History Of Present Illness Research Articles

To study the etiological factors for development of seizure disorder in neonatal age group

This prospective study was conducted over the period of one year at M.Y. Hospital & Chacha Nehru Bal Chikitsalaya, Indore, in the Department of Pediatrics, M.G.M. Medical College, Indore.Detailed history of present illness with duration of convulsion were enquired. A detailed history of mother during antenatal, natal and post natal period was taken. Type of delivery (vaginal/ LSCS; full term / preterm), enquired about the indication of LSCS. History of labour with particular ref to birth injury, asphyxia (delayed cry), neonatal history regarding jaundice & feeding history, detailed family history in relation to epilepsy convulsion and mental diseases were recorded. In 1st 24hrs birth asphyxia (88%) is most common cause of seizures. In 2 to 7 day age group most common cause were metabolic (hypoglycemia (28.5%) & hypocalcaemia (26%)). In > 7 day meningitis (80%) was the most common cause of seizures. P value was < 0.001. Out of 74 term babies most common cause of seizure was birth asphyxia (58%) followed by meningitis (16.2%), hypocalcaemia (13.5%), hypoglycemia (8.1%). Out of 26 preterm babies 30% had meningitis, 30% had hypoglycemia, 19.2% had hypocalcaemia, and 15.3% had birth asphyxia. 1 case of ICH was reported. P value was 0.004. In present study out of total 100 cases most common etiology was birth asphyxia (47%), followed by meningitis (20%), hypocalcaemia (15%), and hypoglycemia (14%). During 1st 24 hrs. most common cause was birth asphyxia (88%). In 2 – 7 day age group metabolic abnormalities (hypocalcaemia & hypoglycemia) was most common (54.5%). And after 7 days meningitis (80%) was most common etiology. In term babies most common etiology was birth asphyxia (58%) followed by metabolic (21%) & meningitis (16.2%). In preterm babies most common cause was metabolic (50%) followed by meningitis (30%).

To observe the clinical presentation of seizure disorder in 0-1 month age group

This prospective study was conducted over the period of one year at M.Y. Hospital & Chacha Nehru Bal Chikitsalaya, Indore, in the Department of Pediatrics, M.G.M. Medical College, Indore.Detailed history of present illness with duration of convulsion were enquired. A detailed history of mother during antenatal, natal and post natal period was taken. Type of delivery (vaginal/ LSCS ; full term / preterm), enquired about the indication of LSCS. History of labour with particular ref to birth injury, asphyxia (delayed cry), neonatal history regarding jaundice & feeding history, detailed family history in relation to epilepsy convulsion and mental diseases were recorded. Out of 100 cases 64% were males and 36% were females. Male female ratio was 1.77:1. Male cases were predominantly present in all 3 age groups. Majority of seizures occurred within 24 hrs. P value is not significant. Out of 100 cases 43 had tonic convulsions, 38 had subtle, and 19 had focal convulsions.43 neonates had seizures in 1st 24 hrs. Subtle seizures (60%) were most common followed by tonic seizures (32.5%) and then focal seizures (7.5%). In 2 – 7 day age group tonic seizures (42.8%) were most common followed by focal seizures (38%). In > 7 day age group also tonic seizures (73.6%) were most common. P value was < 0.001. Detailed clinical examination was done & investigations were carried out in all patients. Cranial USG, EEG, & CT scan were done as per requirement. Out of total 100 cases 74 were full term & 26 were preterm. In our study maximum no. of cases developed seizure within 1st 24 hrs (43%) of life followed by 42% in 2–7 day age group & 15% after 7 days. Convulsions were more common in males (64%) in all age group.

Appropriate Evaluation of Psychiatric Patients Highlighted by Creutzfeldt-Jakob Disease: A Case Report.

IntroductionDetermination of medical stability for patients presenting with psychiatric complaints is common for emergency clinicians. A thorough history and physical examination is important.Case ReportA 53-year-old male presented to the emergency department (ED) with depression, suicidal ideation, and decline in activities of daily living over six months. While his initial neurologic examination was non-focal, subsequent re-evaluations demonstrated significant changes, and he was ultimately diagnosed with Creutzfeldt-Jakob disease.ConclusionThis case demonstrates how a detailed history of the present illness could have led to a more accurate and timely medical disposition from the ED.

Hospital readmission prediction based on long-term and short-term information fusion

The hospital readmission prediction becomes a significant task for healthcare systems and patients. Many predictive models have been developed and make progress in this task. However, most of them roughly combine the patient’s long-term(e.g., the history of present illness) and short-term(e.g., the performed laboratory test results when the patients are discharged) information without considering the inner distinction between them. In this paper, we propose a new approach for hospital readmission prediction based on transformation from numerical features to natural language, which makes better fusion of these two kinds of information. Through a rule-based transformation, the original numerical features are transformed into corresponding descriptive short sentences based on medical knowledge. Meanwhile, with the help of public well pre-trained character embeddings, our model can incorporate the prior semantic knowledge into the data. Moreover, by using the long-term information as the query of short-term feature attention mechanism, our model can capture the effective information in the short-term features from a more global perspective, and better incorporates the long-term and short-term information. Extensive experiment results on a real dataset demonstrate the effectiveness and superiority of our proposed model compared with the baseline methods.

Clinical problem solving and social determinants of health: a descriptive study using unannounced standardized patients to directly observe how resident physicians respond to social determinants of health.

Objectives While the need to address patients' social determinants of health (SDoH) is widely recognized, less is known about physicians' actual clinical problem-solving when it comes to SDoH. Do physicians include SDoH in their assessment strategy? Are SDoH incorporated into their diagnostic thinking and if so, do they document as part of their clinical reasoning? And do physicians directly address SDoH in their "solution" (treatment plan)? Methods We used Unannounced Standardized Patients (USPs) to assess internal medicine residents' clinical problem solving in response to a patient with asthma exacerbation and concern that her moldy apartment is contributing to symptoms - a case designed to represent a clear and direct link between a social determinant and patient health. Residents' clinical practices were assessed through a post-visit checklist and systematic chart review. Patterns of clinical problem solving were identified and then explored, in depth, through review of USP comments and history of present illness (HPI) and treatment plan documentation. Results Residents fell into three groups when it came to clinical problem-solving around a housing trigger for asthma: those who failed to ask about housing and therefore did not uncover mold as a potential trigger (neglectors – 21%; 14/68); those who asked about housing in negative ways that prevented disclosure and response (negative elicitors – 23%, 16/68); and those who elicited and explored the mold issue (full elicitors – 56%; 38/68) [corrected]. Of the full elicitors 53% took no further action, 26% only documented the mold; and 21% provided resources/referral. In-depth review of USP comments/explanations and residents' notes (HPI, treatment plan) revealed possible influences on clinical problem solving. Failure to ask about housing was associated with both contextual factors (rushed visit) and interpersonal skills (not fully engaging with patient) and with possible differences in attention ("known" vs. unknown/new triggers, usual symptoms vs. changes, not attending to relocation, etc.,). Use of close-ended questions often made it difficult for the patient to share mold concerns. Negative responses to sharing of housing information led to missing mold entirely or to the patient not realizing that the physician agreed with her concerns about mold. Residents who fully elicited the mold situation but did not take action seemed to either lack knowledge or feel that action on SDoH was outside their realm of responsibility. Those that took direct action to help the patient address mold appeared to be motivated by an enhanced sense of urgency. Conclusions Findings provide unique insight into residents' problem solving processes including external influences (e.g., time, distractions), the role of core communication and interpersonal skills (eliciting information, creating opportunities for patients to voice concerns, sharing clinical thinking with patients), how traditional cognitive biases operate in practice (premature closure, tunneling, and ascertainment bias), and the ways in which beliefs about expectancies and scope of practice may color clinical problem-solving strategies for addressing SDoH.

Correlation of history and physical examination with imaging in traumatic near-shore aquatic head and spinal injury

ObjectiveIt remains unclear whether clinicians can rely on specific symptoms and signs to detect or exclude serious head and spinal injury sustained during near-shore aquatic activities. Our study investigated patients' history of present illness (HPI) and physical examination (PE) for their utility in detecting serious head and spinal injury. MethodsWe conducted a multicenter retrospective comparative analysis of adult patients who were transported from the beach in Ocean City, Maryland, to three nearby emergency departments for possible spinal injury from 2006 through 2017. Patients suspected to have any spinal injury from beach activities were eligible. We excluded patients who could not verbalize their symptoms or with insufficient emergency department records. We compared components of each patient's HPI and PE with radiologic evidence of spinal injury. We calculated sensitivity, specificity, and negative and positive likelihood ratios (LRs). ResultsWe analyzed 278 patients with suspected spinal injury. Midline spinal tenderness was associated with increased likelihood of thoracic (LR+ 2.6) and lumbar spinal fractures (LR+ 3.5). HPI complaints of paralysis (LR+ 13.9) and sensory loss (LR+ 5.8) had strong associations with spinal cord injuries. Weakness found through PE was also associated with spinal cord injury (LR+ 5.3). ConclusionsWe identified several components of the clinical evaluation that had clinically significant association with spinal injuries from beach-related trauma. While prospective studies are needed to confirm our observations, clinicians may consider these high-risk features in patients with beach-related trauma and adjust testing and level of care appropriately.

Acute peripheral vestibular dysfunction: diagnostics and treatment

The aim of this article is to demonstrate ENT specialists, neurologists and general practitioners how to examine and treat patients with acute vertiginous complaints. Traditional otoneurologic testing that carried out for accurate topic diagnostics of acute vestibular dysfunction is described as available «Vestibular passport». Clinical diagnosis can be achieved after thorough assessment of patient’s complaints as well as history of the present illness. Gaze tests and posture control trials are demonstrated in details. Diagnostic value of each probe is shown from the viewpoint of differential diagnostics of peripheral and central vestibular dysfunction. High diagnostic value of registration and analysis of oculogyric reactions is presented by history cases of acute labyrinthopathy and acute vestibular neuronitis. In these cases absence of saccadic and pursuit gaze disturbances rule out central vestibular system dysfunction. The salient feature of these two variants of peripheral vestibular dysfunction is spontaneous nystagmus that revealed by Frenzel glasses. This significant oculomotor symptom as well as disturbances of static and dynamic postural control confirm patient’s vestibular complaints in objective way. Revelation of decompensation signs of vestibular dysfunction needs urgent medicine vertigo therapy and spare vestibular rehabilitation. Actually, medications of choice are sedative drugs with antiemetic effect, non-loop diuretics and glucocorticoids.

Abstract 367: Are We Over-utilizing Echocardiogram for the Evaluation of Syncope Patients?

Background: Syncope is one of the most common reasons for emergency department visits. The most common causes of syncope include vasovagal, orthostatic, neurogenic and cardiogenic. In some cases, history and physical examination can point towards a specific cause. While in most cases, history and physical alone are insufficient to indicate an obvious etiology. Patients with cardiogenic syncope have an increased rate of all-cause mortality as well as mortality associated with cardiovascular events. The risk of missing these serious conditions often results in low-risk patients being admitted for further workup and undergoing extensive investigation including a transthoracic echocardiogram (TTE). However, the utility of such testing including TTE in patients with a negative initial evaluation with history, physical exam and ECG is uncertain. The aim of this study was to assess the utility of TTE in the evaluation of patients admitted with syncope with an initial negative evaluation Methods: It is a retrospective study. Data was collected from all the patients admitted to the hospital for the workup of syncope from January to October 2019. Baseline characteristics including age, sex and ethnicity were collected for each patient. Data was also collected in regard to their significant cardiac past medical and family history. History of present illness and physical examination at the time of admission was noted. Patients were divided into two groups based on if the medical evaluation indicated a cardiogenic etiology. Cardiac testing data including EKG and TTE were included in the analysis. Abnormal EKG was defined by the presence of bradycardia, arrhythmia, QT prolongation, bundle branch blocks, heart blocks and left ventricular hypertrophy. Positive TTE findings were defined as low ejection fraction, significant left ventricular outflow tract obstruction, significant valvular abnormalities, wall motion abnormality and presence of pericardial effusion. Collected data were analyzed using Chi-square test and multiple linear regression. Results: The mean age of the study group was 72 years with 45% of males. Out of the total of 93 patients included in the study, 57(61%) patients had a TTE done. Out of this only 10(17%) patients had positive TTE. Only 2 patients with positive TTE had a negative EKG. In these two patients, the history was, however suspicious for cardiogenic syncope. A significant association of positive TTE findings with abnormal EKG (p-value: 0.003) was found. The odds of having a positive TTE finding when the EKG was negative was only 6%. These results remained significant with multiple linear regression analyses. Conclusions: TTE is being overutilized in the evaluation of patients presenting with syncope to rule out cardiac etiology. A thorough history and complete physical examination along with the basic cardiac testing including EKG can help reduce the overutilization

608 The Impact of a Nurse Morbidity and Mortality Meeting

Abstract Introduction Physicians have long held Morbidity and Mortality (M&M) conferences to discuss complications and deaths. The format for these conferences is to lay out the case, discuss the care performed, and generate discussion on areas of opportunity. Physician M&M usually focuses on teaching and the presenter may not be the caregiver. There is not much literature on the use of this teaching methodology in nursing. Due to the strong culture of safety on the unit, it was determined that creating a Nurse M&M could prove beneficial for discussion of complications, deaths, errors, and good catches as they related to nursing care. Methods Nurse M&M is held monthly for one hour. All personnel involved in the cases are informed ahead of time what will be discussed. They are given the opportunity to present the individual case or give personal testimony as to the situation from their point of view. Each case is presented in the same format. The initial slides cover background, history of present illness, and the origin of the report. Next is the pertinent review from the electronic medical record and discussions had with those involved in the case. The floor is then open for discussion. If there was a variation in practice, the policy that relates to the error is reviewed. Topics for Nurse M&M are gathered through many venues. The hospital uses an online reporting system for electronic submission of adverse events, variations in care, and good catches. The entire multidisciplinary team have all individually reported something they wanted discussed at Nurse M&M. If clarification is needed on a case, the question is directed to the appropriate decision maker and followed up on. Results Nurse M&M is the most highly attended, non-mandatory, meeting held on the unit. The nursing staff was surveyed to determine their perceptions on how the addition of Nurse M&M had effected them. The results were overwhelmingly positive. All nurses surveyed rated the statement, “I feel that Nurse M&M has had a positive outcome on the unit’s collective practice”, as agree or strongly agree. Over time, the notes taken have evolved from just the discussion to action items created off the case. The staff have will now self-report events before they are entered into the online system. Conclusions The nursing staff are highly engaged Nurse M&M. The staff are open to discussing errors in a way that fosters educational growth and critical thinking development. If the case being discussed is because of a personal error, more often than not, the person responsible will discuss why they made the decision they did and facilitate the discussion as to what could have been done differently. The nurses’ commitment to being present, engaged, and open minded are strong signs of the healthy work environment present on the unit. Applicability of Research to Practice The format of a nursing M&M conference is applicable to all units. Patient safety and nurse engagement are the top factors effected by Nurse M&M.

Fungal Isolates in HIV positive and negative subjects attending Chukwuemeka Odumegwu Ojukwu University Teaching Hospital, Amaku, Awka, Anambra State, Nigeria

Background: Fungal pathogens are the leading cause of severe healthcare-associated infections in immunocompromised patients, especially from low-income countries like Nigeria. Acquired Immunodeficiency Syndrome (AIDS) arising from HIV infection is reputed to be a key in immune suppression globally. Presently, Anambra state is number 5 in HIV prevalence in Nigeria. This study was aimed at screening patients from the Chukwuemeka Odumegwu Ojukwu University Teaching Hospital, for fungal infections. Samples were collected with consideration to gender, age, occupation, education status and clinical presentations. Methods: Sampling was done according to global best practices. Patients’ consent and details were obtained by signing a consent form and filling of questionnaires respectively. Key questionnaire details included sociodemographic and personal details, history of present illness, clinical signs and symptoms. All patients were screened afresh for HIV-1 and HIV-2 using an immuno-chromatographic technique with Determine kit (Alere, Japan) and Stat-pack kit (USA). Specimens screened include Urine, Blood, Oropharyngeal swab, Skin scraping, and Sputum. All samples were labeled, transported and processed within 1-2 hours of collection. Results: A total of 1200 participants (610 males and 590 females) were examined. About 16.5% and 54.41% of the subjects examined were positive for HIV infections and fungal infections respectively. Overall, 233 males (19.41%) and 420 females (35.0%) had fungal infections. Fungal infections were most prevalent in patients between 30-39 years, 17.75%, followed by 40-49 years (15.0%). Infection was least prevalent in patients between 15-29 years at 5.0%. Farmers had the highest prevalence rate of fungal infection, though not significant when compared with those of traders, artisans and public servants (X2 =0.621; df=2; P>0.05). Candida species were the most prevalent fungal pathogen, accounting for 609 (67.1%) followed by Aspergillus spp. 234 (25.8%) and Cryptococcus species 31 (3.4%). Penicillium and Fusarium spp. were the least prevalent pathogens (1.9%). Oropharyngeal candidiasis was the most common fungal infection (49.9%-17.4% HIV negative and 32.46% HIV positive patients); followed by Pneumocystis pneumonia (28.80%-9.50% HIV negative and 19.30% HIV positive patients). Similarly, Cryptococcal meningitis was the least recorded infection at 16.81% (6.43% HIV negative and 10.38% HIV positive patients). Significantly, fungal infections were more prevalent in HIV infected patients (62.14%) compared to HIV negative patients (33.33%). Conclusion: This study has revealed that HIV positive and negative patients are often affected with fungal infections in Anambra State, Nigeria. This may have contributed to impaired immune system in patients and development of AIDS in HIV infected patients. Poor personal hygiene and intimate association with household pets among subjects examined were the suspected sources of infection. Therefore, there is an urgent need for improved surveillance and monitoring of fungal infections in the area and in other Teaching Hospitals in the country as well as treatments of infected subjects.

Evaluation of provider documentation patterns as a tool to deliver ongoing patient-centred diabetes education and support.

Diabetes mellitus (DM) is one of the most common chronic diseases in the world. As a disease with long-term complications requiring changes in management, DM requires not only education at the time of diagnosis, but ongoing diabetes self-management education and support (DSME/S). In the United States, however, only a small proportion of people with DM receive DSME/S, although evidence supports benefits of ongoing DSME/S. The diabetes education that providers deliver during follow-up visits may be an important source for DSME/S for many people with DM. We collected 200 clinic notes of follow-up visits for 100 adults with DM and studied the History of Present Illness (HPI) and Impression and Plan (I&P) sections. Using a codebook based on the seven principles of American Association of Diabetes Educators Self-Care Behaviors (AADE7), we conducted a multi-step deductive thematic analysis to determine the patterns of DSME/S information occurrence in clinic notes. Additionally, we used the generalised linear mixed models for investigating whether providers delivered DSME/S to people with DM based on patient characteristics. During follow-up visits, Monitoring was the most common self-care behaviour mentioned in both HPI and I&P sections. Being Active was the least common self-care behaviour mentioned in the HPI section and Healthy Coping was the least common self-care behaviour mentioned in the I&P section. We found providers delivered more information on Healthy Eating to men compared to women in I&P section. Generally, providers delivered DSME/S to people with DM regardless of patient characteristics. This study focused on the frequency distribution of information providers delivered to the people with DM during follow-up clinic visits based on the AADE7. The results may indicate a lack of patient-centred education when people with DM visit providers for ongoing management. Further studies are needed to identify the underlying reasons why providers have difficulty delivering patient-centred education.

A RETROSPECTIVE STUDY ON EFFECTS OF SERUM CHOLESTEROL ON MORTALITY AND MORBIDITY OF STROKE

Introduction:Stroke or cerebrovascular accident or Intracranial Hemorrhage (ICH) is definedas an abrupt onset of a neurological deficit that is attributable to a focal vascularcause. Stroke is the second leading cause of death worldwide causing 6.2million deaths in 2011. Relation of high total cholesterol and triglycerides withischemic heart disease is well established worldwide. High cholesterol level areestimated to cause 56% of ischemic heart disease. However, dyslipidemia as arisk factor for ischemic stroke has been quite controversial in recent times. Ithas been observed in several studies that higher cholesterol and triglyceridelevels are associated with better outcome after ischemic stroke.Aim:The purpose of this study is to determine the effects of serum cholesterol on themortality and morbidity of stroke.Materials and Method:We retrospectively included 100 consecutive patients over age 18 with Strokeor cerebrovascular accident or Intracranial Hemorrhage (ICH) who wereadmitted in Sree Mookambika Institute of Health Sciences, confirmed by CTwithin 12 hours after onset. Patients with traumatism, brain tumor, previousICH, hemorrhagic transformation of ischemic stroke, vascular cerebralmalformations, and patients who required neurosurgical procedures wereexcluded. Data was collected with meticulous history, clinical examination withdetailed neurological examinations along with appropriate investigations. Astructured questionnaire was used to obtain data on family history of diabetes mellitus, history of hypertension, past and present illness, dietary pattern,addiction and medication. NIH stroke scale (NIHSS) were evaluated atadmission. Descriptive and analytical statistics were performed by SPSSversion 16.IEC clearance and a written informed consent were obtained frompatient or patients attenders. A P value of less than 0.05 was consideredstatistical significant.Results:Out of the 100 patients that were included in the study, the average age was 58.6± 12.15. Male to female ratio was 3:1(75:25) which clearly states that men aremore prone to develop stroke compared to females. Among the patients who hadstroke, risk factors like hypercholesterolemia(75%), hypertension(65%),diabetes mellitus(24%), smoking(40%), alcoholism(40%) were identified.Regarding the stroke severity, 39% of the patients had a minor stroke, 44% hada moderate intensity stroke while 17% of the patient had a severe stoke. A highmorbidity rate i.e., 80% was seen in patients who had had high totalcholesterol(75%) then compared to patients who had normal lipid profile with asignificant p value (<0.02).Only 2 passed away who was also found to have highcholesterol and triglycerides.Conclusion:Our study concluded a positive correlation between serum total cholesterol.Thus early detection of dyslipidemia and treatment with drugs along withdietary modifications & lifestyle changes can reduce the risk of stroke.Keywords: ICH, Stroke, Total Cholesterol, Cerebrovascular accident

Antibiotic Choice and Methicillin-Resistant Staphylococcus aureus Rate in Children Hospitalized for Atopic Dermatitis

To examine the prescribing patterns of systemic antibiotics for children hospitalized for atopic dermatitis (AD) exacerbation compared with infectious complications.A total of 174 patients with AD who were admitted to Children’s Hospital Los Angeles from 2013 to 2018 were included (70 with AD exacerbation and 104 with infectious complications).Subjects were identified via retrospective chart review by International Classification of Diseases, Ninth Revision and International Classification of Diseases, 10th Revision codes for AD. Secondary codes for contact dermatitis and other eczema, dermatitis unspecified, and unspecified contact dermatitis, unspecified cause were only included in patients with a physician diagnosis of AD. Infectious complications of AD included patients experiencing focal infections (cellulitis or abscess), invasive infections (bacteremia, osteomyelitis, septic arthritis, or endocarditis), or eczema herpeticum, whereas acute exacerbation of AD was confirmed in the history of present illness, physical examination, or diagnosis on physician discharge summary.Systemic antibiotics were administered in 80% (56 out of 70) of patients with AD exacerbation and 94% (98 out of 104) of those with infectious complications. The most frequently prescribed antibiotics on admission offered empirical coverage against methicillin-resistant Staphylococcus aureus (MRSA), specifically clindamycin and vancomycin, at a total rate of 88% for both AD exacerbation and infectious complications. Rates of use were similar between both groups (75% and 74% for clindamycin and 13% and 14% for vancomycin, in AD versus infectious groups, respectively). Anti-MRSA agents were prescribed at discharge at similar rates between both groups; clindamycin was most commonly prescribed (54% of AD patients and 59% of patients with infectious complications). Sulfamethoxazole-trimethoprim was also prescribed a similar rates for both groups (4% AD, 5% infectious). MRSA was significantly less common in children with AD exacerbation (22%) versus infectious complications (39%) on wound culture results. Significant differences in patients with infections complications included longer length of stay (P < .0001) and higher C-reactive protein levels and erythrocyte sedimentation rates (P = .007 and P = .003, respectively). Patients with AD exacerbation had higher total serum immunoglobulin E levels, but the difference was not significant (P = .07).Although AD is a risk factor for S aureus infections, distinguishing clinical characteristics between AD exacerbation and infectious complications is challenging, and no standard definition for secondary infection or superinfection of AD exists. Antibiotic use for AD exacerbation varies, but empirical use of anti-MRSA agents may not be appropriate. C-reactive protein or erythrocyte sedimentation rate may have a role in distinguishing patients with infectious complications from those with exacerbation.Overall, this study informs the practice of empirical systemic antibiotic use in pediatric patients admitted for AD exacerbation and infectious complications. Further studies are needed, but empirical antibiotic therapy used for infectious complications may not be appropriate for AD exacerbation, particularly while promoting antimicrobial stewardship.

Can Sudden Cardiac Death Risk in the Young be Identified in the Emergency Department?

Sudden cardiac death in the young is devastating for the family and the community. Although it has diverse etiologies, many are inherited. Discovering the disease in 1 patient offers the chance to save otherwise asymptomatic family members. Although some diseases can be discovered during autopsy, others require electrocardiograms for diagnosis, making it difficult to estimate the prevalence of disease and cause of death. Careful assessment of the history of present illness, family history, and electrocardiogram can guide clinical teams toward sometimes rare and difficult diagnoses. The purpose of this review article is to summarize the bench to bedside diagnosis of inherited dysrhythmia syndromes, which if missed on first presentation to the emergency department, have significant implications for the patient and the entire family.

Consideration of pelvic floor myofascial release for overactive bladder

IntroductionPhysical therapy has been shown to be effective for women with overactive bladder (OAB). We report on our experience with pelvic floor physical therapy (PFPT) with or without myofascial release as treatment for women with symptoms of urinary urgency or urge incontinence. MethodsWe performed a retrospective chart review, of patients who presented to our tertiary care Urogynecology practice. These women were evaluated and treated between August 2016 and December 2016. We abstracted for symptoms as per history of present illness and the pelvic floor muscle examination. PFPT progress notes were reviewed to determine whether patients received myofascial release techniques, or if therapy was limited to behavioral interventions and urge suppression techniques. We recorded the number of PFPT sessions attended, and whether the patient reported improvement. Results77 patients with symptoms of OAB met inclusion criteria and initiated PFPT. Myofascial tenderness of the pelvic floor muscles was found in 56.5% of patients. PFPT was limited to behavioral and urge suppression in 18 patients, while 59 patients received myofascial release techniques. Improvement was reported by 71.4% (n = 55/77) of patients. Improvement increased with number of sessions attended: 1–2: 6% (1/17), 3–5: 94% (16/17), 6–8: 91% (29/32), and >8: 80% (9/11) improved, respectively (p < 0.001). Among patients who had myofascial release, 84.7% reported improvement when compared to only 27.8% of patients without myofascial release. ConclusionsThe data support the inclusion of myofascial release during pelvic floor physical therapy for overactive bladder. At least three sessions of PFPT are necessary for patient reported improvement.

447. Disease Progression in Patients with Acute Bacterial Skin and Skin Structure Infections: A Comparative Analysis Between Oritavancin and Vancomycin

BackgroundWithout the appropriate treatment, acute bacterial skin and skin structure infections (ABSSSI) have the potential to progress to more serious infections such as bacteremia and osteomyelitis. Utilizing single-dose oritavancin rather than vancomycin with step-down oral antibiotics, the need for compliance with outpatient antibiotics is eliminated. The objective of this study was to determine whether oritavancin use may reduce the sequelae from ABSSSI treatment failures, prevent skin infection recurrences, and subsequently improve patient outcomes.MethodsPatients administered oritavancin or vancomycin for treatment of ABSSSI between May 2017 and March 2019 were included in this retrospective evaluation. The primary endpoint was to determine the 30-day ABSSSI progression rate to bacteremia, osteomyelitis, or endocarditis between treatment arms based on hospital readmissions. Study investigators determined that the source of each resultant infection was from the initial ABSSSI based on the presence of their prior skin infection and cultures, as well as history of present illness and reported patient compliance. In cases of osteomyelitis, infection location was also considered. The secondary endpoint was to determine the ABSSSI readmission rates between treatment arms. Data were analyzed by fisher’s exact test, chi-square test or t-test as appropriate.ResultsA total of 99 patients receiving oritavancin and 100 patients receiving vancomycin with prescribed step-down oral antibiotics were identified as meeting inclusion criteria. Eighteen of 100 patients (18%) returned for recurrent ABSSSI infection in the vancomycin arm while 7 of 99 (7.1%) returned in the oritavancin arm (P = 0.0309). Of the 7 returning oritavancin patients, 1 (14.3%) had bacteremia as a result of persistent ABSSSI compared with 7 of 18 (38.9%) patients who previously received vancomycin returned with bacteremia, including 1 case of osteomyelitis (P = 0.0649).ConclusionUtilizing oritavancin for treatment of ABSSSI in this population resulted in improved patient outcomes, significantly fewer hospital readmissions for ABSSSI, and decreased infection sequelae from inadequately treated skin infections.Disclosures All authors: No reported disclosures.

372 Accuracy of History of Present Illness Findings in Detecting Serious Head and Spinal Injury From Traumatic Near Shore Aquatic Injuries

History of present illness (HPI) and physical examinations are important to guide physicians’ medical decision-making process. However, it remains unclear if specific symptoms are reliable to detect or exclude serious head and spinal injury from blunt trauma sustained during near shore aquatic activities. Patients with high risk clinical features for traumatic injury as observed by emergency physicians including HPI findings of loss of consciousness (LOC) or numbness or tingling in the extremities were examined to identify their utility in detecting serious head and spinal injury.

DEMOGRAPHIC PROFILE OF HAEMOPHILIA A CHILDREN WITH JOINT INVOLVEMENT.

Introduction: Worldwide Haemophilia A (HA) is the most common coagulation factor deficiency. It affects all populations and its prevalence varies among different countries, but roughly prevalence is estimated to be of 3-20 cases per 100,000 population. The classification of HA provides a guidance to possible types of bleeding and the rate of occurrence of hemorrhagic episodes. The hemophiliac patients with severe form, can be presented with spontaneous bleeding and hemorrhage after minor trauma about 1-6 times in a month, including hemarthrosis and intramuscular hemorrhage. In moderate form, the patients usually experience bleeding after mild to moderate injuries, while HA patients with mild form may not be diagnosed for years and bleed after surgery or major trauma. About 70% of children who have a positive history of HA in the family are diagnosed at birth or after the first bleeding episode.&#x0D; Material and Methods: A complete medical history of the patient was taken with reference to the name, age, sex, address, occupation, history of present illness, duration illness, education of patient and parent. Previous history of treatment, past and personal history and socio-economic status were noted. Parents were explained the purpose of the study and the procedures involved.The Hemophilia Joint Health Score (HJHS) was used to assess joint health in children included in the study.&#x0D; Results: Age of diagnosis &gt;=12 months was observed in 28 (54.90%) of cases while in 23 (45.10%) cases age of diagnosis was &lt; 12 months. Out of 51 cases Severe disease was observed in 45(88.23%) of cases, moderate in 4(7.84%) and mild form was observed in 2(3.95%).Out of total 51 cases 42 (82.4%) were from the nuclear family while 9(17.6%) were from the joint family. Mean HJHS was higher in patients of nuclear family as compared to joint family.&#x0D; Conclusion: HJHS shows construct validity and is more sensitive for mild arthropathy and can be used for studies in children with hemophilia. No correlation of different demographic parameters in children suffering from hemophilia A was seen.&#x0D; Keywords: HJHS, HA, Hemophilia A and B, CDC, HTCs, UDC,FA.

Human versus machine in medicine: can scientific literature answer the question?

Human versus machine in medicine: can scientific literature answer the question?

Impact of De-Identification on Clinical Text Classification Using Traditional and Deep Learning Classifiers.

Clinical text de-identification enables collaborative research while protecting patient privacy and confidentiality; however, concerns persist about the reduction in the utility of the de-identified text for information extraction and machine learning tasks. In the context of a deep learning experiment to detect altered mental status in emergency department provider notes, we tested several classifiers on clinical notes in their original form and on their automatically de-identified counterpart. We tested both traditional bag-of-words based machine learning models as well as word-embedding based deep learning models. We evaluated the models on 1,113 history of present illness notes. A total of 1,795 protected health information tokens were replaced in the de-identification process across all notes. The deep learning models had the best performance with accuracies of 95% on both original and de-identified notes. However, there was no significant difference in the performance of any of the models on the original vs. the de-identified notes.