Acute Presentation Research Articles

P467 Towards AI-Augmented Clinical Decision Making: An Examination of ChatGPT's Utility in Acute Ulcerative Colitis Presentations

Abstract Background ChatGPT is a large language model based chatbot created by OpenAI. Since its release, ChatGPT has gained widespread attention among the healthcare community regarding its potential utility as a medical practice tool. In addition, ChatGPT can be adapted to serve as a clinical-decision support tool. In this study we explored the potential of ChatGPT as a decision support tool for acute Ulcerative Colitis (UC) presentations in the setting of the emergency department (ED). Methods Our investigation centered around 20 distinct acute UC presentations to the ED, accumulated over two years. Case summaries - embodying crucial data points such as symptoms, vital signs, and laboratory results - were processed by ChatGPT. For each case, we asked ChatGPT to assess disease severity based on the TrueLove and Witts classification, substituting erythrocyte sedimentation rate ≥30 with C-Reactive protein ≥12. Furthermore, it was to recommend hospitalization or outpatient care for each case based on the disease severity. The answers were compared with assessments made by our department's gastroenterologists and the actual decision made by the physician in the ED. Results Overall, ChatGPT categorized 12, 7 and 1 patient with severe, moderate and mild disease, respectively. For each case, ChatGPT supplied a detailed answer depicting severity of every variable of the criteria and an overall severity classification (table 1). Compared to our gastroenterologists’ assessments, ChatGPT graded 16/20 (80%) of the patients with the same severity. A high degree of reliability was found between the two assessments as the average measure intra-class correlation coefficient of absolute agreement was 0.839 (95% confidence interval 0.588-0.937, F= 5.95, p<0.001). Inconsistencies in four cases stemmed primarily from inaccurate cut-off values for systemic variables. Following severity assessment, ChatGPT leaned towards hospitalization for 16 out of 18 (88.9%) patients. For two moderate UC cases, however, it could not provide a decisive recommendation. Comparatively, only 12 out of the 20 patients were hospitalized in actual clinical practice. Conclusion In this unique study, findings suggest that Chat-GPT, has potential as a clinical decision-support tool in assessing UC severity and recommending suitable settings for further treatment. While this concept warrants further investigation and validation, its ability to evaluate a clinical scenario based on established criteria could greatly benefit the field of Inflammatory bowel disease and gastroenterology.

P743 A personalised algorithm predicting the risk of intravenous corticosteroid failure in acute ulcerative colitis

Abstract Background An episode of acute ulcerative colitis (UC) represents an important watershed moment in a patient’s disease course. Foreknowledge of a patient's likely response to intravenous corticosteroid therapy has significant clinical utility. Using a large prospectively collected acute UC patient database and machine learning-based techniques we aimed to derive and validate a personalised algorithm for identifying patients at high risk of corticosteroid therapy failure from variables available at hospital presentation. Methods A prospectively collected database of 600 consecutive presentations of acute UC was collated at a single referral centre between 1996 and 2022. An AIC-based Elastic Net model was used to select variables on the 419 earliest presentations of acute UC (1996-2017). Two risk-scoring algorithms, with and without utilising additional endoscopic variables, were constructed using logistic regression models. These risk scores were then validated on a separate cohort of 181 acute UC presentations (2018-2022). Results The partial risk of rescue (ROR) score included the admission indices of oral corticosteroid treatment; bowel frequency ≥6/24 hours; albumin; CRP ≥12mg/ml and log10CRP. The full ROR score incorporates the same variables with the addition of the Mayo endoscopic subscore and disease extent. The ROC AUCs in the validation cohort were 0.76 (95% CI: 0.69-0.83) and 0.78 (95% CI: 0.71-0.85) for the partial and full ROR scores, respectively. When incomplete cases were excluded, the full ROR score validation cohort ROC AUC increased from 0.78 to 0.80. Conclusion These pragmatic personalised risk scores (available at www.severecolitis.com) have comparably strong performance characteristics and usability enabling the identification of individuals at high risk of corticosteroid treatment failure before or after endoscopic assessment. These patients may be suitable for consideration of early treatment escalation or screening for participation in clinical trials.

Modernising vestibular assessment.

There is a high prevalence of dizziness, vertigo and balance symptoms in the general population. Symptoms can be generated by many inner-ear vestibular disorders and there are several diagnostic tests available that can help identify the site of the vestibular lesion. There is little consensus on what diagnostic tests are appropriate, with diagnostics either not completed or minimally performed, leading to missed diagnosis, unsatisfactory results for patients and costs to healthcare systems. This study explored the literature for different neuro-vestibular diagnostic tests not currently considered in the traditional standard vestibular test battery, and examined how they fit effectively into a patient care pathway to help quickly and succinctly identify vestibular function. A vestibular patient care pathway is presented for acute and subacute presentation of vestibular disorders. An accurate diagnosis following a rigorous anamnesis and vestibular testing is paramount for successful management and favourable outcomes.

Iatrogenic bioprosthetic, self-expandable, transcatheter aortic valve replacement dysfunction after cardiac catheterization.

Bioprosthetic valve dysfunction (BVD) is typically a progressive process related to natural wear of the prosthesis. With acute presentations, possible durability issues or iatrogenic causes need to be considered. Here, we present 2 patients with acute BVD of self-expanding, transcatheter aortic valve replacement post-heart catheterization. The presentations and outcomes, in otherwise normally functioning valves antecedent to the heart catheterizations, raise the question of the increased complexity of coronary access in this valve platform, and whether that or other features provide for greater risk of such events. We believe this to be the first publication of such events and they help to highlight the importance of valve implantation planning, as well as familiarity with the potential complexity of coronary access during heart catheterization.

Outcomes of laparoscopic subtotal cholecystectomy: a comparative analysis of fenestrating and reconstituting approaches in 170 cases.

Laparoscopic subtotal cholecystectomy (LSC) is a recognised alternative to laparoscopic cholecystectomy (LC) when it is unsafe to achieve the "critical view of safety". Although LSC reduces the risk of bile duct injury, it is associated with increased morbidity, primarily due to bile leak. LSC can be classified as fenestrating (F-LSC) or reconstituting (R-LSC), with the latter being more complex. The objective of this study was to evaluate the two LSC techniques, their complications, and overall outcomes. We conducted a retrospective analysis of all adult patients who underwent LSC between January 2015 and December 2021 using our electronic database. Data collected included patient demographics, prior acute biliary presentations, operative details/techniques, length of stay (LOS), 30-day complications, 30-day mortality, readmissions, and follow-up investigations/procedures. Descriptive statistics, Chi-squared tests, and relative risk were employed for data analysis. In the study period, LSC was performed on 170 patients, showing an increasing trend over time. Most procedures (76%) were performed in the acute setting, and 37.1% of patients had a history of previous acute biliary presentations. Fenestrating LSC was the most performed technique (115 [67.6%] vs. 55 [32.4%]). Complications occurred in 80 (47.1%) patients; 60 patients (35.3%) had a bile leak. 16 patients (9.4%) required reoperation, and readmission was observed in 14 patients (8.2%). F-LSC was associated with more complications [p = 0.03 RR 2.46 (95% CI 1.5-4)], more bile leaks [p < 0.01, RR 2.1 (95% CI 1.2-3.7)], greater need for rescue postoperative endoscopic retrograde cholangiopancreatography (ERCP) [p < 0.01, RR 3.8 (95% CI 1.4-10.2)], and longer LOS (6 vs. 4days p < 0.01). Although LSC is seen as a safe alternative to open conversion, our findings demonstrate a high morbidity, including reoperation/reintervention, readmissions, and complications, associated with LSC especially with F-LSC. We suggest that if LSC is performed, the reconstituted technique should be chosen, if feasible.

The evolving phenotype of autoimmune hepatitis across the millennium: The 40-year experience of a referral centre in Italy.

During recent years, there have been major insight into the pathogenesis, diagnosis and treatment of autoimmune hepatitis (AIH). We aim to evaluate modifications of the clinical-epidemiological phenotype of AIH patients from 1980 to our days. Single-centre, tertiary care retrospective study on 507 consecutive Italian patients with AIH. Patients were divided into four subgroups according to the decade of diagnosis: 1981-1990, 1991-2000, 2001-2010 and 2011-2020. We assessed clinical, laboratory and histological features at diagnosis, response to treatment and clinical outcomes. Acute presentation is defined as transaminase levels >10-fold the upper limit and/or bilirubin >5 mg/dL. Complete response is defined as the normalization of transaminases and IgG after 12 months. Clinical progression is defined as the development of cirrhosis in non-cirrhotic patients and hepatic decompensation/hepatocellular carcinoma development in compensated cirrhosis. Median age at diagnosis increased across decades (24, 31, 39, 52 years, p < .001). Acute onset became more common (39.6%, 44.4%, 47.7%, 59.5%, p = .019), while cirrhosis at diagnosis became less frequent (36.5%, 16.3%, 10.8%, 8.7%, p < .001). Complete response rates rose (11.1%, 49.4%, 72.7% 76.2%, p < .001) and clinical progression during follow-up decreased (54.3%, 29.9%, 16.9%, 11.2%, p < .001). Anti-nuclear antibodies positivity increased (40.7%, 52.0%, 73.7%, 79.3%, p < .001), while IgG levels/upper limit progressively decreased (1.546, 1.515, 1.252, 1.120, p < .001). Liver-related death and liver transplantation reduced from 17.1% to 2.1% (p < .001). In the new millennium, the typical AIH patient in Italy is older at diagnosis, more often presents with acute hepatitis, cirrhosis is less frequent and response to treatment is more favourable.

Acute health care use among children during the first 2.5 years of the COVID-19 pandemic in Ontario, Canada: a population-based repeated cross-sectional study.

The effects of the decline in health care use at the start of the COVID-19 pandemic on the health of children are unclear. We sought to estimate changes in rates of severe and potentially preventable health outcomes among children during the pandemic. We conducted a repeated cross-sectional study of children aged 0-17 years using linked population health administrative and disease registry data from January 2017 through August 2022 in Ontario, Canada. We compared observed rates of emergency department visits and hospital admissions during the pandemic to predicted rates based on the 3 years preceding the pandemic. We evaluated outcomes among children and neonates overall, among children with chronic health conditions and among children with specific diseases sensitive to delays in care. All acute care use for children decreased immediately at the onset of the pandemic, reaching its lowest rate in April 2020 for emergency department visits (adjusted relative rate [RR] 0.28, 95% confidence interval [CI] 0.28-0.29) and hospital admissions (adjusted RR 0.43, 95% CI 0.42-0.44). These decreases were sustained until September 2021 and May 2022, respectively. During the pandemic overall, rates of all-cause mortality, admissions for ambulatory care-sensitive conditions, newborn readmissions or emergency department visits or hospital admissions among children with chronic health conditions did not exceed predicted rates. However, after declining significantly between March and May 2020, new presentations of diabetes mellitus increased significantly during most of 2021 (peak adjusted RR 1.49, 95% CI 1.28-1.74 in July 2021) and much of 2022. Among these children, presentations for diabetic ketoacidosis were significantly higher than expected during the pandemic overall (adjusted RR 1.14, 95% CI 1.00-1.30). We observed similar time trends for new presentations of cancer, but we observed no excess presentations of severe cancer overall (adjusted RR 0.91, 95% CI 0.62-1.34). In the first 30 months of the pandemic, disruptions to care were associated with important delays in new diagnoses of diabetes but not with other acute presentations of select preventable conditions or with mortality. Mitigation strategies in future pandemics or other health system disruptions should include education campaigns around important symptoms in children that require medical attention.

Consensus document of the Mexican Society of Cardiology for post-COVID-19 cardiovascular clinical follow-up

The cardiovascular sequelae by the SARS-COV-2 infection is prevalent in a significant portion of the recovered patients from the acute presentation of the SARS-COV-2. Actually, the clinic cardiac control of the post-acute COVID syndrome has been working out without a well-established protocol, making the appropriate diagnosis of the cardiac diseases produced by the different damage mechanisms from COVID-19. Standardize cardiovascular care and the follow up of COVID-19 survivors in the function on disease severity and identify patients who develop SPC-19A for timely care. Through an extensive bibliographic review, this article has the purpose of provide the necessary information to make possible the early diagnosis and following of the cardiac complications that has been recorded trough the months after the acute disease from COVID-19.

Acute Invasive Pulmonary Aspergillosis: Clinical Presentation and Treatment.

Among all clinical manifestations of pulmonary aspergillosis, invasive pulmonary aspergillosis (IPA) is the most acute presentation. IPA is caused by Aspergillus hyphae invading the pulmonary tissue, causing either tracheobronchitis and/or bronchopneumonia. The degree of fungal invasion into the respiratory tissue can be seen as a spectrum, going from colonization to deep tissue penetration with angio-invasion, and largely depends on the host's immune status. Patients with prolonged, severe neutropenia and patients with graft-versus-host disease are at particularly high risk. However, IPA also occurs in other groups of immunocompromised and nonimmunocompromised patients, like solid organ transplant recipients or critically ill patients with severe viral disease. While a diagnosis of proven IPA is challenging and often warranted by safety and feasibility, physicians must rely on a combination of clinical, radiological, and mycological features to assess the likelihood for the presence of IPA. Triazoles are the first-choice regimen, and the choice of the drug should be made on an individual basis. Adjunctive therapy such as immunomodulatory treatment should also be taken into account. Despite an improving and evolving diagnostic and therapeutic armamentarium, the burden and mortality of IPA still remains high. This review aims to give a comprehensive and didactic overview of the current knowledge and best practices regarding the epidemiology, clinical presentation, diagnosis, and treatment of acute IPA.

Deep Learning for Pneumothorax Detection on Chest Radiograph: A Diagnostic Test Accuracy Systematic Review and Meta Analysis.

Pneumothorax is a common acute presentation in healthcare settings. A chest radiograph (CXR) is often necessary to make the diagnosis, and minimizing the time between presentation and diagnosis is critical to deliver optimal treatment. Deep learning (DL) algorithms have been developed to rapidly identify pathologic findings on various imaging modalities. The purpose of this systematic review and meta-analysis was to evaluate the overall performance of studies utilizing DL algorithms to detect pneumothorax on CXR. A study protocol was created and registered a priori (PROSPERO CRD42023391375). The search strategy included studies published up until January 10, 2023. Inclusion criteria were studies that used adult patients, utilized computer-aided detection of pneumothorax on CXR, dataset was evaluated by a qualified physician, and sufficient data was present to create a 2 × 2 contingency table. Risk of bias was assessed using the QUADAS-2 tool. Bivariate random effects meta-analyses and meta-regression modeling were performed. Twenty-three studies were selected, including 34 011 patients and 34 075 CXRs. The pooled sensitivity and specificity were 87% (95% confidence interval, 81%, 92%) and 95% (95% confidence interval, 92%, 97%), respectively. The study design, use of an institutional/public data set and risk of bias had no significant effect on the sensitivity and specificity of pneumothorax detection. The relatively high sensitivity and specificity of pneumothorax detection by deep-learning showcases the vast potential for implementation in clinical settings to both augment the workflow of radiologists and assist in more rapid diagnoses and subsequent patient treatment.

Abnormal retinal vessel filling in central retinal artery occlusion

ABSTRACT Clinical relevance Central retinal artery occlusion (CRAO) is an ophthalmic emergency with a poor prognosis. Several initial CRAO presentation factors can influence the final visual outcome. Fluorescein angiography filling of retinal vessels in CRAO has not been studied in great detail. Background The aim of this paper is to study the aberrant filling of the retinal vessels on fluorescein angiography in patients with CRAO and understand its clinical relevance. Methods Cases of CRAO diagnosed between June 2017 and May 2022 and who had undergone a fundus fluorescein angiography were included. Comparisons were made between the cases with and without aberrant filling of the retinal vessel. Results Twenty-two eyes of 22 patients (14 males and 8 females) with CRAO underwent fluorescein angiography. Ages of the patients ranged from 18 to 73 years, while time interval between development of acute onset vision problems and presentation to the retinal clinic ranged from a minimum of 1 day to a maximum of 30 days. Snellen visual acuity at presentation ranged from perception of light (PL +) to 6/6. On fluorescein angiography, aberrant flow of the fluorescein dye into the retinal vein was observed in four of the 22 (18%) eyes with CRAO. All these cases showed a patient's temporal cilioretinal artery. The cases with aberrant filling of the retinal vessels showed a better presenting visual acuity (6/6–6/60), lesser severity of inner retinal damage and a better final visual acuity (6/6–6/60) compared to CRAO cases without aberrant filling. Conclusion Aberrant filling of the retinal vein can be seen on fluorescein angiography in eyes with CRAO and a patent temporal cilioretinal artery. Such eyes with aberrant retinal vessel filling have a better visual prognosis.

PREVALENCE AND SEVERITY OF INTRA-DISCAL VACUUM PHENOMENON IN A NORMAL AGEING POPULATION

Intra-Discal Vacuum Phenomenon (IDVP) represents an intradiscal nitrogen gas accumulation where a cavity opens in a supine position, lowering intra-discal pressure and generating a bubble. IDVP has been observed in up to 20% of elderly patients and reported in almost 50% of chronic LBP patients. With a highly accurate detection on CT, its significance lacks clarity and consideration within normative data. IDVP occurs with patterns of lumbar and/or lumbopelvic morphology and associated diagnoses. Over-60s population based sample of 2020 unrelated CT abdomen scans without acute spinal presentations, with sagittal reconstructions, inclusive of T12 to femoral heads, were analyzed for IDVP and pelvic incidence (PI). Subjects with diagnostic morphological associations of the lumbar spine, including previous fracture, autofusion, transitional vertebra and listhesis, were selected out and analyzed separately. Subjects were then equally grouped into low, medium and high PI. Prevalence of lumbar spine IDVP is 41.3%. 125 cases were excluded. 1603 subjects yielded 663 IDVP. This was increased in severity towards the lumbosacral junction (L1L2 9.4%, L2L3 10.9%, L3L4 13.7%, L4L5 19.9%, L5S1 28.5%) and those with low PI, while distribution was more even with high PI. 292 had positive diagnostic associations, which were more likely to occur at the level of isthmic spondylolisthesis, adjacent to a previous fracture or suprajacent to lumbosacral transitional vertebra (p&lt;0.05).This study has identified normative values for prevalence and severity of IDVP in a normal aging population. Morphological patterns that influence the pattern of IVDP such as pelvic incidence and diagnostic associations provide novel insights to the function of the aging spine.

Cauda Equina Cavernoma at level L1 Concurred with Intervertebral Disc Herniation at Level L5-S1: A Case Report of Misdiagnosis.

Vascular tumors show an extremely wide spectrum of morphologic appearances and clinical behavior. Hemangiomas or cavernomas occupy a gray zone and, because of their mass effect and localized nature, are designed frequently as tumors. Cavernous angiomas are uncommon vascular malformations found in all locations within the central nervous system. Incidence reported lie between 0.02 and 0.9%. Within the spinal cord they are most likely intramedullary and they account for 5-12% of all vascular lesions [1], [3]. Cauda equina is the least frequent site [3]. We show a case of misdiagnosis of a 45-year-old man complained of low back pain six months prior to surgery. A magnetic resonance imaging (MRI) scan revealed an L5-S1 bulky disc herniation extruding to the center of the lumbar spinal canal and compressing the thecal sac and the L5 left nerve root. An intracanal structure, at L1 level, was found and a tumor was suspected. A contrast enhanced MRI showed a round mass of 4mm diameter, slightly enhanced by gadolinium on T1W scans. Radiological diagnosis was a schwannoma. After neurosurgical and radiological evaluation, the patient underwent to the surgery. Tumor was pathologically confirmed to be cavernoma. Post-surgery, symptoms decreased and the hypoesthesia recovered completely. There were no post-operative complications. There are very few descriptions (to our knowledge, &lt; 30 cases [2] are documented in the literature) of intradural extramedullary cavernomas of the cauda equina. The most frequent presentation of cavernomas of cauda equina is between L1 and L3 [2,3], sometimes extended to more than one level. In our case the level was T12-L1, extended more in L1, on the right side, the presentation was sub-acute. Surgical intervention was direct to the disc herniation, secondary to the exeresis of the tumor. Because of intra-operating and histological findings, the acute presentation was more to be appointed to the cavernomas lesion, so the surgery we performed was precise and effective due the radiological misdiagnosis and sub-acute clinical manifestation. In our opinion their management should be a complete microsurgical removal of the tumor not only to obtain a neurological improvement in symptomatic cases, but also to achieve a definitive diagnosis.

Migrainous vertigo impairs adaptive learning as a function of uncertainty.

In this study, we examined whether vestibular migraine, as a source of increased perceptual uncertainty due to the associated dizziness, interferes with adaptive learning. The IOWA gambling task (IGT) was used to assess adaptive learning in both healthy controls and patients with migraine-related dizziness. Participants were presented with four decks of cards (A, B, C, and D) and requested to select a card over 100 trials. Participants received a monetary reward or a penalty with equal probability when they selected a card. Card decks A and B (high-risk decks) involved high rewards (win £100) and high penalties (lose £250), whereas C and D (low-risk decks; favorable reward-to-punishment ratio) involved lower rewards (win £50) and penalties (lose £50). Task success required participants to decide (i.e., adaptively learn) through the feedback they received that C and D were the advantageous decks. The study revealed that patients with vestibular migraine selected more high-risk cards than the control group. Chronic vestibular migraine patients showed delayed improvement in task performance than those with acute presentation. Only in acute vestibular migraine patients, we observed that impaired learning positively correlated with measures of dizzy symptoms. The findings of this study have clinical implications for how vestibular migraine can affect behavioural adaption in patients, either directly through altered perception or indirectly by impacting cognitive processes that can result in maladaptive behavior.

Virtual neurology survey: Factors influencing virtual care use among Ontario neurologists.

Current virtual care guidance lacks specialty-specific considerations. Neurological care is unique due to its reliance on physical examination and complex patient population. Our aim was to determine which factors impact virtual care suitability in neurology, virtual care adoption patterns, and satisfaction with virtual care among neurologists. Surveys were sent to Ontario neurologists through a shared email from September to November 2021. The survey consisted of four parts: demographics, virtual care adoption patterns, factors influencing virtual care use, and physician satisfaction with virtual care. Sixty-six of 380 (17.4%) neurologists completed the survey. The pandemic resulted in a substantial increase in virtual care use, from 1.6% of all ambulatory visits in 2019 to 70.6% in 2020. Video teleconferencing was considered more appropriate across a broader range of presentations than phone visits, with both methods more suited to follow-ups. Neurologists were largely satisfied with virtual care except for the virtual neurological examination. The neurological presentations identified as least amenable to virtual consultation were movement disorders, limb weakness, gait/balance changes, and vision changes. Four presentations were felt to be most amenable to virtual care: sleep disorders, seizure, headache, and dizziness/syncope. Factors that were felt to reduce virtual care suitability included discussion of sensitive topics and acute presentations. Neurologists were satisfied with virtual care as a means of providing outpatient care, though the specific reason for referral influenced perceived appropriateness. These results can inform the basis of the development of consensus guidelines for virtual care provision in neurology.

Information sharing following discharge of psychiatric inpatients: Improving the quality of discharge summaries

Abstract: BACKGROUND: Discharge summaries are valuable clinical documents providing information not only about the acute presentation and progression but also suggestions for future management to maintain the continuity of care. This is important in multidisciplinary, multiagency mental healthcare. AIM: It was intended to evaluate the discharge summaries for adult psychiatric inpatients, about the information shared such as the reason for admission, diagnoses, medications, progress in the ward, and legal status with an overarching aim to inform about the quality improvement of discharge summaries. METHODS: It was a service evaluation of a stratified random sample of 86 discharges from younger adult psychiatry wards, from which 73 discharge summaries were evaluated. RESULTS: The sample had 44 male and 42 female patients, with an average inpatient stay of 27.3 ± 40.8 days. Most (81.4%) of the patients had informal admission. Most patients (96.5%) had a psychiatric diagnosis; the common diagnoses were schizophrenia (24.4%), bipolar disorder (15.1%), personality disorder (17.4%), and depression (11.6%). Discharge summaries were sent on an average of 21.3 + 17.7 days (median 15 days). Most discharge summaries mentioned psychiatric diagnoses (97.3%), list of medications and dosage (95.9%), legal status during admission (74.0%), reason for admission (97.3%), and progress in the ward (97.3%). CONCLUSIONS: There is a scope to improve discharge summaries by adopting an appropriately structured format containing essential clinical information, which can be useful for maintaining continuity of patient care.

Pancreatic necrosis eroding duodenum as a complication of acute pancreatitis presenting with upper GI bleed – a case report

Pancreatic necrosis eroding duodenum as a complication of acute pancreatitis presenting with upper GI bleed – a case report

Emerging Trend of Acute Poisonings Presenting to an Emergency Department in South India.

Emerging Trend of Acute Poisonings Presenting to an Emergency Department in South India.

Neurological manifestations in dogs with acute leukemia.

Canine acute leukemia is a rare hematopoietic neoplasm. Neurological abnormalities have been frequently reported in dogs with acute leukemia (AL). However, the description of the presentation and findings are limited. This study aimed to describe the clinical findings in dogs with acute leukemia presenting with neurological signs as their primary complaint. The database of a private referral hospital was searched for cases that presented to the neurological department with neurological deficits and were subsequently diagnosed with acute leukemia. Six cases were included; all had neurological clinical signs and an abnormal neurological examination. All cases had a focal neuroanatomical localisation on neurological examination (brain n = 4; spinal = 2). Out of the four dogs with a complete magnetic resonance imaging (MRI) study, there was an ill-defined infiltrative pattern with abnormal signal intensity in the central nervous system (CNS) in three dogs and the loss of grey and white matter differentiation in the brain (n = 2) and/or spinal cord (n = 2). Other MRI findings included abnormal meningeal enhancement (n = 3), changes affecting spinal nerves and epaxial muscles (n = 2), and lymphadenopathy in the field of view (n = 2). The bone marrow assessment on MRI showed evidence of signal change (n = 3), characterized by a loss of normal fat opacity and an abnormal degree of contrast enhancement. The cerebrospinal fluid (CSF) analysis of the four dogs showed an increased protein level with non-specific pleocytosis and without evidence of malignant cells. Treatment with cytotoxic medication was implemented in two dogs. The dogs diagnosed with acute leukemia had focal neuroanatomical localisation, an infiltrative CNS pattern, and bone marrow remodulation on MRI with an increase in CSF protein and negative cytology analysis.

Endovascular thrombectomy is cost-saving in patients with acute ischemic stroke with large infarct.

Endovascular thrombectomy (EVT) is the standard of care for acute large vessel occlusion stroke. Recently, the ANGEL-ASPECT and SELECT 2 trials showed improved outcomes in patients with acute ischemic Stroke presenting with large infarcts. The cost-effectiveness of EVT for this subpopulation of stroke patients has only been calculated using data from the previously published RESCUE-Japan LIMIT trial. It is, therefore, limited in its generalizability to an international population. With this study we primarily simulated patient-level costs to analyze the economic potential of EVT for patients with large ischemic stroke from a public health payer perspective based on the recently published data and secondarily identified determinants of cost-effectiveness. Costs and outcome of patients treated with EVT or only with the best medical care based on the recent prospective clinical trials ANGEL-ASPECT, SELECT2 and RESCUE-Japan LIMIT. A A Markov model was developed using treamtment outcomes derived from the most recent available literature. Deterministic and probabilistic sensitivity analyses addressed uncertainty. Endovascular treatment resulted in an incremental gain of 1.32 QALYs per procedure with cost savings of $17,318 per patient. Lifetime costs resulted to be most sensitive to the costs of the endovascular procedure. EVT is a cost-saving (i.e., dominant) strategy for patients presenting with large ischemic cores defined by inclusion criteria of the recently published ANGEL-ASPECT, SELECT2, and RESCUE-Japan LIMIT trials in comparison to best medical care in our simulation. Prospective data of individual patients need to be collected to validate these results.