Optimizing Diagnosis and Management of Community-acquired Pneumonia in the Emergency Department

Pneumonia is split into 3 diagnostic categories: community-acquired pneumonia (CAP), health care-associated pneumonia, and ventilator-associated pneumonia. This classification scheme is driven not only by the location of infection onset but also by the predominant associated causal microorganisms. Pneumonia is diagnosed in over 1.5 million US emergency department visits annually (1.2% of all visits), and most pneumonia diagnosed by emergency physicians is CAP.

Pulmonary hydatidosis with hepatopleural fistula: A case report

INTRODUCTION AND IMPORTANCE

Cystic echinococcosis (CE) is a chronic illness caused by the tapeworm Echinococcus granulosus. It is classified as a neglected disease and is a priority according to the World Health Organization. CE is prevalent in populations engaged in specific livestock practices and is associated with poor living conditions.

CASE PRESENTATION

41-year-old female Maasai patient who presented with symptoms of cough, dyspnea, fever, and weight loss. Physical examination and CT scans confirmed the presence of cystic masses in the lungs and liver. The patient underwent a thoracotomy procedure to address complications from a hepato-pleural fistula.

CLINICAL DISCUSSION

Echinococcus is a tropical disease that affects over a million people worldwide annually. It primarily affects communities engaged in animal husbandry and causes the development of hydatid cysts. Diagnosis can be challenging due to prolonged asymptomatic periods. In rare cases, cysts can rupture into the pleura and bronchial tree, causing respiratory symptoms. Surgical treatment involves the systematic evacuation of cysts and visceral cyst excision, with concurrent laparotomy and thoracotomy being the optimum approach.

CONCLUSION

Hydatid cysts remain a significant health problem, particularly when large pleural cysts occur with subphrenic liver cysts. Surgical intervention, specifically a single-stage thoracotomy, is the preferred first-line treatment. This approach allows for both cysts to be addressed in a single procedure, providing effective and efficient treatment to patients.

Breaking barriers: can ChatGPT compete with a shoulder and elbow specialist in diagnosis and management?

Background

ChatGPT is an artificial intelligence (AI) language processing model that uses deep learning to generate human-like responses to natural language inputs. Its potential use in health care has raised questions and several studies have assessed its effectiveness in writing articles, clinical reasoning, and solving complex questions. This study aims to investigate ChatGPT's capabilities and implications in diagnosing and managing patients with new shoulder and elbow complaints in a private clinical setting to provide insights into its potential use as a diagnostic tool for patients and a first consultation resource for primary physicians.

Methods

In a private clinical setting, patients were assessed by ChatGPT after being seen by a shoulder and elbow specialist for shoulder and elbow symptoms. To be assessed by the AI model, a research fellow filled out a standardized form (including age, gender, major comorbidities, symptoms and the localization, natural history, and duration, any associated symptoms or movement deficit, aggravating/relieving factors, and x-ray/imaging report if present). This form was submitted through the ChatGPT portal and the AI model was asked for a diagnosis and best management modality.

Results

A total of 29 patients with 15 males and 14 females, were included in this study. The AI model was able to correctly choose the diagnosis and management in 93% (27/29) and 83% (24/29) of the patients, respectively. Furthermore, of the remaining 24 patients that were managed correctly, ChatGPT did not specify the appropriate management in 6 patients and chose only one management in 5 patients, where both were applicable and dependent on the patient's choice. Therefore, 55% of ChatGPT's management was poor.

Conclusion

ChatGPT made a worthy opponent; however, it will not be able to replace in its current form a shoulder and elbow specialist in diagnosing and treating patients for many reasons such as misdiagnosis, poor management, lack of empathy and interactions with patients, its dependence on magnetic resonance imaging reports, and its lack of new knowledge.

Emphysematous cystitis: A rare and life-threatening condition in patients with uncontrolled diabetes mellitus

Emphysematous cystitis is a rare and potentially life-threatening condition characterized by gas formation within the bladder due to bacterial infection. This article presents a case study of emphysematous cystitis in a 74-year-old male patient with uncontrolled diabetes mellitus and recurrent urinary tract infections. The patient had lower abdominal pain, signs of infection, and urinary symptoms. Imaging revealed bladder wall thickening and gas bubbles. Prompt diagnosis and broad-spectrum antimicrobial therapy were initiated, with intensive care monitoring. After a 14-day treatment, significant improvement occurred, leading to the patient's discharge after 20 days. This case emphasizes early recognition and aggressive management for optimal outcomes.

The competence of village clinicians in the diagnosis and management of childhood epilepsy in Southwestern China and its determinants: A cross-sectional study

BACKGROUND

Due to lack of neurologists in low- and middle-income countries, communities of patients living with epilepsy are calling for task-shifting of diagnosis and management from physicians to paramedical providers in the primary health care systems to narrow the huge treatment gap. Evidence to guide this work has been limited. This study assesses the competence of village clinicians (VC)- mostly paramedical providers- in the diagnosis and management of a presumptive case of childhood epilepsy and its determinants.

METHODS

A cross-sectional study was conducted in rural areas of a province in Southwestern China from July 2017 to January 2018. We randomly selected 370 VCs who practiced Western medicine and assumed the main responsibility of providing medical services in his/her clinic. A standardized clinical vignette based on national clinical practice guidelines was used to evaluate clinicians' competence in three domains: number and proportion of recommended (and essential) checklist (questions, examinations, and tests) completed, correctness of diagnosis, and correctness of case management.

FINDINGS

Though VCs completed 14•3% (IQR 9•5%-19•1%) of the recommended checklist, 63•2% (234/370, 95%CI 58•2%-68•0%) provided a correct diagnosis. Only 1•6% of VCs (6/370, 95%CI 0•7%-3•5%) gave correct management with both correct medication and referral, however 90•3% (334/370, 95%CI 86•8%-92•9%) provided partially correct management by referring patients to upper-level health facilities (89•5%, 331/370, 95%CI 85•9%-92•2%) or prescribing anti-epileptic drugs (AEDs) correctly (0•8%, 3/370, 95%CI 0•3%-2•4%). Around 1/4 VCs referred patients to Township Health Centers which usually were not staffed with pediatric neurologists. Fewer provided helpful medical advice to patients for daily management. The heuristic process was found to be negatively associated with the proportion of the recommended checklist that VCs completed, which is positively associated with correctness of diagnosis.

INTERPRETATION

Most VCs could diagnose and refer childhood epilepsy patients correctly; however, they lacked competence when it came to assuming the responsibility of primary care providers, referring efficiently, refilling AEDs, as well as supervising and instructing daily management of patients.

FUNDING

HY received the funding for this study from the "Health and Hope Fund" of the Business Development Center of the RCSC (Beijing) and UCB (Belgium). UCB provided support in the form of a salary for author DET.

Rheumatoid arthritis-associated interstitial lung disease: an overview of epidemiology, pathogenesis and management

Interstitial lung disease (ILD) accounts for the major cause of morbidity and mortality in rheumatoid arthritis (RA). However, little is known of the pathogenesis, diagnosis and treatment of RA-associated ILD. In this review, we describe our present understanding and ongoing research in RA-ILD. Its aetiology does appear to associate with anti-cyclic citrullinated peptide antibodies, MUC5B mutation and smoking. Another focus of this article is on recent diagnostic methods in RA-ILD. Compared with other methods, high-resolution computed tomography (HRCT) imaging is a main method for the evaluation of ILD in RA patients. Pulmonary function is better suited for assessing progression. An important topic relates to therapeutic intervention. Disease-modifying anti-rheumatic drugs (DMARDs) in RA lack strong evidence in the onset or worsening of ILD. The available literature support that methotrexate, leflunomide, abatacept and rituximab play beneficial roles in the prevention and treatment of RA-ILD.

Rupture of visceral artery aneurysm following elective spinal surgery: a case report and review

INTRODUCTION

Visceral artery aneurysms (VAA), an uncommon disorder of splanchnic vasculature, are associated with significant morbidity and mortality. Despite largely being amenable to endovascular therapies, the initial management of symptomatic VAA typically falls under the care of general surgeons. It is thus essential to have knowledge of the diagnosis and treatment of VAA and to be cognisant of deviations from normal gastrointestinal vasculature.

CASE PRESENTATION

In this paper, we describe the case of a 72-year-old male presenting with a VAA following elective spinal surgery, followed by a review of the clinical diagnosis and management of VAA.

CONCLUSION

Visceral artery aneurysm must be considered as a differential diagnosis for acute abdominal pain and anaemia in the post-operative period following all major operations. Knowledge of the clinical features of VAA and indications for specific intervention are essential for all general surgeons. Furthermore, it is imperative to recognise deviations from normal vasculature of the gastrointestinal tract.

Prevalence and Sonographic Detection of Gallbladder Polyps in a Western European Population

BACKGROUND

Gallbladder cancer is rare but associated with significant morbidity and mortality necessitating the early identification of premalignant and malignant lesions to improve overall prognosis. Despite limited evidence regarding the effectiveness of transabdominal ultrasound (US) in the detection of gallbladder polyps, it plays a key role in current European guidelines. The aim of this study was to investigate gallbladder polyp prevalence in a western European population and assess the diagnostic accuracy of transabdominal US.

METHODS

Data from patients who underwent cholecystectomy for US detected gallbladder polypoid lesions at four hospitals in Ireland and the United Kingdom between 2010 and 2018 were retrospectively collected. Patient demographics, ultrasonographic, and histopathologic findings were analyzed.

RESULTS

A total of 134 patients underwent cholecystectomy for US-detected gallbladder polyps. After histopathologic examination, pseudopolyps were found in 75 (56%) specimens with dysplastic or malignant polyps seen in only six (4.5%) specimens. Mean size for neoplastic polyps was 33 mm. The positive predictive value for US in detecting neoplastic polyps in this study was 4.5%, which is significantly lower than the 10%-15% reported previously.

CONCLUSIONS

Although the prevalence of neoplastic polyps in this study is higher than in the previous literature, the distribution of pseudopolyps and true polyps is as expected. With all malignant polyps being >10 mm in diameter, these findings support the current size thresholds stated in European guidelines. The poor diagnostic accuracy of US demonstrated may have led to significant number of patients undergoing unnecessary surgical intervention, further supporting the argument for improved strategies for the investigation of gallbladder polyps.

Atopic dermatitis

Atopic dermatitis (AD) is a common, chronic skin disorder that can significantly impact the quality of life of affected individuals as well as their families. Although the pathogenesis of the disorder is not completely understood, it appears to result from the complex interplay between defects in skin barrier function, environmental and infectious agents, and immune dysregulation. There are no diagnostic tests for AD; therefore, the diagnosis is based on specific clinical criteria that take into account the patient's history and clinical manifestations. Successful management of the disorder requires a multifaceted approach that involves education, optimal skin care practices, anti-inflammatory treatment with topical corticosteroids and/or topical calcineurin inhibitors, the management of pruritus, and the treatment of skin infections. Systemic immunosuppressive agents may also be used, but are generally reserved for severe flare-ups or more difficult-to-control disease. Topical corticosteroids are the first-line pharmacologic treatments for AD, and evidence suggests that these agents may also be beneficial for the prophylaxis of disease flare-ups. Although the prognosis for patients with AD is generally favourable, those patients with severe, widespread disease and concomitant atopic conditions, such as asthma and allergic rhinitis, are likely to experience poorer outcomes.

Gallbladder Polypoid-Lesions: What Are They and How Should They be Treated? A Single-Center Experience Based on 1446 Cholecystectomy Patients

BACKGROUND AND AIM

Gallbladder polypoid-lesions (GPs) are commonly seen on ultrasonography (USG), but several aspects of this problem are ill-defined. This study aimed to analyze clinic and pathologic characteristics of 1446 USG-detected GPs, identify predictive factors for cholesterol lesions and malignancy, and provide comments and recommendations on specific aspects of GPs.

METHODS

We retrospectively analyzed clinic files of 1446 patients who underwent cholecystectomy for USG-detected GPs between 2008 and 2015 in Gallbladder Diseases Center, East Hospital of Tongji University.

RESULTS

For the 1446 patients, the F: M ratio and the mean age were 1.06: 1 and 45 years, and most of them were asymptotic (80.3%) and had multiple polyps (62.5%). All the 1446 GPs were classified into three categories: cholesterol, benign non-cholesterol, and malignant lesions, with respective proportion of 87.1% (1260), 11.2% (162), and 1.7% (24). Over half of benign non-cholesterol lesions, of which most were premalignant neoplasm (adenoma), were less than 10 mm. Multiple number and the presence of lipid abnormalities were significantly more associated with cholesterol than non-cholesterol lesions, with odd ratios (OR) of 2.9 (P < 0.001) and 1.6 (P = 0.023), respectively. Age ≥50 years, present symptoms, size ≥10 mm and concurrent gallstones were independent predictive factors to discriminate malignant polyps from premalignant lesions, with ORs of 16.5 (P < 0.001), 6.3 (P = 0.013), 41.5 (P = 0.014), and 18.0 (P = 0.002), respectively.

CONCLUSIONS

According to our proposed classification, the vast majority of GPs were cholesterol lesions without malignant potential and associating with metabolic diseases. We strongly recommend that risk factors of GPs be investigated by subtypes, and patients with GPs be treated with personalized and differentiated strategies.

Anti-HER-2 therapy following severe trastuzumab-induced cardiac toxicity

The human epidermal growth factor receptor 2 (HER2) is overexpressed in 25%-30% of breast cancer patients. Anti-HER2 therapies have changed the aggressive course of HER2+ breast cancer. In spite of the therapeutic benefits, their cardiotoxicities are major concerns, especially when used concurrently with anthracyclines. Here we present an elderly patient with relapsed HER2+ breast cancer. Her presentation for relapsed disease was unusual for the physical finding as well as the history of trastuzumab-induced severe cardiotoxicity while requiring additional anti-HER2 therapy. She received neoadjuvant anti-HER2 treatment for stage III breast caner. Due to severe reduction of cardiac ejection fraction (EF), she only received five doses of adjuvant transtuzumab. Unfortunately her disease relapsed one year later with chest wall lesions and a persistent low EF. We treated the patient with lapatinib combined with capecitabine which resulted rapid resolution of her chest wall lesion. More importantly, the patient had one year of disease control without deterioration in her ejection fraction. We discussed the management of recurrent HER2+ breast cancer with chest wall disease and the choice of anti-HER2 therapy in patients with a history of transtuzumab-induced cardiac dysfunction.

The diagnosis and management of the Spitz nevus in the pediatric population: a systematic review and meta-analysis protocol

BACKGROUND

Spitz nevi are uncommon melanocytic neoplasms found in children. Historically, the diagnosis and management of these tumors has lacked consensus among oncologists, pathologists, plastic surgeons, and dermatologists. Once interpreted and treated as a "juvenile melanoma", many have argued for the benignancy of such tumors in certain patient age groups, encouraging a conservative approach. The lack of consensus surrounding the diagnosis and perceived malignant potential of these tumors has led physicians to approach them on a case-by-case basis and institutional protocols. To date, no evidence-based management guideline exists. The objective of this systematic review is to both collect and appraise the evidence on the diagnosis and management of these tumors.

METHODS

A comprehensive electronic literature search will be conducted in PubMed, MEDLINE, Embase, and the Cochrane Library from inception to December 2016. Our search involved collaborating with a healthcare librarian to create a strategy for the OVID/MEDLINE databases. A search of electronic databases for oncology, pathology, plastic surgery, and dermatology abstracts will be performed. Key search terms will include, among several others, "Spitz nevi," "Spitzoid melanoma," "juvenile tumor," and "pediatric". The language of publication will be restricted to English and French. Wherever data allows, meta-analyses will be used to assess differences between Spitz nevi and the tumor of comparison. Additionally, data extraction and summarization using tables will be performed. This review has been registered with PROSPERO (CRD42016034045).

CONCLUSIONS

This review will systematically and comprehensively review diagnostic and management practices associated with the Spitz nevus. This overview of current literature will hopefully provide the foundation for future standardization of clinical practice.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016034045.

Complexity of ambulatory care visits of patients with diabetes as reflected by diagnoses per visit

AIMS

As the proportion of people with multiple chronic conditions grows, so does the complexity of patient care. Although office-based visits to subspecialists are expected to be intense, due to the focused nature of the visit, the complexity of office-based visits to primary care physicians has yet to be explored in depth. To explore complexity, we looked at diabetes as a case study to determine whether and how the complexity of office-based visits varies by physician specialty type, as measured by the number of diagnoses reported per visits.

METHODS

The Medical Expenditure Panel Survey data is used to create a nationally-representative sample of adults who self-report a diabetes diagnosis, the specialty of the treating physician for their care, and the number of diagnoses for each visit. Using cross tabulations, the distribution of office-based visits are analyzed based on a categorization of patients by number of visit diagnoses, number of conditions reported, and type of physician seen.

RESULTS

Almost 80 percent of visits made by adults with diabetes to subspecialist involved care for that single diagnosis; while 55 percent of visits to primary care involved care for at least one additional diagnosis. Almost 70 percent of visits in which only one diagnosis was reported were to subspecialist physicians. Almost 90 percent of visits in which four diagnoses were reported were to primary care physicians.

CONCLUSIONS

Office-based visits to primary care physicians are made increasingly complex by growing population morbidity. Adults with diabetes report more conditions being cared for per visit with primary care physicians than with subspecialty physicians. Future studies into where our results hold for other chronic conditions would be beneficial. As recent United States legislation moves health care payment toward paying for value and population health, encounter complexity should be accommodated.

Overview and diagnosis of acute appendicitis in children

Appendicitis represents the most common abdominal surgical emergency in the pediatric age group. Despite being a relatively common condition, the diagnosis of appendicitis in children can prove to be challenging in many cases. The goal of this article is to review the predictive utility for presenting signs and symptoms, laboratory tests, and imaging studies in the diagnostic work-up of appendicitis. Furthermore, we sought to explore the predictive utility of composite measures based on multiple sources of diagnostic information, as well as the utility of clinical pathways as a means to streamline the diagnostic process.

Papillary carcinoma of breast: Minireview

The term “intracystic papillary ductal carcinoma in situ” constitutes only 0.5% to 1% of all breast cancers. It is usually seen in postmenopausal age group. Herein, we are presenting a minireview about this unusual breast malignancy usually difficult to diagnose on clinical grounds and highlighting modalities of diagnosis and management.

Korean Guidelines for Interventional Recanalization of Lower Extremity Arteries

Peripheral arterial occlusive disease caused by atherosclerosis can present with intermittent claudication or critical limb ischemia. Proper diagnosis and management is warranted to improve symptoms and salvage limbs. With the introduction of new techniques and dedicated materials, endovascular recanalization is widely performed for the treatment of peripheral arterial occlusive disease because it is less invasive than surgery. However, there are various opinions regarding the appropriate indications and procedure methods for interventional recanalization according to operator and institution in Korea. Therefore, we intend to provide evidence based guidelines for interventional recanalization by multidisciplinary consensus. These guidelines are the result of a close collaboration between physicians from many different areas of expertise including interventional radiology, interventional cardiology, and vascular surgery. The goal of these guidelines is to ensure better treatment, to serve as a guide to the clinician, and consequently, to contribute to public health care.

Clostridium difficile enteritis: a new role for an old foe

BACKGROUND

Small bowel involvement of Clostridium difficile is increasingly encountered. Data on many management aspects are lacking.

AIM

To synthesis existing reports and assess the frequency, pathophysiology, outcomes, risk factors, diagnosis and management of C. difficle enteritis.

METHODS

A systematic review of the literature was conducted to evaluate evidence regarding frequency, pathophysiology, risk factors, optimal diagnosis, management and outcomes for C. difficle enteritis. Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The review included original articles reporting C. difficle enteritis from January 1950 to December 2012.

RESULTS

C. difficle enteritis is rare but increasingly encountered. Presentation is variable and distinct predisposing factors include emergency surgery, white race and increased age. Diagnosis generally involves a sensitive but often non specific screening test for C. difficile antigens. Oral metronidazole represents first line therapy and surgery may be required for complications. Outcomes are inconsistent but may be improving.

CONCLUSIONS

A high index of clinical suspicion, early diagnosis and treatment are vital. Further prospective studies are needed to determine the significance of asymptomatic small bowel C. difficile infections.

Sodium channels, cardiac arrhythmia, and therapeutic strategy

Cardiac sodium channels are transmembrane proteins distributed in atrial and ventricular myocytes and Purkinje fibers. A large and rapid Na(+) influx through these channels initiates action potential and thus excitation-contraction coupling of cardiac cells. Cardiac sodium channel is composed of a pore-forming α-subunit and one or two accessory β-subunits. The cardiac α-subunit is encoded by gene SCN5A located on chromosome 3p21. There are four types of β-subunits identified so far, and β1 is the primary β-subunit in cardiac Na(+) channels. The gene responsible for β1 subunits is SCNB. The expression of β-subunits together with α subunits enhances the Na(+) current and modifies the channel activities. In addition, interactions of the cardiac Na(+) channel with other proteins may facilitate the channel activity and membrane expression of the channel. Over the past two decades, molecular genetic studies have identified the linkage of gene mutations of the Na(+) channel proteins and other regulatory proteins to many inherited arrhythmogenic diseases. The most common cardiac arrhythmogenic diseases associated with Na(+) channelopathies are long QT syndrome (LQT3) and Brugada syndromes (BrSs). This chapter intends to summarize the current understanding of the normal sodium-channel structure and function, the gene mutation-associated cardiac arrhythmias, and the current diagnosis and management of these diseases.

Principles of diagnosis and management of traumatic pneumothorax

Presence of air and fluid with in the chest might have been documented as early as Fifth Century B.C. by a physician in ancient Greece, who practiced the so-called Hippocratic succession of the chest. This is due to a development of communication between intrapulmonary air space and pleural space, or through the chest wall between the atmosphere and pleural space. Air enters the pleural space until the pressure gradient is eliminated or the communication is closed. Increasing incidence of road traffic accidents, increasing awareness of healthcare leading to more advanced diagnostic procedures, and increasing number of admissions in intensive care units are responsible for traumatic (noniatrogenic and iatrogenic) pneumothorax. Clinical spectrum of pneumothorax varies from asymptomatic patient to life-threatening situations. Diagnosis is usually made by clinical examination. Simple erect chest radiograph is sufficient though; many investigations are useful in accessing the future line of action. However, in certain life-threatening conditions obtaining imaging studies can causes an unnecessary and potential lethal delay in treatment.