Combination Of Clinical Signs Research Articles

Syndrome of ectopic production of the adrenocorticotropic hormone with hypercorticism

The syndrome of the ectopic production of the adrenocorticotropic hormone (ACTH) presents a version of endogenous hypercorticism which is the most challenging one for diagnostics and treatment. The paper discusses a clinical case of the ACTH-ectopic syndrome diagnosed in an elderly female patient. Advanced age and ongoing long-term treatment may obscure the typical manifestations of a disease. At the same time, it is common for doctors to be less focused on identifying rare diseases when working with elderly patients. A combination of clinical signs (resistance to the antihypertensive therapy; poorly controlled glycemia; increasing weakness; hypokalemia and severe skin pigmentation) allowed for suspecting symptomatic hypertension. Doctors need to be alert and to identify rare diseases among patients of any age group. This case also demonstrates the productivity of a multidisciplinary approach (a team including cardiologists, endocrinologists, radiology specialists and surgeons).

Wilson's disease: Revisiting an old friend.

Wilson's disease (WD) is a rare condition caused by copper accumulation primarily in the liver and secondly in other organs, such as the central nervous system. It is a hereditary autosomal recessive disease caused by a deficiency in the ATP7B transporter. This protein facilitates the incorporation of copper into ceruloplasmin. More than 800 mutations associated with WD have been described. The onset of the disease frequently includes manifestations related to the liver (as chronic liver disease or acute liver failure) and neurological symptoms, although it can sometimes be asymptomatic. Despite it being more frequent in young people, WD has been described in all life stages. Due to its fatal prognosis, WD should be suspected in all patients with unexplained biochemical liver abnormalities or neurological or psychiatric symptoms. The diagnosis is established with a combination of clinical signs and tests, including the measurement of ceruloplasmin, urinary copper excretion, copper quantification in liver biopsy, or genetic assessment. The pharmacological therapies include chelating drugs, such as D-penicillamine or trientine, and zinc salts, which are able to change the natural history of the disease, increasing the survival of these patients. In some cases of end-stage liver disease or acute liver failure, liver transplantation must be an option to increase survival. In this narrative review, we offer an overview of WD, focusing on the importance of clinical suspicion, the correct diagnosis, and treatment.

A Case of Hemophagocytic Lymphohistiocytosis Presenting with Neck Mass in a Child

Hemophagocytic lymphohistiocytosis (HLH) is a rare but life-threatening one syndrome of excessive immune activation. This immune dysregulation disorder is prominently associated with cytopenias and combinations of clinical signs and extreme inflammation symptoms. For survival, it is important to diagnose early and treat appropriately. We report a case of 10 years old boy who was admitted to the hospital with a month history of fever and cervical lymph node enlargement. There were signs of hemophagocytic histiocytosis in the lymph node and bone marrow. The etiology, diagnosis, and treatment of hemophagocytic lymphohistiocytosis are reviewed. Key Words: Hemophagocytic lymphohistiocytosis, Head and neck neoplasm, Fever, Child, Differential diagnosis

Diagnostic and therapy of severe Clostridioides difficile infections in the ICU.

The purpose of the review is to provide all the recent data focusing on the diagnostic and treatment of Clostridioides difficile infection in patients admitted in the ICU. In the ICU, diagnosis remains complicated with a large number of alternative diagnosis. The treatment classically relies on vancomycin but fidaxomicin and fecal microbiota transplantation are now potential solutions in selected indications. Data on ICU-related CDI remain limited and conflicting. To date, there is no unique and simple way to obtain a diagnosis for CDI, the combination of clinical signs and a two-step testing algorithm remains the recommended gold-standard. Two molecules can be proposed for first line treatment: vancomycin and fidaxomicin. Although metronidazole may still be discussed as a treatment option for mild CDI in low-risk patients, its use for ICU-patients does not seem reasonable. Several reports suggest that fecal microbiota transplantation could be discussed, as it is well tolerated and associated with a high rate of clinical cure. CDI is a dynamic and active area of research with new diagnostic techniques, molecules, and management concepts likely changing our approach to this old disease in the near future.

Depression, Anxiety and Stress in Egyptian Patients with Chronic Liver Diseases

Background: Patients with chronic liver disease (CLD) can suffer from varied degrees of depression and anxiety. Objectives: to determinate the frequency and severity of depression, anxiety and stress in patients with CLD and to identify the relation between sociodemographic, disease-specific factors and depression, anxiety and stress among those patients. Methods: A cross-sectional study was done in internal medicine outpatient clinic, Zagazig university hospital in the period from June to December 2018. A questionnaire including personal characteristics and etiology of CLD was filled in. The diagnosis of CLD was confirmed by using combination of clinical signs, symptoms, laboratory investigations and ultrasonography. The severity of liver disease was quantified using modified Child-Pugh classification. Mental health was assessed using Depression Anxiety Stress Scale (DASS-21) questionnaire. Results: More than one fourth of cases had mild depression while 16.5% of them had moderate depression. The same percentage reported extremely severe anxiety and severe stress. There are statistically significant differences between gender, patient education, ascites, child pough classification, comorbid diabetes and mean depression, anxiety and stress scores. Comorbid diabetes and decompensated cirrhosis significantly increase risk of depression by 3.84 and 17.7 folds respectively. Absence of comorbid hypertension and being illiterate were protective factors against anxiety or stress. Absence of diabetes protects against stress. Conclusion: Psychiatric symptoms were frequent among patients with CLD. Comorbid diabetes and decompensated cirrhosis increase risk of depression while absence of hypertension and illiteracy were protective factors against both anxiety and stress symptoms.

Spontaneous intracranial hypotension: key features for a frequently misdiagnosed disorder.

Spontaneous intracranial hypotension (SIH) is a rare neurological condition caused by low cerebrospinal fluid (CSF) volume, most commonly due to a CSF leak. The most common presenting symptom is an orthostatic headache, but some patients may present with atypical neurological manifestations such as cranial nerve palsies, an altered mental status, and movement disorders, which complicate the clinical diagnosis. Therefore, the diagnosis is based on the combination of clinical signs and symptoms, neuroimaging, and/or a low cerebrospinal fluid pressure. In this review, we describe the wide variety of neurological manifestations and complications seen in patients with SIH as well as the most common features described on imaging studies, including both subjective and objective measurements, in order to lead the clinician to a correct diagnosis. The prompt and correct management of patients with SIH will help prevent the development of life-threatening complications, such as subdural hematomas, cerebral venous thrombosis, and coma, and avoid unnecessary invasive procedures.

Management of childhood pneumonia in Nigeria.

Management of childhood pneumonia in Nigeria.

Diastolic Heart Failure in Patients With the Fontan Circulation

The Fontan circulation, accomplished by direct surgical connection of the vena cavae to the pulmonary arteries, can be an effective palliation for patients with a single ventricle. However, failure of the Fontan circulation can result from mechanical obstruction, cardiac arrhythmias, increasing pulmonary vascular resistance, or deteriorating ventricular performance. Although systolic ventricular failure can usually be identified by a combination of clinical signs, symptoms, and imaging findings, diastolic ventricular dysfunction is likely an underrecognized cause of Fontan failure. Methods for detection of impaired diastolic function in a single ventricle are evolving, and established techniques appropriate in the biventricular heart lack validation in single ventricle. Association of biomarkers, cardiac magnetic resonance, and echocardiographic findings with invasively acquired pressure-volume loop data in humans may offer a way forward to accurate, noninvasive diagnosis. Today, therapy for severe diastolic ventricular dysfunction in the Fontan circulation is often disappointing and may require consideration of a ventricular assist device or even cardiac transplant. Progress toward improved outcomes of the Fontan palliation likely depends on successful innovation in primary prevention strategies and the development of more effective pharmacotherapy.

Dermatologic manifestations of granulomatosis with polyangiitis: A case report and literature review

Granulomatosis with polyangiitis (GPA) is an ANCA-associated, systemic vasculitis of small and medium-sized blood vessels. GPA causes inflammation and destruction to the vessel wall and eventual tissue and organ damage. It classically affects the tissues and vasculature of the sinuses, lungs, and kidneys. The organ damage results in epistaxis, cough, hemoptysis, shortness of breath and/or even kidney failure. Cutaneous manifestations are rare, but have been reported. We discuss the case of a 27-year-old African American female who presented with skin lesions on her bilateral forearms and hands, several years after diagnosis and treatment for GPA. The lesions were isolated papules, located on bilateral elbows, palms, and the lateral edge of the 3rd digit on her left hand. The lesions were intensely pruritic and non-painful. A skin biopsy of the lesions showed neutrophilic and granulomatous inflammation with nuclear debris, a largely non-specific histopathologic finding. An extensive autoimmune work up revealed elevated c-ANCA/PR3-ANCA levels supporting a diagnosis of cutaneous GPA. GPA is diagnosed by a combination of clinical signs and symptoms, serologic testing, and histology from biopsy of affected organs. Patient’s who meet the criteria should be tested for anti-neutrophil cytoplasmic antibody (ANCA), specifically c-ANCA/PR3-ANCA. A positive ANCA is supportive for GPA diagnosis. However, a negative ANCA does not rule out disease. Patients with cutaneous findings suggestive of GPA and positive c-ANCA/PR3-ANCA serologic testing should be closely followed up, which will lead to overall better prognosis, improved health outcomes and reduced patient and health care expenses.

Arthroscopic Excision of an Intraarticular Osteochondroma of Knee: A Rare Case Report

Background:Osteochondroma is the most common benign bone tumor. Osteochondroma usually grows away from the joint and its presence in the joint is very rare and is often misdiagnosed. The presenting symptoms are generally pain, swelling, reduced range of motion and bursitis. It is rarely known to cause pressure symptoms compromising the nerves and vasculature.Case presentation:A 27 years old male patient presented with pain and clicking sounds in the left knee two months prior to consultations with progressively worsening symptoms. There was no history of trauma, high-intensity sports, twisting of the knee or any previous surgery of the knee. A click was felt at the flexion of the knee. There was no restriction in the range of motion of the knee joint, but mild pain with over 900 to 1100 flexion of the knee. Knee Scoring of the patient measured by the International Knee Documentation Committee (IKDC), The WOMAC and The Lysholm Score was approximately 80. Plain radiography was normal. Magnetic resonance imaging (MRI) showed bony prominence at the medial aspect of the lateral condyle of the femoral bone, with impingement of the anterior cruciate ligament (ACL). Arthroscopy showed an abnormal bony growth in the intercondylar notch impinging on the ACL. The tumor was excised and histopathology findings revealed osteochondroma.Discussion:A combination of clinical signs, plain radiography, and MRI can be used to make a clear diagnosis of osteochondroma. Plain radiography alone is usually insufficient in portraying the extent of clinical disease. MRI is much more useful in comparison when compared to plain radiography in the determination of an accurate diagnosis. The most accurate approach is through arthroscopy and histopathology examination. Early accurate diagnosis is important to determine the prognosis of the patient. If our case was not clearly diagnosed, the ACL would have a higher chance of rupture in this patient.Conclusion:Intraarticular osteochondroma of the knee can be considered a rare cause of pain and in young patients. Arthroscopy excision is accompanied with less pain, minimal infection and results in a faster recovery with Knee Scores of 100 postoperatively.

Canine Degenerative Lumbosacral Stenosis: Prevalence, Impact And Management Strategies.

Canine degenerative lumbosacral stenosis (DLSS) is a syndrome of low back pain with or without neurologic dysfunction associated with compression of the cauda equina. Most commonly occurring in medium- to large-breed dogs of middle to older age, German shepherd and working dogs are predisposed. Diagnosis is based on a combination of clinical signs, advanced imaging and ruling out other differential diagnoses. The volume of the intervertebral foramina at the lumbosacral junction is naturally reduced on extension but degenerative changes lead to a more marked reduction that can impinge the L7 nerve roots. Evidence is lacking on which to base decision-making for treatment of dogs with DLSS. However, surgical intervention may be indicated in dogs that do not respond to conservative management, or for dogs in which there is a requirement to work that prevents lifestyle adjustments. Improvements in electrodiagnosis and novel intra-discal treatments may improve the management of DLSS in the future.

Triple Test Plus Rapid Cognitive Screening Test: A Combination of Clinical Signs and A Tool for Cognitive Assessment in Older Adults

Less time-consuming, easy-to-apply and more reliable cognitive screening tests are essential for use in primary care. The aim of this study was to investigate the diagnostic value of the Turkish version of the Rapid Cognitive Screen (RCS-T) and Triple Test individually and the combination of RCS-T with each sign and Triple Test to screen elderly patients for cognitive impairment (CI). A total of 357 outpatients aged 60 or older, who underwent comprehensive geriatric assessment, were included in the study. Presence or absence of attended alone sign (AAS), head-turning sign, and applause sign was investigated. The mean age of the patients was 74.29 ± 7.46. Of those, 61 patients (28 men, 33 women) had Alzheimer’s disease (AD), 59 patients had mild cognitive impairment (MCI) (29 men, 30 women), and 237 (80 men, 157 women) were cognitively robust. The sensitivity of the combination of RCS-T and negative for AAS for CI, AD and MCI is 0.79, 0.86 and 0.61, respectively; the specificity was 0.92, 0.93 and 0.92, respectively; and the positive and negative predictive values revealed good diagnostic accuracy. The combination of RCS-T and negative for AAS is a simple, effective and rapid way to identify possible CI in older adults.

Tear Metabolomics in Dry Eye Disease: A Review.

Dry eye disease (DED) is a multifactorial syndrome that can be caused by alteration in the quality or quantity of the precorneal tear film. It is considered one of the most common ocular conditions leading patients to seek eye care. The current method for diagnostic evaluations and follow-up examinations of DED is a combination of clinical signs and symptoms determined by clinical tests and questionnaires, respectively. The application of powerful omics technologies has opened new avenues toward analysis of subjects in health and disease. Metabolomics is a new emerging and complementary research discipline to all modern omics in the comprehensive analysis of biological systems. The identification of distinct metabolites and integrated metabolic profiles in patients can potentially inform clinicians at an early stage or during monitoring of disease progression, enhancing diagnosis, prognosis, and the choice of therapy. In ophthalmology, metabolomics has gained considerable attention over the past decade but very limited such studies have been reported on DED. This paper aims to review the application of tear metabolomics in DED.

Variant Creutzfeldt-Jakob disease strain is identical in individuals of two PRNP codon 129 genotypes.

In 2004, a subclinical case of variant Creutzfeldt-Jakob disease in a PRNP 129 methionine/valine heterozygous individual infected via blood transfusion was reported, and we established that the spleen from this individual was infectious. Since host genetics is an important factor in strain modification, the identification of variant Creutzfeldt-Jakob disease infection in a PRNP 129 methionine/valine heterozygous individual has raised the possibility that the properties of the variant Creutzfeldt-Jakob disease agent could change after transmission to this different genetic background and concerns that this could lead to a more virulent strain of variant Creutzfeldt-Jakob disease. The variant Creutzfeldt-Jakob disease strain has to date been characterized only in methionine homozygous individuals, therefore to establish whether the strain characteristics of variant Creutzfeldt-Jakob disease had been modified by the host genotype, spleen material with prion protein deposition from a PRNP 129 methionine/valine individual was inoculated into a panel of wild-type mice. Three passages in mice were undertaken to allow stabilization of the strain characteristics following its passage into mice. In each passage, a combination of clinical signs, neuropathology (transmissible spongiform encephalopathy vacuolation and prion protein deposition) were analysed and biochemical analysis carried out. While some differences were observed at primary and first subpassage, following the second subpassage, strain characteristics in the methionine/valine individual were totally consistent with those of variant Creutzfeldt-Jakob disease transmitted to 129 methionine/methionine individuals thus demonstrated no alteration in strain properties were imposed by passage through the different host genotype. Thus we have demonstrated variant Creutzfeldt-Jakob disease strain properties are not affected by transmission through an individual with the PRNP methionine/valine codon 129 genotype and thus no alteration in virulence should be associated with the different host genotype.

Yerba Mate (Ilex paraguariensis) and Dimethyl Fumarate Can Improve Metabolic Syndrome Condition Induced by High Fat Diet in Mice

IntroductionMetabolic syndrome (MS) is a combination of clinical signs and symptoms that occur together and directly contribute to the risk of developing cardiovascular disease and diabetes. Some studies suggest that the prevalence of MS in the US is 32% of the population, while in Brazil this level reaches 23%. The criteria for the classification of MS are diverse, but according to the WHO, the presence of diabetes or reduced glucose tolerance or insulin resistance, associated with at least two of the following conditions: elevation of blood pressure, dyslipidemia and obesity are considered. MS confers a two‐fold increased risk for developing cardiovascular disease, two to four times the risk of stroke, three to four times the risk of acute myocardial infarction. Our hypothesis is that toasted yerba mate and dimethyl fumarate have a therapeutic effect on the metabolic syndrome in mice.MethodsMetabolic syndrome was induced by hyperlipidic diet (60% of total calorie) in C57BL / 6 mice for 12 weeks, and treatment was performed concomitantly with yerba mate (2 mg / g) and dimethyl fumarate (0.24 mg / g) diluted in water, to which the animals had free access. The groups were separated as follows: control group (standard diet and water), HFD group (hyperlipidic diet and water), HFD + Mate group (hyperlipidic diet and mat herb tea) and HFD + DMF group (hyperlipidic diet and dimethyl fumarate).ResultsIt was observed that the HFD + Mate group obtained an increase in body mass in the same way as the HFD group, also increasing triglyceride levels, but maintained normal HDL levels. The HFD + DMF group, however, remained with body mass equal to the control group, maintaining normal levels of HDL and triglycerides. Both the HFD + Mate group and the HFD + DMF group remained at optimal glycemic levels, including glucose tolerance and insulin resistance tests. Histological analysis of the liver showed hepatic steatosis in the HFD group, but not in the HFD + Mate and HFD + DMF groups.ConclusionDMF was effective to prevent metabolic syndrome, once the hallmarks glucose, body weight, triglycerides and HDL cholesterol were kept similar to control group. DMF also protected against hepatic steatosis. About mate tea, the effect was more modest than DMF, once only HDL cholesterol and glucose were protected, as well as hepatic steatosis was avoided. These data suggest DMF can modulate satiation preventing the syndrome metabolic development.Support or Funding InformationBrazilian Research Agencies ‐ CAPES, CNPq and FAPERJThis abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Abstract P3-02-02: Sensitivity and dynamic range of CellSearch based DTC enumeration in the CSF in patients with leptomeningeal metastases (LMM)

Abstract Improvements in the treatment of patients with MBC and the inefficiency of many drugs in crossing the BBB have led to an increased incidence of symptomatic CNS metastasis. CNS metastases are clinically characterized by two distinct phenotypes, although their combined occurrence is possible. Most patients suffer from solid CNS metastases, but metastatic deposits limited to the leptomeningeal surfaces occur (LMM). In addition to its poor prognosis, neurological impairment in LMM is devastating. Methods: 27 patients with breast cancer (MBC) were diagnosed with LMM and treated with intrathecal (IT) therapy from 2008 to 2018 in a single centre (GZA Hospitals Antwerp). Clinicopathologic and treatment information were collected. Conventional diagnosis was based on positive cytology on CSF and/or on the combination of clinical signs and neuro-imaging findings. For a subset of patients (n=12), we have enumerated circulating tumor cells (CTCs) and CSF DTCs at time of LMM diagnosis. Whole blood and CSF was processed on the CellSearch platform according to the standard method for CTC enumeration in blood. Results: The 27 MBC pts diagnosed with LMM had a median time to LMM of 70.5 months (6.5-241) from the diagnosis of BC. Median age at LMM diagnosis was 56 y (36-75). At time of last follow-up, 23 patients (85%) had died. The median OS from LMM diagnosis was 27 months (4.5-128). From the 27 patients, 52% (14/27) were hormone receptor-positive (HR+), 33% (9/27) were HER2 overexpressing and 15% (4/27) were triple-negative. Coexisting brain metastases are present in 37% of patients. In 11 cases (41%), LMM was not accompanied by extra cranial disease at time of diagnosis. The biochemical data matched the classic CSF findings of LMM including a high protein concentration (75%, 9/12) and a low glucose concentration (42%, 5/12) (Table 1.). CSF lactate was elevated (>2.2 mmol/l) in 100% (10/10). In 70% (7/10) CSF lactate was >3.5 mmol/l. Cytologic evaluation of the CSF demonstrated unequivocal malignant cells in 10/12 (83%). DTC enumeration in the CSF of these patients, however, revealed the presence of tumor cells 12/12 (100%). Furthermore, the cell count ranged between 10 to 3523 Epcam-positive cells/mL CSF. Additional evaluation proved these to be cancer cells. Results off the CSF analysis in 12 patients with LMMPatientWBCGlucoseProteinCTCCytologyDTCVolume mL125<2018566pos21221853422149pos23047317068550pos> 10005413339608neg> 10007.554042280pos114427.56772064410pos63667.5756261211151pos264237.581675161NApos>100039894840pos39311062313200pos191657.511296802.40pos591441225605,113neg7994 Conclusion: Symptomatic LMM has a variable prognosis, with some patients experiencing prolonged survival. LMM occurs in all breast cancer subtypes and can be the sole location (40%). CSF lactate is a sensitive but aspecific marker. DTC enumeration in the CSF is a robust tool to diagnose LMM with apparently a superior sensitivity over conventional cytology. It furthermore has a broad dynamic range rendering it more suitable for treatment effect evaluation. This methodology should be considered in routine workup in MBC patients with suspected LMM. Citation Format: Van Goethem A, Rypens C, Rutten A, Prove A, Van den Mooter T, Erven K, Van Havenbergh T, Van Laere S, Vermeulen P, Dirix L. Sensitivity and dynamic range of CellSearch based DTC enumeration in the CSF in patients with leptomeningeal metastases (LMM) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-02-02.

Inflammatory Pseudotumor of an Orbito-Maxillary Mass Masquerading as a Malignancy

Objective: To present a case of a benign orbito-maxillary tumor behaving as an invasive,
 expansive malignancy.
 
 Design: Case report
 
 Setting: A tertiary care hospital in Metro Manila
 
 Patient: A 4-year-old boy with a seven month history of right orbito-maxillary mass, proptosis and epiphora.
 Result: A series of biopsies were done before a definite diagnosis was made due to inconsistencies in the histopathologic findings, clinical picture, and the radiologic presentation of the case. After diagnosis, appropriate intervention resulted in a dramatic decrease in the size of the mass. At present, the patient is disease-free and asymptomatic.
 
 Conclusion: Histopathologic diagnosis of Inflammatory Pseudotumor is difficult and differentiating it from malignant tumors is often a concern for otolaryngologists and pathologists. In spite of an initial malignant biopsy result, the combination of clinical signs and symptoms and radiologic findings of an infiltrative mass lesion, should not discount the possibility of a benign entity such as Inflammatory Pseudotumor for which treatment is conservative.
 
 Keywords: Orbito-Maxillary Mass, Inflammatory Pseudotumor, Pseudotumor, Orbital Pseudotumor
 
 
 
 
 
 

Chapter 21 - Neonatal hypotonia and neuromuscular conditions

The differential diagnosis of neonatal hypotonia is a complex task, as in newborns hypotonia can be the presenting sign of different underlying causes, including peripheral and central nervous system involvement and genetic and metabolic diseases. This chapter describes how a combined approach, based on the combination of clinical signs and new genetic techniques, can help not only to establish when the hypotonia is related to peripheral involvement but also to achieve an accurate and early diagnosis of the specific neuromuscular diseases with neonatal onset. The early identification of such disorders is important, as this allows early intervention with disease-specific standards of care and, more importantly, because of the possibility to treat some of them, such as spinal muscular atrophy, with therapeutic approaches that have recently become available.

Palliative Care in the Hip Fracture Patient.

Introduction:Older patients with hip fracture have a 20% to 30% mortality rate in the year after surgery. Nonoperative care has higher 1-year mortality rates and is generally only pursued in those with an extraordinarily high surgical risk. As the population ages, more patients with hip fracture may fall into this category. The orthopedic surgeon is typically the main consultant responsible for deciding between surgery and conservative management, and the reasoning behind one decision over the other is often poorly understood. We undertook a review to determine decision-making tools for surgery in high-risk patients with hip fracture.Materials and Methods:A review was conducted using PubMed to determine articles published using the terms palliative care, conservative care, nonoperative, hip fracture, orthopedic procedures, fracture fixation, and surgery. Our search resulted in 13 articles to review. These were further screened to determine tools for use in surgical decision-making.Results:Several potential decision-making tools were found in our search. The potential tools to identify patients who would benefit from nonoperative treatment included the Palliative Performance Scale for severe dementia, the Lawton Instrumental Activities of Daily Living and Katz Activities of Daily Living scales for prefracture immobility, a combination of clinical signs and laboratory tests to determine risk of imminent death, and the Charlson Comorbidity Score for additional serious comorbidities. No tools have been prospectively tested in a clinical setting.Discussion:Evaluation of each patient using a variety of decision making tools should help the orthopedic surgeon determine which patients would be better suited to non-operative management. After determining the benefit of non-operative care, they must effectively allow the fracture to heal while ameliorating pain. Palliative care physicians can fulfill this role by providing support and symptom relief.Conclusions:Surgical decision-making for hip fracture repair in the elderly patients is not straight forward. Several tools may be helpful to the surgeon in determining who may be better suited for nonoperative care or a palliative care referral. Prospective data do not exist in these decision-making tools.

A study of correlation between clinical, radiological and pathological diagnosis of appendicitis: a retrospective analytic study

Background: Acute appendicitis is the most common cause of acute abdominal pain in young adults requiring emergency surgery. Appendicectomy is the most frequently performed surgery. The diagnosis is often challenging and the decision to operate in an emergency setting is always debatable. A combination of clinical signs and symptoms with laboratory findings in many scoring systems are suggesting the probability of appendicitis and the possible subsequent management pathway. The aim was to evaluate accuracy of the clinical Alvarado scoring system, radiological finding and histopathological examination for the diagnosis of acute appendicitis.Methods: A retrospective study was conducted in the department of general surgery in a tertiary care centre in South India. Total of 237 patients with acute abdominal pain were included and evaluated with the clinical Alvarado scoring system, radiological finding with (USG/CT abdomen) and histopathological examination for the diagnosis of acute appendicitis. The data was collected and analyzed retrospectively.Results: Of the 237 patients, 164 patients were male (69.1%) and rest is female. The correlation of the Alvaroda score with histopathological findings in groups with score > 7 and ≤7 the correlation of Alvarado score and the ultrasound findings were comparable between the study groups. The sensitivity of ultrasound in diagnosing acute appendicitis in patients with Alvarado score >7 was 72.99%. The sensitivity of ultrasound in diagnosing acute appendicitis in patients with Alvarado score ≤7 was decreased to 27%.Conclusions: The diagnostic accuracy of clinical features is far better than radiological investigations in the diagnosis of acute appendicitis. Therefore, it is concluded that it is better to use radiological investigations only to confirm the diagnosis of acute appendicitis rather to diagnose it.