Time Of First Presentation Research Articles

Readmission among patients with cancer who were discharged with hospice care.

46 Background: Palliative and hospice care are appropriate recommendations for patients with high symptom burden and who are at end of life. Patients with cancer who are discharged to hospice care are less likely to be readmitted and this is expected. There remains a proportion of patients however, who rescind hospice after enrolling. We sought to describe this subgroup of patients and determine their readmission rate. Methods: This is a retrospective cohort study using administrative data of adult patients discharged from a non-surgical solid tumor service at The MD Anderson Cancer Center who were discharged to hospice care. Readmission was defined as any rehospitalization after discharge regardless of timing. Descriptive statistics are presented. Results: There were 1,452 discharge encounters with a disposition of hospice in our cohort with 50 resulting in readmission (readmission rate=3.4%). The mean age of patients who were readmitted was 59 years. Majority of the readmitted patients were female (60%), had a religious affiliation (83%), were English-speaking (85%), and were from Texas (94%). 54% of the patients who were readmitted were married versus 42% who were either single, divorced, widowed or separated. 42% had Medicare insurance, 44% had private insurance, 4% were indigent, and 10% were self-pay. 75% of the patients had metastatic disease at time of first presentation at MD Anderson. Conclusions: Transitioning to hospice care is a difficult decision for most patients and caregivers. Rescinding hospice after discharge to seek acute care in the hospital potentially reflects the difficult and daunting nature of this transition. Our study provides an insight into the characteristics of patients who are readmitted after hospice care has been initiated. More analysis is needed to determine if the characteristics described are associated with readmission in this population. Other factors such as those that are related to the caregiver, the patient’s symptom burden, or the care setting, may need to be investigated as well to have a better understanding of why patients decide to rescind hospice.

Medically unexplained visual loss in children and young people: an observational single site study of incidence and outcomes.

number of patients diagnosed with MUVL, proportion of patients with a history of or present psychological problems, recovery rate, and improvement in visual acuity.ResultsWe identified 85 cases of MUVL (54 females; median age: 9 years (IQR 7-12)). The median duration of follow-up was 1.2 months (IQR 0-4.3). The estimated annual incidence was 3.5% (95% confidence interval 2.9-4.4%). Thirty-three per cent of children had a history of psychiatric disorders, reported a stressful life event, or showed signs of psychiatric disorder at the time of first presentation. The recovery rate was 25%. Median improvement in best-corrected visual acuity from presentation to last appointment was 0.22 (IQR 0.06-0.43) logMAR.ConclusionThe incidence of MUVL is higher and the rate of resolution lower than previously reported. MUVL may be associated with mental health problems. We recommend screening for psychological problems to facilitate access to psychological treatment.

An evaluation of the neutrophil-to-lymphocyte ratio as a prognostic and predictive marker in thromboangiitis obliterans

Objective The aim of this study was to investigate whether the neutrophil/lymphocyte ratio is an independent predictor of poor prognosis, mortality, co-morbidities, critical limb ischmemia, amputation, or a potential prognostic biomarker predicting pathological and survival outcomes in thromboangiitis obliterans. We also investigated whether there was any relation between an increased neutrophil/lymphocyte ratio in patients with Buerger’s disease and amputation, the ultimate outcome of poor prognosis. Materials and Methods The hospital records of patients treated, followed-up and diagnosed with thromboangiitis obliterans were analyzed retrospectively. Surgical procedures performed and medical treatments applied were recorded from patients’ clinical data. Extremities exposed to the disease during its course were identified. Amputations were recorded as minor and major. Neutrophil and lymphocyte values were recorded from peripheral blood samples at time of first presentation to hospital, with the neutrophil/lymphocyte ratio being calculated from these. One hundred ten subjects were finally enrolled as the patient group (TAO; n=110). A control group (n=49) was established consisting of smoker volunteers with no health problems. Statistical changes in neutrophil/lymphocyte ratio values between the groups were investigated. Results No statistically significant difference was observed between the two groups’ basic characteristics. In terms of neutrophil/lymphocyte ratio values, a statistically significant increase was observed in the patient group compared to the control group. We observed no statistical correlation between amputations and neutrophil/lymphocyte ratio values. Conclusions We think that the neutrophil / lymphocyte ratio, obtained easily and cheaply from routine peripheral blood samples, may be of clinical benefit in thromboangiitis obliterans.

The plethora, clinical manifestations and treatment options of autoimmunity in patients with primary immunodeficiency.

Although the association between primary immunodeficiency and autoimmunity is already well-known, it has once again become a topic of debate with the discovery of newly-defined immunodeficiencies. Thus, investigation of the mechanisms of development of autoimmunity in primary immunodefficiency and new target-specific therapeutic options has come to the fore. In this study, we aimed to examine the clinical findings of autoimmunity, autoimmunity varieties, and treatment responses in patients who were genetically diagnosed as having primary immunodeficiency. The files of patients with primary immunodeficiency who had clinical findings of autoimmunity, who were diagnosed genetically, and followed up in our clinic were investigated. The demographic and clinical features of the patients and their medical treatments were evaluated. Findings of autoimmunity were found in 30 patients whose genetic mutations were identified. The mean age at the time of the first symptoms was 8.96±14.64 months, and the mean age of receiving a genetic diagnosis was 82.55±84.71 months. The most common diseases showing findings of autoimmunity included immune dysregulation, polyendocrinopathy, enteropathy X-linked syndrome (16.7%); autoimmune lymphoproliferative syndrome (10%); lipopolysaccharide-responsive beige-like anchor protein deficiency (10%); and DiGeorge syndrome (10%). Twelve (40%) patients showed findings of autoimmunity at the time of first presentation. The most common findings of autoimmunity included inflammatory bowel disease, inflammatory bowel disease-like findings (n=14, 46.7%), immune thrombocytopenic purpura (n=11, 36.7%), and autoimmune hemolytic anemia (n=9, 30.0%). A response to immunosupressive agents was observed in 15 (50%) patients. Ten patients underwent hematopoietic stem cell transplantation. Six patients were lost to follow-up due to a variety of complications. Autoimmunity is frequently observed in patients with primary immunodeficiency. The possibility of primary immunodeficiency should be considered in patients with early-onset manifestations of autoimmunity, and these patients should be carefully monitored in terms of immunodeficiency development. Early diagnosis of primary immunodeficiency may provide favorable outcomes in terms of survival.

Characterization of Cytogenetic Abnormalities in Myelofibrosis and Relationship to Clinical Outcome

Introduction: Cytogenetic abnormalities occur frequently in patients with myelofibrosis (MF) and carry significant prognostic value. A variety of cytogenetic abnormalities have been reported with variable incidence. While the prognostic significance of more common cytogenetic abnormalities is well documented, the prognostic significance of less common abnormalities are difficult to discern due to limiting cohort size. Further, the specific phenotype associated with various cytogenetic abnormalities is less clear. We reviewed our institutional experience in an effort to describe the spectrum of chromosomal abnormalities, assess their correlation with clinical features, and validate their prognostic impact in a cohort of MF patients.Methods: This was a single institution, retrospective study of all patients with a diagnosis of MF who were seen at our center between 2/2001 - 6/2016.We reviewed cases of myelofibrosis in the Moffitt Cancer Center database. Definitions of primary myelofibrosis (PMF), post-essential thrombocythemia myelofibrosis (post-ET MF) and post-polycythemia vera myelofibrosis (post-PV MF) were according to World Health Organization 2016 criteria and the International Working Group for Myeloproliferative Neoplasms, Research and Treatment, respectively. Cytogenetic analysis was documented with preference to date of diagnosis. Overall survival was measured from time of cytogenetic analysis.Results: We identified 312 eligible. Cytogenetic data were available in 278 of 312 (89%) patients. The cohort was 59% male with a median age of 70 years at time of first presentation. PMF comprised 76% of cases with post-PV MF and post-ET MF accounting for 9% and 15% of cases respectively. Cytogenetic analysis was performed within 3 months of diagnosis in 63% and over a year after diagnosis in 24% of patients.Cytogenetic spectrum and frequency is shown in Figure 1. Normal diploid karyotype was present in 55%. The most common cytogenetic abnormality was a deletion of the long arm of chromosome 20 (del 20q), occurring in 39 (14%) cases. Del 20q occurred as an isolated abnormality in 26/39 cases. When occurring in conjunction with other structural abnormalities, it was most often associated with trisomy 9 (6/39). A deletion of the long arm of chromosome 13 (del 13q) was the second most common chromosomal aberration, occurring in 26 (9%) of cases and usually presenting as the sole abnormality (15/26). An extra copy of chromosome 8 (trisomy 8) occurred in 21 (8%) cases and often occurred in conjunction with other cytogenetic abnormalities (11/21). Less common cytogenetic abnormalities included trisomy 9, deletion 7q and deletion 5q, occurring in less than 4% of cases. Monosomal and complex karyotypes accounted for 10% and 8.3% of cytogenetics, respectively.We then assessed relationships between cytogenetic abnormalities and clinical and pathologic features. Del20q was associated with a lower IPSS score (r = -0.18, p = 0.0006). Deletion 13q was associated with older age at presentation (r = 0.14, p = 0.007). Prevalence of trisomy 8 was highest in post-polycythemia vera myelofibrosis (r = 0.14, p = 0.03) and associated with increased peripheral blast percentage (r = 0.16, p < 0.0001). Deletion 5q was associated with decreased hemoglobin (r = -0.13, p = 0.04), transfusion dependence (r = 0.20, p = 0.0009) and conversion to blast phase (r = 0.23, p = 0.0001).Patients with del 20q, del 13q, and trisomy 9 had median overall survival (OS) comparable to patients with a normal karyotype (45 vs 54 months, respectively, p = 0.69). Patients with unfavorable cytogenetic profiles (del 5q, trisomy 8, and chromosome 17 abnormalities) had significantly worse OS when compared to patients with normal diploid karyotype (20 vs 54 months, p = 0.0002) (figure 2). In multivariate regression analysis, controlling for DIPSS, deletion 5q (HR: 0.34 [0.15-0.78]; p = 0.01) and trisomy 8 (HR: 0.35 [0.17-0.73]; p = 0.005) were significantly associated with inferior overall survival.Conclusions: Cytogenetic abnormalities in myelofibrosis provide significant prognostic discrimination in patients with myelofibrosis. Our findings validate the prognostic value of cytogenetics and raise possible heretofore unrecognized clinical associations. [Display omitted] [Display omitted] DisclosuresLancet:Novartis: Consultancy; Biopath Holdings: Consultancy; Karyopharm: Consultancy; Boehringer-Ingelheim: Consultancy; Quantum First: Consultancy; ERYtech: Consultancy; Pfizer: Research Funding; Celgene: Consultancy, Research Funding; Jazz Pharmaceuticals: Consultancy; Seattle Genetics: Consultancy; Kalo Bios: Consultancy; Baxalta: Consultancy; Amgen: Consultancy. Sweet:Incyte Corporation: Research Funding; Pfizer: Speakers Bureau; Karyopharm: Honoraria, Research Funding; Ariad: Consultancy, Speakers Bureau; Novartis: Consultancy, Speakers Bureau. Komrokji:Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Consultancy, Speakers Bureau.

Dynamics of occurrence of refractory coeliac disease and associated complications over 25years.

Refractory coeliac disease, enteropathy associated T-cell lymphoma and small bowel adenocarcinoma are rare but prognostically important complications in coeliac disease. To analyse potential changes in occurrence of complicated coeliac disease over the last 25years. One thousand one hundred and thirty eight patients were included and evaluated based on their time of first presentation at the Medical University of Vienna, Austria. Occurrences of refractory coeliac disease and associated malignancies were evaluated for 5-year intervals from January 1990 until December 2014 and were compared over time. 2.6% (n=29) were diagnosed with refractory coeliac disease (females 65.6%, mean age at diagnosis 62.8years). The proportion of those patients was 2.6%, 3.1%, 3.3%, 2.7% and 0.5% for the 5year intervals from 1990 onwards. Thus, the number of refractory cases has been decreasing since 2000 (P=0.024). The number of patients presenting with lymphoma (n=7) was 0.6%, 0.4%, 1.1%, 0.8% and 0% from 1990 to 2014. Similarly the number of patients with adenocarcinoma (n=4) decreased to 0% until 2014. Overall mortality in patients suffering from refractory disease was 48%. Of all patients diagnosed with lymphoma 71.4% died with a 5-year survival rate of 28.6%. Over the past 15years the occurrence of complicated coeliac disease has been decreasing. This possibly reflects a higher awareness of coeliac disease and optimised diagnosis and treatment with avoidance of long-term immunological disease activity. Symptomatic disease and a delay in diagnosis are risk factors for refractory coeliac disease and related cancer.

A Study on Incidence and Risk Factors of Inguinal Hernia in ESI Population

Background: Inguinal hernia is one of the most common surgical pathologies. Research studies on clinical factors predisposing a person for the development of inguinal hernia, however, remain scarce. Aims and objective: the present study was to evaluate the incidence and risk factors for the development of inguinal hernia in adult males. Material and Methods: The study was done for a period of one year (January 2015 to December 2015) among the people attending surgical outpatient and inpatient department at Government Medical College and ESIC Hospital, coimbatore. Results: The study population included 130 patients with inguinal hernia , 95% were males and the majority 23% belonged to 41 to 50 years. Approximately 23.8% presented with bilateral inguinal hernia at the time of first presentation. The common risk factors found were heavy object lifting and chronic cough and other co morbid illness. Conclusion: The study had shown a slightly high incidence of bilateral inguinal hernia with the commonest risk factors being chronic cough and heavy weight lifting and affecting the productive group of Esi population.

Hips With Protrusio Acetabuli Are at Increased Risk for Failure After Femoroacetabular Impingement Surgery: A 10-year Followup.

Protrusio acetabuli is a rare anatomic pattern of the hip in which the femoral head protrudes into the true pelvis. The increased depth of the hip and the excessive size of the lunate surface typically lead to severe pincer-type femoroacetabular impingement (FAI); however, to our knowledge, there are no published mid- or long-term studies on results of circumferential acetabular rim trimming through a surgical hip dislocation for patients with this condition. (1) What is the 10-year survivorship of the hips treated with circumferential rim trimming through a surgical hip dislocation compared with a control group of hips that underwent surgery for pincer FAI but that did not have protrusio acetabuli? (2) What are the factors that were associated with a decreased likelihood of survivorship in those hips with the following endpoints: total hip arthroplasty, Merle d'Aubigné score of less than 15, and/or radiographic progression of osteoarthritis (OA)? (3) Does the radiographic pattern of degeneration differ between the two groups? We performed a case-control study comparing two groups: a protrusio group (32 patients [39 hips]) and a control group (66 patients [86 hips]). The control group consisted of hips treated with a surgical hip dislocation for pincer FAI and did not include hips with a positive protrusio sign or a lateral center-edge angle > 39°. The study group did not differ from the control group regarding the preoperative Tönnis OA score, age, and body mass index. However, the study group had more women, decreased mean height and weight, and lower preoperative Merle d'Aubigné-Postel scores, which were inherent differences at the time of first presentation. During the period in question, the indication for performing these procedures was a painfully restricted range of motion in flexion and internal rotation (positive impingement sign). The mean followup of the protrusio group (9 ± 5 years [range, 2-18 years]) did not differ from the control group (11 ± 1 years [range, 10-13 years], p = 0.109). At the respective minimum followup intervals in the underlying database from which cases and control subjects were drawn, followup was 100% for patients with protrusion who underwent FAI surgery and 97% for patients with FAI who underwent surgery for other anatomic patterns (three of 86 hips). We assessed the Merle d'Aubigné-Postel score, Harris hip score, WOMAC, and UCLA activity score at latest followup. A Kaplan-Meier survivorship analysis of the hip was calculated if any of the following endpoints for both groups occurred: conversion to total hip arthroplasty, a Merle d'Aubigné-Postel score < 15, and/or radiographic progression of OA. Differences in survivorship were analyzed using the log-rank test. At 10-year followup, we found a decreased survivorship of the hip for the protrusio group (51% [95% confidence interval {CI}, 34%-67%]) compared with the control group (83% [95% CI, 75%-91%], p < 0.001) with one or more ofthe endpoints stated. We found four multivariate factors associated with a decreased likelihood of survival of the native hip according to the mentioned endpoints: body mass index > 25 kg/m(2) (adjusted hazard ratio, 6.4; 95% CI, 5.2-8.1; p = 0.009), a preoperative Tönnis OA score ≥ 1 (13.3; 95% CI, 11.8-14.9; p = 0.001), a postoperative lateral center-edge angle > 40° (4.2; 95% CI, 2.8-5.6; p = 0.042), and a postoperative posterior coverage > 56% (6.0; 95% CI, 4.3-7.6; p = 0.037). Preoperatively, joint space narrowing and osteophytes were more frequentposteroinferior(jointspace narrowing 18% versus 2%, p = 0.008; osteophytes 21% versus 4%, p = 0.007),medial (joint space narrowing 33% versus 5%, p < 0.001) and anterior (osteophytes 15% versus 1%, p = 0.004) in the protrusio compared with thecontrol group. After correction in hips with protrusio, progression of joint space narrowing (from 6% to 45%, p = 0.001) and osteophyte formation (from 15% to 52%, p = 0.002) was most pronounced laterally. At 10 years, in 51% of all hips undergoing open acetabular rim trimming for protrusio acetabuli, the hip can be preserved without further radiographic degeneration and a Merle d'Aubigné score > 15. Even with the lack of a control group with nonoperative treatment, isolated rim trimming may not entirely resolve the pathomorphology in protrusio hips given the clearly inferior results compared with surgical hip dislocation for FAI without severe overcoverage. Level III, therapeutic study.

Freiburger Keratokonusregister

Keratoconus is a progressive corneal disease with thinning and scarring of the cornea. Diagnostic and treatment options are usually evaluated in large prospective or retrospective trials. Big data and smart data provide the possibility to analyze routine data for clinical research. In this article we report the generation of a monocentric keratoconus registry by means of computerized data analysis of routine data. This demonstrates the potential of clinical research by means of routine data. A "clinical data warehouse" was created from all available routine electronic data. At the time of first presentation, each eye was classified into one out of four categories: suspected, early disease, late disease and status postkeratoplasty. Through integration of multiple data sources the clinical course for each patient was documented in the registry. A total of 3681 eyes from 1841 patients were included. The median follow-up time was 0.54 years. Patient age was higher in the groups with more severe stages of keratoconus, the proportion of female patients was higher in the group of suspected keratoconus and patient age and male to female ratios showed statistically significant differences between the groups (p <0.001). We were able to create a "clinical data warehouse" by linking multiple data sources and normalizing the data. With this tool we established a novel, monocentric keratoconus registry. Only the grading of disease severity and the exclusion of false positive results were carried out manually. In our opinion establishing a structured clinical data warehouse has a huge potential for clinical and retrospective studies and proves the value of the Smart Data concept.

Living with uncertainty: Mapping the transition from pre-diagnosis to a diagnosis of dementia

Across the world, an early and timely diagnosis of dementia is seen to be a policy and practice imperative and a necessary step in order to live well with the condition. However, limited understanding exists regarding the personal and relational meanings attributed to the diagnostic experience. Drawn from the findings of a larger multi-site study conducted in four areas of England, this article presents a subset of the data where five participants and their carers and two people living alone initially presented themselves at a memory clinic for diagnostic testing, with this presentation eventually resulting in a confirmed, and shared, diagnosis of dementia. All 12 participants were interviewed at two time points in the study: at the time of first presentation to the memory clinic and shortly after the diagnosis had been shared with them. Informed by the grounded theory method, constant comparative analysis was applied to the data and this process resulted in a four-phase sequential model of diagnostic transition: (1) becoming self-aware→seeking outside help; (2) being referred→receiving a clinic appointment; (3) undergoing tests→being told what's wrong; and (4) adjusting to the diagnosis→negotiating everyday expectations. Running through each phase was the core category of ‘living with uncertainty’ which summarised the entire diagnostic journey for all study participants. Findings suggest a need for better awareness and information for people living with dementia at all phases and time points in the condition, which may be fostered by embedding these in early clinical encounters.

Reasons for intraocular pressure to resist hypotensive therapy in glaucoma patients

To study the reasons of intraocular pressure (IOP) resistance to therapy in patients with glaucoma. During the period 2011-2013 we examined 72 primary glaucoma patients (stage I-III), 44 women and 28 men, aged 49-87 years (65.2±2.5 years on average) referred by local ophthalmologists due to poor response to hypotensive therapy. We suggest that glaucoma should be regarded as resistant if, despite combination therapy with three antihypertensive drugs at optimal doses, IOP stays above the target. In the present study, the treatment was found suboptimal in 19.4% of cases. About 45% of all patients (33 patients) demonstrated poor compliance to the prescribed treatment. Resistant glaucoma, as we have defined it, was diagnosed in 33% of cases (pigmentary glaucoma, pseudoexfoliation glaucoma, secondary unrecognized glaucoma, etc.). This group also included patients, in whom b-blockers were initially effective, but then seemed to lose their power. 1. The reasons for intraocular pressure to resist hypotensive therapy are often associated with medical inertia (inaccurate diagnosis, inadequate treatment, etc.) and lack of patient compliance. 2. Resistant glaucoma in its true sense accounts for about 35% of cases of IOP being above the target despite conservative treatment. 3. It is advisable that at the time of first presentation, any patient who fails to reach the target IOP is treated as an «uncontrolled glaucoma» case, until the reasons for his/her resistance are clear.

Diagnostically Approach to Pediatric Carpal Fractures: a Retrospective Analysis

Carpal fractures in children are rare, but can be missed, as their clinical symptoms are unspecific and discrete. Even X-ray diagnosis is difficult. Timely diagnosis and consistent therapy are especially important for scaphoid fractures, as they can help to avoid complications such as non-union or avascular necrosis. A diagnostic approach to paediatric carpal fractures will be discussed on the basis of the following group of patients. Retrospective analysis of children under 14 years treated in our institution between 09/2010 and 02/2012 for clinically suspected carpal fracture. In the primary evaluation, all children underwent standard X-rays of the hand and/or wrist. All patients were treated by cast immobilisation until complete clinical recovery. All patients with clinical signs of carpal fracture were treated by cast immobilization, even with normal X-rays. The clinical follow-up examination was after 10 to 14 days. In patients with persistent complaints, MRI was performed. We retrospectively evaluated the records of all patients: the fractured carpal bone, and X-ray and MRI-diagnosis were stated. We calculated the mean difference between first presentation and MRI and the mean period for total recovery, in patients with fracture or non-fracture. 61 children (27 boys and 34 girls, mean age 11.5 y) were included in our study. The mean delay between accident and time of first presentation to our paediatric ED was 0.6 days. In primary X-rays, a carpal fracture was demonstrated in only in 2 (3.3 %) patients, but was suspected in only 6 (9.8 %) of patients. In 53 (87.9 %) patients, there was no radiographic evidence of carpal fracture. 14 patients underwent additional scaphoid views, but scaphoid fracture was confirmed in only 1 (7 %) of these patients. In 3 (21.4 %) patients, a scaphoid fracture was suspected and in 10 patients a carpal fracture could be excluded. After a mean time of 11.8 days, all patients underwent a clinical follow-up examination. 32 (54 %) patients had persistent symptoms and MRI was done after a mean time of 17 days. Carpal fracture was then excluded in 12/32 (37 %) patients and was diagnosed in another 20/32 (63 %) children. There were 14 scaphoid fractures, including 3× bone bruise lesions, 4 capitate fractures, 3 triquetral fractures, including 1× bone bruise lesion and 1 bone bruise lesion of the trapezoid. In patients with proven carpal fracture, it took a mean time of 56 days for complete recovery, in comparison with 15 days in patients with excluded carpal fracture. Surgical therapy was unnecessary in any of the patients, and there were no complications. In children with clinical and radiographic carpal fracture, diagnosis is difficult and often unsuccessful at first. Even in discrete clinical complaints, generous cast immobilization is essential and clinical follow up is recommended not later then 14 days. In patients with persistent clinical symptoms, MRI is the imaging method of choice, as it is capable of detecting carpal fractures and even bone bruise lesions with high sensitivity, thereby avoiding unnecessary diagnostic or therapeutic stress for the patients.

Fronto-orbital mucocele and orbital involvement in occult obstructive frontal sinus disease

AimsTo describe the clinical features of orbital involvement arising from occult obstructive frontal sinus disease and to highlight key features to aid diagnosis.MethodsA retrospective review of the case notes of...

Early Diagnosis of Migraine Necessary in Children: 10-Year Follow-Up

BackgroundThe prevalence of migraine in individuals younger than 20 years old is 8%, with a mean age at onset of younger than 8 years. However, the long-term prognosis of migraine attacks has not been clearly established. ObjectiveOur main objective was to evaluate disease course 10 years after migraine diagnosis in a cohort of children and adolescents. MethodsMigraine was diagnosed in 1999 in a pediatric headache reference center using International Headache Society criteria. In 2009, all patients were interviewed by telephone on the persistence and characteristics of any headaches. The main end point was prevalence of persistent migraine attacks in 2009. Variables associated with persistent attacks were analyzed. ResultsOverall, 142 children were diagnosed with migraine in 1999. Of these, 84 were interviewed by telephone in 2009. In 1999, the mean age was 11.6 ± 3.1 years, 54% were male, and 50% had migraine without aura. Migraine attacks were common (1-3 attacks/week in 38%). Mean age at onset was 7 years and 4 months (±3 years). In 2009, migraine prevalence was 39/84 (46% [95% confidence interval 36-56]), 12 patients (14%) were headache-free, and 62 patients (74%) had tension-type headaches that were isolated headaches in 33 (39%) patients. The rate of patients with at least one migraine attack per week fell from 37% to 8% (P = 0.001) over the 10-year period. Age at the first visit to the center was significantly higher in 2009 migraine sufferers than nonsufferers (12.5 ± 3.0 versus 10.9 ± 3.1 years (P = 0.02)). In multivariate analysis, age ≥12 years at the time of first presentation was the only significant factor associated with long-term chronic migraine (odds ratio = 3.0 [1.1-8.0]). ConclusionsTen years after first presentation, 46% of patients had migraine but the frequency of attacks had diminished. The only factor associated with chronic migraine was age ≥12 years at first presentation.

PTU-025 How accurately is rockall score calculated for patients with acute upper gastrointestinal bleeding (AUGIB)?

Introduction Documentation of Rockall score (RS) in patients with AUGIB should be accurate in order to prioritise patients for gastroscopy. We conducted a pilot study in 2012 which showed that RS was calculated incorrectly in 46% patients. We investigated this further with a larger cohort of patients. Method Information was collected retrospectively on patients who presented with presented with AUGIB from February 2012 to February 2013. Patients who had out-of-hours gastroscopy excluded. Demographics, time to perform gastroscopy, RS documented by the doctor requesting the gastroscopy, RS calculated by analysing patient records (including A&E, paramedic records) were collected. We analysed patients whose RS was either underscored or overscored by the requesting doctor (this was compared to the actual score calculated by us) and correlated the calculated RS with the need for endoscopic intervention. Results There were 248 patients with 149 (60%) males, age 16 to 98 years (mean 69). Presenting symptoms were melaena in 129 (51%), haemetemesis 35 (14%), coffee ground vomiting 64 (25%), rectal bleed 17 (7%), melaena and haematemesis 4. RS was calculated incorrectly in 194 (78%) patients with 110 (44%) over scored (Group A), 84 (34%) underscored (Group B). Mean RS on request form for Group A patients was 3.64 ± 1.97 while the calculated RS was 1.85 ± 1.61. In Group B, mean RS documented was 1.8 ± 0.96 while the calculated RS was 3.9 ± 1.04. Mean time from electronic booking to gastroscopy was 2.02 days – 1.67 days for Group A and 2.04 days in Group B. FY1s calculated incorrect scores in 83 (43%) patients, FY2s in 20 (10%), SHOs in 81 (42%), registrars in 7 (4%) and consultants 3 (2%). Of the 111 FY1s (45%) who calculated the RS, 46 (41%) overscored, 37 (33%) underscored and 28 (25%) calculated RS correctly. The numbers for 27 FY2 (11%) were 11 (41%), 9 (33%) and 7 (26%) respectively. Of the 95 (38%) SHOs, 47 (50%) overscored, 34 (36%) underscored and 14 (15%) calculated RS correctly. There were 11 specialist registrars (4 correct, 4 overscored and 3 underscored) and 4 Consultant request forms (3 incorrect). Of the 248 patients, 37 (15%) required endoscopic intervention. In Group A, 16 (15%) needed endoscopic intervention, compared to 11 (13%) in Group B. Ten (19%) of the 54 patients scored correctly required endoscopic therapy. Conclusion This study shows that it is important to document the RS at the time of first presentation of AUGIB rather than at the time when the patient is seen by the admitting doctor. This study however does not show a direct correlation between the RS and endoscopic intervention. It emphasises the fact that all doctors should be educated about the importance of documenting the correct RS as more than three quarter of the RS on request forms were found to be inaccurate. Disclosure of interest None Declared.

The profile of adult onset Henoch-Schönlein purpura in an Asian population.

Henoch-Schönlein purpura (HSP) is less common in adults and has been linked with a more severe clinical syndrome as well as a higher frequency of renal disease and internal malignancy. Renal involvement in adult HSP has been significantly associated with antecedent infections, pyrexia at time of first presentation, and purpura above the waist. We aim to evaluate the frequency of cutaneous and extra-cutaneous features and identify the predictive factors for renal involvement in Asian adults with HSP. We performed a retrospective study of 48 adult Asian patients diagnosed with HSP based on the European League Against Rheumatism (EULAR) criteria at a tertiary hospital in Singapore between January 2000 and December 2011. The most common cutaneous manifestations were palpable purpura (73%), papules (31%), and petechiae (27%). Forty-percent had cutaneous lesions extending above the waist. Fifteen patients (31%) had gastrointestinal symptoms, 21 (44%) had joint involvement, and 27 (56%) had renal disease. Seventy-percent of patients with pyrexia at presentation experienced renal disease, whereas only 30% without pyrexia had renal involvement (P = 0.018). Sixty-six percent of patients with purpura had renal involvement as compared to 31% in those without purpura (P = 0.049). The frequency of renal involvement in patients with purpura above the waist (52%) was similar to those with purpura below the waist (55%). Our study confirms that HSP in adults tends to be more severe with a high incidence of extracutaneous manifestations, especially renal disease. Pyrexia at presentation and the presence of purpura were significant predictive factors for renal involvement.

Leprosy and disability in children younger than 15 years in an endemic area of northeast Brazil.

Leprosy in children is still a frequent but sometimes unrecognized public health problem and an important cause of disability. Establishing the risk factors that lead to the development of disability is important for the development of suitable prevention programs. We describe the incidence of leprosy and the prevalence and degree of associated disabilities in children<15 years of age at the time of first presentation to the health services in Aracaju, Sergipe, Northeast Brazil. A retrospective case series of 266 cases of leprosy in children under 15 years old of Aracaju from 2001 to 2012. Logistic regressions were performed to identify factors for disability. The average detection rate was 16.5/100,000 children under 15 years old per year over the study period. Physical disability was associated with the presence of affected nerves and multibacillary leprosy. The detection rate of leprosy in children is still high in Aracaju, Northeast Brazil. Having affected nerves and multibacillary leprosy are associated with the development of disability in children.

Impaired gallbladder motility in adults with newly detected type 2 diabetes and lack of reversibility after achieving euglycemia.

The effects of hyperglycemia and normoglycemia on gallbladder emptying have not been studied in detail. This prospective case-control study was designed to investigate the gallbladder ejection fraction in patients with newly detected diabetes and to assess the impact of restoring normoglycemia on gallbladder ejection fraction in such patients. (99m)Tc-mebrofenin scintigraphy was performed in 22 patients with newly detected type 2 diabetes for measurement of gallbladder ejection fraction. The scintigraphy was performed at the time of first presentation and again 6 months after control of diabetes (glycated hemoglobin [A1C] <7%). Also, gallbladder ejection fraction was measured in 20 age- and sex-matched controls without diabetes. Gallbladder ejection fraction was lower in patients with newly detected diabetes compared with controls (31.4%±5.9% vs. 70.7%±4.3%, p<0.001). Gallbladder ejection fraction did not improve after the treatment of diabetes mellitus (21.3%±5.7%, p=0.395). Gallbladder ejection fraction was markedly reduced in patients with newly detected diabetes compared to controls without diabetes. Control of diabetes and normalization of A1C did not reverse the motility defect.

Cancer suspicion in general practice, urgent referral and time to diagnosis: a population-based GP survey and registry study.

BackgroundMany countries have implemented standardised cancer patient pathways (CPPs) to ensure fast diagnosis of patients suspected of having cancer. Yet, studies are sparse on the impact of such CPPs, and few have distinguished between referral routes. For incident cancer patients, we aimed to determine how often GPs suspected cancer at the time of first presentation of symptoms in general practice and to describe the routes of referral for further investigation. In addition, we aimed to analyse if the GP’s suspicion of cancer could predict the choice of referral to a CPP. Finally, we aimed to analyse associations between not only cancer suspicion and time to cancer diagnosis, but also between choice of referral route and time to cancer diagnosis.MethodsWe conducted a population-based, cross-sectional study of incident cancer patients in Denmark who had attended general practice prior to their diagnosis of cancer. Data were collected from GP questionnaires and national registers. We estimated the patients’ chance of being referred to a CPP (prevalence ratio (PR)) using Poisson regression. Associations between the GP’s symptom interpretation, use of CPP and time to diagnosis were estimated using quantile regression.Results5,581 questionnaires were returned (response rate: 73.8%). A GP was involved in diagnosing the cancer in 4,101 (73.5%) cases (3,823 cases analysed). In 48.2% of these cases, the GP interpreted the patient’s symptoms as ‘alarm’ symptoms suggestive of cancer. The GP used CPPs in 1,426 (37.3%) cases. Patients, who had symptoms interpreted as ‘vague’ had a lower chance of being referred to a CPP than when interpreted as ‘alarm’ symptoms (PR = 0.53 (95%CI: 0.48;0.60)). Patients with ‘vague’ symptoms had a 34 (95% CI: 28;41) days longer median time to diagnosis than patients with ‘alarm’ symptoms.ConclusionsGPs suspect cancer more often than they initiate a CPP, and patients were less likely to be referred to a CPP when their symptoms were not interpreted as alarm symptoms of cancer. The GP’s choice of referral route was a strong predictor of the duration of the diagnostic interval, but the GP’s symptom interpretation was approximately twice as strong an indicator of a longer diagnostic interval.

Clinical and epidemiological characteristics of infectious keratitis in Paraguay.

To describe the clinical and epidemiological characteristics of patients with severe infectious keratitis in Asunción, Paraguay between April 2009 and September 2011. All patients with the clinical diagnosis of severe keratitis (ulcer ≥2 mm in size and/or central location) were included. Empiric treatment consisted of topical antibiotics and antimycotics; in cases of advanced keratitis, fortified antibiotics were used. After microbiological analysis, treatment was changed if indicated. In total 48 patients (62.5 % males, 25 % farmers) were included in the analysis. A central ulcer was found in 81.3 % (n = 39). The median delay between onset of symptoms and time of first presentation at our institution was 7 days (range 1-30 days). Fungal keratitis was diagnosed in 64.5 % (n = 31) of patients, of which Fusarium sp. (n = 17) was the most common. Twenty-one patients (43.8 %) reported previous trauma to the eye. The globe could be preserved in all cases. While topical therapy only was sufficient in most patients, a conjunctival flap was necessary in six patients suffering from fungal keratitis. The high rate of fungal keratitis in this series is remarkable, and microbiological analysis provided valuable information for the appropriate treatment. In this setting, one has to be highly suspicious of fungal causes of infectious keratitis.