Common Acute Presentations Research Articles

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

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

634 Analgesia Use in Acute Renal Colic Patients- Complete Audit Cycle

Abstract Aim Prevalence of renal colic is up to 20% worldwide, with recurrence rates approaching 50% within 10 years- making it a common acute presentation. NICE guidance (NG118) states NSAIDs are first-line analgesia for renal colic, followed by intravenous paracetamol and opiates. Our aim was to assess compliance with NG118 within one acute NHS teaching Trust. Method All patients with renal colic as the primary differential diagnosis during March and April 2022 (1st cycle) and September and October 2022 (2nd cycle) were included. Data was extracted retrospectively from electronic patient records into a pre-designed proforma. Findings from the 1st cycle were presented within local departmental meetings. Posters were also installed reminding clinicians of the analgesic pathway within the relevant clinical areas. Subsequently, a re-audit was performed. Results 90 patients were included (60- 1st cycle, 30- 2nd cycle). There was a significant improvement in compliance between the 1st and 2nd audit cycles (60% versus 83%, p = 0.0193). However in cases of non-compliance, documentation was poor (>70% did not state a reason) during both cycles. Imaging confirmed renal colic in 82% of patients in the 1st cycle and 93% of patients in the 2nd cycle. PR Diclofenac was the most common NSAID prescribed. Conclusions Low-cost, easily reproducible interventions resulted in significant prescribing practice changes. Findings from the latest national renal colic audit (2012-13) showed analgesia compliance in only 69% of cases nationally- similar to our 1st audit cycle results. Disseminating our findings to other hospitals regionally and nationally will hopefully result in better outcomes for renal colic patients.

Infectious mononucleosis - should we routinely assess liver function in acute presentation and follow up?

Infectious mononucleosis is a relatively common acute presentation to the ENT department. There is an expected derangement in the liver function test results in most patients. There is no guidance regarding follow up, and practice varies. This study aimed to evaluate the utility of liver function tests and abdominal ultrasound in infectious mononucleosis. This was a retrospective study of all adult patients admitted under ENT with infectious mononucleosis over a five-year period. A total of 153 patients were included; 80 per cent had abnormal liver function test results at presentation. Around 50 per cent had at least one liver function test assessment following discharge. Median (interquartile range) time to resolution of liver function test results was 32 days (20-50 days); maximum time was 10 months. Six patients had in-patient abdominal ultrasound: all showed a normal liver and biliary tree. No patient developed any liver disease sequelae. The findings suggest that serial assessment of liver function is not required in immunocompetent adults with subclinical derangement in liver function.

Creating A Protocol for the Management of Epistaxis in A Tertiary Care Centre-A Practical Application of the British Rhinological Society Multidisciplinary Consensus Recommendations on the Hospital Management of Epistaxis

Epistaxis is the most common acute presentation to ENT services in the UK. The recent British Rhinological Society multidisciplinary consensus recommendations [1] provide new guidance for its management. To better align with these, we reviewed current practice in our tertiary referral centre. We noted practice variation both within and between departments, particularly concerning the timing and utilisation of nasal packing, accounting for inpatient stay.

784 Management of Paediatric Epistaxis: An Appraisal of Cautery Versus Topical Antiseptics in The Prevention of Rebleeding Events

Abstract Introduction Epistaxis is a common acute presentation in childhood that with recurrence often causes great distress for both parent and child alike. For recurrent epistaxis it is common practice in the UK to trial either a topical antiseptic (Naseptin) or silver nitrate cautery. A literature review was conducted to assess which treatment confers greater protection against rebleeding events. Method The literature review was performed via a search on Medline via Ovid. As both cautery and topical antiseptics are not new treatments, an age limit was not set to allow older research to be included and provide perspective. Results In all but one study included, there was no statistically significant difference between the use of Naseptin versus cautery in the reduction of rebleeding events. A higher incidence of complications such as septal perforation and pain were reported in patients who underwent cautery, whilst no adverse side effects were reported with Naseptin. Conclusions The current evidence base relies mostly on short term outcomes, with most patients not being followed up for more than 2 months. If further longitudinal studies provide evidence to support there being a minimal difference in treatment outcomes, using topical antiseptics before considering cautery would be better clinical practice in paediatric patients.

727 Ambulatory Management of Acute Uncomplicated Diverticulitis During COVID-19 Pandemic

IntroductionAcute diverticulitis remains a common acute presentation to the emergency department(ED). During the COVID-19 pandemic, surgical services have been adapted to reduce hospital admissions. Our aim is to assess the safety and efficacy of the surgical ambulatory service in the management of acute diverticulitis.MethodData was retrospectively collected on consecutive patients referred to the surgical team with a suspected diagnosis of diverticulitis between 30.04.20-16.08.20. Unsuccessful ambulation was determined by representation at 30 days.Results83 patients presented with suspected diverticulitis. 36 patients were deemed clinically stable and suitable for ambulation. 21 of these patients underwent a CT abdomen in the ED, confirming uncomplicated diverticulitis and were discharged with oral antibiotics as per trust guidance. 4 patients were discharged from ED for an ambulatory CT abdomen, with a median waiting time of 3 days. 11 patients received no imaging prior to discharge, all of whom had known diverticular disease. 86% of ambulated patients underwent a telephone review within 72 hours of acute presentation. 8.3% of ambulated patients represented within a 30 day window, 0 of which required surgical management.ConclusionsPatients presenting with uncomplicated acute diverticulitis can be safely managed in an ambulatory setting. Access to imaging early can facilitate successful discharge.

Imaging of the knee: Common acute presentations to general practice.

Knee pain is a common symptom in thecommunity. There is a wide range ofconditions that can cause pain. Identifying the type and severity of the condition is important for effective management. There are several guidelines for the appropriate imaging ofpatients presenting with knee pain. Presentation is generally divided into a post-traumatic group and those without known trauma (including arthritis). The aim of this article is to discuss the approach to imaging of the knee with reference to Diagnostic Imaging Pathways and illustrate some of the conditions that may be encountered. The initial workup is typically done in general practice to determine which patients require referral for specialist management and which patients can be cared for in the community. Most cases presented in this article are patients referred from primary care to a metropolitan radiology practice during a six-month period, and they represent examples of some of the more common pathologies.

Management of fever in Australian children: a population-based sample survey

BackgroundFever in childhood is a common acute presentation requiring clinical triage to identify the few children who have serious underlying infection. Clinical practice guidelines (CPGs) have been developed to assist clinicians with this task. This study aimed to assess the proportion of care provided in accordance with CPG recommendations for the management of fever in Australian children.MethodsClinical recommendations were extracted from five CPGs and formulated into 47 clinical indicators for use in auditing adherence. Indicators were categorised by phase of care: assessment, diagnosis and treatment. Patient records from children aged 0 to 15 years were sampled from general practices (GP), emergency departments (ED) and hospital admissions in randomly-selected health districts in Queensland, New South Wales and South Australia during 2012 and 2013. Paediatric nurses, trained to assess eligibility for indicator assessment and adherence, reviewed eligible medical records. Adherence was estimated by individual indicator, phase of care, age-group and setting.ResultsThe field team conducted 14,879 eligible indicator assessments for 708 visits by 550 children with fever in 58 GP, 34 ED and 28 hospital inpatient settings. For the 33 indicators with sufficient data, adherence ranged from 14.7 to 98.1%. Estimated adherence with assessment-related indicators was 51.3% (95% CI: 48.1–54.6), 77.5% (95% CI: 65.3–87.1) for diagnostic-related indicators and 72.7% (95% CI: 65.3–79.3) for treatment-related indicators. Adherence for children < 3 months of age was 73.4% (95% CI: 58.0–85.8) and 64.7% (95% CI: 57.0–71.9) for children 3–11 months of age, both significantly higher than for children aged 4–15 years (53.5%; 95% CI: 50.0–56.9). The proportion of adherent care for children attending an ED was 77.5% (95% CI: 74.2–80.6) and 76.7% (95% CI: 71.7–81.3) for children admitted to hospital, both significantly higher than for children attending a GP (40.3%; 95% CI: 34.6–46.1).ConclusionsThis study reports a wide range of adherence by clinicians to 47 indicators of best practice for the management of febrile children, sampled from urban and rural regions containing 60% of the Australian paediatric population. Documented adherence was lowest for indicators related to patient assessment, for care provided in GP settings, and for children aged 4–15 years.

Demographic features of CERVicofacial infections. A maxillofacial trainee research collaborative (MTReC) project

Introduction/Aims Cervicofacial infection is one of the most common acute presentations to the Oral and Maxillofacial (OMFS) department. Little is known about the epidemiological features of this large patient cohort.

The utility of scrotal ultrasonography in the emergent setting: beyond epididymitis versus torsion

Scrotal pain is a common acute presentation for medical care. Testicular torsion and epididymo-orchitis are two diagnoses for which early detection is critical and their sonographic imaging features have been thoroughly described in the radiologic literature. Other important conditions for which radiologists must be aware have received less attention. This article will highlight key traumatic and non-traumatic causes of acute scrotal pain other than testicular torsion and epididymo-orchitis that may present in the emergency department setting.

LO20: Student Run Simulation Team: A near-peer approach to simulation education

Introduction/Innovation Concept: Student Run Simulation Team (SRST) is an extracurricular medical student group that provided peers with opportunities to learn and teach principles of acute care medicine in a simulated environment. Early exposure to simulation has been identified as a way for medical students to engage in self-directed education. SRST operated through a peer-led model. Senior medical students designed and delivered didactic sessions, simulation scenarios, and debriefed the scenarios to emphasise targeted objectives. Methods: Informal interviews conducted by the SRST as part of a needs analysis identified barriers to an effective transition from pre-clerkship to clerkship. Specifically, principles of team dynamics including effective communication and role clarification in emergency situations were identified as areas where students lacked confidence. The curriculum focused on leadership and an effective team approach to common acute presentations. SRST members acquired simulation skills under the guidance of a simulation team at the University of Calgary. In the inaugural year, 8 second year students developed and delivered the curriculum to 16 first year students. Quality improvement surveys and participant feedback contributed to ongoing program review and refinement. Curriculum, Tool, or Material: Didactic lectures and task-trainer based skills sessions were created to assist the medical students in developing a foundational approach to a patient presenting to the emergency department. Three distinct simulations of increasing complexity were designed for students to build on their skills. SRST members worked with simulation consultants during 4 custom designed training sessions to develop simulation skills (design and debriefing). The distinguishing aspect of SRST is an emphasis on the non-technical skills of teamwork, leadership, and communication, rather than knowledge acquisition alone. The structure also included a succession plan for continued peer-led education where the student participants will form the next year’s team and will receive similar simulation education. Conclusion: SRST is the first student-run simulation initiative to be established in a Canadian medical school. This near-peer team allowed for early practice of non-technical skills in emergency settings. SRST facilitated opportunities for simulation education for both the junior students as participants, and the senior medical students as educators. This is an ongoing initiative, with plans to continue program development in future years.

Acute aortic syndrome: A systems approach to atime-critical disease.

Acute aortic syndrome represents a group of potentially lethal aortic diseases, including classic acute aortic dissection, intramural hematoma, and penetrating atherosclerotic aortic ulcer. Among these conditions, type A aortic dissection is the most common acute presentation. Only surgical interventions are recommended in guidelines as lifesaving procedures for type A dissection. Despite new diagnostic imaging methods, advanced surgical strategy, and improved postoperative management in the over 250-year history of aortic dissection, in-hospital mortality and morbidity rates still remain high. Recently, several new system-based approaches, such as implementation of multidisciplinary experienced high-volume centers and establishment of regional systematic management flow have been reported to improve the outcome. Here, we will describe the pathophysiology, diagnosis, and treatment as well as the new systematic approach to treat acute aortic syndrome.

Unplanned urology readmissions in a district general hospital: are we meeting the standard?

Background Recent changes in practice standards and remuneration to UK Trusts have been refined to penalise institutions for patient readmission within 30 days of discharge. The purpose of this study was to determine if the target rate of less than 6.5% was attained within the setting of a district general hospital (DGH) and also to comment on readmission trends. Materials and methods A retrospective study was performed over 12 months examining all unplanned readmissions to hospital 30 days following discharge from Urology. Elective as well as emergency cases were audited. Results A total of 4124 patients were treated and discharged by the department over 12 months. One hundred and eighty-four (4.4%) patients were readmitted: 93 (51%) patients following acute presentations and 91 (49%) following elective procedures. The commonest causes for unplanned readmission were haematuria, 29 cases (16%), acute urinary retention, 28 cases (15%) and ureteric colic, 25 cases (14%). Readmission rates following flexible cystoscopy and TRUS biopsy were 1% and 3%, respectively. Only six of 70 patients (9%) were readmitted following TURP. Five (3%) of the 184 readmissions required a second procedure. Conclusion Our department met the predetermined standard in achieving an unplanned readmission rate of less than 6.5%. This study also highlighted the need for discharge policies for common acute presentations.

Herpes zoster‐induced acute urinary retention

Urinary retention is a common acute presentation for men in their later decades. Potential contributing pathologies are numerous. We report an unusual case of acute urinary retention requiring catheterisation secondary to sacral herpes zoster reactivation (S2-4) in an 88-year-old man with minimal preceding obstructive symptoms.

Chronic presentation of Boerhaave's syndrome

BackgroundSpontaneous rupture of the esophagus (Boerhaave's syndrome) is a rare, well-defined clinical syndrome caused by a longitudinal perforation of the esophagus. It is a life-threatening condition that necessitates rapid diagnosis and treatment. Patients typically present acutely with a history of vomiting followed by chest or abdominal pain. However, the diagnosis may be difficult or missed when patients present with chronic symptoms that mimic other conditions.Case PresentationIn this report, we present a unique case of Boerhaave's syndrome in a 53-year-old male patient. In contrast to the more common acute presentation, our patient developed non-specific symptoms in association with an intrathoracic cyst. In this report, we will also review the usual presenting signs, symptoms, and treatment of Boerhaave's syndrome.ConclusionOur emphasis in this paper will be on the importance of recognizing and diagnosing Boerhaave's syndrome in an acute as well as a chronic state.

Hepatobiliary and pancreatic: Biliary rupture of an hydatid cyst

Hydatid cysts form when the larvae of Echinococcus granulosis encyst within the liver or other organs. Cysts often grow at a rate of approximately 1 cm per year but it is common for cysts to lose viability in patients over 60 years of age. The majority of human infections are asymptomatic. However, cysts that are 10 cm or more in diameter can cause discomfort or pain in the upper abdomen. The most common acute presentation is that of rupture of the cyst into the biliary system. This usually results in cholangitis with jaundice. Other acute presentations involve liver abscesses, pancreatitis and rupture of hepatic cysts into the peritoneal or pleural cavities. In the patient described below, the hepatic cyst ruptured into the left hepatic duct and resulted in cholangitis. A 54-year-old man was admitted to hospital with upper abdominal pain, jaundice and fever (39.6°C). Abdominal pain had been present for approximately 4 weeks and had been associated with anorexia and weight loss. On physical examination, he had an enlarged liver with upper abdominal tenderness. Blood tests revealed an elevated white cell count (19.4 × 109/l) with a high erythrocyte sedimentation rate (113 mm/h) and an elevated C-reactive protein (75 mg/l). The serum bilirubin was elevated at 323 µmol/l and this was associated with a high alkaline phosphatise (1143 U/L) and a minor elevation of aspartate aminotransferase (126 U/L) and alanine aminotransferase (109 U/L). An upper abdominal ultrasound study showed a cystic lesion in the left lobe of the liver with a dilated left hepatic duct. A contrast-enhanced computed tomography scan (Figure 1) showed a cystic structure in the left lobe of the liver, patchy calcification of the cyst wall, air in the right hepatic duct and mild dilatation of the bile duct (14 mm). No abnormalities were seen in the gallbladder. With magnetic resonance cholangiopancreatography (Figure 2), the irregular cystic structure communicated with the left hepatic duct. In addition, the bile duct was mildly dilated and the cystic structures and the bile duct were filled with spiral filling-defects. The patient was treated with antibiotics and subsequently had a surgical procedure that included a left hepatectomy, cholecystectomy, choledochotomy and T-tube drainage. On microscopic examination, there was hydatid sand with a protoscolex of E. granulosis. In the post-operative period, he was treated with albendazole. Endoscopic sphincterotomy was not performed in the above patient but can facilitate resolution of cholangitis.

A Review of the Evaluation and Management of Syncope in the Acute Medical Unit

Syncope is a common acute presentation and frequently results in hospitalisation. Cardiac syncope is potentially life threatening. The diagnosis and management of syncope demands a careful history, witness account wherever possible, and a comprehensive assessment. This, in combination with routine investigations, will provide an answer in a significant percentage of patients.

Case series of acute presentation of abdominal TB in Ghana

We report on a six-year prospective study to determine the presentation and outcome of acute abdominal TB at Komfo Anokye Teaching Hospital. Between January 1998 and December 2003, material for biopsy including resected bowel was taken from all cases of acute abdomen, which at laparotomy were suspected as one or other form of abdominal TB. TB-positive cases were then retrospectively analysed for clinical presentation and outcome of surgical treatment. There were 96 histologically proven cases of abdominal TB, 60 in women and 36 in men. Seventy patients (72.9%) were admitted as acute intestinal obstruction with acute abdominal pain, vomiting, constipation, distension and fluid levels on abdominal X-ray. Twenty-two (22.9%) patients were admitted as acute diffused peritonitis - with generalized abdominal tenderness, guarding and rebound - and four (4.2%) as acute appendicitis. There were 74 emergency bowel resections (77% resection rate) for 34 ileocaecal masses, 16 strictures, 10 perforations and 14 adhesions, with a mortality of 4.2%. Previous series from our subregion have reported similar emergency resection mortality rates for other abdominal conditions. All the patients received postoperative anti-TB therapy. This paper notes that acute intestinal obstruction is the most common acute presentation of abdominal TB in our environment. The results of emergency resection compare favourably with resection for other acute abdominal conditions.