single tertiary centre over a 5-year period. Methods A retrospective health record audit of SATs received at the Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, during the period November 2012 to October 2017 was performed. Results In total, 107 144 skin cases were received during the audit period. A total of 1615 cases of SATs from 1359 patients were included; 1570 (97·2%) were benign and 45 (2·8%) were malignant. Overall, the average age at presentation was 55 years (range 11 months to 97 years) and the male to female ratio was 0·77 : 1. Sweat gland and hair follicle SATs were most frequently excised; in adults, the most frequent tumour was hidrocystoma, and in children, pilomatrixoma occurred most often. Prebiopsy diagnosis was correct in 28% of cases. Benign SATs are often markers of an associated genetic condition, which warrants improved discrimination of sporadic from genetically related SATs. Conclusions SATs are difficult to diagnose clinically, and clinicopathological correlation may help enhance discrimination of genetically related SATs from sporadic cases. These data have implications for clinical and dermatopathological training provision, the development of reporting standards, and genetic assessment of selected patients.

Background: The current COVID-19 pandemic has attracted great attention from the medical world. In the past year, there have been reports of missed or delayed treatments for conditions that mimic COVID-19. The main symptoms caused by SARS-CoV-2, such as fever and cough, belong to different clinical conditions. It is of the utmost importance that the diagnostic thinking used to analyze data and information to reach a COVID-19 diagnosis does not overlook the plethora of different diagnoses related to these symptoms. Case report: The aim of this work is to present the clinical case of a patient having unrecognized HIV infection with a 4-week history of fever, cough, and hypoxia. When tests were allowed to highlight HIV-related immunodeficiency status, a CMV assay was performed in order to evaluate opportunistic pneumonia. Through this, diagnosis of HIV combined with CMV pneumonia was made, thus excluding COVID-19 respiratory insufficiency. Conclusion: The diagnosis of the two conditions in the COVID-19 era is challenging due to overlapping clinical and radiological features and limitations of current diagnostic assays. This causes clinical implications due to diagnostic delays.

BACKGROUND International Statistical Classification of Disease and Related Health Problems, 10th Revision codes (ICD-10) are used to characterize cohort comorbidities. Recent literature does not demonstrate standardized extraction methods. OBJECTIVE Compare COVID-19 cohort manual-chart-review and ICD-10-based comorbidity data; characterize the accuracy of different methods of extracting ICD-10-code-based comorbidity, including the temporal accuracy with respect to critical time points such as day of admission. METHODS Design: Retrospective cross-sectional study. MEASUREMENTS ICD-10-based-data performance characteristics relative to manual-chart-review. RESULTS Discharge billing diagnoses had a sensitivity of 0.82 (95% Confidence Interval [CI]: 0.79-0.85; comorbidity range 0.35-0.96). The past medical history table had a sensitivity of 0.72 (95% CI: 0.69-0.76; range 0.44-0.87). The active problem list had a sensitivity of 0.67 (95% CI: 0.63-0.71; range 0.47-0.71). On day of admission, the active problem list had a sensitivity of 0.58 (95% CI: 0.54-0.63; range 0.30-0.68) and past medical history table had a sensitivity of 0.48 (95% CI: 0.43-0.53; range 0.30-0.56). CONCLUSIONS AND RELEVANCE ICD-10-based comorbidity data performance varies depending on comorbidity, data source, and time of retrieval; there are notable opportunities for improvement. Future researchers should clearly outline comorbidity data source and validate against manual-chart-review. This article is protected by copyright. All rights reserved.

Purpose This study assessed adherence to, feasibility of, and barriers and facilitators of implementation of an app developed to monitor and follow-up with pain in children with cancer at home. Methods Children (8–18 years) receiving cancer treatment (all diagnoses) or their parents (of children aged 0–7 years) used the KLIK Pain Monitor app for 3 weeks. Pain was assessed twice daily using an 11-point numeric rating scale (NRS-11) (ranging from 0 to 10). Healthcare professionals (HCP’s) from the hospital’s Pediatric Pain Service were instructed to follow-up with clinically significant pain scores (≥ 4) within 120 min (scores 4–6) or 30 min (scores 7–10). Adherence, feasibility, and implementation outcomes were assessed using questionnaires, app log data, and interviews. Results Twenty-seven children (M age = 7.3 years, 51.8% male) and six HCP’s participated. Sixty-three percent (N = 17) of families used the app on a daily basis during three weeks, and 18.5% (N = 5) reported pain scores twice daily during that time (family adherence). Twelve out of 27 children (44.4%) reported a clinically significant pain score at least once. In 70% (14/20) of clinically significant pain scores, HCP’s followed-up with families within the set timeframe (HCP adherence). Outcomes reveal feasibility for the majority of app functions (i.e., positive evaluation by ≥ 70% families/HCP’s), and non-feasible aspects could be resolved. Identified barriers and facilitators were used to improve future implementation efforts. Conclusion Use of the KLIK Pain Monitor app seems feasible. Future research will determine its effectiveness in reducing pain in children with cancer at home.

Objective Emergency departments (EDs) are highly valued settings for HIV screening. Most large-volume ED HIV screening programs have attenuated operational barriers by screening only ED patients who already have a blood sample available for other clinical reasons. Our objective was to estimate the proportion of HIV positive patients who are missed when an ED excludes patients for whom HIV screening would be the only indication to obtain a blood sample. Methods This cross-sectional analysis used existing electronic records of patients seen between 2017 and 2019 by an urban, academic ED and its HIV screening program, which includes patients regardless of whether they receive other ED blood testing. The primary outcome was the proportion of patients tested by the screening program who were newly diagnosed with HIV (Sample 1) for whom HIV screening would be the only indication for venipuncture. We secondarily 1) estimate the proportion of ED patients who received venipuncture using a representative sample of consecutively approached participants which prospectively recorded whether patients had blood obtained or intravenous catheter placement during usual ED care (Sample 2) and 2) report patient characteristics including HIV risk factors for those with and without ED venipuncture for both groups. Results Of 41 persons newly diagnosed with HIV by the ED screening program (Sample 1), 13 (31.7%, 95%CI 18.6–48.2) did not undergo venipuncture for any reason other than their HIV test. The proportion of ED visits without a venipuncture (Sample 2) was 44.2% (95% CI 41.9–46.6). Patient characteristics were similar for both groups. Conclusions Screening only those patients with a blood sample already available or easily obtainable due to usual ED care, misses many opportunities for earlier HIV diagnosis. Innovation in research, policy, and practice is needed to overcome still unaddressed barriers to ED HIV screening when HIV screening is the only indication for collection of a biological sample.

OBJECTIVE There is an unmet need for a reliable biomarker for the differentiation of axial spondyloarthritis (AxSpA) from its mimickers. Serum levels of interleukin-22 (IL-22) have previously been found to be significantly elevated in patients with AxSpA compared with healthy individuals or persons with osteoarthritis. METHODS Consecutive patients with established or suspected AxSpA were enrolled. The clinical data, as well as results of laboratory and imaging studies, were acquired from patients' charts. The final diagnosis of definite or probable SpA, or an alternative diagnosis, was determined, and the serum levels of IL-22 were examined by enzyme-linked immunosorbent immunoassay. RESULTS Interleukin-22 levels were significantly higher in patients with definite AxSpA (29 patients) compared with patients with alternative diagnoses (14 patients) and healthy volunteers (16 individuals; P

This retrospective observational study was undertaken to assess the ENT emergency workload during the COVID-19 pandemic caused by the severe acute respiratory coronavirus‑2 (SARS-CoV-2).All 3230 patients who were treated as an emergency from 23.01.2020 to 06.08.2020 in the Department of Otolaryngology at the SLK-Kliniken Heilbronn were included in this study. Demographic data, diagnostics, diagnosis, and treatment (in-/outpatient) were retrospectively retrieved. Not only did the physicians on call triage the emergency department (ED) ENT patients, but the patients also self-assessed their urgency of treatment.The number of patients consulting our ED decreased significantly during the pandemic, by 42.2%. However, the top diagnoses remained almost constant, with epistaxis being the most frequent diagnosis before, during, and after COVID-19. Facial trauma remained the second most frequent consultation reason. The hospitalization rate decreased from 21.9% before COVID-19 to 16.2% during the pandemic. Surgical therapy was necessary in 17.6% of patients before COVID-19 and this increased to 23.5% during COVID-19. The self-referral rate increased from 61 to 66% during the pandemic. More men than women consulted the ED during COVID-19. Regarding the triage assessment by the physician on call and the patient's self-assessment, a significant discrepancy was noted before, during, and after COVID-19.The reasons for reduction in ENT ED visits are multifactorial. The clinical consequences of decreased hospitalizations remain uncertain. However, health authorities need to advocate the safety of the hospital environment to limit potential damage.HINTERGRUND: Diese retrospektive Beobachtungsstudie wurde durchgeführt, um Veränderungen der HNO-Notfälle während der durch „severe acute respiratory coronavirus-2“ (SARS-CoV-2) verursachten (COVID-19-)Pandemie zu analysieren.In diese Studie wurden insgesamt 3230 Patienten eingeschlossen, die sich vom 23.01.2020 bis zum 06.08.2020 in der Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Halschirurgie, plastische Operationen des SLK-Klinikums Heilbronn als Notfall vorstellten. Demografische Daten, Diagnostik, Diagnose, Therapie und Behandlung (ambulant/stationär) wurden retrospektiv erhoben. Die Triage der Notfallpatienten erfolgte nicht nur durch die diensthabenden Ärzte, sondern auch durch den Patienten selbst, der die Dringlichkeit seiner Behandlung einschätzte.Die Anzahl der Patienten, die unsere Notaufnahme aufsuchten, ging während der Pandemie um 42,2 % zurück. Die häufigsten Diagnosen blieben jedoch fast gleich, wobei Epistaxis die häufigste Diagnose vor, während und nach COVID-19 war. Das Gesichtstrauma blieb der zweithäufigste Vorstellungsgrund. Die Hospitalisierungsrate sank von 21,9 % vor COVID-19 auf 16,2 % während der Pandemie. Eine chirurgische Therapie war bei 17,6 % der Patienten vor COVID-19 notwendig und stieg während COVID-19 auf 23,5 %. Die Selbsteinweisungsrate stieg während der Pandemie von 61 auf 66 %. Während COVID-19 suchten mehr Männer als Frauen die Notaufnahme auf. Hinsichtlich der Dringlichkeitseinschätzung der Behandlung durch den diensthabenden Arzt und durch den Patienten selbst wurde eine signifikante Diskrepanz vor, während und nach COVID-19 festgestellt.Verschiedene Faktoren könnten für den Rückgang der notfallmäßigen Vorstellungen in der HNO-Klinik verantwortlich sein. Die Folgen der verringerten Rate an stationären Behandlungen von Patienten bleiben ungewiss. Sicher ist, dass sich die Gesundheitsbehörden vermehrt für die Sicherheit der Krankenhausumgebung, in diesem Fall besonders bezüglich des Infektionsschutzes einsetzen müssen, um potenzielle kurz- und langfristige gesundheitliche Folgen für die Patienten zu vermeiden.

Our institution developed and continuously improved a Neurodevelopmental Reflex (NDR) algorithm to help physicians with genetic test ordering for neurodevelopmental disorders (NDDs). To assess its performance, we performed a retrospective study of 511 patients tested through NDR from 2018 to 2019. SNP Microarray identified pathogenic/likely pathogenic copy number variations in 27/511 cases (5.28%). Among the 484 patients tested for Fragile X FMR1 CGG repeats, a diagnosis (0.20%) was established for one male mosaic for a full mutation, a premutation, and a one-CGG allele. Within the 101 normocephalic female patients tested for MECP2, two patients were found to carry pathogenic variants (1.98%). This retrospective study suggested the NDR algorithm effectively established diagnoses for patients with NDDs with a yield of 5.87%.

BACKGROUND Accurate pre-operative diagnosis of orbital lesions supports appropriate prioritisation of patients into available theatre time. We examine the accuracy of pre-operative clinico-radiological diagnosis in a tertiary centre with weekly dedicated orbital clinics and associated multi-disciplinary team meetings. METHODS A retrospective case notes review was undertaken for all patients who had an orbital biopsy performed at Bristol Eye Hospital between 2007 and 2017. In this centre, pre-operative clinico-radiological differential diagnoses are discussed during multi-disciplinary team meetings including two orbital specialist ophthalmologists and a specialist neuro-radiologist. Clinico-radiological diagnoses were compared with histopathological outcomes. Subcategory analysis according to histopathological diagnosis was undertaken to look for trends. RESULTS 172 biopsies were taken from 156 patients, median age 59 years (range 3 months to 91 years). 60.9% of patient were females, with equal numbers of right and left-sided biopsies. 11 patients had inconclusive histopathology. 15 patients did not have a documented preoperative diagnosis or differential offered in available notes. 71 patients (49.0%) demonstrated an exact match between clinico-radiological and histopathological diagnosis, 93 (64.1%) demonstrated a category match (e.g. inflammatory, lymphoproliferative) and for 111 (76.6%), the histopathological diagnosis was considered within the list of proffered clinico-radiological differential diagnoses. CONCLUSIONS Accuracy of pre-operative diagnosis of orbital lesions undergoing biopsy was higher in our series than previously reported by Koukoulli et al. Specialist head and neck radiology input via regular orbital multi-disciplinary meetings might be reciprocally educational and explain this difference. The authors recommend all surgeons who perform orbital surgery should have access to such multi-disciplinary meetings.

Background. Patient records’ relevance is associated with a variety of needs and objectives. Substantiating the health of patients perpetually and allowing professionals in the medical field to assess both signs and symptoms that fall in a relatively wider temporal point of view and contributions that lead to enhanced diagnoses and treatment are all quintessential of patient records. The advancement of information technology systems has led to the anticipation that development will be put into digitization and electronic means of storing patient records in order to grease their handling. Cape Coast Teaching Hospital (CCTH) is piloting implementation of patient’s electronic health record system. The introduction of the electronic health record system known as Lightwave Hospital Information Management System (LHIMS) was to provide a permanent solution to patients’ continuity of care. User’s acceptance of new information technology is seen to be one of the most challenging issues in information system. This study assesses healthcare providers’ (HP’) behavioural intention to use LHIMS to attend to clients in Cape Coast Teaching Hospital and other factors influencing it. Methods. A nonexperimental cross-sectional study was used to obtain information from 84 HP recruited from the various departments and units in CCTH who use LHIMS to attend to clients. The sample size of 90, representing 8% of HP in CCTH, was randomly selected from the various departments and units. However, 84 (indicating 93.3% response rate) of the selected HP were available during the period of the research. Results. Perceived ease of use (PEOU) of LHIMS had the strongest direct effect on perceived usefulness (PU), with a highly significant path coefficient of 0.75. PU had the greatest impact on attitude about HP’ behavioural intention to use (BIU) LHIMS to attend to patients’ healthcare delivery in CCTH (0.91). This relationship was highly significant at p < 0.001 . PEOU did not have a significant direct effect on attitude about LHIMS use, as hypothesized in the original technology acceptance model. However, attitude towards use had a strong significant effect on HP’ BIU of LHIMS, with a strong statistically significant path coefficient of 0.98 at p < 0.001 . Conclusions. We conclude that attitude towards use have a significant influence on HP’ behavioural intention to use LHIMS to attend to clients in Cape Coast Teaching Hospital.

Purpose The current literature on pediatric autoimmune encephalitis (AE) focuses on medical identification/diagnosis and medical treatments. Data about the identification and treatment of communication disorders in these children are limited. This clinical focus article provides an example of the speech, language, and communication characteristics, intervention, and recovery of a single child with medical diagnoses of pediatric AE and pediatric acute-onset neuropsychiatric syndrome (PANS) and special education eligibility under the autism spectrum disorder category. Method This is an in-depth illustrative/descriptive case study. Medical, educational, and speech-language documentation of one child diagnosed with AE at age 7 years was reviewed. Methods included interviews with family members, teachers, and the school speech-language pathologist and reviews of documentation including evaluations, reports, and Individualized Education Programs. Results This child received special education and therapy services through his public school and a university speech-language clinic. He concurrently received medical treatment for AE and PANS. Comprehensive augmentative and alternative communication (AAC) intervention included the use of core words, modeling, parallel talk, self-talk, expansive recasts, shared book reading, family counseling, and collaboration with the parents and the school speech-language pathologist. The child made progress on all goals despite irregular attendance to therapy due to medical complications. Discussion Because experimental research including this population is currently limited, this descriptive case study provides valuable information to clinicians, educators, pediatricians, medical diagnosticians, and anyone providing services to a child with a complex neuropsychological disorder like AE. Future research is needed with more children who have AE, especially experimental investigations of the intervention methods utilized here. Additional research of more children with AE can provide information about the scope and severity of speech, language, and communication needs and the trajectory of recovery given AAC intervention.

Introduction Linking emergency medical services (EMS) data to emergency department (ED) data enables assessing the continuum of care and evaluating patient outcomes. We developed novel methods to enhance linkage performance and analysis of EMS and ED data for opioid overdose surveillance in North Carolina. Methods We identified data on all EMS encounters in North Carolina during January 1–November 30, 2017, with documented naloxone administration and transportation to the ED. We linked these data with ED visit data in the North Carolina Disease Event Tracking and Epidemiologic Collection Tool. We manually reviewed a subset of data from 12 counties to create a gold standard that informed developing iterative linkage methods using demographic, time, and destination variables. We calculated the proportion of suspected opioid overdose EMS cases that received International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for opioid overdose in the ED. Results We identified 12 088 EMS encounters of patients treated with naloxone and transported to the ED. The 12-county subset included 1781 linkage-eligible EMS encounters, with historical linkage of 65.4% (1165 of 1781) and 1.6% false linkages. Through iterative linkage methods, performance improved to 91.0% (1620 of 1781) with 0.1% false linkages. Among statewide EMS encounters with naloxone administration, the linkage improved from 47.1% to 91.1%. We found diagnosis codes for opioid overdose in the ED among 27.2% of statewide linked records. Practice Implications Through an iterative linkage approach, EMS–ED data linkage performance improved greatly while reducing the number of false linkages. Improved EMS–ED data linkage quality can enhance surveillance activities, inform emergency response practices, and improve quality of care through evaluating initial patient presentations, field interventions, and ultimate diagnoses.

BACKGROUND After many years of decline, HIV diagnoses attributed to injection drug use in the United States increased in 2015, the year of a large outbreak among persons who inject drugs (PWIDs) in Indiana. We assessed trends in HIV diagnoses among PWID across the urban-rural continuum. METHODS We conducted national and county-level analyses of diagnoses among persons aged ≥13 years with HIV attributed to injection drug use only and reported to the National HIV Surveillance System through December 2019; county of residence at diagnosis was classified according to the Centers for Disease Control and Prevention's National Center for Health Statistics Urban-Rural Classification Scheme. National trends for diagnoses occurring during 2010-2014 and 2014-2018 were assessed by the estimated annual percentage change (EAPC). Counties were considered to have an "alert" (ie, an increase above baseline) if the number of 2019 diagnoses among PWID was >2 SDs and >2 diagnoses greater than the mean of annual diagnoses during 2016-2018. RESULTS Nationally, HIV diagnoses among PWID declined 33% during 2010-2014 from 3314 to 2220 (EAPC: -9.7%; 95% confidence interval: -10.8 to -8.6); EAPCs declined significantly in 5 of 6 urban-rural strata. During 2014-2018, diagnoses increased 11% to 2465 (EAPC: 2.4%; 95% confidence interval: 1.1 to 3.8); EAPCs were >0 for all urban-rural strata, although most were nonsignificant. Alerts were detected in 23 counties, representing 5 urban-rural strata. CONCLUSIONS Vigilance is needed for increases in HIV among PWID in counties across the urban-rural continuum, particularly those with indicators of increased drug use. Prompt detection, investigation, and response are critical for stemming transmission.

In Ottawa, Canada, we initiated protocols to include non-serologic syphilis testing, as direct fluorescence antibody (DFA) for patients with syphilis symptoms. The purpose was to assess the ability of DFA to detect syphilis during acute infection and to determine if non-serologic testing could yield an increased number of syphilis diagnoses. We reviewed charts of patients of our local sexual health clinic for whom syphilis was suspected. A total of 69 clinical encounters were recorded for 67 unique patients, most of whom were male. The most common symptom was a painless genital lesion. Of the 67 patients, 29 were found to have a new syphilis diagnosis, among whom, 52% had positive syphilis serology and positive DFA, 34% had a positive syphilis serology and negative DFA, and 14% had negative syphilis serology and positive DFA. While DFA testing did not yield an abundance of new cases, it was useful to support findings from syphilis serology or confirm diagnosis where serology was negative. Where available, alternate non-serologic tests, such as nucleic acid amplification tests, should be considered above DFA due to its higher sensitivity for detecting syphilis in primary lesions; however, in clinical situations, when new syphilis infection is suspected, empiric treatment should not be delayed.

Background: This study aimed to identify clinical features that predate the diagnosis of PD in a primary care setting. Methods: This retrospective case-control study was based on data from the Disease Analyzer database (IQVIA) and included 17,702 patients with Parkinson’s disease and 17,702 non-PD controls matched for age, sex, and index year. We analyzed the prevalence of 15 defined diagnoses and symptoms documented within 2 years, ≥2 to Results: The prevalence of motor, neuropsychiatric, and autonomic features was higher in those with a later diagnosis of Parkinson’s disease than controls for all 3 periods except for rigidity in the ≥2 to Conclusion: The prodromal features of PD could be identified in this large primary care database in Germany with similar results to those found in previous database studies despite differences in methodologies and systems.

Frailty has been widely recognized as a predictor of postoperative outcomes. Given the paucity of standardized frailty measurements in thoracic procedures, this study aimed to determine the impact of coding-based frailty on clinical outcomes and resource use after anatomic lung resection.All adults undergoing elective, anatomic lung resections (segmentectomy, lobectomy, pneumonectomy) from 2005 to 2014 were identified using the National Inpatient Sample. Patients were categorized as either frail or nonfrail on the basis of the presence of any frailty-defining diagnoses defined by the Johns Hopkins Adjusted Clinical Groups. Multivariable models were used to assess the independent association of frailty with in-hospital mortality, nonhome discharge, complications, duration of stay, and costs.Of an estimated 366,357 hospitalizations for elective lung resection during the study period, 4.4% were in frail patients. Patients who underwent pneumonectomy or were treated at low-volume hospitals were more commonly frail. Relative to nonfrail patients, frailty was associated with increased unadjusted mortality (9.1% vs 1.7%; P.001) and nonhome discharge (44.7% vs 10.5%; P.001). Frail patients had 3.47 increased adjusted odds of mortality across resection types (95% confidence interval, 2.94 to 4.09). Frailty conferred the greatest increase in mortality, complications, and resource use after pneumonectomy relative to lobectomy or segmentectomy, although significant differences were evident for all 3 operations.Frailty exhibits a strong association with inferior clinical outcomes and increased resource use after elective lung resection, particularly pneumonectomy. This readily available tool may improve preoperative risk assessment and allow for better selection of treatment modalities for frail patients with pulmonary disorders.

Introduction. Radiomics could be potential imaging biomarkers by capturing and analyzing the features. Children and adolescents with CHD have worse neurodevelopmental and functional outcomes compared with their peers. Early diagnosis and intervention are the necessity to improve neurological outcomes in CHD patients. Methods. School-aged TOF patients and their healthy peers were recruited for MRI and neurodevelopmental assessment. LASSO regression was used for dimension reduction. ROC curve graph showed the performance of the model. Results. Six related features were finally selected for modeling. The final model AUC was 0.750. The radiomics features can be potential significant predictors for neurodevelopmental diagnoses. Conclusion. The radiomics on the conventional MRI can help predict the neurodevelopment of school-aged children and provide parents with rehabilitation advice as early as possible.

Of new sexually transmitted infections (STIs) in the United States, 50% occur among youth aged 15 to 24 years. Previous studies among youth with HIV (YHIV) do not distinguish STI trends among individuals with perinatally (YPHIV) and nonperinatally (YNPHIV) acquired HIV.Among 3 Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) studies conducted between 2009 and 2015, we estimated incident diagnoses of trichomonal, bacterial, viral, and overall STIs stratified by sex assigned at birth, mode of HIV acquisition (perinatal [YPHIV] and nonperinatal [YNPHIV]), age (13-17 and 18-24 years), CD4 count (200, 200-499, and ≥500/μL), and HIV viral load (VL) (400 and ≥400 copies/mL).Among 3131 YHIV, across the 3 studies, mean (SD) age was 20.6 (2.6) years, 888 (28%) were female, 2498 (80%) had nonperinatal HIV acquisition recorded, and 2298 (73%) were African American/Black. Mean follow-up was 0.9 (0.3) years. Compared with YPHIV, YNPHIV spent less person-time with VL400 copies/mL (47% vs. 53%) and more time off antiretroviral therapy (49% vs. 15%), and had higher overall STI rates (males, 65.9 vs. 8.5/100 person-years [PY]; females, 54.7 vs. 17.2/100 PY). Among YPHIV, bacterial STIs were higher during person-time spent with VL ≥400 vs.400 copies/mL (male YPHIV, 10.9 vs. 0.6/100 PY; female YPHIV, 11.2 vs. 2.9/100 PY); no difference was observed among YNPHIV, which may be due to concurrent acquisition of HIV and other STIs and limited follow-up.Compared with YPHIV, YNPHIV spent less time on antiretroviral therapy and virologically suppressed; YNPHIV also had higher STI diagnosis rates. Very high STI diagnosis rates among YHIV, including among those without virologic suppression, highlight the importance of youth-focused efforts to support durable virologic suppression and identify and treat STIs.

Background Evidence of patterns of medical utilization and distribution of comorbidities among individuals using methamphetamine remains limited. Objective This study aims to investigate changes in medical utilization and comorbidities before and after a diagnosis of methamphetamine use disorder. Methods A total of 3321 cases (79% were male) of methamphetamine use disorder between January 1, 1996, and December 31, 2012, were identified from Psychiatric Inpatient Medical Claims database in Taiwan. Information was collected on demographics, diagnoses, and medical utilizations. The date of newly diagnosed with methamphetamine use disorder was defined as the baseline. Mirror-image study design was used to compare changes in medical utilization and comorbidities between the pre-baseline period (within 1 year before diagnosis) and the post-baseline period (within 1 year after diagnosis). Conditional logistic regression was used to estimate changes in medical utilization and comorbidities. Results Most cases (77%) were first identified in a psychiatric department. There is a significant increase (P Conclusions We found significant increases of medical utilization and psychiatric comorbidities after diagnosed with methamphetamine use disorder. These findings may reflect the problem of delayed diagnosis and treatment. Enhancement of early identification of methamphetamine use disorder in general practice is required for early intervention and decreased subsequent morbidities.

Made available in DSpace on 2022-04-28T19:46:00Z (GMT). No. of bitstreams: 0 Previous issue date: 2022-02-01 Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) We documented the outcome of an over 10-year (2011–2021) effort to diagnose acute and early HIV infections (AEHI) in an Infectious Diseases Outpatient Clinic with limited resources. Of a total of 132, 119 HIV-RNA tests were performed from 2017 to 2020, 12 cases were identified, using a simple algorithm: risk exposure of 6 weeks or less before the visit and/or symptoms compatible with acute retroviral syndrome 7–30 days after exposure and/or undetermined 3rd generation rapid diagnostic test or serology. AEHI diagnoses varied from 2.4% among asymptomatic to 25% for undetermined serology cases using this simple screening applicable to different settings. Infectious Diseases Outpatient Clinic Santo André Health Secretary Virology Center Adolfo Lutz Institute Santo André Regional Center Adolfo Lutz Institute Bioprocess and Biotecnology Engeneering São Paulo State University—UNESP Avenida Universitária Bioprocess and Biotecnology Engeneering São Paulo State University—UNESP Avenida Universitária

Background Despite widespread clinical use, lymph node fine-needle aspiration cytology (LN-FNAC) lacks universal acceptance for definitively diagnosing lymphomas. This is likely due to reports of lower diagnostic performance, inconsistent terminology use in cytopathology diagnostic reports, and only limited data on the clinical implications of LN-FNAC diagnoses. Recently, a uniform LN-FNAC cytopathological diagnostic reporting system was proposed (the Sydney System). This study evaluated LN-FNAC diagnostic performance and risks of malignancy associated with the proposed diagnostic categories. Methods LN-FNAC specimens obtained in 2018-2019, with and without concurrent core biopsy, to evaluate for suspected lymphoma were analyzed (n = 349). LN-FNAC diagnoses were compared with final diagnoses obtained via subsequent tissue biopsy and/or clinical assessment. Results The mean patient age was 57.6 years, and 41% were female. LN-FNAC was the initial diagnostic test in 223 (63.9%), and it was used to evaluate for recurrence in 126 (36.1%). LN-FNAC diagnosed 202 hematological malignancies (57.9%), 23 nonhematological malignancies (6.6%), and 124 reactive processes (35.5%). Subsequent tissue biopsy was performed in 42 (12%). The risks of malignancy per diagnostic category were as follows: inadequate, 58.3%; benign, 6.4%; atypical, 69.2%; suspicious, 96.7%; and malignant, 99.3%. LN-FNAC demonstrated up to 96.3% sensitivity, 91.91% specificity, and 87.35% accuracy. Optimal specimen quality and the use of intradepartmental consultation reduced diagnostic error rates in FNA cases without concurrent core biopsy (P = .029 and P = .0002 respectively). Conclusions LN-FNAC is accurate and reliable for the diagnosis of lymphoma. Inadequate LN-FNAC samples should be resampled due to a significant associated risk of lymphoma. The diagnostic performance of LN-FNAC may be improved with good specimen quality and reviews by multiple pathologists. Understanding the risks of malignancy associated with LN-FNAC diagnostic categories will help to guide optimal patient management.

Inherited metabolic disorders (IMDs) are a heterogeneous group of rare disorders characterized by disruption of metabolic pathways. To date, data on incidence and prevalence of IMDs are limited. Taking advantage of a functioning network within the Austrian metabolic group, our registry research aimed to update the data of the "Registry for Inherited Metabolic Disorders" started between 1985 and 1995 with retrospectively retrieved data on patients with IMDs according to the Society for the Study of Inborn Errors of Metabolism International Classification of Diseases 11 (SSIEM ICD11) catalogue. Included in this retrospective register were 2631 patients with an IMD according to the SSIEM ICD11 Classification, who were treated in Austria. Thus, a prevalence of 1.8/10 000 for 2020 and a median minimal birth prevalence of 16.9/100 000 (range 0.7/100 000-113/100 000) were calculated for the period 1921 to February 2021. We detected a male predominance (m:f = 1.2:1) and a mean age of currently alive patients of 17.6 years (range 5.16 months-100 years). Most common diagnoses were phenylketonuria (17.7%), classical galactosaemia (6.6%), and biotinidase deficiency (4.2%). The most common diagnosis categories were disorders of amino acid and peptide metabolism (819/2631; 31.1%), disorders of energy metabolism (396/2631; 15.1%), and lysosomal disorders (395/2631; 15.0%). In addition to its epidemiological relevance, the "Registry for Inherited Metabolic Disorders" is an important tool for enhancing an exchange between care providers. Moreover, by pooling expertise it prospectively improves patient treatment, similar to pediatric oncology protocols. A substantial requirement for ful filling this goal is to regularly update the registry and provide nationwide coverage with inclusion of all medical specialties.

Myositis-specific antibodies (MSA) and myositis-associated antibodies (MAA) are a feature of the idiopathic inflammatory myopathies (IIM), but are also seen in other rheumatic diseases, and in individuals with no clinical symptoms. The aim of this study was to assess the clinical utility of MSA and MAA and in particular the clinical relevance of weakly positive results. We included all patients at our institution who had at least one positive result on the Immunoblot EUROLINE myositis panel over a 6-year period (2015–2020). Associations with clinical features and final diagnosis were evaluated. Eighty-seven of 225 (39%) myositis panel tests met the inclusion criteria. There were 52 strong positives and 35 weak positives for one or more MSA/MAAs. Among the strong positive group, 15% (8/52) were diagnosed with IIM, 34.6% (18/52) with interstitial lung disease, 7.7% (4/52) with anti-synthetase syndrome, 25% (13/52) with connective tissue disease, and others accounted for 25% (13/52). In weak-positive cases, only 14% (5/35) had connective tissue disease and none had IIM. 60% (21/35) of weak-positive cases were not associated with a specific rheumatic disease. A significant number of positive myositis panel results, particularly weak positives, are not associated with IIM or CTD. Supplementary Information The online version contains supplementary material available at 10.1007/s00296-021-05012-0.

Although electrocardiography (ECG) is a fundamental skill for most physicians, trainees have poor diagnostic performance when interpreting ECGs. In this study, we examine a strategy to improve learning ECG interpretation: self-generation of diagnoses during online practice. We randomly assigned medical students and residents to one of 2 ECG interpretation training formats: multiple-choice (MCQ) or self-generation (SG) format, where participants free-text type their diagnosis aided by an autocomplete feature. The training phase consisted of 30 ECGs, after which participants completed an immediate post test and delayed post test (3-4 weeks later). Forty-eight participants completed the training module, 45 completed the immediate post test, and 27 completed the delayed post test. Participants assigned to the SG format scored higher on the immediate post test compared with those who practiced with the MCQ format, with a large effect size (78% vs 57%; d = 0.94; P = 0.02). There was a trend favouring SG on the delayed post test, with a moderate effect size (67% vs 56%; d = 0.65; P = 0.09). However, only 60% of participants completed the delayed post test, which hindered the detection of a statistically significant difference. The SG group made the correct primary diagnosis at a faster rate (32 vs 56 seconds; P0.001) but had a lower detection of secondary diagnoses (22 vs 42%; P = 0.007). Practicing ECG interpretation using self-generation of diagnoses improved immediate post test performance and fluency. Replication in other contexts and with other populations is required to confirm our findings and to further study retention.

OBJECTIVE Torcular dural sinus malformations (tDSMs) are rare pediatric cerebrovascular malformations characterized by giant venous lakes localized to the midline confluence of sinuses. Historical clinical outcomes of patients with these lesions were poor, though better prognoses have been reported in the more recent literature. Long-term outcomes in children with tDSMs are uncertain and require further characterization. The goal of this study was to review a cohort of tDSM patients with an emphasis on long-term outcomes and to describe the treatment strategy. METHODS This study is a single-center retrospective review of a prospectively maintained data bank including patients referred to and cared for at The Hospital for Sick Children for tDSM from January 1996 to March 2019. Each patient’s clinical, radiological, and demographic information, as well as their mother’s demographic information, was collected for review. RESULTS Ten patients with tDSM, with a mean follow-up of 58 months, were included in the study. Diagnoses were made antenatally in 8 patients, and among those cases, 4 families opted for either elective termination (n = 1) or no further care following delivery (n = 3). Of the 6 patients treated, 5 had a favorable long-term neurological outcome, and follow-up imaging demonstrated a decrease or stability in the size of the tDSM over time. Staged embolization was performed in 3 patients, and anticoagulation was utilized in 5 treated patients. CONCLUSIONS The authors add to a growing body of literature indicating that clinical outcomes in tDSM may not be as poor as initially perceived. Greater awareness of the lesion’s natural history and pathophysiology, advancing endovascular techniques, and individualized anticoagulation regimens may lead to continued improvement in outcomes.

PURPOSE: A reduction in cancer services during the COVID-19 pandemic has impacted cancer diagnosis. The purpose of this study is to quantitatively determine the impact on cancer diagnostic service in public facilities across Hong Kong. Quantifying the temporal changes in the number of cancer diagnosis before, during and after the outbreak, is useful to establish the scale of the problem and to assess if there has been an adequate level of response. METHODS AND MATERIALS: Retrospective cohort study using a territory-wide database in Hong Kong from 2017 to 2020 using consecutive specimens received for pathological diagnosis in public laboratories in 41 hospitals were retrieved. RESULTS: In 2020, a total of 455,453 pathological specimens were received, which amounted to a 15.5% reduction compared to prior 3-year average (p-value < 0.001). Analysis on confirmed malignant pathological diagnosis revealed a statistically significant reduction in colorectal (-10.0%, p-value < 0.001), prostate (-19.7%, p-value < 0.001), non-significant reduction for lung (-3.0%, p-value = 0.0526), and a marginal but non-significant increase for breast (0.7%, p-value = 0.7592) regions. Based on time series projection data, the estimated missed cancers for the 3 regions with reduced investigations were colorectal (10.0%), lung (3.0%) and prostate (19.7%). CONCLUSIONS: Variable impact on actual malignant pathological diagnoses based on 4 body regions was observed, with a statistically significant reduction in colorectal, lung and prostate regions, marginal but insignificant increase in breast regions. The findings could help public health policy future planning and intervention.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is a multilevel problematic disease. Major septal deviation (SD) can lead to severe nasal congestion, which, in turn, can lead to sleep apnea. Although SD seems to be related to OSA, very few studies have quantitatively examined this relationship. In this study, we investigate this using a 9-year large-scale cohort study. METHODS: The SD group was selected out of 1 million individuals randomly extracted by the National Health Insurance Service. The non-SD group was obtained through propensity score matching considering several variables. The primary end point was OSA diagnosis. RESULTS: The study (SD) group included 11,238 individuals and the non-SD group (control group) included 22,476 persons. The overall hazard ratio for OSA in the SD group was 4.39 (95% confidence interval [CI]: 3.56–5.42). In subgroup analysis, the hazard ratio for OSA of male individuals was 3.77 (95% CI: 2.83–5.03), high economic status was 1.27 (95% CI: 1.05–1.56), metropolitan area was 1.31 (95% CI: 1.07–1.62), young age was 0.79 (95% CI: 0.64–0.98), hypertension was 1.00 (95% CI: 0.37–2.7), and diabetes mellitus was 2.44 (95% CI: 1.15–5.21). In the SD group, the hazard ratio for OSA after septoplasty was 0.71 (95% CI: 0.54–0.94). CONCLUSIONS: From long-term follow-up, the prevalence of OSA was 4.39 times higher in the SD group compared with the control group. This phenomenon was more pronounced with increasing body mass index and decreased significantly after septoplasty. CITATION: Yeom SW, Chung SK, Lee EJ, et al. Association between septal deviation and OSA diagnoses: a nationwide 9-year follow-up cohort study. J Clin Sleep Med. 2021;17(10):2099–2106.

OBJECTIVES Diagnosis-related groups (DRGs) is a patient classification system used to characterize the types of patients that the hospital manages and to compare the resources needed during hospitalization. The DRG classification is based on International Classification of Diseases diagnoses, procedures, demographics, discharge status, and complications or comorbidities and compares hospital resources and outcomes used to determine how much Medicare pays the hospital for each "product/medical condition." The All-Patient Refined DRG (APR-DRG) incorporated severity of illness (SOI) and risk of mortality (ROM) into the DRG system to adjust for patient complexity to compare resource utilization, complication rates, and lengths of stay. METHODS This study included 18,478 adult patients admitted to a tertiary care center in Lubbock, Texas during a 1-year period. We recorded the APR-DRG SOI and ROM and some clinical information on these patients, including age, sex, admission shock index, admission glucose and lactate levels, diagnoses based on International Classification of Diseases, Tenth Revision discharge coding, length of stay, and mortality. We compared the levels of SOI and ROM across this clinical information. RESULTS As the levels of SOI and ROM increase (which indicates increased disease severity and risk of mortality), age, glucose levels, lactate levels, shock index, length of stay, and mortality increased significantly (P < 0.001). Multiple logistic regression analysis demonstrated that each unit increase in ROM and SOI level was significantly associated with an 11.45 and a 10.37 times increase in the odds of in-hospital mortality, respectively. The C-statistics for the corresponding models are 0.947 and 0.929, respectively. When both ROM and SOI were included in the model, the magnitudes of increase in odds of in-hospital mortality were 5.61 and 1.17 times for ROM and SOI, respectively. The C-statistic is 0.949. CONCLUSIONS This study indicates that the APR-DRG SOI and ROM scores provide a classification system that is associated with mortality and correlates with other clinical variables, such as the shock index and lactate levels, which are available on admission.

Objective To determine how often travel histories are obtained in pediatric patients. Methods A retrospective medical record review was performed at a single tertiary care children's hospital for patients aged 2 months to 18 years who were admitted October 2015-December 2017 with International Classification of Diseases, 10th Revision codes for potential travel-related illnesses. Demographic information and travel history documentation were obtained, along with travel-related testing. From May to June 2018, prospective, single-blinded, direct observation of a convenience sample of pediatric residents was performed during the initial patient encounter to determine the frequency and quality of travel histories obtained regardless of documentation. Results Of 249 charts reviewed, 27 (10.8%) patients had a travel history query documented. Patients with complex chronic conditions were significantly less likely to have a travel history documented (37% vs 67%; P = 0.005). Age, sex, length of stay, race, payer status, and critical care admission did not significantly differ between groups. Those with a travel history documented were more likely to have a documented exposure history (100% vs 52%; P Conclusions Travel histories are rarely asked for in pediatric patients. Missed diagnoses may not only affect the patient but also have broader public health implications. Simulation is an effective tool to improve history-taking skills, yet more work is still needed.

BACKGROUND. Lumbar spine MRI is associated with a high prevalence of interpretive errors by radiologists. Treating physicians can obtain symptom information, correlate symptoms with MRI findings, and distinguish presumptive pain generators from incidental abnormalities. OBJECTIVE. The purpose of this study was to capture symptom information using a patient questionnaire, review lumbar spine MRI examinations with and without symptom information, diagnose pain generators, and compare MRI diagnoses with clinical reference diagnoses. METHODS. In this prospective study, 120 participants (70 men and 50 women; median age, 64 years; interquartile range, 49.5-74 years) were recruited from patients referred for lumbar spine injections between February and June 2019. Participants completed electronic questionnaires regarding their symptoms before receiving the injections. For three research arms, six radiologists diagnosed pain generators in MRI studies reviewed with symptom information from questionnaires, MRI studies reviewed without symptom information, and MRI reports. Interreading agreement was analyzed. Blinded to the questionnaire results, the radiologists who performed injections obtained patient histories, correlated symptoms with MRI findings, and diagnosed presumptive pain generators. These diagnoses served as clinical reference standards. Pain generators were categorized by type, level, and side and were compared using kappa statistics. Diagnostic certainty was recorded using numeric values (0-100) and was compared using Wilcoxon rank-sum test RESULTS. When compared with the reference standard, agreement for the type, level, and side of pain generator was almost perfect in MRI examinations reviewed with symptom information (κ = 0.82-0.90), fair to moderate in MRI examinations reviewed without symptom information (κ = 0.28-0.51) (all p < .001), and fair to moderate in MRI reports (κ = 0.27-0.45) (all p < .001). Interreading agreement was almost perfect when MRI examinations were reviewed with symptom information (κ = 0.82-0.90) but was only moderate without symptom information (κ = 0.42-0.56) (all p < .001). Diagnostic certainty levels were highest for radiologists performing injections (mean [± SD], 90.0 ± 9.9) and were significantly higher for MRI review with symptom information versus without symptom information (means for reading 1, 84.6 ± 13.1 vs 62.9 ± 20.7; p < .001). CONCLUSION. In lumbar spine MRI, presumptive pain generators diagnosed using symptom information from electronic questionnaires showed almost perfect agreement with pain generators diagnosed using symptom information from direct patient interviews. CLINICAL IMPACT. Patient-reported symptom information from a brief questionnaire can be correlated with MRI findings to distinguish presumptive pain generators from incidental abnormalities.

Background The COVID‐19 pandemic delayed diagnosis and care for some acute conditions and reduced monitoring for some chronic conditions. It is unclear whether new diagnoses of chronic conditions such as dementia were also affected. We compared the pattern of incident Alzheimer's disease and related dementia (ADRD) diagnosis codes from 2017 to 2019 through 2020, the first pandemic year. Methods Retrospective cohort design, leveraging 2015–2020 data on all members 65 years and older with no prior ADRD diagnosis, enrolled in a large integrated healthcare system for at least 2 years. Incident ADRD was defined as the first ICD‐10 code at any encounter, including outpatient (face‐to‐face, video, or phone), hospital (emergency department, observation, or inpatient), or continuing care (home, skilled nursing facility, and long‐term care). We also examined incident ADRD codes and use of telehealth by age, sex, race/ethnicity, and spoken language. Results Compared to overall annual incidence rates for ADRD codes in 2017–2019, 2020 incidence was slightly lower (1.30% vs. 1.40%), partially compensating later in the year for reduced rates during the early months of the pandemic. No racial or ethnic group differences were identified. Telehealth ADRD codes increased fourfold, making up for a 39% drop from face‐to‐face outpatient encounters. Older age (85+) was associated with higher odds of receiving telecare versus face‐to‐face care in 2020 (OR:1.50, 95%CI: 1.25–1.80) and a slightly lower incidence of new codes; no racial/ethnic, sex, or language differences were identified in the mode of care. Conclusions Rates of incident ADRD codes dropped early in the first pandemic year but rose again to near pre‐pandemic rates for the year as a whole, as clinicians rapidly pivoted to telehealth. With refinement of protocols for remote dementia detection and diagnosis, health systems could improve access to equitable detection and diagnosis of ADRD going forward.

Objectives: To evaluate videofluoroscopic swallow study (VFSS) findings in infants with dysphagia and without prior diagnoses, and to characterize the outcomes and any diagnoses that follow. Methods: A chart review of all pediatric patients who received a VFSS at a tertiary children’s hospital from November 2008 to March 2017 was performed. Results: There were 106 infants (57 males and 49 females) with 108 VFSS. VFSS was normal in 18 (16.98%) infants. Regarding airway protection, 50 (47.17%) infants had laryngeal penetration, and 8 (7.55%) had tracheal aspiration; 3 (2.83%, 37.5% of all aspirators) exhibited silent aspiration. Of the 75 infants with minimum 2-year follow-up, 35 (46.67%) had no sequelae of disease and received no diagnoses. The most common diagnoses and pathologic sequelae were gastroesophageal reflux (n = 18, 24.00%), asthma (n = 8, 10.67%), laryngomalacia (n = 6, 8.00%), and tracheomalacia (n = 4, 5.33%), all consistent with United States pediatric data on prevalence. All infants (n = 51) with follow-up for dysphagia had resolution of symptoms within 9 months from VFSS order date. Conclusions: Otherwise healthy infants may show signs of dysphagia and not develop later illness. Parents can thus be counseled on the implications of dysphagia in a previously healthy infant. Our findings provide comparative statistics for future research in pediatric dysphagia.

To evaluate MRI performance on both initial and long-term rheumatologic diagnosis of spondyloarthritis (SpA), taking into account clinical evolution and treatment response, and the impact of gadolinium injection. In this single-center study, patients who underwent both spinal and sacroiliac (SI) joint MRI were prospectively recruited between May 2013 and January 2014 and followed for 7 years until 2020. Clinical, biological, and radiologic parameters were collected. At 7-year follow-up (2020), two independent readers reevaluated the initial MRI datasets for specific radiological features of SpA with a 5-point Likert scale to record the estimation of confidence. The centralized MRI interpretations were compared to the established rheumatologic diagnoses in 2013 and 2020. In total, 145 patients (52 men and 93 women) were included. During the 7-year follow-up, the number of patients with positive SpA diagnosis decreased from 93 to 58. Mean sensitivity, specificity, and accuracy of non-contrast MRI were 18, 97, and 49% and 27, 97, and 69% considering 2013 and 2020 rheumatologic diagnoses, respectively. Mean sensitivity, specificity, and accuracy values of gadolinium-enhanced MRI were 26, 97, and 54% and 38, 97, and 73% considering 2013 and 2020 diagnoses, respectively. Post-contrast MRI enabled identification of a subgroup of enthesis-only lesions, without any bone lesions, corresponding to 14% of the pathological cohort. It confirmed uncertain diagnoses in an additional 8.5% of pathological cases. MRI performance for SpA diagnosis is higher when long-term clinical follow-up is considered than when compared to initial diagnosis. Gadolinium injection increases MRI diagnostic performance and may demonstrate a pure enthesic form of the disease, without bone abnormality. • Compared to the rheumatologist’s diagnosis over long-term clinical follow-up, MRI performance for SpA is higher than usually estimated. • Gadolinium injection increases diagnostic performance of MRI as it may identify a purely enthesis form of the disease. • Gadolinium injection should be discussed in patients for whom the diagnostic suspicion is strong and whose initial non-injected examination is normal or doubtful.

Skin cancer remains the most commonly diagnosed cancer in the USA with more than 1 million new cases each year. Melanomas account for about 1% of all skin cancers and most skin cancer deaths. Multiethnic individuals whose skin is pigmented underestimate their risk for skin cancers and melanomas and may delay seeking a diagnosis. The use of artificial intelligence may help improve the diagnostic precision of dermatologists/physicians to identify malignant lesions. To validate our artificial intelligence's efficiency in distinguishing between images, we utilized 50 images obtained from our International Skin Imaging Collaboration dataset (n = 25) and pathologically confirmed lesions (n = 25). We compared the ability of our artificial intelligence to visually diagnose these 50 skin cancer lesions with a panel of three dermatologists. The artificial intelligence model better differentiated between melanoma vs. nonmelanoma with an area under the curve of 0.948. The three-panel member dermatologists correctly diagnosed a similar number of images (n = 35) as the artificial intelligence program (n = 34). Fleiss' kappa (ĸ) score for the raters and artificial intelligence indicated fair (0.247) agreement. However, the combined result of the dermatologists panel with the artificial intelligence assessments correctly identified 100% of the images from the test data set. Our artificial intelligence platform was able to utilize visual images to discriminate melanoma from nonmelanoma, using de-identified images. The combined results of the artificial intelligence with those of the dermatologists support the use of artificial intelligence as an efficient lesion assessment strategy to reduce time and expense in diagnoses to reduce delays in treatment.

Background The brainstem has the critical role of regulating cardiac and respiratory function and it also provides motor and sensory function to the face via the cranial nerves. Despite the observation of a brainstem lesion in a radiological examination, it is difficult to obtain tissues for a pathological diagnosis because of the location and small volume of the brainstem. Thus, we aimed to share our 6‐year experience with stereotactic biopsies from brainstem lesions and confirm the value and safety of stereotactic biopsy on this highly eloquent area in this study. Methods We retrospectively reviewed the medical records of 42 adult patients who underwent stereotactic biopsy on brainstem lesions from 2015 to 2020. The radiological findings, surgical records, pathological diagnosis, and postoperative complications of all patients were analyzed. Results Histopathological diagnoses were made in 40 (95.2%) patients. Astrocytic tumors were diagnosed in 29 (69.0%) patients, diffuse large B cell lymphoma in 5 (11.9%) patients, demyelinating disease in 4 (9.5%) patients, germinoma in 1 (2.4%) patient, and radiation necrosis in 1 (2.4%) patient. In the 40 patients with successful stereotactic biopsy, 10 (25.0%) patients had inconsistent preoperative radiological diagnosis and postoperative pathological diagnosis. In addition, there was a difference between the treatments prescribed by the radiological and pathological diagnoses in 8 out of 10 patients whose diagnoses changed after biopsy. There was no operative mortality among the 42 patients. Conclusions A pathological diagnosis can be made safely and efficiently in brainstem lesions using stereotactic biopsy. This pathological diagnosis will enable patients to receive appropriate treatment., Three approaches to stereotactic biopsy for brainstem and a Venn diagram showing the location of 42 brainstem lesion that performed stereotactic biopsy.

Contains fulltext : 244841.pdf (Publisher’s version ) (Open Access) INTRODUCTION/AIMS: As life expectancy improves for patients with Duchenne muscular dystrophy (DMD), new symptoms are likely to arise. This aims of this study are: (1) to explore the prevalence of a broad variety of symptoms in the various stages of DMD (with and without steroid use); (2) to explore the prevalence of common secondary diagnoses; and (3) to evaluate the social participation level of patients with DMD older than 16 y of age; and to explore correlations between social participation and symptoms. METHODS: A cross-sectional self-report questionnaire, including questions on functional level and health status, as well as a standardized participation scale was distributed among Dutch patients with DMD. RESULTS: Eighty-four male patients with a mean age of 22.0 (SD = 10.0) y were enrolled. The most prevalent and limiting symptoms were difficulty coughing (58%), coldness of hands (57%), contractures (51%), stiffness (49%), fatigue (40%), myalgia (38%), and low speech volume (33%). Prevalent secondary diagnoses included cardiac disease (14%), neurobehavioral diagnosis (13%), low blood pressure (13%), and arthrosis (5%). Social participation correlated negatively with coldness of hands (r = - .29; P

Purpose To assess the percentage of computed tomography pulmonary angiography (CTPA) procedures that could have been avoided by methodical application of the Revised Geneva Score (RGS) coupled with age-adjusted D-dimer cut-offs rather than only clinical judgment in Emergency Department patients with suspected pulmonary embolism (PE). Material and methods Between November 2019 and May 2020, 437 patients with suspected PE based on symptoms and D-dimer test were included in this study. All patients underwent to CTPA. For each patient, we retrospectively calculated the age-adjusted D-dimer cut-offs and the RGS in the original version. Finally, CT images were retrospectively reviewed, and the presence of PE was recorded. Results In total, 43 (9.84%) CTPA could have been avoided by use of RGS coupled with age-adjusted D-dimer cut-offs. Prevalence of PE was 14.87%. From the analysis of 43 inappropriate CTPA, 24 (55.81%) of patients did not show any thoracic signs, two (4.65%) of patients had PE, and the remaining patients had alternative thoracic findings. Conclusion The study showed good prevalence of PE diagnoses in our department using only physician assessment, although 9.84% CTPA could have been avoided by methodical application of RGS coupled with age-adjusted D-dimer cut-offs.

Background: Evidence-based recommendations on the optimal evaluation approach for dementia diagnostics are limited. This impedes a harmonized workup across clinics and nations. Objective: To evaluate the diagnostic performance of a multidisciplinary consensus conference compared to a single clinician approach. Methods: In this prospective study, we enrolled 457 patients with suspected cognitive decline, from two European memory clinics. A diagnostic evaluation was performed at baseline independently in two ways: 1) by a single clinician and 2) at a multidisciplinary consensus conference. A syndrome diagnosis and an etiological diagnosis was made. The confidence in the diagnosis was recorded using a visual analogue scale. An expert panel re-evaluation diagnosis served as reference for the baseline syndrome diagnosis and a 12-24-month follow-up diagnosis for the etiological diagnosis. Results: 439 patients completed the study. We observed 12.5%discrepancy (k = 0.81) comparing the baseline syndrome diagnoses of the single clinician to the consensus conference, and 22.3%discrepancy (k = 0.68) for the baseline etiological diagnosis. The accuracy of the baseline etiological diagnosis was significantly higher at the consensus conference and was driven mainly by increased accuracy in the MCI group. Confidence in the etiological diagnosis at baseline was significantly higher at the consensus conference (p