Clinical Reassessment Research Articles

Decentralization Matters: Association of Adherence to Treatment and Distance for the Management of Non-Communicable Diseases in Rural Tanzania

Since March 2019, a non-communicable diseases program has been established at hospital level, with enrollment and clinical reassessment every 6 months. Since July 2023, monthly enrollment and visits have also been conducted at health center level. This study aimed at assessing the adherence to scheduled follow-up visits following the decentralization of the integrated NCDs program from Hospital to Health Center level and investigate factors influencing follow-up adherence. The study was performed in a rural district in Iringa Region, Tanzania. Adherence was measured at both levels. Multivariate regression analysis was conducted to describe socio-demographic and clinical factors influencing attendance at the 6-month hospital-level visit. Among 2198 patients enrolled at the hospital level, weighted adherence over 42 months was 40.8% (95% CI 39.0–42.6%) at the 6-month visit. Multivariate analysis revealed that as the distance from the hospital increased, the probability of attendance decreased (OR 0.17; 95% CI: 0.08–0.39). Among 571 patients enrolled at the residence level, adherence over the first 10 months of program implementation was 91.6% (90.4–92.8%). The findings showed that distance was by far the most important barrier to follow-up adherence and suggested that decentralizing the program from the hospital to peripheral health centers may ensure high follow-up rates.

497. ENDOFLIP AND BOTULIN TOXIN INJECTION: THERAPEUTIC MANAGEMENT IN ESOPHAGEAL AND GASTRIC MOTILITY DISORDERS

Abstract Introduction Esophageal motility disorders present diagnostic and therapeutic challenges, with dysphagia being a common symptom prompting evaluation. The Endolumenal Functional Lumen Imaging Probe (EndoFLIP) has recently gained recognition as a valuable tool for assessing esophageal function. This study aims to evaluate the utility of EndoFLIP in guiding therapeutic interventions, specifically focusing on botulinum toxin injections, among patients presenting with diverse esophageal disorders. Moreover, the study acknowledges the potential of EndoFLIP as a diagnostic adjunct during diagnostic upper gastrointestinal endoscopy in cases where therapeutic alternatives are limited or as therapeutic trial. Methods A retrospective analysis was conducted on 21 patients who underwent EndoFLIP assessment and subsequently received botulinum toxin injection at the same procedure. These patients were identified from records at a tertiary center, covering the period from January 2022 to February 2023. EndoFLIP procedures were analyzed, focusing on patient symptoms and indication for the procedure. Data regarding clinical symptoms, EndoFLIP findings, and therapeutic interventions were extracted and analyzed to assess the role of EndoFLIP in guiding treatment decisions for esophageal disorders. The used cutoffs for esophagogastric junction (EGJ) distensibility index were < 2 mm2/mmHg and < 10 mm2/mmHg for pyloric distensibility. Results All patients referred for esophageal motility evaluation with EndoFLIP presented with dysphagia as the primary symptom. Two patients presented with postprandial bloating, leading to further evaluation with impedance planimetry to assess pyloric distensibility, suspected to be due to diabetic gastroparesis. Following EndoFLIP assessment, a conclusive diagnosis was achieved in all patients: 10 patients were diagnosed with esophagogastric junction outflow obstruction, 1 patient with absent contractility, 7 patients with achalasia, and 1 patient with hypercontractile esophagus. Patients who underwent planimetry to evaluate pyloric distensibility both exhibited reduced distensibility index. Following treatment, 10 patients showed clinical improvement and 11 await clinical reassessment. Conclusions Regarding the evaluation of the EGJ distensibility index in patients with achalasia without indication for invasive treatment, the EndoFLIP emerges as a diagnostic tool that allows for immediate guidance if intervention is recommended. Likewise, patients with refractory gastroparesis and pylorospasm identified through EndoFLIP may benefit from toxin injection for future myotomy decision. In conclusion, EndoFLIP serves as a valuable tool in diagnosing and guiding therapeutic interventions in patients with esophageal and gastric motility disorders. Further research is warranted to validate the role of EndoFLIP in optimizing treatment outcomes for esophageal disorders.

2024 update in heart failure.

In the last years, major progress has occurred in heart failure (HF) management. The 2023 ESC focused update of the 2021 HF guidelines introduced new key recommendations based on the results of the last years of science. First, two drugs, sodium-glucose co-transporter-2 (SGLT2) inhibitors and finerenone, a novel nonsteroidal, selective mineralocorticoid receptor antagonist (MRA), are recommended for the prevention of HF in patients with diabetic chronic kidney disease (CKD). Second, SGLT2 inhibitors are now recommended for the treatment of HF across the entire left ventricular ejection fraction spectrum. The benefits of quadruple therapy in patients with HF with reduced ejection fraction (HFrEF) are well established. Its rapid and early up-titration along with a close follow-up with frequent clinical and laboratory re-assessment after an episode of acute HF (the so-called 'high-intensity care' strategy) was associated with better outcomes in the STRONG-HF trial. Patients experiencing an episode of worsening HF might require a fifth drug, vericiguat. In the STEP-HFpEF-DM and STEP-HFpEF trials, semaglutide 2.4mg once weekly administered for 1year decreased body weight and significantly improved quality of life and the 6min walk distance in obese patients with HF with preserved ejection fraction (HFpEF) with or without a history of diabetes. Further data on safety and efficacy, including also hard endpoints, are needed to support the addition of acetazolamide or hydrochlorothiazide to a standard diuretic regimen in patients hospitalized due to acute HF. In the meantime, PUSH-AHF supported the use of natriuresis-guided diuretic therapy. Further options and most recent evidence for the treatment of HF, including specific drugs for cardiomyopathies (i.e., mavacamten in hypertrophic cardiomyopathy and tafamidis in transthyretin cardiac amyloidosis), device therapies, cardiac contractility modulation and percutaneous treatment of valvulopathies, with the recent finding from the TRILUMINATE Pivotal trial, are also reviewed in this article.

Memory complaint in a middle-income country: a four-year longitudinal study in a cohort with low-education

Abstract Background Memory complaints are frequent in older adults and are associated with higher risk of cognitive decline. Objective To investigate the functional outcome of individuals with memory complaints followed up at primary care centers. Methods Data were collected between 2016 e 2020 in primary health care centers in Brazil. Patients underwent the Brief Cognitive Screening Battery, and the Functional Activities Questionnaire. Results The initial sample (2016) comprised 91 individuals classified into those with subjective cognitive decline (SCD, n = 15), mild cognitive impairment (MCI, n = 45), or dementia (n = 31). During follow-up, 8 individuals (8.8% of the initial sample) died and 26 (28.5% of the initial sample) were not found. Fifty-seven participants underwent clinical reassessment. Of 15 individuals with SCD, 7 were not found (46.7%), 4 (26.7%) progressed to MCI, and 4 (26.7%) remained stable. Of 45 individuals with MCI, 11 were not found (24.4%), 2 (4.4%) died, 6 (13.4%) progressed to dementia, 12 (26.7%) regressed to SCD, and 14 (31.1%) remained stable. Of 31 individuals with dementia, 8 were not found (25.8%), 6 (19.4%) died, 2 (6.5%) regressed to SCD, 7 (22.6%) regressed to MCI, and 8 remained stable (25.8%). Clinical improvement was due to the treatment of reversible causes, such as B12 hypovitaminosis and mood disorders. Older age, lower Mini-Mental State Examination, and higher scores of memory complaint, but not the use of benzodiazepines and of proton pump inhibitors, were predictors of functional status. Conclusion Despite their limits (short sample size, missing data), these results support the idea that adequate screening, follow-up, and treatment of reversible causes of dementia in primary care are essential.

Laser Test Spots: A Scoping Review.

Laser test spots are commonly suggested for the assessment of clinical response and adverse effects, but use by laser operators is not well described. To describe the use of laser test spots in the existing published literature regarding methodology (location, treatment parameters) and objective (clinical efficacy, safety, other). This scoping review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines and included indexed studies performing test spots in human subjects for dermatologic conditions with clinical reassessment at a subsequent visit. Among 5,261 identified publications, 103 studies with 959 test spots were selected for inclusion. Test spots conducted were mostly on lesional skin (89.3%) assessing both clinical response and adverse effects (76.9%). Most test spots used multiple laser parameters with a single wavelength (48.3%). Fluence was most frequently adjusted either alone (30.1%) or in combination with pulse duration or spot size. Other described test spots examined single set of laser parameters, multiple wavelengths with various parameters, or were left unspecified. Laser test spot methodology was diverse and performed for dual objectives of efficacy and safety. The authors have compiled clinical considerations to assist laser operators in deciding whether performing a test spot may be beneficial to their patient.

Misdiagnosis of Cutaneous Epithelioid Angiosarcoma as Diabetic Foot Ulcer: A Case Study

Background. AS is a malignant tumor that originates from vascular endothelial cells and is known for a high rate of local recurrence and metastasis. Case Report. A 48-year-old male presented with cutaneous epithelioid AS. Cutaneous AS of the foot is quite rare, especially in the absence of predisposing factors, and in this patient it was previously misdiagnosed as a DFU. Conclusion. Physicians should be aware of this rare presentation of cutaneous AS. The authors of the current report advise regular clinical reassessment of chronic ulcers and biopsies of nonhealing wounds, even when adequate wound treatment has been administered, with the goal of identifying ulcerated skin malignancies and preventing delay in providing appropriate treatment.

A novel radiographic projection for the detection of a scapula body fracture in a Thoroughbred foal

SummaryThis case report describes the clinical and diagnostic imaging findings, treatment and outcome of a 3‐month‐old Thoroughbred foal referred for the evaluation of severe left forelimb lameness and presents the acquisition of a novel radiographic projection of the scapula used to achieve the diagnosis. No abnormalities were found with the standard radiographic examination of the left shoulder. A right dorsal 45° lateral‐ left ventral lateral oblique radiographic view was performed to evaluate the body of the left scapula. A longitudinal, minimally displaced fracture of the infraspinous fossa was diagnosed with this projection. Ultrasound was used in conjunction to confirm the diagnosis, assess the displacement of the fracture in the sagittal plane and evaluate soft tissue damage. The foal was treated conservatively with anti‐inflammatory drugs and stall rest. A radiographic follow‐up and clinical reassessment were performed, and the horse appeared sound, no atrophy of the region was appreciated and no radiographic abnormalities were found.

Epidemiology and Clinical Course of Chronic Autoimmune Neuropathies During the SARS-CoV-2 Pandemic in Latvia

Background: Chronic autoimmune neuropathies are a group of rare neurological disorders caused by the immune response to autoantigens in the peripheral nervous system. Objective: This study aimed to report epidemiological data in Latvia on the most common chronic autoimmune neuropathies and evaluate SARS-CoV-2 infections or vaccinations’ impact on our patient’s clinical course of the disease. Methods: A single-center observational study was performed, which included all patients diagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN) in Latvia since 2015. Prevalence and incidence were calculated by using population data from the corresponding time of the Central Statistics Bureau of Latvia. Detailed clinical evaluation and re-assessment of diagnostic criteria were performed in the whole study group. All patients underwent telephone interviews regarding their SARS-CoV-2 vaccination or infection status. Results: This study included 23 CIDP and 8 MMN patients. The point prevalence and incidence of CIDP were 1.21 per 100 000 people and 1.16 per 100 000 people, respectively. The point prevalence and incidence of MMN were 0.42 per 100 000 individuals and 0.40 per 100 000 individuals, respectively. Most of the patients involved in this study (90%, n=28) with CIDP or MMN were vaccinated against SARS-CoV-2 infection, and none of the patients experienced fluctuations or relapse regarding autoimmune polyneuropathy. Conclusion: The incidence and prevalence of CIDP and MMN in Latvia are similar to previously reported European studies. In our study group, vaccination against SARS-CoV-2 was safe and did not negatively affect the clinical course of CIDP and MMN patients.

Properties of ultrasound-rapid MRI clinical diagnostic pathway in suspected pediatric appendicitis

Objectiveto determine diagnostic accuracy of an US-MRI clinical diagnostic pathway to detect appendicitis in the emergency department (ED). Study designprospective cohort study of 624 previously healthy children 4–17 years old undergoing US for suspected appendicitis and clinical re-assessment. Children with non-diagnostic USs and persistent appendicitis concern/conclusive US-reassessment discrepancies underwent ultra-rapid MRI (US-MRI pathway), interpreted as positive, negative or non-diagnostic. Cases with missed appendicitis, negative appendectomies, and CT utilization were considered clinically diagnostically inaccurate. Primary outcome was the proportion of accurate diagnoses of appendicitis/lack thereof by the pathway. Results150/624 (24%) children had appendicitis;255 USs (40.9%) were non-diagnostic. Of 139 US-MRI pathway children (after 117 non-diagnostic and 22 conclusive USs), 137 [98.6%; 95% CI 0.96–1.00] had clinically accurate outcomes (1 CT, 1 negative appendectomy): sensitivity 18/18 [100%], specificity 119/121 [98.3%], positive predictive value 18/20 [90.5%], negative predictive value 119/119 [100%]. MRI imaging accuracy was 134/139 (96.4%); 3 MRIs were non-diagnostic (no appendicitis).In the overall algorithm, 616/624 [98.7% (0.97–0.99)] patients had accurate outcomes: 147/150 (98.0%) appendicitis cases had confirmatory surgeries (3 CTs) and 469/474 (98.9%) appendicitis-negative children had no surgery/CT. Conclusionthis study demonstrated high clinical accuracy of the US-rapid-MRI pathway in suspected pediatric appendicitis after non-diagnostic US.

Misdiagnosis of Uncomplicated Cellulitis: a Systematic Review and Meta-analysis.

Cellulitis is a clinical diagnosis with several mimics and no gold standard diagnostic criteria. Misdiagnosis is common. This review aims to quantify the proportion of cellulitis misdiagnosis in primary or unscheduled care settings based on a second clinical assessment and describe the proportion and types of alternative diagnoses. Electronic searches of Medline, Embase and Cochrane library (including CENTRAL) using MeSH and other subject terms identified 887 randomised and non-randomised clinical trials, and cohort studies. Included articles assessed the proportion of cellulitis misdiagnosis in primary or unscheduled care settings through a second clinical assessment up to 14days post initial diagnosis of uncomplicated cellulitis. Studies on infants and patients with (peri-)orbital, purulent and severe or complex cellulitis were excluded. Screening and data extraction was conducted independently in pairs. Risk of bias was assessed using a modified risk of bias tool from Hoy et al. Meta-analyses were undertaken where ≥ 3 studies reported the same outcome. Nine studies conducted in the USA, UK and Canada, including a total of 1600 participants, were eligible for inclusion. Six studies were conducted in the inpatient setting; three were in outpatient clinics. All nine included studies provided estimates of the proportion cellulitis misdiagnosis, with a range from 19 to 83%. The mean proportion misdiagnosed was 41% (95% CI 28 to 56% for random effects model). Heterogeneity between studies was very high both statistically (I2 96%, p-value for heterogeneity < 0.001) and clinically. Of the misdiagnoses, 54% were attributed to three conditions (stasis dermatitis, eczematous dermatitis and edema/lymphedema). The proportion of cellulitis misdiagnosis when reviewed within 14days was substantial though highly variable, with the majority attributable to three diagnoses. This highlights the need for timely clinical reassessment and system initiatives to improve diagnostic accuracy of cellulitis and its most common mimics. Open Science Framework ( https://osf.io/9zt72 ).

SARS-CoV-2 omicron (B.1.1.529)-related COVID-19 sequelae in vaccinated and unvaccinated patients with cancer: results from the OnCovid registry.

COVID-19 sequelae can affect about 15% of patients with cancer who survive the acute phase of SARS-CoV-2 infection and can substantially impair their survival and continuity of oncological care. We aimed to investigate whether previous immunisation affects long-term sequelae in the context of evolving variants of concern of SARS-CoV-2. OnCovid is an active registry that includes patients aged 18 years or older from 37 institutions across Belgium, France, Germany, Italy, Spain, and the UK with a laboratory-confirmed diagnosis of COVID-19 and a history of solid or haematological malignancy, either active or in remission, followed up from COVID-19 diagnosis until death. We evaluated the prevalence of COVID-19 sequelae in patients who survived COVID-19 and underwent a formal clinical reassessment, categorising infection according to the date of diagnosis as the omicron (B.1.1.529) phase from Dec 15, 2021, to Jan 31, 2022; the alpha (B.1.1.7)-delta (B.1.617.2) phase from Dec 1, 2020, to Dec 14, 2021; and the pre-vaccination phase from Feb 27 to Nov 30, 2020. The prevalence of overall COVID-19 sequelae was compared according to SARS-CoV-2 immunisation status and in relation to post-COVID-19 survival and resumption of systemic anticancer therapy. This study is registered with ClinicalTrials.gov, NCT04393974. At the follow-up update on June 20, 2022, 1909 eligible patients, evaluated after a median of 39 days (IQR 24-68) from COVID-19 diagnosis, were included (964 [50·7%] of 1902 patients with sex data were female and 938 [49·3%] were male). Overall, 317 (16·6%; 95% CI 14·8-18·5) of 1909 patients had at least one sequela from COVID-19 at the first oncological reassessment. The prevalence of COVID-19 sequelae was highest in the pre-vaccination phase (191 [19·1%; 95% CI 16·4-22·0] of 1000 patients). The prevalence was similar in the alpha-delta phase (110 [16·8%; 13·8-20·3] of 653 patients, p=0·24), but significantly lower in the omicron phase (16 [6·2%; 3·5-10·2] of 256 patients, p<0·0001). In the alpha-delta phase, 84 (18·3%; 95% CI 14·6-22·7) of 458 unvaccinated patients and three (9·4%; 1·9-27·3) of 32 unvaccinated patients in the omicron phase had sequelae. Patients who received a booster and those who received two vaccine doses had a significantly lower prevalence of overall COVID-19 sequelae than unvaccinated or partially vaccinated patients (ten [7·4%; 95% CI 3·5-13·5] of 136 boosted patients, 18 [9·8%; 5·8-15·5] of 183 patients who had two vaccine doses vs 277 [18·5%; 16·5-20·9] of 1489 unvaccinated patients, p=0·0001), respiratory sequelae (six [4·4%; 1·6-9·6], 11 [6·0%; 3·0-10·7] vs 148 [9·9%; 8·4-11·6], p=0·030), and prolonged fatigue (three [2·2%; 0·1-6·4], ten [5·4%; 2·6-10·0] vs 115 [7·7%; 6·3-9·3], p=0·037). Unvaccinated patients with cancer remain highly vulnerable to COVID-19 sequelae irrespective of viral strain. This study confirms the role of previous SARS-CoV-2 immunisation as an effective measure to protect patients from COVID-19 sequelae, disruption of therapy, and ensuing mortality. UK National Institute for Health and Care Research Imperial Biomedical Research Centre and the Cancer Treatment and Research Trust.

Reliability and validity of visual analysis of [ 18 F]FE-PE2I PET/CT in early Parkinsonian disease.

[ 18 F]FE-PE2I (FE-PE2I) is a new radiotracer for dopamine transporter (DAT) imaging with PET. The aim of this study was to evaluate the visual interpretation of FE-PE2I images for the diagnosis of idiopathic Parkinsonian syndrome (IPS). The inter-rater variability, sensitivity, specificity, and diagnostic accuracy for visual interpretation of striatal FE-PE2I compared to [ 123 I]FP-CIT (FP-CIT) single-photon emission computed tomography (SPECT) was evaluated. Thirty patients with newly onset parkinsonism and 32 healthy controls with both an FE-PE2I and FP-CIT were included in the study. Four patients had normal DAT imaging, of which three did not fulfil the IPS criteria at the clinical reassessment after 2 years. Six raters evaluated the DAT images blinded to the clinical diagnosis, interpreting the image as being 'normal' or 'pathological', and assessed the degree of DAT-reduction in the caudate and putamen. The inter-rater agreement was assessed with intra-class correlation and Cronbach's α . For calculation of sensitivity and specificity, DAT images were defined as correctly classified if categorized as normal or pathological by ≥4/6 raters. The overall agreement in visual evaluation of the FE-PE2I- and FP-CIT images was high for the IPS patients ( α = 0.960 and 0.898, respectively), but lower in healthy controls (FE-PE2I: α = 0.693, FP-CIT: α = 0.657). Visual interpretation gave high sensitivity (both 0.96) but lower specificity (FE-PE2I: 0.86, FP-CIT: 0.63) with an accuracy of 90% for FE-PE2I and 77% for FP-CIT. Visual evaluation of FE-PE2I PET imaging demonstrates high reliability and diagnostic accuracy for IPS.

Recanalization and outcomes after cerebral venous thrombosis: a systematic review and meta-analysis

BackgroundRecanalization in cerebral venous thrombosis (CVT) can begin as early as 1 week after initiating therapeutic anticoagulation. The clinical significance of recanalization remains uncertain. ObjectivesWe aimed to investigate the association between recanalization and functional outcomes and explored predictors of recanalization. MethodsA systematic literature search was conducted (EMBASE, MEDLINE, Cochrane library) to identify: (1) patients with CVT aged ≥18 years treated with anticoagulation only; (2) case series, cohort, or randomized controlled trial studies; and (3) reported recanalization rates and functional outcomes using either a modified Rankin Scale (mRS) or sequelae of CVT at last follow-up. Meta-analysis was performed using pooled odds ratios (ORs) with exploration of sex and age effects using meta-regression. ResultsTwenty-three studies were eligible with 1418 individual patients in total. Timing of reimaging and clinical reassessment was variable. Absence of recanalization was associated with increased odds of an unfavorable functional outcome (mRS 2-6 versus 0-1; OR, 3.66; 95% CI, 1.73-7.74; p = 0.001), CVT recurrence (OR, 8.81; 95% CI, 1.63-47.7; p = 0.01), and chronic headache (OR, 2.78; 95% CI, 1.16-6.70; p = 0.02). On meta-regression, the relationship between recanalization and mRS differed by the proportion of female patients, where lower proportions of women were associated with higher likelihood of a worse outcome, but not by mean participant age. There was no incremental benefit of full compared with partial recanalization with respect to favorable mRS or recurrence, but odds of chronic headache were higher with partial versus full recanalization (OR, 3.80; 95% CI, 1.43-10.11; p = 0.008). Epilepsy and visual sequelae were not associated with recanalization. ConclusionsAbsence of recanalization was associated with worse functional outcomes, CVT recurrence, and headache, but outcomes were modified by sex. The degree of recanalization was significant in relation to headache outcomes, where partial compared with complete recanalization resulted in a greater likelihood of residual headache. Prospective studies with common timing of repeat clinical-neuroimaging assessments will help to better ascertain the relationship and directionality between the degree of recanalization and outcomes.

Rhythm and conduction complications after COVID-19 infection in physiological hypertrophy of myocardium (athlete&#39;s heart).

The term 'athletic heart syndrome' (AHS) is used to describe specific circulatory and morphological changes in individuals who participate in sports competitions. The syndrome is characterized by normal cardiac function and reversible myocardial remodelling.The incidence and severity of the post-COVID-19 cardiac pathology in active athletes are so far unclear. One of the complications involving the heart is myocarditis. We present a case of a 23-year-old rower after having a moderate COVID-19 infection. Electrocardiograms showed evidence of a shift in conduction and rhythm disturbances ranging from Group 1 (normal ECG findings) to Group 2 (abnormal ECG findings) on the background of an AHS. Echocardiography (with new methods of evaluating deformity - Global Longitudinal Strain) revealed an area with mildly reduced left ventricular deformity around the apex. To assess the subtle alterations in the myocardium, magnetic resonance imaging was used and focal myocarditis was detected. In our patient, considering the degree of severity of his COVID-19 infection - a moderate one, a decision was taken to perform a clinical and instrumental reassessment of his cardiovascular complications 6 months after the infection.This clinical case presents two substantial issues. First, is the AHS more susceptible to rhythm and conduction disturbances after a COVID-19 infection than that of a person who does not actively participate in sports? Second, what the reversibility or the definitive nature of these disturbances is, and how this impacts the prognosis associated with an active sporting activity.

Evaluation of a treatment pathway for the management of uncomplicated diverticulitis.

Recent clinical practice recommendations have radically modified the management of colonic diverticulitis. The goal of our study was to evaluate a treatment pathway for uncomplicated diverticulitis and to analyze the outcome (patient compliance, treatment failure and complications). All patients who presented to the emergency department with the diagnosis of uncomplicated diverticulitis were prospectively included in this study. The treatment pathway included an outpatient clinical re-assessment by a gastrointestinal surgeon. In case of symptomatic treatment failure, oral antibiotics were prescribed. If developed clinical signs of severity developed, the patient was referred to the emergency department for new laboratory and imaging workup. Eighty-seven patients were included. The mean interval before re-assessment was 2.8 days. Fifty-nine patients (67.8%) had symptomatic treatment upon discharge from the emergency department and were reassessed as outpatients by the surgical team. Patient evolution was satisfactory for 45 (76.3%); 10 (16.9%) required oral antibiotics. One (1.7%) patient developed complicated diverticulitis. Thirty-four (39.1%) patients did not comply with the current recommendations. In our experience, uncomplicated diverticulitis can be treated effectively in an ambulatory setting followed by early re-assessment by a surgeon.

Knee laxity after anterior tibial eminence fracture in children: A 35-case series

IntroductionAnterior tibial eminence (ATE) fractures are characterized by avulsion of the anterior cruciate ligament insertion. The aim of our study was to evaluate the long-term incidence of laxity and instability in the aftermath of these fractures. The secondary objective was to identify factors for instability. HypothesisATE fracture in children is responsible for laxity and instability in the medium and long term. Material and methodsThis retrospective, single-center study included 35 isolated fractures of the tibial intercondylar eminence during skeletal growth between January 2006 and January 2020. Analysis comprised demographics, laxity measured by GNRB™, range of motion and IKDC and Lysholm scores. Clinical reassessment was performed in 24 patients, the other 11 being interviewed by telephone. ResultsMean laxity on GNRB™ was 1.46mm, and 3 patients had>3mm differential with respect to the healthy knee. Mean IKDC score was 92.2 and mean Lysholm score 93.1. Four patients showed instability, 2 of whom required surgical management. There was no significant difference in occurrence of laxity according to fracture type or reduction quality. Mean follow-up was 5.9years (range, 1.1–14.8). DiscussionOur clinical and functional results were in accordance with the literature. The long-term clinical results were satisfactory. ATE fractures require long-term follow-up to screen for instability and laxity on GNRB™. Level of evidenceIV, retrospective study.

Treatment of Achilles tendon partial injuries with injection of peripheral blood mononuclear cells (PB-MNCs): a case series.

Three patients with Achilles tendon partial injury were treated with local injection of peripheral blood mononuclear cells (PB-MNCs). All subjects were evaluated both clinically (American Orthopedic Foot and Ankle Society - AOFAS scale) and radiologically (MRI examination) at 2 months, and a clinical reassessment with the AOFAS scale was performed at 6 months. Functional and radiological signs of tendon healing processes were detected as early as 2 months after the procedure and the AOFAS scale rose from an initial average value of 37.0 to 82.7. Even though this study only involved a limited number of participants, our preliminary results indicate that regenerative therapies with PB-MNCs may be a valid alternative to surgical options for Achilles tendon partial injuries, especially in patients with contraindications to surgery, when other conservative approaches (exercises, physical therapies, sclerosing treatment) have failed. Further investigations on the subject seem rationally supported and advisable.

Blue Light-Emitting Diode Therapy for Chronic Vulvovaginitis Symptoms: A Series of Cases.

Objective: This pilot study aimed to evaluate the characteristic signs and symptoms of chronic vulvovaginitis after blue light-emitting diode (LED) treatment. Methods: Women with characteristic signs and symptoms of vulvovaginitis were interviewed to obtain clinical and sociodemographic data. They answered the Female Sexual Function Index (FSFI) and the World Health Organization Quality of Life (WHOQOL)-bref questionnaires. Women with a suspected diagnosis of vulvovaginitis underwent clinical examination by a gynecologist, followed by microbiological evaluation, potassium hydroxide testing, vaginal pH assessment, and collection of vaginal fluid for oncotic cytology and fungal culture. The study participants were instructed to return after 15 days to undergo the 405 nm blue LED treatment, which consisted of three biweekly sessions. After 28 days of treatment completion, the patients returned for clinical re-evaluation and reassessment of the FSFI and WHOQOL-bref scores. Results: All eight women reported improvement or cure of at least one characteristic sign or symptom of vulvovaginitis, and five showed improvement in total FSFI and WHOQOL-bref scores. Conclusions: Treatment with blue LED may improve or cure symptoms associated with vulvovaginitis, sexual function, and the global quality of life score. Clinical Trial registration: NCT03075046 dated March 9, 2017.

Reducing COVID-19 Health Inequities by Identifying Social Needs and Clinical Deterioration of Discharged Emergency Department Patients.

The decision to discharge a patient from the hospital with confirmed or suspected coronavirus 2019 (COVID-19) is fraught with challenges. Patients who are discharged home must be both medically stable and able to safely isolate to prevent disease spread. Socioeconomically disadvantaged patient populations in particular may lack resources to safely quarantine and are at high risk for COVID-19 morbidity. We developed a telehealth follow-up program for emergency department (ED) patients who received testing for COVID-19 from April 24-June 29, 2020 and were discharged home. Patients who were discharged with a pending COVID-19 test received follow-up calls on Days 1, 4, and 8. The objective of our program was to screen and provide referrals for health-related social needs (HRSN), conduct clinical screening for worsening symptoms, and deliver risk-reduction strategies for vulnerable individuals. We conducted retrospective chart reviews on all patients in this cohort to collect demographic information, testing results, and outcomes of clinical symptom and HRSN screening. Our primary outcome measurement was the need for clinical reassessment and referral for an unmet HRSN. From April 24-June 29, 2020, we made calls to 1,468 patients tested for COVID-19 and discharged home. On Day 4, we reached 67.0% of the 1,468 patients called. Of these, 15.9% were referred to a physician's assistant (PA) out of concern for clinical worsening and 12.4% were referred to an emergency department (ED) patient navigator for HRSNs. On Day 8, we reached 81.8% of the 122 patients called. Of these, 19.7% were referred to a PA for clinical reassessment and 14.0% were referred to an ED patient navigator for HRSNs. Our intervention reached 1,069 patients, of whom 12.6% required referral for HRSNs and 1.3% (n = 14) were referred to the ED or Respiratory Illness Clinic due to concern for worsening clinical symptoms. In this patient population, the demand for interventions to address social needs was as high as the need for clinical reassessment. Similar ED-based programs should be considered to help support patients' interdependent social and health needs beyond those related to COVID-19.

Long-term efficacy of percutaneous tibial nerve stimulation for faecal incontinence and a new approach for partial responders

BackgroundThe aim of the present study was to evaluate the long-term efficacy of percutaneous tibial nerve stimulation (PTNS) for patients with faecal incontinence (FI) refractory to conservative treatment. Secondary aims were to identify predictors of response and validate new treatment pathways for partial responders.MethodsA prospective, interventional study was carried out in a specialist defecatory disorder unit from a university hospital between January 2010 and June 2017 on patients > 18 years old with FI refractory to conservative treatment. Thirty-minute PTNS sessions were performed in three phases (weekly, biweekly and monthly) up to a year, with clinical reassessment at 3, 6, 12 and 36 months.Patients were classified as optimal responders when their pretreatment Wexner score decreased > 50%; partial responders when it decreased 25–50%; and insufficient responders if it decreased < 25%. Only optimal and partial responders progressed into successive phases.ResultsBetween 2010 and 2017, 139 patients (110 women, median age 63 years [range 22–82 years]) were recruited. After the first phase, 4 patients were optimal responders, 93 were partial responders and 36 were insufficient responders. At 6 and 12 months, 66 and 89 patients respectively were optimal responders, with an optimal response rate of 64% at the end of treatment. A total of 93.3% patients with a partial response initially finally became optimal responders. Furthermore, at 36 months, 71.9% of patients were still optimal responders without supplementary treatment, although their quality of life did not improve significantly. Baseline Wexner scores ≤ 10 and symptom duration < 1 year were identified as predictive factors for positive responses to PTNS.ConclusionsPatients undergoing PTNS for 1 year following this protocol had optimal long-term responses. PTNS sessions for up to 1 year in patients who were partial responders prevents a high percentage of them from needing more invasive treatments, and maintains long-term continence in patients who were optimal responders.