Presenting Symptoms Research Articles

OGC SO38 - Laparoscopic repair of para-conduit hernia post minimally invasive esophagectomy using anterior hiatal suture repair and mobilisation of left liver lobe as reinforcement

Abstract Background Para-conduit hernia (PCH) formation is a rare and late complication of oesophagectomy that is associated with high risk morbidity. Minimally invasive oesophagectomy is associated with increased incidence of PCHs when compared to open or trans-hiatal oesophagectomies. Various techniques to repair PCHs including mesh repair, anterior/posterior hiatal suture repairs or even careful 360 degree repairs have been described in the literature1,2. But the risk of recurrence of PCH still remains high. We describe a unique laparoscopic technique which we believe to be associated with reduced risk of recurrence of PCH post-surgical repair. Method We present 4 cases of symptomatic PCH repairs performed laparoscopically. In this unique technique the contents of the sac is reduced and the hiatus is repaired anteriorly with interrupted ethibond sutures. The left lobe of the liver is mobilised and glued to the greater curve omentum along the conduit and the hiatus. This latter step is an additional way of preventing intraabdominal contents from entering the mediastinum. Data was collected retrospectively to include: patient demographics, details of original MIO surgery, pre-op imaging and details of the presenting symptoms with PCH including imaging, operative details and all available follow up. Results Between January 2022 and July 2024, 4 patients underwent laparoscopic repair of paraconduit hernia within 1-2 years post MIO. 3 were male and 1 female aged between 56-71 years. 3 of the procedures were performed electively and one as an emergency. All presented with symptomatic paraconduit hernias and managed with surgery using the technique described above. We present a video of laparoscopic repair as described. Conclusion We report a case series of 4 patients presenting with symptomatic PCH that were managed safely with a unique laparoscopic technique using suture repair and left liver lobe mobilisation to prevent recurrence of PCH.

A Prospective Observational Study on the Clinical Profile Assessment of Myocardial Infarction Patients in a Tertiary Care Teaching Hospital

Background: Cardiovascular Diseases (CVDs) are the single largest contributor to the global burden of disease and are recognized as the leading cause of death globally. CHD has various clinical manifestations ranging from asymptomatic to acute conditions, namely acute coronary syndrome. Cardiovascular risk factors for acute coronary syndrome (ACS) are on the rise in people of Indian origin. Myocardial Infarction (MI) also called as heart attack, infarction means the death of an area of tissue because of interrupted blood supply. Myocardial Infarction has become a growing concern among the cardiovascular diseases, hence the study is conducted in order to assess the clinical profile of patients suffering from MI. Aim: To assess the clinical presentations, risk factors, short-term complications and management of patients with MI. Methodology: A prospective observational study was conducted in a tertiary care teaching hospital over six months. A total of 121 patients were selected based on inclusion and exclusion criteria. Results: Among the 121 patients included, the predominant were males (63.63%). Most of the patients fell under the age group of 51-60 (n=46). The common presenting symptoms were chest pain (42.32%), followed by breathlessness (26.04%) and sweating (15.34%). Most patients had NSTEMI (62.80%) and STEMI (37.19%). Alcohol (23.44%) was major risk factor followed by smoking (22.48%) and diabetes (14.35%). The elevated biomarkers noted were Troponin I (42.14%), Troponin T (37.19%) and CK-MB (6.61%) respectively. The majority of infarctions occurred on inferior wall (30.57%). The most prevalent complication observed was heart failure (14.8%) followed by sinus tachycardia (6.61%), and sinus bradycardia (5.78%). The majority of patients received key medications like anti-platelet agents, statins and anti-coagulants during hospital stay. Conclusion: The risk of men developing myocardial infarction is more compared to women due to various reasons. It is more likely that the diagnosis of myocardial infarction is neglected due to certain presenting symptoms like epigastric pain, syncope, vomiting, sweating etc., hence this study was conducted with an overview of creating awareness regarding the severity of myocardial infarction along with the advantages of early diagnosis.

Abstract 4120196: Temporal Trends and Predictors of Cardiac Biomarker Testing in the Emergency Department, 2014-2021

Background: Presenting symptoms risk stratify patients presenting to the Emergency Department (ED) to determine their likelihood of having a myocardial infarction (MI) and need for cardiac biomarker testing. Since the 2014 AHA/ACC non-ST segment elevation MI (NSTEMI) guideline, little is known regarding cardiac biomarker testing trends in the United States. Methods: We analyzed data from the National Hospital Ambulatory Medical Care Survey for consecutive adult ED visits between 2014 and 2021 in the United States. The primary outcome was the proportion of ED visits where cardiac biomarker testing occurred. Subgroup analysis was performed for visits with chest pain, non-chest pain anginal equivalents, and non-anginal symptoms. Survey-weighted multivariable logistic regression was used to generate adjusted odds ratios (aOR) to assess predictors of cardiac biomarker utilization. Results: In total, 87,965 ED visits were sampled, representing a weighted total of 644,531,395 visits. Cardiac biomarker testing occurred in 7.21% of all ED visits (95% CI, 6.27%-8.29%) and increased over time (Figure, P =0.03 for trend). When stratified by symptoms, utilization of testing mainly increased among patients with non-chest pain anginal equivalents (Figure, P =0.02 for trend). Cardiac biomarker testing was most frequently used for patients with chest pain (34.9%) and non-chest pain anginal equivalents (39.3%). Nonetheless, 25.8% of patients who underwent testing had no chest pain or anginal equivalents. Cardiac biomarker testing was more frequent among patients with older age (aOR 1.03 per year, 95% CI 1.03-1.04), tachycardia (aOR 1.26, 95% CI 1.13-1.41), tachypnea (aOR 1.71, 95% CI 1.47-1.98), history of heart failure (aOR 1.33, 95% CI 1.15-1.54), prior venous thromboembolism (aOR 1.43, 95% CI 1.12-1.83), and those treated in a rural setting (aOR 1.63, 95% CI 1.14-2.32). Conclusion: Cardiac biomarker testing in the ED has increased over time, mostly attributed to increased utilization among patients with a low pre-test probability of MI. Notably, 25% of individuals who underwent cardiac biomarker testing had no chest pain or anginal-equivalent symptoms. More judicious utilization of cardiac biomarker testing may be needed.

INNV-23. UNDERSTANDING THE BURDEN OF MIDH1/2 DIFFUSE GLIOMA AND THE COMPLEXITY OF NAVIGATING THE PATIENT PATHWAY: INSIGHTS FROM PATIENTS AND CAREGIVERS

Abstract Diffuse gliomas with mutations in isocitrate dehydrogenase 1 or 2 (mIDH1/2) are characterized by a slow-progressing yet life-limiting disease predominantly in young people. We report interim findings from a qualitative study to describe the mIDH1/2 diffuse glioma patient pathway, experience of the disease, and treatment approaches. Patients, caregivers, and patient-association group (PAG) representatives undertook individual interviews, with patients also completing standardized exercises as pre-work. Materials were developed in collaboration with the International Brain Tumour Alliance. Patients were aged ≥12 years with mIDH1/2 glioma and last resection ≥6 months before enrollment, either undergoing active observation or receiving chemotherapy/radiotherapy. Caregivers were living with the patient. PAG representatives were active members of a brain tumor PAG. From November 2023 to March 2024, 30 patients (Australia: n=10; China: n=6; France, UK: n=5 each; Canada, Japan: n=2 each), two caregivers (China, Australia: n=1 each) and one PAG (UK) participated. Median age of patients was 41.5 years, with 17 astrocytoma and 13 oligodendroglioma diagnoses. Presentation symptoms, circumstances of diagnosis and treatment, access to care, and navigation in the healthcare system differed per patient and within countries. Surgical resection was perceived as a crucial stage, both feared and desired. A second opinion was more often sought for surgery than for subsequent treatment approaches. Patients undergoing chemotherapy/radiotherapy (n=17) or active observation (n=13) expressed substantial physical, socioeconomic, financial, and psychological burden. Patients receiving active observation experienced strong and ongoing anxiety, as the uncertainty of tumor recurrence took a toll on their emotional wellbeing in the long term. The experience of people living with mIDH1/2 diffuse glioma is heterogeneous regarding their pathway and complexity navigating the healthcare system, with a substantial psychological and socioeconomic impact. Improved education, as well as facilitating early navigation and prioritizing shared decision-making along the disease pathway, will better support people living with mIDH1/2 diffuse glioma.

Straight-to-Test Pathway in Faecal Immunochemical Testing (FIT)-Negative Patients: A Cost-Effective Approach.

Colorectal cancer (CRC) is the fourth most common malignancy in the UK and represents a high-volume diagnostic and clinical burden on the National Health Service (NHS). To maximise the use of limited diagnostic resources and increase efficiency, the colorectal services at University Hospitals North Midlands Trust (UHNM) developed the triage-to-test (TTT) service with risk stratification for diagnostic testing in patients with suspected colorectal cancer using faecal immunochemical testing (FIT) result. Our retrospective cohort study looked at the pick-up rate of colorectal cancer (CRC) and non-colorectal cancer (non-CRC) in FIT-negative patients. The study was a retrospective review of all symptomatic patients over 18 years of age who had undergone FIT testing in the community between 1November 2021 and 11February 2022 and whowere referred directly to the UHNM colorectal pathway from primary care (n=2,374). FIT negativity was set at <9.9 μg/g of faeces, as per the National Institute for Health and Care Excellence (NICE) DG30 guidelines. Patients were investigated and risk stratified in accordance with their FIT result and presenting symptoms. About 61.5% of patients referred were FIT negative (n=1,459) and 38.5% were FIT positive (n=915). Of those FIT-negative patients, 82 were excluded as their clinical outcomes were pending at the time of analysis. FIT positivity conferred a greater likelihood of colorectal cancer when compared with FIT-negative patients (p<0.0001). FIT-negative patients were most likely to have no significant pathology (32.5%, n=474). Incidence of colorectal cancer in the FIT-negative group was 0.5% (n=7) compared with 9.8% (n=89) in the FIT-positive group (odds ratio: 5.252, 95% CI: 4.012-6.875). Within the FIT-negative cohort, five patients were diagnosed with rectal cancer, one proximal descending colon cancer and one caecal cancer. The use of a FIT-negative TTT pathway ensures that any symptomatic patients presenting with red flag symptoms can be investigated appropriately. It also provides reassurance to clinicians who have an ethical duty to investigate patients in whom they suspect sinister pathology. Moreover, a triage-to-Test pathway reduces outpatient capacity burden onhealthcare trusts as they may send patients directly for investigation.

EPID-04. VESTIBULAR SCHWANNOMA IN PREGNANCY: A SYSTEMATIC REVIEW

Abstract INTRODUCTION Vestibular Schwannomas (VS) are intracranial tumors of the nervous system originating from peripherally myelinating Schwann cells. There are sparse reports of this tumor presenting in pregnant patients but many of the cardinal symptoms of pregnancy overlap with the presentation of VS. For this reason, we systematically reviewed reports of VS in pregnant patients to identify the most specific clinical symptoms to aid diagnosis of and address management considerations for this population. METHODS Our systematic review was performed according to PRISMA guidelines. The data extracted includes study characteristics, symptom presence and onset relative to tumor diagnosis, tumor size, treatment modality, complications, and maternal/fetal health outcomes. This data was analyzed for overlap with commonly presenting symptoms and current management trends. RESULTS Sixteen papers between 1967 and 2018 reported a total of 26 pregnant patients who met criteria for inclusion. The most common presenting symptoms were hearing loss (76.9%), ataxia (42.3%), headache (38.5%), and vomiting (38.5%). The symptoms that presented with the longest duration were dizziness/vertigo (145.33 weeks), tinnitus (155 weeks), and hearing loss (145.67 weeks). The most common complications were post-op facial paralysis (46.2%), hydrocephalus (23.1%), and post-op hearing loss (19.2%). CONCLUSIONS A heightened clinical suspicion for VS in pregnant patients is needed due to the large overlap of cardinal symptoms of pregnancy and VS presentation. The way pregnancy changes patients’ normal physiology should be considered when determining optimal management. We hope that this review will improve diagnostic accuracy and prevent complications in pregnant patients with VS.

Demographic and clinical profile of patients with acute biliary pancreatitis: an experience in Patan academy of health sciences

Background: Acute pancreatitis is one of the most common causes of acute abdomen encountered in emergency department with wide range of severity from mild self-limiting disease to severe and rapidly progressive illness leading to multi organ failure and even death. Gall stones are leading cause of acute pancreatitis. This study has been carried out to find out demographic pattern and clinical profile of patients with acute biliary pancreatitis. Methods: This is a prospective cross-sectional study carried out in the department of surgery in Patan academy of health sciences (PAHS) in the time period between May 1, 2021 and April 30, 2022. The process of data collection was started after obtaining ethical approval from institutional review committee (IRC) of PAHS, and written informed consent was obtained from patients. Total sampling was done and 66 patients were enrolled into the study, who were diagnosed as acute biliary pancreatitis. Data was analyzed with SPSS ver 25 and Microsoft excel 2016. Results: Out of total 66 patients in the study 25 (37.9%) were male and 41 (62.1%) were female with male: female ratio of 1:1.64. Mean age was 48.42±16.62 years. ranging from 16-88 years. Epigastric abdominal pain was predominant presenting symptoms accounting for 57 (86.4%) cases. Pleural effusion was most common complication seen in 17 (25.8%) cases. Mortality occurs in 2 (3%) cases, both of cases had severe pancreatitis. Only 21 (31.8%) patients underwent cholecystectomy among which 13 (19.7%) interval and 8 (12.1%) index cholecystectomy. Conclusions: Female gender with age group of 40-60 years. predominates acute biliary pancreatitis. Though most of the cases are mild and have benign course, severe cases and patients with advanced age are associated with high mortality. Acceptance of index cholecystectomy is very low.

Robotic Management of Complex Obstructive Megaureter Needing Ureteral Dismembering and/or Tapering in Children: A Single-Center Case Series

Background and Objectives: Robot-assisted extravesical ureteral reimplantation (REVUR) has been described as valuable alternative to open reimplantation in the pediatric population. This study aimed to report the outcome of REVUR in children with complex obstructed megaureter (COM) needing ureteral dismembering and/or tapering. Materials and Methods: The records of patients with COM, who received REVUR with ureteral dismembering and/or tapering over the last 3 years (2021–2024), were retrospectively reviewed. The inclusion criteria for COM included previous surgery, paraureteral diverticula, or ectopic megaureter. Results: A total of 16 patients (15 boys), with a median age of 7.8 years (range 2–16), were treated over the study period. COM was associated with paraureteral diverticula (n = 6), previous failed endoscopic balloon dilation (n = 4), ectopic megaureter (n = 2), and previous bulking agent endoscopic injection causing iatrogenic ureteral obstruction (n = 4). Presentation symptoms included febrile urinary tract infections (n = 8), flank pain (n = 4), hematuria (n = 2), and pseudo-incontinence (n = 2). All surgical procedures were accomplished robotically without conversions or intra-operative complications. Ureteral tapering was performed in 7/16 (43.7%). The median operative time (including robot docking) was 220 min (range 155–290). The median length of stay was 3.8 days (range 3–7). The indwelling double J stent was removed 4–6 weeks postoperatively. Clavien 2 grade complications occurred postoperatively in 2/16 (12.5%). At median follow-up of 34.5 months, all patients were asymptomatic and showed improved hydroureteronephrosis on ultrasound and improved drainage on diuretic renogram. Conclusions: This study demonstrates that robot-assisted extravesical ureteral reimplantation is a safe and effective treatment for primary obstructive megaureter and other complex ureteral anomalies in our patient cohort. The procedure showed low complication rates, high success rates, and favorable long-term outcomes, supporting the feasibility and effectiveness of robotic surgery for these conditions.

Pulmonary hypertension in patients carrying FLNA loss-of-function variants.

Pulmonary hypertension (PH) is an unusual complication of X-linked disease caused by loss-of-function (LOF) variants in the filamin A (FLNA) gene. Patients with FLNA LOF may also present dysmorphic facial features, aortic dilation, thrombopenia, and periventricular nodular heterotopia (PVNH). We reported clinical, functional, radiologic, and hemodynamic characteristics of patients with FLNA LOF variants and PH from the French PH Network. Nine patients were identified with a female to male ratio of 8:1. PH was diagnosed at a median age of 36 [0-69] years. Associated conditions included epilepsy (n=5), PVNH (n=7), valvular heart disease (n=8), congenital heart diseases (n=4), thrombocytopenia (n=4), and hyperlaxity (n=4). Right heart catheterisation confirmed moderate-to-severe precapillary PH with a median mPAP of 33 [22-49] mmHg and PVR of 4.7 [2.4-8.0] WU. The DLCO was markedly decreased (48 [22-64] %pred) and five patients had obstructive ventilatory disorder. High-resolution CT showed heterogeneous parenchyma (n=8), emphysema (n=3), presence of a peripheral hyperclear band (n=3) and aortic ectasia (n=4). Pathologic assessment available in one patient revealed significant remodelling of small pulmonary arteries, interstitial edema, and irregular alveoli shapes. During follow-up, three patients died, including two from right heart failure. No patient died from aortic rupture. Precapillary PH, likely due to multiple mechanisms, may complicate the course of patients with LOF FLNA variants and may be the presenting symptom leading to diagnosis. The combination of PH with parenchymal involvement and extrapulmonary symptoms (epilepsy, congenital heart diseases, valvular and aortic involvement, thrombocytopenia) should prompt genetic screening for FLNA.

Neuropsychiatric Manifestations of COVID-19 Disease and Post Covid Syndrome: The Role of N Acetyl-cysteine and Acetyl-L-carnitine.

COVID-19 is associated with neuropsychiatric symptoms, such as anosmia, anxiety, depression, stress-related reactions, and psychoses. The illness can cause persistent cognitive impairment and "brain fog", suggesting chronic brain involvement. Clinical entities of ongoing symptomatic COVID-19 and Post COVID Syndrome (PCS) mainly present neuropsychiatric symptoms such as dysgeusia, headache, fatigue, anxiety, depression, sleep disturbances, and post-traumatic stress disorder. The pathophysiology of COVID-19-related brain damage is unclear, but it is linked to various mechanisms such as inflammation, oxidative stress, immune dysregulation, impaired glutamate homeostasis, glial and glymphatic damage, and hippocampal degeneration. Noteworthy is that the metabotropic receptor mGluR2 was discovered as a mechanism of internalisation of SARS-CoV-2 in Central Nervous System (CNS) cells. N-acetylcysteine (NAC) and acetyl-L-carnitine (ALC) are two supplements that have already been found effective in treating psychiatric conditions. Furthermore, NAC showed evidence in relieving cognitive symptomatology in PCS, and ALC was found effective in treating depressive symptomatology of PCS. The overlapping effects on the glutamatergic system of ALC and NAC could help treat COVID-19 psychiatric symptoms and PCS, acting through different mechanisms on the xc-mGluR2 network, with potentially synergistic effects on chronic pain and neuro-astrocyte protection. This paper aims to summarise the current evidence on the potential therapeutic role of NAC and ALC, providing an overview of the underlying molecular mechanisms and pathophysiology. It proposes a pathophysiological model explaining the effectiveness of NAC and ALC in treating COVID-19-related neuropsychiatric symptoms.

Type-1 spinal muscular atrophy cohort before and after disease-modifying therapies.

Spinal muscular atrophy (SMA-5q) is a neurodegenerative disease characterized by progressive muscle atrophy, hypotonia, and weakness, with SMA 1 presenting symptoms within the first 6 months of life. Disease-modifying therapies have been approved, with better outcomes with earlier treatment. To describe the safety and clinical efficacy of disease-modifying therapies based on SMN1 and SMN2 gene strategies concerning motor, respiratory, and bulbar function. Patients with SMA 1 were divided into 2 groups: those exclusively on nusinersen (group 1) and those transitioning to onasemnogene abeparvovec (OA) (group 2). Over 18 months, patients were assessed using the Children's Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOP-INTEND) scale, developmental milestones, ventilation needs and duration, nutritional support needs, consistency of food, and signs of dysphagia. There were ten patients, divided between the groups; in group 1, the average age for starting nusinersen was 53.6 (12-115) months, and, in group 2, the age was 7 (1-12) months for nusinersen and 15.2 (10-19) months for OA. Our results indicate that 70% of patients reached some motor milestones, with group 1 increasing by 10.2 points on the CHOP-INTEND scale, while group 2 increased by 33 points. Additionally, 90% of the patients experienced no respiratory decline, and 30% maintained oral feeding. No serious adverse effects or deaths were recorded. Both groups showed improvement in motor function and stabilization of respiratory and bulbar function, with the difference between the groups possibly being related to the earlier treatment initiation. Thus, the present study provides valuable insights into the real-world safety and clinical efficacy of disease-modifying therapies for SMA 1 patients.

Latent factors underlying the symptoms of adult-onset myotonic dystrophy type 1 during the clinical course

BackgroundMyotonic dystrophy type 1 (DM1) is a multisystem genetic disorder that classically presents with symptoms associated with myotonia, early onset cataracts, and muscular weakness, although the presentation and pattern of disease progression is quite varied. Presenting symptoms are well documented among adults with DM1. However, less is known about the co-occurrence of symptoms over time. We aimed to use factor analysis to explore the correlation pattern of signs and symptoms (S/S) that emerged during the clinical course.ResultsClinical records of 228 individuals with adult onset DM1 were abstracted using the Muscular Dystrophy Surveillance, Tracking, and Research Network (MD STARnet) from a six-site cohort in the United States during an eight-year study period. Factor analysis was used to group the correlated S/S into latent factors. Three factors were identified. Group 1: ‘Facial Weakness/Myotonia’ includes the two most common S/S, as indicated by its name. Group 2: ‘Skeletal Muscle Weakness’ includes eight muscular S/S and is more frequently reported by males and those with older age at onset. Group 3: ‘Gastrointestinal distress/Sleepiness’ includes four non-muscular S/S and hand stiffness. The abstracted medical records reported that over 63% of individuals had S/S from all three groups. Associations of covariates with factor scores were also examined using linear regression. CTG repeat length was significantly positively associated with higher factor scores for all three factors.ConclusionsThis study identified three latent factors of S/S which accumulated during the clinical course of adult onset DM1.

Double Vision as the Presenting Symptom of Metastatic Breast Cancer in an 83-Year-Old Lady

Breast cancer is the most common type of malignant tumor that occurs in women. Despite this, physicians report that they screen elderly patients for breast cancer less than young patients, regardless of cancer history. This case report describes an elderly patient who presented with diplopia, eyelid swelling, and restricted eye movement, leading to the discovery of a diffuse orbital tumor and Stage IV left breast carcinoma with metastases to bone, liver, and peritoneum. The patient had been told to stop mammograms years prior to her diagnosis despite her past history of uterine cancer. The case underscores the possibility of orbital metastasis from breast cancer and highlights the necessity of diligent cancer screening in elderly women.

Synchronous bilateral typical pulmonary carcinoid tumours diagnosed by robotic navigation bronchoscopy: A unique case.

Pulmonary carcinoids are uncommon malignant neoplasms, believed to derive from specialized neuroendocrine cells known as Kulchitsky cells. We evaluated a 69-year-old female presenting symptoms consistent with carcinoid syndrome, such as intermittent flushing and diarrhoea, along with complaints of shortness of breath and cough. Imaging revealed bilateral lung nodules, confirmed by biopsy to be carcinoid tumours. The treatment of choice for carcinoid tumours is complete surgical resection. Nonetheless, individualized management plans are crafted based on the tumour's location and the patient's respiratory function as these present challenges to anatomical resection of tumours.

Covid-19 Related Seizures

Background: The Coronavirus (Sars-CoV-2, COVID-19) has been evolving its viral strains, prevalence, symptomatology, and sequelae of disease for the past three years. Although the most recognized COVID-19 symptoms involve the respiratory tract; neurological symptoms have been documented. Specifically, seizures have specifically been discussed in the literature but remain both under-recognized and under-reported in clinical practice. Aim: To review of the literature of adult patients with COVID-19 and seizures and integrate into clinical practice in the acute care environment; from presentation to the emergency Department to discharge. Methods: A narrative literature review was conducted to identify all reported clinical studies involving adult patients with COVID-19 and de novo seizures from MEDLINE, yielding 108 relevant publication titles and abstracts. Additional three relevant studies were discovered through manual search of reference lists of included studies. After excluding non-related publications, 58 publications underwent full-text review. Reporting of results was guided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Results: Data was organized into the following themes in the literature: prevalence of seizure occurrence in patients with COVID-19; pathophysiology discussing possible cause; CSF and EEG findings in these patients, and outcomes both in and out of hospital. Conclusion: Seizures were reported as both the presenting symptom of COVID-19 infection and a sequelae of the disease. Heterogeneity identified in both severity and pathogenesis of disease may partly account for the variability in reporting. Seizures may occur as single incidences, with no further implication to the patient or they may occur in the context of New Onset Refractory Status Epilepticus. Patients may require critical care for management of Status Epilepticus or encephalopathy with accompanying seizures. Clinician vigilance is essential in identifying COVID-19 infection in patients presenting to Emergency Services with seizures. Early recognition impacts patient care both in-hospital and at post-discharge follow-up.

Deciphering the Symptom Spectrum: A Comprehensive Analysis of Migraine Patterns and Types

Complex neurological diseases like migraine migraine affect a large section of the global population, causing health, social, and economic issues. Migraine causes intense, painful headaches that are usually one-sided and pulsing. Auras, nausea, vomiting, and excessive light and sound sensitivity may precede these episodes. Migraine affect millions worldwide and can be intermittent or persistent, impairing function. Diet and stress may induce it, but the cause is unknown. Prevention and symptom treatment drugs and lifestyle changes are used. Debilitating migraines are hard to diagnose due to their varied presentation and subjective symptom reporting. Traditional migraine diagnosis, based on clinical evaluation, typically fails to classify migraine types, requiring more objective and rigorous instruments. This study proposes a machine learning-based migraine categorization method to address this issue. The dataset includes different patient demographics and clinical variables; thus, we use complex algorithms like Random for Forest, XGBoost, and Extra Trees. These algorithms are great for deciphering migraine patterns because they excel at evaluating complex datasets. The research seeks to close this gap to improve migraine classification accuracy, objectivity, and reliability, enabling tailored migraine management and treatment. This neurology study could im- prove migraine diagnosis and treatment with more effective and personalized plans.

Clinical, Radiological Features and Treatment Outcomes of Tuberculosis in Patients Aged 75 Years and Older.

Tuberculosis (TB) is a significant contributor to morbidity and mortality. With a progressively aging population, TB is increasingly encountered in older adults. Understanding the clinical presentation and optimal treatment strategies for TB in this population is essential. Clinical, radiological features, treatment, and outcome of patients aged 75 and above who were diagnosed with tuberculosis at King Abdulaziz Medical City in Riyadh in the period between January 2015 to December 2021wereevaluated retrospectively. Among 92 elderly tuberculosis patients, most were male (76.1%) with a mean age of 82.5 years. Pulmonary TB was diagnosed in 52.2% of patients, Extra Pulmonary TB in 32.6%, and Disseminated TB in 15.2%. Comorbidities included Diabetes Mellitus (59.8%) and Congestive Heart Failure (41.3%). The most common presentation symptoms included cough (51.1%), fever (43.5%), dyspnea (39.1%), and weight loss (31.5%). Delay of TB diagnosis for up to 3 months was observed in 31.5% of patients. Weight loss and male gender were significant predictors of delayed diagnosis. Laboratory findings varied among TB types, with disseminated TB showing higher eosinophilia and thrombocytopenia. Completion of an initial RIPE treatment protocol was achieved in 67.6% of patients. Mortality during treatment occurred in 23.9% of patients. Pulmonary TB was associated with higher mortality compared to extrapulmonary TB (p = 0.007). Tuberculosis is associated with high mortality in patients above the age of 75. There is still a substantial delay in TB diagnosis in the elderly. RIPE regimen is frequently changed due to side effects. Alternative regimen choices were quite variable. More studies on tuberculosis in this patient's population are needed to define the most effective therapeutic approach.

Fastidious adherence to 0/1-hour high-sensitivity troponin T testing reduces emergency department length of stay in patients presenting with suspected acute coronary syndromes

Abstract Background High-sensitivity cardiac troponins (hs-cTn) are key clinical biomarkers in patients presenting with suspected acute coronary syndromes (ACS) to Emergency Departments (EDs). They have facilitated rapid 0h/1h troponin testing protocols, leading to safe, effective, and efficient triage of patients. However, early distinction of myocardial infarction (MI), which has a reported frequency of less than 10% in most cohorts, from the apparently stable hs-cTn elevations of chronic myocardial injury (CMI) remains a challenge. Often CMI patients require confirmation by further testing and observation, prolonging patient length of stay. Further, reliably obtaining serial hs-cTn samples at 60-minutes in a busy ED setting may be difficult. A potential explanation for only 5-6% of Australian sites adopting 0h/1h hs-cTn testing. Methods and Results We undertook a case-control study between March and August 2023 among patients with suspected ACS presenting to Liverpool Hospital ED (Sydney, Australia). 185 patients (cases) underwent hs-cTnT sampling at 30- and 60-minutes (± 5 minutes) after baseline. Diagnosis of MI was made in 8.6%, 35.7% were placed into a further observation group and MI ruled-out in 55.7%. The latter two groups were matched to 169 patients (controls) who received ‘usual’ care, which was a 0h/1h hs-cTnT testing protocol. The case and control arms were matched by age, gender, time from symptom onset and main presenting symptom. Control patients had a median sampling interval of 118 [85 to 174] minutes, rather 60 minutes as the protocol directs. When comparing the paired differences between the case and control arms, there was a mean reduction in length of stay of 104 (95% CI: 41 to 186, P = 0.01) and 47 (95% CI: 11 to 84, P = 0.01) minutes, for the observation and rule-out MI groups respectively. The figure shows the distribution of lengths of stay by group. Among the rule-out group, Wilcoxon signed rank test indicated the control arm had a longer median length of stay of 6.3 [5.1 to 8.4] hours, compared to 5.0 [4.5 to 7.1] hours in the case arm (P=0.005). Similarly, in the further observation group, control patients also had a longer median length of stay of 9.2 [6.9 to 10.4] hours compared to case patients of 8.1 [5.1 to 10.3] hours (P = 0.009). At 30-days, ED representation rates were 10.7% in controls and 8.3% in cases, rehospitalisation 3.6% in controls and 5.3% in cases, cardiac death 0% in both arms and non-cardiac death 1% in both arms. There were no differences in event rates between each arm (P &amp;gt; 0.05). Conclusion Accurate 0h/1h hs-cTnT testing reduces patient length of stay in ED and offers more personalised prediction of MI risk. The importance of adherence to protocol-directed sampling times is clear, where further studies are required regarding routine implementation in a busy ED setting.Exact 60 min TnT and LOSOutcomes at 30 days

Clinical, echocardiographic, and pathologic characteristics of patients with pathology-proven nonbacterial thrombotic endocarditis

Abstract Background Non-bacterial thrombotic endocarditis (NBTE) is a non-infectious condition characterized by thrombotic and/or inflammatory depositions involving the cardiac valves. It is a challenging diagnosis of exclusion. Purpose This study aimed to better characterize patients with pathologically proven NBTE and assess its clinical, echocardiographic characteristics and prognostic implications. Methods We retrospectively identified patients with pathology-proven NBTE at a single center. Patients with positive preoperative blood cultures, a history of active or treated infective endocarditis, or identification of valvular organisms by special stains were excluded from the study. Patients with pathology reports of valve perforation or chordal rupture were also excluded because of the high likelihood of an infectious etiology for these lesions. Results A total of 53 patients with NBTE (median age 57 years; 61% females) were identified. In this cohort, 22% had a history of malignancy, 30% had connective tissue disease, 32% had coronary artery disease, and 11% prior history of NBTE. Neurological events accounted for 18 (34%) of the presenting symptoms (TIA n=17, CVA n=9), while new valvular dysfunction in 7 (13%) and fever in 8 (15%) of patients. Five patients (9%) had NBTE involving more than one valve. NBTE involved the mitral valve in 64%, aortic valve in 38% prosthetic/mechanical valve in 11%, and tricuspid valve in 5%. NBTE was identified at the time of autopsy in 34% of patients. NBTE recurred in 3 patients during follow-up. Excluding patients diagnosed at the time of autopsy, 9% of patients died within 1 year of NBTE diagnosis. Conclusion NBTE was diagnosed pathologically in the presence of hyper-inflammatory states due to critical illness or immunological diseases. It was predominantly on the left side of the heart and was associated with embolic phenomena, either clinically or on imaging. Patients diagnosed with antemortem with NBTE have a high mortality in the first year (9%).

Bartonella endocarditis: lessons learnt from an African cohort

Abstract Background Bartonella (B) quintana endocarditis is a preventable, vector-borne, and important cause of blood culture-negative endocarditis (BCNE). The ESC guideline for the management of endocarditis recommends blood serology (IgG titer ≥800) and polymerase chain reaction (PCR) testing on both blood and valvular tissue for diagnosis. Access to these molecular technologies is limited in Africa and there is a paucity of B. quintana endocarditis research on the continent. Purpose Record the clinical picture and explore the risk factors for disease and the diagnostic utility of immunofluorescence (IFA) in PCR-proven cases with B. quintana endocarditis. Methods Data were analysed from a prospective observational cohort study of patients with infective endocarditis managed at our institution. All BCNE cases from October 2019 to January 2024 were evaluated to identify patients with PCR-proven B. quintana on valvular tissue. A commercially available IFA was used for blood serology testing. 16S rRNA PCR testing with sequencing was performed on valvular tissue. Results Thirty five of the 58 cases (60.3%) with BCNE were diagnosed with Bartonella endocarditis. A diagnosis of PCR-proven B. quintana endocarditis was made in 21 cases. Of these, seven patients (33.3%) were either homeless or lived in informal housing. Thirteen patients (61.9%) had an alcohol-use disorder. Four patients (19%) were Human Immunodeficiency (HIV) virus- positive. Eighteen patients (85.7%) reported the onset of symptoms more than two weeks before presentation. Common presenting symptoms were dyspnea (n=21;100%), loss of weight (n=10;47.6%) and fever (n=7;33.3%). Common clinical features were digital clubbing (n=17;80.9%), pallor (n=13; 61.9%), microscopic haematuria (n=12; 57.1%) and severe regurgitant lesions (n=21; 100%). Blood serology was available in 17 patients with an IgG titer (1≥256) in all patients apart from one (1:64). Only one case (5.8%) had an IgG titre ≥800. The most common isolated valve lesion on echocardiography was severe aortic regurgitation (n=10;47.6%). Surgical replacement and repair were performed in 17(80.9%) and 4(19%) patients respectively. The one-, three- and six-month mortality was 14%, 14 % and 14% respectively. No cases of relapse were reported. Discussion B.quintana is the most prevalent cause of BCNE in our centre. The typical clinical and echocardiographic profile was consistent with the reported literature of a destructive endocarditis in a patient with a low socioeconomic background. Despite this, the surgical outcome is fair and comparable to European data. The IFA used in this study is different to the assay referenced in the ESC guideline and may explain the relatively low serology titres observed (despite PCR-proven disease). Further study with the commercial IFA is needed to determine a cut-off titre that will give a comparable sensitivity to the referenced in-house IFA.Destructive aortic valve endocarditisResultant severe aortic regurgitation