Abnormal Physical Exam Findings Research Articles

SAT544 Abnormal Labs Reveal Metastatic Papillary Thyroid Cancer

Abstract Disclosure: M. Shahid: None. S. Bellamy: None. A. Ottley: None. M. Griffith: None. Objective:Abnormal thyroid function studies are commonly referred to Endocrinology for further evaluation. In most cases, once studies are repeated and normal no further work up is considered. It is uncommon to order a thyroid ultrasound if the patient is asymptomatic with repeat normal labs and physical exam. Clinical Case:43 yo female with no significant medical history who presented to Endocrine clinic for evaluation of abnormal thyroid function labs. She denied taking any medications. Review of systems was positive only for a five pound weight gain over three months. Her physical exam was unremarkable. Labs were significant for TSH level of 0.25 uIU/mL (normal range 0.45 - 5.33 uIU/mL), free T4 of 0.57 ng/dL (normal range 0.61 - 1.12 ng/dL). At the initial visit, thyroid function tests, thyroid antibodies, and thyroid ultrasound were ordered. Results included a normal serum TSH , Free T4 and Thyroid Stimulating Immunoglobulin. Thyroid Peroxidase Antibody resulted as detectable at 124 IU/mL (normal value <9 IU/mL). Thyroid ultrasound showed nodules bilaterally; some subcentimeter in size with two meeting criteria for FNA; one in the right mid pole measuring up to 1.8 cm with suspicious features of hypoechogenicity and a feeding blood vessel, and another isoechoic left mid pole nodule measuring up to 1.8 cm. Per pathology, the right mid pole nodule was considered Betheseda Category V, suspicious for Hurtle cell neoplasm or Hashimoto’s thyroiditis, with the possibility of medullary or papillary thyroid carcinoma. The left mid pole nodule was considered Bethesda Category II. Following surgical consultation, the patient underwent total thyroidectomy with right cervical neck dissection. Pathology revealed pT3N1Mx Metastatic Papillary Thyroid Cancer (conventional type) involving the skeletal muscle and one out of six right cervical neck lymph nodes. The resection margins were negative for carcinoma. Post operatively the patient received radioactive iodine treatment and Levothyroxine was initiated. DISCUSSION:In Endocrine practice, the use of thyroid ultrasonography is common. However, the clinician is usually prompted to order an ultrasound due to consistent abnormal thyroid studies revealing thyrotoxicosis and/or abnormal physical exam findings such as nodular goiter. Or in the case of known diagnoses such as thyroid cancer, it is useful for pre and post surgical management. Nonetheless, in some cases, when ordered outside of common practice, unexpected pathology may be discovered. CONCLUSION:This case demonstrated an unexpected finding of metastatic papillary thyroid cancer , despite initial presentation of abnormal thyroid function tests with normal repeat result and physical exam. Thyroid ultrasound was useful in revealing the diagnosis, preventing a delay in treatment. Presentation Date: Saturday, June 17, 2023

A Retrospective Analysis of the Clinical Use and Utility of Advanced Imaging in the Evaluation of Near-Hanging and Strangulation Injuries at a Canadian Level One Trauma Centre

IntroductionComputed tomography (CT) of the neck is highly sensitive and may effectively rule-out cervical spine, cerebrovascular, and aerodigestive injuries after blunt and penetrating trauma. However, CT may be overutilized in the evaluation of hanging or strangulation injuries. The objective of this study was to determine the diagnostic yield of CT imaging among patients evaluated for hanging or strangulation mechanisms at a Canadian level-1 trauma center. MethodsAll adult patients evaluated for hanging or strangulation injuries over an eight-year period were reviewed. The primary outcome was the diagnostic yield of CT imaging for major aerodigestive, cervical spine, cerebrovascular, or neurological injuries. Multiple logistic regression were performed to determine predictive factors for the use of CT imaging and the identification of injury on imaging. ResultsAmong 124 patients evaluated for hanging or strangulation injuries during the study period, 101 (80%) were evaluated with CT of the head or neck. A total of 26 injuries were identified in 21 patients (18 anoxic brain injuries, 4 aerodigestive, 3 cerebrovascular, and 1 of cervical spine injury). The overall diagnostic yield of neck CT for cervical injuries was 7.8%, 4.7% for laryngeal-tracheal injuries, 3.5% for carotid and vertebral artery injuries, and 1.1% for cervical spine injury. The diagnostic yield of CT head for anoxic brain injury was 22.8%. Factors predicting the use of CT imaging were abnormal physical exam findings (RR 1.7 95% CI [1.2, 2.3]) and transfer accepted by the trauma team leader (RR 1.3 95% CI [1.1, 1.5]). ConclusionCT imaging is often used in the evaluation of patients presenting with hanging or strangulation mechanisms. Seven cerebrovascular, aerodigestive, or cervical spine injuries were identified on imaging during the study period, representing a diagnostic yield of 7%. No injuries were identified among patient with a normal GCS or physical exam. Factors predicting the use of CT imaging included transfer accepted by the trauma team leader and abnormal physical exam findings. The variable clinical presentation of near-hanging and strangulation injuries and the relatively low diagnostic yield of CT imaging should prompt the development of tools and institutional protocols to guide the evaluation of hanging and strangulation injuries.

Flea-borne typhus with rare neurological manifestations–Case report

We report an inpatient case of flea-borne typhus (FBT) and normal pressure hydrocephalus in a 75-year-old male patient with a prior diagnosis of mixed Alzheimer and vascular dementia, who presented with acute onset of altered mental status, behavioral changes, Parkinsonism symptoms, and abnormal physical exam findings. Throughout his 11 day hospitalization, the patient demonstrated mixed hyperactive/hypoactive delirium in addition to his baseline dementia, resulting in a complex and unique presentation of FBT in a geriatric patient. The patient was treated with doxycycline, and his physical and cognitive symptoms improved over the course of his hospitalization.

The utility of physical examination in ovarian cancer recurrence detection: a retrospective analysis informing virtual surveillance care

ObjectivesGiven the recent rapid increase in telemedicine in the setting of the COVID-19 pandemic, we sought to investigate the utility of symptom review, CA125, and physical examination in the detection...

Factors Affecting Hematologic and Serum Biochemical Parameters in Healthy Common Marmosets (Callithrix jacchus).

Physiologic changes during development, aging, and pregnancy may affect clinical parameters. Previously available reference values have been based on samples that may include wild and captive marmosets, with little representation of geriatric or pregnant animals. Establishing reference values under various conditions would support better recognition of pathologic conditions in marmosets. One hundred and forty-seven (70 males and 77 females) healthy marmosets from a research colony were included in this study. Exclusion criteria were abnormal physical exam findings at the time of blood sampling, chronic medications, or clinical or pathologic evidence of disease. Reference intervals were calculated for serum chemistry and hematology. Using metadata, samples were classified based on age, sex, colony source and pregnancy status. Multiple tests indicated significant differences with varying effect sizes, indicating that developing reference intervals based on metadata can be useful. Across all the comparisons, medium or large effect sizes were observed most frequently in blood urea nitrogen (BUN), calcium, total protein, alkaline phosphatase (ALP), weight and serum albumin. We report normative clinical pathologic data for captive common marmosets through all life stages and reproductive status. Significant differences were observed in most parameters when stratifying data based on age, sex, colony source, or pregnancy, suggesting that developing reference intervals considering this information is important for clinicians.

Association of coccygodynia with pelvic floor symptoms in women with pelvic pain.

Coccygodynia is a painful condition of the tailbone that occurs more commonly in females. The association of coccyx pain with pelvic floor symptoms and the prevalence of coccyx pain in women with pelvic pain has not previously been reported. To identify the prevalence of coccygodynia in women with pelvic pain and to describe the association of coccygodynia with pelvic floor examination findings and symptoms. Retrospective cohort analysis. Tertiary medical institution. One hundred twenty-seven women presenting for outpatient pelvic floor physical therapy treatment who underwent vaginal and rectal pelvic floor examination. Prevalence of coccygodynia, pain scores, association of coccygodynia with other comorbidities and diagnoses, and association of coccygodynia with physical examination findings. Sixty-three (49.6%) of 127 women with pelvic pain presented with coccygodynia and 64 (50.4%) did not. Women with coccygodynia had significantly higher rates of muscle spasm (50.8% vs. 31.2%, p=.025) higher visual analog scale pain scores (median 5 vs. 3, p=.014), higher rates of outlet dysfunction constipation (31.7% vs. 10.0%, p=.032), and higher rates of fibromyalgia (15.9% vs. 3.1%, p=.014). On pelvic examination, women with coccygodynia were significantly more likely to have sacrococcygeal joint hypomobility (65.1% vs. 14.1%, p < .001), coccygeus muscle spasm (77.8% vs. 17.2%, p < .001), anococcygeal ligament pain (63.5% vs. 9.4%, p < .001), external anal sphincter pain/spasm (33.3% vs. 13.1%, p < .001), and impaired pelvic floor muscle coordination (77.8% vs. 57.8%, p=.016). Almost 50% of women seeking pelvic floor physical therapy for pelvic pain had coexisting coccygodynia. These women had higher pain scores, increased pelvic floor dysfunction, and significantly greater abnormal physical exam findings. This study demonstrates a strong link between coccygodynia, pelvic floor symptoms, and pelvic pain and highlights the importance of screening for and identifying coccyx pain when evaluating women with pelvic pain.

Prospective Study of Holter Monitoring in Pediatric Patients at Sohag University Hospital

Background: To estimate the various indications, values and misuses of Holter monitoring in the diagnosis and management of pediatric patients. Methods: The study was a prospective observational study, carried out at Pediatric Arrhythmia Clinic and at PICU of Sohag University Hospital over two years from 09/2017 to 09/2019. It encountered 80 pediatric patients (34 females), their age ranged from 29 days to 15 years with mean age of 6.18 years. All patients were subjected to echocardiography, 12 leads ECG and holter monitoring for 24 hours. Minimum, mean, maximum heart rate, rhythms and corrected QT were evaluated. Indications of Holter examination, its abnormalities were analyzed, also its positive diagnosis and management were defined. Results: Palpitations and syncopy were the main indications for holter examination 22 (27.50%) patients for each, abnormal examination in 17 (21.25%), chest pain in 13 patients (16.25%) and cardiomyopathy (7.5%) (one with Hypertrophic Cardiomyopathy and five with Dilated Cardiomyopathy). There were 50 (62.50%) patients had abnormalities in Holter recordings. The highest contribution to diagnosis was in cardiomyopathy (83.3%) where the most common abnormalities were ventricular tachycardia (50%) and ventricular premature beats in (33.3%). An abnormal ECG was significantly associated with a higher diagnostic yield (p = 0.0001). Conclusion: The most important indications for Holter monitoring include palpitations, syncope, abnormal physical exam findings, chest pain, and cardiomyopathy. Holter monitoring is an extremely important tool in the assessment of patients with dilated cardiomyopathy. HM detects serious arrhythmias to identify patients who are at increased risk for subsequent morbid events. The abnormal ECG findings were associated with having an abnormal Holter, therefore Holter monitoring can be used to help select which patients should get this screening tool especially in low budget programs countries.

Surveillance and outcomes after curative resection for gastroesophageal adenocarcinoma (GEAC).

e15579 Background: Although commonly performed, evidence supporting routine surveillance testing (SvT) in patients (pts) with resected GEAC is lacking. We evaluated patterns of relapse, frequency of salvage therapy and outcomes among pts with resected GEAC who underwent surveillance. Methods: Between 2011 and 2016, 210 consecutive pts with GEAC followed at Princess Margaret Cancer Center after resection were reviewed. SvT was any investigation performed in the absence of pt-reported symptoms, abnormal physical exam findings, or bloodwork. Relapse patterns were classified as locoregional (LRR; surgical anastomosis/gastroesophageal lumen/regional nodes) or distant (DR; beyond locoregional). Time-to-relapse (TTR) and overall survival (OS) were calculated from initial diagnosis, post recurrence survival (PRS) from initial relapse. Results: Median age was 64.1 years. Esophageal (14%), gastroesophageal junction (40%), and gastric adenocarcinomas (45%) were treated with surgery alone (29%), surgery plus perioperative chemotherapy (26%) or surgery plus chemoradiation (45%). SvT included imaging (71%), endoscopy (19%), tumor markers (6%), and clinical visits alone (9%). After median follow-up of 38.3 months (mo) (range 5.6-122.3), 3- and 5-year OS rates were 68% (95% confidence interval (CI) 62-75%) and 56% (95% CI 49-64%) respectively. Among 97 relapses (46%), 51 were detected by SvT, 45 by symptoms. Relapse patterns included LRR alone (4%), DR alone (86%) and both (10%). The majority of relapses (93%) occurred within 3 years. Pts with SvT-detected relapse had similar median TTR (16.2 vs 13.3 mo, p = 0.40) but longer PRS (16.5 vs 4.6 mo, p &lt; 0.001) and OS (36.2 vs 23.7 mo, p = 0.004) than pts with symptomatic relapse. Salvage therapy in 4 pts (2%) resulted in post recurrence disease-free survival ≥2 years. Duration of palliative chemotherapy was similar between 28 pts with SvT-detected relapse and 18 pts with symptomatic relapses (3.9 vs 3.3 mo, p = 0.64). Conclusions: Following curative resection, 96% of relapses were distant. Routine SvT rarely enabled successful salvage therapy and did not extend duration of palliative chemotherapy. Longer OS in SvT-detected relapses was not due to earlier disease detection. These findings do not support routine SvT in pts with resected GEAC.

Cylindrical Battery Ingestion: Emergent Endoscopic Retrieval or Patient Observation? A Case Report and Literature Review

Battery ingestion, particularly in the pediatric population, has become more common since the development of button-shaped batteries. Consequently, formal recommendations regarding management of this battery type have been developed. However, larger, cylindrical battery (CB) ingestion is less common, with fewer cases reported. As such, there are no clear guidelines regarding its management. We present a case of an adult prison inmate who ingested two AA batteries in a suicide attempt. One battery was retrieved endoscopically (Figure 1) & the other with a laxative & supportive care (Figure 2). In our review, we found that most reported patients who had ingested CB remained asymptotic & if present, symptoms usually manifested as upper GI complaints or abd pain. However, there have been unusual presentations such as ST-segment abnormalities on ECG & a grand-mal seizure reported. Other than in one patient, all patients with history of prior abd surgery required either surgical or endoscopic intervention for battery retrieval. Otherwise, several cases demonstrated spontaneous passage of the ingested CB by rectum as demonstrated by the largest case series by Hindley et al. On the other hand, we found that in all cases (except for one) where there was evidence of corrosive changes, leakage or damage to the battery casing, patients were symptomatic or had evidence of mucosal damage. It would appear, both from our experience & reviewed literature, that CB swallowing not accompanied by abd symptoms or history of encasement defect before ingestion can be managed conservatively and with the aid of radiologic imaging. In accordance with current guidelines, we propose that if there is no history or evidence of encasement defect, absence of symptoms or abnormal physical exam findings, & as long as the batteries are confirmed to be beyond the esophagus, then CB ingestion should be managed conservatively. Non-urgent EGD may be considered if the batteries remain within reach of an endoscope. Clinical monitoring & following battery progression through the GI tract with serial abdominal radiographs until batteries are discharged by rectum should be achieved. However, it should be emphasized that in the presence of prior abdominal surgery, history or evidence of damage to the battery, or any clinical symptoms should prompt urgent endoscopy & battery retrieval or surgical consultation if the batteries are beyond endoscopic reach.Figure: Endoscopic image in retro flexion revealing one ingested battery in the gastric fundus.Figure: Anterior posterior supine views of the abdomen demonstrating the single ingested cylindrical structure advancing through the GI tract C. Within the RLQ and either in the distal ileum or proximal colon D. Within the region of the ascending colon E. Within the region of the ascending colon F. Within the left mid abdomen and in the region of the descending colon G. Within the region of the sigmoid colon H. Projects over the pelvis in the region of the rectum (Hospitalization day 2,3,4,5, 6, & 7)Table: No Caption available

An Atypical Association of Hepatitis C Infection With Extra Nodal Marginal Zone Lymphoma

Marginal Zone lymphomas (MZLs),uncommon form of B cell Non Hodgkin lymphomas, are classified into 3 groups based on the tissue involved: Extra Nodal MZL or Mucosa associated Lymphatic tissue lymphoma (MALT lymphoma),Splenic MZL & Nodal MZL. We present a rare case of extra nodal MZL of the ocular adnexa due to hepatitis C Infection. The paucity of evidence of this association makes our case unique, offering a different therapeutic outcome with treatment of hepatitis C infection in conjunction with traditional chemotherapy. A 68 year old male presented with 3 week history of right eye pain, swelling, blurry vision and diplopia. He was an active cocaine user and drank alcohol socially. He had unintentional weight loss of 20 pounds in 2 months. He had no blood transfusions prior to 1980 and no tattoos. Abnormal physical exam findings included proptosis of the right eye, bilateral eye lid swelling, non-tender axillary and inguinal lymphadenopathy. He tested positive for hepatitis C infection with an elevated viral load, PCR with active virus, 1a genotype, F1-2 fibrosis. Hepatitis B core IgG antibody testing was positive with a negative surface antigen/antibody and HBV DNA.CT head/orbits showed enlargement of the right superior rectus muscle with resultant proptosis of the right globe. CT chest/abdomen/pelvis revealed mediastinal and axillary lymphadenopathy. Subsequent excision biopsy of the right axillary lymph node established the diagnosis of MZL, supported by bone marrow biopsy and tandem flow cytometry .His symptoms improved with a 5 day course of Prednisone 80 mg daily. He was discharged with a plan to follow up with oncology and gastroenterology for initiation of chemotherapy and treatment of hepatitis C infection. MALT Lymphoma develops in sites that are normally without any lymphoid tissues such as the GI tract, salivary glands and eyes due to long standing antigen stimulation either in the form of an autoimmune disease(Salivary gland lymphoma & Sjogren's syndrome) or a chronic infectious process (MALT lymphoma & H.pylori). Growing evidence supports the association of hepatitis C virus with B cell NHL such as diffuse large B cell lymphoma, small lymphocytic lymphoma, splenic and nodal MZLs. Extra nodal MZLs such as orbital MZL are not associated with hepatitis C. Hepatitis C virus was the potential cause of the patient's orbital MZL and it needs to be further validated in future research as it has significant therapeutic implications.Figure: Proptosis of the right eye and bilateral eye lid swelling.Figure: CT head/orbits with mass like enlargement of the right superior rectus muscle with resultant proptosis of the right globe.Figure: Excision biopsy of the right axillary lymph node showing histopathology features consistent with diagnosis of marginal zone lymphoma.

68 An Urban Fire Department's Experience With Left Ventricular Assist Devices

There has been little literature published describing the nature of out-of-hospital care of patients with implanted left ventricular assist devices (LVADs). Patients sent home from the hospital with these devices pose a unique challenge to the out-of-hospital medical provider. By describing the reasons for their presentations and interventions provided, we hope to contribute to a more understanding of complications of LVADs and which treatments are most appropriate out-of-hospital. This is a retrospective chart review of a level 1 academic center’s LVAD patients transported by the city fire agency to the academic center’s emergency department (ED) from January 2012 to December 2015. We sought to describe the frequency, 911 chief complaint, and interventions provided by the city fire agency. Medical records were queried for LVAD patients presenting to the ED during the study period. We extracted patient demographics (date of birth, sex, race, gender) and the list was then queried against the fire agency’s database to collect the out-of-hospital visits. Chief complaint, vital signs, abnormal physical exam findings, and interventions provided were obtained from the out-of-hospital database. During the study period, 95 LVAD patients presented to the academic university ED. Of these visits, ten were brought in by the fire agency. Of the ten patients, the most common chief complaint was weakness (5/10) followed by chest pain (2/10). In the patients with weakness, one patient had a battery change, another had a stroke scale performed, and all five had their glucose measured. Only 3/5 patients with weakness were documented to have a known LVAD in place. Of note, there was one patient, whom the out-of-hospital providers were unaware of the LVAD, who had shortness of breath and was found to be diaphoretic, had diminished lung sounds, and chest pain. This patient was given continuous positive airway pressure, nitroglycerin and aspirin per chest pain protocol. Another patient, with a known LVAD, received Lidocaine for a pacemaker firing issue. The crew was aware of the LVAD in 6/10 patients and the coordinator was contacted with all 6 patients. Most LVAD patients presenting to the emergency department do not present by ambulance. Of patients that do interact with out-of-hospital providers, the most common presenting symptom is weakness followed by chest pain. Given the LVAD requires coordination and consideration, a focus on how to improve out-of-hospital awareness of LVADs is key. Further research in this area is needed.

Endometrial cancer surveillance adherence reduces utilization and subsequent costs

ObjectivesIn June 2011, the SGO recommended that physical exam and symptoms be the primary surveillance methods in patients with endometrial cancer. We sought to evaluate adherence to these guidelines by comparing the use of CT scans, paps and serum CA125 ordered for endometrial cancer surveillance before and after publication of these guidelines. MethodsA retrospective review was performed for all patients undergoing surveillance for endometrial cancer at a single institution between June 2009 and June 2013. We assessed the number of patients without symptoms or abnormal physical exam findings who underwent surveillance CT scans, paps and/or CA125 during the 2years pre- and 2years post-SGO guidelines. Results92 patients (n=48 pre-6/2011, n=44 post-6/2011) were identified. Mean patient age was 58years. No significant difference in age, ethnicity, body mass index, or disease grade or stage was noted. There was a significant decline in surveillance CT scans (n=13, 27% vs. n=4, 9%, p=0.03), CA125 (n=14, 29% vs. 5, 11%, p=0.035) and paps (n=34, 71% vs. n=8 vs. 18%, p<0.001). There was no significant difference in disease status at the last follow-up. Institutional cost of surveillance also declined ($14,102.46 2years pre-guidelines, $3,054.99 2years post-guidelines). ConclusionsIn a single urban academic public hospital, after only 2years, clinical adherence to the 2011 SGO endometrial cancer surveillance guidelines resulted in a significant decline in the use of CT scans, CA125 and paps. This reduction does not appear to affect patient outcomes and led to an appreciable decrease in surveillance costs.

Are we missing the mark? Fever, respiratory symptoms, chest radiographs, and acute chest syndrome in sickle cell disease

Are we missing the mark? Fever, respiratory symptoms, chest radiographs, and acute chest syndrome in sickle cell disease

Abstract 15309: Resource Reduction by Use of Pediatric Chest Pain Standardized Clinical Assessment and Management Plan

Using a Standardized Clinical Assessment and Management Plan (SCAMP) for pediatric patients presenting to clinic with chest pain, we evaluated the cost impact associated with implementation of the care algorithm. Previously, we analyzed charges for 406 patients (7-21 yrs) with chest pain seen in 2009, prior to introduction of the SCAMP, and predicted 21% reduction of overall charges had the SCAMP methodology been used. The SCAMP recommended an echocardiogram for history, exam, or ECG findings suggestive of a cardiac etiology for chest pain. Resource utilization for 1520 patients evaluated by the SCAMP from 12/11-4/14 was reviewed in this study. Compared to the 2009 cohort, patients evaluated in the SCAMP presented with similar rates of exertional chest pain (33%, SCAMP vs. 37%, 2009) and significant past medical history (1% vs. 1%). The SCAMP cohort had fewer abnormal physical exam findings (1% vs. 4%) and ECG abnormalities (3% vs. 6%), and more pertinent family history (4% vs. 1%). Echocardiograms were additionally recommended by the SCAMP for exertional syncope (1%), pain worse by supine position, or radiation to the back, jaw, or left arm (5%). Ancillary testing for concurrent symptoms was reduced compared to the 2009 cohort (Figure 1) and compared to predicted: Holter (4% vs. 6%), event monitors (3% vs. 8%), MRI (&lt;1% vs. 1%). Stress testing was not recommended though 4% underwent evaluation. Adherence to SCAMP guidelines for recommended testing approached 80%; slightly fewer echocardiograms were actually performed than recommended. Total testing charges were reduced by an estimated 30% ($740,000) despite a small increase in echocardiogram utilization, and overall charges were reduced by 17% by use of the Chest Pain SCAMP. Given the low incidence of cardiac disease historically as well as detected by the SCAMP algorithm (&lt;1%), further modifications to the algorithm should refine indications for echocardiography, particularly related to exertional symptoms.

Are We Missing the Mark? Respiratory Symptoms, Cxr’s and Acute Chest Syndrome (ACS) in Sickle Cell Disease (SCD)

Background: Acute chest syndrome (ACS) is a common complication of SCD detected by chest radiography (CXR) with significant morbidity and mortality. Previous studies show that clinical assessment alone grossly underestimates the presence of ACS. We evaluate whether abnormal respiratory signs and symptoms are predictive of ACS.Methods: Data was obtained by electronic medical record using ICD-9 codes linked to fever and SCD in the year 2013 in children 2 months to 18 years at two Children’s Healthcare of Atlanta campuses (Egleston and Scottish Rite). Information on demographics, vital signs, respiratory symptoms on review of systems (ROS), physical exam (PE) findings and ACS diagnosis were obtained by direct chart review.Results: 610 visits of 356 patients with SCD/fever were included. 95 patients were excluded prior to analysis due to lack of measured fever, inaccurate sickle cell diagnosis, age, or CXR already completed by another institution. Mean age was 5.7±5 years & 178 (50%) were female. 67% had Hb-SS, 23% had Hb-SC, & 10% had other genotype. 379 CXR’s (62%) were ordered, of which 66 (17%) were positive (Table 1). Of the patients who were admitted for ACS (n=64), the average length of stay was 4.4±3 days, 15 (23%) required oxygen, 3 required BIPAP (5 %) and 8 (12%) required transfusions. None required ICU level care. Five patients who were admitted with negative CXRs from the ED developed ACS on the ward (5%). One discharged patient was called back for a radiology diagnosis of ACS not noted by the ED physician. 63 (16%) additional patients discharged from the ED returned within 72 hours. 33/63 (52%) received CXRs on repeat visit and 7/63 (11%) had developed ACS. 6 of these patients had a negative CXR at their initial ED encounter. One patient who was discharged without a CXR returned within 24 hours with ACS. History of ACS (odds ratio=2.5, 95% CI: 1.4-4.4, p<0.01), tachypnea (OR=2.0, 95% CI: 1.1-3.4, p=0.03), and abnormal physical exam findings (OR=2.8, 95% CI: 1.5-5, p<0.01) were all associated with positive CXR finding and ACS.Conclusions: CXRs were ordered in only 62% of encounters of febrile children with SCD. The prevalence of ACS among patients evaluated by CXR at the initial ED encounter was 17%. Patients with a past history of ACS were more likely to receive CXR’s & more likely to have ACS. Tachypneic patients were not more likely to receive CXR’s, but were more likely to have ACS. Respiratory signs/symptoms & abnormal lung PE findings made physicians more likely to order CXR’s, & also were predictive of ACS. Tachypnea & history of ACS are high risk factors for ACS in febrile children with SCD, in addition to abnormal ROS and PE. However, 62% of children with ACS had a normal lung exam. Clinical assessment alone is a poor predictor for ACS. Abstract 1378. TableNo CXRN=231 visitsCXR OrderedN=379 visitspPositive CXRN= 66Negative CXRN= 313pAge (years; mean±SD)5.2±4.56.0±4.70.065.7±3.76.0±4.80.60Fever (Tm Celcius±SD)39.1±0.539.3 ±3.30.3639.2±0.639.3±3.60.86Tachypnea (n, %) (age adjusted)71 (31%)119 (31%)0.8629 (44%)90 (29%)0.02H/O ACS (n, %)87 (38%)191 (50%)<0.0146 (70%)145 (46%)<0.01H/O Asthma (n, %)57 (25%)124 (33%)0.0326 (39%)98 (31%)0.20Abnormal ROS (n, %)86 (59%)301 (79%)<0.0161 (92%)240 (77)<0.01Abnormal Lung PE (n, %)7 (3%)84 (22%)<0.0125 (38%)59 (19%)<0.01Admissions (n, %)53 (23%)161 (43%)<0.0162 (94%)99 (32%)<0.01Length of Stay (days±SD)3.2±1.14.0±2.50.034.2±2.43.9±2.90.59Oxygen Use0 (0%)35 (9%)0.0415 (23%)20 (6%)<0.01BIPAP Use0 (0%)7 (2%)0.043 (5%)4 (1%)0.07Transfusion9 (4%)29 (8%)0.068 (12%)21 (7%)0.13 DisclosuresNo relevant conflicts of interest to declare.

Calcific myonecrosis as a late complication of an open fracture

In June 2011, the SGO recommended that physical exam and symptoms be the primary surveillance methods in patients with endometrial cancer. We sought to evaluate adherence to these guidelines by comparing the use of CT scans, paps and serum CA125 ordered for endometrial cancer surveillance before and after publication of these guidelines.A retrospective review was performed for all patients undergoing surveillance for endometrial cancer at a single institution between June 2009 and June 2013. We assessed the number of patients without symptoms or abnormal physical exam findings who underwent surveillance CT scans, paps and/or CA125 during the 2 years pre- and 2 years post-SGO guidelines.92 patients (n = 48 pre-6/2011, n = 44 post-6/2011) were identified. Mean patient age was 58 years. No significant difference in age, ethnicity, body mass index, or disease grade or stage was noted. There was a significant decline in surveillance CT scans (n = 13, 27% vs. n = 4, 9%, p = 0.03), CA125 (n = 14, 29% vs. 5, 11%, p = 0.035) and paps (n = 34, 71% vs. n = 8 vs. 18%, p < 0.001). There was no significant difference in disease status at the last follow-up. Institutional cost of surveillance also declined ($14,102.46 2 years pre-guidelines, $3,054.99 2 years post-guidelines).In a single urban academic public hospital, after only 2 years, clinical adherence to the 2011 SGO endometrial cancer surveillance guidelines resulted in a significant decline in the use of CT scans, CA125 and paps. This reduction does not appear to affect patient outcomes and led to an appreciable decrease in surveillance costs.

A Phase I Study of Low-Pressure Hyperbaric Oxygen Therapy for Blast-Induced Post-Concussion Syndrome and Post-Traumatic Stress Disorder

This is a preliminary report on the safety and efficacy of 1.5 ATA hyperbaric oxygen therapy (HBOT) in military subjects with chronic blast-induced mild to moderate traumatic brain injury (TBI)/post-concussion syndrome (PCS) and post-traumatic stress disorder (PTSD). Sixteen military subjects received 40 1.5 ATA/60 min HBOT sessions in 30 days. Symptoms, physical and neurological exams, SPECT brain imaging, and neuropsychological and psychological testing were completed before and within 1 week after treatment. Subjects experienced reversible middle ear barotrauma (5), transient deterioration in symptoms (4), and reversible bronchospasm (1); one subject withdrew. Post-treatment testing demonstrated significant improvement in: symptoms, neurological exam, full-scale IQ (+14.8 points; p<0.001), WMS IV Delayed Memory (p=0.026), WMS-IV Working Memory (p=0.003), Stroop Test (p<0.001), TOVA Impulsivity (p=0.041), TOVA Variability (p=0.045), Grooved Pegboard (p=0.028), PCS symptoms (Rivermead PCSQ: p=0.0002), PTSD symptoms (PCL-M: p<0.001), depression (PHQ-9: p<0.001), anxiety (GAD-7: p=0.007), quality of life (MPQoL: p=0.003), and self-report of percent of normal (p<0.001), SPECT coefficient of variation in all white matter and some gray matter ROIs after the first HBOT, and in half of white matter ROIs after 40 HBOT sessions, and SPECT statistical parametric mapping analysis (diffuse improvements in regional cerebral blood flow after 1 and 40 HBOT sessions). Forty 1.5 ATA HBOT sessions in 1 month was safe in a military cohort with chronic blast-induced PCS and PTSD. Significant improvements occurred in symptoms, abnormal physical exam findings, cognitive testing, and quality-of-life measurements, with concomitant significant improvements in SPECT.

Incorporating simulators in a standardized patient exam.

Using simulated patients during a clinical skills exam that involves many students has the advantage of standardizing the delivery of historical data. One major disadvantage is the inability to standardize the physical exam findings. We designed a simulated patient exam that incorporates simulated abnormal physical exam findings. The simulated patient exam case was divided into three separate stations: (1) the simulated patient's history, (2) the simulated physical exam, and (3) the presentation station. Dyspnea was chosen as the chief complaint because of the broad differential of possible cardiac and pulmonary auscultatory findings. In the first station, students obtained historical data from the standardized simulated patient. Students were graded on their ability to ask appropriate historical questions. Trained observers were used to verify the numbers of historical cues obtained by the students. The second station consisted of simulated physical exam findings. Students first measured the blood pressure on a commercially available blood pressure simulator arm from the Medical Plastics Laboratory, Inc., Gatesville, TX. Students then auscultated an abnormal digital heart sound and pulmonary sound from a small auscultation transducer developed by Andries Acoustics, Spicewood, TX. Students also palpated a simulated pulse from a newly developed pulse transducer. Digital cardiopulmonary sounds and pulse data were recorded onto a CD-ROM disc and transmitted to the small transducers via a CD-ROM disc player. Students used their own stethoscopes to auscultate cardiopulmonary sounds from the small transducers. The students were graded in the second station on their ability to accurately measure a blood pressure, identify abnormal cardiopulmonary digital sounds, and finally describe a peripheral pulse. In the third station, students presented the historical data and physical exam findings to a faculty member, and then provided a differential diagnosis list based on their key findings from the other two stations. A total of 171 students (n = 171) completed the simulated patient exam. Each student completed the exam in 45 minutes. In our simulated patient exam, students were evaluated not only on their data-gathering skills for key historical findings but also on the ability to correctly identify key physical exam findings such as abnormal cardiopulmonary sounds. Key physical exam findings were then integrated into the clinical decision-making process, which was presented in the faculty presentation station. Simulated patients with abnormal cardiopulmonary findings can be used for testing purposes. However, cardiac auscultatory abnormalities such as the ventricular S3 gallop are difficult to find and usually occur in a decompensated state such as heart failure. Other physical exam findings such as pulmonary crackles and wheezes also occur in decompensated conditions. Therefore, the use of simulators during a simulated patient exam offers the possibility of introducing several abnormal physical exam findings without having an unstable patient present in an exam setting. Further, the use of simulated physical exam findings allows for complete standardization of a clinical-simulated patient exam.

SENSITIVITY, SPECIFICITY, AND PREDICTIVE VALUE OF PHYSICAL EXAMINATION, CULTURE, AND OTHER LABORATORY STUDIES IN THE DIAGNOSIS DURING EARLY INFANCY OF VERTICALLY ACQUIRED HUMAN IMMUNODEFICIENCY VIRUS INFECTION

Purpose of the Study. To determine the HIV vertical transmission rate in an unselected group of infants born to HIV-infected mothers, and to examine the sensitivity, specificity, and positive and negative predictive values of physical examination and diagnostic laboratory studies (HIV culture, serum quantitative immunoglobulins and HIV-1 p24 antigen) in the diagnosis of HIV infection. Study Population. A group of 142 infants referred solely because they were born to HIV-infected mothers were selected for this study. Methods. Epidemiological and clinical data were obtained retrospectively from the Baylor Pediatric AIDS Clinical Trials Group HIV Infection Registry and medical records. The information recorded included results of physical examination and diagnostic laboratory tests (HIV culture, serum quantitative immunoglobulins, and HIV-1 p24 antigen). HIV cultures were performed according to a consensus protocol developed for the National Institute of Allergy and Infectious Diseases AIDS Clinical Trials Group. Results. Of 142 infants whose HIV infection status was known at the time of the study, 17 (20%) had confirmed infection, and 68 (80%) had seroreverted with no evidence of infection. All HIV-infected infants were at least 3 months old when abnormal physical exam findings became apparent (lymphadenopathy and hepatosplenomegaly), but similar findings were noted in an equal number of HIV-uninfected infants. All infected infants available were HIV culture positive by 6 months of age (16/16). There was no positive cultures reported in the infants who seroreverted (32/32). Elevated immunoglobulins (IgG, IgA, IgM) were present by 6 months of age in a high percentage of infected infants. Nearly one-half of the uninfected infants had elevated immunoglobulin levels during the first 6 months of life, but in 50% of the cases it was IgG alone.