Diagnostic Errors in Initial Misdiagnosis of Foreign Body Aspiration in Children: A Retrospective Observational Study in a Tertiary Care Hospital in China

Background: Foreign body aspiration (FBA) in children is a common emergency that can easily be missed, leading to delays in treatment. Few large cohort studies have focused on errors in diagnostic assessment. The main purpose of this study was to analyze factors contributing to the initial misdiagnosis of FBA in children.Methods: We retrospectively reviewed the charts of 226 children diagnosed with FBA at the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University from January 2018 to November 2020. Cases were divided into two groups according to whether or not patients were initially misdiagnosed. The clinical characteristics of the two groups were then compared. The Diagnosis Error Evaluation and Research (DEER) taxonomy tool was applied to cases with initial misdiagnosis.Results: Of the 226 included children with a final diagnosis of FBA, 153 (67.7%) were boys. Ninety percent of patients were under 3 years old. More than half (61.9%) of the children were referred from primary institutions, and 38.1% visited tertiary hospitals directly. A total of 80 (35.4%) patients were initially misdiagnosed. More than half of misdiagnosed children received an alternative diagnosis of bronchiolitis (51.3%), the most common alternative diagnosis. Test failures (i.e., errors in test ordering, test performance, and clinician processing) were primarily responsible for the majority of initial diagnostic errors (76.3%), followed by failure or delay in eliciting critical case history information (20.0%). Characteristics significantly associated with initial misdiagnosis were: presentation over 24 h (OR 9.2, 95% CI 4.8–17.5), being referred from primary institutions (OR 8.8, 4.1–19.0), no witnessed aspiration crisis (OR 7.8, 3.0–20.3), (4) atypical signs or symptoms (OR 3.2, 1.8–5.7), foreign body not visible on CT (OR 36.2, 2.1–636.8), foreign body located in secondary bronchi (OR 4.8, 1.3–17.2), organic foreign body (OR 6.2, 1.4–27.2), and history of recurrent respiratory infections (OR 2.7, 1.4–5.3). Children with misdiagnosis tended to have a longer time from symptom onset to the definitive diagnosis of FBA (P < 0.001).Conclusions: More than one-third of children with FBA were missed at first presentation. Errors in diagnostic testing and history taking were the main reasons leading to initial misdiagnosis.

Effect of SARS-CoV-2 vaccination on symptoms from post-acute COVID syndrome: results from the national VAXILONG survey

Introduction: Few data are available concerning the effect of SARS-CoV-2 vaccination on the persistent symptoms associated with COVID-19, also called long-COVID or post-acute COVID-19 syndrome (PACS). Patients and methods: We conducted a nationwide online survey among adult patients with PACS as defined by symptoms persisting over 4 weeks following a confirmed or probable COVID-19, without any identified alternative diagnosis. Information concerning PACS symptoms, vaccine type and scheme and its effect on PACS symptoms were studied. Results: Six hundred and twenty surveys were completed and 567 satisfied the inclusion criteria and were analyzed. Respondents were 83.4% of women of median age 44 (IQR 25-75: 37-50). Initial infection was proven in 365 patients (64%) and 5.1% had been hospitalized to receive oxygen. 396 patients had received at least one injection of SARS-CoV-2 vaccine at the time of the survey, after a median of 357 [198-431] days following the initially-reported SARS-CoV-2 infection. Among the 380 patients who reported persistent symptoms at the time of SARS-CoV-2 vaccination, 201 (52.8%) reported variation of symptoms following the injection, without difference based on the type of vaccine used. After a complete vaccination scheme, 93.3% (28/30) of initially seronegative patients reported a positive anti-SARS-CoV-2 IgG. 170 PACS patients had not been vaccinated. The most common reasons for postponing SARS-CoV-2 vaccine were a fear of worsening PACS symptoms (55.9%) and the idea that vaccination was contraindicated because of PACS (15.6%). Conclusion: Our study suggests that SARS-CoV-2 vaccination is well tolerated in the majority of PACS patients and has good immunogenicity. Disseminating these reassuring data might prove crucial to increase vaccine coverage in patients with PACS.

P07 Rheumatoid arthritis, joint pain with raised CRP: more than a flare

Case report - Introduction Rheumatoid arthritis is a chronic inflammatory autoimmune systemic disorder of unknown aetiology that predominantly affects the joints. Moreover, it is a systemic illness associated with a variety of extraarticular manifestations, including haematological complications such as lymphoma. We are presenting a case highlighting the importance of surveillance in these patients, particularly elderly patients with longstanding disease. Case report - Case description A 72-year-old female patient of African-Caribbean origin was referred to the rheumatology department from the community clinic for RA deterioration. She was diagnosed with RA RF anti-CCP positive in 2007 and was treated with sc MTX 25 mg weekly, HQ 200 mg bd, pred 5 mg and naproxen 250 mg. Her past medical history included HTN, OA, R TKR and degenerative lower back pain. Patient reported: ‘Doctor, I ‘ve had RA for many years, but never before I had such a pain’. She was complaining of multiple joint pains, morning stiffness of up to 2hrs, widespread pain and fatigue. She reported weight loss of 5 pounds in the last 2 months. For the last 2 weeks, she was suffering from lower back pain, L leg sciatica, with pins and needles, L leg weakness and incontinence. She was otherwise well. On examination she had 8 mildly swollen, 0 tender joints, VAS score was 90/100. DAS-28 was 4.92. Blood tests showed normocytic anaemia Hb 107, raised ESR 58 and CRP 124, previously 22 and 5.8. Anaemia screening, immunoglobulins and free light chains were normal. Biologic screening was normal. Repeating the blood tests following IM steroid injection, ESR was 81 and CRP 187. Alternative diagnosis such as infection and malignancy were suspected. A plan was made to review in the clinic and arrange further investigations with a CT scan. MRI spine was arranged which identified multiple osseous deposits L3-L5, T8-T12, T1, C2, retroperitoneal psoas mass, paravertebral mass and multiple retroperitoneal lymph nodes. CT revealed lung nodules and splenic lesions possible metastatic and right ileac destructive lesion. PET CT showed multiple active uptake in lymph nodes above and below diaphragm, the spleen and lung nodules, axial and appendicular skeleton. Patient had a bone marrow biopsy which revealed diffuse large B-cell lymphoma. Case report - Discussion This is a case of a patient with a 13-year history of rheumatoid arthritis, who was stable until last year and presented with worsening joint pain. Joint examination did not correlate with the severity of her pain. However. fluctuations in disease activity and variation throughout the day are common in rheumatoid arthritis and patient reported morning stiffness. Differential diagnosis initially included RA flare up with the possibility that osteoarthritis, fibromyalgia and degenerative spinal disease could also exacerbate her pain. However, ESR and CRP were significantly raised disproportionally for the joint count. Moreover, she had systemic symptoms with weight loss and fatigue raising the question of an alternative diagnosis such as malignancy or infection. Patient did not have obvious symptoms or signs of infection, and baseline investigations, such as CXR and urine dipstick were normal and TB spot was negative. However, there was concern for an occult infection. Malignancy could be a potential diagnosis as the risk increases with age, and haematological malignancies, particularly lymphoma, have been associated with RA. Myeloma could be an alternative diagnosis, based on anaemia and back pain; however, myeloma screening came back normal. Patient was diagnosed with stage IVB diffuse large B-cell lymphoma with metastatic bone disease, paravertebral mass, retroperitoneal lymph nodes, psoas mass, pulmonary nodules, and splenic lesions. Her joint and back pain were related to metastatic bone disease. She was treated with 2 cycles R-CHOP, 4 cycles R mini-CHOP. She repeated the PET CT which showed improvement. CRP dropped to 1.3. Case report - Key learning points Rheumatoid arthritis is a systemic disease and the raised inflammatory markers do not necessarily indicate RA flare. We should consider other causes in our differential diagnosis, such as infection and malignancy. Studies have shown 2-fold increased risk for lymphoma in RA patients, HL, NHL and particularly the diffuse large B-cell Lymphoma. The risk of having lymphoma correlates with disease activity. DMARD treatment including anti-TNF does not seem to increase the risk which is probably driven by the systemic inflammation causing persistent immunologic stimulation, B cell clonal expansion and transformation along with decreased T suppressor cells and NK activity. Therefore, EULAR recommends systemic screening for infections and malignancy, along with other co-morbidities as part of the routine care in patients with rheumatoid arthritis. At the end, we should always listen to the patient’s story.

Outcomes of a virtual craniofacial clinic for assessing plagiocephaly during the COVID-19 pandemic

OBJECTIVE The aim of this study was to carry out a quantitative analysis of a virtual craniofacial clinic during the COVID-19 pandemic. METHODS The charts of 90 patients from a single institution were reviewed. Of these patients, 45 visited the virtual clinic during the COVID-19 pandemic. The other 45 patients visited the clinic in the 3 months prior to COVID-19. Demographics including the mean age at the visit, chief complaint, visit diagnosis, appointment duration, helmet usage, accuracy of the diagnosis, need for a CT scan, and the need for a follow-up appointment were assessed. Diagnostic accuracy, the frequency of follow-up appointments, and patient satisfaction (via survey), as well as additional associated factors, were analyzed to determine the efficacy and satisfaction associated with the virtual clinic approach. RESULTS The mean patient age at time of the visit was 5.6 and 7.3 months (p = 0.244), and the mean time from referral to appointment was 19.2 and 19 days (p = 0.934), in the in-person and virtual cohorts, respectively. There was no significant difference in the variety of chief complaints between the in-person and virtual visits, with 97.8% and 93.3% of patients’ parents reporting abnormal head shape, respectively, and the remainder reporting more infrequent complaints (p = 0.435). The visit diagnosis was plagiocephaly in 93.3% of the in-person cohort and 80.0% of the virtual cohort (p = 0.118). The final diagnosis exhibited a similar pattern, with 95.6% of the in-person cohort and 88.9% of the virtual cohort observed as positional plagiocephaly; the remaining diagnoses were more infrequent (p = 0.434). The most common alternative diagnosis in the virtual visit cohort was a metopic ridge (8.4%). In the in-person visit cohort, the most common alternative diagnosis was equally a benign enlargement of the subarachnoid space in infancy, scalp mass, and skull lesion (2.2% each). None of the patients in either cohort were diagnosed with synostosis. Eighty percent of the in-person visits were 15 to 30 minutes in duration, with the remaining 20% being 31 minutes or longer; virtual visits were all 30 minutes or less, with 95.6% being 15 to 30 minutes (p = 0.002). Helmets were prescribed for 2 patients in the in-person cohort and no patients in the virtual cohort (p = 0.494). Alterations in diagnosis were made in 2.2% of in-person visits and 6.7% of virtual visits (p = 0.616). Follow-up was required in 15.6% of the in-person visits and 31.1% of the virtual visits (p = 0.134). CT was only utilized twice, once in the in-person visit cohort and once in the virtual visit cohort. CONCLUSIONS Virtual clinic encounters resulted in comparable diagnostic accuracy. The trend toward frequent follow-up assessments and changes in the final diagnosis in the virtual clinic cohort has indicated a level of diagnostic uncertainty via the virtual interface, which required in-person assessment for confirmation. This finding did not contribute toward diagnostic inaccuracy with respect to missed synostosis. The study results have indicated that telemedicine can be an effective modality in assessing craniofacial pathology.

Long COVID syndrome – general aspects

2020), growing scientific evidence worldwide suggests that a small percentage of people who have developed COVID-19 and healed after the initial infection may experience a series of persistent symptoms over a period of more than 12 weeks, such as marked fatigue, shortness of breath, confusion, diarrhea, or other symptoms that cannot be explained by an alternative diagnosis. This status has been called “long COVID syndrome” or ”post COVID syndrome”.

Use of β-D-glucan in diagnosis of suspected Pneumocystis jirovecii pneumonia in adults with HIV infection

Objectives: An elevated serum (1-3)-β-D-glucan (BDG) concentration has high sensitivity for a diagnosis of Pneumocystis pneumonia (PCP) in people with HIV (PWH). At the current manufacturer-recommended positive threshold of 80 pg/mL (Fungitell), specificity for PCP is variable and other diagnostic tests are required. We evaluated the utility of serum BDG for diagnosis of suspected PCP in PWH at three inner-London hospitals to determine BDG concentrations for diagnosis and exclusion of PCP. Methods: From clinical case records, we abstracted demographic and clinical information and categorised patients as having confirmed or probable PCP, or an alternative diagnosis. We calculated sensitivity, specificity and positive predictive value (PPV) of serum BDG concentrations >400 pg/mL and negative predictive value (NPV) of BDG <80 pg/mL. Results: 76 patients were included; 29 had laboratory-confirmed PCP, 17 had probable PCP and 30 had an alternative diagnosis. Serum BDG >400 pg/mL had a sensitivity of 83%, specificity of 97% and PPV 97% for diagnosis of PCP; BDG <80 pg/mL had 100% NPV for exclusion of PCP. Conclusions: In PWH with suspected PCP, BDG <80 pg/mL excludes a diagnosis of PCP, whereas BDG concentrations >400 pg/mL effectively confirm the diagnosis. Values 80–400 pg/mL should prompt additional diagnostic tests.

Spectrum of neurological manifestations and systematic evaluation of cerebrospinal fluid for SARS-CoV2 in patients admitted to hospital during the COVID-19 epidemic in South Africa

Neurological manifestations of COVID-19 are increasingly described in the literature. There is uncertainty whether these occur due to direct neuroinvasion of the virus, para-infectious immunopathology, as result of systemic complications of disease such as hypercoagulability or due to a combination of these mechanisms. Here we describe clinical and radiological manifestations in a sequential cohort of patients presenting to a district hospital in South Africa with neurological symptoms with and without confirmed COVID-19 during the first peak of the epidemic. In these patients, where symptoms suggestive of meningitis and encephalitis were most common, thorough assessment of presence in CSF via PCR for SARS-CoV2 did not explain neurological presentations, notwithstanding very high rates of COVID-19 admissions. Although an understanding of potential neurotropic mechanisms remains an important area of research, these results provide rationale for greater focus towards the understanding of para-immune pathogenic processes and the contribution of systemic coagulopathy and their interaction with pre-existing risk factors in order to better manage neurological disease in the context of COVID-19. These results also inform the clinician that consideration of an alternative diagnosis and treatment for neurological presentations in this context is crucial, even in the patient with a confirmed diagnosis COVID-19.

Look up rather than down: Karl Polanyi’s fascism and radical right-wing ‘populism’

Radical right-wing politics is often regarded as a populist movement for social protection against economic globalisation. As a solution, contemporary Polanyian critics often suggest reforming left parties to reorient populist movements from the right to the left by building a broad non-capitalist coalition. Through a close reading of Polanyi’s works, this article offers an alternative diagnosis and prescription for preventing radical right-wing empowerment. Polanyi explains that fascists gained political power through support from capitalist elites. Political democratisation threatened the separation of the market from politics, and the war and depression resulted in the dysfunction of the market economy. In this situation, capitalist elites chose fascism – a radical measure to protect capitalism by destroying democracy. This article argues that, in order to prevent radical right-wing empowerment, we should look up, to the capitalist economy and the ruling classes, rather than only down, to welfare chauvinism and the ‘people’.

Hypothermia in a 6-Week Infant-an Atypical Presentation of Multisystem Inflammatory Syndrome (MIS-C)

MIS-C is a rare complication of covid-19. The definition across the organizations is based on 6 principle elements: pediatric age, persistence of fever, presence of laboratory markers of inflammation, manifestation of signs or symptoms of organ dysfunction, lacking an alternative diagnosis, and a temporal relation to COVID-19 infection or exposure [1]. We describe an atypical case of MIS-C with myocarditis in a 6-week-old infant presenting with hypothermia rather than fever.

Prevalence of Mimics and Severe Comorbidity in Patients with Clinically Suspected Transient Global Amnesia

<b><i>Background:</i></b> Transient global amnesia (TGA) is a syndrome featuring acute anterograde amnesia as the most striking clinical symptom. Its etiology is still a matter of debate. Most neurological guidelines allow the diagnosis on the basis of clinical criteria only; a more extensive evaluation is recommended only for patients with “red flags” like severe headache, nausea or vomiting, or metabolic abnormalities. The aim of our study was to assess the frequency of a severe underlying disease or alternative diagnoses (mimics) in patients fulfilling the clinical criteria. <b><i>Methods:</i></b> We evaluated the medical records and the imaging data of an unselected consecutive cohort of patients with suspected TGA over a 7-year period. All patients were hospitalized and received a neurological workup including brain imaging, color-coded duplex sonography of the brain supplying arteries, electroencephalography, and laboratory studies of blood and (in selected cases) cerebrospinal fluid. <b><i>Results:</i></b> 163 patients with 166 episodes of suspected TGA were hospitalized (3 patients twice). After the workup, the diagnosis of TGA was confirmed in 148/166 (89.2%) episodes (“simple TGA”). Eighteen patients (10.8%) either had an alternative diagnosis or a severe comorbidity that was assumed to have had an impact on the occurrence of the amnestic episode (“complicated TGA/mimic”). The most important differential diagnosis was stroke (11 patients, 6.6% of all TGA suspects and 61.1% of the complicated TGA/mimic group). Other mimics were transient epileptic amnesia (2 patients) and steroid-induced delirium (1 patient). Important comorbidities that had not been obvious at the time of presentation were severe sleep apnea (2 patients), triptan overuse (1 patient), and an involuntary amlodipine intoxication during TGA. <b><i>Conclusion:</i></b> As approximately every tenth patient with suspected TGA either had an alternative diagnosis or a severe comorbidity, which had not been obvious at the time of admission, we consider in-patient treatment of all suspected TGA cases as appropriate, preferably in the setting of a stroke unit, as ischemic stroke was the by far most important diagnosis mimicking TGA.