Acute Presentation Research Articles

A Case Report of Acute Pericarditis Presenting With Acute Aortic Dissection

A Case Report of Acute Pericarditis Presenting With Acute Aortic Dissection

Correlation of Point of Care Ultrasound (POCUS) Guided Pupillary Assessment Parameter with Glasgow Coma Scale in Patients with Altered Mental Status– A Cross Sectional Study

Background: Earlier studies have proved deteriorating Glasgow Coma Scale (GCS) as a marker of raised intracranial pressure (ICP). Low GCS is associated with abnormal pupillary parameters. Currently, many studies have proved that ultrasound provides a feasible and objective assessment of pupillary light reflex. However, literature is lacking to evaluate objective pupillary parameters to predict GCS of the patients by point of care ultrasound (POCUS). Materials and methods: In this prospective, cross-sectional study, 200 patients were recruited in the emergency department. The inclusion criteria were patients older than 18 years with acute presentation of altered mental status. Exclusion criteria were patients who had partial globe rupture or dementia. The patients underwent a B-mode POCUS-guided evaluation at rest and after light stimulation. Statistical analysis of relationship between pupillary assessment parameters and GCS was performed using Spearman's Rank correlation coefficient, Kruskal-Wallis equality-of-populations rank test, and area under the receiver operating characteristic. Results: The study consisted of 200 (42 female, 158 male) patients with mean (± standard deviation) of age and GCS of 43.56 ± 16.50 years and 5.54 ± 3.00, respectively. Majority of non-reactive pupils had a GCS Score of 3-8 (74 cases, 97.37%). The Pupillary diameter (PD) and PD variation showed statistically significant agreement with pupil reactivity to light stimulation and GCS, with Spearman's correlation coefficient ranging from 0.28 to 0.33 for PD, and -0.55 to -0.50 (p-value <0.05) for PD variation, respectively. PD variation rate (PDVR) is the percentage change in the magnitude of constriction of PD on light stimulation. PDVR of >19.68% had a sensitivity of 86.96% (95% CI: 82.04 - 91.88%) and specificity of 64.97% (95% CI: 58.00 - 71.94%) to detect GCS>8. Conclusion: PD variation and PDVR measured by POCUS has significant correlation with GCS >8. The study showed good sensitivity and low specificity of PDVR on light stimulation to detect GCS >8.

HPB SO57 - Imaging in Acute Pancreatitis: Are We Getting It Right?

Abstract Background Guidelines indicate that routine use of imaging is unwarranted in patients with acute uncomplicated pancreatitis presenting with abdominal pain and increased serum amylase or lipase levels without signs of severe disease. Moreover, early CT scans may fail to accurately reflect disease severity and provide no diagnostic advantage. Method We performed a retrospective clinical audit at a district general hospital in the United Kingdom to find out the current practice regarding the use of imaging in patients presenting with acute pancreatitis. The patients were studied from January 2023 to March 2023 for the 1st cycle, and from April 2024 to May 2024 for the 2nd cycle. The list was identified by the clinical audit department – adult patients who presented to the A&E with symptoms of acute pancreatitis were included. Results Between January - March 2023, 44 patients presented to A&E with symptoms of acute pancreatitis. Of these, 25 (56%) had a CT-scan within 72-hours, with 80% showing evidence of acute pancreatitis —1 with pancreatic necrosis, 7 with intra-peritoneal fluid, & 5 with peri-pancreatic fat-stranding. The study revealed poor compliance with standards, prompting efforts to raise awareness. Findings were shared at the departmental audit meeting, & posters were displayed in A&E and GeneralSurgery departments. In the 2nd-cycle (April-May 2024), 32 patients presented, with 14 (53%) having a CT-scan within 72-hours & all had serum amylase levels checked, with 11 within normal limits. Conclusion This closed-loop clinical audit demonstrated that with appropriate measures and improved awareness of current guidelines, there can be increased compliance to the guidelines by the clinicians. This, in turn, reduces the risk of radiation exposure to patients and optimizes the use of CT scans.

Acute presentation of short‑segment Hirschsprung's disease treated with Soave's procedure in a 20‑year‑old male: A case report and mini‑review of the literature

Acute presentation of short‑segment Hirschsprung's disease treated with Soave's procedure in a 20‑year‑old male: A case report and mini‑review of the literature

Abstract 4145883: Elevated International Normalized Ratio Is Associated with Severity of Intracerebral Hemorrhage for Patients Taking Direct Oral Anticoagulants

Introduction/Background: While the international normalized ratio (INR), a marker of functioning of the extrinsic and final common pathways of the coagulation cascade is associated with increased intracerebral hemorrhage (ICH) mortality for patients taking warfarin, it is not understood how it might be associated with outcomes in patients taking direct oral anticoagulants (DOACs), given the inconsistent and variable effect of DOACs on INR. Research Questions/Hypothesis: To determine whether INR is associated with increased ICH severity in patients with recent exposure to a DOAC. Methods/Approach: We included patients taking Apixaban or Rivaroxaban prior to acute presentation with ICH to hospitals participating in the Get With the Guidelines - Stroke registry, a nationwide quality improvement registry. The primary exposure was INR, which we modeled as a continuous variable with restricted cubic splines. The primary endpoint was stroke severity on presentation, measured by the National Institutes of Health Stroke Scale (NIHSS). Secondary endpoints included Glasgow Coma Scale (GCS) <=8 on admission, in-hospital mortality, composite of in-hospital mortality and discharge to hospice, and modified Rankin Scale (mRS) at discharge. We adjusted for key confounding factors, specifically age, sex, race/ethnicity, insurance status, and medical history, while taking into account within-hospital clustering. Results/Data: In total, 13,251 patients were included of whom 7,545 were exposed to apixaban and 5,706 were exposed to rivaroxaban. As shown in Table 1, for patients taking Apixaban, elevated INR was associated with increased likelihood of NIHSS >=21 (aOR 1.02 [95% CI 1.00-1.04, p=0.03] per 0.1 above 1.1) and in-hospital mortality (aOR 1.11 [95% CI 1.05-1.16, p<.001) per 0.1 above 1.1). For patients taking Rivaroxaban, similar trends were seen (aOR 1.21 [95% CI 1.08-1.35, p<.001] per 0.1 up to 1.2 for NIHSS >=21, aOR 1.13, [95% CI 1.09-1.16, p<.001] per 0.1 up to 1.6, for in-hospital mortality). Conclusion(s): Elevated INR at admission is associated with worsened ICH severity for patients taking Apixaban or Rivaroxaban.

NCOG-15. CONNECTOME-BASED APPROACHES FOR PRESERVING COGNITIVE FUNCTION AND MINIMIZING DELIRIUM DURING GLIOMA RESECTION: A PILOT STUDY

Abstract AIM The surgical treatment of gliomas poses significant challenges due to the involvement of complex neural networks critical for cognitive functions. This study reviews the application of connectome-based approaches to minimize cognitive impairments and delirium during glioma resection, focusing on networks related to cognitive functions: the Default Mode Network (DMN), Dorsal Attention Network (DAN), Salience Network (SN), and Central Executive Network (CEN). METHODS Ten patients underwent surgery utilizing cloud-based connectomics software (Quicktome®), which maps the brain’s structural and functional connectivity. Preoperative MRIs with structural and functional connectome were performed for preoperative planning and intraoperative navigation. Preoperative neuropsychological assessments were conducted for elective cases. Only one patient was able to undergo awake craniotomy due to various medical, neurological and psychological limitations. Intraoperatively, with connectome-navigation guidance, a connectomics-based approach was conducted to preserve the networks. A semiquantitative analysis was performed as described (https://pubmed.ncbi.nlm.nih.gov/36719613). Pre- and postoperative (inpatient and 2 week follow up) RASS and NuDESC delirium screenings were performed, with long-term cognitive evaluations and repeat connectomics imaging planned. RESULTS Three out of ten patients presented with rapid functional deterioration and needed urgent surgical decompression had postoperative delirium. Connectome analysis showed involvement of cognition-related networks in these patients. Two out of 3 patients showed improvement in delirium scores at a two-week follow-up after tumor resection. CONCLUSION This pilot study suggests that factors such as acute presentation, emergency surgery, and tumor location involving and disrupting the DMN, SN, DAN, and CEN networks may contribute to early postoperative delirium. The study may pave the way for the efficacy of connectomics in preserving cognitive functions post-operatively, particularly when awake craniotomy is not possible. This approach holds promise for improving surgical outcomes, survival, and the quality of life for patients with gliomas by mitigating the cognitive impacts of tumor resection and postoperative complications.

Acute Hemorrhagic Rectal Ulcer Presenting With Severe Lower Gastrointestinal Bleeding: A Case Report of an Emerging Entity

Acute Hemorrhagic Rectal Ulcer Presenting With Severe Lower Gastrointestinal Bleeding: A Case Report of an Emerging Entity

Distal femur osteosarcoma in a seven-year-old: A case report on acute symptom presentation

Distal femur osteosarcoma in a seven-year-old: A case report on acute symptom presentation

Adolescent social anxiety is associated with diminished discrimination of anticipated threat and safety in the bed nucleus of the stria terminalis.

Social anxiety-which typically emerges in adolescence-lies on a continuum and, when extreme, can be devastating. Socially anxious individuals are prone to heightened fear, anxiety, and the avoidance of contexts associated with potential social scrutiny. Yet most neuroimaging research has focused on acute social threat. Much less attention has been devoted to understanding the neural systems recruited during the uncertain anticipation of potential encounters with social threat. Here we used a novel functional magnetic resonance imaging paradigm to probe the neural circuitry engaged during the anticipation and acute presentation of threatening faces and voices in a racially diverse sample of 66 adolescents selectively recruited to encompass a range of social anxiety and enriched for clinically significant levels of distress and impairment. Results demonstrated that adolescents with more severe social anxiety symptoms experience heightened distress when anticipating encounters with social threat, and reduced discrimination of uncertain social threat and safety in the bed nucleus of the stria terminalis, a key division of the central extended amygdala (EAc). Although the EAc-including the bed nucleus of the stria terminalis and central nucleus of the amygdala-was robustly engaged by the acute presentation of threatening faces and voices, the degree of EAc engagement was unrelated to the severity of social anxiety. Together, these observations provide a neurobiologically grounded framework for conceptualizing adolescent social anxiety and set the stage for the kinds of prospective-longitudinal and mechanistic research that will be necessary to determine causation and, ultimately, to develop improved interventions for this often-debilitating illness. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Acute Mitral Regurgitation Presenting as Unilateral Pulmonary Edema

Acute Mitral Regurgitation Presenting as Unilateral Pulmonary Edema

Effect of Intravenous Tirofiban Versus Placebo on First-Pass Successful Reperfusion in Endovascular Stroke Thrombectomy: Insights From the RESCUE BT Randomized Clinical Trial.

First-pass successful reperfusion (FPSR), defined as a successful/complete reperfusion achieved after a single thrombectomy pass, is predictive of favorable outcome in patients with acute ischemic stroke with large-vessel occlusion. It is unknown whether intravenous tirofiban is effective in increasing the rate of FPSR in acute anterior large-vessel occlusion stroke. Patients who had acute large-vessel occlusion stroke presenting within 24 hours and underwent endovascular thrombectomy were analyzed from the RESCUE BT (Intravenous Tirofiban for Patients With Large Vessel Occlusion Stroke) clinical trial, of which the main analysis was neutral. The RESCUE BT trial randomized patients to receive either intravenous tirofiban or placebo before endovascular thrombectomy. The primary end point was FPSR, defined as successful reperfusion (extended thrombolysis in cerebral infarction scale 2b50, 2c, or 3) at first thrombectomy attempt. A modified Poisson regression analysis assessed the association between intravenous tirofiban treatment and FPSR. Of 948 enrolled patients, 463 patients were randomized to the tirofiban group and 485 to the placebo group. The mean age was 67 years, and 41.0% of the patients were women. FPSR was achieved more often in the tirofiban group (30.5% versus 23.5%; adjusted risk ratio, 1.24 [95% CI, 1.01-1.51]; P=0.04). FPSR was associated with a favorable shift to lower modified Rankin Scale disability levels at 90 days (common odds ratio, 1.42 [95% CI, 1.08-1.86]; P=0.01). In this post hoc analysis of the RESCUE BT trial, treatment with intravenous tirofiban before endovascular thrombectomy was associated with increased FPSR in patients with acute ischemic stroke due to large-vessel occlusion in the anterior circulation. FPSR was associated with reduced 90-day levels of disability. URL: http://chictr.org; Unique Identifier: ChiCTR-INR-17014167.

Thiamine: An indispensable regulator of paediatric neuro-cardiovascular health and diseases.

Physicians are recommended to have a low threshold for suspecting thiamine deficiency especially in vulnerable populations. Laboratory diagnosis of thiamine deficiency needs to be implemented as a standard of care, especially in endemic regions. Further, public health policies on food fortification, mandatory supplementation, and surveillance are imperative to eliminate thiamine deficiency-induced health hazards. • South Asian countries report a higher incidence of neonatal and under-five mortalities, many of which are attributed to maternal and perinatal micronutrient deficiencies. • Preventable causes of neonatal/ infantile deaths include birth factors (low birth weight, birth asphyxia), infectious diseases (pneumonia, diarrhoea, tetanus, tuberculosis, measles, diphtheria, malaria, acute infections), deficiency diseases and genetic diseases (vitamin & mineral deficiencies, IEMs, congenital heart disease, unexplained PPHN, SIDS etc). • Acute thiamine deficiency presenting as multisystemic syndromes, has unfortunately been a long standing unresolved public health concern. However, accessible surveillance and diagnostic strategies remain elusive in most clinical settings. • Despite decades of reports and emerging guidelines, diagnosis of thiamine deficiency is often missed and policy mandates at national level are yet to be implemented even in endemic countries. • This review provides a comprehensive summary of the biochemical role of thiamine, its key functions and effects on major organ systems, the diagnostic gap, the enigmatic presentation of acute thiamine deficiency, the plausible role of thiamine in other pathologies and the preventive measures at individual and community level.

P44 An acutely unwell and rare presentation of systemic lupus erythematosus; a case report

Abstract Introduction Systemic lupus erythematosus (SLE) is a systemic autoimmune disease with multisystem involvement. The condition has varying clinical presentations from mild mucocutaneous manifestations to severe multiorgan and central nervous system involvement. It is challenging to diagnose someone with SLE during acute admission. Apart from infection and malignancies, autoimmune and connective tissue diseases should always be one of our differentials in an acutely unwell patient with multisystem involvement. This case demonstrates how unwell and rare a patient with SLE can present. We also acknowledge the need to further understand and raise awareness of this uncommon condition. Case description A 48 year old Thai lady with no known medical illness presented with 2-3 weeks history of viral like illness. On admission, she was tachycardic, hypotensive and hypoxic. Clinical examination revealed bi-basal crepitations and elevated JVP. Her ECG showed sinus tachycardia. Admission bloods showed anemia, raised white cell count, lymphopenia, thrombocytopenia, raised inflammatory markers and acute kidney injury (AKI). CT scan revealed evidence of pericardial effusion with small free fluid in abdomen and pelvis. ECHO showed large pericardial effusion and pericardiocentesis was performed which drained purulent fluid. Blood culture was positive for E. Coli. 3rd Day blood tests were strongly positive for CTD screening. She was reviewed by the rheumatology team and was diagnosed as acute presentation of SLE causing serositis having fulfilled the SLICC criteria with E. Coli bacteremia. SLE DAI – 2K score was 11. She reported history of Raynaud’s since moving to UK, hair loss and two miscarriages in the past. She denied history of oral ulcers, facial rash or significant joint involvement. Renal team advised that AKI was due to infection rather than lupus. She was commenced on high dose oral prednisolone (40 mg/day) and antibiotics. Her condition responded to steroids and subsequently was commenced on mycophenolate as outpatient. Discussion SLE is an autoimmune disease that affects multiple organ systems. Symptoms and signs can vary although majority of patients present with cutaneous manifestation. Most of the clinical manifestations of the disease are due to abnormal inflammatory response. Patients with SLE are usually diagnosed at outpatient settings although they can present acutely unwell as seen in this patient. Serositis refers to inflammation of serous tissue which includes pleura, pericardium and peritoneum. It is considerably a rare condition which is only seen in only around 10% of patients with SLE. Patients can present with shortness of breath, abdominal pain, diarrhoea, fatigue chest pain and even cardiac tamponade. Due to the heterogeneity of SLE presentations, it is challenging for clinicians to diagnose and manage the symptoms. Besides infection and malignancies, it is always important to consider connective tissue disease as one of the differentials in an acutely unwell patient presenting with multisystem involvement. SLICC criteria can be used as a diagnosing tool for SLE which includes clinical and immunological criteria. SLEDAI-2K score can be used to assess disease activity. Her biochemical parameters as well as clinical symptoms drastically improved following steroid initiation. Early recognition and treatment initiation can improve mortality and morbidity significantly. Despite how unwell she was during admission; she improved quickly and was discharged relatively early. Her condition continues to improve on DMARDs, and she is on regular clinic follow up. Key learning points • A good clinical history and examination is essential and aids reaching a diagnosis. As reflected in this case, our patient was a female at childbearing age, south Asian (non-Caucasian ethnicity) who presented with multisystem involvement. Her initial finding of serositis, acute kidney injury, anemia, raised ESR and E. coli bacteremia were not fitting with a typical sepsis picture. There should be strong grounds for considering SLE during such clinical presentations. Suspecting SLE in an acute setting is really challenging due to various reasons, like wide symptomology of SLE, minimal exposure of SLE to physicians and their tendency of leaning towards other common conditions, like sepsis. As SLE is mostly diagnosed as outpatient, inpatient presentations are rare. Furthermore, blood results for connective tissue disease which is a major criteria for diagnosis, can take between 3 to 5 working days to be reported. However, early and appropriate consideration of autoimmune conditions as differentials of an acutely ill patient with multisystem involvement can expedite the process of diagnosis, involvement of related specialty and commencement of appropriate treatment. This approach will benefit patients producing favourable outcomes and minimal hospital stay.

Assessment of Coronary Artery Disease in Non-Valvular Atrial Fibrillation: Is This Light at the End of the Tunnel?

Non-valvular atrial fibrillation (NVAF) is the most common sustained arrhythmia worldwide, and is associated with significant morbidity and mortality. Increasing life expectancy, coupled with a surge in comorbidity burden, has resulted in a sharp increase in NVAF prevalence over the last three decades. Coronary artery disease (CAD) is an important and clinically relevant risk factor of AF. Concomitant CAD has significant implications for AF management and is a major determinant of the overall outcomes. Shared risk factors, a common pathophysiological basis, and heightened thrombogenesis culminating in cardiovascular adverse events, highlight the close association between the two. The clinical course of AF is worse when associated with CAD, resulting in poor heart rate control, increased propensity to develop stroke and myocardial infarction, increased likelihood of acute presentation with hemodynamic collapse and pulmonary edema, increased bleeding tendencies, and poor response to ablation therapies. Emerging research highlighting the significant role of underlying CAD as an independent predictor of thromboembolic risk has paved the way for the adoption of CAD beyond prior myocardial infarction into the symbol "V" of the CHA2DS2-VASc score. In our opinion, elderly patients aged >65 years with AF, with a history of one or more cardiovascular comorbidities, or evidence of atherosclerosis in other vascular beds should warrant a closer look and a dedicated effort to look for associated CAD. This would allow for a more holistic and comprehensive approach to patients with AF and ultimately help reduce the disease burden and improve the overall outcomes.

Sex differences in clinical data and long-term outcomes of elderly patients with acute myocardial infarction presenting with cardiogenic shock undergoing percutaneous coronary intervention

Abstract Background Data on contemporary clinical practice and long-term outcomes for sex differences in elderly patients with acute myocardial infarction (MI) who have undergone percutaneous coronary intervention (PCI) presenting with cardiogenic shock (CS) is limited. Purpose This study aimed to investigate contemporary clinical data and long-term clinical outcomes according to sex differences in elderly patients undergoing PCI for acute MI complicated by CS. Methods We analyzed data from a nationwide, prospective, and real-world registry comprising elderly patients (≥65 years) with acute MI who have undergone PCI and presented with CS. Of the 540 patients included, 228 were women, and 312 were men. We compared major adverse cardiac events (MACE; all-cause death, recurrent MI, any revascularization, stroke, heart failure [HF] readmission, or definite/probable stent thrombosis [ST]) and the components of MACE between the groups using multivariable Cox regression, propensity score (PS) matching, and PS-adjusted analyses. Results Compared to men, women were younger and had higher incidences of hypertension and elevated pro-BNP levels. No significant differences were observed in other cardiovascular risk factors, left ventricular systolic function levels, or adherence to guideline-directed medical therapy between the groups. Over a median follow-up of 1035 days, MACE, all-cause death, and cardiac death occurred in 257 (47.6%), 212 (39.3%), and 170 (31.5%) patients, respectively. Women exhibited significantly increased risks of MACE (overall: 53.5% vs. 43.3%, hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.59-0.97, p=0.023; PS-matched: n=368, 52.3% vs. 41.8%, HR 0.73, 95% CI 0.53-0.94, p=0.033), all-cause death (overall: 44.7% vs. 35.3%, HR 0.77, 95% CI 0.58-0.97, p=0.032; PS-matched: 42.8% vs. 33.4%, HR 0.71, 95% CI 0.54-0.95, p=0.041), cardiac death (overall: 35.1% vs. 28.8%, HR 0.81, 95% CI 0.60-0.97, p=0.048; PS-matched: 34.4% vs. 26.9%, HR 0.78, 95% CI 0.54-0.95, p=0.043) compared to men. There were no significant differences in the risks of recurrent MI, any revascularization, stroke, HF readmission, and definite/probable ST between the groups. Conclusions In this nationwide registry, women compared to men exhibited increased risks of long-term clinical outcomes in elderly patients with acute MI who have undergone PCI presenting with CS.

Acute myocarditis presentation and intra-hospital prognosis: results of the multicenter prospective MYOCARDITIRM study

Abstract Background Acute myocarditis (AM) usually presents as chest pain with rising troponin and normal coronary arteries. Despite frequent favorable evolution at the acute phase, it is associated with heart failure and ventricular rhythm disorders and is considered the leading cause of sudden cardiac death in young apparently healthy adults. There is no recommendation for AM, only expert consensus, given the lack of important databases for a strong level of confidence. Methods We performed a multicenter prospective observational study of patients admitted for AM acknowledged by cardiac MRI to describe baseline characteristics, management, in-hospital and long-term outcomes of AM patients in France. Secondary objectives were to investigate determinants of prognosis, modalities of treatment and follow-up, and to identify gaps between expert consensus and real-life management. Results We enrolled 805 consecutive patients hospitalized for AM in 49 participating centers between May 2016 and February 2019. Median age was 31 (IQR 23-41) with 19% of female. Chest pain was the most frequent symptom (93%) and 112 (14%) had severity criteria upon admission (LVEF<50% or severe ventricular arrythmia or high-grade AV block or cardiogenic shock). ST elevation was observed in 49% of patients. One 26-years old patient died during initial hospital stay. Overall, 62 patients (8%) experienced intra-hospital complication of their AM, defined as a combined endpoint of death, LVEF<40% (MRI), sustained ventricular or supraventricular arrythmia, acute renal failure, cardiogenic shock, need for ventricular assistance device, need for inotropic drugs, temporary cardiac pacing, pace-maker or cardiac defibrillator implantation. Patients with initial severity criteria were 10 times more likely to present intra-hospital complication (33% vs 3.6%, p<0.001). Conclusion This prospective cohort represents the largest database on AM worldwide. Here we report baseline characteristics and in hospital events. Most patients had typical presentation with favorable outcomes but as much as 8% of patients did exhibit intra-hospital complication. The prospective follow up will provide valuable data to better identify subset of patients with poor prognosis that may be of interest to develop new therapeutic strategies.Acute myocarditis on cardiac MRI

Hickam's Dictum: An Analysis of Multiple Diagnoses.

Hickam's dictum ("a patient can have as many diseases as he damn well pleases") has been touted as a counterargument to Ockham's razor, which enjoins clinicians to seek a single, simple, or unifying diagnosis. Yet the phenomenon of multiple diagnoses has not been formally analyzed. We evaluated multiple diagnoses using three methods of inquiry: (1) a review of 83 case reports; (2) a review of 220 cases from the New England Journal of Medicine; and (3) an online survey of providers' intuitions. Eighty-three published case reports claimed to instantiate Hickam's dictum or violate Ockham's razor. All reported a primary diagnosis that explained the presenting illness, and one or more additional diagnoses which could be classified into four categories: (1) an incidentaloma (n = 21; 25.3%); (2) a pre-existing disease (n = 26; 31.3%); (3) a disease causally linked to the primary diagnosis (n = 33, 39.8%); and (4) a causally unrelated second disease contributing to the acute presentation (n = 3, 3.6%). Among 220 cases from the New England Journal of Medicine, all reported a unifying final diagnosis. In an online survey, 265 respondents recruited using social media evaluated four hypothetical cases with multiple diagnoses representing this categorization scheme. A majority of respondents (79%; 95% CI, 74-84%) chose the case representing category 4 - a coincident, causally unrelated second diagnosis - as the most unlikely or surprising diagnostic combination. Multiple diagnoses commonly occur. However, the majority of the multiple diagnoses we analyzed were causally linked, or represented incidentalomas or known pre-existing diseases. These diagnostic combinations were unsurprising to a majority of surveyed providers. We show that multiple diagnoses can be arranged in a framework that considers time, probability, and causation. This framework reconciles the alleged conflict between Hickam's dictum and Ockham's razor and has greater practical and pedagogical utility.

Radiological indicators of chronicity in patients with acute symptomatic pulmonary embolism treated with ultrasound-assisted catheter-directed thrombolysis: a study of 180 consecutive cases

Abstract Background Radiological signs of chronic thrombi are present in up to 20% of patients that present acutely with pulmonary embolism (PE). Ultrasound-Assisted Catheter-Directed Thrombolysis (USAT) can swiftly reverse right ventricular dysfunction in patients with acute PE. Purpose To investigate the frequency of radiological signs of chronic PE and pre-existing chronic thromboembolic pulmonary hypertension in patients treated with USAT and their impact on early and long-term hemodynamic and clinical outcomes. Methods The index CT scans of patients receiving USAT for acute intermediate-high and high-risk PE at a tertiary academic institution (2017-2022) were adjudicated by three expert radiologists blinded for treatment scheme and outcomes. Changes in invasively-measured mean pulmonary artery pressure (mPAP) at 24 hours post USAT, presence of post-PE impairment (PPEI), and CTEPH diagnoses after at least 3 months were studied. A total of 15 radiological signs of chronicity were assessed, including 6 major criteria that have been previously validated to raise the suspicion of pre-existing CTEPH. In this study, acute-on-chronic PE was defined when at least 3 of the 6 validated radiological criteria for chronicity were present together with acute findings. Pre-existing CTEPH was defined based on the results of follow-up (vs. index) CT scan and on the anatomical consistency of pathology specimens after pulmonary endarterectomy. PPEI was defined by the presence of residual respiratory symptoms and right ventricular dysfunction during follow-up. Results Of 180 consecutive patients (median age 65 years, 61% men, 17% high-risk PE), 31 had at least 3 of 6 radiological criteria at the time of acute presentation; Table 1. The median modified Miller Score was 24 points and baseline mPAP was 35 mmHg in both groups. The absolute mPAP reduction after USAT was 11 (Q1-Q3: 5-17) mmHg in patients with <3 and 10 (Q1-Q3: 5, 17) mmHg in those with ≥3 criteria; Table 2. Three (1.7%) patients were diagnosed with CTEPH after a median of 3 months and underwent pulmonary endarterectomy: in all 3 patients, CTEPH was pre-existing. At least 3 of the 6 previously validated criteria were present in all CTEPH patients at index CT. In the 3 patients with acute PE on pre-existing CTEPH, the median baseline mPAP was much higher (median 53 mmHg) than in the remaining patient group and the absolute reduction after USAT was 9 mmHg, corresponding to a relative reduction of 19%. During follow-up, PPEI was more frequent in patients with <3 signs (n=4, 2.7%) than in those with ≥3 signs (n=4, 12.9%). Conclusion(s) The evaluation of six radiological parameters in initial CT scans successfully identified all cases of pre-existing CTEPH in patients presenting with acute PE. However, these parameters did not prove effective in determining which patients would benefit from USAT in terms of mPAP reduction.Baseline characteristicsHemodynamic and clinical outcomes

Acute rheumatic fever presenting as fulminant myocarditis.

Acute rheumatic fever presenting as fulminant myocarditis.

Acute Lymphoblastic Leukemia Presenting With Skin Rash And Forehead Swelling In A 31-Year-Old Male

Leukemia cutis is the infiltration of neoplastic leukocytes or their precursors into the epidermis, the dermis, or the subcutis of patients with leukemia, resulting in clinically identifiable cutaneous lesions. It is especially rare as the presenting symptom of leukemia and is associated with a poor prognosis. We present a case of acute lymphoblastic leukemia, whose initial complaints were skin lesions and forehead swelling, which we believe to be features of leukemia cutis. J Dhaka Med Coll. 2023; 32(1) : 96-98