Bedside Examination Research Articles

Ethically Translating Novel Neurotechnologies for Detecting Covert Consciousness: Clinician Perspectives from an Interim Analysis of the DECODE Study (S11.005)

<h3>Objective:</h3> To develop an ethical framework for responsible clinical translation of novel neurotechnologies to detect covert consciousness in patients following severe brain injury. <h3>Background:</h3> Up to 20% of behaviorally unresponsive patients following severe brain injury may harbor covert awareness that evades detection via bedside examination, but which may be identified through advanced neurotechnologies including task-based or stimulus-based EEG and functional MRI. However, questions surrounding how to optimally deploy these neurotechnologies, communicate results, and translate findings into clinical practice are crucially underexplored. <h3>Design/Methods:</h3> Semi-structured interviews with 14 clinicians were conducted as part of DECODE (Data-driven neuroEthics for COnsciousness DEtection). Qualitative research methodology utilizing grounded theory and empirical neuroethics analysis were used to capture salient concerns and perspectives among clinicians surrounding the ethics of deploying and responsibly sharing results of advanced neurotechnologies to detect consciousness in patients with disorders of consciousness (DoC). <h3>Results:</h3> Clinicians with expertise caring for patients with DoC in diverse practice settings displayed varied ethical, clinical and philosophical perspectives surrounding the optimal use of neurotechnologies to detect consciousness in patients following brain injury. A general consensus was noted surrounding ethical obligations to ensure equitable access and communicate test results from novel neurotechnologies with families/surrogates, however, significant differences were observed in how clinicians perceived optimally contextualizing and conveying such information to surrogates/family members. Furthermore, divergent perspectives were highlighted surrounding optimum methods of clinical translation as well as which patients could benefit from the use of neurotechnologies for covert consciousness detection. <h3>Conclusions:</h3> Salient ethical themes emerging from interim analyses of interviews with clinicians revealed substantial variation in ethical perspectives on how to most effectively deploy these neurotechnologies in clinical practice. Further study is necessary and planned to capture perspectives of individuals from other stakeholder groups, including patients, surrogates and researchers, to inform the creation of a harmonized neuroethical framework for responsible clinical translation of these neurotechnologies. <b>Disclosure:</b> Dr. Young has nothing to disclose. Ms. A Lissak has nothing to disclose. Dr. Bodien has nothing to disclose. The institution of Dr. Hochberg has received research support from Paradromics, Synchron, and Neuralink through the MGH Translational Research Center. Dr. Hochberg has received intellectual property interests from a discovery or technology relating to health care. Dr. Edlow has received research support from NIH.

Neurological Wake-Up Test for Severe Neurotrauma Patients

A structured assessment of patients with severe traumatic brain injury (TBI) is routinely used in the neurointensive care units. A judicious clinical evaluation of heterogeneous pathologies such as TBI, stroke, and subarachnoid hemorrhage requires training specific to master the fundamental tools of neuro bedside examination. The wake-up test has been a strategy that has emerged as a source of valuable information[1] [2] to know about the progression of these patients and make an adequate correlation between neuromonitoring and neuroradiological imaging.[3]

Optokinetic Nystagmus: Five Reasons Why Every Neurologist Should Evaluate It (P3-9.006)

<h3>Objective:</h3> To highlight the clinical utility of optokinetic nystagmus (OKN) through five illustrative video cases. <h3>Background:</h3> Bedside evaluation of OKN allows for rapid assessment of smooth pursuit (slow phase) and saccades (fast phase). Specific abnormalities of OKN have localizing value and may also suggest specific neurologic disorders. <h3>Design/Methods:</h3> We provide five video cases where OKN was helpful in localization and/or diagnosis. Video cases are provided from https://novel.utah.edu/Gold/. <h3>Results:</h3> (1) OKN can be used to make an early diagnosis of progressive supranuclear palsy before there is ophthalmoparesis. Vertical OKN can demonstrate absent or attenuated saccades, particularly when compared to a normal response to horizontal OKN. (2) A subtle sign of internuclear opthalmoparesis, when there is no obvious limitation of adduction, can be demonstrated with horizontal OKN by noting a slow (lagging) adducting saccade. (3) In patients with dorsal midbrain (Parinaud) syndrome, upgaze is often limited or absent, and the characteristic finding of convergence-retraction nystagmus (CRN) can be easily appreciated when an optokinetic stimulus is moved downward (e.g., downward slow phase followed by CRN instead of an upward fast phase). (4) Patients with a homonymous hemianopsia due to an occipital lesion will have normal OKN; whereas, patients with a homonymous hemianopsia due to a parietal lesion will have absent OKN when the stimulus is directed toward the side of the lesion. (5) In patients who claim to have binocular or monocular blindness, the presence of OKN (when monocular, with the good eye covered) is highly suggestive of functional vision loss. Observing OKN does not prove that the patient’s visual function is normal, but does rule out blindness. <h3>Conclusions:</h3> Assessing optokinetic nystagmus with a flag, tape, drum, or the examiner’s fingertips is a portable, inexpensive, and rapid bedside examination to localize and diagnose a variety of neurologic and neuro-ophthalmic disorders. <b>Disclosure:</b> Dr. Hale has nothing to disclose. Dr. Reich has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Best Doctors. Dr. Reich has received personal compensation in the range of $500-$4,999 for serving as a Consultant for UpToDate. Dr. Reich has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Enterin. Dr. Reich has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for NIH. Dr. Reich has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Various law firms. The institution of Dr. Reich has received research support from ninds. Dr. Reich has received publishing royalties from a publication relating to health care. Dr. Reich has received publishing royalties from a publication relating to health care. Dr. Gold has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Springer .

Partial detachment of the aorta: a fatal complication of CPR chest compressions

BackgroundPartial aorta detachment is a rare and fatal complication of mechanical chest compression.Case presentationThe paper describes a patient in cardiac arrest who died despite receiving CPR using mechanical chest compression. After death, an autopsy showed the presence of a partial rupture of the aortic wall in the intra-pericardial section.DiscussionIn the discussion, for this case, we propose to deepen our knowledge of post-resuscitation complications, which may help to understand the need to maintain the recommended parameters of chest compressions, respond more confidently to changes in the patient's condition during CPR, to interpret the results of bedside examinations better, and to understand the autopsy results better. In our opinion, the best method of diagnosing internal injuries, which we provide with Point-of-Care (POCUS) ultrasound, allows for therapeutic interventions that maximize the chances of spontaneous circulation. Education and skill development are also indispensable aspects of CPR. Particular attention should be paid to the same quality of chest compressions performed.ConclusionsAs conclusions drawn from the analysis of this case, we propose paying particular attention to the difficulty of explaining changes in the patient's condition during CPR, the widespread use of POCUS, and considering the use of compressions performed by staff in situations where it is possible and safe.

Contrast-enhanced ultrasonography-based renal blood perfusion in brain-dead donors predicts early graft function.

The aim of this study was to quantify renal microcirculatory perfusion in braindead donors using contrast-enhanced ultrasonography (CEUS), and to establish an accurate, noninvasive, and convenient index for predicting delayed graft function (DGF) post-transplantation. In total, 90 brain-dead donor kidneys (training group, n=60; validation group, n=30) examined between August 2020 and November 2022 were recruited in this prospective study. CEUS was performed on the kidneys of brain-dead donors 24 hours before organ procurement and time-intensity curves were constructed. The main measures were arrival time, time to peak, and peak intensity of the kidney segmental arteries, cortex, and medulla. Recipients were divided into DGF and non-DGF groups according to early post-transplant graft function. The area under the receiver operating characteristic curve (AUC) was used to assess diagnostic performance. The arrival time of the kidney segmental artery and cortex and the time interval between the time to peak of the segmental artery and cortex were identified as independent factors associated with DGF by multivariate stepwise regression analysis. A new index for the joint prediction model of three variables, the contrast-enhanced ultrasonography/Kidney Donor Profile index (CEUS-KDPI), was developed. CEUS-KDPI showed high accuracy for predicting DGF (training group: AUC, 0.91; sensitivity, 90.5%; specificity, 92.3%; validation group: AUC, 0.84; sensitivity, 75.0%; specificity, 92.3%). CEUS-KDPI accurately predicted DGF after kidney transplantation. CEUS may be a potential noninvasive tool for bedside examinations before organ procurement and may be used to predict early renal function after kidney transplants kidneys from donors after brain death.

Dorsal Column Bedside Examination Test: Tips for the Neurosurgical Resident.

The dorsal column medial lemniscus (DCML) system is a sensory pathway of the central nervous system; it carries sensations of soft touch, vibration, proprioception, two-point discrimination, and pressure from the skin and joints. The clinical signs of the DCML pathway lesions include loss of soft touch, vibratory sense, proprioception, discrimination sense, and a positive Rhomberg test. Diseases that affect this pathway are usually degenerative, for example, spinal cord degeneration due to vitamin B12 deficiency; it can also be affected by trauma or infarction of the posterior spinal artery causing posterior cord syndrome. This video manuscript provides a step-by-step examination technique of the dorsal column examination, specially catered for Malaysian medical students and trainees. A series of videos show the techniques for soft touch sensation examination, examination of the vibratory sense, examination of the joint position sense, examination of two-point discrimination and the Rhomberg test. We hope that students can adhere to these techniques and apply them in their daily neurological assessments.

The management of accidental perineal injuries in pediatric females: Retrospective review at a single institution

BackgroundThe indications for operative management of pediatric perineal injuries are debated. We aimed to investigate our institution's experience with perineal injuries in girls and identify factors for which patients require examination under anesthesia (EUA). MethodsAll female pediatric patients presenting to our institution June 2015–2021 with an isolated perineal injury were reviewed. Demographics, symptoms, exam findings, Genitourinary Injury Score (GIS), and management strategy were recorded and analyzed. Patients were divided based on level of intervention – bedside examination without sedation, Emergency Department (ED) exam with sedation, or EUA. ResultsIn total, 202 patients with a median age of 6 years were analyzed. Bleeding was reported most frequently by patients and families (90.1%), but only 27.2% of patients had bleeding noted on ED exam. Over half of patients (n = 110, 54.5%) were managed nonoperatively; the remaining 92 (45.5%) underwent EUA. The majority of patients (n = 150, 74.3%) had a GIS of I. EUA patients had a higher estimated median total injury size (2.5 (1.5–3.5) cm vs 1.0 (0.5–1.5) cm, p < 0.001), higher percentage of active bleeding (53.3% vs. 4.8%), and higher GIS (≥ II). No one discharged from the ED required operative intervention at a later time. ConclusionAlthough further prospective evaluation is required, our investigation suggests the majority of patients presenting with perineal injuries can be managed in the emergency department, but operative intervention should be considered for patients presenting with active bleeding on physical exam, laceration or hematoma > 2 cm, or GIS ≥ II.

Development of deep-learning models for a hybrid simulation of auscultation training on standard patients using an ECG-based virtual pathology stethoscope

Cardiac auscultation (CA), the act of listening to the heart’s sound, is a critical skill that provides valuable information for identifying serious heart diseases. Proficiency in cardiac auscultation requires repeated stethoscope practice and experience in identifying abnormal or irregular cardiac rhythms. However, nowadays, most hospital admissions are short and intensely focused, with fewer opportunities for medical trainees to learn and practice bedside examination skills. It is common practice in many institutions to incorporate standardized patients (SPs) into CA training because these actors are able to represent the patient and convey the symptoms. However, SPs are typically healthy individuals, limiting the kinds of abnormalities that students can hear. In this work, we develop a novel real-time simulation-based method for virtual pathology stethoscope (VPS) detection. The VPS system uses augmented reality (AR) to teach medical students how to perform cardiac examinations by listening to abnormal heart sounds in SPs who are otherwise healthy. A digital stethoscope with two electrodes on the chest piece collects electrocardiogram (ECG) signal data sets from SPs at the four primary auscultation sites. Next, different deep-learning methods are evaluated for classifying the location of the stethoscope by taking advantage of subtle differences in the ECG signals. This study would significantly extend the simulation capabilities of SPs by allowing medical students and trainees to perform realistic CA and hear CA in a clinical environment.

Manual Muscle Testing of the Scapula and the Upper Limb through Bedside Examination.

Neurological examination is an important tool in diagnosing patients with neurological and neurosurgical conditions. As the complexity and knowledge of neurological and neurosurgical conditions increases, we are now required to learn and indoctrinate our peers and students with the correct skills and methods of examination. Emphasis on the correct techniques of testing muscle strength is essential to avoid errors in recording muscle power and in testing specific muscles which may have overlapping functions. The manual muscle testing of muscles of scapula and upper limbs was performed as to mimic a bedside clinical examination and involved an examiner, a patient and a videographer. The manual muscle testing has been performed in rostrocaudal manner starting from the scapula and ending with the thumbs. A reliable and consistent method of manual muscle testing is lacking among students and clinicians. By adhering to the methods delineated in our text and accompanying video, we hope to reduce inter-examiner variability and increase the reliability and validity of this important examination.

A bedside ultrasound protocol to the measurement of the systemic vascular resistances: Preliminary results in the patients with sepsis.

The use of the ultrasound (US) bedside examination is increasing for the detailed evaluation of the hemodynamic parameters, allowing the physicians to set the appropriate therapeutic strategies with greater precision. The aim of this study is to evaluate the hemodynamic parameters (the cardiac output or CO, the central venous pressure or CVP and the systemic vascular resistance or SVR) in the patients with sepsis, by using a bedside US approach. We consecutively enrolled n.82 patients of S.Andrea Hospital (n.47 with sepsis and n.35 without sepsis), examining the hemodynamic parameters by a bedside US evaluation. The incidence of sepsis was more than 50% of cases. The patients with sepsis presented higher comorbidity and polypharmacy (p < 0.01, p < 0.001), with increased creatinine (p < 0.001) and consequent esteemed glomerular filtration rate (p < 0.01), C-reactive protein (p < 0.01), SOFA (Sepsis-related Organ Failure Assessment) score (p < 1.58×10-7) and reduced SVR (p < 0.05). The SOFA score was inversely related to the SVR (p < 0.05). To our best knowledge, this is the first study with a bedside US protocol to measure SVR, beyond the abdominal and cardiac qualitative evaluation.

Site matters: Central neuropathic pain characteristics and somatosensory findings after brain and spinal cord lesions.

It is unknown if different etiologies or lesion topographies influence central neuropathic pain (CNP) clinical manifestation. We explored the symptom-somatosensory profile relationships in CNP patients with different types of lesions to the central nervous system to gain insight into CNP mechanisms. We compared the CNP profile through pain descriptors, standardized bedside examination, and quantitative sensory test in two different etiologies with segregated lesion locations: the brain, central poststroke pain (CPSP, n=39), and the spinal cord central pain due to spinal cord injury (CPSCI, n=40) in neuromyelitis optica. Results are expressed as median (25th to 75th percentiles). CPSP presented higher evoked and paroxysmal pain scores compared to CPSCI (p < 0.001), and lower cold thermal limen (5.6°C [0.0-12.9]) compared to CPSCI (20.0°C [4.2-22.9]; p=0.004). CPSCI also had higher mechanical pain thresholds (784.5 mN [255.0-1078.0]) compared to CPSP (235.2mN [81.4-1078.0], p=0.006) and higher mechanical detection threshold compared to control areas (2.7 [1.5-6.2] vs. 1.0 [1.0-3.3], p=0.007). Evoked pain scores negatively correlated with mechanical pain thresholds (r=-0.38, p < 0.001) and wind-up ratio (r=-0.57, p < 0.001). CNP of different etiologies may present different pain descriptors and somatosensory profiles, which is likely due to injury site differences within the neuroaxis. This information may help better design phenotype mechanism correlations and impact trial designs for the main etiologies of CNP, namely stroke and spinal cord lesions. This study provides evidence that topography may influence pain symptoms and sensory profile. The findings suggest that CNP mechanisms might vary according to pain etiology or lesion topography, impacting future mechanism-based treatment choices.

Point-Of-Care Ultrasound Screening for Proximal Lower Extremity Deep Venous Thrombosis.

Acute lower extremity deep venous thrombosis (DVT) is a serious vascular disorder that requires accurate and early diagnosis to prevent life-threatening sequelae. While whole leg compression ultrasound with color and spectral Doppler is commonly performed in radiology and vascular labs, point-of-care ultrasound (POCUS) is becoming more common in the acute care setting. Providers appropriately trained in focused POCUS can perform a rapid bedside examination with high sensitivity and specificity in critically ill patients. This paper describes a simplified yet validated approach to POCUS by describing a three-zone protocol for lower extremity DVT POCUS image acquisition. The protocol explains the steps in obtaining vascular images at six compression points in the lower extremity. Beginning at the level of the proximal thigh and moving distally to the popliteal space, the protocol guides the user through each of the compression points in a stepwise manner: from the common femoral vein to the femoral and deep femoral vein bifurcation, and, finally, to the popliteal vein. Further, a visual aid is provided that may assist providers during real-time image acquisition. The goal in presenting this protocol is to help make proximal lower extremity DVT exams more accessible and efficient for POCUS users at the patient's bedside.

The Role of Ultrasound in Diagnosing Community-Acquired Pneumonia

BACKGROUND The literature review is devoted to an urgent problem of the diagnosis of pneumonia in the practice of an anesthesiologist-resuscitator using ultrasound. The literature review describes the methodological foundations of this method, its advantages and disadvantages, sensitivity and specificity for the diagnosis of severe community-acquired pneumonia in the practice of an anesthesiologist-resuscitator.AIM OF STUDY The analysis of the most modern domestic and foreign evidence base based on the information content of lung ultrasound in CAP in the practice of an anesthesiologist-resuscitator.MATERIAL AND METHODS Russian publications were searched in the elibrary.ru database, foreign publications were searched in the PubMed database. Publications (literature reviews, observational studies, double-blind randomized trials) were searched for the period 2010–2020. A total of 1379 publications were initially selected, identified through database searches. After removing duplicates, the number of publications was reduced to 695. Of this number, 503 publications were excluded. The remaining 192 full-text articles were evaluated for text acceptability. Due to inconsistency with the main sections of the review, 77 articles were deleted from them. The remaining 115 ones were included in the qualitative synthesis and 67 ones were selected in the quantitative synthesis.RESULTS The ultrasound is a promising and worthy alternative to other imaging modalities. According to the results chest X-ray was inferior to lung ultrasound in diagnosing the presence of fluid in the pleural cavities. The sensitivity of ultrasound in assessing pleural effusion reaches 100%, the specificity is 99.7%. Pulmonary ultrasonography plays an important role in the diagnosis of pneumonia and is a promising alternative to chest X-ray and chest CT.DISCUSSION Since POCUS is performed at the patient’s bedside, the results are available to the doctor in real time, which helps in diagnosis and treatment. Sequential examinations can be performed to monitor disease progression and response to treatment. However, many facilities do not have the ability to store ultrasound images, so other healthcare professionals cannot see them.FINDINGS The ultrasound examination of the lungs is unlikely to replace computed tomography of the chest, as it does not have 100% specificity, however, it is indispensable in bedside examination and is the doctor’s sonographic “stethoscope”, which significantly expands diagnostic capabilities.

How to approach jaundice in the MRCP PACES exam.

For every medical trainee, the Membership of the Royal College of Physicians' Practical Assessment of Clinical Examination Skills (PACES) exam is one of the most difficult exams they must face in their career. It is designed to assess the clinical knowledge and skills of the trainee doctors who are entering higher specialist training. It sets rigorous standards to ensure the competence of the candidates across a range of skills. This article discusses a systematic approach to a patient with jaundice, which is a commonly encountered station in the exam, so that candidates will become more familiar with common causes and how to differentiate between these, as well as important bedside examination skills.

Abstract TMP20: Performing The Pediatric National Institutions Of Health Stroke Scale Over Televideo: A Pilot Study

Introduction: Telestroke networks are widely used by stroke neurologists to rapidly assess adults presenting to remote facilities with suspected acute stroke. Televideo assessment of acute neurological deficits in children is potentially useful for children who live in remote areas, but has not been studied. This study tested the feasibility of assessing the pediatric National Institutes of Health stroke scale (PedNIHSS) by televideo in children. Methods: Children ages 2-17 years with and without strokes were recruited and examined in the outpatient neurology clinic. The PedNIHSS was performed on each child by separate neurologists; one by televideo and the other at the bedside. The total PedNIHSS, subscores and time to complete each exam were recorded. Intraclass correlation coefficients (ICC) were used to analyze inter-rater reliability. Results: Twenty children were recruited with an average range of 9.2 years (range 2-17 years). Six children had chronic stroke. By bedside exam, the total PedNIHSS score ranged from 0-8 with a mean of 1.65. By televideo, the PedNIHSS total score was identical to the bedside examination in 12/20 (60%) of the children and identical or within 1 point in 19/20 children (95%). All total PedNIHSS were scored higher by the bedside vs remote examiner in cases where there was a difference. There was excellent overall inter-rater reliability (ICC=0.92; 95% CI: 0.81, 0.97) for the total PedNIHSS when comparing bedside and video exams. In the subgroup of children less than 6 years of age, ICC was 0.88 (95% CI: 0.44-0.98). The PedNIHSS subscores with lowest reliability between exams were dysarthria, ataxia and sensory change. The average time to complete the bedside and remote examinations were 5 minutes and 7 minutes, respectively. Conclusions: It is feasible to perform the full PedNIHSS over televideo with reasonable accuracy and in a similar amount of time as compared to bedside evaluations. Limitations of this study include a small number of patients and overall low burden of neurologic deficits. Future studies focusing on children presenting with focal neurologic deficits in the acute care setting are needed to further determine the reliability of performing the PedNIHSS over televideo.

Abstract TP46: Eye Telestroke Exam Device For Improved Triage In Stroke Pilot Study

Background: Telemedicine has enabled hospitals without stroke specialists to efficiently triage acute ischemic stroke patients; however, ~10-15% of patients with posterior circulation stroke present with visual loss, visual field deficit, or visual obscuration that can only be detected by thorough bedside examination. We have developed a novel, provisionally patented, device which allows for remote visual field assessment in patients with suspected stroke. The Eye Telestroke Exam Device consists of 3D goggles and custom software that tracks a patient’s eye movements when they respond to visual stimuli within the goggle’s screens and verbal commands given by the remote Neurology specialist. The device system is designed to pair (via Bluetooth technology) with any telemedicine system and will allow the remote examiner to perform a detailed visual field examination remotely. Objective: In this pilot study, we aim to evaluate the sensitivity and specificity of the Telestroke Eye Exam device to evaluate visual fields in healthy individuals and in patients who already have suffered a posterior circulation stroke and have permanent visual field deficits. Methods and Design: The Eye Telestroke Exam Device for Improved Triage in Stroke (EYE-TEST) Pilot study is a 2-arm, prospective study of patients with either a history of posterior circulation stroke with visual disturbances (stroke group) or patients with no visual disturbances (control). A roll in phase of 5 patients in each group will be performed, prior to enrollment of 20 patients into each arm. Investigators performing the device exam will be blinded to patient history. Device performance (sensitivity and specificity) will be compared to conventional bedside visual field assessment in each group. The device exam will be repeated twice for each patient. Results: The roll-in phase of the EYE-STUDY showed 100% sensitivity and specificity for detecting visual field disturbances in the stroke group. No abnormalities were detected in the control group. Conclusion: Enrollment into the study is ongoing and estimated study completion will occur October 2022. Final results of the EYE-TEST study will be presented at ISC 2023. Results of this study will inform future design iterations and studies.

Chapter 16 - Motor sequela of adult and pediatric stroke: Imminent losses and ultimate gains

Stroke is the leading cause of neurological disability in the United States and worldwide. Remarkable advances have been made over the past 20 years in acute vascular treatments to reduce infarct size and improve neurological outcome. Substantially less progress has been made in the understanding and clinical approaches to neurological recovery after stroke. This chapter reviews the epidemiology, bedside examination, localization approaches, and classification of stroke, with an emphasis on motor stroke presentations and management, and promising research approaches to enhancing motor aspects of stroke recovery.

Aspiration Risk Screening With Tongue Pressure Measurement in Acute Stroke: A Diagnostic Accuracy Study Using STARD Guidelines.

Dysphagia can affect more than 50% of stroke patients in the acute phase. Aspiration pneumonia is a serious complication that can be prevented with dysphagia screening and assessment. Measurement of tongue elevation pressure is suggested to be a useful tool in aspiration risk screening. This study aimed to assess the diagnostic accuracy of maximum anterior tongue elevation strength (Pmax) in acute stroke care. In this prospective study, data were collected in a neurology department (stroke center) where patients formed a consecutive case series. The sample consisted of thirty stroke patients who failed an initial dysphagia screening. Patients underwent anterior tongue elevation strength measurement (index test) during bedside dysphagia assessment by a speech-language pathologist and flexible endoscopic evaluation of swallowing (reference test) by an otorhinolaryngologist on the same day. Outcome variables (index values in kPa, reference values interpreted on the penetration-aspiration scale) were used for estimating measures of diagnostic accuracy in aspiration risk screening. Ten patients aspirated on instrumental evaluation. At the cut-off point of ≤ 34 kPa the analysis showed 90% sensitivity, 35% specificity, 41% positive predictive value, and 88% negative predictive value. The area under the curve (AUC) for Pmax was AUC = 0.700 (95% CI [0.500-0.900]). Although individuals with low anterior tongue elevation strength tend to have a higher risk of aspiration, this variable alone is not capable of screening aspiration in acute stroke. In combination with a thorough noninstrumental bedside examination, it might have the potential to reduce the number of false positive cases. Further studies in this area would be worthwhile.

Dizziness Evaluation and Characterisation of Patients with Posterior Circulation Stroke in the Emergency Department; a Case Series Study.

Dizziness is a common scenario in the Emergency Departments (EDs). Among dizziness underlying causes, the posterior circulation stroke is especially relevant due to its mobimortality and concerning misdiagnosis rates. Therefore, we conducted this study to assess dizziness evaluation and baseline characteristics of patients with PS in the ED. We conducted a 3-year retrospective observational study on PS cases confirmed by magnetic resonance imaging (MRI). Concretely, we analysed the demographic profile of these patients, the initial PS clinical presentation, and diagnostic workup (with emphasis on dizziness evaluation) performed at the ED. During the study period, 85 cases were registered. Risk factors for cardiovascular disease were present in 85.5% and previous visits to the ED due to dizziness were recorded in 16.5%. The main clinical presentation was dizziness, concretely as an acute vestibular syndrome (38.8%) with additional neurological signs or symptoms (80%). Evaluation by the otolaryngologist on call was requested in less than 10% of the cases and included the HINTS protocol use with a sensitivity of 100% for central nervous system underlying causality. A brain CT study was always performed with a sensitivity of 27%. However, 96.47% of patients were primarily admitted to the Neurology hospitalization ward and MRI was always performed in a mean time of 3.21 days confirming the diagnosis. Dizziness is the most frequent symptom of PS. Patients usually present an AVS (associated with additional N-SS or not) and HINTS bedside examination is the most adequate protocol to differentiate a PS from other AVS causes until the diagnostic confirmation via MRI. Interestingly, mainly otolaryngologists seem to use HINTS. However, the use of CT is widespread despite its poor value.

388. Does This Patient Have C. difficile Infection? A Systematic Review and Meta-Analysis

Abstract Background The clinical features of Clostridioides difficile infection overlap with many conditions. Accurate and early diagnosis of C. difficile is essential for reducing morbidity and mortality. We performed a systematic review to evaluate the diagnostic utility of clinical findings associated with C. difficile. Methods We included all studies that reported clinical features of C. difficile, a valid reference standard test for confirming diagnosis of C. difficile, and a comparison among patients with a positive and negative test result. The MEDLINE, EMBASE, CINAHL, and Cochrane databases were searched up to September 2021. Meta-analyses using univariate and bivariate methods were used to determine estimates of sensitivity, specificity, and likelihood ratios (LRs). Results A total of 11,231 articles were screened and 46 were included for final analysis, enabling evaluation of 67 features for their diagnostic utility for C. difficile (10 clinical examination findings, 4 laboratory tests, 10 radiographic findings, prior exposure to 14 antibiotic types, and 29 clinical risk factors). Of the ten features identified on clinical examination, none were associated with increased likelihood of C. difficile infection. Features that increased likelihood of C. difficileinfection were stool leukocytes (LR 5.31, 95% CI 3.29-8.56), hospital admission in prior three months (LR 2.39, 95% CI 1.68-3.30), leukocytosis (LR 1.50, 95% CI 1.24-1.75), and low serum albumin (LR 1.43, 95% CI 1.06-1.97). Some clinical co-morbidities increased likelihood of C. difficile including congestive heart failure (LR 3.01, 95% CI 2.26-3.80) and end-stage renal disease (LR 3.85, 95% CI 1.73-7.57). Several radiographic findings also strongly increased the likelihood of C. difficile infection like pericolonic stranding (LR 10.72, 95% CI 9.59-11.84) and ascites (LR 2.91, 95% CI 1.76-4.80). Conclusion There is limited utility of bedside clinical examination alone in detecting or ruling out C. difficile infection. Accurate diagnosis of C. difficile infection requires a combination of thoughtful clinical assessment and interpretation of test results. However, microbiologic testing is needed for confirmation in all suspected cases. Disclosures All Authors: No reported disclosures.