Incomplete Workup Research Articles

Hyperandrogenism by Liquid Chromatography Tandem Mass Spectrometry in PCOS: Focus on Testosterone and Androstenedione.

The identification of hyperandrogenism in polycystic ovary syndrome (PCOS) is concerning because of the poor accuracy of the androgen immunoassays (IA) and controversies regarding which androgens should be measured. The aim of our study was to evaluate the impact of the assessment of testosterone (T) and androstenedione (A) by liquid chromatography in tandem with mass spectrometry (LC/MS-MS), in the diagnosis of PCOS. We evaluated 131 patients referred for suspected PCOS. Fourteen patients in total were excluded, some because of other diagnosis (n = 7) or incomplete diagnostic workup (n = 7). We measured T and A both by IA and LC-MS/MS in the 117 subjects included. We calculated free T (fT) by the Vermeulen formula and recorded clinical and metabolic data. 73 healthy females served as controls to derive immunoassays (IA) and LC-MS/MS reference intervals for T, fT and A. PCOS was confirmed in 90 subjects by IA and in 93 (+3.3%) by LC-MS/MS. The prevalence of biochemical hyperandrogenism in PCOS by LC-MS/MS increased from 81.7% to 89.2% if A was also considered. The most frequently elevated androgens were fT (73.1%) and A (64.5%) and they had similar levels of accuracy in differentiating PCOS and controls (0.34 ng/dL, Sn 91% Sp 89%; 1.16 ng/mL, Sn 91% Sp 88%, respectively). Free testosterone correlated with body mass index (BMI), homeostatic model assessment (HOMA)-index, glycated hemoglobin (HbA1c), and sex-binding globulin (SHBG). The results confirm that LC-MS/MS is slightly more sensitive than IA in the diagnosis of PCOS with LC-MS/MS detecting higher levels of fT and A. Moreover, assessment of fT and A by LC-MS/MS had a similar level of accuracy in discriminating between PCOs and control subjects. Lastly, fT by LC-MS/MS correlates with adverse metabolic parameters.

Diagnostic gap in genetic epilepsies: A matter of age

ObjectiveThis study aimed to evaluate the access to advanced diagnostic tests in patients with epilepsy and intellectual disability, with special focus on genetics. MethodsPatients with epilepsy and intellectual disability evaluated between 2016 and 2018 at the Epilepsy Unit of two hospitals in Madrid, Spain were included. The main inclusion criterion was an undetermined etiological diagnosis after clinical assessment, neuroimaging, and electroencephalogram (EEG). ResultsTwo hundred and five patients with epilepsy and intellectual disability were evaluated, with 124 fulfilling the inclusion criteria (mean age: 33.9 years). Regarding the etiological workup, advanced neuroimaging, prolonged video-EEG, and any type of genetic test had been performed in 58%, 41%, and 40%, respectively. An etiological diagnosis was reached in 18.5%. The workup was considered incomplete in 67%. Variables that showed the strongest association with an incomplete diagnostic workup in the multivariate analysis were current age and seizure freedom. ConclusionsDespite the multiple implications of modern diagnostic techniques, especially genetic testing, there is a large proportion of patients with epilepsy and intellectual disability who do not have access to them. Older age and seizure freedom seem to be associated with the highest diagnostic gap.

Prospective study of an AI enabled online intervention to increase delivery of guideline compliant cancer care, on the ground.

2011 Background: Despite survival benefits of guideline compliant cancer care, under treatment and over treatment are prevalent. Navya is an AI enabled online intervention that matches a patient’s medical record with NCCN and NCG guidelines (National Cancer Grid, India) and layers live multidisciplinary expert review to recommend actionable treatment plans. It was developed to standardize care and mitigate morbidity and mortality, by delivering on-t ime, guideline based expert treatment plans. Methods: From July 2019 to January 2020, all patients who received a Navya treatment plan based on guidelines and live expert review were included. Intended treatment plans were prospectively collected from the patient. Compliance of intended plans with NCCN (including Resource Stratified Framework) or NCG was measured. Noncompliant intended plans were categorized as overtreatment or undertreatment. After delivery of Navya plan, prospective phone follow up assessed whether noncompliant intended plans were changed to guideline compliant care. Results: Of 1707 consecutive patients who received a Navya plan, 1549 intended plans were available. Patients were diverse with respect to geographic, socioeconomic, and primary tumor distribution: West of India: 28%, North: 26%, East: 21%, South: 15%, Central: 7%, International: 3%; 35% of patients with income < $300/month; GI: 23%, Breast: 14%, Head & Neck: 11%, Thoracic: 10%. Of the 1549 intended plans, 441 (28.47% (95% CI ± 0.26%)) were not compliant with NCCN or NCG. Undertreatment was 35%, overtreatment 26%, incomplete staging workup 28% and 11% could not be categorized. Of 441 patients with noncompliant intended plans, 80.19% (± 0.97%) shared the Navya plan with their treating oncologists and 50.40% (± 0.88%) changed their intended plan to receive the Navya treatment plan. Intervention with Navya increased on-the -ground guideline compliance by ~15% (from 71.53% ±0.42% to 85.87% ± 1.73%). Conclusions: Guideline compliant care ensures best achievable clinical outcomes with existing therapies. A technological earthshot that significantly increases adoption of guideline based care is the first step towards cancer moonshots.

Central Nervous System Fungal Infection-Related Stroke: A Descriptive Study of Mold and Yeast-Associated Ischemic Stroke

Objective: Central nervous system (CNS) ischemic events caused by fungal infections are rare, and clinical characteristics of these ischemic events are largely unknown. The objective of this manuscript is to highlight characteristics of fungal-related strokes and describe possible mechanistic differences between CNS mold and yeast infection-related strokes. Methods: We report a single-center retrospective case series of all adult patients who presented with concurrent CNS fungal infection and stroke between 2010 and 2018. Patients believed to have a stroke etiology due to cardioembolic, atheroembolic, or strokes nontemporally associated with a CNS fungal infection and those with incomplete stroke workups were excluded from analysis. Results: Fourteen patients were identified with ischemic stroke and concurrent CNS fungal infection without other known ischemic stroke etiology. Eight patients had a CNS yeast infection, and 6 had a CNS mold infection. All patients presented with recurrent or progressive stroke symptoms. Six patients were immune-compromised. Four patients admitted to intravenous drug use. All yeast infections were identified by cerebrospinal fluid culture or immunologic studies while all but one of the mold infections required identification by tissue biopsy. Leptomeningeal enhancement was only associated with CNS yeast infections, while basal ganglia stroke was only associated with CNS mold infections. Conclusion: Ischemic stroke secondary to CNS fungal infections should be considered in patients with recurrent or progressive cryptogenic stroke, regardless of immune status and cerebrospinal fluid profile. CNS yeast and mold infections have slightly different stroke and laboratory characteristics and should have a distinct diagnostic method. Depending on clinical suspicion, a thorough diagnostic approach including spinal fluid analysis and biopsy should be considered.

Comprehensive infectious disease screening in a cohort of unaccompanied refugee minors in Germany from 2016 to 2017: A cross-sectional study.

Information regarding the prevalence of infectious diseases (IDs) in child and adolescent refugees in Europe is scarce. Here, we evaluate a standardized ID screening protocol in a cohort of unaccompanied refugee minors (URMs) in a municipal region of southwest Germany. From January 2016 to December 2017, we employed a structured questionnaire to screen a cohort of 890 URMs. Collecting sociodemographic information and medical history, we also performed a standardized diagnostics panel, including complete blood count, urine status, microbial stool testing, tuberculosis (TB) screening, and serologies for hepatitis B virus (HBV) and human immunodeficiency virus (HIV). The mean age was 16.2 years; 94.0% were male, and 93.6% originated from an African country. The most common health complaints were dental problems (66.0%). The single most frequent ID was scabies (14.2%). Of the 776 URMs originating from high-prevalence countries, 7.7% and 0.4% tested positive for HBV and HIV, respectively. Nineteen pathogens were detected in a total of 119 stool samples (16.0% positivity), with intestinal schistosomiasis being the most frequent pathogen (6.7%). Blood eosinophilia proved to be a nonspecific criterion for the detection of parasitic infections. Active pulmonary TB was identified in 1.7% of URMs screened. Of note, clinical warning symptoms (fever, cough >2 weeks, and weight loss) were insensitive parameters for the identification of patients with active TB. Study limitations include the possibility of an incomplete eosinophilia workup (as no parasite serologies or malaria diagnostics were performed), as well as the inherent selection bias in our cohort because refugee populations differ across Europe. Our study found that standardized ID screening in a URM cohort was practicable and helped collection of relevant patient data in a thorough and time-effective manner. However, screening practices need to be ameliorated, especially in relation to testing for parasitic infections. Most importantly, we found that only a minority of infections were able to be detected clinically. This underscores the importance of active surveillance of IDs among refugees.

A Cautionary Tale and Update on Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL).

Breast implant-associated anaplastic large T-cell lymphoma (BIA-ALCL) was first recognized by the World Health Organization in 2016. The total number of cases worldwide continues to increase, with >800 cases confirmed through a combination of the FDA, verified reports, and registries. There are 33 deaths currently reported. Typical presentation includes a late seroma containing monoclonal T cells that are CD30+ and anaplastic lymphoma kinase (ALK) negative. We present a review of the current literature and report on three cases of BIA-ALCL at our institution, which serve to illustrate our approach to diagnosis and management of this disease. In two cases, the diagnosis of BIA-ALCL was not initially confirmed due to an incomplete workup but was recognized upon explantation. The seroma fluid was sent for flow cytometry. Initially, the cells were reported as morphologically suspicious for malignancy with phenotypically normal T-cells based on standard CD3+ T-cell gating. Subsequent cytology specimens were reported as consistent with recurrent adenocarcinoma. However, upon re-gating of flow cytometry data, a population of CD30+, CD3- T-cells was noted and the diagnosis of BIA-ALCL was confirmed by immunohistochemical stains of the excised breast capsule specimen. Given the increasing incidence of this disease, as plastic surgeons we must stay informed to order the correct workup to avoid misdiagnosis and be prepared to appropriately refer affected patients to centers with multidisciplinary teams experienced in the management of BIA-ALCL.

Clinical and Etiological Characteristics of Epilepsy in the Elderly: A Hospital-Based Study from a Tertiary Care Referral Center of Niamey, Niger.

Objectives The aim of this study is to evaluate the management of epilepsy in the elderly at a tertiary referral center in Niger to obtain a comprehensive understanding to determine the intrahospital deficiencies to improve and to make recommendations in terms to improve the management of epilepsy in the elderly in Niger. Materials and Methods We conducted a retrospective study at the Neurology Outpatient Clinic of the National Hospital of Niamey (Niger) over a period of 5 years from May 2013 to May 2018, collecting all cases of patients aged 60 years or over diagnosed with epilepsy by neurologists. From the registers of consultation, we collected and analyzed for each patient the demographic, clinical, etiological, and therapeutic data, as well as the outcomes during follow-up visits. Results Of the 4,576 patients of all ages seen during the period of our study, we included 62 patients aged 60 years or over diagnosed with epilepsy with a hospital frequency of 1.35%. The mean age of patients was 65.82 ± 5.72 years (range: 60 and 83 years) with a predominance of the male sex (sex ratio at 1.6). Patients aged 60 to 64 years were the most represented (43.5%). Generalized tonic–clonic seizures were the most frequent (41.9%), followed by focal to bilateral tonic-clonic seizures (25.8%). All patients underwent electroencephalogram. Only 30 patients (48.4%) underwent brain imaging, and mainly brain computed tomography scan. The etiologies included poststroke epilepsy (25.8%), brain tumors (3.2%), cerebral toxoplasmosis (3.2%), and cerebral meningioma (1.6%). We found 41 cases (66.1%) of epilepsy without definite etiology and with an incomplete workup. Carbamazepine and phenobarbital were the only two antiepileptic drugs (AEDs) used. Conclusion The present study shows limited access to newer generation AEDs and diagnostic tests of epilepsy in Niger. Considerable efforts should be made to facilitate for people living with epilepsy the accessibility to diagnostic tests and the newer generation AEDs to improve the quality of epilepsy management in Niger.

Got stage fright? A fellow-led initiative to improve cancer staging documentation.

310 Background: Accurate cancer staging is essential for estimating prognosis, guiding treatment, populating cancer registries, and assessing clinical trial eligibility. Hence, timely staging of new solid oncology patients (NSOP) is an ASCO QOPI priority. At our institution, baseline review of staging documentation revealed fellows staged only 47% of NSOP, generally as unstructured free text. During the 2017-18 academic year, our structured electronic medical record (EMR) staging tool (ST) was used in only 11% of NSOP. We used Quality Improvement (QI) methods to improve structured EMR staging documentation rates of NSOP seen by fellows during the 2018-19 academic year. Methods: A fellow focus group identified poor integration of the EMR ST as root cause of our low staging rates. We set a cumulative goal of 70% structured EMR staging of NSOP within 1 month of initial visit as our target (50% increase from baseline). We incorporated the EMR ST into our visit workflow and used promotional flyers and fellow orientation to introduce our QI initiative. Staging rates were tracked by EMR-generated reports. We used periodic emails and QI-specific boards to disseminate progress among our oncology practices. Fellows were anonymously surveyed for feedback. Results: Over an 8-month period, the cumulative rate of NSOP staging by fellows increased from 47% to 70% (Table). Statistical process control analysis showed special-cause variation in July 2018 (low performance) and December 2018 (high performance). Fellow feedback highlighted the educational value of this QI intervention and identified incomplete workup as a barrier to staging. Conclusions: Our fellow-led QI intervention achieved our goal of leveraging an existing EMR tool to increase staging documentation. In addition, this QI intervention facilitated fellow education and use of data for clinical and research purposes. Future steps include ensuring sustainability and expansion into our hematology clinics. [Table: see text]

Evaluation of Long Bone Fractures in Infants for Non-Accidental Trauma: An Analysis of Physician Assessment and Documentation at a Tertiary Care Medical Center

Background: Fractures are the second most common infant and toddler injury resulting from child abuse. Yet fractures are not always evaluated for possible non-accidental trauma often due to the lack of recognition and incomplete work-up by the evaluating physician. When non-accidental injuries are missed it can result in more serious or fatal injury. In this study, we aim to determine how well a tertiary center follows the clinical guidelines in evaluating infants with long bone fractures established by the American Academy of Pediatrics (AAP). …

Aetiologies of Hyperprolactinaemia: A retrospective analysis from a tertiary healthcare centre.

ObjectivesThis study aimed to evaluate the aetiologies of hyperprolactinaemia in the United Arab Emirates (UAE).MethodsThis retrospective study used laboratory databases to identify all patients who underwent evaluation for prolactin at Tawam Hospital, Al Ain, UAE, between 2009 and 2015. Of those 2,280 patients, all patients with low or normal prolactin (n = 1,315) were excluded. Subsequently, charts of the remaining patients (n = 965) with hyperprolactinaemia were reviewed and those with incomplete work-ups or insufficient documentation of the hyperprolactinaemia’s aetiology were excluded (n = 458).ResultsA total of 507 patients were included in the study. The average age at prolactin evaluation was 36 ± 13.2 years and the majority (67.1%) of patients were female. The most common reasons for requesting prolactin were menstrual disorders (29.5%), infertility (18%), evaluation of sellar masses (14.3%), ruling out seizures (13.4 %) and monitoring while on psychiatric medications (8.7%). The most common causes of hyperprolactinaemia were prolactinoma (17%), transient hyperprolactinaemia (14.6%), drug-induced side effects (14.4%), polycystic ovarian syndrome (11.8%) and seizure disorder (7.7%). In females, common aetiologies were prolactinomas, transient and idiopathic hyperprolactinaemia, while sellar masses, seizures, chronic kidney disease and acute illnesses were common aetiologies of hyperprolactinaemia in males. The prolactin level varied between the different aetiologies and a level of >250 ng/mL was suggestive of macro-prolactinoma.ConclusionA significant proportion of patients with hyperprolactinaemia have transient hyperprolactinaemia. Before further investigations are carried out, prolactin level assessment should be repeated, especially in patients with mild hyperprolactinaemia.

Can We Prevent Stillbirth?

This study aimed to identify the frequency of potentially preventable causes of stillbirth in a large heterogeneous population. This is a retrospective study of all stillbirth cases between January 2011 and December 2016 at a single tertiary medical center. Deliveries resulting from a nonviable fetus prior to 24 weeks of gestation, intrapartum fetal death, and incomplete stillbirth workup were excluded. Potentially preventable stillbirth was defined as that of a nonanomalous fetus that most likely resulted from one or more of the following: (1) placental-mediated complications, (2) postterm pregnancy, (3) monochorionicity-associated complications, (4) cholestasis of pregnancy, (5) preventable or treatable infections, and (6) isoimmunization. During the study period, 312 stillbirths were identified, 228 of which met the inclusion criteria. Of the 110 cases with a recognized cause, 47 (20.6%) were potentially preventable. The most common causes were placental-mediated complications and preventable or treatable infections, accounting for 75 and 9% of all potentially preventable causes, respectively. There were no recognizable maternal risk factors for potentially preventable stillbirth. One-fifth of all causes of stillbirth are potentially preventable. Due to the significant contribution of placental-mediated complications to preventable stillbirth, close sonographic surveillance and timely delivery may decrease risk substantially.

Limbic encephalitis: Experience of a moroccan center.

ObjectivesHistologically defined as an inflammation—degeneration of limbic structures, limbic encephalitis (LE) is a rare disease and often difficult to diagnose particularly in institutions with limited access to laboratory tests such as antineuronal antibodies or HSV‐PCR, and functional imaging. We aimed to describe the demographic, clinical, paraclinical, and etiological features of LE, as well as its medium‐term prognosis in Moroccan patients.Materials and MethodsWe collected retrospectively all patients diagnosed with LE in the Department of Neurology of the University Hospital Hassan II of Fez (Morocco) between September 2008 and December 2016. We analyzed their demographic features, clinical manifestations, magnetic resonance imaging and laboratory findings, etiologies, and medium‐term prognoses.ResultsWe included 22 men and 9 women aged 14–76 years (mean age: 45.8 years). In 64.5% of cases, the onset of symptoms was acute. The clinical manifestations included generalized status epilepticus (16.1%), confusional syndrome (29%), epileptic seizures (38.7%), psychiatric disorders (48.4%), and memory disorders (45.2%). The nonlimbic symptoms were nuchal stiffness (22.6%), headaches (9.7%), fever (61.3%), vesicular rash (3.2%), and language disorders (6.5%). The different etiologies found were herpes simplex virus (6.5%), syphilis (16.1%), tuberculosis (3.2%), varicella (3.2%), paraneoplastic autoimmune LE (22.6%), anti‐NMDA‐R LE (6.5%), and sarcoidosis (3.2%). We found 12 cases (38.7%) of LE without definite etiology and with an incomplete diagnostic workup. The medium‐term clinical course includes a complete remission in 45.2% of cases and partial remission in 45.1% of cases. The different sequelae were temporal lobe epilepsy (9.7%), anterograde amnesia (16.1%), and severe cognitive impairment (19.4%). The mortality rate was 9.7% (3 patients).ConclusionOur study shows a wide diversity of etiologies of LE in Morocco with essentially an acute mode of onset of symptoms.

Hemophagocytic lymphohistiocytosis is a sign of poor outcome in pediatric Epstein-Barr virus-associated post-transplant lymphoproliferative disease after allogeneic hematopoietic stem cell transplantation.

EBV-related PTLD developing after HSCT is a potentially life-threatening disease. HLH is uncommon after allogeneic HSCT. Data on outcome of patients with PTLD and concomitant HLH after allogeneic HSCT are limited. In this retrospective study, we collected demographic, clinical, laboratory, and outcome data for 408 patients who underwent allogeneic HSCT from 2006 to 2015. Graft source included CB (n=135; 33.1%), PBSCs (n=34; 8.3%), and BM (n=239; 58.6%). Eight out of 408 patients (2%) developed EBV-PTLD with a median age at HSCT of 5.9years (range: 2.3-17.3). All eight patients received ATG as part of the conditioning regimen. Graft source was PBSC in three patients (37.5%), BM in four patients (50%), and CB in one patient (12.5%). Donors were matched unrelated in five patients (62.5%) and matched sibling in three patients (37.5%). Seven out of eight patients developed EBV-PTLD within the first 100-day post-HSCT. Lymph node biopsy revealed early lesions in three patients, polymorphic in three patients, and monomorphic PTLD in two patients. Three patients (37.5%) died within 1month of EBV-PTLD diagnosis. All deceased patients developed HLH manifestations with two of them meeting HLH diagnostic criteria and one having an incomplete workup. PTLD after allogeneic HSCT with manifestations of HLH is associated with high mortality. Early identification and treatment of EBV-PTLD seems imperative to control the disease, especially if signs of HLH are evolving.

Safe Use of Epidural Analgesia in a Parturient With Spinocerebellar Ataxia: A Case Report.

A 28-year-old, gravida 7, para 4 woman with medical history of sickle cell trait presented to labor and delivery at 39 weeks of gestation for rupture of membranes. The patient had a history of suspected spinocerebellar ataxia with incomplete workup before the current admission. The patient requested epidural analgesia for labor. Epidural was placed at L3-L4 interspace without any complications and the rest of the labor was uneventful. Magnetic resonance imaging of the brain was performed after the delivery and the diagnosis of spinocerebellar ataxia was confirmed. The patient's neurological status remained stable after the procedure.

Impact of recent guidelines on overtreatment of asymptomatic pancreatic cystic lesions

Background: Resection of pancreatic cystic lesions can prevent pancreas cancer but aggressive resection of benign cysts may cause harm. More conservative guidelines for cyst management have been proposed. We hypothesized that if conservative guidelines were applied to our patient population, pancreas resections for benign cystic lesions would decrease without failure to resect malignant lesions. Methods: A retrospective review of a prospectively maintained database was performed from 2006–2017. Patients who underwent resection for asymptomatic cystic lesions were retrospectively categorized as candidates for resection or surveillance according to the Fukuoka and AGA guidelines. Final surgical pathology was reviewed. Results: 264 patients underwent resection for pancreatic cysts. 212 were symptomatic and 7 were excluded because incomplete work-up precluded retrospective application of guidelines. Among 52 patients with asymptomatic cysts, 17 (38%) would have continued surveillance by Fukuoka guidelines and 24 (53%) by AGA guidelines. Guidelines were followed similarly regardless of cyst location (9 of 16 head (56%)/ 18 of 28 tail (64%)) and compliance increased throughout the series. Final surgical pathologic diagnosis was of no malignant potential in 16 (36%), IPMN 23 (51%), PNET 1 (2%), other premalignant lesions 2 (4%), and IPMN with invasive cancer 3 (7%). No patient that would have been relegated to surveillance by the new guidelines harbored severe dysplasia or invasive cancer. Conclusion: Consistent application of the Fukuoka or AGA guidelines in our practice may reduce the morbidity of unnecessary surgery without failing to resect malignant pathology.

Validation of the ACR-EULAR criteria for primary Sjögren's syndrome in a Dutch prospective diagnostic cohort.

To validate the ACR-EULAR classification criteria for primary SS (pSS), and compare them to the American-European Consensus Group (AECG) and ACR criteria in a Dutch prospective diagnostic cohort. Consecutive patients (n = 129) referred for suspicion of pSS underwent a multidisciplinary evaluation, including a labial and/or parotid gland biopsy. Patients with an incomplete work-up (n = 8) or associated systemic auto-immune disease (n = 7) were excluded. The ACR-EULAR classification was compared with expert classification, AECG and ACR classification. Additionally, the accuracy of individual ACR-EULAR items in discriminating pSS from non-pSS was evaluated. The validity of criteria sets was described separately using parotid or labial gland biopsy results for classification. Of the 114 evaluated patients, the expert panel classified 34 (30%) as pSS and 80 (70%) as non-pSS. Using labial gland biopsy results, ACR-EULAR classification showed 87% absolute agreement (κ = 0.73) with expert classification, with a sensitivity of 97% and specificity of 83%. Using the parotid gland biopsy results, the ACR-EULAR criteria performed excellently as well. Focus score, anti-SSA titre and ocular staining score showed good to excellent accuracy, whereas unstimulated whole saliva and Schirmer's test had poor accuracy. The ACR-EULAR and AECG criteria had equal validity. Compared with ACR classification, ACR-EULAR classification showed higher sensitivity but lower specificity. The ACR-EULAR criteria showed good agreement with expert classification, but some patients may be misclassified as pSS. Unstimulated whole saliva and Schirmer's test showed poor discriminative value. The ACR-EULAR criteria performed equally to the AECG criteria, and had higher sensitivity but lower specificity than the ACR criteria.

Are patients being evaluated for periprosthetic joint infection prior to referral to a tertiary care center?

BackgroundPatients with a painful or failed total joint arthroplasties should be evaluated for periprosthetic joint infection (PJI). The purpose of this study is to determine if patients referred to a tertiary care center had been evaluated for PJI according to the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines.MethodsOne hundred thirteen patients with painful hip (43) or knee (70) arthroplasties were referred to a single provider by orthopaedic surgeons outside our practice between 2012 and 2014. We retrospectively evaluated the workup by referring physicians, including measurement of serum erythrocyte sedimentation rate and C-reactive protein, performance of a joint aspiration if these values were abnormal, and obtainment of synovial fluid white blood cell count, differential, and cultures.ResultsSixty-two of 113 patients (55%) did not have a workup that followed AAOS guidelines. Serum erythrocyte sedimentation rate and C-reactive protein were ordered for 64 of the 113 patients (57%). Of 25 patients with elevated inflammatory markers warranting aspiration, 15 (60%) had an aspiration attempted, with synovial fluid white blood cell, differential, and cultures obtained in 9 of 12 (75%) aspirations that yielded fluid. Of the 62 patients with an incomplete infection workup, 11 (18%) had a bone scan, 6 (10%) a computed tomography scan, and 3 (5%) a magnetic resonance imaging. Twelve of the 113 patients (11%) were ultimately diagnosed with PJI, with 5 undiagnosed prior to referral.ConclusionsThe AAOS guidelines to evaluate for PJI are frequently not being followed. Improving awareness of these guidelines may avoid unnecessary and costly evaluations and delay in the diagnosis of PJI.

Comparison of Treatment Methods and Responsiveness Between Patients With Usual Interstitial Pneumonia and Possible Usual Interstitial Pneumonia Radiographic Patterns

SESSION TITLE: Diffuse Lung Disease 1 SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: The usual interstitial pneumonia (UIP) pattern of radiographic and histologic findings is commonly associated with idiopathic pulmonary fibrosis (IPF), although it can be associated with secondary interstitial lung diseases (ILD). Based on the radiographic findings, ILD can be classified as “UIP, “possible UIP”, or “inconsistent with UIP.” The purpose of this study is to analyze and compare treatment patterns and responsiveness between UIP and possible UIP radiographic patterns. METHODS: 220 patients seen and evaluated at Rush University Medical Center and/or Rush Oak Park Hospital for newly diagnosed interstitial lung disease were identified. Patients with previous workup, incomplete workup, or with an “inconsistent with UIP” pattern on radiography were excluded (180 patients). Patients were then split into the categories “UIP” or “possible UIP” based on the radiologist’s read of high-resolution CT. The rates of use of immunosuppressants and other medications (including anti-fibrotic agents, such as pirfenidone and nintedanib) were compared between the two groups. Response to treatment was also analyzed based on PFT data, using a cutoff of a 10% change in VC, TLC, or DLCO. Fisher’s exact tests compared frequencies between groups. RESULTS: 40 patients met inclusion criteria. There were 11 total pulmonologists who evaluated these patients. 13 patients had the UIP pattern and 27 patients had possible UIP, based on the radiologist’s read of a high-resolution CT scan. 8 UIP patients were treated with immunosuppressants, compared to 11 possible UIP patients (p = 0.3140); 2 UIP patients were treated with other medications, compared to 7 possible UIP patients (p = 0.6904). In UIP patients, 2 had improved VC, 5 had stable VC, and 3 had a worsened VC, compared to 1 improved, 12 stable, and 9 worsened VCs in possible UIP patients (p = 0.406). 1 UIP patient demonstrated improvement in TLC, 5 showed stable TLC, and 2 had a worsened TLC, compared to 2 improved, 13 stable, and 7 worsened TLCs in possible UIP patients (p = 0.999). Finally, for UIP, 1 patient had improved DLCO, 3 had stable DLCOs, and 4 had worsened DLCO, compared to 4 improved, 7 stable, and 11 worsened DLCOs in possible UIP (p = 0 .999). There were no statistically significant changes in PFTs when comparing UIP patients treated with immunosuppressants or other medications to those not treated; similarly, there were no statistically significant changes in PFT data comparing treated possible UIP pattern patients to those not treated. 3 out of the 13 typical UIP patients had a biopsy, compared to 8 of the 27 possible UIP patients (p = 1.000). CONCLUSIONS: Patients with both UIP and possible UIP patterns on radiographic imaging are more commonly treated with immunosuppressants. Despite this, there is no statistically significant improvement or prevention of decline in treated or untreated patients. CLINICAL IMPLICATIONS: Possible UIP and typical UIP patients tend to have similarly poor response to treatment with antifibrotic agent and immunosuppresants. When treating ILD with a UIP pattern, providers should carefully weigh subjective benefits against the risks of immunosuppressant or antifibrotic therapies. DISCLOSURE: The following authors have nothing to disclose: Krishnan Warrior, Mark Yoder No Product/Research Disclosure Information

Efficacy and safety of oral sildenafil in children with Down syndrome and pulmonary hypertension

BackgroundDespite the increased risk for pulmonary hypertension in children with Down syndrome, the response to treatment with targeted therapies for pulmonary hypertension in these patients is not well characterized. The Sildenafil in Treatment-naive children, Aged 1–17 years, with pulmonary arterial hypertension (STARTS-1) trial was a dose-ranging study of the short-term efficacy and safety of oral sildenafil in children with pulmonary arterial hypertension. We assessed the safety and efficacy of oral sildenafil in children with Down syndrome and pulmonary arterial hypertension.MethodsThis was a post-hoc analysis of children with Down syndrome and pulmonary arterial hypertension enrolled in the STARTS-1 trial. Mean pulmonary arterial pressure (mPAP), pulmonary vascular resistance index (PVRI), and cardiac index (CI) were assessed at baseline and following 16 weeks of treatment with sildenafil.ResultsOf 234 patients randomized and treated in the STARTS-1 trial, 48 (20.5%) had Down syndrome. Although sildenafil produced dose-related reductions in PVRI and mPAP, compared with placebo, in non–Down syndrome patients and children developmentally able to exercise, this was not satisfactorily marked in patients with Down syndrome. The dose-related reductions in PVRI, compared with placebo, occurred in all subgroups, with the exception of the Down syndrome subgroup. Sildenafil appeared to be well tolerated in the Down syndrome subpopulation and the most frequently reported AEs were similar to those reported for the entire STARTS-1 population.ConclusionSildenafil treatment for 16 weeks had no effect on PVRI or mPAP in children with Down syndrome and pulmonary arterial hypertension. The results suggest that children with Down syndrome may be less responsive to sildenafil for pulmonary arterial hypertension, but the incomplete work-up for the etiology of pulmonary arterial hypertension may have introduced a potential bias.Trial registrationStudy received, September 8, 2005 (retrospectively registered); Study start, August 2003; ClinicalTrials.gov identifier, NCT00159913.

The role of magnetic resonance cholangiopancreatography and diffusion-weighted imaging for the differential diagnosis of obstructive biliary disorders

Background: Although endoscopic retrograde cholangiopancreatography (ERCP) is accepted as the gold standard, there is a place for magnetic resonance cholangiopancreatography (MRCP) and diffusion-weighted imaging (DWI) in the diagnosis of obstructive biliary disorders.Aim: To compare the findings of MRCP with ERCP in patients with obstructive biliary disorders and to investigate the diagnostic efficacy of MRCP combined with DWI.Study design: Retrospective, analytic, cross-sectional study.Methods: The MRCP images of 126 patients who underwent both MRCP and ERCP owing to biliary obstruction were reviewed. Nine patients were excluded because of incomplete diagnostic workup or a long period (>3 months) between MRCP and ERCP. Ninety-two patients underwent DWI, which was also evaluated. The sensitivity, specificity and accuracy of MRCP and DWI were analysed.Results: The sensitivity, specificity and accuracy of MRCP according to ERCP results as the gold standard was 97%, 71% and 93% for assessment of biliary dilatation; 100%, 94.7% and 97.5% for the diagnosis of choledocholithiasis; 93.7%, 100% and 99% for the identification of benign strictures; 100%, 100% and 100% for the diagnosis of malignant tumours; and 100%, 100% and 100% for the detection of complicated hydatid cysts; respectively. The sensitivity and specificity of DWI for the diagnosis of malignant tumour was 100%. In the detection of choledocholithiasis, the sensitivity and specificity of DWI was 70.8% and 100%.Conclusions: MRCP is an alternative, non-invasive, diagnostic modality, comparable with ERCP for the evaluation of pancreaticobiliary diseases. DWI can be helpful for diagnosis of choledocholithiasis and tumours.