Practical Approach to Hair Loss Diagnosis

Hair loss is one of the common complaints encountered in a cosmetic practice. Evaluating a patient with hair loss requires a thorough understanding of the various causes of hair loss and practical knowledge in hair cosmetics and hair styling procedures. A systematic approach in hair loss evaluation helps the treating physician in arriving at a diagnosis. Various bedside tests and advent of trichoscopy has empowered the physician in arriving at a diagnosis. This article aims to provide the physician a systematic approach in evaluating a patient with hair loss.

Evaluation of Bedside Tests of Attention and Arousal Assessing Delirium in Parkinson’s Disease, Dementia, and Older Adults

Background: Delirium is a serious acute neuropsychiatric condition associated with altered attention and arousal. Objective: To evaluate simple bedside tests for attention and arousal to detect delirium in those with and without Parkinson’s disease (PD) and dementia. Methods: Participants from two prospective delirium studies were pooled comprising 30 with PD without cognitive impairment, 24 with Lewy body cognitive impairment (PD dementia or dementia with Lewy bodies), 16 with another dementia and 179 PD and dementia-free older adults. Participants completed standardised delirium assessments including tests of attention: digit span, Memorial Delirium Assessment Scale (MDAS) attention and months of the year backwards; and arousal: Glasgow Coma Scale (GSC), Observational Scale of Level of Arousal (OSLA), Modified Richmond Agitation Scale and MDAS consciousness. Delirium was diagnosed using the DSM-5 criteria. Results: On their first admission, 21.7%participants had prevalent delirium. Arousal measures accurately detected delirium in all participants (p < 0.01 for all), but only selected attention measures detected delirium in PD and dementia. In PD and dementia-free older adults, impaired digit span and OSLA were the optimal tests to detect delirium (area under the curve [AUC] = 0.838, p < 0.001) while in PD and dementia the optimal tests were MDAS attention and GCS LB. Conclusion: Simple bedside tests of attention and arousal at a single visit could accurately detect delirium in PD, dementia and PD and dementia-free older adults; however, the optimal tests differed between groups. Combined attention and arousal scores increased accuracy, which could have clinical utility to aid the identification of delirium neurodegenerative disorders.

What is a tilt table test and why is it performed during the investigation of syncope?

Falls are one of the most common reasons for patients to present to the emergency department. Syncope is a common cause of falls, which disproportionately affects older people. In most cases, syncope can be confirmed with a detailed history and simple bedside tests, but tilt table testing remains an invaluable diagnostic adjunct in more complex cases. Often misunderstood, the tilt table test is a useful way to reproduce a patient’s symptoms in a safe and controlled environment. The tilt table test is considered positive if the patient experiences symptoms associated with a drop in blood pressure or postural tachycardia. The test can support a diagnosis and can direct therapeutic interventions.

Back to basics: a rare and aggressive case of Aggregatibacter aphrophilus endocarditis

ABSTRACT We present the case of a 25-year-old with a history of bicuspid aortic valve and ascending aortopathy who was successfully treated for infective endocarditis (IE) due to Aggregatibacter aphrophilus. His clinical course was complicated by a large aortic root abscess not initially visualised on transthoracic echocardiography or computerised tomography. The cardinal feature of progressive prolongation of the PR interval on serial electrocardiograms was the only sign associated with clinical deterioration and was the trigger for rapid investigation and urgent management. Our case emphasises the importance of simple bedside tests to identify dynamic clinical scenarios and the requirement for early further imaging in the management of IE.

Current Perspective: Vertigo in the Elderly

Vertigo is a relatively complex condition demanding a skilfully collected and analyzed history. When an elderly patient presents with vertigo, some conditions are most commonly considered highly possible and likely whereas others (prevalent more in young) tend to be excluded from the mental algorithm of the clinician. It also matters to whom the patient presents first-internist, neurologist or the otolaryngologist. An important feature in vertigo in the elderly is the probability of it being multifactorial because of co-morbid conditions that could contribute to the complexity of manifestations. Conducting and appropriately interpreting the bedside tests/maneuvers and thereafter selecting battery of tests/investigations in a sequential manner can clinch the issue of a fair diagnosis in most cases. The Covid Dimension: Any discussion on vertigo would be incomplete without noting the findings on vertigo reported abundantly over the last one year. The compounding COVID angle merits being duly and appropriately considered.

Diagnosis of Myasthenia Gravis

The diagnosis of autoimmune Myasthenia Gravis (MG) remains clinical and rests on the history and physical findings of fatigable, fluctuating muscle weakness in a specific distribution. Ancillary bedside tests and laboratory methods help confirm the synaptic disorder, define its type and severity, classify MG according to the causative antibodies, and assess the effect of treatment objectively. We present an update on the tests used in the diagnosis and follow-up of MG and the suggested approach for their application.

A comprehensive scheme for the objective upper body assessments of subjects with cerebellar ataxia

Background Cerebellar ataxia refers to the disturbance in movement resulting from cerebellar dysfunction. It manifests as inaccurate movements with delayed onset and overshoot, especially when movements are repetitive or rhythmic. Identification of ataxia is integral to the diagnosis and assessment of severity, and is important in monitoring progression and improvement. Ataxia is identified and assessed by clinicians observing subjects perform standardised movement tasks that emphasise ataxic movements. Our aim in this paper was to use data recorded from motion sensors worn while subjects performed these tasks, in order to make an objective assessment of ataxia that accurately modelled the clinical assessment. Methods Inertial measurement units and a Kinect© system were used to record motion data while control and ataxic subjects performed four instrumented version of upper extremities tests, i.e. finger chase test (FCT), finger tapping test (FTT), finger to nose test (FNT) and dysdiadochokinesia test (DDKT). Kinematic features were extracted from this data and correlated with clinical ratings of severity of ataxia using the Scale for the Assessment and Rating of Ataxia (SARA). These features were refined using Feed Backward feature Elimination (the best performing method of four). Using several different learning models, including Linear Discrimination, Quadratic Discrimination Analysis, Support Vector Machine and K-Nearest Neighbour these extracted features were used to accurately discriminate between ataxics and control subjects. Leave-One-Out cross validation estimated the generalised performance of the diagnostic model as well as the severity predicting regression model. Results The selected model accurately ($$96.4\%$$ 96.4 % ) predicted the clinical scores for ataxia and correlated well with clinical scores of the severity of ataxia ($$rho = 0.8$$ r h o = 0.8 , $$p < 0.001$$ p < 0.001 ). The severity estimation was also considered in a 4-level scale to provide a rating that is familiar to the current clinically-used rating of upper limb impairments. The combination of FCT and FTT performed as well as all four test combined in predicting the presence and severity of ataxia. Conclusion Individual bedside tests can be emulated using features derived from sensors worn while bedside tests of cerebellar ataxia were being performed. Each test emphasises different aspects of stability, timing, accuracy and rhythmicity of movements. Using the current models it is possible to model the clinician in identifying ataxia and assessing severity but also to identify those test which provide the optimum set of data. Trial registration Human Research and Ethics Committee, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia (HREC Reference Number: 11/994H/16).

A Comprehensive Scheme for the Objective Upper Body Assessments of Subjects with Cerebellar Ataxia

BackgroundCerebellar Ataxia refers to the disturbance in movement resulting from cerebellar dysfunction. It manifests as inaccurate movements with delayed onset and overshoot, especially when movements are repetitive or rhythmic. Identification of ataxia is integral to the diagnosis and assessment of severity, and is important in monitoring progression and improvement. Ataxia is identified and assessed by clinicians observing subjects perform standardised movement tasks that emphasise ataxic movements. Our aim in this paper was to use data recorded from motion sensors worn while subjects performed these tasks, in order to make an objective assessment of ataxia that accurately modelled the clinical assessment.MethodsInertial measurement units and a Kinect system were used to record motion data while control and ataxic subjects performed four instrumented version of upper extremities tests, i.e. Finger Chase Test (FCT), Finger Tapping Test (FTT), Finger to Nose Test (FNT) and Dysdiadochokinesia Test (DDKT). Kinematic features were extracted from this data and correlated with clinical ratings of severity of ataxia using the Scale for the Assessment and Rating of Ataxia (SARA). These features were refined using Feed Backward feature Elimination (the best performing method of four). Using several different learning models, including Linear Discrimination, Quadratic Discrimination Analysis, Support Vector Machine and K-Nearest Neighbour these extracted features were used to accurately discriminate between ataxics and control subjects. Leave-One-Out cross validation estimated the generalised performance of the diagnostic model as well as the severity predicting regression model.ResultsThe selected model accurately (96.4%) predicted the clinical scores for ataxia and correlated well with clinical scores of the severity of ataxia (rho = 0.8, p < 0.001). The severity estimation was also considered in a 4-level scale to provide a rating that is familiar to the current clinically-used rating of upper limb impairments. The combination of FCT and FTT performed as well as all four test combined in predicting the presence and severity of ataxia.ConclusionIndividual bedside tests can be emulated using features derived from sensors worn while bedside tests of cerebellar ataxia were being performed. Each test emphasises different aspects of stability, timing, accuracy and rhythmicity of movements. Using the current models it is possible to model the clinician in identifying ataxia and assessing severity but also to identify those test which provide the optimum set of data.Trial registrationHuman Research and Ethics Committee, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia (HREC Reference Number: 11/994H/16).

Pediatric Neck Trauma

Pediatric neck injuries have significant potential morbidity. Any hemodynamically unstable patient with hard signs of neck injury should be taken to the operating room immediately. Assurance of airway stability in all other pediatric patients with neck injury should take first priority. Bedside tests, including the extended focused assessment with sonography for trauma examination and plain films of the neck and chest, are readily available and can provide helpful information. High-resolution computed tomography (CT) with angiogram has been shown to be the superior imaging study when evaluating the neck for vascular or aerodigestive injury. Additional diagnostic modalities are based on clinical suspicion, signs and symptoms, injury location, and CT results.

Reliability and Validity of the Boston Bedside Quantitative Sensory Testing Battery for Neuropathic Pain

Objective Recent studies suggest that sensory phenotyping may provide critical information for the diagnosis and management of patients with chronic neuropathic pain (NP). However, many formal quantitative sensory testing (QST) paradigms require expensive equipment, a dedicated location, and substantial time commitments on the part of patient and examiner, highlighting the need for a convenient and portable “bedside” QST battery. We developed and tested a bedside QST battery in a sample of patients with chronic NP. Methods Participants (N = 51) attended two in-person visits over approximately two weeks, during which they underwent QST using both laboratory-based equipment and simple, easily accessible bedside tools. Participants also completed questionnaires about their daily pain and NP symptoms. Results Test–retest reliability estimates were highly statistically significant and did not differ between bedside (mean r = 0.60) and laboratory-based (mean r = 0.72) QST. Bedside QST variables and corresponding laboratory-based QST variables were highly correlated, suggesting adequate criterion validity for the bedside tests. Conclusions Results from the present study may have important implications for the sensory phenotyping and subsequent management of patients with chronic NP. Implementation of a protocol that uses inexpensive, portable, and convenient tools may allow for the application of QST in variety of clinical settings and advance NP research.