Daily Department Research Articles

A Deep Learning Framework for Image-Based Screening of Kawasaki Disease.

Kawasaki disease (KD) is a leading cause of acquired heart disease in children and is characterized by the presence of a combination of five clinical signs assessed during the physical examination. Timely treatment of intravenous immunoglobin is needed to prevent coronary artery aneurysm formation, but KD is usually diagnosed when pediatric patients are evaluated by a clinician in the emergency department days after onset. One or more of the five clinical signs usually manifests in pediatric patients prior to ED admission, presenting an opportunity for earlier intervention if families receive guidance to seek medical care as soon as clinical signs are observed along with a fever for at least five days. We present a deep learning framework for a novel screening tool to calculate the relative risk of KD by analyzing images of the five clinical signs. The framework consists of convolutional neural networks to separately calculate the risk for each clinical sign, and a new algorithm to determine what clinical sign is in an image. We achieved a mean accuracy of 90% during 10-fold cross-validation and 88% during external validation for the new algorithm. These results demonstrate the algorithms in the proposed screening tool can be utilized by families to determine if their child should be evaluated by a clinician based on the number of clinical signs consistent with KD.Clinical Relevance- This screening framework has the potential for earlier clinical evaluation and detection of KD to reduce the risk of coronary artery complications.

Delayed Onset Facial Palsy After Temporal Bone Fracture: A Case Series

Study Design Retrospective Case Series Objective This study’s objective is to identify gaps in facial trauma care by exploring 4 cases of delayed onset facial nerve palsy after temporal bone fracture. Methods A retrospective chart review was performed on 4 patients who presented to the emergency department with facial palsy after a previous trauma. Relevant physical exam findings, radiological images and follow-up was documented. Results We present a case series of young, previously healthy patients who presented to the emergency department days or weeks after traumatic temporal bone fracture with delayed onset unilateral facial nerve paralysis. None of these patients were warned of this potential complication, connected to an outpatient physician and all received a costly workup. Conclusions Patients presenting with temporal bone fracture and intact facial nerve function can develop delayed-onset facial paralysis several days after their injury. To offset costly and stressful return visits to the emergency department, patients with temporal bone fractures along the course of the facial nerve should receive education regarding the possible delayed development of facial palsy prior to discharge and otolaryngological or primary care follow-up within 2 weeks of the injury.

The Use of Biomarkers in the Early Diagnosis of Septic Arthritis and Osteomyelitis-A Pilot Study.

The diagnosis of septic arthritis (SA) and osteomyelitis (OM) has remained challenging in the pediatric population, often accompanied by delays and requiring invasive interventions. The purpose of this pilot study is to identify a novel panel of biomarkers and cytokines that can accurately differentiate SA and OM at initial presentation using serum alone. Twenty patients below 18 years old whose working diagnosis included SA (n=10) and OM (n=10) were identified. Serum was collected at initial evaluation. Each sample underwent seven ELISA [C1-C2, COMP, CS-846, hyaluronan, procalcitonin, PIIANP, C-terminal telopeptide of type II collagen (CTX-II)] and 65-plex cytokine panels. Principal component and Lasso regression analysis were performed to identify a limited set of predictive biomarkers. Mean age was 4.7 and 9.5 years in SA and OM patients, respectively (P=0.029). 50% of SA patients presented within 24 hours of symptom onset, compared with 0% of OM patients (P=0.033). 30% of SA patients were discharged home with an incorrect diagnosis and re-presented to the emergency department days later. At time of presentation: temperature ≥38.5°C was present in 10% of SA and 40% of OM patients (P=0.12), mean erythrocyte sedimentation rate (mm/h) was 51.6 in SA and 44.9 in OM patients (P=0.63), mean C-reactive protein (mg/dL) was 55.8 in SA and 71.8 in OM patients (P=0.53), and mean white blood cells (K/mm3) was 12.5 in SA and 10.4 in OM patients (P=0.34). 90% of SA patients presented with ≤2 of the Kocher criteria. 100% of SA and 40% of OM patients underwent surgery. 70% of SA cultures were culture negative, 10% MSSA, 10% Kingella, and 10% Strep pyogenes. 40% of OM cultures were culture negative, 50% MSSA, and 10% MRSA. Four biomarkers [CTx-II, transforming growth factor alpha (TGF-α), monocyte chemoattractant protein 1 (MCP-1), B cell-attracting chemokine 1] were identified that were able to classify and differentiate 18 of the 20 SA and OM cases correctly, with 90% sensitivity and 80% specificity. This pilot study identifies a panel of biomarkers that can differentiate between SA and OM at initial presentation using serum alone. Level II-diagnostic study.

Substance Use Screening, Brief Intervention, and Referral to Treatment Among Medicaid Patients in Wisconsin: Impacts on Healthcare Utilization and Costs.

Unhealthy substance use in the USA results in significant mortality and morbidity. This study measured the effectiveness of paraprofessional-administered substance use screening, brief intervention, and referral to treatment (SBIRT) services on subsequent healthcare utilization and costs. The pre-post with comparison group study design used a population-based sample of Medicaid patients 18-64years receiving healthcare services from 33 clinics in Wisconsin. Substance use screens were completed by 7367 Medicaid beneficiaries, who were compared to 6751 randomly selected treatment-as-usual Medicaid patients. Compared to unscreened patients, those screened changed their utilization over the 24-month follow-up periodby 0.143 outpatient days per member per month (PMPM) (p < 0.001), -0.036 inpatient days PMPM (p < 0.05), -0.001 inpatient admissions PMPM (non-significant), and -0.004 emergency department days PMPM (non-significant). The best estimate of net annual savings is $391 per Medicaid adult beneficiary (2014 dollars). SBIRT was associated with significantly greater outpatient visits and significant reductions in inpatient days among working-age Medicaid beneficiaries in Wisconsin.

Causes of Death and Risk Factors for Mortality in Patients With Severe Chronic Obstructive Pulmonary Disease

Objective The objective of this study was to assess the causes of death and risk factors for mortality in a cohort of patients with severe chronic obstructive pulmonary disease (COPD). Patients and methods We studied 203 patients with severe COPD (forced expiratory volume in 1 second [FEV 1] <50%), who were attended in our respiratory department day hospital (2001-2006). Clinical variables were recorded on inclusion, and clinical course and causes of death were retrospectively reviewed. Results The mean (SD) age of patients was 69 (8) years and the mean FEV 1 was 30.8% (8.2%). One-hundred and nine patients died (53.7%); death was attributed to respiratory causes in 72 (80.9%), with COPD exacerbation being the most frequent specific cause within this category (48.3%). During follow-up, 18.7% required admission to the intensive care unit (ICU). Survival at 1, 3, and 5 years was 80%, 53%, and 26%, respectively. The multivariate analysis showed that mortality was associated with age, stage IV classification according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD), cor pulmonale, and hospital admission during the year prior to inclusion. Need for admission to the ICU during follow-up was a factor independently associated with higher mortality. Conclusions Mortality in patients with severe COPD was high and exacerbation of the disease was one of the most frequent causes of death. Age, GOLD stage, cor pulmonale, prior admission to hospital, and need for admission to the ICU during follow-up were independent predictors of mortality.

Causas de muerte en pacientes con EPOC grave. Factores pronósticos

Objective The objective of this study was to assess the causes of death and risk factors for mortality in a cohort of patients with severe chronic obstructive pulmonary disease (COPD). Patients and methods We studied 203 patients with severe COPD (forced expiratory volume in 1 second [FEV 1] <50%), who were attended in our respiratory department day hospital (2001–2006). Clinical variables were recorded on inclusion, and clinical course and causes of death were retrospectively reviewed. Results The mean (SD) age of patients was 69 (8) years and the mean FEV 1 was 30.8% (8.2%). One-hundred and nine patients died (53.7%); death was attributed to respiratory causes in 72 (80.9%), with COPD exacerbation being the most frequent specific cause within this category (48.3%). During follow-up, 18.7% required admission to the intensive care unit (ICU). Survival at 1, 3, and 5 years was 80%, 53%, and 26%, respectively. The multivariate analysis showed that mortality was associated with age, stage IV classification according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD), cor pulmonale, and hospital admission during the year prior to inclusion. Need for admission to the ICU during follow-up was a factor independently associated with higher mortality. Conclusions Mortality in patients with severe COPD was high and exacerbation of the disease was one of the most frequent causes of death. Age, GOLD stage, cor pulmonale, prior admission to hospital, and need for admission to the ICU during follow-up were independent predictors of mortality.

Measles outbreak in a day nursery

During the control of measles epidemic in a Social Services Department Day Nursery, the uptake of the measles vaccine was found to be 25/100, much lower than one would have expected from such a captive population. It is suggested that organizational factors are the major contribution to this low uptake as well as the lethargy of health personnel rather than the supposition that mothers are not keen to let their children have the measles vaccine. No further case of measles occurred after the measles vaccine had been given to thosechildren who had not been immunized against measles and had not yet had measles. This may have been due to attenuated vaccine virus “blocking” the entry of wild virus. Larger numbers would be necessary to measure the value of vaccine for this purpose.

Reflections on the Teaching of Religion in America

RECENTLY, the new editor of this journal asked me if I would be willing to set down my reflections on the pace and character of change in the study of religion in American higher education on the assumption, presumably, that my own zig-zag career from department of religion (four years) to seminary (ten years) back to department of religion must have been accompanied if not motivated by some opinions regarding the state of the discipline. At first, I was reluctant to accept the invitation. Although my recent departure from a theological seminary did, indeed, reflect some convictions about the field, it was rooted, like all such decisions, as much in my own personal interests and concerns as it was in some more abstract beliefs about this field. I did not see how I could disentangle these personal reasons from the more abstract considerations. But not to do so, involved me in a question of taste. To do so, however, would be to give a somewhat unreal account of the matter. Moreover, I particularly wanted to avoid giving any suggestion that I regarded my move as reflecting the view one hears frequently these days in department of religion circles, namely, that the future of scholarship in religion belongs to the university rather than to the divinity school. As I reflected on this latter issue, it occurred to me that my reasons for resisting having my decision so interpreted might itself prove interesting to some readers, and so I accepted the invitation. But when I put the matter in this fashion, it seemed that I could scarcely avoid being more autobiographical than suited my taste. I have tried to check this tendency by concentrating upon matters of intellectual autobiography, so to speak, and by eliminating any reference to those concrete personal reasons that were involved. This gives my account a more rationally consistent character than