Initial Evaluation Of Patients Research Articles

Artificial Intelligence Improves Initial Evaluation and Follow-up of Patients With AAAs

Artificial Intelligence Improves Initial Evaluation and Follow-up of Patients With AAAs

A139 EARLY VIDEO CAPSULE ENDOSCOPY VERSUS COLONOSCOPY FOLLOWING NEGATIVE ESOPHAGOGASTRODUDENOSCOPY IN PATIENTS WITH SUSPECTED UPPER GASTROINTESTINAL BLEEDING: PRELIMINARY DATA FROM A RANDOMIZED CONTROLLED TRIAL

Abstract Background Esophagogastroduodenoscopy (EGD) is recommended for initial endoscopic evaluation of patients with suspected upper gastrointestinal bleeding (UGIB). When this is negative, the standard recommendation is to perform a colonoscopy, despite low diagnostic yield of less than 5%. In these patients, the question remains as to whether small bowel investigations would be of higher yield prior to colonoscopy. Aims To compare the diagnostic yield between early video capsule endoscopy (VCE) versus colonoscopy after a negative EGD in patients with suspected UGIB. Methods This is preliminary data from a prospective randomized control trial (RCT) of adult patients with suspected UGIB (melena and hemoglobin drop of more than 20 g/L within 48 hours of admission). Patients at a single centre were enrolled prior to initial EGD; those with negative EGD were included and randomized to either colonoscopy (next day) or early VCE (immediately after EGD). Patients with a confirmed source of bleeding in their group required no further testing, but those without underwent further testing with the alternative (VCE or colonoscopy). We evaluated patient outcomes, including bleeding localization time, hospitalization duration, procedure count, complications and rebleeding rates. Results A total of 19 adult patients have been enrolled, of which 12 had negative EGD and were randomized to either VCE or colonoscopy, with six patients in each arm (Figure 1). In the VCE group, 100% (6/6) of patients had bleeding sources detected by early VCE, with 50% (3/6) of them undergoing endoscopic treatment. In the colonoscopy group, only one patient had a positive finding (1/6), the rest underwent subsequent VCE. The VCE identified the bleeding source in 80% (4/5) of patients with negative colonoscopy. Patient are outlined in Table 1. Conclusions Based on our preliminary data, the diagnostic yield of early and subsequent VCE was higher when compared to colonoscopy after initial negative EGD in patients with suspected UGIB. Table 1. Summary of findings and patient outcomes Funding Agencies Medtronic Canada (Brampton, ON, CA) will provide the video capsule in the treatment group. This is the only equipment funding required in this study.

Evaluating Safety of Telehealth for Initial Surgical Evaluation of General Thoracic Patients

BackgroundThe use of telehealth has grown exponentially since the COVID-19 pandemic. The safety of an initial telehealth preoperative evaluation for patients undergoing general thoracic procedures is unknown. MethodsWe retrospectively reviewed all patients who underwent a general thoracic surgical procedure at our academic tertiary care institution from January 2021 to December 2022. We determined that visits were performed through telehealth or an in-person visit and linked to our institutional Society of Thoracic Surgeons database to abstract outcomes. Our outcomes of interest included complications, readmissions, intraoperative conversions, and intensive care unit admissions. Hierarchical multivariate logistic regression was used and clustered within procedure type. ResultsOf 1348 patients who underwent a procedure in our institution, 469 (34.8%) patients had an initial telehealth preoperative evaluation. We analyzed outcomes for 757 patients who underwent a major thoracic procedure. Patients who had an in-person visit tended to be older with worse functional status. After multivariable adjustment, an initial telehealth evaluation was associated with a lower adjusted complication rate (31.6% vs 40.4%; odds ratio, 0.63 [95% CI, 0.46-0.88]; P = .006), with no significant difference in readmissions, intensive care unit admissions, or intraoperative conversions. ConclusionsThis preliminary study of the use of telehealth for preoperative evaluation of patients undergoing general thoracic procedures suggests that it is a safe and feasible alternative to an in-person evaluation. Care must be taken to ensure that this pandemic-induced trend continues to improve patient access to surgical care without worsening or creating new disparities.

Using Bedside Spectral Doppler Ultrasound for the Assessment of Patients With Thyrotoxicosis

ObjectiveTo assess the bedside utility of Spectral Doppler Ultrasound (SDUS) in the initial evaluation of patients presenting with thyrotoxicosis. MethodsThis is a retrospective cross-sectional study of patients diagnosed with thyrotoxicosis at an academic outpatient endocrinology clinic from August 2019 to November 2022. The thyroid arteries' peak systolic velocities (PSV) were measured bilaterally using SDUS. PSV ≥40 cm/s in at least a single thyroid artery was considered a reasonable cut-off for Graves’ disease and PSV of perinodular artery ≥ 25 cm/s for toxic adenoma. ResultsWe identified 73 patients. Mean age ± standard deviation 45.2 ± 16.4 years, 54 (74.0%) were female, 49 (67.1%) were Caucasian, 23 (31.5%) were African American, and 1 (1.4%) was Asian. The confirmed diagnoses were 48 (65.8%) Graves’ disease, 13 (17.8%) thyroiditis, four (5.5%) toxic adenoma, four (5.5%) amiodarone-induced thyroiditis type 2, 1 (1.4%) toxic multinodular goiter, 1 (1.4%) had an unremarkable repeat thyroid function testing, and two (2.7%) were unconfirmed. Diagnosis based on the SDUS initial assessment was accurate in 65 (89.0%) of the patients, and it was conclusive and confirmatory during the initial encounter in 55 (75.3%) of the patients before additional testing. A thyroid scan was obtained in nine (12.3%) patients. Incorrectly diagnosed patients were observed in two patients of each of the following categories: Graves’ disease, thyroiditis, toxic adenoma, and unconfirmed diagnoses. ConclusionsSDUS can be a valuable, efficient, and cost-effective bedside tool in the initial assessment of patients presenting with thyrotoxicosis.

Abstract WP111: Stroke Team Member Perspectives on Factors That Influence Hospital Door-to-Needle Time Performance: A Qualitative Analysis

Background: Despite substantial to minimize ischemic stroke treatment delays, hospital door-to-needle (DTN) time variations persist. We sought to identify sources of variation in practice as well as understand stroke team member perceptions of factors that influence DTN performance in a sample of hospitals that participate in a statewide stroke registry. Methods: We conducted a series of semi-structured interviews with stroke coordinators and emergency department (ED) staff. Participants were invited from hospitals with the fastest or slowest DTN times in 2022. Transcripts of the interviews were coded to identify differences in hospital acute stroke code processes as well as interviewee perceptions of facilitators and barriers to optimal performance. Results: Ten individuals from 6 hospitals participated in interviews (6 stroke coordinators, 3 ED physicians, 1 ED nurse). Variations in stroke code processes included location of initial patient evaluation, stroke team composition (inclusion of pharmacy or in-person neurology provider), imaging strategy for large-vessel occlusion stroke screening, thrombolytic medication utilized, and team members primarily responsible for thrombolytic decision-making, mixing, and delivery. Common facilitators of rapid DTN times included integration of EMS, multidisciplinary engagement with quality improvement teams (especially physician engagement), embedding critical care nurses in stroke teams, and providing rapid, individualized feedback to clinical personnel. Common barriers included identifying stroke in triage, staff turnover, and inadequate stroke coordinator resources. Participants from higher performing hospitals reported having larger stroke teams with in-person neurology support. Participants from lower performing hospitals highlighted staffing shortages and difficulties with video-based teleneurology. Conclusion: Stroke code process variation is common and largely driven by hospital resources. Highly engaged, physician-led multidisciplinary teams and timely, actionable feedback were seen as key elements of achieving DTN goals. Staffing shortages and lack of access to timely neurological consultation are system-level barriers to optimal stroke care.

First-in-human study of PSMA-targeting agent, [18F]AlF-P16-093: dosimetry and initial evaluation in prostate cancer patients.

This is a first-in-human study to evaluate the radiation dosimetry of a new prostate-specific membrane antigen (PSMA)-targeted radiopharmaceutical, [18F]AlF-P16-093, and also initial investigation of its ability to detect PSMA-positive tumors using PET scans in a cohort of prostate cancer (PCa) patients. The [18F]AlF-P16-093 was automatically synthesized with a GE TRACERlab. A total of 23 patients with histopathologically proven PCa were prospectively enrolled. Dosimetry and biodistribution study investigations were carried out on a subset of six (6) PCa patients, involving multiple time-point scanning. The mean absorbed doses were estimated with PMOD and OLINDA software. [18F]AlF-P16-093 was successfully synthesized, and radiochemical purity was > 95%, and average labeling yield was 36.5 ± 8.3% (decay correction, n = 12). The highest tracer uptake was observed in the kidneys, spleen, and liver, contributing to an effective dose of 16.8 ± 1.3 μSv/MBq, which was ~ 30% lower than that of [68Ga]Ga-P16-093. All subjects tolerated the PET examination well, and no reportable side-effects were observed. The PSMA-positive tumors displayed rapid uptake, and they were all detectable within 10 min, and no additional lesions were observed in the following multi-time points scanning. Each patient had at least one detectable tumor lesion, and a total of 356 tumor lesions were observed, including intraprostatic, lymph node metastases, bone metastases, and other soft tissue metastases. We report herein a streamlined method for high yield synthesis of [18F]AlF-P16-093. Preliminary study in PCa patients has demonstrated its safety and acceptable radiation dosimetry. The initial diagnostic study indicated that [18F]AlF-P16-093 PET/CT is efficacious and potentially useful for a widespread application in the diagnosis of PCa patients.

Prognostic value of scales for aneurysmal subarachnoid hemorrhage: Report of a reference center in Peru

IntroductionMultiple scales have been designed to stratify the severity and predict the prognosis in the initial evaluation of patients with aneurysmal subarachnoid hemorrhage (aSAH). Our study aimed to validate the most commonly used prognostic scales for aSAH in our population: Hunt-Hess, modified Hunt-Hess, World Federation of Neurosurgical Societies (WFNS), Prognosis on Admission of Aneurysmal Subarachnoid Hemorrhage (PAASH), and Barrow Aneurysm Institute (BAI) scales. MethodsThis study includes all aSAH cases treated at our institution between June 2019 and December 2020. We developed a retrospective cohort by reviewing medical records and radiologic images performed during hospitalization. The outcome was evaluated using the modified Rankin scale (mRS). It was defined as a poor outcome (mRS 4–5) and mortality (mRS 6). The ROC curves and the area under the curve (AUC) of each of the prognostic scales were calculated to evaluate their prognostic prediction capacity. ResultsA total of 142 patients were diagnosed with aSAH. A poor outcome occurred in 52.1% of the patients, whereas mortality was 27.5%. The AUC of the scales studied was similar and no significant difference was found between them for predicting a poor outcome (P = .709) or mortality (P = .715). ConclusionWe determined that the prognostic scales for aSAH had a similar predictive value for poor clinical outcomes and mortality in our institution, with no significant difference. Thus, we recommend the most simple and well-known scale used institutionally.

Impact of a Point-of Care Ultrasound Examination on the Management of Acute Respiratory or Circulatory Failure Patients in the Emergency Department: The Impulse Before-and-After Implementation Study

Background: Despite its diagnostic accuracy, the clinical impact of the use of Point-of-care Ultrasound (POCUS) in the emergency department (ED) is not well described, especially when performed by junior in-training residents. Aim of the study: To assess the effect of a short, structured POCUS training program on the management of ED patients by in-training residents. Method: IMPULSE is a before-and-after implementation study, evaluating the impact of a structured POCUS training program for ED in-training residents on the management of patients admitted for acute respiratory and/or circulatory failure in a Swiss regional hospital. The training curriculum was organized in three stages and combined an on-line training course, an 8-hour practical hands-on session, and 10 supervised POCUS exams. The ED residents who successfully completed the curriculum participated in the study. Observed outcomes were time to ED diagnosis, rate of correct diagnosis made during the ED stay and time needed to reach it, time to prescribe an appropriate treatment, and hospital mortality. Standard statistical analyses were performed with the use of Chi-square and Mann-Whitney U tests as appropriate, completed by a Bayesian analysis, with a Bayes Factor (BF) >3 considered as significant. Results: Sixty-nine patients were included before the training program implementation and 54 after. After implementation, the median time to ED diagnosis was 25 minutes (IQR 44) vs 30 minutes (IQR 56) before implementation, a difference that was significant (BF 9.6). The rate of correct diagnosis was higher (95 vs 52%) (p<0.001) and the time to make this correct diagnosis was significantly shorter after implementation (25 minutes, IQR 45, vs 43, IQR 60) (BF 5.0). This had an impact on the median time to prescribe the appropriate therapy, with a trend toward a shorter delay (47 minutes, IQR 76, vs 70, IQR 100) (BF 2.0). Eventually, there was a significant difference in hospital mortality (13% vs 5.5%, BF 15.7). Conclusion: The IMPULSE study shows that the implementation of a short, structured POCUS training program for ED residents to use ultrasound for the initial evaluation of acute respiratory and circulatory failure patients has an impact on diagnostic accuracy, on time to make a correct diagnosis and to prescribe an appropriate therapy, and eventually possibly on hospital mortality. If these results are reproduced in other settings, POCUS use by ED residents after short, structured training curriculum could become the standard of care for these patients.

Neurorehabilitation of post-stroke patients using a noninvasive spinal neuroprosthesis

Neurorehabilitation of post-stroke patients with motor impairments is a significant and yet unresolved issue in restorative medicine. We propose a novel approach to rehabilitating such patients using transcutaneous electrical spinal cord stimulation (scTS), which targets the neural locomotor networks of the lumbar enlargement of the human spinal cord [1]. The Spinal Neuroprosthesis device was developed to control stimulation, providing noninvasive and phase-dependent activation of motoneuronal pools of flexors and extensors during a certain phase of the stepping cycle, combined with the activation of neuronal locomotor networks [2]. The aim of this study is to assess the efficacy of Spinal Neuroprosthesis in regulating locomotor functions among post-stroke patients with motor disorders. The study is designed to provide an objective evaluation of the medical device’s effectiveness. The study was conducted at the Russian Research Institute of Neurosurgery named after Prof. A.L. Polenov. The study enrolled 20 patients who had been experiencing severe motor disorders of the lower extremities in the form of hemiparesis. The duration of stroke among these patients ranged from 3 to 12 months. They were divided into two groups: control and experimental. The control group underwent sham (scTS-) stimulation during a motor rehabilitation session, while the experimental group received real scTS, establishing the difference between the groups. The rehabilitation program comprised 15 sessions of stimulation to the spinal cord. The treatment protocol comprised an initial evaluation of patients’ neurological and rehabilitation status and an investigation of spatial-temporal and kinematic parameters of walking. Subsequently, patients participated in rehabilitation sessions, which entailed walking on the treadmill and over-ground stepping with scTS. Finally, patients underwent a follow-up examination that included a re-evaluation of their neurological and rehabilitation status, as well as an investigation of spatial-temporal and kinematic parameters of walking. At the beginning of the program, the distance traveled by patients in the control and experimental groups during a six-minute walk test, according to the study results, did not differ significantly. However, following the treatment, patients in the experimental group demonstrated a substantially lengthier distance covered during the 6-minute test than the control group. Both groups of patients in the 10-meter walk test demonstrated an increase in distance walking speed, although the patients in the experimental group had a greater increase in speed compared to those in the control group. These improvements were more pronounced in patients from the experimental group. The results from neurological scales indicated an increase in muscular strength, improvement in balance functions, and an increase in functional independence in both groups. The findings provide evidence that the Spinal Neuroprosthesis effectively regulates stepping movements and restores locomotor function in patients post-stroke. Clinically significant improvements are observed within two weeks of neuroprosthesis use. Additionally, training increases patients’ exercise tolerance while walking, speed of movement, and functional independence.

Lymphoscintigraphy is frequently recommended but seldom used in a “real world setting”

ObjectiveLymphedema (LED) lacks a standard, simple, guiding noninvasive diagnostic test, unlike the two other circulatory disorders—arterial or venous disease. Lymphoscintigraphy (LSG) has been recommended by several guidelines as the diagnostic test of choice for LED. Several recent expert panels, however, have suggested from anecdotal experience that LSG was used infrequently, and that the diagnosis of LED is usually based on clinical examination. MethodsTo determine the use of LSG in a large real-world LED population, the International Business Machines MarketScan Research Database was examined from April 2012 to March 2020 for patients with a new diagnosis of LED (the index date). Use of LSG (LSG+) was ascertained during the period beginning 12 months prior to the initial coding of a LED diagnosis and ending 12 months after the index date based on the corresponding Current Procedural Terminology code; LSG use for sentinel node mapping at the time of oncologic surgery was excluded. Demographic profiles, comorbidities, and causes of LED among patients with and without evidence of LSG were characterized. ResultsWe identified 57,674 patients, aged ≥18 years, who had a new diagnosis of LED and health care coverage for ≥12 months before and after this index date. Only a small number (1429; 2.5%) of these patients underwent LSG during the study period. The LSG + cohort was younger (53.7 vs 60.7 years), had a higher proportion of women (91.3% vs 73.4%), but a lower percentage of diabetes (12.8% vs 27.5%), heart failure (2.2% vs 8.7%), hypertension (32.4% vs 51.0%), and obesity (15.1% vs 22.2%) compared with the LED population who did not undergo LSG (all P < .001). Most importantly, the use of LSG for diagnosis varied with the etiology of LED (LSG was most frequently utilized among patients with melanoma-LED (9.5%) and patients with breast cancer-LED (6.7%), in contrast to patients with advanced venous disease-related LED (1.1%; P < .05 for both comparisons). ConclusionsDespite four guidelines recommending LSG, including the Guidelines of the American Venous Forum (Handbook of Venous and Lymphatic Disease-4th edition), which recommended LSG “for the initial evaluation of patients with LED” with a 1B recommendation, LSG plays a minor role in establishing the diagnosis of LED in the United States. This underlines the need for a better, simple diagnostic test for LED to complement clinical examination.

Cluster analysis of flowcytometric immunophenotyping with extended T cell subsets in suspected immunodeficiency.

Patients with immunodeficiencies commonly experience diagnostic delays resulting in morbidity. There is an unmet need to identify patients earlier, especially those with high risk for complications. Compared to immunoglobulin quantification and flowcytometric B cell subset analysis, expanded T cell subset analysis is rarely performed in the initial evaluation of patients with suspected immunodeficiency. The simultaneous interpretation of multiple immune variables, including lymphocyte subsets, is challenging. To evaluate the diagnostic value of cluster analyses of immune variables in patients with suspected immunodeficiency. Retrospective analysis of 38 immune system variables, including seven B cell and sixteen T cell subpopulations, in 107 adult patients (73 with immunodeficiency, 34 without) evaluated at a tertiary outpatient immunology clinic. Correlation analyses of individual variables, k-means cluster analysis with evaluation of the classification into "no immunodeficiency" versus "immunodeficiency" and visual analyses of hierarchical heatmaps were performed. Binary classification of patients into groups with and without immunodeficiency was correct in 54% of cases with the full data set and increased to 69% and 75% of cases, respectively, when only 16 variables with moderate (p < .05) or 7 variables with strong evidence (p < .01) for a difference between groups were included. In a cluster heatmap with all patients but only moderately differing variables and a heatmap with only immunodeficient patients restricted to T cell variables alone, segregation of most patients with common variable immunodeficiency and combined immunodeficiency was observed. Cluster analyses of immune variables, including detailed lymphocyte flowcytometry with T cell subpopulations, may support clinical decision making for suspected immunodeficiency in daily practice.

Diagnostic approach at specialized syncope units in the netherlands: a cross-sectional, nationwide survey

Abstract Introduction The European Society of Cardiology Guidelines recommend a structural approach for the initial evaluation of syncope patients, yet implementation of such approach appears cumbersome. There are several specialized Syncope Units in the Netherlands. Here we investigated the diagnostic strategy of specialized Syncope Units and adherence areas for syncope patients. Purpose We aimed to identify the current network of Syncope Units in the Netherlands and to assess to which extent the units fulfil requirements as indicated by the European Heart Rhythm Association consensus and the current guidelines. Methods All units Neurology, Internal Medicine, and Cardiology in hospitals in the Netherlands were contacted. Units with specialized Syncope care were included and requested to fill out a questionnaire of 25 questions regarding which medical specialties are involved during evaluation, which diagnostic tests are available and being performed and which adherence regions were associated. We specifically investigated whether the Syncope Units adhered to the consensus statements 1 and 3 as described by the European Heart Rhythm Association position paper as gold standard for best practices. Results Specialized care for syncope was reported in 20/72 hospitals. Most (17/20) reported that multiple specialties are involved during the initial evaluation. 19/20 had either Neurology, Cardiology, or both responsible for the Syncope Unit. 18/20 perform guideline-based orthostatic blood pressure measurement. A non-invasive-beat-to-beat blood pressure monitor was present in 11/20 units. 16/20 perform tilt table testing and do &amp;gt; 48 per year, 3/16 this was during the initial evaluation and 15/20 perform carotid sinus massage. The adherence areas cover 64.2% of the Netherlands. Both European Heart Rhythm Association consensus statements 1 and 3 for best practice were met in 4/20 of the Syncope Units, 4/20 only met consensus statement 1 and 14/20 only met consensus statement 3. Conclusion We identified 20 Syncope Units in the Netherlands. The diagnostic approach varies in the medical specialties involved, protocols for cardiovascular testing, and timing of diagnostic tests. Most units did not completely perform the Guideline suggested initial evaluation. Four out of 20 Syncope Units met the European Heart Rhythm Association consensus statements for best clinical practice.Overview Syncope Units NetherlandsAdherence of the Syncope Unit

Prevalence of Objective Voice Measurement Use in Laryngology Practices in the United States.

The aim of this study was to assess the prevalence of use of objective voice measurements (OVM), instrumentation, and factors that may impact OVM outcomes, such as setting and implementation to clarify current practice. Doing so should clarify the impact of OVM research on patient care. A 12-question, one-time anonymous survey using the Research Electronic Data Capture tool was distributed during January 2023 to laryngologists in the United States identified through membership in The Voice Foundation (TVF) or previous participation in a TVF symposium. A total of 101 responses to 418 emails yielded a response rate of 24.2%. Seventeen point eight percentage (N=18) were in private practice, 63.4% (N=64) were in academic settings, and 18.8% (N=19) were classified as mixed private and academic. Common OVMs used were fundamental frequency 95.12% (N=78), maximum phonation time 90.24% (N=74), noise-to-harmonic ratio 71.95% (N=59), jitter 71.95% (N=59), and shimmer 70.73% (N=58). Common equipment and software used Pentax Multi-Dimensional Voice Program 42.68% (N=35), Pentax Computerized Speech Lab Model 4500B 37.80% (N=31), and Pentax Visi-Pitch, Model 3950C 23.17% (N=19), PRAAT 21.95% (N=18), OperaVOX 4.88% (N=4), VoceVista 3.66% (N=3). Fifty one point two percentage (N=42) stated that they used OVMs with the majority of their patients, most commonly for the assessment of treatment effectiveness (84.1%, N=69), documentation (78.0%, N=64), research (70.7%, N=58), and/or diagnosis (61.0%, N=50). Ninety point two percentage (N=74) stated that OVMs were used during initial evaluation of patients. This study estimates of the prevalence of OVM use among laryngologists in the United States. There appears to be sufficient consistency among laryngology centers to permit comparison of results between centers, although additional research is needed. Future OVM research should compare measurements and equipment commonly used by laryngologists to define further the generalizability of results.

Diagnostic Approaches for Idiopathic Pulmonary Fibrosis.

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, fibrosing interstitial pneumonia with a very poor prognosis. Accurate diagnosis of IPF is essential for good outcomes but remains a major medical challenge due to variability in clinical presentation and the shortcomings of existing diagnostic tests. Medical history collection is the first and most important step in the IPF diagnosis process; the clinical probability of IPF is high if the suspected patient is 60 years or older, male, and has a history of cigarette smoking. Systemic assessment for connective tissue disease is essential in the initial evaluation of patients with suspected IPF to identify potential causes of interstitial lung disease (ILD). Radiologic examination using high-resolution computed tomography plays a pivotal role in the evaluation of patients with ILD, and prone and expiratory computed tomography images can be considered. If additional tests such as surgical lung biopsy or transbronchial lung cryobiopsy are needed, transbronchial lung cryobiopsy should be considered as an alternative to surgical lung biopsy in medical centers with experience performing this procedure. Diagnosis through multidisciplinary discussion (MDD) is strongly recommended as MDD has become the cornerstone for diagnosis of IPF, and the scope of MDD has expanded to monitoring of disease progression and suggestion of appropriate treatment options.

Analysis of Leukocyte Subpopulations by Flow Cytometry during Hospitalization Depending on the Severity of COVID-19 Course.

The mechanisms underlying the immune response to coronavirus disease 2019 (COVID-19) and the recovery process have not been fully elucidated. The aim of the study was to analyze leukocyte subpopulations in patients at significant time points (at diagnosis, and 3 and 6 months after infection) selected according to the analysis of changes in the lungs by the CT classification system, considering the severity of the disease. The study groups consisted of severe and non-severe COVID-19 patients. There was a significant decrease in CD8+ T cells, NK and eosinophils, with an increasing percentage of neutrophils during hospitalization. We noticed lower levels of CD4 and CD8 T lymphocytes, eosinophils, basophils, and CD16+ monocytes and elevated neutrophil levels in severe patients relative to non-severe patients. Three months after infection, we observed higher levels of basophils, and after 6 months, higher CD4/CD8 ratios and T cell levels in the severe compared to non-severe group. Non-severe patients showed significant changes in the leukocyte populations studied at time of hospitalization and both within 3 months and 6 months of onset. The CT CSS classification with parameters of the flow cytometry method used for COVID-19 patients determined changes that proved useful in the initial evaluation of patients.

Localization and Diagnostic Evaluation of Peripheral Nerve Disorders.

This article provides a framework for the initial evaluation of patients with suspected peripheral nerve disease. The key clinical elements of peripheral nerve diseases can help the practicing neurologist differentiate among peripheral neuropathies with similar presentations. The wide range of peripheral nerve diseases with similar clinical presentations can pose a diagnostic challenge. The large array of available testing modalities (including imaging and electrodiagnostic, autonomic, laboratory, biopsy, and genetic testing) further complicates clinical decision making. Recent developments (eg, discovery of new autoantibodies, genetic variations, and histopathologic techniques) across the peripheral neuropathy spectrum have resulted in an increased need to evaluate patients logically and with a tailored diagnostic approach. A careful approach that focuses on key clinical elements combined with an understanding of purposeful diagnostic testing can lead to a successful diagnosis of peripheral nerve diseases.

Prevalence of Enteric Infections in Patients on Immune Checkpoint Inhibitors and Impact on Management and Outcomes.

Stool pathogen testing is recommended as part of the initial evaluation for patients with new-onset diarrhea on immune checkpoint inhibitors (ICIs), yet its significance has not been well-studied. We aimed to determine the impact of multiplex gastrointestinal (GI) pathogen PCR testing on the clinical course and use of immunosuppressive therapy in patients who develop diarrhea on ICIs. This retrospective cohort included individuals who underwent GI pathogen panel PCR for diarrhea on ICIs at Memorial Sloan Kettering between 7/2015 and 7/2021. The primary outcome was use of immunosuppressive therapy for suspected immunotherapy-related enterocolitis (irEC). Secondary outcomes included diarrhea severity and endoscopic and histologic disease patterns. Among 521 ICI-treated patients tested for GI pathogens, 61 (11.7%) had a positive PCR. Compared to patients without detectable infections, patients with infections had more frequent grades 3-4 diarrhea (37.7% vs. 19.6%, P < .01) and colitis (39.3% vs. 14.7%, P < .01). However, patients with infections did not have higher rates of persistent or recurrent diarrhea and were less likely to receive steroids (P < .01) and second-line immunosuppressive agents (P = .03). In 105 patients with lower endoscopy, similar trends were observed and no differences in endoscopic severity or histologic patterns were noted between groups. GI infections in ICI-treated patients presenting with diarrhea are linked to more severe but self-limited clinical presentations and may be optimally treated with observation and supportive care alone. Routine and timely stool pathogen testing may help avert unnecessary empiric immunosuppression for suspected irEC, which has been linked to blunted antitumor responses and numerous adverse effects.

Suboptimal diagnostic accuracy of ultrasound and CT for compensated cirrhosis: Evidence from prospective cohort studies.

Abdominal ultrasound (US) and CT are important tools for the initial evaluation of patients with liver disease. Our study aimed to determine the accuracy of these methods for diagnosing cirrhosis. In all, 377 participants from 4 prospective cohort studies evaluating patients with various liver diseases were included. All patients were included between 2017 and 2022 and had undergone a liver biopsy as well as US and/or CT. Using the histological assessment as the gold standard, we calculated diagnostic accuracy for US and CT. Liver biopsies were evaluated by expert histopathologists and diagnostic scans by experienced radiologists. The mean age was 54 ± 14 years and 47% were female. Most patients had NAFLD (58.3%) or alcohol-associated liver disease (25.5%). The liver biopsy showed cirrhosis in 147 patients (39.0%). Eighty-three patients with cirrhosis had Child-Pugh A (56.4% of patients with cirrhosis) and 64 had Child-Pugh B/C (43.6%). Overall, the sensitivity for diagnosing cirrhosis by US was 0.71 (95% CI 0.62-0.79) and for CT 0.74 (95% CI 0.64-0.83). The specificity was high for US (0.94, 95% CI 0.90-0.97) and for CT (0.93, 95% CI 0.83-0.98). When evaluating patients with Child-Pugh A cirrhosis, sensitivity was only 0.62 (95% CI 0.49-0.74) for US and 0.60 (95% CI 0.43-0.75) for CT. For patients with Child-Pugh B/C, sensitivity was 0.83 (95% CI 0.70-0.92) for US and 0.87 (95% CI 0.74-0.95) for CT. When limiting our analysis to NAFLD (20% with cirrhosis), the sensitivity for US was 0.45 (95% CI 0.28-0.64) and specificity was 0.97 (95% CI 0.93-0.99). US and CT show moderate sensitivity and may potentially overlook compensated cirrhosis underlining the need for additional diagnostic testing.

Association between red blood cell distribution width and the prognosis of brain death in patients with a Glasgow Coma Scale < 6

Red blood cell distribution width (RDW) has been reported as a meaningful prognostic factor in various diseases. Our study compared patients’ RDW levels and prognosis at admission and discharge time. A total of 128 patients 77 patients who suffered brain death (subject group), and 51 patients who were discharged from the hospital (control group) with GCS ≤ 6 were recruited from 60 hospitals for this study. Demographical data and RDW measurements in these patients at admission time and brain death/discharge time were extracted into two groups. 46 (35.9%) patients were females and 82 patients (64.1%) were males with a median age of 36 years old. A significant difference in baseline characteristics of GCS (P < 0.001), RDW at admission time (P < 0.001), and RDW at discharge or brain death time (P < 0.001) were noted between the two groups. In the overall population, RDW at admission time had a median value of 13.75% and was positively correlated with gender (P < 0.04, rs = 0.582) and age (P < 0.023, rs = − 0.201). Initially, there were no significant differences in RDW upon admission. However, upon discharge, although the RDW in the control group was not significant (P < 0. 1), the RDW level at the time of brain death was notably 0.45 fold higher (P = 0.001) compared to the time of admission. The standardized residuals at the two-time points showed an approximately normal distribution. The most effective RDW cut-off in Brain death was determined as 14.55. Based on the findings, using RDW as a prognostic factor has a sensitivity of 0.468 and a specificity of 0.137 in diagnosing brain death. RDW biomarker is a simple and inexpensive laboratory test that may be seen as a valuable perspective for initial patient evaluation. RDW is a powerful marker for the prognosis of brain death in patients with a GCS ≤ 6 at admission time, in order to identify a subset of patients who may require more aggressive management in the trauma center.

ROLE OF MRI IN EVALUATION OF SEIZURE DISORDER

Objectives: The present study was conducted to identify structural abnormalities on the brain imaging that may be associated with the cause of seizures and to study the spectrum of MRI findings in patients with seizures. Methods: This time-bound descriptive study was conducted on 100 seizure patients in the department of radiodiagnosis of GMC, Patiala. Informed consent was obtained and then MR imaging of brain was done. The results were analyzed. Results: Mean age was 39.59±15.96 years (range: 18–85 years) with 70% male and 30% female patients. The majority of the patients (80%) had generalized tonic–clonic seizures, followed by myoclonic seizures (8%), simple partial seizures (5%), complex partial seizures (2%), absence seizures (2%), motor seizures (1%), febrile seizures (1%), and tonic seizures (1%). The mean seizure duration was 2.15±1.48 months. On magnetic resource imaging (MRI), 44% patients had normal MRI. In remaining patients, MRI findings were infarct with gliosis (20%), ring enhancing lesions (18%), atrophy (6%), neoplasm (4%), thrombosis (3%), venous malformation (2%), and developmental malformations (3%). Conclusion: The most common type of seizures is GTCS. MRI can be normal in the majority of the patients of seizures. Common MRI abnormalities were infarct with gliosis and ring-enhancing lesions. Hence, MRI plays a significant role in the initial evaluation of seizures patients to rule out any organic or developmental lesions.