Kevin R. Weaver

Differential Diagnosis Generators: an Evaluation of Currently Available Computer Programs

BackgroundDifferential diagnosis (DDX) generators are computer programs that generate a DDX based on various clinical data.ObjectiveWe identified evaluation criteria through consensus, applied these criteria to describe the features of DDX generators, and tested performance using cases from the New England Journal of Medicine (NEJM©) and the Medical Knowledge Self Assessment Program (MKSAP©).MethodsWe first identified evaluation criteria by consensus. Then we performed Google® and Pubmed searches to identify DDX generators. To be included, DDX generators had to do the following: generate a list of potential diagnoses rather than text or article references; rank or indicate critical diagnoses that need to be considered or eliminated; accept at least two signs, symptoms or disease characteristics; provide the ability to compare the clinical presentations of diagnoses; and provide diagnoses in general medicine. The evaluation criteria were then applied to the included DDX generators. Lastly, the performance of the DDX generators was tested with findings from 20 test cases. Each case performance was scored one through five, with a score of five indicating presence of the exact diagnosis. Mean scores and confidence intervals were calculated.Key ResultsTwenty three programs were initially identified and four met the inclusion criteria. These four programs were evaluated using the consensus criteria, which included the following: input method; mobile access; filtering and refinement; lab values, medications, and geography as diagnostic factors; evidence based medicine (EBM) content; references; and drug information content source. The mean scores (95% Confidence Interval) from performance testing on a five-point scale were Isabel© 3.45 (2.53, 4.37), DxPlain® 3.45 (2.63–4.27), Diagnosis Pro® 2.65 (1.75–3.55) and PEPID™ 1.70 (0.71–2.69). The number of exact matches paralleled the mean score finding.ConclusionsConsensus criteria for DDX generator evaluation were developed. Application of these criteria as well as performance testing supports the use of DxPlain® and Isabel© over the other currently available DDX generators.

Food Protein-Induced Enterocolitis Syndrome as a Cause for Infant Hypotension

Infants with food protein-induced enterocolitis syndrome (FPIES) may present to the emergency department (ED) with vomiting and hypotension. A previously healthy, 5-month-old male presented with vomiting and hypotension 2 to 3 hours after eating squash. The patient was resuscitated with intravenous fluids, antibiotics, and admitted for presumed sepsis. No source of infection was ever found and the patient was discharged. The patient returned 8 days later with the same symptoms after eating sweet potatoes; the diagnosis of FPIES was made during this admission. Two additional ED visits occurred requiring hydration after new food exposure. FPIES should be considered in infants presenting with gastrointestinal complaints and hypotension. A dietary history, including if a new food has been introduced in the last few hours, may help facilitate earlier recognition of the syndrome.

A randomized, controlled trial to evaluate topical anesthetic for 15 minutes before venipuncture in pediatrics.

OBJECTIVES The aim of the study was to assess the differences in reported pain from venipuncture comparing liposomal 4% lidocaine with placebo cream in a pediatric population. Other factors assessed were patient anxiety, difficulty of venipuncture, and history of venipuncture. METHODS A prospective, randomized, double-blind, placebo control study design was used in which subjects were assigned to receive either liposomal 4% lidocaine or placebo cream. The study population consisted of pediatric patients aged 5 to 18 years old who presented to 1 site of a multisite, academic, community emergency department. Once subjects had consented and randomized, the liposomal 4% lidocaine or placebo cream was applied for 15 minutes under occlusion. A 6-point validated FACES pain scale was used to evaluate each patients level of pain during venipuncture. Patient anxiety was evaluated using a 100-mm visual analogue scale before, during, and after the venipuncture. Heart rate was captured as an indirect measurement of pain. RESULTS There were no significant differences between the study and placebo groups (P > .05) in mean levels of patient ratings of anxiety, patient heart rate, or the patients mean rating of pain before, during, or after the venipuncture procedure. There was an association between increased anxiety with an increase in venipuncture pain and an inverse association between age and pain. CONCLUSION Topical liposomal 4% lidocaine cream in this case did not prove to be effective with a 15-minute dwell time under occlusion because there were no differences in pain between study groups.

Emergency Medicine Gender-Specific Education.

The 2014 Academic Emergency Medicine consensus conference has taken the first step in identifying gender-specific care as an area of importance to both emergency medicine (EM) and research. To improve patient care, we need to address educational gaps in this area concurrent with research gaps. In this article, the authors highlight the need for sex- and gender-specific education in EM and propose guidelines for medical student, resident, and faculty education. Specific examples of incorporating this content into grand rounds, simulation, bedside teaching, and journal club sessions are reviewed. Future challenges and strategies to fill the gaps in the current education model are also described.

MRI diagnosis of herpes simplex encephalitis in an elderly man with nonspecific symptoms

A 78-year-old male presented to the Emergency Department complaining of a 1-week onset of increasing fatigue and anorexia. The patient was previously well but had a history of depression, chronic diarrhea, and hypertension. His examination was remarkable for mild fever (100.1°F). He had no acute neurologic deficits. The patient felt better after intravenous fluids and was discharged to follow-up with the primary care provider. With no resolution of symptoms and new memory loss, the patients primary care doctor ordered an MRI which revealed abnormal signal/patchy enhancement of the left temporal lobe indicative (pathognomonic) of herpes simplex encephalitis. This case emphasizes the importance of early consideration of herpes simplex encephalitis in the differential of patients with these symptoms.

Subtle presentation of herpes simplex encephalitis

Herpes Simplex Encephalitis (HSE), while relatively rare, is of relevance to the emergency medicine provider due to its destructive, rapid progression and its often unexpected and sudden onset. We present a case of an older man who arrived at the Emergency Department with a mild fever (100.1°F), and an insidious weeklong onset of increasing fatigue and anorexia in the context of chronic hypertension, diarrhea, anxiety, depression and baseline mild bilateral hand tremors. Urinalysis revealed moderate blood, and complete blood count showed leukocytosis, which leads to the tentative diagnosis of a urinary tract infection with secondary diagnoses of depression and fatigue. He was instructed to follow up with his primary care provider the following day. On follow-up the patient had new-onset memory loss and confusion and a magnetic resonance imaging ordered by the primary care provider revealed abnormal signal enhancement of the left temporal lobe compatible with herpes encephalitis. The patient was admitted, and the diagnosis was supported by cerebrospinal fluid lymphocyte pleocytosis and later confirmed by viral polymerase chain reaction. The patient was treated with acyclovir andwas dischargedfive days after admission. At discharge, he stated feeling better, but had some residualmild confusion and general weakness. Because of the severity of the diseases progression, its lack of predictability, and the risks of delay in diagnosis, it is imperative that it be given consideration in the clinicians differential diagnosis. Listedon theNationalOrganizations List ofRareDiseases,herpes simplex encephalitis (HSE) has an annual prevalence of 0.2 to 0.4 in 100 000 in the general population, yet represents themost common cause of fatal sporadic encephalitis [1,2]. Early diagnosis and treatment of HSE is imperative, as demonstratedby its untreatedmortality rate of 70%,with only 3%of untreated survivors retaining normal neurological function [2,3]. HSE is characterized by signs and symptoms of neurological infection including focal deficits of the lesioned site (most commonly in the temporal lobe), fever, seizures, and, less commonly, meningitis [4]. Missed diagnosis and treatment with acyclovir increases mortality from 19% to more than 70%, and delays in treatment often result in permanent neuropsychological impairment with amnesia [5]. We present a case in which a patient initially presented with seemingly nonspecific distress that was eventually found to be HSE. A 78-year-old man presented to the Emergency Department complaining of a 1-week onset of increasing fatigue and decreased appetite. In addition to the new symptoms, the patient reported a several month history of intermittent loose stools and amild bilateral hand tremor, which the patients wife reported as increasing in severity over the previous week. He denied fever, headache, nausea, dysuria, and dyspnea. ☆ The authors have no outside support information, conflicts or financial interest to

Traumatic dislocation of the first carpometacarpal joint

We present a case report and review of the literature of traumatic dislocation of the carpometacarpal joint of the left thumb without associated fracture. The injury was sustained while skiing, and after emergency department diagnosis, the dislocation was reduced and the joint stabilized with a splint. The patient was discharged with close follow-up with a hand surgeon for definitive surgical fixation. Carpometacarpal joint dislocations of the thumb are exceedingly rare injuries and require appropriate diagnosis and treatment to minimize the morbidity and loss of function that can occur with these injuries.