Gradual Onset Of Symptoms Research Articles

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Patient perspectives of barriers and facilitators of treatment-seeking behaviors for stroke care.

Delays in seeking treatment for stroke care are associated with greater disability and reductions in stroke outcomes. The objective of this study was to qualitatively examine facilitators and barriers to urgently seeking stroke-related care. A qualitative analytic approach was used to explore facilitators and barriers to seeking stroke care in an urgent manner. Sixty-four stroke survivors offered information related to facilitators and barriers to stroke care via a structured survey as part of a larger mixed-methods study designed to measure stroke outcomes. Three themes emerged related to facilitators and barriers: (a) recognition of symptoms, (b) social support, and (c) knowledge and ability to call emergency medical services as a first response. Facilitators to urgent care-seeking behaviors included classic stroke symptoms, severe symptoms, sudden symptom onset, and high perceived level of emergency. Social support and knowledge/ability to call emergency medical services also emerged as facilitators of urgent care. Barriers to urgent care-seeking behaviors included atypical symptoms, mild symptoms, gradual symptom onset, and low perceived level of emergency. Individuals who experience strokes face a number of facilitators and barriers to seeking urgent care for their condition. Facilitators and barriers are associated with stroke symptoms and their personal environments. Additional study of barriers to stroke care is needed to adequately design interventions to reduce delays in seeking treatment.

Case Series of all three types of Ushers Syndrome of varying severity in the same family

Introduction: Ushers syndrome is an autosomal recessive disorder characterized by hearing loss and visual impairment due to retinitis pigmentosa. There are three types of Ushers syndrome with decreasing order of severity. Type 1 has onset of illness at birth with rapid progression of symptoms. Type 2 has gradual onset of symptoms with moderate hearing loss and later onset of night vision problems. Type 3 is the least severe form with onset of symptoms at late teenage. Case Series: We report here four siblings with Ushers. The first and second child had clinical symptoms suggestive of type1 Ushers. Third child has clinical features of Type 3 Ushers. Fourth child who had presented to us was having clinical features supportive of type 2 Ushers. There was a family history of similar symptoms in their cousin brother. All the four siblings were product of consanguineous marriage. Their mother was suffering from discoid lupus erythematosus. Conclusion: Timely diagnosis of Ushers could have decreased the morbidity of these children. Universal Screening for newborn hearing at birth will help in early detection of children with hearing loss and associated syndromes. Cochlear implantation is the only treatment in Ushers and earlier the implantation better is the prognosis. Hence in developing countries like India where genetic diagnosis is not possible most of the times due to financial constraints we can at least implement programs like hearing screening at birth.

P13. Childhood narcolepsy with cataplexy: Clinical characteristics of 4 cases

Introduction Childhood narcolepsy with cataplexy is a rare lifelong disorder which usually emerges in adolescence. Diagnosis is often delayed for many years due to poor awareness and gradual onset of symptoms. Excessive daytime sleepiness can be mistaken as a physiological phenomenon of the teenage years and cataplexy might be overlooked. Methods 4 proven cases of narcolepsy are presented that were referred to our outpatient clinic during the past 2 years. Results We report on 3 boys and 1 girl aged 6 to 13 years at disease onset. In all patients excessive daytime sleepiness was the main complaint. At the time of first presentation cataplexy was not reported but recognized by patients and parents when asked for. Loss of muscle tone affected the face and the trunk. None of the patients had drop attacks. 1 boy had major weight gain. The girl was the only patient who reported on night-time hallucinations and sleep paralysis and therefore presented with all disease defining symptoms. Rapid disease onset after a viral infection occurred in 2 boys. In 2 patients a peculiar facial expression with unusual tongue protrusion was reported and evident on physical exam. Mood changes and aggressive behaviour occurred in 2 patients. Polysomnography (PSG) and multiple sleep latency (MSLT) tests were performed in all patients and revealed typical findings of narcolepsy with sleep fragmentation, sleep onset REM and short sleep latency in 3 patients, while in 1 patient PSG and MSLT were normal. Carriage of the HLA-DQB1∗0602 haplotype and low CSF hypocretin levels were confirmed in the 3 boys. In one patient intravenous immunoglobulins were administered and lead to a transient symptom relief but failed to induce an increase of CSF hypocretin. Excessive daytime sleepiness was assessed using the Epworth Sleepiness Scale (ESS). All patients were treated with methylphenidate resulting in reduction of the ESS score. In 2 patients improvement is not yet considered as sufficient. As expected cataplexy did not respond to treatment. Conclusions Narcolepsy with cataplexy is a severely disabling, most probably autoimmune disease. Early diagnosis and treatment initiation may improve school performance and quality of life during the teenage years and hopefully also the longterm course. Treatment recommendations are adopted from adult medicine but are still controversial due to addictive potential and off-label use of some substances, as sodium oxybate in children.

Characteristics of chemosensory disorders--results from a survey.

This survey was undertaken to investigate the nature of chemosensory dysfunction in relation to the underlying cause, severity, and course of the disease and to elucidate their clinical significance. A total of 269 patients (116 men and 149 women) with chemosensory disorders participated in the survey. Approximately 89 % had olfactory loss, either alone or in combination with taste loss and 2 % had gustatory loss alone; 7.4 % had chemosensory distortions. Dysosmia was significantly higher in those on more than four medicines per day (p < 0.02). Most patients (51.6 %) reported sudden onset of symptoms. Self-reported etiologies included: flu/infection (39.4 %), medication intake (13 %), sinusitis (12 %), operation (10.7 %), head-trauma (9.3 %), and not-specified (12.7 %). The most frequent complaint was diminished pleasure from eating followed by a decrease in general quality of life (QoL). Patients with gradual onset of symptoms or long-standing disease complained the least (p < 0.005). Of all etiologies, patients with SND complained the most (p < 0.04). Overall, 18.6 % ate more and 7.3 % ate less, 7.5 % changed their food preferences, and 19 % reported weight gain and 15.8 % weight loss. Haptic feedback was considered more important than visual appeal and acoustic feedback of food. Older patients however valued visual appeal more. When asked directly, 63 % reported having experienced household-mishaps, 58.1 % problems with social communication, 56.8 % reported having changed their sexual behavior and 35.9 % suffered depression. 60.4 % did not cope well with the changes in their lives. Women reported more problems than men, particularly relating to interpersonal communication (64.5 vs. 57.6 %) and mood (47.9 vs. 40.9 %). Women also had more frequent spontaneous recollections of smells (p < 0.02). Chemosensory disorders have a significant impact on QoL. Reduced pleasure from eating is the predominant complaint of patients seeking medical attention. The steeper the onset of symptoms, the worse the ability to cope with changes in daily life. Older patients value the visual appeal, whereas younger patients value the haptic feedback of foods.

THU0414 The Incidence and Presentation of Systemic Lupus Erythematosus (SLE) in UK Primary Care Using the UK Clinical Practice Research Datalink (CPRD)

BackgroundThe onset of SLE is often described as varied and insidious yet few studies have described the pattern of the onset of symptoms using primary care data. We used the...

Treatment of chronic obstructive pulmonary disease in hospitalized geriatric patients.

Chronic obstructive pulmonary disease (COPD) is frequent in older subjects due to deterioration of pulmonary function and lifelong exposure to risk factors. Furthermore, COPD is often underreported because of the gradual onset of symptoms and reduced perception of symptoms in the elderly. There is thus a risk of undertreatment of COPD in older subjects. We retrospectively analyzed dossiers of 229hospitalized geriatric patients with COPD, complete assessment datasets and successful lung function tests. The sample comprised 78men (38 %; mean age 77 ± 7years) and 151women (66 %; mean age 81 ± 6years). The number of untreated patients decreased from 68(28 %) at admission to 35(14 %) at discharge (p < 0.01). Absence of treatment was associated with severity of disease: mild COPD was less likely to be treated. During the hospital stay, the prescription of metered dose inhalers (MDIs) decreased and the prescription of nebulizers increased, most likely due to the coordination problems associated with using inhalers. Undertreatment of COPD is frequent among hospitalized geriatric patients. There is a need for adaption of current guidelines to the needs of older patients with frailty or cognitive impairment.

Serious shoulder injuries in professional soccer: return to participation after surgery

An evidence base for the management and prevention of shoulder injuries in soccer is lacking. The aim of this study was to demonstrate the type, mechanism and recovery time after surgery associated with serious shoulder injuries sustained in professional soccer to build an evidence base foundation. Fifty-two professional soccer players underwent shoulder surgery for injuries sustained during match play. Of these, 25 fulfilled the inclusion criteria. Data were collected for injury mechanism and type; clinical, radiological and surgical findings and procedures; and return to full participation. Subjects were all managed by the same surgeon. Labral injuries represented the most common injury type affecting 21 (84 %) subjects; two rotator cuff (8 %) and two combined labral/rotator cuff (8 %) injuries were less common. Fourteen (56 %) subjects sustained a high-energy trauma injury in a combined abduction and external rotation position. Six (24 %) subjects sustained a low-energy trauma mechanism in variable positions, while five (20 %) had a gradual onset of symptoms. Twenty-two (88 %) subjects reported a dislocation as a feature of their presentation. All of the subjects with high- and low-energy trauma mechanisms reported a dislocation occurring at the time of injury. Eight (32 %) subjects had sustained a previous significant shoulder injury to the ipsilateral side. Goalkeepers did not sustain low-energy trauma injuries. Outfield players returned to full participation in a mean time of 11.6 weeks, while goalkeepers did so in 11.1 weeks post-surgery. Return to participation time ranged from 7 to 24 weeks with a median of 11 weeks. Professional soccer players can expect a return to participation within 12 weeks post-surgery. The majority of serious shoulder injuries in soccer occur at a positional extreme of external rotation and abduction in high-energy situations, while a significant number occur in low-energy situations away from this position. Most serious shoulder injuries in professional soccer are dislocations. Previous shoulder injury is considered a risk factor. IV.

Multivariate analysis of predictors of pre-hospital delay in acute coronary syndrome

Few studies have had the opportunity to examine a broad range of predictors of pre-hospital delay from a multivariate perspective that includes not only sociodemographic and clinical features but also atypical symptoms, patient appraisal and behavior, across the acute coronary syndrome (ACS) spectrum. A total of 1894 hospitalized ACS patients were recruited predischarge after an ACS event. Patients completed a detailed questionnaire and clinical details were verified with their case notes. The median pre-hospital delay times were, 4.06, 2.70, 4.51 and 5.50h, for all ACS, ST elevated myocardial infarction (STEMI), non-STEMI and unstable angina (UA) subgroups respectively. Multiple regression models examining 33 predictors of pre-hospital delay were significant (p<0.001), accounting for 32%, 42%, 34% and 29% of the variance for all ACS, STEMI, non-STEMI and UA subgroups respectively. The predictors that were singularly significantly associated with longer pre-hospital delay within all ACS were: taking medications, visiting family physician, and symptoms that were intermittent in nature. In the MI subgroups, not using an ambulance and gradual symptom onset, were also associated with longer delay. In STEMI patients non-attribution of symptoms to heart was also associated with longer pre-hospital delay. Multivariable analyses found that although sociodemographic, clinical history or situational predictors contributed to the variance in pre-hospital delay, the main predictors of pre-hospital delay were behavioral and symptom presentation factors. These factors should therefore be incorporated into patient education and interventions, to further improve patient pre-hospital delay time.

Estudio epidemiológico de los pacientes con nódulos vocales

ObjectiveWe aimed to perform an epidemiologic study of patients with vocal nodules in relation to age, sex, profession, relevant medical history, vocal behavior, smoking, form of presentation, and symptom duration. We carried out a wide review of recent and classical literature. Material and methodsA systematized protocol was applied in 97 patients diagnosed with vocal nodules over a period of 5 years. ResultsThe mean age was 33 years, and 97% were women. Most of the patients worked in professions that involved contact with the public or were voice professionals. The most frequent antecedents were anxiety, depression, allergic rhinitis and gastric reflux. Vocal behavior was characterized by poor vocal use and abuse, cervical tension, singing and hoarseness. A total of 64.9% reported smoking, 64.9% reported gradual symptom onset and the mean duration was approximately 4 years. ConclusionVocal nodules are frequent in women aged between 20 and 40 years and mainly affect people working in professions that involve excessive use of the voice. The most frequently associated disorders are anxiety-depression, gastric reflux and allergic processes. In most patients, vocal behavior is characterized by poor use and abuse, singing, cervical tension and hoarseness. Symptom onset is usually gradual.

Reasons for medical help-seeking behaviour of patients with recent-onset arthralgia

ObjectivePatient delay in seeking medical help may cause suboptimal use of the therapeutic window in rheumatoid arthritis. We aimed to assess the motivations and the urgency with which patients with...

Time course and pattern of COPD exacerbation onset

BackgroundThe natural history and time course of the onset of exacerbation events of chronic obstructive pulmonary disease (COPD) is incompletely understood.MethodsA prospective cohort of 212 patients with COPD was monitored...

Long‐term impact of delay in assessment of patients with early arthritis

During the last decade, rheumatologists have learned to initiate disease-modifying antirheumatic drugs (DMARDs) early to improve the outcome of rheumatoid arthritis (RA). However, the effect of delay in assessment by a rheumatologist on the outcome of RA has scarcely been explored. The purpose of this study was to examine the association between delay in assessment by a rheumatologist, rates of joint destruction, and probability of achieving DMARD-free remission in patients with RA. Patient characteristics associated with components of delay (by the patient, by the general practitioner [GP], and overall) were assessed. A total of 1,674 early arthritis patients from the Leiden Early Arthritis Clinic cohort were evaluated for patient delay, GP delay, and total delay in assessment by a rheumatologist. Among 598 RA patients, associations between total delay, achievement of sustained DMARD-free remission, and the rate of joint destruction over 6 years followup were determined. The median patient, GP, and total delays in seeing a rheumatologist among patients with early arthritis were 2.4 weeks, 8.0 weeks, and 13.7 weeks, respectively. Among all diagnoses, those diagnosed as having RA or spondylarthritis had the longest total delay (18 weeks). Among the RA patients, 69% were assessed in ≥12 weeks; this was associated with a hazard ratio of 1.87 for not achieving DMARD-free remission and a 1.3 times higher rate of joint destruction over 6 years, as compared with assessment in <12 weeks. Older age, female sex, gradual symptom onset, involvement of the small joints, lower levels of C-reactive protein, and the presence of autoantibodies were associated with longer total delay. Only 31% of the RA patients were assessed in <12 weeks of symptom onset. Assessment in <12 weeks is associated with less joint destruction and a higher chance of achieving DMARD-free remission as compared with a longer delay in assessment. These results imply that attempts to diminish the delay in seeing a rheumatologist will improve disease outcome in patients with RA.

TruFit Plugs for Articular Cartilage Repair in the Knee: 2 Year Experience, Results and MRI Appearances (SS-59)

To report on early clinical experience with 2 year results of articular cartilage repair in the knee using Synthetic TruFit CB plugs. This techinique is off-label in US but is approved for use in UK, where this study took place. 26 Patients have undergone cartilage repair in the knee using TruFit Plugs (Smith and Nephew UK), a biphasic absorbable scaffold designed to capture mmarrow elements and encourage differentiation into articular cartilage and into bone. All patients have been prospecitively analysed collecting demographic, operative, clinical and MRI radiological outcome assessment. Data was collected at 12, 18 and 24 months post implantation. Protected weight bearing was advised for 4 weeks and sport avoided for 3 months. Of the 26 patients, 22 are male and 4 female with mean age 34.5 years (range 19-49). Repair was performed for lesions less than 2 cm diameter on the medial femoral condyle in 15, the lateral femoral condyle in 4, and the trochlea in 7. In 13 the cause was sport related, 2 had osteochondral defects and the remainder had gradual onset of symptoms. The number of plug used ranged from 1 to 4 per patient. All patients have improved and there have been no infective or thromboembolic complications. At 12 months the mean Tegner activity score improved from 2.4 to 6 (p =0.009). The mean Lysholm score improved from 48.3 to 71 (p = 0.008) and IKDC subjective scores improved from a mean of 37.7 to 65.1 (p = 0.004). KOOS outcome data showed statistically significant improvement in all domains with the mean KOOS sport and recreation score improving an average of 46 points (p<0.001). Within the SF-36 Health Outcome measures, the physical component score (PCS) improved from 39.5 to 50.3 (p = 0.018), and the mental component score (MCS) showed no significant differences, changing from 52.1 to 51.3 (p = 0.37). At 24 months all paramaters show a trend for further improvement but not statistically significant. Two patients underwent second look arthroscopy because they still had pain at more than 6 months post surgery. Arthroscopy in the first patient, performed for medial pain, showed a well integrated and firm repaired area, consistent with MRI appearances. Pain has subsequently settled. Arthroscopy in the second patient showed the repaired area to have filled in but the surface was very soft. Effusion and pain were slow to settle. The graft (3 plugs) remained in position and by 18 months he has become pain free and is playing impact sport. MRI imaging on this series has shown reformation of the subchondral lamina and T2 Mapping has shown tissue values similar to normal surronding cartilage by 9 months. We believe that TruFit plugs offer an attractive solution to the management of full thickness chondral injuries enabling rapid mobilisation and return to sport. TruFit plugs provide a stable scaffold for early mobilisation of the knee post operatively, avoiding the prolonged period of limited weight bearing as follows microfracture, and the long recovery time following ACI. We believe that TruFit plugs appear to provide a simple one step solution in the management of small areas of chondral injury (<2cm diameter), particularly in patients who require rapid rehabilitation, and are keen to remain active at a high level.

Multiple sclerosis

Multiple sclerosis (MS) is caused by inflammatory demyelination and axonal loss in the central nervous system (CNS) (brain and spinal cord). The key characteristics of the scarring (“sclerosis”) and its...

Slipped capital femoral epiphysis update

Slipped capital femoral epiphysis (SCFE) is the most common adolescent hip condition. Its importance lies in its high morbidity if not diagnosed and treated in its early stages, not only in childhood but also as a cause of osteoarthritis in adulthood. This article highlights key diagnostic tools and optimal treatment plans for SCFE. SCFE involves displacement between the proximal femoral neck and the femoral head at the level of the open physis, with biomechanical and biochemical factors implicated. Acute major trauma is rarely involved; a gradual onset of symptoms and deformity is more common. Patients with unstable SCFE are in severe pain and unable to bear weight. SCFE occasionally is associated with endocrine or metabolic abnormality (hypothyroidism, panhypopituitarism and renal rickets). On physical examination, limited internal rotation of the affected hip is usual; obligatory external rotation of hip in flexion is classic. Diagnosis is confirmed on anteroposterior and frog-leg lateral radiographs of both hips. Treatment is surgical, with stabilization across the physis by in-situ pinning being the gold standard. Prompt diagnosis and timely surgical treatment usually lead to excellent long-term results with minimal morbidity. It is crucial to recognize that groin pulls are very rare in adolescents. Children with suggestive groin symptoms should have hip anteroposterior and frog-leg lateral radiographs to rule out the much more common SCFE.

Misdiagnosis of Transient Ischemic Attacks in the Emergency Room

Background: To determine a pattern of symptoms and/or risk factors that distinguishes transient ischemic attack (TIA) from nonischemic causes of transient neurologic attacks (NI-TNA). Methods: We reviewed demographic, clinical, and hospital data on 100 consecutive patients with transient focal neurologic episode(s) lasting less than 24 h and in whom the initial diagnosis was TIA. After inpatient evaluation and review, final diagnoses were made by two stroke neurologists. Using stepwise multivariable logistic regression, we estimated odds ratios (OR) for independent predictors of NI-TNA. p < 0.05 was considered significant. Results: Of the 100 patients, 40 were confirmed to have TIA and 60 NI-TNA. Compared to TIA patients, those with NI-TNA were less likely to be male and white but more likely to have a history of prior unexplained TNA, gradual symptom onset, associated nonspecific symptoms, longer symptom duration, and delayed presentation. Other variables were similar between the two groups. In a multivariable logistic regression model, gradual symptom onset (adjusted OR 6.7, p = 0.002), prior history of unexplained transient neurologic attack (adjusted OR 10.6, p = 0.031), and presence of nonspecific symptoms (adjusted OR 4.2, p = 0.008) were independent predictors of the final diagnosis of NI-TNA. Conclusions: Distinguishing TIA from nonischemic causes is difficult in the emergency room, with 60% of suspected TIA patients having nonischemic causes on inpatient evaluation. We found 3 clinical features that may be useful in the emergency room triage of transient neurologic attacks. Further study is needed to develop tools that can accurately diagnose TIA.

VIPoma – A Case of Abrupt Onset Diarrhea in an Elderly Patient

An 85 year old previously healthy Caucasian female presented with a 2 month history of a sudden onset diarrhea involving 7–10 large, watery, non-bloody bowel movements per day. The diarrhea was unaffected by fasting, and she denied any abdominal pain, fevers, sick contacts, or recent travel. Physical exam was significant for orthostasis. Laboratory data demonstrated hypokalemia and a non-anion gap metabolic acidosis. Common infectious etiologies were initially ruled out with negative fecal leukocytes, stool gram stain and culture, Clostridium difficile toxin, ova and parasites, and Giardia studies. A colonoscopy was unremarkable, and an EGD revealed no evidence of celiac sprue. Stool electrolytes revealed a low stool osmotic gap suggesting a secretory diarrhea. Subsequent studies for gastrin and 5-HIAA were normal, and the patient denied any laxative use. However, a VIP level was found to be elevated at 359. A subsequent CT and MRI showed no masses or evidence of metastasis. An iodine 123 meta-iodobenzylguanidine (I-123 MIBG) scan ultimately indicated an area of increase uptake in the fourth part of the duodenum. The patient refused surgical intervention, and she was placed on octreotide injections, which significantly improved her diarrhea. A follow-up VIP level showed a decrease to 28. VIPomas are extremely rare neuroendocrine tumors with an incidence of 1:10,000,000 per year. The hypersecretion of vasoactive intestinal peptide results in the Verner-Morrison or WDHA syndrome, which includes large volume watery diarrhea, hypokalemia, and achlorhydria. VIPomas are typically found in adults 30–50 years of age and have a gradual onset of symptoms. The majority of these tumors are located in the tail of the pancreas and are often metastatic at the time of diagnosis. Treatment usually involves octreotide to inhibit hormonal secretion. This particular case represents an uncommon presentation as the patient was considerably beyond the normal age range and presented with a sudden rather than gradual onset of symptoms. In addition, the tumor was ultimately located in the duodenum. Although neuroendocrine tumors such as VIPomas are an exceedingly rare cause of diarrhea especially in the elderly, they should be considered as a potential etiology in any secretory diarrhea.

The Tuberculous Bronchoesophageal Fistula Detected during Induction of General Anesthesia in Brain Abscess Patient -A case report -

We report a case of bronchoesophageal fistula detected during induction of general anesthesia in brain abscess patient. Bubbling sound at substernal area and gas bubble at oral cavity during manually assisted mask ventilation, especially inspiration, were detected. Barium esophagography, gastroscopy and bronchoscophy were performed to know the nature of fistula after neurosurgical operation. The patient had a bronchoesophageal fistula due to unproperly treated old pulmonary tuberculosis. Esophageal opening of fistula located at midesophagus about 27 cm distance from incisor, while bronchial opening located at apical segment of right superior bronchus. It depends on the size, location, and duration of fistula to manifest clinical symptom. In bronchoesophageal fistula, the size of opening tends to be small and gradual symptom onset while relatively large and early in TEF. Therefore, knowledge of the differences of two types of fistula are essential to manage the patient who have these types of fistula.

Magnetic Resonance Imaging of Brain Abscess With Hemorrhage: Implications for the Mechanism of Hemorrhage -Case Report-

A 68-year-old woman presented with an extremely rare brain abscess associated with old and acute hemorrhages manifesting as gradual onset of symptoms of headache and fever. Magnetic resonance imaging clearly visualized the hemorrhage as heterogeneously hyperintense on diffusion-weighted imaging, concentric hypo-isointense on T(1)-weighted imaging, and homogeneously hyperintense with a hypointense rim on T(2)(*)-weighted imaging. T(1)-weighted imaging with contrast medium revealed a well-enhanced cyst wall. In spite of treatment with antibiotics, the neurological status of the patient deteriorated due to expansion of the abscess and perifocal edema. Needle aspiration of the cyst yielded bloody purulent fluid. The magnetic resonance imaging findings indicate that neovascularization of the cyst wall is involved in the mechanism of hemorrhage in brain abscess. Careful follow-up examinations are recommended in patients with brain abscess to detect warning signs of neurological deterioration.