Frequent Final Diagnosis Research Articles

Diagnosing Hirschsprung Disease in Children Older than Six Months of Age: Complications After Rectal Biopsy, Insight in Final Diagnoses and Factors Associated With Hirschsprung Disease

IntroductionIt is challenging to distinguish between patients with Hirschsprung disease (HD) and patients with other causes of defecation problems based on clinical presentation in patients older than six months. Pathological examination of the rectal biopsy is the gold standard for the diagnosis of HD. The aim of this study was to gain insight into 1) the prevalence and severity of complications following rectal biopsy, 2) the final diagnoses of patients referred for biopsy, and 3) clinical factors associated with HD in patients older than six months. MethodsChildren suspected of HD above the age of six months referred for biopsies were analyzed retrospectively. Severity of complications of rectal suction biopsy (RSB) and full thickness biopsy (FTB) were assessed using Clavien-Madadi (CM) grading. Factors associated with HD were tested using multivariate logistic regression analysis. ResultsFrom 2000 to 2022, 234 children older than six months of age underwent biopsies because of defecation problems (median age of 47.2 months (IQR = 17.2–87.2)). Of these, 130 out of 234 children underwent RSB and 112 out of 234 children underwent FTB. One patient (0.4 %) developed a complication following RSB (CM1-A): fever without evident cause. Two patients (0.9 %) had ongoing rectal bleeding following FTB. One patient did not require an intervention (CM1-A), the other received rectal spongostan to stop the bleeding and erythrocyte transfusion (CM2). The most frequent final diagnoses were functional constipation (n = 179, 76.5 %), HD (n = 25, 10.6 %) and food intolerance (n = 5, 2.1 %). Associated factors for HD were distended abdomen (OR 5.41, CI 2.05–14.31), vomiting (OR 4.14, CI 1.64–11.85) and no abdominal pain (OR 0.14, CI 0.03–0.65) (model R2 = 0.278). ConclusionIn children older than six months suspected of HD, presenting with distended abdomen, vomiting and no abdominal pain, we advise obtaining a rectal biopsy in case other causes of constipation are ruled out, because a rectal biopsy is a safe procedure with only minor complications. The most common diagnosis in patients older than six months of age referred for rectal biopsy was functional constipation. Level of EvidenceLevel III.

Clinical characteristics, resource use, and diagnostic accuracy of natriuretic peptides in cancer patients presenting with acute dyspnea to the Emergency Department

Abstract Background Previous studies suggest that dyspnea is a common presenting symptom in cancer patients and 6% of patients hospitalized for acute heart failure (AHF) have a history of cancer [1]. However, the clinical characteristics and diagnostic accuracy of natriuretic peptides in patients with active or past cancer presenting to the emergency department (ED) with acute dyspnea is largely unknown. Purpose We aimed to evaluate (1) the characteristics of patients presenting with acute dyspnea, (2) the prevalence of AHF, (3) the time to discharge and hospitalization rate, and (4) the diagnostic accuracy of natriuretic peptides (BNP and NT-proBNP) and the recommended algorithm to diagnose AHF in patients with and without cancer [2]. Methods Patients presenting with acute dyspnea to the ED were prospectively enrolled in a multicenter diagnostic study. Patient characteristics, including cancer status was prospectively assessed. Final diagnosis was centrally adjudicated by two independent cardiologists using all individual patient information including cardiac imaging, natriuretic peptides and follow-up data. Discrimination was assessed using the area under the curve (AUC). Results Among 2153 patients, 474 (22.0%) had cancer. Cancer patients were older, more frequently smokers, presented more often with productive cough and less often with paroxysmal nocturnal dyspnea, and had a higher prevalence of previous pulmonary embolism. Prevalence of AHF was 44.9% vs 51.0% in patients with and without cancer, respectively (P = 0.02), although it was the most frequent final adjudicated diagnosis for both groups. Cancer patients had a higher prevalence of pneumonia (18.1% vs 14.4%, P = 0.046) and lower prevalence of psychogenic hyperventilation (1.9% vs 5.2%, P = 0.002). Cancer-related dyspnea accounted for up to 30.4% of final diagnoses. Length of stay in the ED was similar in the two groups, although cancer patients had a higher hospitalization rate (85.0% vs 79.0%, P = 0.004) and the hospitalization was longer (median 9 vs 7 days, P<0.001). The diagnostic accuracy of NT-proBNP was high in cancer patients, but significantly lower compared to non-cancer patients (AUC 0.90 vs 0.93; P=0.02). The diagnostic accuracy of BNP was very high and comparable between groups (0.94 vs 0.95. P=0.40, Figure 1). In cancer patients, the AHF NT-proBNP algorithm maintained a very high safety for ruling out AHF but had lower efficacy with more patients remaining in the gray zone compared with patients without cancer (28.9% vs 18.9%, respectively; P<0.01, Figure 2). Conclusions Patients with cancer presenting with dyspnea have lower prevalence of AHF. Hospitalization rates are increased. The diagnostic performance of NT-proBNP, but not of BNP, is reduced. The efficacy of the NT-proBNP algorithm is reduced with more patients triaged to the grey zone and so is rule-in performance, possibly leading to overdiagnosis and mistreatment.Diagnostic accuracy of BNP and NT-proBNPNT-proBNP ESC algorithm

Clinical Profile, Trends, and Management in Pediatric Patients with Audiovestibular Disorders: Can We Predict Emotional Disability in Pediatric Patients with Episodes of Vertigo and Dizziness?

Audiovestibular disorders in childhood occur with considerable frequency. However, the difficulty of obtaining medical history, the nonspecificity of symptoms, and the lack of cooperation during complementary tests often contribute significantly to diagnostic biases, attributing clinical presentations to psychosomatic disorders. The objectives of this work are, firstly, to characterize, from an auditory and vestibular perspective, the most frequent causes of vertigo in childhood and a possible relationship with emotional symptoms. On the other hand, to propose the usefulness of the MSSQ-Short questionnaire as a predictive variable in the evolution of children diagnosed with recurrent vertigo of childhood (RVC). An observational cross-sectional study was designed with retrospective data collection at three tertiary hospitals. Among the 117 patients recruited between 2016 and 2024, 32 patients (27.35%) were diagnosed with an anxious-depressive syndrome prior to audiovestibular testing. The mean age was 11.19 ± 5.61 years and the most frequent final diagnoses were vestibular migraine (VM) with 41.03% and RVC with 23.93%. Patients with VM, compared with RVC, are approximately 1.12 times more likely to have psychosomatic pathology (CI 0.39 to 3.25). The most sensitive and frequently altered test was VEMPS (39.32%), with statistical significance in VM and otic capsule dehiscence, while regarding the MSSQ-Short questionnaire, the linear regression of 0.28 indicates an increase in clinical duration with high questionnaire scores. Vestibular disorders causing dizziness and vertigo are challenging to diagnose, often due to lack of cooperation and/or symptom nonspecificity. A thorough medical history and complementary tests, including audiovestibular and imaging studies, are advisable, thus avoiding systematically attributing children's complaints to other psychosomatic disorders.

Kidney Biopsy Findings After Lung Transplantation

The early diagnosis of histological kidney damage after lung transplantation (LT) is of paramount importance given the negative prognostic implications of kidney disease. Three pathologists analyzed all kidney biopsies (KBs) (N= 100) performed from 2010 to 2021 on lung transplant patients in 4 Paris transplantation centers. The main indication for biopsy was chronic renal dysfunction (72% of patients). Biopsies were performed at a median of 26.3 months after transplantation and 15 months after a decline in estimated glomerular filtration rate (eGFR) or the onset of proteinuria. Biopsies revealed a wide spectrum of chronic lesions involving the glomerular, vascular, and tubulointerstitial compartments. The 4 most frequent final diagnoses, observed in 18% to 49% of biopsies, were arteriosclerosis, acute calcineurin inhibitor (CNI) toxicity, thrombotic microangiopathy (TMA) and acute tubular necrosis (ATN). TMA was significantly associated with a combination of mTOR inhibitors (mTORi) or CNIs with biological signs present in only 50% of patients. The eGFR was poorly correlated with most lesions, particularly percent glomerulosclerosis, and with the risk of end-stage renal disease (ESRD). Thirty-four patients progressed to ESRD at an average of 20.1 months after biopsy. Three factors were independently associated with the risk of ESRD: postoperative dialysis, proteinuria >3 g/g and percent glomerulosclerosis >4%. Given the great diversity of renal lesions observed in lung transplant recipients, early referral to nephrologists for KB should be considered for these patients when they present with signs of kidney disease.

Discordance Between the Initial Diagnosis of Sarcomas and Subsequent Histopathological Revision and Molecular Analyses in a Sarcoma Reference Center in Brazil.

To investigate the discordance in sarcoma diagnoses between nonspecialized institutions following revision by dedicated sarcoma pathologists at a reference center in Brazil and the relevance of molecular pathology in this context. We conducted a retrospective analysis of sarcoma samples initially analyzed at outside laboratories and subsequently reviewed by two specialized pathologists between January 2014 and December 2020. After obtaining demographic and tumor characteristics, pathology results were matched and classified as complete discordance (CD; benign v malignant, sarcoma v other malignancies), partial concordance (similar diagnosis of connective tumor, but different grade/histological subtype/differentiation), and complete concordance (CC). The concordance for histology or grade, and the role of molecular assessments supporting the diagnosis were also independently determined. Statistical analyses were conducted through the kappa coefficient of agreement and adherence by χ2 test, χ2 test by Person, and Fisher exact test. In total, 197 cases were included, with samples obtained predominately from male patients (57.9%) and localized/primary tumors (86.8%). Following revision, the most frequent final diagnoses were undifferentiated pleomorphic sarcoma (17.8%), well-differentiated/dedifferentiated liposarcoma (8.6%), and leiomyosarcoma (7.6%). CD was found in 13.2%, partial discordance in 45.2%, and CC in 41.6% of reviews (P < .001). We found a concordance for histology or grade of 53.5% (P < .001) and 51.8% (P < .001), respectively. Molecular assessments, comprising next-generation sequencing panels (79.5%) and fluorescent in situ hybridization (20.5%), were performed in 44 (22.3%) cases, with findings classified as of diagnostic relevance in 31.8%. In nearly 60% of the cases, the initial sarcoma diagnosis was modified when revised by a reference center and dedicated pathologists, assisted by molecular pathology techniques. These results justify the assembly of referral networks in countries with limited health care resources.

Substance Use in Patients Admitted to the Psychiatric Emergency Department in Northern Iran

Background: Acute psychiatric problems are increasingly observed following substance abuse in emergency departments. To address this significant societal issue, it is essential to understand its various dimensions in order to develop comprehensive control policies. Objectives: This study aimed to evaluate substance use and its related factors in patients admitted to a psychiatric emergency ward in Sari, Mazandaran, Iran. Methods: In this cross sectional investigation, all patients who were admitted to the emergency department of Zare referral psychiatry hospital during the previous one year were studied. A checklist of demographic and psychiatric factors was completed for each patient based on their medical records. Urine rapid tests were routinely conducted in this department to screen for drug consumption. Descriptive statistics, central and dispersion indices, and the chi-square test were used to analyze the data. Results: A total of 578 cases, comprising 406 males (70.2%) and 172 females (29.8%), were examined. The mean age of patients was 34.7 ± 11.2 years. The most common symptoms reported were aggression (50.5%), insomnia (11.2%), paranoia (10.7%), and self-talk (8.1%), respectively. The most frequent final clinical diagnosis was bipolar disorder in 145 cases (25.1%), followed by schizophrenia in 131 cases (22.7%), and substance-induced psychotic disorder in 63 cases (10.9%). In the substance use screening among patients, the urine test was positive for morphine in 17.6% of the patients. Methamphetamine, methadone, and cannabis tests were positive in 16.1%, 9.5%, and 3.5% of cases, respectively. Among patients with positive urine tests (for methamphetamine, methadone, or morphine), the most common clinical diagnosis was substance-induced psychotic disorder, followed by schizophrenia. Schizophrenia and substance-induced psychotic disorder were the two most common diagnoses in patients with positive cannabis urine tests, respectively. Conclusions: The high rate of substance abuse among psychiatric emergency patients, often co-occurring with other psychiatric disorders, the high prevalence of psychosis, and the behavioral risks associated with these patients emphasize the need for special attention to this biopsychosocial problem.

Evaluation of inpatients neurology consultations in the department of gynecology, obstetrics, and reproductive medicine of a tertiary hospital in Turkey

Background &amp; Objective: It is important to be aware of hormonal changes in neurological disease in neurology training. We aimed to investigate the most common disorders which resulted in the clinicians from the Department of Gynecology, Obstetrics, and Reproductive Medicine (GORM) to ask for neurology consultation from the Department of Neurology. Methods: All the neurology consultations requested from the Department of GORM between 2015 and 2023 at Harran University Hospital, Sanliurfa, Turkey, were retrospectively evaluated with regard to demographic characteristics, the reason for referral, neurologic diagnoses, and treatment, imaging features. SPSS statistical software version 22 (IBM Inc. NC, USA) was used to perform all statistical analyses. Results: There were 333 patients with a mean age of 32.5 years (range 17-68) seeking consultations; 287 had obstetric problems, and 46 had gynecological issues. In the obstetric group, pre-eclampsia and Posterior Reversible Encephalopathy Syndrome (PRES) were the most frequent final neurological diagnoses, while headache and acute cerebrovascular disease were the most common frequent problems in the gynecological group. The number of consultations rose from 23 in 2015 to 66 in 2022. The predicted rate of final diagnosis of GORM residents was 58%. The neurologist’s contribution has substantial influence on the management of 208 (62%) patients. Conclusion: Neurologists have a significant contribution to the management of GORM inpatients. In neurological training, importance should be given to the effect of hormonal changes on neurological diseases in neurology training.

Diagnostic pitfalls in patients referred for arrhythmogenic right ventricular cardiomyopathy

The diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC) is challenging because of nonspecific clinical findings and lack of conclusive answers from genetic testing (ie, an ARVC-related variant is neither necessary nor sufficient for diagnosis). Despite the revised 2010 Task Force Criteria, patients are still misdiagnosed with ARVC. In patients referred for ARVC, we sought to identify the clinical characteristics and diagnostic confounders for those patients in whom ARVC was ultimately ruled out. Patients who were referred to our center with previously diagnosed or suspected ARVC (between January 2011 and September 2019; N = 726) were included in this analysis. Among 726 patients, ARVC was ruled out in 365 (50.3%). The most common presenting symptoms in ruled-out patients were palpitations (n = 139, 38.1%), ventricular arrhythmias (n = 62, 17.0%), and chest pain (n = 53, 14.5%). On the basis of outside evaluation, 23.8% of these patients had received implantable cardioverter-defibrillators (ICDs) and device extraction was recommended in 9.0% after reevaluation. An additional 5.5% had received ICD recommendations, all of which were reversed on reevaluation. The most frequent final diagnoses were idiopathic premature ventricular contractions/ventricular tachycardia/ventricular fibrillation (46.6%), absence of disease (19.2%), and noncardiac presyncope/syncope (17.5%). The most common contributor to diagnostic error was cardiac magnetic resonance imaging, including mistaken right ventricular wall motion abnormalities (33.2%) and nonspecific fat (12.1%). False suspicion or misdiagnosis was found in the majority of patients referred for ARVC, resulting in inappropriate ICD implantation or recommendation in 14.5% of these patients. Misdiagnosis or false suspicion was most commonly due to misinterpretation of cardiac magnetic resonance imaging.

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.

Staring Spells: An Age-based Approach Toward Differential Diagnosis.

Evaluations to rule out epileptic vs nonepileptic staring spells may entail unnecessary evaluations that can be costly and time consuming. Our study aims to identify common etiologies for staring spells across 3 different pediatric age groups and to propose an age-based clinical guidance to help determine which patients warrant further workup. Methods: This was a single-center retrospective chart analysis of 1496 patients aged 0.0-17.9 years presenting with confirmed staring spell diagnosis from January 2011 to January 2021. The patients were divided into 3 groups based on their age: 0.0-2.9, 3.0-12.9, and 13.0-17.9 years. Patient information collected included demographics, clinical presentation, comorbidities, and final diagnosis. Multilevel likelihood ratios and a receiver operating characteristic curve were determined using 8 of the 11 clinical variables. A total of 1142 patients who met the inclusion criteria were included for the final analysis. The most common final diagnosis was attention-deficit hyperactivity disorder (ADHD) (35%), followed by normal behavior (33%). Generalized and focal epilepsy were diagnosed in 8% and 4% of the patients, respectively. In the 0.0-2.9-year age group, normal behavior was the final diagnosis in 72% patients. In the 3.0-12.9-year and 13.0-17.9-year age groups, ADHD was the most frequent final diagnosis in 46% and 60%, respectively. Overall, ADHD and normal behaviors remain the most common final diagnoses. Multilevel likelihood ratios can be used to develop an age-based guidance to differentiate between epileptic and nonepileptic staring spell diagnoses.

Diagnostic Role of Direct Immunofluorescence Assay in Determining The Etiology of Erythroderma: Experience in a Tertiary Referral Hospital.

Erythroderma is a life-threatening dermatologic emergency which is characterized by diffuse erythema and exfoliation affecting more than 90% of the body surface area. Most common cutaneous diseases associated with erythroderma are systemic contact dermatitis, psoriasis, drug eruption and atopic dermatitis. Clinical-pathological correlation is used to determine the underlying disease. In addition, direct immunofluorescence (DIF) may provide significant clues for etiology of erythroderma especially in the case of autoimmune bullous skin diseases (ABSDs). In our study, we aimed to analyze the demographic data, clinical pre-diagnoses, final diagnosis, histopathological and DIF examination findings, accompanying systemic signs and laboratory abnormalities of erythrodermic patients. We conducted a retrospective study of 31 erythroderma patients in a referral hospital between 2014 and 2021. Cutaneous biopsies were taken from all patients for H&E and DIF examination. Average age was 54.6 ± 23 years, 48.4% of the patients were female (N = 15) whereas 51.6 % of the patients were male (N = 16). Average time between the onset of rash and biopsy was 18.8 days. DIF analysis showed immune deposits in 19.4% (N = 6) of the patients; whereas no immune deposits were detected in 80.6% (N = 25) of the patients. The most frequent final diagnosis was adverse cutaneous drug eruption followed by ABSDs. Our findings suggest that DIF may be used in conjunction with clinical-pathologic and clinical findings to reveal the associated skin diseases in erythrodermic patients. Erythrodermic patients presenting with clinical findings of ABSD should be considered for DIF examination.

Adult brainstem glioma differential diagnoses: an MRI-based approach in a series of 68 patients.

Brainstem gliomas are rare in adults. The diagnosis is often difficult, as some teams still consider brainstem biopsies dangerous and often avoid this procedure. The aim of this study was to describe differential diagnoses that can mimic brainstem glioma, to help clinicians avoid diagnostic and therapeutic mistakes, and to propose a diagnostic algorithm according to radiological presentations. The French network of adult brainstem gliomas (GLITRAD) retrospectively collected all reported cases of differential diagnoses between 2006 and 2017. The inclusion criteria were as follows: age over 18years, lesion epicenter in the brainstem, radiological pattern suggestive of a glioma and diagnostic confirmation (histopathological or not, depending on the disease). We identified a total of 68 cases. Most cases (58/68, 85%) presented as contrast-enhancing lesions. The most frequent final diagnosis in this group was metastases in 24/58 (41%), followed by central nervous system lymphoma in 8/58 (14%). Conversely, MRI findings revealed 10/68 nonenhancing lesions. The most frequent diagnosis in this group was demyelinating disease (3/10, 30%). The risk of diagnostic mistakes illustrates the need to consider the more systematic use of a brainstem biopsy when reasonably possible. However, we propose an MRI-based approach to the differential diagnosis of gliomas to limit the risk of misdiagnosis in cases where a biopsy is not a reasonable option.

High frequency of functional cognitive decline among patients with low education

AbstractBackgroundFunctional cognitive decline (FCD) has been increasingly described as a blind spot of dementia care. Psychological distress, affective symptoms and disturbed self‐perception comprehend the most common causes of FCD. Herein, we aim to identify the frequency of FCD in a tertiary memory clinic from a very low education setting.MethodA retrospective analysis was conducted to identify new referrals to our tertiary memory clinic (Porto Alegre, southern Brazil) over a 6‐year period (2014 ‐ 2020). All individuals referred from the primary care setting of the public health system in this time period were included in this analysis. Patients underwent a diagnostic protocol including neurologic evaluation, cognitive screening, neuroimaging (CT or MRI) and laboratory testing. FCD was defined as patients with cognitive complaints/objective cognitive decline associated with psychological distress and affective symptoms, without evidence of underlying neurodegenerative disease. Data is shown in median [interquartile range].ResultA total of 474 patients (287 females, median age 72 [65‐78]) with a median of 5 [0‐10] years of education were referred to our memory clinic within the period from 2014 to 2020. FCD was the second more frequent final diagnosis (95, 19.8%), only behind of dementia due to Alzheimer's disease (106, 22.4%); other diagnosis were less frequent: Mild Cognitive Impairment (49, 10.3%), Subjective Cognitive Decline (35, 7.4%), Vascular dementia (34, 7.2%), Mixed‐type dementia (24, 5.1%), behavioral variant Frontotemporal Dementia (5, 1.1%), and other types (36, 7.6%). Patients with FCD were younger (69 [63‐75] vs. 74 [67‐78], p&lt;0.001), and showed higher Geriatric Depression Scale (GDS‐15) than non‐FCD individuals (9 [5‐12] vs. 5 [2‐8], p&lt;0.001). The education level did not differ (p&gt;0.05).ConclusionFunctional Cognitive Decline was the second most frequent diagnosis among patients with very low education in a tertiary memory clinic. FCD individuals were younger, showed increased depressive symptoms than non‐FCD patients. Taken altogether with Subjective Cognitive Decline, functional disorders account for the majority of consultations referred to this tertiary setting. Public health strategies including the primary care setting may greatly improve early diagnosis and treatment to these patients.

Retrospective evaluation of the utility of blood cultures in dogs (2009-2018): 45 cases.

There is no consensus on obtaining blood cultures routinely in companion animals with suspected sepsis, and there is a paucity of evidence concerning their utility. The objectives of this retrospective study were to determine the yield of positive blood cultures from hospitalized dogs, the prevalence of resistant bacteria, and the frequency and nature of changes to antimicrobial therapy once the culture result became available. Forty-five dogs had a blood culture submitted over a 10-year period, of which 9(20%) yielded positive growth and 36 (80%) yielded no bacterial growth. The most frequent reasons for submission of blood culture were pyrexia of unknown origin (n=14), suspected soft tissue infection (7), and suspected discospondylitis (7). The most frequent final diagnoses were soft tissue infection (n=11), discospondylitis (7), and unknown (6). No significant difference was found between the culture-positive versus culture-negative groups with regard to the most frequent reasons for blood culture (P=0.55), final diagnoses (P=0.80), survival until the blood culture result (P=0.37), or whether the infection was hospital- or community-acquired (P=0.99). There were significantly more immunosuppressed dogs in the culture-positive group (P=0.02). Resistance to one or more antimicrobials was documented in all dogs with susceptibility reported. In the culture-positive dogs, 63% had antimicrobial de-escalation and none had escalation, whereas 19% of the culture-negative dogs had de-escalation and 7% had escalation. Blood cultures were submitted infrequently, but the proportion of resistance was higher than expected and supports the use of blood cultures in cases of suspected infection resulting in bacteremia.

Pre-hospital predictors of an adverse outcome among patients with dyspnoea as the main symptom assessed by pre-hospital emergency nurses - a retrospective observational study

BackgroundDyspnoea is one of the most common reasons for patients contacting emergency medical services (EMS). Pre-hospital Emergency Nurses (PENs) are independently responsible for advanced care and to meet these patients individual needs. Patients with dyspnoea constitute a complex group, with multiple different final diagnoses and with a high risk of death. This study aimed to describe on-scene factors associated with an increased risk of a time-sensitive final diagnosis and the risk of death.MethodsA retrospective observational study including patients aged ≥16 years, presenting mainly with dyspnoea was conducted. Patients were identified thorough an EMS database, and were assessed by PENs in the south-western part of Sweden during January to December 2017. Of 7260 missions (9% of all primary missions), 6354 were included. Among those, 4587 patients were randomly selected in conjunction with adjusting for unique patients with single occasions. Data were manually collected through both EMS- and hospital records and final diagnoses were determined through the final diagnoses verified in hospital records. Analysis was performed using multiple logistic regression and multiple imputations.ResultsAmong all unique patients with dyspnoea as the main symptom, 13% had a time-sensitive final diagnosis. The three most frequent final time-sensitive diagnoses were cardiac diseases (4.1% of all diagnoses), infectious/inflammatory diseases (2.6%), and vascular diseases (2.4%). A history of hypertension, renal disease, symptoms of pain, abnormal respiratory rate, impaired consciousness, a pathologic ECG and a short delay until call for EMS were associated with an increased risk of a time-sensitive final diagnosis. Among patients with time-sensitive diagnoses, approximately 27% died within 30 days. Increasing age, a history of renal disease, cancer, low systolic blood pressures, impaired consciousness and abnormal body temperature were associated with an increased risk of death.ConclusionsAmong patients with dyspnoea as the main symptom, age, previous medical history, deviating vital signs, ECG pattern, symptoms of pain, and a short delay until call for EMS are important factors to consider in the prehospital assessment of the combined risk of either having a time-sensitive diagnosis or death.

Diagnosis and treatment of women with radiologic findings suspicious for uterine arteriovenous malformations

This study investigated the clinical outcomes for patients with pelvic ultrasound findings suspicious for uterine arteriovenous malformations (AVMs) at a single institution. We reviewed the electronic medical record to identify women with pelvic ultrasound reports read as possible uterine AVM, and used medical records to determine clinical outcomes. Among the 39 women with ultrasounds suspicious for AVM, 14 had subsequent MRIs, 10 had additional ultrasounds, and 10 underwent pelvic angiography. Five of the 39 women were ultimately diagnosed with AVMs. Of the 34 women who did not have an AVM, 12 were diagnosed with retained products of conception. Women may be receiving overtreatment for possible uterine AVMs; careful clinical consideration is warranted as the most common clinical diagnosis for women with radiologic findings suspicious of uterine AVM is retained products of conception. Impact statement What is already known on the subject: An acquired uterine arteriovenous malformation (AVM) is an abnormal arterio-venous connection in the myometrium that may cause life-threatening haemorrhage. Over the past decade, it has been noted that the characteristic ultrasound findings of uterine AVM may represent other causes of uterine hypervascularity including retained products of conception. What the results of this study add: As there is no consensus on the management of highly vascular myometrial lesions suspicious for uterine AVMs, this study reports our institution’s experience with pelvic ultrasound findings suspicious for uterine AVMs. We found that further diagnostic workup, including MRI and angiography were common, but that the most frequent final diagnosis was retained products of conception. What the implications are of these findings for future clinical practice: This study contributes to the growing body of work noting spectrum of conditions with similar vascular ultrasound findings, and suggests that at least in this sample, women may be receiving overtreatment for these presumed uterine AVMs. Close collaboration among gynaecologists and radiologists is needed to interpret the significance of these radiographic images and to determine the appropriate intervention, as women with radiologic findings suspicious of uterine AVM will frequently have retained products of conception.

Telemedicine Improves Access to Hepatology Consultation with High Patient Satisfaction

Telemedicine between health care providers could be useful for improving the access to hepatology consultations, which is challenging in some regions. The primary objective of this study was to estimate the proportion of consultations that were resolved through a telemedicine program. Additionally, we evaluated patient satisfaction with this strategy. Consecutive telemedicine consultations made by non-hepatologist health care providers from different regions of Argentina to a specialty hepatology team were included. Participants and hepatologists used e-mail, teleconference systems, WhatsApp, or telephone to interact, depending on their preferences. Consultations were considered to be resolved through telemedicine when a diagnosis and an adequate follow-up were achieved without the need to refer the patient to a hepatologist or other specialist. Patient satisfaction with telemedicine was evaluated using the Patient Satisfaction Questionnaire Short Form and Telemedicine Satisfaction Questionnaire. A total of 200 telemedicine consultations made by 24 physicians from 10 different provinces of Argentina were evaluated, of which 145 (73%; 95% CI: 66%-79%) were resolved through telemedicine. Practitioners specialities were as follows: family physicians, internists, gastroenterologists, infectious diseases, and obstetrics. The most frequent final diagnoses for those patients whose consultation was resolved through telemedicine were non-alcoholic fatty liver disease, viral hepatitis, and benign hepatic lesions. A high degree of patient satisfaction with telemedicine was observed in both questionnaires. Our results show the effectiveness of telemedicine in hepatology, with high resolution rate of consultations and rapid access to experts' assessment. Additionally, a high degree of patient satisfaction was observed using prevalidated questionnaires.

Invalidation of Parkinson's disease diagnosis after years of follow-up based on clinical, radiological and neurophysiological examination

IntroductionDiagnosis of Parkinson's disease (PD) is mainly based on clinical features. Accurate neurological examination is required but dopamine transporter (DaT) single photon emission computed tomography (SPECT) could be perfomed to support the diagnosis in ambiguous cases. The aim of this work is to describe the characteristics of patients with a prolonged PD misdiagnosis. MethodsWe collected data from 24 patients initially diagnosed with PD who had an atypical long-term evolution. We analyzed demographic and clinical characteristics and antiparkinsonian drugs medication. Brain MRI, DaT-SPECT and/or accelerometry/electromyography (EMG) recording were performed in a subgroup of patients. We analyzed the causes of erroneous PD diagnosis as well as the final diagnoses. ResultsMean age at PD diagnosis was 60.4 ± 14.8 years. Symptoms at onset were rest tremor (n = 19), gait instability (n = 7) and micrographia (n = 4). Mean duration before diagnosis correction was 8.4 ± 5.3 years. All patients were treated by antiparkinsonian drugs with a mean daily levodopa equivalent dose (LED) of 508.1 ± 528.4 mg. All 18 patients who underwent DaT-SPECT had a normal result. The most frequent final diagnoses were essential tremor (n = 11) and functional movement disorders (n = 9). ConclusionCases that have been initially diagnosed as PD and then progress in an atypical long-duration fashion may have been misdiagnosed. Absence of genuine bradykinesia, non-sustained response to antiparkinsonian drugs, or absence of levodopa-related side effects should prompt the clinician to reappraise the diagnosis and to consider performing a DaT-SPECT.

Seizure in code stroke: Stroke mimic and initial manifestation of stroke

BackgroundAlthough seizure is one of the common causes of stroke mimics and can be an initial manifestation of acute stroke, accurate diagnosis of seizure during acute stroke management is frequently difficult. The objective of this study was to analyze the frequency, characteristics and results of neuroimaging including CT perfusion in patients with seizures manifesting initially as stroke-like symptoms. MethodsWe retrospectively reviewed the medical records of patients who were treated with code stroke alarming system. We studied the frequency and characteristics of patients who were finally diagnosed with seizures and further correlated their clinical features with the results of neuroimaging including CT perfusion. ResultsAmong the 4673 patients who were treated with code stroke alarming system, seizure was the third most frequent diagnosis (188 patients, 4.0%) among the causes of stroke mimics including 27 patients who manifested seizure as an initial manifestation of acute stroke. CT perfusion showed perfusion changes in more than 25% of them (49 of 188 patients, 26.1%). Thrombolysis was not performed in six patients who presented with seizure as an initial presentation of stroke for delayed diagnosis while one patient underwent thrombolysis for misdiagnosis of seizure. ConclusionsSeizure is a frequent final diagnosis in acute stroke management. However, careful interpretation of clinical features and results of perfusion imaging is necessary to avoid unnecessary thrombolysis in patients with seizure as a stroke mimic and thrombolysis failure due to delayed diagnosis of seizure as an initial manifestation of stroke.

2497. Acute Flaccid Paralysis: 17-Year’s Active Epidemiological Surveillance in a Pediatric Hospital in Argentina

BackgroundArgentina, as the same of LATAM countries certifies the elimination of polio in 1990. Acute flaccid paralysis (AFP) surveillance is a key strategy for monitoring the progress of poliomyelitis eradication in the world. The aim of this study was to describe the epidemiological pattern of patients reported with AFP.MethodsA cross-sectional study was carried out from January 2000 to December 2016 at the “R. Gutierrez” Children`s Hospital. All children aged <15 years who met the WHO definition for AFP were included. Stool samples were sent to the national reference laboratory to be tested for enteroviruses (non-polio enterovirus, poliovirus, Sabin, Sabin-derived)in compliance with the AFP protocol.ResultsA total of 174 cases were included; median age 62 months (IQR: 29–108); 53.5% males. No seasonality pattern was observed; 137(79%) stool samples were tested and no wild poliovirus was isolated. The median time between the onset of the paralysis and the admission was 4 days (IQR 2–9); the most common prodromal symptoms were: fever(39%),respiratory infection (35%), digestive (31%), myalgia (34%) and meningeal (5%). Symmetric paralysis (78%) without progression was the most frequent clinical presentation. The median length of stay at the hospital was 9 days (IQR 1-17). None of the patients was diagnosed as having polio vaccine related paralysis. Guillain-Barre syndrome was the most frequent final diagnosis (n = 72) followed by transverse myelitis (n = 14), botulism (n = 12) and encephalitis (n = 6). Between years 2000 and 2016 a total of eight cases of non-polio enterovirus (NPEV) were found: 6 cases of acute myelitis (AFM) associated to D68 enterovirus, clustered in winter 2016. Five of them were detected by PCR in nasopharyngeal aspirates and only one in stool samples. All of them present motor sequels.ConclusionEpidemiological surveillance of AFP allows ruling out poliovirus infection and detect other flaccid paralysis etiologies. In 2016 D-68 enterovirus AFM outbreak was detected in Argentina when conducting AFP routine surveillance. Nasopharyngeal aspirates, in AFM suspected cases, must be part of the study AFP protocol.Disclosures All authors: No reported disclosures.