Final Diagnosis Of Patients Research Articles

Exploring the appropriate situation of performing CSF mNGS in patients with proposed intracranial infections

BackgroundIdentifying the responsible pathogen is crucial for precision medicine in intracranial infections, and Cerebrospinal Fluid (CSF) Metagenomic Next-Generation Sequencing (mNGS) is a reliable method for this detection. However, the indiscriminate utilization of this approach may impose a financial burden on both patients and society. The study aims to investigate the optimal conditions for applying CSF mNGS in patients with suspected intracranial infections, offering valuable references for precision medicine of intracranial infections.MethodsA total of 175 hospitalized patients presenting with suspected intracranial infections were selected for retrospective analysis. Base on the detection of responsible pathogens using CSF mNGS, the patients were categorized into two groups, responsible pathogens in Group A were detected but not in Group B. The types of responsible pathogens in group A and the final diagnosis of patients in group B were analyzed. Demographic data, clinical presentation, CSF analysis, imaging results, and electroencephalography (EEG) findings were analyzed for both groups. Finally, a scoring system was established to promptly assess the appropriateness of CSF mNGS for patients with suspected intracranial infections. Each independent predictor was assigned a score of 1, and the patients were subsequently scored. We advocate sending patients’ CSF for mNGS when the cumulative score is ≥ 2.ResultsIn Group A, the predominant responsible pathogen was the varicella-zoster virus (VZV), while Group B exhibited the highest proportion of final diagnoses related to epilepsy. The logistic regression model indicates that headache [OR = 2.982, 95% CI (1.204–7.383), p = 0.018], increased cerebrospinal fluid white cell count [OR = 4.022, 95% CI (1.331–12.156), p = 0.014], and decreased cerebrospinal fluid glucose levels [OR = 9.006, 95% CI (2.778–29.194), P < 0.001] are independent predictive factors for intracranial infection pathogens detected by CSF mNGS. Under this scoring system, the sensitivity for detecting the responsible pathogen was 57.5%, and the specificity was 87.4%.ConclusionThe likelihood of detecting the responsible pathogen through CSF mNGS in patients with suspected intracranial infections can be evaluated using the scoring system. Furthermore, it is crucial to consider the possibility of another condition, such as epilepsy, when the responsible pathogen is not detected using cerebrospinal fluid mNGS.

Analysis of Final Diagnosis of Patients with Suspected Nonodontogenic Toothache: A Retrospective Study

Analysis of Final Diagnosis of Patients with Suspected Nonodontogenic Toothache: A Retrospective Study

Importance of mediastinal granulomatous/sarcoid-like lymphadenopathy in extrathoracic malignancies.

In patients with extrathoracic malignancies (ETM), granulomatous lymph adenopathy called sarcoid-like reactions (SLR) can be seen in the regional or draining lymph nodes. We hypothesized that SLR may be a sign of imminent metastasis and investigated the clinical course and rate of recurrence in patients with ETM and granulomatous mediastinal lymphadenopathy (MLN). In this retrospective observational study, we reviewed the medical files of patients with known ETM and who underwent EBUS-TBNA for initial staging or detection of recurrence from 2011 to 2023. Patients with granulomatous MLN were included. Forty-one patients (29 female) enrolled in the study. Breast and colorectal carcinomas were the most common malignancies. A total of 81 lymph nodes were sampled. The final diagnosis of patients was five sarcoidosis, one tuberculosis, one second primary, one drug reaction, and 33 SLR. Among patients with SLR, in one patient lymph nodes progressed during the follow-up and were accepted as false-negative without confirmatory biopsy. The negative predictive value (NPV) of granulomatous MLN for metastasis was 97.05%. Granulomatous MLN may be due to tuberculosis, drug reaction, sarcoidosis, or SLR in patients with ETM. SLR has a high NPV in patients with ETM. Follow-up imaging rather than confirmatory biopsy is reasonable in these patients.

Using Antinuclear Antibody Testing in Pediatric Rheumatology.

The antinuclear antibody (ANA) test is frequently used for the identification of patients who are at a high risk of developing autoimmune rheumatological diseases. The aim of this study is to evaluate the final diagnoses of patients applied to the pediatric rheumatology outpatient clinic with a positive ANA test result. In this study, the medical records of 283 children who had ANA positivity between January 2010 and January 2022 were evaluated retrospectively. All patients were younger than 18 years of age at diagnosis and were followed up in the pediatric rheumatology department for at least 6 months. The majority of the patients were females (69%), and the mean age was 9.9 ± 4.7 years. 94% of the ANA tests were requested in pediatric rheumatology outpatient clinics, and 6% in general pediatrics and other outpatient clinics. Arthritis was the most common reason for ANA testing (41.7%). Of the patients who had ANA positivity, 37% were diagnosed with juvenile idiopathic arthritis (JIA), 15% with connective tissue diseases, 10% with autoinflammatory disease, and 7% with vasculitides. Positivity at 1/320 and 1/640 titers were more common in the patients diagnosed with autoimmune connective tissue diseases or JIA compared to the patients without these diagnoses (P = .009 and P = .013, respectively). The ANA test should be judiciously requested by pediatric rheumatologists, especially in suspected cases of autoimmune rheumatic disorders and JIA patients to aid in classification. Indiscriminate use of the ANA test for screening may potentially misguide clinicians.

Infectious causes and outcomes of patients with high fever in the emergency department

Aims: The aim of this study is to investigate the reasons for presentation, diagnoses, and outcomes of patients with high fever in the emergency department. Methods: This research is a retrospective study planned by examining the files and data of patients who presented to the emergency department between 01.03.2021 and 01.03.2023, and whose body temperature was above 38 degrees Celsius. Patient data was analyzed from patient files and the Hospital Information Management System (HIMS). The demographic characteristics, vital signs at admission, reasons for presentation, diagnoses, and outcomes of patients with complete data from patient files and HIMS were investigated. Results: Of the 288 patients included in the study, 151 (52.4%) were male, and the mean age was 47.04 ± 18.75. When examining the reasons for patients' presentation to the emergency department, 79 (27.4%) patients presented with sore throat, and 44 (15.3%) patients presented with fever. When examining the final diagnoses of patients, acute tonsillopharyngitis was the most common diagnosis with 99 (34.4%) patients, followed by 30 (10.4%) patients with Covid-19. Regarding the outcomes of patients, 190 (66%) patients were discharged from the emergency department, 63 (21.9%) were admitted to the ward, and 26 (9%) were admitted to the intensive care unit. Conclusion: Cases with high fever in the emergency department encompass a wide range of conditions, ranging from mild viral upper respiratory tract infections to potentially fatal infections such as meningoencephalitis and myocarditis. Therefore, in febrile cases in the emergency department, serious infectious causes should be considered in terms of the focus of fever. Additionally, non-infectious causes should also be kept in mind as they can cause high fever.

The role of baseline 2-[18 F]-FDG-PET/CT metrics and radiomics features in predicting primary gastric lymphoma diagnosis.

Diffuse Large B-Cell Lymphomas (DLCBL) and mucosa-associated lymphoid tissue (MALT) are the two most common primary gastric lymphomas (PGLs), but have strongly different features. DLBCL is more aggressive, is frequently diagnosed at an advanced stage and has a poorer prognosis. The aim of this retrospective study was to explore the role of fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (2-[18 F]-FDG-PET/CT) and radiomics features (RFs) in predicting the final diagnosis of patients with PGLs. Ninety-one patients with newly diagnosed PGLs who underwent pre-treatment 2-[18 F]-FDG-PET/CT were included. PET images were qualitatively and semi-quantitatively analyzed by deriving maximum standardized uptake value body weight (SUVbw), maximum standardized uptake value lean body mass (SUVlbm), maximum standardized uptake value body surface area (SUVbsa), lesion to liver SUVmax ratio (L-L SUV R), lesion to blood-pool SUVmax ratio (L-BP SUV R), metabolic tumor volume (gMTV) and total lesion glycolysis of gastric lesion (gTLG), total MTV (tMTV), TLG, and first-order RFs (histogram-related and shape related). Receiver-operating characteristic (ROC) curve analyses were performed to determine the differential diagnostic values of PET parameters. The final diagnosis was DLBCL in 54 (59%) cases and MALT in 37 cases (41%). PGLs showed FDG avidity in 83 cases (90%), 54/54 of DLBCL and 29/37 of MALT. All PET/CT metabolic features, such as stage of disease and tumor size, were significantly higher in DLBCL than MALT; while the presence of H. Pylori infection was more common in MALT. At univariate analysis, all PET/CT metrics were significantly higher in DLBCL than MALT lymphomas, while among RFs only Shape volume_vx and Shape sphericity showed a significant difference between the two groups. In conclusion we demonstrated that 2-[18 F]-FDG-PET/CT parameters can potentially discriminate between DLBCL and MALT lymphomas with high accuracy. Among first-order RFs, only Shape volume_vx and Shape sphericity helped in the differential diagnosis.

Analysis of Antinuclear Antibody Test Referral Patterns in a Tertiary Care Hospital over Three Years: A Retrospective Observational Study

Introduction: Antinuclear Antibodies (ANA) detection by Human Epithelial Substrate (Hep2) is the recommended screening test for the diagnosis of ANA-Associated Rheumatic Diseases (AARD). ANA is ordered by various specialists in a tertiary care hospital, and a positive ANA result is followed by testing for specific autoantibodies. High pretest probability, pattern type with intensity, and referral departments are key factors determining the autoimmune diagnosis. Aim: To analyse the ANA referral patterns among the various departments and also to estimate the prevalence and clinical significance of rare ANA patterns. Materials and Methods: A retrospective observational study was conducted at Nizam's Institute of Medical Sciences, Hyderabad, a tertiary care hospital, in Hyderabad, Telangana, India where ANA test reports (n=16,994) from various departments over three years (November 2017 to October 2020) were evaluated between November 2022 to December 2022. ANA tests were performed on Hep2 substrate at a 1:100 dilution, and ANA patterns were reported according to the International Consensus on ANA Patterns (ICAP) nomenclature. Statistical analysis of department- wise ANA positivity and fluorescence intensity was conducted, and the final diagnoses of patients with rare ANA patterns (&lt;1%) were noted from clinical records. Fischer's-exact test was used for comparing categorical variables, considering p-value &lt;0.05 as statistically significant. Results: The majority of ANA requests were from the Rheumatology department (5859; 34.5%), followed by nephrology (3132; 18.4%), neurology (1940; 11.4%), general medicine (1646; 9.7%), haematology (1106; 6.5%), and casualty (878; 5.2%), accounting for 85.6% of total referrals. The highest percentage of positivity among ANA referrals was observed in Rheumatology (333; 5.7%), with 58% of positive ANA showing 4+ intensity. No positives were observed from many surgical departments. Rare ANA patterns with a prevalence of less than 1% were observed in 22 patients with mitotic patterns accounting for the majority of rare patterns seen in 11 out of 22 (50%) cases followed by nuclear envelope, rods rings, and nuclear dense fine speckled patterns were observed in six, four, and one patient(s), respectively. The majority of rare ANA patterns had 2+ fluorescence intensity without any associated autoimmune diagnosis. Conclusion: The highest and lowest positivity among ANA referrals were observed in the rheumatology and surgical departments, respectively. Considering the pretest probability of AARD before ordering an ANA test would lead to the optimum utilisation of laboratory services. Mitotic patterns constituted the majority of rare ANA patterns and need to be clinically correlated with antibody titers.

Timeliness and accuracy of the 7-Item Japan Urgent Stroke Triage (JUST-7) score, a prehospital stroke triage tool, assessed by emergency medical services.

The prompt initiation of stroke treatment significantly influences patient outcomes, highlighting the crucial role of prehospital triage. This study aimed to assess the implementation of the 7-Item Japan Urgent Stroke Triage (JUST-7) score by emergency medical services (EMS) in our region and its effect on emergency transportation for suspected stroke patients. Data were collected from patients suspected of having an acute stroke with a Cincinnati Prehospital Stroke Scale (CPSS) score of 1 or more who were transferred by ambulance within 24 h of symptom onset. Two prehospital stroke scales were employed during different periods: period 1 with CPSS alone (January to December 2020) and period 2 with both CPSS and JUST-7 (January 2021 to March 2023). On-scene time data were obtained from the EMS crews, and data regarding the final diagnosis of patients and their outcomes were obtained from the respective hospitals to which the patients were transferred. These data were compared between periods 1 and 2 and between the CPSS and JUST-7. The results revealed that additional evaluation with JUST-7 did not affect ambulance transport time. The CPSS+JUST-7 approach demonstrated higher specificity in identifying stroke and major artery occlusion than with the CPSS alone; however, an appropriate cut-off value needs to be considered. The JUST-7 achieved a diagnostic concordance rate of 35.9% for the most likely stroke type and 64.0% for the first two most likely types. This research emphasizes the potential of JUST-7 as a valuable addition to prehospital stroke diagnosis protocols. Its flexibility in adapting cut-off values based on regional factors and available medical resources optimizes its utility in diverse healthcare settings. The JUST-7 score is a promising tool for improving patient outcomes through prompt and accurate prehospital assessments.

Frequency and Characteristics of Non-Neurological and Neurological Stroke Mimics in the Emergency Department.

Stroke mimics are common in the emergency department (ED) and early detection is important to initiate appropriate treatment and withhold unnecessary procedures. We aimed to compare the frequency, clinical characteristics and predictors of non-neurological and neurological stroke mimics transferred to our ED for suspected stroke. This was a cross-sectional study of consecutive patients with suspected stroke transported to the ED of the University Hospital Essen between January 2017 and December 2021 by the city's Emergency Medical Service. We investigated patient characteristics, preclinical data, symptoms and final diagnoses in patients with non-neurological and neurological stroke mimics. Multinominal logistic regression analysis was performed to assess predictors of both etiologic groups. Of 2167 patients with suspected stroke, 762 (35.2%) were diagnosed with a stroke mimic. Etiology was non-neurological in 369 (48.4%) and neurological in 393 (51.6%) cases. The most common diagnoses were seizures (23.2%) and infections (14.7%). Patients with non-neurological mimics were older (78.0 vs. 72.0 y, p < 0.001) and more likely to have chronic kidney disease (17.3% vs. 9.2%, p < 0.001) or heart failure (12.5% vs. 7.1%, p = 0.014). Prevalence of malignancy (8.7% vs. 13.7%, p = 0.031) and focal symptoms (38.8 vs. 57.3%, p < 0.001) was lower in this group. More than two-fifths required hospitalization (39.3 vs. 47.1%, p = 0.034). Adjusted multinominal logistic regression revealed chronic kidney and liver disease as independent positive predictors of stroke mimics regardless of etiology, while atrial fibrillation and hypertension were negative predictors in both groups. Prehospital vital signs were independently associated with non-neurological stroke mimics only, while age was exclusively associated with neurological mimics. Up to half of stroke mimics in the neurological ED are of non-neurological origin. Preclinical identification is challenging and a high proportion requires hospitalization. Awareness of underlying etiologies and differences in clinical characteristics is important to provide optimal care.

Clinical profile of pathological urticarial vasculitis: A retrospective study

AbstractBackgroundAs there are no definite classification criteria for urticarial vasculitis (UV), its diagnosis is often challenging and usually proposed when urticarial lesions and pathological vasculitis coexist. By analysing the final diagnosis of patients whose skin biopsies showed both urticaria and vasculitis, we sought to decipher the clinical heterogeneity of this condition.ObjectivesTo describe the characteristics of patients with pathological signs of urticaria and vasculitis.MethodsWe conducted a retrospective, descriptive, single‐centre study within Lille University Hospital and included adult patients with a skin biopsy performed between 2000 and 2021, and whose pathological report mentioned the codes for “leukocytoclastic angiitis” and “urticaria”. Clinical data were then collected from medical records.ResultsWe identified 61 patients with pathological diagnosis of UV and classified them into four groups according to the final diagnosis made by the managing clinicians: 14 patients were diagnosed with UV (normo‐[NUV] or hypocomplementemic UV [HUV]), 10 with urticaria (including 8 chronic urticaria [CU]), 24 with an “undetermined diagnosis” (when elements did not allow firm diagnosis between CU and UV, due to an atypical clinical presentation of urticarial lesions), and 13 with an “other but well‐defined diagnosis”. Fibrinoid necrosis, classically associated with UV, was observed in 4/9 patients (44%) in the urticaria group. Antihistamines were effective not only in all patients with urticaria, but also in NUV and “undetermined diagnosis” group.ConclusionsThese data suggest that pathological signs of UV may be shared by various clinical situations, raising the hypothesis of a continuous spectrum between CU and UV.

The coronary microvascular angina cardiovascular magnetic resonance imaging trial: Rationale and design

BackgroundCoronary microvascular dysfunction may cause myocardial ischemia with no obstructive coronary artery disease (INOCA). If functional testing is not performed INOCA may pass undetected. Stress perfusion cardiovascular MRI (CMR) quantifies myocardial blood flow (MBF) but the clinical utility of stress CMR in the management of patients with suspected angina with no obstructive coronary arteries (ANOCA) is uncertain. ObjectivesFirst, to undertake a diagnostic study using stress CMR in patients with ANOCA following invasive coronary angiography and, second, in a nested, double-blind, randomized, controlled trial to assess the effect of disclosure on the final diagnosis and health status in the longer term. DesignAll-comers referred for clinically indicated coronary angiography for the investigation of suspected coronary artery disease will be screened in 3 regional centers in the United Kingdom. Following invasive coronary angiography, patients with ANOCA who provide informed consent will undergo noninvasive endotyping using stress CMR within 3 months of the angiogram. Diagnostic studyStress perfusion CMR imaging to assess the prevalence of coronary microvascular dysfunction and clinically significant incidental findings in patients with ANOCA. The primary outcome is the between-group difference in the reclassification rate of the initial diagnosis based on invasive angiography versus the final diagnosis after CMR imaging. Randomized, controlled trialParticipants will be randomized to inclusion (intervention group) or exclusion (control group) of myocardial blood flow to inform the final diagnosis. The primary outcome of the clinical trial is the mean within-subject change in the Seattle Angina Questionnaire summary score (SAQSS) at 6 months. Secondary outcome assessments include the EUROQOL EQ-5D-5L questionnaire, the Brief Illness Perception Questionnaire (Brief-IPQ), the Treatment Satisfaction Questionnaire (TSQM-9), the Patient Health Questionnaire-4 (PHQ-4), the Duke Activity Status Index (DASI), the International Physical Activity Questionnaire- Short Form (IPAQ-SF), the Montreal Cognitive Assessment (MOCA) and the 8-item Productivity Cost Questionnaire (iPCQ). Health and economic outcomes will be assessed using electronic healthcare records. ValueTo clarify if routine stress perfusion CMR imaging reclassifies the final diagnosis in patients with ANOCA and whether this strategy improves symptoms, health-related quality of life and health economic outcomes. Clinicaltrials.govNCT04805814

The impact of a point-of-care visual clinical decision support tool on admissions for cellulitis in the University of Maryland medical system.

Cellulitis is commonly diagnosed in emergency departments (EDs), yet roughly one third of ED patients admitted for presumed cellulitis have another, usually benign, condition instead (eg, stasis dermatitis). This suggests there is an opportunity to reduce health care resource use through improved diagnosis at the point of care. This study seeks to test whether a clinical decision support (CDS) tool interoperable with the electronic medical record (EMR) can reduce inappropriate hospital admissions and drive more appropriate and accurate care. This study was a trial of an EMR-interoperable, image-based CDS tool for evaluation of ED patients with suspected cellulitis. At the point of assigning a provisional diagnosis of cellulitis in the EMR, the clinician was randomly prompted to use the CDS. Based on the patient features entered into the CDS by the clinician, the CDS provided the clinician a list of likely diagnoses. The following were recorded: patient demographics, disposition and final diagnosis of patients, and whether antibiotics were prescribed. Logistic regression methods were used to determine the impact of CDS engagement on our primary outcome of admission for cellulitis, adjusted for patient factors. Antibiotic use was a secondary end point. From September 2019 to February 2020 (or 7 months), the CDS tool was deployed in the EMR at 4 major hospitals in the University of Maryland Medical System. There were 1269 encounters for cellulitis during the study period. The engagement with the CDS was low (24.1%, 95/394), but engagement was associated with an absolute reduction in admissions (7.1%, p=0.03). After adjusting for age greater than 65 years, female sex, non-White race, and private insurance, CDS engagement was associated with a significant reduction of admissions (adjusted OR=0.62, 95% confidence interval (CI): 0.40-0.97, p=0.04) and antibiotic use (Adjusted OR=0.63, 95% CI: 0.40-0.99, p=0.04). CDS engagement was associated with decreased admissions for cellulitis and decreased antibiotic use in this study, despite low levels of CDS engagement. Further research should examine the impact of CDS engagement in other practice environments and measure longer-term outcomes in patients discharged from the ED.

Diagnosing Hirschsprung Disease in Children Younger than 6 Months of Age: Insights in Incidence of Complications of Rectal Suction Biopsy and Other Final Diagnoses.

The gold standard for diagnosing Hirschsprung disease (HD) in patients younger than 6 months is pathological examination of rectal suction biopsy (RSB). The aim of this study was to gain insight into the following: (1) complications following RSB, (2) final diagnosis of patients referred for RSB, and (3) factors associated with HD. Patients suspected of HD referred for RSB at our center were analyzed retrospectively. Severity of complications of RSB was assessed using Clavien-Dindo (CD) grading. Factors associated with HD were tested using multivariate logistic regression analysis. From 2000 to 2021, 371 patients underwent RSB because of infrequent defecation, at a median age of 44 days. Three patients developed ongoing rectal bleeding (0.8%) graded CD1. Most frequent final diagnoses were: HD (n = 151, 40.7%), functional constipation (n = 113, 31%), idiopathic meconium ileus (n = 11, 3%), and food intolerance (n = 11, 3%). Associated factors for HD were male sex (odds ratio [OR], 3.19; confidence interval [CI], 1.56-6.53), presence of syndrome (OR, 7.18; CI, 1.63-31.69), younger age at time of RSB (OR, 0.98; CI, 0.85-0.98), meconium passage for more than 48 hours (OR, 3.15; CI, 1.51-6.56), distended abdomen (OR, 2.09; CI, 1.07-4.07), bilious vomiting (OR, 6.39; CI, 3.28-12.47), and failure to thrive (OR, 8.46; CI, 2.11-34.02) (model R 2 = 0.566). RSB is a safe procedure with few and only minor complications. In the majority of patients referred for RSB under the age of 6 months, HD was found followed by a functional cause for the defecation problems. RSB should be obtained on a low threshold in all patients under the age of 6 months with the suspicion of HD.

Disparity between clinical and final diagnosis of patients undergoing hysterectomy

Background: Hysterectomy is by far the commonest major gynaecological procedure done for several indications. A thorough history, careful physical examination and some simple investigations are all that is needed to establish the diagnosis justifying the need for hysterectomy in most of the cases. But even with the advent of modern technologies, a good proportion of patients are misdiagnosed preoperatively which is evident after histopathological confirmation. This study aimed to evaluate the clinical diagnoses which ultimately lead to hysterectomy and to find out to what extent they are consistent with the final diagnoses after confirmation by histopathological examination.&#x0D; Methods: This observational study was carried out in the Department of Obstetrics and Gynaecology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from January to June 2018. Total 100 patients, irrespective of age and parity, were included whose total abdominal hysterectomy was planned. History, clinical findings, investigation reports and histopathological reports were recorded. Then clinical and histopathological diagnoses were tabulated and expressed as proportion.&#x0D; Results: The incidence of total abdominal hysterectomy was highest (49%) among the age group of 41-50 years. Average age of the study subjects was 45.3 years. Majority of the hysterectomies were done for fibroid uterus (48%) and abnormal uterine bleeding due to ovulatory dysfunction (AUB-O) (16%). Histopathology confirmed fibroid or leiomyoma in 39% cases versus clinical diagnosis of 48% and 18% of the specimens revealed no organic lesion on histopathology.&#x0D; Conclusion: Though not remarkable, still a certain proportion of clinical diagnoses differ with histopathological findings in patients undergoing hysterectomy even in tertiary level.&#x0D; BIRDEM Med J 2023; 13(1): 27-33

Association of accompanying dyspnea with diagnoses and outcome of patients presenting with suspected acute coronary syndromes

Abstract Background The presence of accompanying dyspnea is routinely assessed and common in chest pain patients with suspected acute coronary syndromes (ACS), but its impact on differential diagnoses, diagnostic work-up and outcome is incompletely understood. Purpose To determine the association of accompanying dyspnea with diagnoses, diagnostic work-up, and outcome of patients presenting with suspected ACS to the emergency department (ED). Methods We prospectively enrolled unselected patients presenting to the ED with chest pain as the main symptom suggestive of ACS in an international multicenter study. Final diagnoses were adjudicated by two independent cardiologists using all information including cardiac imaging. Patients were stratified by the presence or absence of self-reported dyspnea. The primary diagnostic endpoint was the differential diagnosis. The secondary diagnostic endpoint was the performance of high-sensitivity cardiac troponin (hs-cTn) and the European Society of Cardiology (ESC) 0/1h-algorithms for the diagnosis of myocardial infarction (MI). The primary prognostic endpoint was all-cause mortality at two years. Results Among 6045 patients, 2892/6045 (48%) had accompanying dyspnea. Final diagnoses in patients with versus without dyspnea were different (overall p&amp;lt;0.001), but prevalence of ACS was comparable (MI 22.4% vs. 21.9%, p=0.602, unstable angina 8.7% vs. 7.9%, p=0.291). In contrast, patients with dyspnea more often had cardiac, non-coronary disease (15.3% vs. 10.2%, p&amp;lt;0.001). Diagnostic accuracy of high-sensitivity cardiac troponin (hs-cTn)T/I concentrations at presentation for the diagnosis of MI was high and not affected by the presence of dyspnea (area under the curve 0.89–0.91 in both groups). The ESC 0/1h-algorithms performed excellent in both groups with negative predictive values &amp;gt;99.4%. The presence of dyspnea was associated with all-cause death at two years (hazard ratio [HR] 2.487 [95% CI, 2.001–3.091, p&amp;lt;0.001) and remained an independent predictor after adjustment for covariates at baseline (HR 1.813 [95% CI, 1.453–2.261, p=0.001]). Overall mortality rates were higher in patients with dyspnea at two years (9.0% vs. 3.7%, p&amp;lt;0.001). Conclusion Accompanying dyspnea was not associated with a higher prevalence of ACS but with cardiac, non-coronary disease such as heart failure. While the safety of the diagnostic work-up was not affected, accompanying dyspnea was associated with and an independent predictor for two-year all-cause mortality. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Swiss Heart Foundation, University of Basel.

THIRD bedside ultrasound protocol for rapid diagnosis of undifferentiated shock: a prospective observational study.

It is clinically challenging to differentiate the pathophysiological types of shock in emergency situations. Here, we evaluated the ability of a novel bedside ultrasound protocol (Tamponade/tension pneumothorax, Heart, Inferior vena cava, Respiratory system, Deep venous thrombosis/aorta dissection [THIRD]) to predict types of shock in the emergency department. An emergency physician performed the THIRD protocol on all patients with shock who were admitted to the emergency department. All patients were closely followed to determine their final clinical diagnoses. The kappa index, sensitivity, specificity, positive predictive value, and negative predictive value were calculated for the initial diagnostic impression provided by the THIRD protocol, compared with each patient's final diagnosis. In total, 112 patients were enrolled in this study. The kappa index between initial impression and final diagnosis was 0.81 (95% confidence interval=0.73-0.89; P<0.001). For hypovolaemic, cardiogenic, distributive, and obstructive types of shock, the sensitivities of the THIRD protocol were 100%, 100%, 93%, and 100%, respectively; the sensitivity for a 'mixed' shock aetiology was 86%. The negative predictive value of the THIRD protocol for all five types of shock was ≥96%. Initial diagnostic judgements determined using the THIRD protocol showed favourable agreement with the final diagnosis in patients who presented with undifferentiated shock. The THIRD protocol has great potential for use as a bedside approach that can guide the rapid management of undifferentiated shock in emergency settings, particularly for patients with obstructive, hypovolaemic, or cardiogenic shock.

Comprehensive Assessment of Acute Isolated or Prominent Dysarthria in the Emergency Department: A Neuro-Emergency Expert's Experience beyond Stroke.

We investigated the clinical characteristics, neuroimaging findings, and final diagnosis of patients with acute isolated or prominent dysarthria who visited the emergency department (ED) between 1 January 2020 and 31 December 2021. Of 2028 patients aged ≥ 18 years with neurologic symptoms treated by a neuro-emergency expert, 75 with acute isolated or predominant dysarthria within 1 week were enrolled. Patients were categorized as having isolated dysarthria (n = 28, 37.3%) and prominent dysarthria (n = 47, 62.7%). The causes of stroke were acute ischemic stroke (AIS) (n = 37, 49.3%), transient ischemic attack (TIA) (n = 14, 18.7%), intracerebral hemorrhage (n = 1, 1.3%), and non-stroke causes (n = 23, 30.7%). The most common additional symptoms were gait disturbance or imbalance (n = 8, 15.4%) and dizziness (n = 3, 13.0%) in the stroke and non-stroke groups, respectively. The isolated dysarthria group had a higher rate of TIA (n = 7, 38.9%), single and small lesions (n = 10, 83.3%), and small-vessel occlusion in Trial of Org 101072 in acute stroke treatment (n = 8, 66.7%). Acute isolated or prominent dysarthria in the ED mostly presented as clinical symptoms of AIS, but other non-stroke and medical causes were not uncommon. In acute dysarthria with ischemic stroke, multiple territorial and small and single lesions are considered a cause.

420 Cardiac Investigation Trends Among Primary Care Physicians: A Paradigm Shift

Introduction: While numerous recent guidelines support coronary computed tomography angiography (CCTA) as a first-line test for the investigation of stable chest pain in patients at low or intermediate pre-test risk of coronary artery disease (CAD), it remains underutilized by primary care providers (PCPs). We aimed to evaluate the trends in first-line cardiac investigation requisition practices, the total number of tests required to rule-in or rule-out CAD, investigation booking times, and time to final diagnoses for patients presenting with stable chest pain to PCPs at a major urban center.

Etiologic diagnosis of acute shortness of breath in the emergency department

Background-Dyspnea is the term applied to sensation of breathlessness and the patient’s reaction to that sensation, In the BLUE (Bedside Lung Ultrasound in Emergency) protocol, lung profiles have been designed for the main etiologies of dyspnea (acute pulmonary edema, COPD, pulmonary embolism, pneumothorax, pneumonia) with an accuracy of &gt;90%. Objectives-•To investigate if BLUE protocol will improve diagnostic accuracy of patients with acute dyspnea •To compare the diagnostic accuracy of BLUE protocol findings alone with final diagnosis in patients with acute dyspnea. Methods-This study was a cross-sectional, hospital-based, follow-up observational study conducted in 130 patients who presented to the Emergency Department of Pushpagiri Institute of Medical Sciences, Tiruvalla, Kerala during January 2020 to August 2020, with complains of dyspnea of acute onset. It was done by incorporating the Bedside Lung Ultrasound in Emergency (BLUE) protocol for diagnosing the etiology of dyspnea. Epiinfo 7 was used for analysis. Results-the study sample included 130 subjects who fulfilled the inclusion criteria.Amongthestudypopulation,76(58.5%)weremalesand54(41.5%) were females. The mean age of the study population was 66.6 with a standard deviation of 14.1. The minimum age included in the study was 32 years and the maximum age was 91years.

Predicting diagnoses from illness experiences with common cold symptoms before physician consultation: a mixed-methods research

ObjectivesWe aimed to explore whether patients’ illness experiences with common cold symptoms could help with predicting the final diagnosis before consultation.DesignExploratory sequential design of mixed methods: Qualitative and quantitative studies...