Final Clinical Diagnosis Research Articles

Utility of Inferior Lead Q-waveforms in diagnosing Ventricular Tachycardia.

Background:Electrocardiogram (ECG) differentiation of wide complex tachycardia (WCT) into ventricular tachycardia (VT) and supraventricular tachycardia with aberration (SVT-A) is often challenging.Objective:To determine if the presence of Q-waveforms (QS, Qr, QRs) in the inferior leads (II, III, aVF) can differentiate VT from SVT-A in a WCT compared to Brugada algorithm. We studied 2 inferior lead criteria namely QWC-A where all the inferior leads had a similar Q wave pattern and QWC-B where only lead aVF had a Q-waveform.Methods:A total of 181 consecutive cases of WCT were identified, digitally separated into precordial leads and inferior leads and independently reviewed by 2 electrophysiologists. An electrocardiographic diagnosis of VT or SVT-A was assigned based on Brugada and inferior lead algorithms. Results were compared to the final clinical diagnosis.Results:VT was the final clinical diagnosis in 24.9% of ECG cohort (45/181); 75.1% (136/181) were SVT-A. QWC-A and QWC-B had a high specificity (93.3% and 82.8%) and accuracy (78.2% and 71.0%), but low sensitivity (33.3% and 35.6%) in differentiating VT from SVT-A. The Brugada algorithm yielded a sensitivity of 82.2% and specificity of 68.4%. Area under the curve in ROC analysis was highest with Brugada algorithm (0.75, 95% CI 0.69-0.81) followed by QWC-A (0.63, 95% CI 0.56-0.70) and QWC-B (0.59, 95% CI 0.52-0.67).Conclusion:QWC-A and QWC-B criteria had poor sensitivity but high specificity in diagnosing VT in patients presenting with WCT. Further research combining this simple criterion with other newer diagnostic algorithms can potentially improve the accuracy of the overall diagnostic algorithm.

A comparative observational study based on two radiographic techniques in suspected unilateral mandibular condylar fracture

Objective: This hypothetical comparative study aimed to compare two radiographic techniques based on the traditional radiograph (orthopantomography [OPG]) and computed tomography (CT) scans and find the best radiographic techniques to be used to confirm diagnostic accuracy and treatment planning in suspected unilateral condylar fractures. Materials and Methods: All patients with suspected unilateral condylar fractures were initially subjected to a radiologic assessment through a conventional radiographic technique of OPG to select the treatment modality, that is, open or closed. Subsequently, all patients were made to undergo a standard CT scan for the study of the temporomandibular joint, with the same objective, that is, (eighty radiographic imaging: forty OPG + forty CT scan) was done to determine which radiographic technique is more helpful in determining the final clinical diagnosis including treatment planning of suspected unilateral mandible condyle fracture. The findings were compared and cross-checked with those of conventional radiographic analysis. Results: It was found that out of the selected patients of confirmed forty unilateral condylar fractures, 33 patients were indicated for closed reduction by conventional radiography, were revealed to have a lateral extracapsular displacement on CT scan, and hence were treated by open reduction. Seven patients satisfied the criteria for closed reduction, both by conventional radiographs and CT scans. Conclusion: Through this theoretical research, it was found that both radiographic techniques are indispensable, specific, and standard in the detection of mandibular fractures. It was noted that CT scan radiographic information might help alter the approach and the treatment plan and prevent erroneous management in mandibular condylar fractures.

Morphological diagnostics of pathology of the thorax organs in HIV-infected patients of a phthisiopulmonology hospital.

Background. Intravital differential diagnostics of HIV-associated of the thorax pathology is complex. Currently in the diagnostic algorithm various mini-invasive diagnostic procedures with morphological examination of biopsy material are widely used. Objective – to evaluate the effectiveness of the morphological diagnostics of the thorax diseases in HIV-infected patients. Methods. A retrospective analysis of 205 cases of a morphological study of a biopsy and surgical material from hospitalized HIV-infected patients of a phthisiopulmonological profile over a 5-year period was carried out. Comparison of the histological conclusion with the final clinical diagnosis was made. Results. Among all hospitalized HIV patients in 45,5 % of cases in the diagnostic algorithm of the thorax pathology there was a need for a morphological study. Endoscopic procedures with a biopsy were performed in 93,6 % of cases; typical surgeries – in 5,8 % of cases. In 60,0 % of cases the material was obtained in video assisted thoracoscopy. Histological examination of the lungs was carried out in 23,4 %, lymph nodes in 25,4 % and parietal pleura in 50,7 % of cases. Conclusion. In 77,1 % of cases of all histological studies the final clinical diagnosis and histological conclusion coincided. In 12,7 % of the histological examination there was a clarification of the preliminary clinical diagnosis. The effectiveness of histological diagnostics of thorax diseases in HIV-infected patients was: lung pathology – 81,3 %, lymphatic system pathology – 84,6 % and pleural pathology – 95,2 %. The overall effectiveness of histological examination of biopsy and surgical material among hospitalized HIV-infected patients was 89,8 %.

Multifactorial Clinical and Anatomical Analysis of Lethal Outcome

Aim. To establish signifi cant factors infl uencing the discrepancy of lifetime and postmortem diagnoses and to offer a technique of comparison of diagnoses when carrying out the clinical and anatomical analysis of a lethal outcome.Material and methods. The material for the study was 1420 acts of forensic examination of corpses recorded at the Bureau of forensic medical examination of the Moscow region during the 2014–2018 period. We studied the cases of deaths in hospitals of medical organisations with fi nal clinical diagnoses of the initial causes of death from diseases of the circulatory system (1085), respiratory diseases (157), digestive system (178). An analytical comparison of nosological forms of diseases in all headings of the fi nal clinical and forensic diagnoses was carried out. The frequency of occurrence of objective and subjective causes of discrepancy of diagnoses was determined. The most signifi cant factors of erroneous formulation of the fi nal clinical diagnosis, which create risks in the formation of divergence of diagnoses, were established. The causes of divergence of diagnoses relevant to the choice of inadequate treatment and the onset of death were established. Absolute (abs) values were calculated for qualitative variables and relative (%) frequencies. The frequency comparison was carried out using Fisher’s two-way exact criterion. Risk ratios with 95 % bilateral confi dence intervals for risk ratios were calculated to identify the factors causing the highest level of divergence. Statistically signifi cant differences were considered when the probability of error of the fi rst kind was less than 5 % (p < 0.05). Data processing was carried out using the Excel 2016 (Microsoft, USA) and IBM SPSS Statistics 25 (IBM, USA) software.Results. The study found that the discrepancy between the lifetime diagnosis criteria of reliability, etiopathogenetic and timeliness are the most signifi cant factors affecting the discrepancy of diagnoses under the heading “underlying disease”. The causes of divergence of diagnoses, which are of the greatest importance for the choice of inadequate treatment and the formation of a lethal outcome, were revealed. On the basis of the obtained data, a method for comparing the in vivo and postmortem diagnoses during the clinical and anatomical analysis of the lethal outcome was developed.Conclusion. Incorrect clinical diagnosis is important in the onset of death only if the erroneous diagnosis is due to insuffi cient examination of the patient, the lack of clinical data, the severity of the condition and the short duration of stay, which does not allow the underlying disease and fatal complication to be determined and adequate medical measures to be carried out. The proposed method for comparing the in vivo and postmortem diagnoses allows a correct, reliable and convincing clinical and anatomical analysis of the case of death in the hospital to be performed.

ACTINIC PRURIGO OF THE LOWER LIP: CASE REPORT

A 53-year-old black woman was referred complaining of "lip infection" 4 months ago. After medical consultation she was diagnosed as having a stress injury. Anamnesis revealed systemic arterial hypertension. Extraoral examination showed swollen resected lower lip, painful ulcers covered by crusts and pseudomembrane throughout lower lip, and periodic pulsatile pain. Intraoral examination was normal. Diagnostic hypotheses were exfoliative cheilitis and actinic prurigo. Treatment consisted of local hydration with dexpanthenol cream and ketoconazole, betamethasone, and neomycin topical cream. After 15 days, there was significant clinical improvement, but erythematous regions remained. The medication was maintained for another 15 days without complete resolution. Final clinical diagnosis was actinic prurigo of the lip. Actinic prurigo is an idiopathic photodermatosis that affects skin exposed to sunlight and labial and conjunctival mucosa. It more often affects young women and presents clinically as pruritic lower lip cheilitis that normally does not respond to conventional therapy. A 53-year-old black woman was referred complaining of "lip infection" 4 months ago. After medical consultation she was diagnosed as having a stress injury. Anamnesis revealed systemic arterial hypertension. Extraoral examination showed swollen resected lower lip, painful ulcers covered by crusts and pseudomembrane throughout lower lip, and periodic pulsatile pain. Intraoral examination was normal. Diagnostic hypotheses were exfoliative cheilitis and actinic prurigo. Treatment consisted of local hydration with dexpanthenol cream and ketoconazole, betamethasone, and neomycin topical cream. After 15 days, there was significant clinical improvement, but erythematous regions remained. The medication was maintained for another 15 days without complete resolution. Final clinical diagnosis was actinic prurigo of the lip. Actinic prurigo is an idiopathic photodermatosis that affects skin exposed to sunlight and labial and conjunctival mucosa. It more often affects young women and presents clinically as pruritic lower lip cheilitis that normally does not respond to conventional therapy.

The utility and challenges of histopathologic evaluation in the diagnosis of nonmalignant skin ulcers.

Histopathologic evaluation of cutaneous ulcers is indicated when the clinical diagnosis is unclear or when ulcers have not responded to standard of care. Many nonmalignant skin ulcers lack specific histologic findings on biopsy and pose a diagnostic challenge. While the usefulness of skin biopsies to diagnose underlying malignancy in ulcerated lesions has been demonstrated in previous studies, their utility in the diagnosis of ulcers of other etiologies has not been reported. We conducted a retrospective study of 45 nonmalignant ulcer biopsies in a 3-year period to compare the histologic diagnosis with the final diagnosis. Additionally, we assessed the diagnostic concordance among three blinded dermatopathologists when reviewing these cases. The leading histologic diagnosis from each of the three observers agreed with the final clinical diagnosis, on average, for 29.6% of the cases (average pairwise kappa = 0.15). Inflammatory ulcers had the lowest concordance between the observers and final diagnosis with an average of 26.0% of cases (average pairwise kappa = 0.06). The observers agreed with each other for 35.6% of the cases (Fleiss' kappa = 0.32). The highest agreement among observers was in the vascular/vasculopathic category (50%, Fleiss' kappa = 0.44). Our results indicate that skin biopsies alone are useful in the evaluation of nonmalignant ulcers to rule out other conditions (e.g. neoplasm) but frequently not sufficient to establish a definitive diagnosis. Additional clinicopathologic correlation is necessary in the final assessment of nonmalignant ulcers to determine the diagnosis. Future research endeavors should explore alternative approaches to more efficiently diagnose nonmalignant skin ulcers.

Lymph Node Metastasis Prediction from Primary Breast Cancer US Images Using Deep Learning.

Background Deep learning (DL) algorithms are gaining extensive attention for their excellent performance in image recognition tasks. DL models can automatically make a quantitative assessment of complex medical image characteristics and achieve increased accuracy in diagnosis with higher efficiency. Purpose To determine the feasibility of using a DL approach to predict clinically negative axillary lymph node metastasis from US images in patients with primary breast cancer. Materials and Methods A data set of US images in patients with primary breast cancer with clinically negative axillary lymph nodes from Tongji Hospital (974 imaging studies from 2016 to 2018, 756 patients) and an independent test set from Hubei Cancer Hospital (81 imaging studies from 2018 to 2019, 78 patients) were collected. Axillary lymph node status was confirmed with pathologic examination. Three different convolutional neural networks (CNNs) of Inception V3, Inception-ResNet V2, and ResNet-101 architectures were trained on 90% of the Tongji Hospital data set and tested on the remaining 10%, as well as on the independent test set. The performance of the models was compared with that of five radiologists. The models' performance was analyzed in terms of accuracy, sensitivity, specificity, receiver operating characteristic curves, areas under the receiver operating characteristic curve (AUCs), and heat maps. Results The best-performing CNN model, Inception V3, achieved an AUC of 0.89 (95% confidence interval [CI]: 0.83, 0.95) in the prediction of the final clinical diagnosis of axillary lymph node metastasis in the independent test set. The model achieved 85% sensitivity (35 of 41 images; 95% CI: 70%, 94%) and 73% specificity (29 of 40 images; 95% CI: 56%, 85%), and the radiologists achieved 73% sensitivity (30 of 41 images; 95% CI: 57%, 85%; P = .17) and 63% specificity (25 of 40 images; 95% CI: 46%, 77%; P = .34). Conclusion Using US images from patients with primary breast cancer, deep learning models can effectively predict clinically negative axillary lymph node metastasis. Artificial intelligence may provide an early diagnostic strategy for lymph node metastasis in patients with breast cancer with clinically negative lymph nodes. Published under a CC BY 4.0 license. Online supplemental material is available for this article. See also the editorial by Bae in this issue.

A/H1N1 INFLUENZA CLINICAL CASE, COMPLICATED BY RAY SYNDROME

The flu problem is becoming more urgent, as the incidence in Ukraine over the last decade is 7-8 million people annually, of which about 30% are children. Hospitalization of children under 5 years 120-123 per 100 thousand population per year and average bed-day is 6.5 days. Influenza complications are a major threat to the lives of children. According to the Public Health Center of the Ministry of Health of Ukraine, 5.4 million people were infected with influenza and SARS during the 2018/2019 epidemic, 65.3% of whom were children. The flu claimed the lives of 64 Ukrainians, including 12 children, under the age of 17. None of the dead were vaccinated for the flu, 11 people did not seek medical help at all, and one of five people sought help with a critical deterioration in health on the 6 day or later. Among 2927 laboratory-tested influenza patients, 30% had positive results, with the predominance of type A influenza virus. For the purpose of the publication, the authors set out to focus on the circumstances of the occurrence of Ray syndrome with the analysis of a clinical case of a 2 years child, who was in the regional clinical infectious hospital, in the intensive care unit. The condition of the child was found to be severe and a fatal incident was noted on the 5th day of stay in the department of the intensive care unit in the regional infectious hospital. The final clinical diagnosis after a detailed laboratory and instrumental examination was made at an expanded council of doctors of the regional clinical infectious hospital in Poltava and the above mentioned narrow specialists: Flu A / H1N1, toxic form, severe course. Toxic encephalopathy. Brain edema, dislocation of its structures. Toxic hepatitis. Ascites. Erosive gastritis. Gastrointestinal bleeding. Acute kidney damage. Gastrointestinal bleeding. Anuria. Acute renal failure. ICE Syndrome. Non-rheumatic carditis (pancarditis, pericarditis). Heart failure 3 degree. Polyseritis. Deficiency anemia. Ray syndrome.

Polymorbidity: a View on Combined Pathology

Aim. To describe clinical cases exhibiting a rare combination of dermatoses in one patient in order to prevent iatrogenic errors.Results. The present article describes clinical cases of patients with polymorbid pathologies, which constitutes one of the current interdisciplinary healthcare problems. The described clinical cases indicate the co-occurrence and overlap of various diseases, which complicates the final diagnosis. Polymorbidity in modern patients turns the diagnostic process into a search for an optimal solution, which frequently requires innovative approaches. A mixed clinical picture leads to iatrogenic errors. A detailed differential diagnostics should be performed when establishing the final clinical diagnosis, which could reduce the frequency of medical-diagnostic and tactical errors. In this connection, a prolonged diagnostic route contributes to the timely detection of interdependent pathologies. The analysis of clinical cases related to managing patients with polymorbid pathologies facilitates the prevention of the progression of each disease, as well as the determination of prognostic aspects.Conclusion. Considering the narrow specialisation of medical institutions, the management of patients with polymorbid pathologies is a challenging problem. The management of such patients requires adherence to a clear clinical diagnostic algorithm and a multidisciplinary approach, which allows diagnostic errors and complications associated with drug therapy to be avoided, thus improving the quality of healthcare services. Polymorbid pathology constitutes an interdisciplinary problem requiring the development of a unified procedure for the management of patients, which should be aimed at the early detection of combined pathology, eliminating polypharmacy, reducing the overall risk of diseases and improving the life quality of patients.

Clinical Evaluation of Diagnosis Efficacy of Active Mycobacterium tuberculosis Complex Infection via Metagenomic Next-Generation Sequencing of Direct Clinical Samples.

Background: Tuberculosis (TB) is now the leading cause of death from infectious disease. Rapid screening and diagnostic methods for TB are urgently required. Rapid development of metagenomics next-generation sequencing (mNGS) in recent years showed promising and satisfying application of mNGS in several kinds of infectious diseases. However, research directly evaluating the ability of mNGS in TB infection is still scarce.Methods: We conducted an adult prospective study in mainland China to evaluate the diagnostic performance of mNGS for detection of Mycobacterium tuberculosis complex (MTB) in multiple forms of direct clinical samples compared with GeneXpert MTB/RIF assay (Xpert), traditional diagnostic methods, and the clinical final diagnosis.Results: Of 123 patients presenting with suspected active TB infection between June 1, 2017, and May 21, 2018, 105 patients underwent synchronous tuberculous testing with culture, Xpert, and mNGS on direct clinical samples including sputum, cerebrospinal fluids, pus, etc. During follow-up, 45 of 105 participants had clinical final diagnosis of active TB infection, including 13 pulmonary TB cases and 32 extrapulmonary TB cases. Compared to clinical final diagnosis, mNGS produced a sensitivity of 44% for all active TB cases, which was similar to Xpert (42%) but much higher than conventional methods (29%). With only one false-positive result, mNGS had a specificity of 98% in our study. mNGS yielded significantly much higher sensitivity in pre-treatment samples (76%) than post-treatment ones (31%) (P = 0.005), which was also true for Xpert and conventional methods. Combining Xpert and mNGS together, the study identified 27 of 45 active TB cases (60%), including all 13 conventional method-identified cases, and the result reached statistical significance compared to conventional methods (McNemar-test P < 0.001).Conclusions: mNGS had a similar diagnostic ability of MTB compared with Xpert and showed potential for a variety of clinical samples. Combined mNGS and Xpert showed an overall superior advantage over conventional methods and significantly improved the etiology diagnosis of both MTB and other pathogens. The result that anti-TB treatment significantly reduced diagnostic efficacy of culture, Xpert, and mNGS highlighted the importance of collecting samples before empirical treatment.

Tuberculosis and HIV co-infection in inpatients of phthisio-pulmonological profile: frequency, form of lesion, diagnostic features (according to data of highly specialized institution)

Objective — to clarify the prevalence of tuberculosis infection in HIV-positive inpatients of the TB hospital for 2014—2018 and features of its diagnosis in the affection of the chest cavity organs.Materials and methods. The method of retrospective analysis was used to process medical records of the Institute’s clinic for the period 2014—2018. A database has been formed that includes all patients with HIV infection treated in the hospital, from which a group of patients with a final clinical diagnosis of co-infection tuberculosis and HIV was subsequently selected.Among them were 195 (68.9 %) men and 88 (31.1 %) women. The average age of men was (37.0 ± 0.5), women — (38.0 ± 1.2) years. Separate subgroups of patients were selected, taking into account the localization of the tuberculous process in the chest cavity. The general clinical data of patients, the presence of comorbidities, diagnostic methods, localization and prevalence of the tuberculous process were taken into account.Results and discussion. Among 496 hospitalized HIV-positive patients with various pathologies of the chest cavity, the diagnosis of tuberculosis, that is, the presence of HIV-TB co-infection, was established in 283 (57.1 %) cases. In 46 (16.3 %) cases the diagnosis of HIV infection was established for the first time during hospitalization. Comorbid pathology was present in 184 (65.0 %) patients.Specific lung damage prevailed, 123 (44 %) cases, most often infiltrative tuberculosis (48.8 %). In 33 % of cases, there was a widespread tuberculous lesion — pulmonary and extrapulmonary (pleura or lymph nodes were involved). Isolated pleural lesion was diagnosed in 13 % of cases. The main methods of laboratory diagnostics were classical bacteriological methods — simple direct light microscopy and MBT culture, the positive results of which were obtained in only half of all studies, as well as molecular-genotypic tests. Prevalence of multidrug-resistant MBT strains was found (66.7 %).In about half of the cases, (44.9 %), additional mini-invasive procedures or surgical interventions with therapeutic and diagnostic purposes were performed. Histological examination confirmed the diagnosis of tuberculosis in 92 % of cases, whereas in the absence of signs of tuberculosis, diagnoses of other opportunistic diseases were most often specified/established.Conclusions. In HIV-positive inpatients of a phthisiopulmonary profile, tuberculosis infection prevails in the structure of opportunistic morbidity, 57.1 %. The largest proportion of patients consist cases with pulmonary tuberculosis (44 %), is also a large group (33 %), formed by patients with the extended lesion of the organs of the chest cavity.Positive results of traditional bacteriological studies were obtained in approximately half of the cases, which required an expansion of the diagnostic algorithm with the implementation of mini-invasive diagnostic procedures with biopsy of the affected tissues and subsequent histological examination.Analysis of the results of laboratory diagnostics of tuberculosis in cases of TB/HIV co-infection showed that the use of not only different microbiological research methods is most effective, but an important component in the diagnostic search is the histological examination of biopsy material.

The role of 99mTc-HMPAO-labelled white blood cell scintigraphy in the diagnosis of cardiac device-related infective endocarditis.

The hybrid technique of single-photon emission tomography and computed tomography with technetium99m-hexamethylpropyleneamine oxime-labelled leucocytes (99mTc-HMPAO-SPECT/CT) is an emerging diagnostic technique in patients with cardiac device-related infective endocarditis (CDRIE). This prospective study assessed the 99mTc-HMPAO-SPECT/CT diagnostic profile and its added value to the modified Duke criteria (mDuke) in CDRIE diagnostic work-up. The study examined 103 consecutive patients with suspected CDRIE, who underwent 99mTc-HMPAO-SPECT/CT. Diagnostic accuracy was calculated based on a final clinical CDRIE diagnosis, including microbiology, echocardiography, and a 6-month follow-up. Subsequently, we compared the diagnostic value of the initial mDuke classification with a classification including 99mTc-HMPAO-SPECT/CT positive results as an additional major CDRIE criterion: mDuke-SPECT/CT.Overall, CDRIE was diagnosed in 31 (31%) patients, whereas 35 (34%) 99mTc-HMPAO-SPECT/CT were positive. 99mTc-HMPAO-SPECT/CT was characterized by 86% accuracy, 0.69 Cohen's kappa coefficient, 84% sensitivity, 88% specificity, 93% negative, and 74% positive predictive values. The original mDuke displayed 83% accuracy, 0.52 kappa, whereas mDuke-SPECT/CT had 88% accuracy, and 0.73 kappa. Compared with mDuke, mDuke-SPECT/CT showed significantly higher sensitivity (87% vs. 48%, P < 0.001). According to mDuke, 49.5% of patients had possible CDRIE, and after reclassification, that figure dropped to 37%. Furthermore, having assessed the diagnosis categorization improvement following the incorporation of 99mTc-HMPAO-SPECT/CT, the net reclassification index value was found to be 31.4%. In patients with CDRIE, 99mTc-HMPAO-SPECT/CT provides high diagnostic accuracy, whereas a negative scan excludes CDRIE with high probability. Inclusion of 99mTc-HMPAO-SPECT/CT into mDuke diagnostic criteria yields significantly higher sensitivity and a reduction in possible CDRIE diagnoses.

RULE OF RUSH PROTOCOL IN MANAGEMENT OF SHOCKED PATIENTS

SESSION TITLE: Wednesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM PURPOSE: Background: Clinical assessment and classification of shock is extremely difficult to conduct on critically ill patients. Rapid Ultrasound in Shock (RUSH) is an easily learned and quickly performed shock ultrasound protocol, it allows for rapid evaluation of reversible causes of shock and improves accurate diagnosis in undifferentiated hypotension. Objectives: To evaluated the accuracy of early RUSH protocol performed by chest physicians to predict type of shock and its guide of resuscitation in critically ill patients. METHODS: Study was conducted on 68 patients with shock state in RICU and evaluated for the cause of shock by performing early RUSH protocol for patients. Patients received all needed standard therapeutic and diagnostic interventions without delay and were followed to document their final clinical diagnosis. The agreement between the initial impression provided by RUSH and the final diagnosis was investigated by calculating the Kappa index. Sensitivity, Specificity, positive predictive value PPV and negative predictive value NPV of RUSH for diagnosis of each case. RESULTS: We performed RUSH examination on 68 shocked patients. 39 were males (58%) and 29 were females (41%), with mean age 58 years. Kappa index was 0.85 (P= 0.0001), reflecting acceptable general agreement between initial impression and final diagnosis. For hypovolemic, cardiogenic and obstructive shock, the protocol had an NPV above 97%, but it had low sensitivity. For shock with distributive or mixed etiology, RUSH showed a PPV of {97% & 100%} respectively, with high sensitivity. The agreement of protocol for final diagnosis was highest in distributive and obstructive shock followed by cardiogenic and hypovolemic shock [(94% & 93%), P < 0.001 & (84% & 73%), P < 0.001,] respectively. CONCLUSIONS: We highlight the role of integrating focused ultrasound techniques, such as the RUSH examination, in the physician resuscitation pathways to diagnose shock etiology, augment their clinical evaluation and guide resuscitation CLINICAL IMPLICATIONS: Early identification of causes of shock in critically ill patients allow good clinical evaluation and guide resuscitation and help physician to used correct treatment. DISCLOSURES: no disclosure on file for Esrra Abdei-All; no disclosure on file for Gamal Agamy; no disclosure on file for AzzA Ahmad; No relevant relationships by Hamdy Mohammadien, source=Web Response

P3362Added value of radiolabeled leukocyte scintigraphy to cardiac device-related infective endocarditis diagnostic criteria

Abstract Background Radiolabeled leukocyte scintigraphy – hybrid technique of single photon emission tomography and computed tomography with application of technetium99m-hexamethylpropyleneamine oxime-labeled autologous leukocytes (99mTc-HMPAO-SPECT/CT) is an emerging technique in patients with suspected cardiac device-related infective endocarditis (CDRIE). Purpose The aim of this prospective study was to assess 99mTc-HMPAO-SPECT/CT added value to modified Duke criteria (mDuke) in CDRIE diagnostic process. Methods During the period 2015–2018, we enrolled 103 consecutive patients with suspected CDRIE [70 males (68%), mean age: 61±18 years, mean left ventricle ejection fraction value: 44±17%)]. All patients underwent clinical, microbiologic, echocardiographic evaluation according to ESC guidelines and additionally 99mTc-HMPAO-SPECT/CT (370–740 MBq). Scans were classified as positive in the presence of abnormal tracer uptake involving cardiac and intravascular sections of device electrodes. In the analysis, we added positive 99mTc-HMPAO-SPECT/CT result as an additional major criterion to mDuke classification. Additionally, we compared the diagnostic value of the mDuke classification including 99mTc-HMPAO-SPECT/CT (mDuke-SPET/CT) with the original mDuke classification. The sensitivity and specificity of those two scales were compared with McNemar's test. Diagnostic accuracy was calculated based on final clinical CDRIE diagnosis, including microbiology, echocardiography and 6 month-long follow-up with subsequent outpatient visit. Results Overall 58% patients had pacemakers, 25% had implantable cardioverter defibrillators, 16% had resynchronization therapy and 1% had an epicardial lead. Mean time from device implantation was 3.4±3.8 years. Final CDRIE diagnosis was established in 31 (30%) patients. The most common pathogens causing CDRIE were Enterococci (39%) and Staphylococci (35%). According to the original mDuke classification 16.5% patients had definite CDRIE, 49.5% had possible and in 34% CDRIE was excluded. Overall, 34% of 99mTc-HMPAO-SPECT/CT scans were positive for CDRIE. After reclassification, according to mDuke-SPET/CT the proportion of patients with definite CDRIE increased to 34%, whereas in 37% patients CDRIE was possible and in 29% cases CDRIE was excluded. Overall, mDuke was characterized with 83% accuracy, 0.52 Cohen's kappa coefficient, 48% sensitivity, 97% specificity, 81% negative predictive value (NPV), 88% positive predictive value (PPV). Whereas mDuke-SPET/CT had 88% accuracy, 0.73 Cohen's kappa coefficient, 87% sensitivity, 89% specificity, 94% NPV, 77% PPV. Compared to mDuke, mDuke-SPET/CT had significantly higher sensitivity (p&lt;0.001). Conclusions In patients with suspected CDRIE inclusion of positive radiolabeled leukocyte scintigraphy into modified Duke diagnostic criteria yields significantly higher sensitivity, as well as modest reduction of possible CDRIE diagnoses. Acknowledgement/Funding Grant from the Jagiellonian University Medical College (K/DSC/004383)

LUNG CANCER DETECTION VIA WHOLE-TRANSCRIPTOME RNA SEQUENCING OF NASAL EPITHELIUM

SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM PURPOSE: We have previously established the clinical utility of a molecular test (Percepta) that utilizes a brushing of normal-appearing bronchial epithelium to improve lung cancer detection in former and current smokers. This “field of injury” principle has been extended to the nose with evidence that genomic changes associated with cancer can be detected in the nasal epithelium (Perez-Rogers et al. 2017). We report the feasibility of a molecular test developed from non-invasive nasal brush samples for lung cancer detection in current and former smokers. METHODS: Brushings of the nasal epithelium were prospectively collected during the AEGIS clinical trials from current and former smokers undergoing a bronchoscopy for suspected lung cancer lesions found on chest CT. Patients were followed for up to one year until a final diagnosis of lung cancer or benign disease was made. Purified RNA was analyzed using whole-transcriptome RNA sequencing. A total of 675 patients were divided into a training set of 411 nasal samples and an independent test set of 264 nasal samples. Classifiers were developed using gene expression as well as clinical factors such as age, gender, smoking status and nodule characteristics. RESULTS: The independent test set was analyzed using the developed classifiers and results compared to the final clinical diagnosis (malignant or benign). A nasal genomic-clinical classifier demonstrated sensitivity of 97% (95% CI: 93-99) and a specificity of 46% (95% CI: 32-59). While the prevalence of lung cancer in the overall test set is 78%, reflecting the high-risk clinical setting of this bronchoscopy-based cohort, it also includes a subset of patients with low/intermediate pre-test risk of cancer (n=57). In this subset, sensitivity is 95% (95% CI: 74-100) and specificity is 45% (95% CI: 29-62), similar to that of the overall test set. CONCLUSIONS: A nasal genomic-clinical classifier developed using whole transcriptome RNA sequencing shows early feasibility in detecting lung-cancer related gene expression changes in nasal brushings from high-risk smokers. Further research is warranted to understand its impact on patient care in a real-world clinical setting. CLINICAL IMPLICATIONS: A nasal genomic-clinical classifier has the potential to serve as a non-invasive tool for lung cancer risk-stratification among patients with pulmonary nodules. 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Please note: >$100000 Added 06/25/2019 by Jie Ding, source=Web Response, value=Salary Employee relationship with Veracyte Inc Please note: >$100000 Added 03/15/2019 by Jing Huang, source=Web Response, value=Salary no disclosure on file for Giulia Kennedy; Consultant relationship with Boston Scientific Please note: $1001 - $5000 Added 11/30/2018 by Carla Lamb, source=Web Response, value=Honoraria Advisory Committee Member relationship with Veracyte Please note: $1001 - $5000 Added 03/25/2019 by Carla Lamb, source=Web Response, value=Consulting fee Consultant relationship with Veracyte Please note: $5001 - $20000 Added 06/21/2019 by Marc Lenburg, source=Web Response, value=Consulting fee Consultant relationship with Johnson and Johnson Please note: $5001 - $20000 Added 06/21/2019 by Marc Lenburg, source=Web Response, value=Consulting fee Employee relationship with Veracyte Please note: >$100000 Added 03/15/2019 by Lori Lofaro, source=Web Response, value=Salary Employee relationship with Veracyte Please note: >$100000 Added 03/18/2019 by Daniel Pankratz, source=Web Response, value=Salary no disclosure on file for Saeed Saberi; Employee relationship with Johnson and Johnson Please note: >$100000 Added 06/25/2019 by Avrum Spira, source=Web Response, value=Salary Employee relationship with Johnson and Johnson Please note: >$100000 Added 07/01/2019 by Christopher Stevenson, source=Web Response, value=Salary Employee relationship with Johnson and Johnson Please note: >$100000 Added 07/01/2019 by Christopher Stevenson, source=Web Response, value=Salary Employee relationship with Veracyte Please note: >$100000 Added 03/18/2019 by Patric Walsh, source=Web Response, value=Salary Employee relationship with Johnson & Johnson Please note: >$100000 Added 06/23/2019 by Duncan Whitney, source=Web Response, value=Salary Employee relationship with Veracyte Please note: >$100000 Added 06/25/2019 by Jonathan Wilde, source=Web Response, value=Salary

Performance of the Procalcitonin Test in Diagnosing Pneumonia in Real-World Practice

Abstract Background Procalcitonin (PCT) rises early upon bacterial infection and has a long-half life, making it useful in the diagnosis of infections and antibiotic stewardship. We sought to determine the utility of PCT in diagnosing pneumonia (PNU) in the patient population presenting to our hospital during real-world clinical practice. Methods PCT results from patients in 2015 were reviewed retrospectively. Patients were eligible for inclusion if all of following criteria were met: PCT in 2015 and a lower respiratory tract culture, respiratory virus testing, chest x-ray, and white blood cell (WBC) count within 1 day of the PCT. Patients who opted out of research and those with mycobacterial infections and culture-positive infections of body sites other than urine and lower respiratory tract were excluded from further analysis. Results A total of 400 patients remained with 413 eligible PCT results across the ED (109), ICU (134), and inpatient (167) and outpatient (3) areas with a mean (SD) age of 66.2 (18.1). PCT was higher in patients with multiple pathogens reported on their respiratory cultures, direct fluorescence antibody (DFA), or PCR-based tests (mean ± SD = 2.43 ± 0.74 ng/mL; N = 32), than those with no pathogens reported (3.25 ± 1.13 ng/mL; N = 224; P &lt; .05). Patients were grouped for the presence or absence of clinically defined PNU, according to a modification of the Centers for Disease Control (CDC) PNU1 criteria incorporating (1) chest x-ray results, (2) altered WBC number/altered mental status/fever, and (3) respiratory/breathing signs. PCT was higher in patients with clinically defined PNU, and the high PCTs were consistent with positive chest x-rays (criterion 1), and positive criterion 2 but not criterion 3. Incorporation of an elevated PCT &gt;0.1 ng/mL into the PNU score slightly improved the area under the ROC curve (AUC) for the algorithm’s detection of PNU against the final clinical diagnosis (0.73 without PCT vs 0.76 with PCT). Furthermore, higher PCT was associated with higher 30-day and 1-year mortality. Conclusion PCT results were largely consistent with other markers of PNU such as imaging and CDC criterion 2, which suggests that PCT can be useful in evaluating for the presence of PNU. However, the PCT may not add additional information to assist in decision making above the already commonly ordered tests.

Lung ultrasonography findings in dogs with various underlying causes of cough.

To characterize lung ultrasonography (LUS) findings in dogs with a primary clinical complaint of cough. 100 client-owned coughing dogs. A standardized LUS examination was performed for all dogs to quantify the number of B lines and identify subpleural abnormalities at 4 sites on each hemithorax. The final clinical diagnosis (reference standard) was determined by medical record review, and sensitivity and specificity of LUS for the diagnosis of selected causes of cough was determined. Common underlying causes of cough included dynamic airway collapse (n = 37), cardiogenic pulmonary edema (CPE; 12), and bronchitis (10). Compared with dogs with other causes of cough, dogs with bacterial pneumonia (n = 7) were more likely to have subpleural shred signs, whereas dogs with pulmonary neoplasia (4) were more likely to have subpleural nodule signs. Dogs with CPE had higher total B-line scores and higher numbers of LUS sites strongly positive for B lines (> 3 B lines/site) than other dogs. The LUS criteria of total B-line score ≥ 10 and presence of ≥ 2 sites strongly positive for B lines were each 92% sensitive and 94% specific for CPE diagnosis. Notably, 18% (16/88) of dogs with noncardiac causes of cough had been treated previously with diuretics because of prior CPE misdiagnosis. LUS profiles in dogs with cough differed by the underlying cause. In dogs with a clinical history of cough, this imaging modality could be diagnostically useful, particularly to help exclude the possibility of underlying CPE.

Clinical Usefulness of the Korean Developmental Screening Test (K-DST) for Developmental Delays.

ObjectiveTo evaluate the clinical usefulness of the Korean Developmental Screening Test (K-DST) via comparison with Korean Ages and Stages Questionnaire (K-ASQ) for the diagnosis of developmental delay in pediatric patients.MethodsThe K-DST and K-ASQ were used to screen pediatric patients who visited the hospital for evaluation and diagnosis of delayed development. Korean Bayley Scales of Infant Development-II (K-BSID-II) or Korean Wechsler Preschool and Primary Scale of Intelligence III (K-WPPSI-III) were used for the standardized assessment. Moreover, the final clinical diagnosis was confirmed by three expert physicians (rehabilitation doctor, psychiatrist, and neurologist). The sensitivity and specificity of each screening tool for the final diagnosis were investigated and correlated with standardized assessments.ResultsA total of 145 pediatric consultations were conducted, which included 123 developmental disorders (40 autism spectrum disorders, 46 global developmental delay/intellectual disability, and 37 developmental language disorders) and another 22 that were not associated with any such disorders. The sensitivity and specificity of K-DST based on the final clinical diagnosis were 82.9% and 90.9%, respectively, which were not significantly different from that of K-ASQ (83.7% and 77.3%). Both K-DST and K-ASQ showed good correlation with K-BSID-II and K-WPPSI-III. No significant difference was found between the K-DST and K-ASQ measures.ConclusionK-DST is an excellent screening tool and is expected to replace K-ASQ with high validity.

Lung ultrasound in the diagnosis of neonatal respiratory failure prior to patient transport.

Lung ultrasound (LUS) at the point-of-care is a new method that is increasingly used in neonatology. The aim of this study was to determine the utility of the addition of LUS prior to the interhospital transport of neonates with respiratory failure. LUS was performed on 50 newborns with respiratory failure prior to transport to a tertiary neonatal intensive care unit. We analyzed the performance of LUS for diagnosing the cause of respiratory failure, the concordance between LUS, chest X-ray (CXR) and final clinical diagnosis, and the impact of LUS on clinical decision making before transport. LUS sensitivity for the diagnosis of respiratory distress syndrome was 91.3% (95%CI: 70.5-98.5%), and specificity was 92.6% (95%CI: 74.2-98.7%), whereas sensitivity and specificity of CXR were 69.6% (95%CI: 47.0-85.9%) and 81.5% (95%CI: 61.2-92.9%), respectively. For the recognition of pneumothorax (PTX) LUS had a sensitivity of 83.3% (95%CI: 36.5-99.1%) and a specificity of 100% (95%CI: 89.9-100%). For CXR, sensitivity was 16.7% (95%CI: 0.01-63.5%) and specificity was 97.7% (95%CI: 86.4-99.9%). The agreement between LUS and CXR in diagnosing the cause of respiratory failure was substantial (κ of 0.57 [95%CI: 0.40-0.74]) and the agreement between LUS and the final clinical diagnosis was very good (κ of 0.86 [95%CI: 0.74-0.98]). In 42% of the patients, a LUS examination prior to transport indicated the need for endotracheal tube repositioning or PTX decompression. LUS may be a reliable imaging technique for differentiating the causes of respiratory failure before neonatal transport. Use of LUS may optimize the care of infants during transport.

A comparison of ventilation perfusion combined with pulmonary perfusion fusion tomography imaging and CT pulmonary angiography for diagnosis of pulmonary embolism

Objective To compare the diagnostic value of ventilation/perfusion (V/Q) combined with pulmonary perfusion single photon emission computed tomography combined with CT (SPECT/CT) fusion tomography imaging and computed tomographic pulmonary angiography (CTPA) in evaluation of pulmonary embolism. Methods We retrospectively analyzed 60 patients with clinically suspected pulmonary embolism diagnosed in Shanxi Dayi Hospital from May 2015 to May 2017. All patients underwent pulmonary V/Q imaging and lung perfusion SPECT/CT fusion tomography, and CTPA inspections were completed within 3 days. The final clinical diagnosis and follow-up confirmed the presence or absence of pulmonary embolism. The diagnostic efficacy of two imaging methods for pulmonary embolism were calculated and compared. Results Of the 60 cases of patients, 33 cases were diagnosed with pulmonary embolism; the sensitivity, specificity, and accuracy of V/Q combined with pulmonary perfusion SPECT/CT fusion tomography were 96.97% (32/33), 92.59% (25/27) and 95% (57/60), respectively; the sensitivity, specificity, and accuracy of CTPA were 81.82% (27/33), 92.59% (25/27) and 86.67% (52/60), respectively; both have no diagnostic uncertainty, there was no significant difference in the qualitative diagnosis of pulmonary embolism between the two examination methods (P>0.05). V/Q combined with pulmonary perfusion SPECT/CT fusion tomography found 253 lung segment and 50 unmatched sub-pulmonary segments, including 15 V/Q mismatch lung segment and 5 sub-segment caused by lung lesions which were confirmed by lung perfusion SPECT/CT fusion image (5 interlobular or pleural effusion, 4 local emphysema and pulmonary bulla, 3 interlobular hypertrophy, 8 pulmonary parenchymal inflammation); CTPA found 3 sub-segmental pulmonary filling defects, 6 cases of false-negative cases were multiple sub-pulmonary segment pulmonary embolism. Conclusions V/Q combined with pulmonary perfusion SPECT/CT fusion tomography is similar to CTPA in diagnosing pulmonary embolism, and both of them have better diagnostic efficacy; the former has advantages in the diagnosis of sub-pulmonary segment pulmonary embolism, and can exclude false-positive diagnoses due to other lung lesions and provide additional diagnostic information for lung disease. Key words: Pulmonary embolism; Tomography, emission-computed, single-photon; Radionuclide imaging; Angiography; Tomography, spiral computed