Nonspecific Diagnosis Research Articles

TEVAR in Connective Tissue Disease Patients is Not a Definitive Option

Open surgery is the gold standard for connective tissue disorder (CTD) patients. Thoracic endovascular aortic repair (TEVAR) is utilized in emergencies and patient specific situations. Limited data on durability of TEVAR in CTD patients exists. The purpose of this study is to investigate durability, complications, and outcomes of TEVAR in CTD patients. This single center retrospective study included 40 CTD patients who underwent TEVAR for thoracoabdominal aortic aneurysm or aortic dissection from 2/2014 - 4/2021. CTDs included Marfan Syndrome (MFS), Loey-Dietz Syndrome (LDS), and non-specific CTD related diagnoses. Primary outcomes included aortic-related morbidities, time to and type of post-operative reinterventions, and time to open/hybrid conversion. Time to conversion and reintervention was calculated using Kaplan-Meier estimation. Predictors of reintervention and open/hybrid conversion were evaluated using Cox proportional hazards models. Median age was 53yrs with 52.5% being female. MFS was diagnosed in 57.5%, LDS in 2.5%, and 40% had diagnosed non-specific or other CTD. Thirty-two (80%) had prior aortic interventions. Thoracic aneurysm existed in 52.5% and dissection in 82.5%. Average maximum thoracic aortic diameter was 55.2mm. There were 2 mortalities within the first month. Of the remaining 38 patients, 71.1% had aneurysm related morbidities including 81.5% with aneurysmal degeneration and 33.3% with endoleak. Overall, 62.5% required reintervention. Of those, median time to reintervention was 9.1mths, including redo-TEVAR/extension in 32%, ascending/arch repair in 24%, open thoracoabdominal aortic repair in 56%, and false lumen embolization in 16%. Open conversions and reintervention were most likely to occur within the first year, with freedom of open conversion at 67.2% at 1 year, and 59.7% at 2 and 3 years, and freedom of reintervention at 49.8%, 36%, and 30% at 1, 2, and 3 years, respectively. This study suggests that TEVAR for CTD patients can be performed safely, however, patients are at high risk for aortic-related morbidities and reintervention. Reinterventions and open conversion are common and more likely to occur within one year. TEVAR should remain limited in this population until more durable outcomes are possible.

The incidence, providers involved, and patient factors associated with diagnosis of specific lumbar spine pathology subsequent an initial nonspecific low back pain diagnosis

Background ContextLow back pain (LBP) is an exceedingly common diagnosis with significant societal and healthcare burden. While nonspecific LBP diagnoses are frequently assigned and often resolve soon thereafter, some patients may subsequently be diagnosed with specific underlying lumbar spine pathology. PurposeTo characterize the incidence, providers involved, and factors associated with specific pathology LBP (SP-LBP) diagnosed subsequent an initial nonspecific LBP (NS-LBP) diagnosis. Study DesignRetrospective cohort study. Patient SampleAdult patients diagnosed with NS-LBP between 2010 – Q1 2022 were abstracted from a large national administrative database. Outcome MeasurementsIncidence of subsequent SP-LBP diagnoses, providers involved, and factors associated with SP-LBP diagnoses in the 12-months following initial NS-LBP diagnosis. MethodsAdult patients diagnosed with NS-LBP were identified based on International Classification of Disease (ICD) codes ICD-9-D-724.2 and ICD-10-D-M54.5. These patients diagnosed with new NS-LBP were reported based on incidence per 100,000 covered lives. Exclusion criteria included: patients less than 18 years old, those with any prior NS-LBP diagnosis, any prior SP-LBP diagnoses, and those with trauma, neoplasm, or infection diagnosed within 3-months prior to the initial NS-LBP diagnosis. Patients who subsequently received SP-LBP diagnoses within 12-months following initial NS-LBP were then identified. Patients were characterized based on age, sex, history of cancer, obesity, opioid use disorder, anxiety, and depression and then compared with patients receiving no additional LBP diagnosis by univariable and multivariable analysis. Provider specialties who initially diagnosed NS-LBP and those involved with subsequent SP-LBP diagnoses were identified. ResultsNS-LBP was identified for a robust cohort of 6,861,235 patients, yielding an incidence of 4,258 diagnoses per 100,000 covered lives. Subsequent SP-LBP diagnoses were identified for 562,982 (8.21%) within 12-months, of which 62.57% of these SP-LBP diagnoses occurred within 3-months. The most common of these subsequent diagnoses included radiculopathy (3.01% of the overall study population), disc degeneration (2.84%), and disc herniation (1.23%). Patients receiving a subsequent SP-LBP diagnosis were more likely older (per year increase, odds ratio [OR] 1.02), male (OR 1.10), had a history of cancer (OR 1.32), obesity (OR 1.30), opioid use disorder (OR 1.17), anxiety (OR 1.21), or depression (OR 1.17) (p<0.001 for all). NS-LBP was initially diagnosed predominantly by primary care providers (PCPs) in family medicine (44.09%) and internal medicine (27.49%). These PCP providers also contributed to the majority of SP-LBP diagnoses, while specialty providers contributed to a greater degree in SP-LBP diagnoses than NS-LBP. ConclusionNS-LBP is a common diagnosis that usually, 91.79% of the time, does not subsequently convert to a SP-LBP diagnosis within 12-months. This may reflect improvement of LBP symptoms and/or accurate initial triage, largely by PCPs. Of the minority of patients receiving a subsequent SP-LBP diagnosis, various patient factors were significantly associated, and a greater degree of specialty providers were involved, which highlights potential contributors to diagnostic difficulty of SP-LBP and the multidisciplinary nature of LBP management.

Chronic Lower Respiratory Diseases detection based on Deep Recursive Convolutional Neural Network

Recently, symptoms of Chronic Obstructive Pulmonary Disease (COPD) have been identified concerning long-term continuous treatment. Furthermore, predicting the life probability of patients with COPD is crucial for formative ensuing treatment and conduct plans. Additionally, it plays a vital role in providing complementary solutions using technologies such as Deep Learning (DL) to address experiments in the medical field. Early and timely analysis of clinical images can improve prognostic accuracy. These include COPD, pneumonia, asthma, tuberculosis and fibrosis. Conventional methods of diagnosing COPD often rely on physical exams and tests such as spirometers, chest and genetic analysis. However, respiratory diseases pose an enormous comprehensive health burden for many patients. Thus these methods are not always accurate or obtainable. However, succeeding in their accuracy involves a nonspecific diagnosis rate, time-consuming manual procedures, and extensive clinical imaging knowledge of the radiologist. To solve this problem, we use a Deep Recursive Convolutional Neural Network (DRCNN) method to detect chronic lower respiratory disease. Initially, we collected the images from the Kaggle repository, and evaluate the result based on the following stage. The first stage is pre-processing using a Gaussian filter to reduce noise and detect the edges. The second stage is segmentation used on Image Threshold Based Segmentation (ITBS), used for counting the binary image and separating the regions. In the third stage, we use the chi-square test to select the best features and evaluate the image values for each feature and threshold. Finally, classification using DRCNN detects CLRD classifying better than the previous method. In synthesis, CLRD can be detected by many staging measures, such as sensitivity, specificity, accuracy, precision, and Recall

Patients with Non-Specific Complaints in Emergency Departments: A Growing Patient Safety Concern in an Aging Population with Multimorbidity.

In this opinion, we offer a new perspective on the important and persistent problem of diagnostic errors for patients with non-specific complaints (NSCs). As an increasing number of complex patients present clinicians with challenging diagnostic work in the time-pressured and high-volume contexts of EDs, we need to improve how clinicians and healthcare organizations can understand and perform safe diagnostics for patients with NSCs. The combination of a growing number of patients with NSCs and the ways in which clinicians use the categories 'non-specific complaints' and 'non-specific diagnosis' in diagnostic work in emergency departments presents a growing patient safety concern especially for older patients with multimorbidity that require the integration of clinical and organizational research. We argue why the growing numbers of patients with NSCs and clinicians' use of these categories have implications for patient safety both within and beyond the acute care context. We end by pointing to the importance of an interdisciplinary patient safety research agenda, ideally followed by the development of targeted usable protocols for older multimorbid patients with non-specific complaints.

Dizziness and vertigo sick leave before and after insurance restrictions – a descriptive Swedish nationwide register linkage study

BackgroundVertigo and dizziness can be disabling symptoms that result in sick leave. Research regarding sickness absence due to dizziness has focused on specific vestibular diagnoses rather than the nonspecific vertigo/dizziness diagnoses. Strict sick leave regulations were introduced in Sweden in 2008. The aim of this study was to describe the vertigo/dizziness sick leave prevalence and duration considering both specific and nonspecific diagnoses according to International Classification of diseases 10th revision (ICD-10) on the 3-digit level, including the less specific “R” diagnoses.MethodsThrough Swedish nationwide registers we identified individuals aged 16–64 years who during the years 2005–2018 were sickness absent > 14 consecutive days – minimum register threshold – due to vertigo/dizziness diagnoses according to ICD10 codes: specific diagnoses (H81.0, H81.1, H81.2, H81.3, H81.4, G11x) and nonspecific (R42, R26, R27, H81.9). We described the demographic characteristics, prevalence and duration of such sick-leave spells. Data were stratified according to diagnostic groups: ataxias, vestibular and nonspecific.ResultsWe identified 52,179 dizziness/vertigo sick leave episodes > 14 days in 45,353 unique individuals between 2005–2018, which constitutes 0.83% from all sick leave episodes in the given period.The nonspecific diagnoses represented 72% (n = 37741) of sick leave episodes and specific vestibular H-diagnoses 27% (n = 14083). The most common specific vestibular codes was Benign paroxysmal positional vertigo (BPPV) 9.4% (n = 4929). The median duration of sick leave was 31 days (IQR 21–61). Women on sick leave were younger than men (47 vs 51 years, p < 0.05) and had a higher proportion of nonspecific diagnoses compared with men (74% vs 70%, p < 0.05).ConclusionsThe vast majority of vertigo/dizziness sick leave episodes were coded as nonspecific diagnoses and occurred in women. BPPV, a curable vestibular condition, was the most common specific diagnosis. This suggests a potential for improved diagnostics. Women on sick leave due to dizziness/vertigo were younger and more often received nonspecific diagnostic codes. Future studies should determine the frequency of use of evidence based therapies and investigate further the gender differences.

Race and Ethnicity and Diagnostic Testing for Common Conditions in the Acute Care Setting

Overuse of diagnostic testing is pervasive, but the extent to which it varies by race and ethnicity in the acute care setting is poorly understood. To use a previously validated diagnostic intensity index to evaluate differences in diagnostic testing rates by race and ethnicity in the acute care setting, which may serve as a surrogate for diagnostic test overuse. This was a cross-sectional study of emergency department (ED) discharges, hospital observation stays, and hospital admissions using administrative claims among EDs and acute care hospitals in Kentucky, Maryland, North Carolina, and New Jersey, from 2016 through 2018. The diagnostic intensity index pairs nonspecific principal discharge diagnoses (nausea and vomiting, abdominal pain, chest pain, and syncope) with related diagnostic tests to estimate rates of nondiagnostic testing. Adults with an acute care encounter with a principal discharge diagnosis of interest were included. Data were analyzed from January to February 2024. Race and ethnicity (Asian, Black, Hispanic, White, other [including American Indian, multiracial, and multiethnic], and missing). Receipt of a diagnostic test. Generalized linear models with a hospital-specific indicator variable were estimated to calculate the adjusted odds ratio of receiving a test related to the principal discharge diagnosis by race and ethnicity, controlling for primary payer and zip code income quartile. Of 3 683 055 encounters (1 055 575 encounters [28.7%] for Black, 300 333 encounters [8.2%] for Hispanic, and 2 140 335 encounters [58.1%] for White patients; mean [SD] age of patients with encounters, 47.3 [18.8] years; 2 233 024 encounters among females [60.6%]), most (2 969 974 encounters [80.6%]) were ED discharges. Black compared with White patients discharged from the ED with a diagnosis of interest had an adjusted odds ratio of 0.74 (95% CI, 0.72-0.75) of having related diagnostic testing. No other racial or ethnic disparities of a similar magnitude were observed in any acute care settings. In this study, White patients discharged from the ED with a nonspecific diagnosis of interest were significantly more likely than Black patients to receive related diagnostic testing. The extent to which this represents diagnostic test overuse in White patients vs undertesting and missed diagnoses in Black patients deserves further study.

Role of Gender in Health and Disease: Methods of Reporting and Interactions with Sex and Other Factors.

Sex and gender are distinct terms that must be used correctly. Data regarding sex and gender may be collected using a 2-step method that separates biological sex and self-reported gender identity. The PhenX Toolkit, funded by the National Institutes of Health (NIH), is one tool that provides investigators with recommended standard data-collection protocols. Another tool is the Diversity Minimal Item Set questionnaire. Importantly, sex and gender interact: for example, pain has both biological aspects (sex differences in electrical, ischemic, thermal, pressure, and muscle pain sensitivity) and cultural aspects (gender factors in how people report pain and how physicians understand and treat pain in patients). Gender norms, identity, and relations all impact patient care. Gender norms, for instance, may influence how a person experiences pain, gender identity may influence a person's willingness to report pain, and gender relations may influence a physician's gendered expectations in relation to a patient's gendered behaviors. Clinicians may perceive women's pain to be psychological; as a result, women may receive more nonspecific diagnoses, wait longer for treatment, and receive more antidepressants and fewer analgesics than men. Research on gender-diverse people and pain is just now emerging. Resources for methods of reporting include The Lancet, Nature, and the Sex and Gender Equity in Research (SAGER) Guidelines. We must consider all relevant factors intersecting with sex and gender, including age, disabilities, educational background, ethnicity, family configuration, geographic location, race, sexuality, social and economic status, sustainability, and more.

Indications for a brain biopsy in neurological diseases of unknown etiology: The role of magnetic resonance imaging findings and liquid biopsy in yielding definitive pathological diagnoses

Brain biopsies are often considered for patients who cannot be diagnosed with various laboratory test results. However, physicians tend to be hesitant regarding their application in possibly non-neoplastic brain diseases, due to the invasiveness and risks. The aim was to determine the indications for brain biopsies in cases of neurological diseases of unknown etiology. We retrospectively evaluated diagnostic accuracy, laboratory findings (including a liquid biopsy for malignant lymphoma), magnetic resonance imaging (MRI) characteristics and the post-treatment outcomes of patients undergoing brain biopsies for neurological diseases of unknown etiology. The data of patients who had undergone a brain biopsy during their admission to Niigata University Hospital, between 2011 and 2024, were reviewed. Moreover, the laboratory data and MRI findings between patients with definitive and nonspecific biopsy diagnoses were compared. Twenty-six patients underwent a brain biopsy, and a definitive diagnosis was obtained in 14 patients (53.8%). Even in cases where a nonspecific diagnosis was made, biopsy findings helped rule out malignancy and guide clinical diagnosis and treatment decisions. The liquid biopsy for malignant lymphoma was performed in eight patients, with one yielding a positive result, consistent with primary central nervous system lymphoma. The sensitivity and specificity of liquid biopsy were 0.5 and 1, respectively. Diffusely contrasted cortical lesions and the presence of mass effects on MRI, were significantly associated with a definitive diagnosis, compared to a nonspecific diagnosis. In conclusion, brain MRI and liquid biopsies can assist in determining the appropriate indications for brain biopsies in neurological diseases of unknown etiology.

Pregnancy and Unilateral Krukenberg Tumour: Factual or Fictious – A Case Report

Krukenburg tumor, a secondary ovarian neoplasm, arises from various primary sites. It’s occurrence during pregnancy is extremely rare. We are reporting the case of a 24 year old G2P1L1 lady with a unilateral Krukenberg tumor diagnosed in first trimester of pregnancy. The case posed as a diagnostic challenge as the presentation is non-specific and radiological diagnosis is very challenging owing to the similarity of the tumour to ectopic pregnancy on imaging. The sparsity of data and unique presentation of the patient inspired us to write this report. This is a 24 year old lady who presented to the emergency department with the complaints of amenorrhea for 2 months, pain abdomen and bleeding per vaginum for 2 days. Urine Pregnancy Test done at home was positive. She was found to be in shock and was resuscitated. Ultrasonography done showed a possibility of an ectopic pregnancy with rupture or a partial molar pregnancy. She was taken up for emergency laparotomy, a lobulated, irregular right sided ovarian mass suggestive of a right ovarian neoplasm with a normal left ovary and an intrauterine incomplete abortion was found. She underwent right salpingo-oophorectomy along with the ovarian mass; with stepwise exploration of pelvis and abdomen followed by dilatation and curettage for the evacuation of the retained product of conception. Histopathological examination revealed features suggestive of metastatic Signet Ring Cell Carcinoma. Further investigation with CECT chest, abdomen and pelvis and upper GI endoscopy revealed a gastric primary. This case depicts the challenges faced by physicians in correctly diagnosing malignant tumours during pregnancy. By reporting this case, we aim to raise awareness among physicians regarding the need for heightened vigilance and multi-disciplinary approach in order to timely and accurately diagnose such conditions.

Diagnosing an overcrowded emergency department from its Electronic Health Records

Emergency department overcrowding is a complex problem that persists globally. Data of visits constitute an opportunity to understand its dynamics. However, the gap between the collected information and the real-life clinical processes, and the lack of a whole-system perspective, still constitute a relevant limitation. An analytical pipeline was developed to analyse one-year of production data following the patients that came from the ED (n = 49,938) at Uppsala University Hospital (Uppsala, Sweden) by involving clinical experts in all the steps of the analysis. The key internal issues to the ED were the high volume of generic or non-specific diagnoses from non-urgent visits, and the delayed decision regarding hospital admission caused by several imaging assessments and lack of hospital beds. Furthermore, the external pressure of high frequent re-visits of geriatric, psychiatric, and patients with unspecified diagnoses dramatically contributed to the overcrowding. Our work demonstrates that through analysis of production data of the ED patient flow and participation of clinical experts in the pipeline, it was possible to identify systemic issues and directions for solutions. A critical factor was to take a whole systems perspective, as it opened the scope to the boundary effects of inflow and outflow in the whole healthcare system.

A case report on cocoon abdomen

Abdominal Cocoon is one of the rare causes of intestinal obstruction. A complete or partial small bowel encapsulation caused by thick fibro collagenous membrane. Cocoon Abdomen is otherwise called Sclerosing Encapsulating Peritonitis (SEP). This SEP is divided into two: abdominal cocoon (AC) also known as idiopathic or primary sclerosing encapsulating peritonitis, which is extremely a rare and secondary sclerosing encapsulating peritonitis, which is a common one. Symptoms are nonspecific and preoperative diagnosis was extremely difficult. Surgery is very essential to take membrane samples that confirm diagnosis and for treatment.

Acute patients discharged without an established diagnosis: risk of mortality and readmission of nonspecific diagnoses compared to disease-specific diagnoses.

Nonspecific discharge diagnoses after acute hospital courses represent patients discharged without an established cause of their complaints. These patients should have a low risk of adverse outcomes as serious conditions should have been ruled out. We aimed to investigate the mortality and readmissions following nonspecific discharge diagnoses compared to disease-specific diagnoses and assessed different nonspecific subgroups. Register-based cohort study including hospital courses beginning in emergency departments across 3 regions of Denmark during March 2019-February 2020. We identified nonspecific diagnoses from the R- and Z03-chapter in the ICD-10 classification and excluded injuries, among others-remaining diagnoses were considered disease-specific. Outcomes were 30-day mortality and readmission, the groups were compared by Cox regression hazard ratios (HR), unadjusted and adjusted for socioeconomics, comorbidity, administrative information and laboratory results. We stratified into short (3-<12h) or lengthier (12-168h) hospital courses. We included 192,185 hospital courses where nonspecific discharge diagnoses accounted for 50.7% of short and 25.9% of lengthier discharges. The cumulative risk of mortality for nonspecific vs. disease-specific discharge diagnoses was 0.6% (0.6-0.7%) vs. 0.8% (0.7-0.9%) after short and 1.6% (1.5-1.7%) vs. 2.6% (2.5-2.7%) after lengthier courses with adjusted HRs of 0.97 (0.83-1.13) and 0.94 (0.85-1.05), respectively. The cumulative risk of readmission for nonspecific vs. disease-specific discharge diagnoses was 7.3% (7.1-7.5%) vs. 8.4% (8.2-8.6%) after short and 11.1% (10.8-11.5%) vs. 13.7% (13.4-13.9%) after lengthier courses with adjusted HRs of 0.94 (0.90-0.98) and 0.95 (0.91-0.99), respectively. We identified 50 clinical subgroups of nonspecific diagnoses, of which Abdominal pain (n = 12,462; 17.1%) and Chest pain (n = 9,599; 13.1%) were the most frequent. The subgroups described differences in characteristics with mean age 41.9 to 80.8 years and mean length of stay 7.1 to 59.5h, and outcomes with < 0.2-8.1% risk of 30-day mortality and 3.5-22.6% risk of 30-day readmission. In unadjusted analyses, nonspecific diagnoses had a lower risk of mortality and readmission than disease-specific diagnoses but had a similar risk after adjustments. We identified 509 clinical subgroups of nonspecific diagnoses with vastly different characteristics and prognosis.

Reductions in sustained prescription opioid use within the US between 2017 and 2021

Over the last decade, various efforts have been made to curtail the opioid crisis. The impact of these efforts, since the onset of the COVID-19 pandemic, has not been well characterized. We sought to develop national estimates of the prevalence of sustained prescription opioid use for a time period spanning the COVID-19 pandemic (2017–2021). We used TRICARE claims data (fiscal year 2017–2021) to identify patients who were prescription opioid non-users prior to receipt of a new opioid medication. We evaluated eligible patients for subsequent sustained prescription opioid use. The prevalence of sustained prescription opioid use during 2020–2021 was compared to 2017–2019. We performed multivariable logistic regression analyses to adjust for confounding. We performed secondary analyses that accounted for interactions between the time period and age, as well as a proxy for socioeconomic status. We determined there was a 68% reduction in the odds of sustained prescription opioid use (OR 0.32; 95% CI 0.27, 0.38; p < 0.001) in 2020–2021 as compared to 2017–2019. Significant reductions were identified across all US census divisions and all patient age groups. In both time periods, the plurality of encounters associated with initial receipt of an opioid that culminated in sustained prescription opioid use were associated with non-specific primary diagnoses. We found significant reductions in sustained prescription opioid use in 2020–2021 as compared to 2017–2019. The persistence of prescribing behaviors that result in issue of opioids for poorly characterized conditions remains an area of concern.

Diagnosis of “intensive care unit-acquired weakness” and “critical illness myopathy”: Do the diagnostic criteria need to be revised?

ObjectivesIntensive care unit acquired weakness (ICUAW) is a clinical diagnosis and an umbrella term for acquired weakness due to neuromuscular disorders such as critical illness myopathy (CIM) but also muscular inactivity/atrophy. Without a clear understanding of the distinct aetiology, it seems difficult to predict outcomes of ICUAW and to test and apply effective future treatments. The present study contrasts ICUAW with CIM and assesses the diagnostic and clinical relevance for affected patients. MethodsData from a previous prospective cohort study investigating critically ill COVID-19 patients was analysed in a retrospective fashion. Patients were examined ten days after intubation with clinical assessment, nerve conduction studies, electromyography and muscle biopsy. Mortality was assessed during critical illness and at three months after hospital discharge. ICUAW and CIM were diagnosed according to the current diagnostic guidelines. ResultsIn this patient sample (n = 22), 92 % developed ICUAW, 55 % developed ICUAW and CIM, and 36 % had ICUAW but did not develop CIM. Overall, 27 % patients died during their stay in the intensive care unit. At three months after discharge, there were no further deaths, but in 14 % of patients the outcome was unknown. The diagnosis of CIM was more strongly associated with death during critical illness than ICUAW. No patient with ICUAW who did not fulfil the criteria for CIM died. Both clinical and electrophysiological criteria showed excellent sensitivity for CIM diagnosis, but only electrophysiological criteria had a high specificity. Determination of the myosin:actin ratio showed neither high sensitivity nor specificity for the diagnosis of CIM. ConclusionsThe results of the present study support that ICUAW is a non-specific clinical diagnosis of low predictive power with regard to mortality. Further, diagnosing “ICUAW” seems also of little research value for both exploring the aetiology and pathophysiology of muscle weakness in critically ill patients and for evaluating potential treatment effects. Thus, more specific diagnoses such as CIM are more appropriate. Within the different diagnostic criteria for CIM, electrophysiological studies are the most sensitive and specific examinations compared to clinical and muscle tissue assessment. SignificanceAvoiding an overarching diagnosis of “ICUAW” and instead focusing on specific diagnoses appears to have several relevant consequences: more precise diagnosis making, more accurate referral to aetiology and pathophysiology, improved outcome prediction, and development of more appropriate treatments.

Treatment with direct thrombolytic infusion via mesenteric catheter and thrombectomy in superior mesenteric vein thrombosis due to synthetic drug use

Mesenteric vein thrombosis (MVT) is a rare cause of acute abdomen and accounts for only 5-15% of all acute mesenteric ischaemia cases. MVTs are classified as either primary MVT, in which the underlying cause can not be determined, or secondary MVT, in which the etiology can be determined. Symptoms usually begin with nonspecific abdominal pain. Progressively increasing abdominal pain is often accompanied by nausea, vomiting and bloody diarrhea. In severe cases, sepsis and septic shock are seen. As the cases usually present with nonspecific symptoms, diagnosis and treatment may be delayed. Despite advanced diagnostic techniques, high mortality rates are seen. We aimed to present a case with a complaint of abdominal pain who underwent interventional thrombectomy and thrombolysis with the diagnosis of superior MVT.

Diagnostic Yield vs Diagnostic Accuracy for Peripheral Lung Biopsy Evaluation: Evidence Supporting a Future Pragmatic End Point

Diagnostic yield and accuracy endpoints have been used inconsistently in the evaluation of advanced diagnostic bronchoscopy devices and techniques, limiting between-study comparisons. In addition, diagnostic accuracy can only be adjudicated after prolonged clinical follow-up which delays reporting on the performance of novel devices. Will a conservative diagnostic yield definition would result in few false negative initial results to closely approximate diagnostic accuracy and represent a useful outcome for future studies of diagnostic utility? Commonly utilized definitions of diagnostic yield were applied to a prospective dataset of consecutive peripheral pulmonary lesions sampled by navigational bronchoscopy from 2017 to 2019. All consider malignancy to be diagnostic but differ in their classification of non-malignant biopsy findings, which were subcategorized as specific benign, nonspecific benign, or normal lung. Diagnostic yield calculations were also compared to diagnostic accuracy, defined as the proportion of biopsies deemed diagnostic by each definition that were confirmed accurate through two years of follow-up. A total of 450 biopsied lesions were analyzed. The prevalence of malignancy was 60.9% (274 of 450). On initial bronchoscopy pathology, there were 227 malignant diagnoses (50.4%), with a single false-positive (0.4%). Among 104 biopsies with specific benign findings, only two were false negative for malignancy (1.9%). There were 119 nonspecific benign biopsies with 46 false negatives for malignancy (38.7%). The discrepancy between diagnostic yield and accuracy was 0.7% for the conservative definition which only considered malignant or specific benign findings as diagnostic. A conservative diagnostic yield definition excluding nonspecific benign diagnoses closely approximated diagnostic accuracy through two years follow-up, with a less than 1% discrepancy. Using this conservative yield definition may allow for dissemination of reliable diagnostic utility data without protracted delays needed for follow-up data in this era of rapid technological change in advanced diagnostic bronchoscopy.

Deaths Among Ambulance Patients Released from the Emergency Department Within the First 24 Hours With Nonspecific Diagnoses - Expected or Not?

BackgroundEmergency patients are frequently assigned nonspecific diagnoses. Nonspecific diagnoses describe observations or symptoms and are found in chapters R and Z of the International Classification of Diseases, 10th edition (ICD-10). Patients with such diagnoses have relatively low mortality, but due to patient volume, the absolute number of deaths is substantial. However, information on cause of short-term mortality is limited. ObjectivesTo investigate whether death could be expected for ambulance patients brought to the emergency department (ED) after a 1-1-2 call, released with a nonspecific ICD-10 diagnosis within 24 h, and who subsequently died within 30 days. MethodsRetrospective medical record review of adult 1-1-2 emergency ambulance patients brought to an ED in the North Denmark Region during 2017–2021. Patients were divided into three categories: unexpected death, expected death (terminal illness), and miscellaneous. Charlson Comorbidity Index (CCI) was assessed. ResultsWe included 492 patients. Mortality was distributed as follows: Unexpected death 59.2% (n = 291), expected death (terminal illness) 25.8% (n = 127), and miscellaneous 15.0% (n = 74). Patients who died unexpectedly were old (median age of 82 years) and had CCI 1–2 (58.1%); 43.0% used at least five daily prescription drugs, and they were severely acutely ill upon arrival (24.7% with red triage, 60.1% died within 24 h). ConclusionsMore than half of ambulance patients released within 24 h from the ED with nonspecific diagnoses, and who subsequently died within 30 days, died unexpectedly. One-fourth died from a pre-existing terminal illness. Patients dying unexpectedly were old, treated with polypharmacy, and often life-threateningly sick at arrival.

Maternal Mental Health Diagnoses and Infant Emergency Department Use, Hospitalizations, and Death

BackgroundThe period surrounding childbirth is a uniquely vulnerable time for women and their mental health. We sought to describe the association between maternal mental health diagnoses in the year prior and after birth and infant Emergency Department (ED) utilization, hospitalization, and death. MethodsWe studied mothers who gave singleton live birth in California (2011–2017) and their infants using linked infant birth and death certificates and maternal and infant discharge records. Maternal mental health diagnoses in the year before and after birth were identified using International Classification of Diseases (ICD) codes. We abstracted infant ED visits, hospitalizations, discharge diagnoses, deaths, and causes of death. Log-linear regression was used to compare relative risks of infant outcomes between mothers with and without mental health diagnoses, adjusting for maternal variables. ResultsOf the 3,067,069 mother-infant pairs, 85,047 (2.8%) mothers had at least one mental health diagnosis in the year before and after birth. Infants of mothers with mental health diagnoses were more likely to visit the ED (aRR 1.2, CI:1.1–1.2), have three or more ED visits (aRR 1.4, CI:1.3–1.4), be hospitalized (aRR 1.1, CI:1.04–1.1), and die (aRR 1.7, CI:1.6–1.8) in the first year of life. These infants were also more likely to be diagnosed with accidental injuries, nonaccidental trauma, and non-specific descriptive diagnosis (fussiness/fatigue/brief resolved unexplained event). ConclusionThis large administrative cohort study showed associations between maternal mental health diagnoses and infant acute ED visits, hospitalization, and death. This study underscores the urgent need to understand what is driving these findings and how to mitigate this risk.

Pseudotumor inflamatorio ocular asociado a IgG4. Reporte de un caso

IgG4-associated ocular inflammatory pseudotumor is a rare, non-neoplastic inflammatory process with an incidence of 0.28-1.08 per 100,000 people. The diagnosis of this pathology is one of exclusion, having to meet histopathological criteria, enlargement of a specific organ, and serious concentrations of IgG4. Treatment aims to avoid secondary complications. Clinical case: A 54-year-old woman with no previous re-ported pathologies, reports that for the past 6 months she has itching at the level of the eyeball and the left eyelid, suddenly and without apparent cause, in addition to decreased visual acuity and retro-ocular pain; this is why she asked for the evaluation. The physical examination revealed normal eye movements, left proptosis, pain on palpation, subconjunctival hyperemia, corneal opacity, absence of red reflex, and the left eye being more resistant to pressure in relation to the contralateral eye. The cranio-thoraco-abdominal tomography reported images at the left ocular level that were suggestive of choroidal melanoma without findings of metastatic activity. Enucleation of the left eye was performed. The specimen was sent to pathology which reported diffuse lymphoplasmacytic infiltrate positive for IgG4. Conclusion: Ocular IgG4 disease is a very rare pathology with non-specific symptoms and complex diagnosis. However, a quick and correct approach is essential to avoid complications.

Critically deviating vital signs among patients with non-specific diagnoses-A register-based historic cohort study.

One third of ambulance patients receive non-specific diagnoses in hospital. Mortality is 3-4%, however due to the high patient volume this group accounts for 20% of all deaths at day 30. Non-specific diagnoses do not provide much information on causes for death. Vital signs at first contact with ambulance personnel can act as a proxy for the patient's condition. Thus, we aimed to describe the prevalence of abnormal vital signs, as determined by a modified NEWS2, in ambulance patients who received a non-specific hospital diagnosis. Secondly, we examined the association between vital signs, NEWS2 scores, type of non-specific diagnosis, and mortality among these patients. Register-based historic cohort study of ambulance patients aged 16+ in the North Denmark Region during 2012-2016, who received a non-specific diagnosis (ICD-10 chapters R or Z) at hospital. We used NEWS2 scores to determine if first vital signs were normal or deviating (including critical). Mortality was estimated with the Kaplan-Meier estimator. Association between vital signs and mortality was evaluated by logistic regression. We included 41,539 patients, 20.9% (N = 8,691) had normal vital signs, 16.3% (N = 6,766) had incomplete vital sign registration, 62.8% (N = 26,082) had deviating vital signs, and of these 6.8% (N = 1,779) were critical. If vital signs were incompletely registered or deviating, mortality was higher compared to normal vital signs. Patients with critical vital signs displayed the highest crude 48-hour and 30-day mortality (7.0% (5.9-8.3) and 13.4% (11.9-15.1)). Adjusting for age, sex, and comorbidity did not change that pattern. Across all vital sign groups, despite severity, the most frequent diagnosis assigned was Z039 observation for suspected disease or condition unspecified. Most ambulance patients with non-specific diagnoses had normal or non-critical deviating vital signs and low mortality. Around 4% had critical vital signs and high mortality, not explained by age or comorbidity.