Physical Exam Findings Research Articles

486 Quantification of serum neurofilament light chain (NfL) in cubital tunnel

OBJECTIVES/GOALS: The long-term goal of our lab is to develop clinical and intra-operative methods to aid in assessment of compressive and traumatic peripheral neuropathies. The overall objective of this project is toidentify the potential of serum neurofilament light chain as a diagnostic biomarker for nerve injury. METHODS/STUDY POPULATION: The objective of this prospective study is to obtain data on serum NfL levels in patients with cubital tunnel syndrome and traumatic nerve injuries. Serum NfL from patients with cubital tunnel and traumatic nerve injuries will be compared to serum NfL of asymptomatic, sex and aged matched controls. Pre-operative and post-operative serum levels will be measured and compared topatient’s pre-operative physical exam findings, motor and sensory function testing, electrodiagnostic studies, ultrasound, presence of intraneural vascularity, and post-operative patient reported outcome measures for cubital tunnel patients. For patients with traumatic nerve injury, acute phase and a subsequent serum NfL measurement will be used to assess temporal changes in NfL. RESULTS/ANTICIPATED RESULTS: The central hypothesis of this study is that symptomatic compression of the ulnar nerve or traumatic injury to the brachial plexus leading to axonotmesis will result in measurable increases in serum NfL proportional to the degree of nerve injury. This hypothesis has been formulated based on clinical experience and published studies demonstrating increased expression of serum NfL levels with axonal injury secondary to varying forms of peripheral neuropathy. DISCUSSION/SIGNIFICANCE: The significance of this project is that characterization of the relationship of clinical symptoms, non-invasive imaging and expression of NfL will lead to better diagnostic and prognostic algorithms in the treatment of compressive and traumatic peripheral neuropathies.

Rash and Fever in a Returned Traveler.

A 21-year-old, otherwise healthy female presented to the emergency department with fever among other nonspecific symptoms after recently returning from Ghana. On physical exam, she had a characteristic upper extremity rash, and a tourniquet test revealed numerous petechiae. The diagnosis of dengue was suspected and subsequently confirmed. Dengue is one of many viral illnesses that should be considered in returning travelers presenting with fever and other nonspecific symptoms. Emergency physicians must keep a broad differential when evaluating fever in returned travelers and prioritize history and physical exam findings to help narrow the diagnosis and provide appropriate management and supportive care while awaiting further confirmatory testing.

Abstract 5065: Integrating blood based liquid biopsies with TNM stage improves survival prediction model for non-small cell lung cancer

Abstract Introduction:Stage is the most important prognostic factor for survival in non-small cell lung cancer (NSCLC). The current TNM (Tumor, Node, Metastasis) staging system for NSCLC uses physical exam, histology, imaging, and surgical findings to define the extent and spread of a patient’s cancer. Despite advances in molecular testing which can impact treatment and prognosis for NSCLC patients, the current system does not incorporate molecular data into staging. We proposed a novel predictive model for survival analysis which integrates molecular analysis of liquid biopsies (B) into the TNM staging system (1). In this study, we tested this new staging system and our predictive model shows TNM + B (TNMB) provides a better predictive model for survival compared to TNM alone. Methods:176 patients were identified at Atrium Health Wake Forest Baptist with Guardant 360 liquid biopsies sent at diagnosis for NSCLC. Clinical data was obtained through retrospective chart review. Molecular analysis was performed on 81 genes across all Guardant 360 liquid biopsies. Using Cox proportional hazards model, we identified significant gene mutations or genes with significant magnitude of variant allele frequency (VAF) that improved survival prediction. We then designed a novel staging system incorporating whether a patient had a positive liquid biopsy test (B1), defined by the presence of these impact gene variables, to TNM stage. Results: Three impact genes STK11 (p=0.0253), NFE2L2 (p = 0.0025), TP53 (p=0.0129) and one gene with a magnitude of VAF, ARID1A (p=0.0082) was identified which significantly improved the predictive model for survival. Patients with negative liquid biopsy test, B0, had improved survival compared to patients with a positive liquid biopsy test, B1 (p<0.005). In our cohort, TNM staging alone did not show a significant survival difference between stage II and III (p = 0.19). Whereas TNMB staging showed a significant survival difference between stage II, III and IV. Conclusions: While TNM stage remains a major prognostic factor for NSCLC patients, it fails to incorporate molecular data which has a critical impact on management and prognosis. We designed a novel method to analyze molecular data obtained by liquid biopsy to identify significant gene mutations and gene magnitude of VAF that impacts survival prediction. In our cohort, we showed 4 impact genes which we used to create a new TNMB staging system which led to improved survival prediction compared to TNM alone. Acknowledgments: Research partly supported by NIH T32 Grant (T32CA247819) and Cancer Center Support Grant (P30CA012197) Reference: (1) Yang M, Forbes ME, Bitting RL, O'Neill SS, Chou PC, Topaloglu U, Miller LD, Hawkins GA, Grant SC, DeYoung BR, Petty WJ, Chen K, Pasche BC, Zhang W. Incorporating Blood-based Liquid Biopsy Information into Cancer Staging: Time for a TNMB System? Ann Oncol. 2018 Feb 1;29(2):311-323. Citation Format: Lauren Schmalz, Cetin Urtis, Liang Liu, Elizabeth Forbes, Fang-Chi Hsu, Nury Steuerwald, Alberto de Hoyos, Thomas Lycan, Jimmy Ruiz, William Petty, Wei Zhang. Integrating blood based liquid biopsies with TNM stage improves survival prediction model for non-small cell lung cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 5065.

Peri-articular elbow fracture fixations with magnesium implants and a review of current literature: A case series.

In recent years, the use of Magnesium alloy implants have gained renewed popularity, especially after the first commercially available Conformité Européenne approved Magnesium implant became available (MAGNEZIX® CS, Syntellix) in 2013. To document our clinical and radiographical outcomes using magnesium implants in treating peri-articular elbow fractures. Our paper was based on a retrospective case series design. Intra-operatively, a standardized surgical technique was utilized for insertion of the magnesium implants. Post - operatively, clinic visits were standardized and physical exam findings, functional scores, and radiographs were obtained at each visit. All complications were recorded. Five patients with 6 fractures were recruited (2 coronoid, 3 radial head and 1 capitellum). The mean patient age and length of follow up was 54.6 years and 11 months respectively. All fractures healed, and none exhibited loss of reduction or complications requiring revision surgery. No patient developed synovitis of the elbow joint or suffered electrolytic reactions when titanium implants were used concurrently. Although there is still a paucity of literature available on the subject and further studies are required, magnesium implants appear to be a feasible tool for fixation of peri-articular elbow fractures with promising results in our series.

A clinical review of hand manifestations of cervical myelopathy, cervical radiculopathy, radial, ulnar, and median nerve neuropathies.

Cervical spondylotic myelopathy (CSM) is defined as compression of the spinal cord in the neck, resulting in problems with fine motor skills, hand numbness, pain or stiffness of the neck, and difficulty walking due to loss of balance. Brachial plexus (BP) neuropathies arise due to compression to any distal branches arising from C5-T1, whereas cervical radiculopathy involves compression at the nerve root in the neck. Such conditions can present with variable degrees of musculoskeletal pain, weakness, sensory changes, and reflex changes. The pronounced convergence in symptomatic manifestation within these conditions can pose a formidable challenge to clinicians, particularly in primary care. Thus, the primary objective of this paper is to enhance clarity and distinction among these pathological conditions. This objective is pursued through comprehensive delineation of the dermatomal and myotomal distributions characteristic of each condition. Furthermore, a meticulous examination is undertaken to elucidate physical indicators and maneuvers that exhibit a notably high sensitivity in detecting these conditions. Accurate diagnosis and treatment of each nerve pathology is important as long-term spinal cord compression and its roots may result in permanent disability and severely impact one's quality of life. As such, this systematic review serves as a guide that aids clinicians in differentiating the aforementioned conditions based on anatomy, physical exam findings, and imaging studies. Furthermore, this study aims to outline common peripheral nerve neuropathies in the upper extremities and ways to mitigate these pathologies using the least to most invasive treatment modalities.

Current Concepts in Management of Acromioclavicular Joint Injury.

Background: The management of acromioclavicular joint injuries requires a thorough understanding of the anatomy and biomechanics of the joint, as well as knowledge of the pertinent physical exam findings and classification to determine an appropriate treatment approach, whether operative or nonoperative. In this article, we present a narrative review of the current state of understanding surrounding these issues. Although there are a large number of options for operative intervention, we additionally present our experience with anatomic coracoclavicular ligament reconstruction (ACCR) with imbrication of the deltoid fascia. Methods: A retrospective review of prospectively collected data on a total of 45 patients who had undergone ACCR between 2003 and 2016 were collected. Results: We found that improvements were seen in American Shoulder and Elbow Surgeons Score (ASES) (53 ± 19 to 81 ± 23), Simple Shoulder Test (SST) (6 ± 3 to 12 ± 13), Constant-Murley (CM) (60 ± 18 to 92 ± 8), and Rowe (67 ± 14 to 89 ± 11) and the mean post-operative SANE score was 86 ± 17. Conclusions: ACCR has the advantage of addressing both horizontal and vertical stability with good outcomes.

Toe Walking in a Formerly Preterm Child: Is it Just Cerebral Palsy?

AbstractSpastic diplegic cerebral palsy (CP) is common among children born preterm and is a known cause of toe walking. By contrast, pediatric tumors of the conus medullaris are rare. We report the case of a 28-month-old formerly extremely preterm male with global developmental delay who presented with toe walking, constipation, and asymmetric hypertonia of the lower extremities. Brain imaging revealed periventricular leukomalacia, ex-vacuo ventricular dilation, and cerebellar dysplasia consistent with a diagnosis of CP secondary to perinatal injury. Lumbar spine imaging obtained due to his worsening constipation and pain while walking demonstrated an intramedullary, well-circumscribed, contrast-enhancing lesion in the conus medullaris. Postresection pathology revealed a pilocytic astrocytoma. Following surgery, the patient had improved constipation and lower extremity tone, allowing him to walk with bilateral heel strike. His symptomatic improvement supported the contribution of the tumor to his bowel dysfunction and gait abnormality.This case of comorbid CP and conus pilocytic astrocytoma in a child with toe walking supports careful consideration of possible concurrent neurologic pathologies in the setting of atypical history and physical exam findings, such as pain while walking and bowel/bladder dysfunction. A higher degree of suspicion and consideration of parental report of pain while walking is especially important in cases in which the patient's ability to report subjective symptoms, such as pain, subtle bowel/bladder dysfunction, and sensory changes, is limited.

Calcific bursitis of the Gruberi bursa: a case report

BackgroundBursitis is the inflammation of a synovial bursa, a small synovial fluid-filled sac that acts as a cushion between muscles, tendons, and bones. Further, calcific bursitis results from calcium deposits on the synovial joint that exacerbates pain and swelling. The Gruberi bursa is located dorsolaterally in the ankle, between the extensor digitorium longus and the talus. Despite limited literature on its pathophysiology, the aim of this case is to discuss the bursa’s association with calcific bursitis and its management via a case presented to our clinic.Case presentationA 47-year-old Caucasian female with no past medical or family history presents with acute right ankle pain following a minor injury 3 months prior with no improvement on analgesic or steroid therapy. Imaging demonstrated incidental calcium deposits. The day prior to presentation, the patient stated she used 1-pound ankle weights that resulted in mild swelling and gradual pain to the right dorsoanterior ankle. Physical exam findings displayed a significant reduction in the range of motion limited by pain. Imaging confirmed calcification within the capsule of the talonavicular joint, consistent with Gruberi bursitis. Initial management with prednisone yielded minimal improvement, requiring an interventional approach with ultrasound-guided barbotage that elicited immediate improvement.ConclusionThe presented case report highlights a rare and unique instance of acute ankle pain and swelling caused by calcific Gruberi bursitis in a young female. Although the Gruberi bursa is a relatively new discovery, it contains inflammatory components that may predispose it to calcification and should be considered in the differential of ankle swelling. Therefore, utilizing a systematic approach to a clinical presentation and considering all differential diagnoses is essential.

380 - Congenital pelvic venousmalformation with unique physical exam findings at birth: case report

380 - Congenital pelvic venousmalformation with unique physical exam findings at birth: case report

Venous thromboembolic outcomes in patients with lymphedema and lipedema: An analysis from the National Inpatient Sample.

Patients with lymphedema and lipedema share physical exam findings that may lead to misdiagnosis. Poor mobility is common in patients with obesity and patients with lymphedema and lipedema. This may constitute a risk factor for venous thromboembolism (VTE). Our objective was to evaluate the association of VTE in obese patients with lymphedema and lipedema. The National Inpatient Sample (NIS) was searched from 2016 to 2020 to identify hospital admissions of obese female patients with lymphedema and lipedema. Patients were analyzed in the context of presence or absence of VTE while adjusting for complex cluster sampling techniques. Predictors of VTE were accessed by multivariable regression. Lymphedema was identified in 189,985 patients and lipedema in 50,645 patients. VTE was observed in 3.12% (n = 374,210) of patients with obesity. In patients with obesity, VTE was more common in patients with lymphedema than without (2.6% vs 1.6%; p < 0.01). Similarly, VTE was more common in patients with lipedema than without (0.6% vs 0.4%; p < 0.01). After multivariable logistic regression, VTE events in obese patients with lymphedema were higher versus without (OR 1.6; CI 1.08-2.43; p = 0.02). Similarly, VTE events were more common in obese patients with lipedema versus obese patients without lipedema (OR 1.20; CI 1.03-1.41; p = 0.02). In this hypothesis-generating study, lymphedema and lipedema show a positive association with VTE after adjusting for baseline patient characteristics such as obesity, which is a known independent risk factor for VTE. Mechanisms whereby lymphedema and lipedema are associated with VTE should be investigated.

Unrecognized sciatic lipomatosis of the nerve diagnosed by telehealth: illustrative case.

Lipomatosis of the nerve (LN) is a rare congenital hamartoma in which abundant fibroadipose tissue is found within the epineurium of peripheral nerves. It is frequently associated with nerve territory overgrowth affecting bones or soft tissues. The clinicoradiological features are well known and pathognomonic. A 38-year-old female was evaluated via telehealth for worsened sciatica after the resection of a sciatic notch lipoma, after having been evaluated over a decade for symptoms. Virtual physical examination revealed previously unrecognized subtle limb discrepancy (i.e., overgrowth). Although preoperative radiographs were unavailable during the initial evaluation, postoperative magnetic resonance imaging studies showed evidence of sciatic nerve LN. A diagnosis of LN and nerve territory overgrowth was established. Despite its limitations, telehealth can be an effective alternative or adjunct to in-person evaluations in making complex diagnoses. Dedicated examination without clinical suspicion can miss subtle findings. An iterative process prompted by a focused history, knowledge of clinical associations, and pattern recognition can facilitate an accurate diagnosis without obvious face-to-face visual clues. In patients with rare disorders, asynchronous evaluation allows in-person visits to be supplemented by subsequent telehealth virtual physical exam findings. This case illustrates how examination via telehealth can be used to effectively diagnose a rare syndrome.

CLINICAL FINDINGS OF DENTAL DISEASE AND POTENTIAL CONTRIBUTING FACTORS IN PYGMY SLOW LORISES (NYCTICEBUS PYGMAEUS) UNDER HUMAN CARE.

Dental disease is a common finding in pygmy slow lorises (Nycticebus pygmaeus) under human care, but the etiology is not fully understood. The small oral cavity in this species can make diagnosis of dental disease difficult. This retrospective study evaluated medical records and diet and husbandry protocols from 18 participating institutions with the objective of describing the signalment, clinical signs, physical exam findings, tooth type, tooth location, diagnostics used, and treatments performed to help guide care for dental disease. In addition, the study aimed to identify potential contributing factors to dental disease in this species. Of 59 animals with medical records evaluated, 42 (71.2%) had dental disease: 19 (44.2%) males, 20 (46.5%) females, and 3 (9.3%) without gender documented. Average age at onset of dental disease was 7.6 yr in males and 9 yr in females. Multiple lorises with dental disease (n = 12; 28.6%) had no premonitory clinical signs, and dental disease was found incidentally on examination. On dental examination, 30 lorises (71.4%) had evidence of gingivitis. In 13 cases skull radiographs were taken, but the majority of images (n = 8; 61.5%) were nondiagnostic for pathologic dental changes. A small proportion of cases with dental abnormalities (n = 4; 9.5%) were diagnosed using computed tomography. In total, 175 teeth were extracted from 31 patients; molars were the most frequently extracted tooth (n = 55; 31.4%). No substantial differences in diets were noted among many of the participating institutions, and not all slow lorises evaluated developed dental disease (n = 17; 28.8%). This retrospective study provides clinical findings on slow loris dental disease and guidance for the veterinary care and management of slow lorises under human care.

Breaking Stereotypes: Sectoral Varicocele Diagnosis Revolutionized by Doppler Ultrasound Advancements

Varicocele is a common cause of male infertility and is traditionally diagnosed by physical examination. However, earlier research demonstrated physical examination has limited reliability. This study investigated the accuracy of Doppler ultrasound (DUS) for varicocele diagnosis compared to the standard physical exam. In a cohort of 200 patients with possible varicocele, sensitivity and specificity of physical examination alone were 61.4% and 71.4%, respectively, versus DUS at 91.7% and 94.3%, respectively. When combining physical exam findings with DUS, sensitivity and specificity increased to 92.9% and 95.7%. These findings suggest DUS should replace physical exam as the primary diagnostic tool given its much higher accuracy. Widespread adoption of DUS would enable earlier diagnosis and treatment of varicocele, improving patient outcomes and advancing our understanding of varicocele etiology.

An Appy That Needs Epi: An Atypical Presentation of Anaphylaxis.

An Appy That Needs Epi: An Atypical Presentation of Anaphylaxis.

Validation of the International Classification of Diseases, Tenth Revision-Clinical Modification Diagnostic Code for Essential Tremor.

The positive predictive value (PPV) of the International Classification of Diseases, Ninth Revision-Clinical Modification (ICD-9-CM) code for "essential and other specified forms of tremor" in identifying essential tremor (ET) cases was found to be less than 50%. The ability of the ICD-10-CM G25.0 code for "essential tremor" to identify ET has not been determined. The study objective was to determine the PPV of the G25.0 code. Patients in a tertiary health system with a primary care encounter associated with ICD-10-CM code G25.0 in 2022 underwent medical record review to determine if the consensus criteria from the International Parkinson and Movement Disorder Society for an ET diagnosis were met. 442 patients were included. The PPV of G25.0 in identifying probable ET cases was 74.7% (95% confidence interval (CI) 70.4-78.5%). Among patients prescribed propranolol, the PPV improved to 87.8% (95% CI 78.0-93.6%). Compared to the ICD-9-CM code 333.1, G25.0 is superior for identifying ET cases. A potential limitation of this study is that the consensus criteria applied relies on nonspecific physical exam findings which may lead to an overestimation of the PPV of G25.0. The ICD-10-CM diagnosis code for essential tremor has not been previously validated. The objective of this study was to determine the PPV of the G25.0 code. The PPV in identifying essential tremor cases was 74.7%. The PPV improved among patients prescribed propranolol.

A Variant of Miller-Fisher Syndrome: A Case Report

This report describes the case of a patient who presented to the hospital with weakness, neuropathy, ataxia, and diplopia who was found to meet the criteria for Miller-Fisher syndrome but had symptoms, physical exam findings, and lab results inconsistent with typical Miller-Fisher syndrome and suggestive of a potential variant who experienced only a partial response to typical Guillain-Barré syndrome treatment.

Hoffman Sign

The Hoffmann sign or reflex is commonly taught as part of the physical examination to detect abstract upper motor neuron pathology. We present a case of a patient with congenital spinal stenosis and a fall who had a positive Hoffmann sign as the result of a central cord syndrome. The materials contain a video of this physical exam finding and briefly review its history, reliability and clinical utility.

Anemia Outside the Box: Nonimmune Intramedullary Hemolytic Anemia Driven By Vitamin B12 Deficiency

Introduction: Vitamin B12 and folate deficiencies are common etiologies of macrocytic anemia, mostly encountered with chronic alcohol use, and uncommon for healthy individuals with unremarkable medical history. The pathogenesis of the resulting anemia is described by two possible mechanisms: either ineffective erythropoiesis, driven by vitamin B12 deficiency, or more rarely, via nonimmune intramedullary hemolysis. We present a very rare case of severe vitamin B12 deficiency leading to nonimmune intramedullary hemolysis and highlight the diagnostic evaluation and tailored management. Case Presentation: A 49-year-old female with history of depression, chronic alcohol use and chronic nitrous oxide inhalation, presented with lethargy, hypotension and fevers with visual hallucinations, and was subsequently admitted for acute encephalopathy. Findings on physical examination included diminished proprioception and diminished sensation to fine touch, pinprick and vibration of the lower extremities with distal hyperreflexia of the patellar and Achilles tendon reflexes bilaterally. Lab work was notable for leukopenia and macrocytic anemia with a significant drop in hemoglobin to 9.6 from a baseline of 13.2 within 5 months and MCV of 103. Extensive investigation of encephalopathy was undertaken, of which we note infectious workup, prompted by the septic presentation, which showed Staphylococcus aureus bacteremia. On the other hand, the patient's anemia was concurrently investigated. Hemolysis workup was positive (LDH 394 U/L; direct bilirubin 1.6 mg/dL; haptoglobin&amp;lt;8 mg/dL; reticulocyte count 6.1%); however, schistocytes were low on peripheral smear (Figures 1 and 2). As such, nonimmune intramedullary hemolysis was suspected. Further anemia workup revealed severe vitamin B12 deficiency (75 ng/L), consistent with the physical exam findings, but normal folate levels. Of note, methylmalonic acid levels and homocysteine were also elevated (respectively 4.39 nmol/mL, and 142 umol/L). The constellation of the clinical presentation and all the laboratory findings confirmed a nonimmune intramedullary hemolytic process, elicited by vitamin B12 deficiency. This deficiency was thought to be multifactorial, mainly caused by chronic alcohol abuse, in addition to persistent nitrous oxide use. It was also suggested that hemolysis could be a consequence of drug-induced carboxyhemoglobinemia (level was 9.4%), whereby carboxyhemoglobin can form during the binding and release of nitric oxide from hemoglobin. Treatment was focused on replacing vitamin B12 with 1000 mcg daily intramuscular injections for 7 days, then weekly thereafter for 4 weeks, followed by monthly injections. Improvement of hemoglobin to 11.1 with improvement of neurologic exam findings were noted prior to discharge. Conclusion: Nonimmune hemolytic anemia must be included in the differential diagnosis when evaluating patients with anemia concurrent with vitamin B12 deficiency, mostly encountered with chronic alcohol use. Vitamin B12 supplementation remains the key treatment to correct this rare, but serious outcome of vitamin B12 deficiency.

A Working Definition of Acute Chest Syndrome without the Requirement of Chest X-Rays

Introduction:Sickle Cell Disease (SCD) is a rare genetic disease in high-income countries where most of the cited literature used to guide clinical management emanate from. One of the most serious and potentially fatal complications of SCD is acute chest syndrome (ACS) which requires immediate medical attention. Approximately 50% of individuals with SCD will eventually develop ACS ( Blood 84, 643-649 (1994)). Despite the high frequency of ACS and its associated risk of death, no consensus diagnosis has been established that applies to children and adults living in low-middle income countries, where 95% of the children born with SCD are found. To create a uniform definition of ACS in both low, middle, and high-income countries, we propose using a new ACS definition that does not require a chest X-ray. Additionally, the new ACS definition should have a quantifiable and reproducible physical examination and clinical findings to allow for the reproducibility of the definition in all settings. This definition was developed over several years at Korle Bu Teaching Hospital, Accra Ghana, in pregnant women with SCD. Before we started the multidisciplinary team care in pregnant women with SCD, ACS was the most common cause of maternal death. Subsequently, based on the new ACS definition that did not require a chest X-ray, we developed strategies to prevent, aid early diagnosis, and treat ACS resulting in an 89% relative risk reduction of death. We refer to this new definition as the Korle Bu Teaching Hospital (KBTH)-ACS definition. In this study, we compare the ACS definition in the top 20 cited ACS articles as of July 2023 with our proposed KBTH-ACS definition. Methods:Using Google Scholar, we identified the top 20 cited articles with ACS in children or adults with SCD as primary or secondary outcomes. Each article was reviewed for the presence of the following criteria: chest x-ray, vitals, hemoglobin oxygen saturation, and lung physical exam findings. We compared the definition of ACS in the top 20 cited ACS articles to the KBTH-ACS definition that included the following features: “abnormal findings on lung auscultation and the presence of at least 2 of the following criteria: 1) temperature ≥ 38.0°C, 2) increased respiratory rate greater than the 90th percentile for age, positive chest pain or pulmonary auscultatory findings, 3) hemoglobin oxygen saturation decrease by ≥3% from a documented steady-state value on room air, and 4) a new radiodensity on chest roentgenogram. A diagnosis of pneumonia was considered an ACS episode.”. Results:The 20 most cited ACS articles required radiographical criteria to diagnose ACS. Fourteen of twenty articles included fever in their ACS definition. However, only 4 articles specified any temperature and all specified ≥ 38.5 ºC. A total of 17 articles mentioned the presence of lung or respiratory findings, but only 12 articles specifically identified the pulmonary findings. Among the 12 articles that specified lung findings, 5 included increased respiratory rate (tachypnea) without a specific definition, 2 included abnormal auscultatory findings, and 3 included hypoxemia/hypoxia in their definition. However. One study defined hypoxemia/hypoxia as “transcutaneous oxygen saturation &amp;lt;85% despite supplemental oxygen.”. Another article included “SpO2 of ≥ 3% compared to baseline steady-state values.”. In addition, among the twelve studies that specified respiratory findings, the following were present or absent features: chest pain (n=12), wheezing (n=3), coughing(n=3), and respiratory distress without a formal definition (n=3). No article included pneumonia in the ACS definition nor defined a threshold for tachypnea that was age-adjusted. None of the articles would allow for a direct comparison with the KBTH-ACS definition. Conclusion: All the 20 most cited ACS articles required a chest X-ray with various clinical and physical examination findings. Many of the ACS definitions in these studies were based on clinical impressions that were not quantifiable or reproducible. We propose using the KBTH-ACS definition in future ACS studies to improve generalizability, reproducibility, and genotype and phenotype studies designed to elucidate the genetic variation of lung disease in children and adults with SCD.

Femoral neuropathy: A clinical and electrodiagnostic review.

Femoral neuropathies can cause severe, prolonged debility, yet there have been few clinical and electrodiagnostic (EDx) studies addressing this condition. The aim of this study was to better understand the etiologies, EDx features, and clinical course of femoral neuropathy. We identified patients evaluated at Mayo Clinic Rochester between January 1, 1999 and July 31, 2019, with possible new femoral neuropathy ascertained via International Classification of Diseases-versions 9 and 10 diagnosis codes presenting within 6 months of symptom onset. A retrospective review of 1084 records was performed and we ultimately identified 159 patients with isolated femoral neuropathy for inclusion. The most common femoral neuropathy etiologies were compressive (40%), perioperative stretch (35%), and inflammatory (6%). Presenting symptoms included weakness (96%), sensory loss (73%), and pain (53%). Presenting motor physical exam findings demonstrated moderate weakness (34%) or no activation (25%) of knee extension and mild (32%) or moderate (35%) weakness of hip flexion. Seventy-two percent of patients underwent EDx testing, including 22 with femoral motor nerve conduction studies. Treatment often involved physical therapy (89%) and was otherwise etiology-specific. In patients with follow-up data available (n = 154), 83% had subjective clinical improvement at follow-up with a mean time to initial improvement of 3.3 months and mean time to recovery at final follow-up of 14.8 months. Only 48% of patients had nearly complete or complete recovery. In our cohort, the most common etiologies of femoral neuropathy were compression or perioperative stretch with high initial morbidity. Although motor recovery is common, improvement is often prolonged and incomplete.