Physical Examination Findings Research Articles

MYRF Variants in Patients With 46,XY Differences/Disorders of Sex Development and Literature Review.

46,XY differences/disorders of sex development (DSD) are genetically heterogeneous conditions characterized by atypical development of the reproductive system. MYRF, a gene encoding a transcription factor, has been identified as a potential causative gene for DSD and cardiac urogenital syndrome (CUGS). This study aims to delineate the clinical manifestations of patients with 46,XY DSD and MYRF mutations, encompassing both from our cohort and cases reported in the literature. Patients with 46,XY DSD were recruited from Peking Union Medical College Hospital and identified through a comprehensive review of published literature. Whole-exome sequencing was conducted to elucidate the genetic etiology. Comprehensive clinical data, including physical examination findings, hormonal profiles, and imaging results, were retrospectively gathered from medical records and published sources. Three of our patients with 46,XY DSD were found to harbor heterozygous loss-of-function mutations in the MYRF gene, including the recurrent variant c.789dup and two novel variants c.1915C>T and c.2154del. The patients exhibited underdeveloped testicular tissue, inadequate masculinization, and the persistence of Müllerian ducts. A review of the literature indentified 31 MYRF-linked 46,XY DSD patients and two 46,XX DSD patients. Among these, 11 cases presented with isolated testicular dysgenesis, 20 cases exhibited severe cardiopulmonary issues, and the majority of patients had congenital diaphragmatic hernia. Genetic analysis revealed 26 distinct MYRF variants among these patients, including 10 missense, 8 frameshift, 5 nonsense, and 3 splice site alterations, affecting critical domains of the MYRF gene. Our study broadens the spectrum of MYRF mutations in 46,XY DSD patients and highlighting the gene's indispensable role in gonadal development. However, a clear genotype-phenotype correlation in MYRF-related DSD remain elusive.

The Definition and Diagnostic Criteria for Flexion Instability after Total Knee Arthroplasty is Highly Variable in the Published Literature.

Flexion instability (FI) is increasingly being recognized as a common reason for failure after total knee arthroplasty (TKA). However, the diagnosis remains loosely defined and is often described by a constellation of symptoms and findings with the exclusion of other clinical entities. The purpose of this study was to examine the definition and diagnostic criteria of FI used in the current peer-reviewed literature. Clinically oriented primary research articles reporting on patients who have FI after TKA and published in English from 2010 to 2023 were systematically identified. Included publications were independently evaluated by multiple reviewers to determine how FI was defined. Of papers that defined FI, the diagnostic criteria were evaluated for several metrics including clinical symptoms, physical exam findings, aspiration results, lab evaluations, and radiographic parameters. Of 19 eligible articles, only 58% clearly defined FI, with significant variation among studies. Of these publications, 89% directly described clinical symptoms and physical examination findings that aided in diagnosis. Also, 74% of authors described using radiographic analysis, 53% used aspiration, and 47% used lab values to aid in excluding other causes of failure such as periprosthetic joint infection. Only 16% of authors distinguished FI from mid-flexion instability. Less than two-thirds of clinical studies focusing on patients who have FI after TKA provided a clear, concrete definition of FI. The use of aspiration, lab values, and radiographic factors was highly variable. Importantly, many authors defined the diagnosis loosely without objective criteria, which may hinder comparison between clinical studies. A standardized definition of FI could improve research and clinical care on this topic.

Outcome and Predisposing Factors for Intracranial Hemorrhage in Turkish Children with Hemophilia

Background/Objectives: Childhood hemophilia, a hereditary bleeding disorder predominantly affecting males, arises due to gene mutations encoding clotting factors VIII or IX. Intracranial hemorrhage represents a significant and life-threatening complication in pediatric patients with hemophilia. The incidence of intracranial hemorrhage in children with hemophilia, although relatively low, is notably higher compared to the general pediatric population. Methods: In this study, the objective is to examine patients with hemophilia who have experienced intracranial hemorrhage retrospectively. This study is a multicenter, retrospective analysis using data from three tertiary care centers in a provincial city in Turkey. Data were obtained from the participants’ hospital records. The presence of inhibitors against FVIII in the participants and the prophylaxis used against them were included in the analysis. Trauma history was queried, with types of traumas examined, including traffic accidents, falls, and a traumatic vaginal delivery. The duration and causes of complaints among the participants were investigated. The causes of complaints were categorized as fever, hematoma, convulsions, loss of consciousness, and hemiparesis. The participants’ Physical Examination Findings were classified as fever, hematoma, and loss of consciousness. The duration of hospital stays was evaluated. The hemorrhage location was classified into five groups: parenchymal, subdural, scalp, subarachnoid, and multiple hemorrhagic foci. The recurrence of bleeding, the need for transfusion, surgical intervention, and mortality were also examined. Results: A significant difference was identified between the participants’ survival rates and age variables, as well as transfusion in <36 months. A total of 9 participants had spontaneous intracranial bleeding, 2 experienced cranial trauma as a result of traffic accidents, and 25 participants were exposed to head trauma due to falls. Of the remaining individuals, one suffered head trauma from a severe impact, and one had cranial trauma following a traumatic vaginal delivery. Fourteen participants required transfusion, and three underwent surgical intervention. Conclusions: According to the results of the statistical analyses, the variables Factor Level, Physical Examination Findings, Transfusion, Recurrent Bleeding, Inhibitor, and Prophylaxis were found to affect survival significantly. No significant relationship was determined between the other analyzed variables and survival. During our study, five of the participants examined died. Accordingly, the mortality rate identified in our study is 13.1%.

DOP098 Development of BEN8744, a phase 2 ready, peripherally restricted PDE10 inhibitor targeting a new mechanism of action for the treatment of ulcerative colitis.

Abstract Background To identify novel therapeutic targets for ulcerative colitis (UC), a disease-agnostic Knowledge Graph1, comprising multi-modal data sources was used as input to a machine learning gene/protein prioritisation model2. Following in-depth target assessment, phosphodiesterase 10 (PDE10) was selected as a promising novel target for further investigation. Methods Our aim was to develop a novel therapeutic target for UC that will have not just anti-inflammatory properties but improve barrier function. PDE10 hydrolyses both cAMP and cGMP. In UC patients, reduced cAMP levels promote inflammation, while guanylate cyclase-C and its endogenous activators are downregulated in the colon, with lower levels correlating to higher disease severity. Our transcriptional analysis revealed that PDE10 is upregulated in UC patients’ colonic mucosa, correlating with disease severity, suggesting that PDE10 inhibition could potentially restore normal cyclic nucleotide signalling. Following successful experimental target validation, we developed BEN8744 a potent, selective, peripherally restricted oral PDE10 inhibitor. Supporting its therapeutic potential, BEN8744 significantly reduced TNFα, IL-6, and IL-8 in ex vivo inflamed UC patient colonic mucosa biopsy samples, and improved barrier integrity in an in vitro intestinal epithelial cell model. In a Phase 1, randomised, double-blind, placebo-controlled trial with 74 healthy subjects, we assessed the safety, tolerability, pharmacokinetics (PK), and food effect of BEN8744 (NCT06118385). The trial was in 3 parts: Part A investigated single ascending oral doses of BEN8744; Part B was a 2-way crossover assessment of the effect of food on the PK of BEN8744; and Part C investigated multiple ascending oral doses of BEN8744 for 14 days. Results All treatment emergent adverse events (TEASs) were mild or moderate in severity with no clinically significant findings in physical examination, laboratory variables, ECGs, OAAS/S or VAS results, during the study. No class effects previously seen with centrally active PDE10 inhibitors were observed in the present trial. Neither were there any dose dependent nervous system related TEAEs. Conclusion BEN8744 is a potent, peripherally restricted, well tolerated Phase 2 ready PDE10 inhibitor targeting a novel mechanism of action for the treatment of UC. The Phase 1 study showed a favourable safety, tolerability, and PK profile for BEN8744, supporting its further development. We are now planning a study in patients with moderate to severely active ulcerative colitis.

P0606 The efficacy of upadacitinib in Intestinal Behçet’s Disease refractory to anti-TNF-α therapy in a retrospective study

Abstract Background Behçet’s syndrome is a chronic, systemic vasculitis that affects multiple organs, with intestinal involvement referred to as intestinal Behçet’s disease. The understanding of effective treatments for this condition remains limited. Anti-tumor necrosis factor-α (TNF-α) therapy is recommended for moderate to severe or refractory cases. However, managing patients unresponsive to anti-TNF-α therapy presents a significant clinical challenge. Upadacitinib, a Janus kinase (JAK) inhibitor, has not previously been studied in this context. This study aims to evaluate the efficacy of upadacitinib in patients with anti-TNF-refractory intestinal Behçet’s disease. Methods We retrospectively included patients with refractory intestinal Behçet’s disease treated with upadacitinib at the First Affiliated Hospital of Zhejiang University School of Medicine. Data collected included clinical manifestations, medication history, physical examination findings, laboratory results, and endoscopic evaluations before and after treatment. Results Six patients with intestinal Behçet’s disease were included, five of whom were female, with an average age of 35.5±11.0 years. All patients presented with recurrent oral ulcers and abdominal symptoms, accompanied by endoscopic evidence of ileocecal ulcers. They had previously failed treatment with corticosteroids, immunosuppressants, and at least one anti-TNF-α biologic agent. Following 6.1±2.1 months of upadacitinib treatment, all patients showed clinical symptom improvement or relief. Compared to baseline, hemoglobin levels increased (107.2±11.3 vs. 127.5±7.9, P=0.030), serum albumin levels improved (39.2±4.0 vs. 47.2±1.4, P=0.009), C-reactive protein levels decreased (39.9±37.4 vs. 3.0±3.4, P=0.048), and Endoscopic performance improved (P=0.026). No serious adverse events were reported in either of the 6 patients during follow-up. Conclusion Upadacitinib appears to be a promising therapeutic option for patients with intestinal Behçet’s disease refractory to anti-TNF-α therapy.

Coffin-Lowry Syndrome: A Case of Clinical Convergence for Psychology, Neuropsychology, Psychiatry, Genetics, and Neurology.

We present the case of a 15-year-old girl with new-onset psychosis and abnormal white matter activity on neuroimaging, engaging multidisciplinary care between genetics, neurology, psychiatry, and neuropsychology. She functioned well in mainstream education despite below average intellectual functioning. Physical examination findings enabled the diagnosis, and patient improved with joint psychological and behavioral outpatient services.

Can ChatGPT 4.0 Diagnose Acute Aortic Dissection? Integrating Artificial Intelligence into Medical Diagnostics.

Acute aortic dissection (AD) is a critical condition characterized by high mortality and frequent misdiagnoses, primarily due to symptom overlap with other medical pathologies. This study explores the diagnostic utility of ChatGPT 4.0, an artificial intelligence model developed by OpenAI, in identifying acute AD from patients' presentations and general physical examination findings documented in published case reports. A systematic search was conducted on the PubMed database using the search term "acute aortic dissection," applying filters for articles published within the past year and categorized as case reports. The primary symptoms and physical examination details from each case were inputted into ChatGPT 4.0, which was prompted to generate three differential diagnoses and one main provisional diagnosis based on the case presentation. The search yielded a total of 163 results, from which ten case reports were randomly selected. The patient demographics across all ten case reports demonstrated an age range of 29 to 82 years, with equal gender distribution (5 males, 5 females) and hypertension as the most prevalent baseline comorbidity. ChatGPT 4.0 accurately identified acute AD as one of the top three differential diagnoses in all selected cases and identified acute AD as the provisional diagnosis in five of the ten cases. In conclusion, while ChatGPT 4.0 demonstrates potential in suggesting acute AD as a differential diagnosis based on clinical data, its role should be considered supportive rather than definitive. Based on our findings, it could serve as an early, cost-effective, and quick screening tool, helping physicians adopt a "think aorta" approach.

Retrospective analysis of the incidence and clinicopathological findings associated with ammonium urate urolithiasis in dogs with congenital portosystemic shunts: 363 cases (2010-2023).

To assess the incidence and clinical findings associated with the presence of ammonium urate urolithiasis in dogs with congenital portosystemic shunts. A retrospective review of dogs diagnosed with extrahepatic portosystemic shunts or intrahepatic portosystemic shunts in 15 referral hospitals between 2010 and 2023. Data including signalment, clinical signs, physical examination findings and clinicopathologic test results at the time of the diagnosis were collected, and the presence of ammonium urate urolithiasis was recorded. A total of 363 dogs were included. The overall incidence of ammonium urate urolithiasis was 19.3%. Dogs with extrahepatic portosystemic shunts were more likely to have urolithiasis compared to those with intrahepatic portosystemic shunts (32.2% vs. 8.0%). Dogs with urolithiasis were older (median 40 vs. 8 months) and more likely to be neutered males (51.4% vs. 9.8%). Ammonia was significantly lower in dogs with urolithiasis. Dogs with urolithiasis were more likely to have haematuria on dipstick analysis and sediment examination. Dogs with extrahepatic portosystemic shunts were more likely to have urolithiasis when compared to dogs with intrahepatic portosystemic shunts. Dogs with higher ammonia levels were less likely to have ammonium urate urolithiasis, and older dogs, neutered males, or those with evidence of haematuria had an increased incidence of urolithiasis.

Improving vascular access knowledge and assessment skill of hemodialysis staff.

Vascular access malfunction and failure contribute to morbidity and hospitalization in hemodialysis populations. Although controversy still exists over the identification and appropriate management of access malfunction, recognition of sentinel signs during physical examination remains an efficient way to screen for access malfunction. Dialysis staff are on the front line of providing quality care to dialysis patients, often being the first ones who could detect early physical signs of access malfunction. The study's purpose is to determine the effect of an advanced vascular access educational module presented to hemodialysis nurses and technicians, focusing on physical examination findings to identify a dialysis access at risk for malfunction. Utilizing a quasi-experimental pretest and posttest group design with a nonequivalent comparison control group, the effect of an advanced vascular access education module to improve vascular access knowledge and skill in recognition of sentinel signs of access malfunction was studied in a group of hemodialysis nurses (registered nurses [RNs]) and certified patient care technicians (PCTs). Knowledge post-test scores (RN, M=94.44, SD=7.05; PCT, M=90.83, SD=7.93) were significantly higher than pretest scores (RN, M=79.54, SD=12.47; PCT M=80.67, SD=7.99) in the intervention group (p<0.001) but not in the comparison group. There were no statistically significant differences in mean skill scores between dialysis nurses (p=0.38) and PCTs (p=0.826) or between intervention and comparison groups (p=0.332). This study exposes a critical gap in the transition of vascular access knowledge to the practical skill of access assessment. The findings suggest the need for restructuring the clinical training of dialysis nurses and PCTs in vascular access management and care. Newer active learning educational strategies in physical assessment of hemodialysis vascular access should be explored to further support dialysis nurses and PCTs in providing optimal patient care.

Knowledge, Attitude, and Perception Toward Evaluation of Acute Heart Failure Among Emergency Medicine Residents in Riyadh, Saudi Arabia.

Acute heart failure (AHF) poses significant challenges in clinical practice due to its varied clinical presentations and complex management strategies. Adequate confidence levels among medical residents in diagnosing and managing AHF are crucial for timely and effective patient care. This cross-sectional study aimed to assess medical residents' knowledge, attitude, and perception levels in diagnosing and managing AHF and explore factors influencing their confidence levels. A total of 52 medical residents from various specialties participated in the study. Based on different clinical parameters, participants completed a questionnaire assessing their confidence levels in diagnosing AHF. Descriptive statistics were used to summarize confidence levels, while chi-square tests explored associations between demographic/clinical factors and confidence levels. The majority of residents exhibited high confidence levels in diagnosing heart failure (HF) based on history and physical examination findings alone (22 (42.3%) and 16 (30.8%), respectively). However, confidence levels were lower when relying solely on laboratory tests and imaging modalities for diagnosis (17 (32.7%) and 18 (34.6%), respectively). Factors such as symptoms (e.g., dizziness) and availability of ultrasound equipment were associated with higher confidence levels (p < 0.05). However, demographic factors such as age, gender, and residency year did not significantly influence confidence levels (p > 0.05). Our study highlights variations in confidence levels among medical residents in diagnosing and managing AHF. While clinical assessment remains paramount, targeted educational interventions focusing on interpreting diagnostic tests and imaging findings are warranted to enhance residents' confidence levels and improve patient care.

Examining the Anatomy, Pathophysiology, and Clinical Presentation of Lower Extremity Neurologic Deficits: A Spine Surgeon's Guide to Foot Drop

Foot drop is relatively common and can be a notable source of patient dissatisfaction and even potential litigation. For the spine surgeon evaluating such a patient, the natural inclination is to investigate a spinal etiology; however, foot drop can develop from a multitude of distinct insults along several locations, extending from the cerebral cortex to the leg musculature itself. In-depth understanding of the relevant anatomy implicated in foot drop, as well as the pathologies that may impede those structures, is paramount to expanding a surgeon's differential diagnosis. Specific physical examination findings and diagnostic tests can further delineate the etiology of a patient's foot drop, guide treatment options, and help determine a patient's prognosis. Finally, clinical cases highlight how the application of a thorough grasp of relevant anatomy, a comprehensive physical examination, and appropriate diagnostic studies can accurately localize foot drop and enhance clinical decision making.

Thoracic and abdominal diagnostic imaging findings in dogs diagnosed with immune-mediated polyarthritis: 71 cases (2011-2023).

To describe thoracic and abdominal imaging findings in dogs with immune-mediated polyarthritis and to evaluate their impact on the decision to commence immunosuppressive therapy. Retrospective case series describing imaging findings in dogs with immune-mediated polyarthritis across modalities, including thoracic radiographs, abdominal ultrasound, computed tomography, and where available, echocardiography. Additionally, two internal medicine clinicians reviewed the signalment, clinical signs, clinicopathological findings and diagnostic imaging results on two separate occasions, reaching a consensus for each dog on whether immunosuppression would be their treatment of choice or whether their recommendations would be altered by the results of diagnostic imaging. Seventy-one dogs met the inclusion criteria. Abnormal diagnostic imaging findings were identified in 25.4% (18/71) of dogs. Thoracic radiography did not identify significant imaging findings in any of the dogs. Lymphadenomegaly was the most commonly reported finding on computed tomography (32/40) and abdominal ultrasound (13/34). Neoplasia was identified in three dogs (3/71). Four (4/13) dogs had echocardiography findings consistent with endocarditis. Immunosuppression without performing diagnostic imaging would have been considered in 41 of 71 (57.7%) dogs, based on the signalment, presenting signs, results of physical examination and clinicopathological testing. Of these, 10 dogs (24.3%) had diagnostic imaging findings suggestive of an underlying trigger, therefore changing the clinician's decision to proceed with immunosuppression. Abdominal imaging and echocardiography should be prioritised over thoracic radiography, in dogs with immune-mediated polyarthritis. Signalment, presenting complaint, physical examination findings and clinicopathological results are not reliable predictors of abnormal diagnostic imaging findings in dogs with immune-mediated polyarthritis.

MOUNTAINEER-03 phase III study design: first-line mFOLFOX6 + tucatinib + trastuzumab for HER2+ metastatic colorectal cancer.

Patients diagnosed with metastatic colorectal cancer (mCRC) have a poor prognosis with survival ranging 2-3 years. The prevalence of human epidermal growth factor receptor 2 (HER2) amplification is approximately 3-4% in mCRC and increases up to 8% in patients with KRAS/NRAS/BRAF wild-type (WT) CRC tumors. Tucatinib is a highly selective HER2-directed tyrosine kinase inhibitor that, in combination with trastuzumab, has demonstrated clinically meaningful activity in patients with chemotherapy-refractory, HER2-positive (HER2+), RAS WT mCRC in the MOUNTAINEER trial. The MOUNTAINEER-03 phase III trial is designed to investigate the efficacy and safety of first-line tucatinib in combination with trastuzumab and modified FOLFOX6 (mFOLFOX6) versus standard of care (mFOLFOX6 plus bevacizumab or cetuximab) in patients with untreated HER2+, RAS WT locally advanced unresectable or mCRC. MOUNTAINEER-03 will include two arms of approximately 400 patients randomized 1:1 to either treatment arm. The primary endpoint is progression-free survival per RECIST v1.1 by blinded independent central review (BICR). Key secondary endpoints are overall survival and confirmed objective response rate (according to RECIST v1.1 per BICR). Safety assessments will include surveillance and recording of adverse events, physical examination findings, vital signs, cardiac assessments, Eastern Cooperative Oncology Group performance status, concomitant medications, and laboratory tests.Clinical trial registration: NCT05253651 (ClinicalTrials.gov).

Machine-learning based prediction of appendicitis for patients presenting with acute abdominal pain at the emergency department

Abstract Background Acute abdominal pain (AAP) constitutes 5–10% of all emergency department (ED) visits, with appendicitis being a prevalent AAP etiology often necessitating surgical intervention. The variability in AAP symptoms and causes, combined with the challenge of identifying appendicitis, complicate timely intervention. To estimate the risk of appendicitis, scoring systems such as the Alvarado score have been developed. However, diagnostic errors and delays remain common. Although various machine learning (ML) models have been proposed to enhance appendicitis detection, none have been seamlessly integrated into the ED workflows for AAP or are specifically designed to diagnose appendicitis as early as possible within the clinical decision-making process. To mimic daily clinical practice, this proof-of-concept study aims to develop ML models that support decision-making using comprehensive clinical data up to key decision points in the ED workflow to detect appendicitis in patients presenting with AAP. Methods Data from the Dutch triage system at the ED, vital signs, complete medical history and physical examination findings and routine laboratory test results were retrospectively extracted from 350 AAP patients presenting to the ED of a Dutch teaching hospital from 2016 to 2023. Two eXtreme Gradient Boosting ML models were developed to differentiate cases with appendicitis from other AAP causes: one model used all data up to and including physical examination, and the other was extended with routine laboratory test results. The performance of both models was evaluated on a validation set (n = 68) and compared to the Alvarado scoring system as well as three ED physicians in a reader study. Results The ML models achieved AUROCs of 0.919 without laboratory test results and 0.923 with the addition of laboratory test results. The Alvarado scoring system attained an AUROC of 0.824. ED physicians achieved AUROCs of 0.894, 0.826, and 0.791 without laboratory test results, increasing to AUROCs of 0.923, 0.892, and 0.859 with laboratory test results. Conclusions Both ML models demonstrated comparable high accuracy in predicting appendicitis in patients with AAP, outperforming the Alvarado scoring system. The ML models matched or surpassed ED physician performance in detecting appendicitis, with the largest potential performance gain observed in absence of laboratory test results. Integration could assist ED physicians in early and accurate diagnosis of appendicitis. Graphical abstract

Evidence-based approach to the shoulder examination for subacromial bursitis and rotator cuff tears: a systematic review and meta-analysis

IntroductionShoulder pain represents a common patient complaint evaluated in a primary care setting. Approximately two thirds of these patients have rotator cuff injuries, with rotator cuff tears (RCTs) and subacromial impingement syndrome (SIS) accounting for a majority of causes. An accurate and efficient diagnostic strategy focused on physical examination findings may lead to improved outcomes and less functional disability.ObjectiveTo identify the most accurate physical examination tests for the diagnosis of RCT and SIS, we performed a systematic review and meta-analysis.MethodsThe database for our systematic review was compiled by using keywords and common indexing strategies to search PubMed, Ovid MEDLINE, Embase and the Cochrane Library from January 1, 1980, to March 15, 2024. Included studies evaluated a physical examination being performed prior to a reference standard diagnostic test for either RCT or SIS. Data was extracted in dual fashion and meta-analyses were performed regarding physical examination tests identified in our included studies.ResultsA total of twenty studies, which include 3,438 patients, met our inclusion criteria and had data extracted for statistical analysis. Data was adequate to perform meta-analyses on ten physical examination tests for RCT and five physical examination tests for SIS. There were six physical examination tests which had significant diagnostic odds ratios (DORs) when used in the diagnostic evaluation of suspected RCT, with the External Rotation Lag Sign at 90 Degrees having the highest magnitude of significance (DOR, 12.70; 95% CI, 3.68 – 43.86; P < .0001). Four physical examination tests had significant DORs for physical examination tests when used in the diagnostic evaluation of SIS, with the Yergason’s Test having the highest magnitude of significance (DOR, 4.71; 95% CI; 2.16 – 10.32; P = .0001).ConclusionWe present a large body of low-quality evidence for the diagnostic accuracies of physical examination tests for the identification of both RCT and SIS. We have identified novel data for the accuracy of the External Rotation Lag Sign at 90 Degrees and the Internal Rotation Lag Sign that have high to moderate diagnostic accuracy for ruling in tears of the rotator cuff.

Pulmonary involvement in newly diagnosed and untreated rheumatoid arthritis and psoriatic arthritis: a prospective longitudinal study

ObjectivesTo longitudinally assesses pulmonary involvement in newly diagnosed rheumatoid arthritis (RA) and psoriatic arthritis (PsA) patients over a 12-months follow-up. To identify biomarkers and establish a diagnostic algorithm for monitoring pulmonary changes.MethodsNewly diagnosed RA and PsA patients were examined with clinical and laboratory assessments, pulmonary function tests (PFT), and chest radiography (CXR) at three-months intervals for one year.ResultsThe study enrolled 50 patients (26 RA, 24 PsA) and 26 controls. At baseline, 37.0% of arthritis patients (50.0% RA, 22.7% PsA) exhibited radiographic pulmonary involvement, with 64.7% being asymptomatic. No association was observed between CXR and PFTs. Reduced pathological breathing width was noted in 64.0% of patients (RA 69.2%, PsA 58.3%) and 23.1% of controls (p < .001). Thoracic excursion and lung auscultation showed no differences. During follow-up, PFT and physical examination findings remained stable. Mean CRP levels significantly decreased in RA patients from 23.5 mg/l (± 33.6; 95% CI: 9.9–37.1) to 2.7 mg/L (± 3.4; 95% CI: 1.0-4.3), and in PsA patients from 13.3 mg/L (± 18.0; 95% CI: 5.7–20.9) to 8.1 mg/L (± 16.2; 95% CI: 0.1–16.2) (p < .001). Additionally, significant reductions in disease activity scores and improvements in six-minute walking distance were observed (p < .001). No associations were identified between PFT outcomes, disease activity, or rheumatological medications throughout the disease course.ConclusionOur study underscores the prevalence of significant, predominantly asymptomatic pulmonary involvement in newly diagnosed RA and PsA patients. The lack of correlation between pulmonary function, disease activity, and medication during disease progression suggests that reducing arthritic disease activity does not necessarily mitigate the risk or severity of pulmonary involvement. Finally, our finding underscore the need for more sensitive biomarkers and optimized monitoring strategies.

PROFOUND HYPOGLYCEMIA AND BLOOD GLUCOSE TESTING METHODOLOGIES IN FLORIDA MANATEES (TRICHECHUS MANATUS LATIROSTRIS) PRESENTED TO A CRITICAL CARE CENTER.

Florida manatees (Trichechus manatus latirostris) continue to experience pressure from various stressors that frequently result in the need for rescue and veterinary assistance. Interestingly, a subset of rescued manatees in critical condition exhibits profound hypoglycemia. The goals of this study were to enhance our understanding of this important aspect of manatee care by 1) characterizing the clinical presentation and factors associated with manatees that present with profound hypoglycemia, and 2) assessing agreement across blood glucose testing modalities [glucometer (whole blood), in-house bench-top analyzer (whole blood), a point of care analyzer (whole blood), and a local human hospital laboratory analyzer (serum)]. Twenty-five manatees were admitted to the Jacksonville Zoo and Gardens from 2017 to 2021. Seven manatees were profoundly hypoglycemic on presentation with blood glucose concentrations of < 30 mg/dL. Hypoglycemic manatees were admitted due to cold stress syndrome (n = 3; 1 calf, 2 adults) or emaciation consistent with an unusual mortality event (n = 4; 2 calves, 2 adults). Physical examination findings in hypoglycemic animals included emaciation (n = 7, 100%), lethargy (n = 7, 100%), and intermittent mild muscle fasciculations of the muzzle (n = 3, 42.8%). Hypoglycemia resolved with intense supportive care and monitoring in all affected animals within 32 h of admission. No associations were identified between hypoglycemia on presentation and life-stage, sex, transport distance to JZG's critical care facility, or rehabilitation outcome (death/euthanasia vs. release). Statistical agreement was observed between all blood glucose testing modalities except for the glucometer vs. the human hospital analyzer. Despite the limited sample size, these findings inform on the clinical presentation of severe hypoglycemia, the importance of close blood glucose monitoring after admission, blood glucose testing modalities, and clinical decision-making in Florida manatees admitted to critical care centers.

Scanning the aged to minimize missed injury: An Eastern Association for the Surgery of Trauma multicenter study.

Despite the high incidence of blunt trauma in older adults, there is a lack of evidence-based guidance for computed tomography (CT) imaging in this population. We aimed to identify an algorithm to guide use of a pan-scan (head/cervical spine [C-spine]/torso) or a selective scan (head/C-spine ± torso). We hypothesized that a patient's initial history and examination could be used to guide imaging. We prospectively studied blunt trauma patients 65 years or older at 18 Level I/II trauma centers. Patients presenting >24 hours after injury or who died upon arrival were excluded. We collected history and physical elements and final injury diagnoses. Injury diagnoses were categorized into CT body regions of head/C-spine or Torso (chest, abdomen/pelvis, and thoracolumbar spine). Using machine learning and regression modeling as well as a priori clinical algorithms based, we tested various decision rules against our data set. Our priority was to identify a simple rule, which could be applied at the bedside, maximizing sensitivity and negative predictive value (NPV) to minimize missed injuries. We enrolled 5,498 patients with 3,082 injuries. Nearly half (n = 2,587 [47.1%]) had an injury within the defined CT body regions. No rule to guide a pan-scan could be identified with suitable sensitivity/NPV for clinical use. A clinical algorithm to identify patients for pan-scan, using a combination of physical examination findings and specific high-risk criteria, was identified and had a sensitivity of 0.94 and NPV of 0.86. This rule would have identified injuries in all but 90 patients (1.6%) and would theoretically spare 11.9% (655) of blunt trauma patients a torso CT. Our findings advocate for head/C-spine CT in all geriatric patients with the addition of torso CT in the setting of positive clinical findings and high-risk criteria. Prospective validation of this rule could lead to streamlined diagnostic care of this growing trauma population. Diagnostic Tests or Criteria; Level II.

Management of Traumatic Undiagnosed Condyle Fracture in Children

Background: Condyle trauma is considered to be the major cause of TMJ ankylosis but it is also the most neglected and under-managed problem in children. ?TMJ ankylosis leads to be malocclusion and facial disfigurement. The aim of early treatment is to restore the mandibular mobility and to enhance further growth in order to reduce the possibility of future facial asymmetry. Patients and Methods: We report two patients with inability to open mouth few months following injury. They most probably suffered missed diagnosis condyle fracture by the previous physician. The latest physical examination and radiological finding shows the mandible was micrognathic and unilateral TMJ ankylosis was confirmed. A sequential protocol of TMJ ankylosis management based on aggressive resection of ankylotic mass was performed and followed withphysiotherapy.Result: In 2 month-follow up, both patients showed significant improvement in mouth opening and the mastication function was restored, accompanied with physical therapy to gain maximum mouth opening for at least a year.Summary: A detail history, clinical and functional examination, radiographic examination facilitating correct diagnosis followed by immediate surgical intervention, and physiotherapy can help us to restore physical, psychological, and emotional health of the child patient.

Management of endometriosis: a call to multidisciplinary approach.

Endometriosis is defined as the presence of endometrial-like glands and stroma outside of the uterus. There are three types of endometriotic lesions: superficial or peritoneal endometriosis, ovarian endometrioma, and deep infiltrating disease. Endometriosis not only occurs in the pelvis but also can be found in extrapelvic sites such as the gastrointestinal tract, upper abdominal viscera, genitourinary tract, abdominal wall, diaphragm, and thoracic cavity. After thorough history and physical examination is performed, imaging, such as ultrasound or magnetic resonance imaging (MRI), should be obtained if there is high suspicion for deep-infiltrating endometriosis to better assess visceral involvement. Endometriosis can be suspected based on symptoms, physical examination findings, and imaging. However, a definitive diagnosis requires histopathologic confirmation. Treatment options include expectant, medical, and surgical management. Endometriosis is largely a quality-of-life issue, and treatment should be tailored accordingly with empiric medical therapy frequently utilized. Medical management focuses on symptom improvement. Surgical management with excision of endometriosis is preferred over ablation or fulguration of endometriotic lesions. In the case of deep or extrapelvic endometriosis, treatment with a multidisciplinary team with experience in the treatment of advanced-stage endometriosis is essential to minimizing morbidity and increasing long-term success.