Time Of First Symptoms Research Articles

Abstract WP190: Central Retinal Artery Occlusion: Do Patient Presentation Patterns Complicate Use Of Potential Treatments?

Introduction: For patients diagnosed with central retinal artery occlusion (CRAO), timely screening for underlying risk factors to prevent secondary stroke and other cardiovascular events is required. Given the profound impact on vision, there is also great interest in the potential to treat CRAO. Thrombolytic therapy is the current standard of care in acute ischemic cerebral stroke, but the window for administration is short. As part of a larger pilot to investigate the prospect of intravenous thrombolysis for patients presenting with acute CRAO in our institution, we set out to evaluate the specific presentation patterns of this population within our system. Methods: Retrospective study performed on 804 patients correctly diagnosed with CRAO from 2011-2020. From this cohort of patients, we identified 484 for whom we could accurately determine the time of first symptoms, the time of first contact with the healthcare system, and the time of evaluation by an ophthalmologist. Results: While 18.0% (87/484) of patients waited over 24 hours from time of vision loss to contact the health care system, 50.2% of patients did connect in under 4.5 hours (243/484). However, only 16.7% (81/484) of patients saw an ophthalmologist within that window, and 35.5% (172/484) did not have any ophthalmologic evaluation within 24 hours of vision loss. Conclusion: Half of CRAO patients within our institution connect with the health care system within a potential window for intravenous thrombolytic treatment, but the majority do not receive ophthalmic diagnosis within that time frame. In conclusion, public health education efforts to speed up presentation times and system-based strategies to decrease the time to ophthalmic diagnosis are needed if thrombolytic treatment either via compassionate use or within a clinical trial setting is to be more widely offered.

Central Retinal Artery Occlusion: Time to Presentation and Diagnosis

To evaluate the presentation patterns of patients diagnosed with central retinal artery occlusion (CRAO) from 2011 to2020. Retrospective cohort study SUBJECTS: The present study was conducted in 484 patients presenting within 30 days of symptom onset with accurate documentation of time of symptom onset, time of presentation to the health care system, and time of presentation to an ophthalmologist. An independent chart review of patients with CRAO was conducted. Demographic information including age, sex, and race were collected. Presentation patterns such as time of first symptoms, time of first contact with the health care system, and time of evaluation by an ophthalmologist were analyzed. Additionally, information regarding the medical venue or specialty of initial patient contact was collected. A total of 247 (51%) patients contacted the health care system within 4.5 hours of system onset, whereas 86 (17.8%) patients waited over 24 hours. Only 81 (32.8%) of the 247 patients who presented within 4.5hours saw an ophthalmologist within that time frame, whereas 172 (35.5%) of the entire cohort of 484 did not present to an ophthalmologist within 24 hours of vision loss. There was significant variability with regards to medical specialty of initial patient contact, with 292 (60.3%) patients first presenting to an emergency department and 133 (27.5%) patients first presenting to an ophthalmologist. Black and Hispanic patients presented later than patients of White, Asian, or other racial backgrounds (40.4 ± 10.2 hours versus 23.0 ± 3.4 hours, P= 0.05). Although no level 1 evidence-based treatment is currently available for CRAO, thrombolytic therapy may be promising. Even though over half of patients with CRAO within our institution connected with the health care system within a potential window for thrombolytic therapy, most did not receive a definitive ophthalmic diagnosis within that time frame. Public health educational campaigns and infrastructure optimization must speed up presentation times, decrease the time to ophthalmic diagnosis, and target vulnerable populations to offer and research timely administration of thrombolytic therapy. The authors have no proprietary or commercial interest in any materials discussed in this article.

Near real-time surveillance of the SARS-CoV-2 epidemic with incomplete data.

When responding to infectious disease outbreaks, rapid and accurate estimation of the epidemic trajectory is critical. However, two common data collection problems affect the reliability of the epidemiological data in real time: missing information on the time of first symptoms, and retrospective revision of historical information, including right censoring. Here, we propose an approach to construct epidemic curves in near real time that addresses these two challenges by 1) imputation of dates of symptom onset for reported cases using a dynamically-estimated "backward" reporting delay conditional distribution, and 2) adjustment for right censoring using the NobBS software package to nowcast cases by date of symptom onset. This process allows us to obtain an approximation of the time-varying reproduction number (Rt) in real time. We apply this approach to characterize the early SARS-CoV-2 outbreak in two Spanish regions between March and April 2020. We evaluate how these real-time estimates compare with more complete epidemiological data that became available later. We explore the impact of the different assumptions on the estimates, and compare our estimates with those obtained from commonly used surveillance approaches. Our framework can help improve accuracy, quantify uncertainty, and evaluate frequently unstated assumptions when recovering the epidemic curves from limited data obtained from public health systems in other locations.

P09 The use of ESR and pain scores to determine the duration of antibiotic therapy in patients with necrotizing otitis externa

BackgroundDiagnosis of necrotizing otitis externa is often delayed despite patients having severe pain disproportionate to the clinical findings as well as cranial nerve palsies. The incidence is increasing in elderly, diabetic or immunocompromised patients and can be fatal without ‘appropriate’ antibiotic therapy.1,2ObjectivesCT, MRI, and technetium 99 bone scans are often performed but poorly correlate to the clinical response to empirical treatment.3 This novel study evaluated the use of erythrocyte sedimentation rate (ESR) and pain scores as measures of response to determine the dose and duration of antibiotic therapy in patients diagnosed with NOE over a 4 year period from November 2015.MethodsPatients diagnosed with NOE were evaluated using pain scores (0–10/10 where 0 = no pain and 10 = worst pain) and ESR at presentation and then at subsequent outpatient visits. Patients received 6 weeks of IV antibiotics (most receiving piperacillin/tazobactam 13.5 g daily via a 24 h infusion pump administered through a ‘mid-line’ as an outpatient when they were clinically well to go home) followed by oral ciprofloxacin. Initially ciprofloxacin was prescribed at 750 to 500 mg twice daily and the dose and duration of treatment was personalized according to pain scores and ESR. No ethical approval was required since this was an observational study of standard management of this condition at the Trust.ResultsTwelve patients (10 males; 2 females) aged 49 to 91 years (median 74.5 years) were treated. Five had diabetes mellitus and three had been treated for a malignancy. The time of first symptoms to diagnosis ranged from 3 weeks to 32 months (median 3 months). Six had developed facial nerve palsies; three of whom had additional cranial nerve involvement. All had swabs positive for Pseudomonas aeruginosa which in four patients was resistant to gentamicin and in two of these patients also to ciprofloxacin. At presentation pain score was 10/10 in all but three patients (5/10 in one patient and 8/10 in two patients) and ESR values ranged from 31 to 82 (median 66). Both values fell within 1–2 weeks of commencing IV antibiotics and after 6 weeks pain scores were 0/10 in eight patients, 3/10 in the others. ESR at this stage fell to 10–33 (median 15). One patient developed diarrhoea and stopped ciprofloxacin after only 2 weeks remaining well at 6 months follow-up. Eight patients required 3 to 12 months ciprofloxacin. Four patients required restarting or increasing ciprofloxacin dose to control rising pain scores which reflected an increase in their ESR values but in one of these patients having grown Pseudomonas resistant to ciprofloxacin, two further 6 week courses of piperacillin/tazobactam were required. Three patients currently remain on ciprofloxacin at the lowest dose to keep their pain scores and ESR under controlConclusionsPain scores with ESR values are invaluable in determining the activity of NOE thereby personalizing the antibiotic dose and duration in patients with this life-threatening infection.

Crowding at hospitals- the main reason for not seeking medical care when affected by an acute myocardial infarction during the first wave of COVID-19

Abstract Background Delay in seeking treatment for AMI reduces the success rate of reperfusion therapy and affects both morbidity and mortality. During the outbreak of COVID-19 pandemic, rates of hospitalization for cardiovascular diseases has decreased nationally as well as internationally and a reduction of STEMI patients with 25–48% was reported in European and US registries. The reasons for this change in health care seeking behaviour in AMI are still unknown. Purpose To evaluate possible behavioral changes in patients seeking medical care when affected by an acute myocardial infarction during the first wave on ongoing COVID-19 pandemic. Methods This was a cross sectional study in a Region in Sweden during the first wave of the COVID-19 pandemic (March-June) with patients selected from the national registry (SWEDEHEART). Eligible were patients with AMI and totally 602 patients were invited. A self-administrated psychometric evaluated queastionnaire (PA-AMI) was sent to the patientes by post and questions regarding COVID-19 were added. PA-AMI includes 14 items regarding thoughts, feelings and actions prior to care-seeking. All items are answered on a Likert-type rating scale with six grades from 1 'do not agree at all' to 6 'totally agree'. Additionally, there were questions about age, gender, country of birth, when symptoms started and when decide to seek medical care. COVID-19 questions were 'would you have sought medical care earlier if the pandemic COVID-19 would not have existed', 'if yes, why did you not seek medical care' with follow-up questions. From SWEDEHEART the following were obtained, e.g. type of AMI, history of: AMI, diabetes and percutaneous coronary intervention (PCI), date and time of first symptoms to arrival at hospital/ward or PCI lab. Results A total of 326 patients answered the questionnaire. Of these, 17% hesitated to seek medical care due to the pandemic. Patients characteristics are shown in Table 1. These patients mainly hesitated due to a fear that the healthcare was overcrowded with patients with COVID-19, followed by a fear of becoming infected by COVID-19 at the hospital (Fig 1). Women and patients not born in SWEDEN were significant more represented in this group. The self-assessed patient delay was 22 h (median) versus 4.5 h registered in SWEDEHEART. PA-AMI displayed that symptom perception and seriousness of symptoms, unsureness where to turn and difficulties to decide seek medical care, was ssociated to those who hesitated to seek medical care due to the pandemic. Conclusions During the first wave of the COVID-19 pandemic, women and patients not born in SWEDEN, as well as patients with more than one risk factor (smoking, diabetes) had a longer delay in seeking medical care for AMI due to fear of overcrowded hospitals. Therefore, these patients should be encouraged to seek medical care and there is an importance of information about how and when to seek medical care, especially in the light of COVID-19. Funding Acknowledgement Type of funding sources: None. Table 1Figure 1

Epidemiology and outcomes of ischemic stroke treatment in two public hospitals of Campos dos Goytacazes, RJ.

Background: The main origin of functional dependence in Brazil and the world is the ischemic stroke. The early thrombolytic treatment reduces this morbidity. However, the extended in-hospital delay is the main risk factor for the suboptimal number of ischemic stroke patients who receive this treatment. Objective: To describe the management of patients admitted with ischemic stroke in two Brazilian public hospitals. Methods: This cross-sectional study was carried out in two emergency units in 2016 in Campos dos Goytacazes: Hospital Ferreira Machado (HFM) and Hospital Geral de Guarus (HGG). We analyzed the prevalence of sex, age, risk factors, time of first symptoms, prescription of thrombolytic therapy and contraindications to its use. Results: None of the 130 patients with ischemic stroke received a prescription of rt-PA, even though HFM had rt-PA available throughout the period of the study. HGG does not keep this data documented. Of all, 41 patients died (31,54%). Advancing age (p < 0.0005) and atrial fibrillation 3.458 (CI = 95%, 1.239 to 10.16, p = 0.0238) were risks factors for the mortality in this population. Conclusions: The lack of information in medical records reveals that low staff training may be the main reason why thrombolytic therapy was not prescribed. The elevated mortality rate shows that medical care for patients admitted with ischemic stroke in our region is far from ideal.

Primary congenital glaucoma in Denmark, 1977-2016.

To perform an epidemiological survey of all patients in Denmark diagnosed with primary congenital glaucoma (PCG) from 1977 to 2016. A retrospective, nationwide study based on a review of medical files of all children with PCG born in Denmark from 1977 to 2016. PCG was defined as glaucoma due to isolated angle dysgenesis affecting children from birth and including late onset/late recognized PCG, excluding glaucoma associated with other congenital abnormalities. Incidence and risk factors of PCG including gender, consanguinity, family history, ethnicity, comorbidity and prematurity were evaluated and stratified by decade (1977-1986, 1987-1996, 1997-2006 and 2007-2016). Age at first symptoms, age at diagnosis, age at time of first surgery and possible diagnostic delay were assessed. Of 118 patients were identified, annual incidence of PCG was 4.8 per 100000 live born. 62.3% of cases were bilateral. The relative risk (RR) of PCG was significantly higher in boys (62.7% of patients, RR 1.60 (95% CI 1.10-2.32)). 13.6% had comorbidity. Median age at time of first symptoms was 75days, median age at time of diagnosis was 150days and median diagnostic delay was 75days with no significant difference throughout the decades. Unilateral cases presented symptoms and were diagnosed significantly later than bilateral cases. We provide unique nation-based information on the incidence of PCG from a single country covering 40years. Male gender was a risk factor. Diagnostic delay was unchanged throughout the 4 decades and a high percentage of comorbidity was revealed. Introducing a standardized paediatric screening of all PCG children should be considered.

Natural History of Treated Subarachnoid Neurocysticercosis.

.Subarachnoid neurocysticercosis (SUBNCC) is usually caused by an aberrant proliferative form of Taenia solium causing mass effect and arachnoiditis. Thirty of 34 SUBNCC patients were treated with extended cysticidal and anti-inflammatory regimens and followed up a median of 4.2 years posttreatment (range: 15 for ≥ 4 years, 20 ≥ 2 years, 26 > 1 year, and 3 < 1 year). The median ages at the time of first symptom, diagnosis, and enrollment were 29.7, 35.6, and 37.9 years, respectively; 58.8% were male and 82.4% were Hispanic. The median time from immigration to symptoms (minimum incubation) was 10 years and the estimated true incubation period considerably greater. Fifty percent also had other forms of NCC. Common complications were hydrocephalus (56%), shunt placement (41%), infarcts (18%), and symptomatic spinal disease (15%). Thirty patients (88.2%) required prolonged treatment with albendazole (88.2%, median 0.55 year) and/or praziquantel (61.8%; median 0.96 year), corticosteroids (88.2%, median 1.09 years), methotrexate (50%, median 1.37 years), and etanercept (34.2%, median 0.81 year), which led to sustained inactive disease in 29/30 (96.7%) patients. Three were treated successfully for recurrences and one has continuing infection. Normalization of cerebral spinal fluid parameters and cestode antigen levels guided treatment decisions. All 15 patients with undetectable cestode antigen values have sustained inactive disease. There were no deaths and moderate morbidity posttreatment. Corticosteroid-related side effects were common, avascular necrosis of joints being the most serious (8/33, 24.2%). Prolonged cysticidal treatment and effective control of inflammation led to good clinical outcomes and sustained inactive disease which is likely curative.

Near-infrared spectroscopy in evaluating psychogenic pseudosyncope-a novel diagnostic approach.

Psychogenic pseudosyncope (PPS), a conversion disorder and syncope mimic, accounts for a large proportion of 'unexplained syncope'. PPS is diagnosed by reproduction of patients' symptoms during head-up tilt (HUT). Electroencephalogram (EEG), a time consuming and resource intensive technology, is used during HUT to demonstrate absence of cerebral hypoperfusion during transient loss of consciousness (TLOC). Near-infrared spectroscopy (NIRS) is a simple, non-invasive technology for continuous monitoring of cerebral perfusion. We present a series of patients for whom PPS diagnosis was supported by NIRS during HUT. Eight consecutive patients with suspected PPS referred to a syncope unit underwent evaluation. During HUT, continuous beat-to-beat blood pressure (BP), heart rate (HR) and NIRS-derived tissue saturation index (TSI) were measured. BP, HR and TSI at baseline, time of first symptom, presyncope and apparent TLOC were measured. Patients were given feedback and followed for symptom recurrence. Eight predominantly female patients (6/8, 75%) aged 31 years (16-54) were studied with (5/8, 63%) having comorbid psychiatric diagnoses, and (5/8, 63%) presenting with frequent episodes of prolonged TLOC with eyes closed (6/8, 75%). All patients experienced reproduction of typical events during HUT. Systolic BP (mmHg) increased from baseline (129.7 (interquartile range [IQR] 124.9-133.4)) at TLOC (153.0 (IQR 146.7-159.0)) (P-value = 0.012). HR (bpm) increased from baseline 78 (IQR 68.6-90.0) to 115.7 (IQR 93.5-127.9) (P-value = 0.012). TSI (%) remained stable throughout, 71.4 (IQR 67.5-72.9) at baseline vs. 71.0 (IQR 68.2-73.0) at TLOC (P-value = 0.484). NIRS provides a non-invasive surrogate of cerebral perfusion during HUT. We propose HUT incorporating NIRS monitoring in the diagnostic algorithm for patients with suspected PPS.

Clinico-demographic, Investigation and Outcomes Profiles of Subacute Sclerosing Panencephalitis (SSPE) Patients at A Referral Neurology Hospital in Bangladesh

Background: SSPE is a late complication of measles and is fatal in most cases.&#x0D; Objectives: The purpose of the study was to observe the clinico-demographic, investigation and outcome profiles of SSPE patients.&#x0D; Methodology: This prospective cohort study was conducted in the Department of Neurophysiology at National Institute of Neurosciences and Hospital, Dhaka, Bangladesh from September 2014 to August 2017. Patients of SSPE who were diagnosed by Dyken's Criteria were selected as study population. Details socio-demographic, clinical profiles, investigations and outcome were recorded. The outcome was assessed from the time of first onset of the symptoms till closing of the study.&#x0D; Results: The mean age of the study population was 14.3±4.209 years with the male predominance (73.5%). Majority were from rural area (70.6%) and were of low socio-economic condition (52.9%). The mean age of onset of disease was 13.6±4.30 years. History of previous measles infection was reported in 13(38.2%) cases among which 12(92.3%) cases were vaccinated. The mean age of measles infection was 17.0±15.44 months. The time of first symptom of SSPE from primary measles infection was 11.50±4.80 years. Recurrent fall (47.1%) and myoclonic jerks (17.6%) were the most frequent initial symptoms of the patient. Cognitive decline was observed in 28(82.4%) cases. EEG background was slow in 23(67.6%) patients and periodic burst was observed in all (100.0%) cases. Anti-measles antibody in CSF was positive in all cases. MRI was abnormal in 7(25.9%) cases out of 27 cases. Twelve (35.3%) patients died, 18(52.9%) were alive and 4(11.8%) were lost to follow up when the study was closed.&#x0D; Conclusion: Early aged male from lower socioeconomic condition are found to be suffering from SSPE. Recurrent fall is the commonest initial presentation. Spontaneous recovery can occur in very few patients.&#x0D; Journal of National Institute of Neurosciences Bangladesh, 2019;5(2): 97-100

The path to specialist multidisciplinary care in amyotrophic lateral sclerosis: A population- based study of consultations, interventions and costs.

BackgroundAmyotrophic Lateral Sclerosis (ALS) is a devastating neurological condition that requires coordinated, multidisciplinary clinical management. ALS is prone to misdiagnosis as its signs and symptoms may be non-specific, which may prolong patients’ journey to multidisciplinary ALS care.MethodsUsing chart review and national register data, we have detailed the journey of a national cohort of ALS patients (n = 155) from the time of first symptom to presentation at a multidisciplinary clinic (MDC). Key milestones were analysed, including frequency of consultations, clinical interventions, and associated economic cost.ResultsA majority of patients was male (60%), 65 years of age and over (54%), and had spinal onset ALS (72%). Time from onset of first symptoms to ALS diagnosis was a mean of 15.1 months (median, 11). There was a mean interval of 17.4 months (median 12.5) from first symptoms to arrival at the MDC, and a mean of 4.09 (median, 4) consultations with health care professionals. Electromyography and nerve conduction studies were among the most common interventions. Direct referral by a general practitioner (GP) to a neurologist was associated with reduced cost, but not reduced diagnostic delay. Bulbar ALS was associated with shorter time from symptom onset to diagnosis. Neurologist consultation in the first three consultations was associated with lower costs prior to the ALS clinic attendance but not a shorter time from first symptom to final diagnosis. Mean cost prior to attending the MDC was €3,486 per patient.ConclusionsExpedited referral to the multidisciplinary ALS clinic would have reduced costs by an estimated €2,072 per patient. Development of a standardised pathway with early referral to neurology of patients with suspected symptoms of ALS could limit unnecessary interventions and reduce cost of care.

Meeting the Informational, Educational, and Psychosocial Support Needs of Persons Living With Dementia and Their Family Caregivers.

Meeting the unique and changing needs of individuals living with Alzheimer's disease and their family caregivers can be very challenging given the dynamic and often unpredictable nature of the disease. Effective programs are available to help families manage the challenges they will face. This article first describes the educational, information, and support needs of individuals living dementia and their family caregivers across all stages of Alzheimer's. Next, we describe the variety of services and program models targeted to the needs of individuals living with Alzheimer's disease or other types of dementia and their families. These programs can help ensure that person- and family-centered care is maintained from time of first symptoms through end-of-life. We end with our recommendations for maintaining person- and family-centered care through the provision of targeted information, education, and support to individuals and their families.

MP08-12 IS TRANSFER OF ADOLESCENTS FOR TESTICULAR TORSION APPROPRIATE?

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety II1 Apr 2016MP08-12 IS TRANSFER OF ADOLESCENTS FOR TESTICULAR TORSION APPROPRIATE? Amul Bhalodi, Mark Ferretti, Michael Goltzman, Ivan Miller, and Israel Franco Amul BhalodiAmul Bhalodi More articles by this author , Mark FerrettiMark Ferretti More articles by this author , Michael GoltzmanMichael Goltzman More articles by this author , Ivan MillerIvan Miller More articles by this author , and Israel FrancoIsrael Franco More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2257AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Testicular torsion (TT) is defined as a surgical emergency resulting from an abnormally mobile testicle twisting on its vascular pedicle causing obstruction to its blood supply. The testis salvage rate approaches 100% in patients who undergo detorsion within 6 hours of the start of pain. However, acute testicular torsion may cause a loss of testis viability only 4 hours after the appearance of symptoms. The rapid decline of function supports early surgical exploration with high suspicion of TT. The aim of this study was to analyze testis loss and healthcare access parameters together. We critically evaluated the management of the cohort with TT presenting to a tertiary pediatric urology referral center. We hypothesized that factors other than symptom duration, such as transfer from an outside facility, age, time of day of presentation, insurance type or ethnicity, may affect testicular salvage in patients with TT. METHODS A retrospective chart review, from January 2009 to October 2014, revealed 54 cases of TT presenting to a tertiary pediatric referral center. Demographic, presentation, management, ultrasound, and outcome data were recorded. Statistical analysis was performed with Microsoft Office Excel and Statpages statistical software. Analyses of categorical data were performed using chi-squared and Fishers exact test. Logistical regression was used for continuous variables. A p-value of less than 0.05 was considered statistically significant. RESULTS Logistical regression analysis demonstrated a 9% risk of orchiectomy per hour delay in time from onset of symptoms until operating room (OR) start time (p=0.0036) as well as a 9.6% risk of orchiectomy per hour delay in time of first symptoms until initial evaluation (p=0.0024). The average delay to OR secondary to transfer from another facility was 155 minutes (2.59 hours). No statistically significant difference was seen between whether a patient had private vs public insurance (p=0.27). CONCLUSIONS We have shown that any delay in therapy for TT places patients at undue risk of orchiectomy. The practice of transferring adolescent patients from facilities with the ability to treat these patients rapidly increases the risk of orchiectomy in our cohort by almost 30%. This increased risk of loss of testis requires that we consider the first responding urologist be responsible for the immediate surgery and avoid transfer unless the case is considered complex. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e89 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Amul Bhalodi More articles by this author Mark Ferretti More articles by this author Michael Goltzman More articles by this author Ivan Miller More articles by this author Israel Franco More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Information Needs and Concerns of Patients with Inflammatory Bowel Disease: What Can We Learn from Participants in a Bilingual Clinical Cohort?

BackgroundInflammatory Bowel Disease (IBD) patients are confronted with needs and concerns related to their disease.AimTo explore information expectations of patients included in a national bilingual IBD cohort in Switzerland (SIBDC).MethodsThis is a mixed-methods study, comprising 1) a semi-narrative survey sent to 1506 patients from the SIBDC and 2) two focus groups conducted with 14 patients to explore and assess the relevance of the survey’s findings. Data collected within the framework of the SIBDC was used to characterize survey’s responders.Results728 patients (48%) replied to the survey: 52.5% females, 56% Crohn’s disease (CD), 87% secondary/tertiary level educated, 70% full/part-time employed. On average, 47% of patients sought for information, regardless of the disease stage; 27% of them were dissatisfied with information received at the time of first symptoms. During flares, 43% were concerned about drugs and therapies; in remission, 57% had concerns on research and developments; 27% searched for information linked to daily disease management. Information-seeking increased when active disease, for CD with high levels of perceived stress (OR = 2.47; p = 0.003), and for all with higher posttraumatic stress symptoms. The focus groups confirmed a perceived lack of information about general functioning, disease course, treatments and their risks, extra-intestinal symptoms and manifestations.ConclusionsInformation remains insufficient for IBD patients. Lack of information in specific domains can potentially cause stress and hinder detection of symptoms. Better information should be considered as a potentially important component in improving patients’ outcomes in IBD.

Predictors of delay in the diagnosis and treatment of suspected tuberculosis in HIV co-infected patients in South Africa

In South Africa, the majority of tuberculosis (TB) patients are co-infected with the human immunodeficiency virus (HIV), and delays in diagnosis and treatment likely exacerbate morbidity and mortality. To determine predictors of delays in the diagnosis and treatment of hospitalised suspected pulmonary TB patients co-infected with HIV. Post-analysis of data collected in a three-centre prospective cohort of in-patients clinically diagnosed with active TB in three hospitals in South Africa between 2006 and 2009 during the first 24 h of admission. Delay was assessed by asking time of first symptoms and any prior health-seeking behaviour for this episode of illness. Data from a total of 891 participants with a median age of 36 years and a CD4 count of 67 cells/mm(3) were analysed. Median patient, system and total delays were respectively 28, 1 and 28 days. Unemployment, treatment at Tshepong Hospital, alcohol consumption, crowding index, seeking prior treatment, cotrimoxazole treatment and WHO Stage 4 disease predicted prolonged total delay. Patient delay in seeking care for TB in this high HIV prevalence setting is substantial. Factors identified with delay could be used to develop interventions to improve care seeking and earlier diagnosis of TB.

Improving Treadmill Performance in Patients with Lumbar Stenosis

The aim of this study was to evaluate a custom angle load reduction rolling walker to determine the relationship between flexion and load reduction on walking performance in patients with lumbar spinal stenosis.The hypothesis was that walking performance in patients with lumbar spinal stenosis would be significantly improved using the Oliver Static Measuring Apparatus device compared with unaided treadmill walking. Fifteen patients with symptomatic neurogenic intermittent claudication caused by lumbar spinal stenosis were recruited at a Veterans Affairs Medical Center. This study used a cross-sectional design with two random-order treadmill conditions: (1) spinal flexion and unloading and (2) level walking. Primary outcome measures included initiation time of first symptoms, total walking time, spinal flexion angle, and unloading force. Secondary measures included baseline pain, fatigue, and disability severity. The participants' initiation time of symptoms and total walking time were significantly greater with the use of the Oliver Static Measuring Apparatus compared with the unaided walking trial. The participants with increased baseline pain, fatigue, and disability severity had decreased walking performance for the unaided condition but not for the Oliver Static Measuring Apparatus condition. The results show that spinal flexion is important for pain reduction in lumbar spinal stenosis. The Oliver Static Measuring Apparatus device used in this study was shown to be effective and immediate in significantly increasing total walking time and prolonging the onset of neurogenic intermittent claudication symptoms while ambulating.

Increased serum levels of soluble tumor necrosis factor receptor-2 (sTNFR2) in patients with active toxoplasmic retinochoroiditis

This study aimed to investigate the serum levels of the cytokine TNF-α and its soluble receptors (sTNFR1 and sTNFR2) in patients with toxoplasmosis retinochoroidits (TR) and controls. 37 patients with TR and 30 subjects with positive serology for toxoplasmosis but without history and signs of uveitis were included in this study. Serum concentrations of TNF-α, sTNFR1, and sTNFR2 were determined by ELISA. Serum concentrations of TNF-α and sTNFR1 were similar in controls (mean ± SD median values; 56.57±141.96 and 504.37±163.87, respectively) and TR patients (mean ± SD values, 121.62±217.56 and 511.15±189.30, respectively). Serum concentrations of sTNFR2 were higher in the uveitis group when compared to the control group (respectively, mean ± SD values, 1734.84±379.32 and 1442.75±309.47; p=0.002). There was no association between the serum levels of the molecules and the time of first symptoms, severity of vitreous haze, size or localization of active lesions, levels of visual acuity, and presence of vasculitis. These results suggest that TR is associated with changes in the circulating levels of inflammatory biomarkers, but they are not correlated with local/ocular signs.

Fecal calprotectin and alpha-1 antitrypsin predict severity and response to corticosteroids in gastrointestinal graft-versus-host disease

AbstractDiagnosis of gastrointestinal GVHD (GI-GVHD) is based on clinical symptoms and histologic findings. No biomarkers predicting responses to treatment are routinely available even though 30% to 50% of patients will not respond to corticosteroids. In this study, we aimed to evaluate fecal calprotectin, α-1-antitrypsin (α1-AT), and elastase at the time of first symptoms as diagnostic and prognostic tools for GI-GVHD in 72 consecutive patients, of whom 51 developed GI-GVHD. The prognostic value of markers was evaluated by their association with complete response (CR) and steroid-resistant (SR) GVHD. Calprotectin and α1-AT concentrations increased with GI-GVHD initial stages but patients with initial stage 1 GI-GVHD had similar marker levels to patients without GI-GVHD, so sensitivity to diagnose GI-GVHD was weak. In contrast, calprotectin and α1-AT were predictors for SR-GVHD and CR. Multiple regression modeling identified calprotectin and α1-AT concentration as independently predicting SR-GVHD together with initial stage > 2 GI-GVHD. Our results showed that fecal calprotectin and α1-AT levels at the time of diagnosis are predictive for responses to treatment but are not diagnostic markers for initial stage 1 to 3 GI-GVHD.

Can Pre-Endoscopic Assessment Predict Active Upper Gastrointestinal Bleeding? A Retrospective Study in Patients with Symptoms of Upper Gastrointestinal Bleeding Outside Regular Working Hours

To evaluate the usefulness of pre-endoscopic assessment for predicting active up-per gastrointestinal bleeding (UGI-B) at emergency esophagogastroduodenoscopy (E-EGD, within 6 hours). We retrospectively analysed the medical records of patients that had an E-EGD performed outside working hours and considered 15 pre-endoscopic variables in a univariate analysis. Active UGI-Bat E-EGD was taken as end-point. Of 228 E-EGD performed during 75 months, 195 were motivated by the suspicion of UGI-B. We excluded 83 cases as they were hospitalised at the time of first symptoms of bleeding. Thus, 112 cases were included. The following clinical signs triggered E-EGD: hematemesis (56/50%),melena (55/49.1%), hematochezia (20/17.8%), anae- mia (7/6.2%). Patients' age was 65.5+14.2 years. Sixty nine (61.6%) cases were male. The relative risk and p-value of the variables for the presence of active bleeding at E-EGD were as follows: hematemesis: 1.54/0.3; malignancy and cirrhosis: 1.73/0.07; haemoglobin <8g/dL: 1.38/0.3; white blood count >12,000/tL: 1.18/0.6;systolic blood pressure (SBP) <100 mmHg: 0.53/0.03;pulse >100/min: 1.42/0.2; platelets <14000/nL:1.5/0.2; INR >1.17: 1.89/0.049. In the multivariate analysis none of these variables independently predicted UGI-B. No relevant pre-endoscopic variables for the prediction of active UGI-B at E-EGD could be found. Our data suggest that pre-endoscopic evaluation cannot replace rapid endoscopy.

High Levels of Fecal Calprotectin and alpha1-Antitrypsin At Diagnosis of Acute Gastro-Intestinal Graft-Versus-Host Disease Are Correlated with Severity and Response to Corticosteroids

Abstract 3041 Rational:Diagnosis of gastrointestinal acute graft-versus-host disease (GI-GVHD) after allogeneic hematopoietic stem cell transplantation (HSCT) is based on clinical symptoms (nausea, vomiting and diarrhea quantification) and histological findings. No biomarkers are currently routinely used to predict the response to treatment whereas 30 to 50% of patients will not respond to the first line therapy. Histology can be an indicator for severity but as it’s an invasive procedure, it’s not available in all patients. Fecal calprotectin, alpha-1-antitrypsin (α1-AT) and elastase are noninvasive biomarkers used in the screening of intestinal inflammation, protein-losing enteropathy and exocrine pancreatic dysfunction, respectively. These markers have not been yet validated in the context of HSCT and we aim to evaluate them as diagnostic and prognostic biomarkers of GI-GVHD. Methods:From 09/2008 to 12/2010, 56 patients who developed GI symptoms for the first time after HSCT were prospectively included after inform consent in our center. Twenty patients who developed an acute GVHD without GI symptoms were also included as controls. At time of first symptoms (after a median of 2 days), fecal samples were collected to measure calprotectin, α1-AT and elastase concentrations. Data regarding GI symptoms, GVHD stage, immunosuppressive treatment, albuminemia and performance status were also collected and tested in statistical model with fecal markers. Prognostic value of markers was evaluated by their association with complete response (CR) and steroid-refractory (SR) GVHD using a multiple logistic regression. Model calibration was assessed by the calibration slope and the bootstrap bias-corrected calibration slope and model discrimination by the c-index with or without bootstrap correction for over-optimism. Cumulative incidence (CI) functions were compared using Gray’s test and adjustment was performed using the Fine and Gray method. Results:Among the 76 patients, median age was 44 years (8–66), a majority of them received a reduced intensity conditioning regimen (62%) and peripheral blood stem cells as source of stem cells (75%) from an unrelated donor (62%). Definitive diagnosis in patients with GI symptoms was GI-GVHD in 51 (histology in 43) and infection in 5 patients.Calprotectin concentration was higher in patients with GI symptoms than in controls. α1-AT concentration was higher in patients with GI-GVHD than in those with GI infections or controls. The concentration of elastase in patients with GI-GVHD was decreased but associated with high levels of calprotectin and α1-AT (76%) attesting from mucosal damage possibly not related to a pancreatic dysfunction. In patients with GI-GVHD, the concentrations of calprotectin and α1-AT increase with GI-GVHD stage but patients with stage 1 GI-GVHD have similar marker levels than patients without GI-GVHD (values in normal ranges in 87 and 83% for stage 1 vs. 92 and 88% for stage 0).Regarding CR of GI-GVHD after treatment, initial concentrations of calprotectin ≥100μg/g and α1-AT > 1.5 mg/g of dry stools decrease the probability of CR after treatment (56% vs. 86%, p=0.005; 67% vs. 90%, p=0.00007, respectively). Similarly, high level of calprotectin and α1-AT predict a 93% (vs. 33%, p=0.00001) and a 72% (vs. 21%, p=0.00009) probability of SR-GVHD.Calprotectin and α1-AT concentration were independently and exclusively associated with a lower probability of CR (HR: 0.47, [p=0.028] and HR: 0.47, [p=0.037], respectively). The model selection procedure also identified a mode with both variables together with stage > 2 GI-GVHD as best predicting SR-GVHD, although marginal testing did not yield a significant odds ratio (OR) for α1-AT (calprotectin: OR 17.1 [p=0.016]; GI stage III-IV: OR 7.11 [p=0.043]; α1-AT: OR 3.67 [p=0.11]). Interestingly, excluding GVHD stage from the model, Calprotectin and α1-AT concentration could also independently predict SR-GVHD (OR :15.8, p=0.015 & OR :4.93, p=0.038). Conclusion:Our results showed that fecal calprotectin and α1-AT levels are biomarkers of GI-GVHD, particularly in GI stage > I. Furthermore, an increase level of those markers predicts the response to treatment. Their use as predictors from severe GI-GVHD are very promising including in patients in whom GI-GVHD stage or histology are not available. Disclosures:Peffault de Latour:Alexion: Consultancy, Research Funding.