Abdominal Pain in the Emergency Department: Missed Diagnoses

Association Between Physician Age and Imaging Utilization in Emergency Department Abdominal Pain Evaluation

BACKGROUND

Emergency department (ED) workup of abdominal pain commonly utilizes substantial healthcare resources including laboratory tests and advanced imaging. Although studies have explored various characteristics that influence resource utilization, the relationship between physician age and use of imaging modalities is unclear.

OBJECTIVES

Determine the correlation between physician age and ordering of abdominal imaging in the ED.

METHODS

We extracted data from 5 years of patient visits across multiple EDs. The primary outcome was use of abdominal imaging, with secondary outcomes of hospital admission, ED length of stay (LOS), and 72-h revisits. Multivariable logistic regression was used to assess binary outcomes, and multivariable linear regression was used for LOS. Physician age was categorized into cohorts of <36, 36-44, 45-54, ≥55 years.

RESULTS

Evaluation of 91,922 unique encounters revealed that the most senior physicians had lower odds of ordering imaging than younger physicians of any group and had lower odds of 72-h revisits with no difference in admission or ED LOS when compared to physicians <36 years. The middle groups (36-44 and 45-54 years) had higher odds of hospital admission than the youngest. The 2 most senior groups had lower odds of 72-h ED revisits than physicians <36 years.

CONCLUSION

For patients presenting to the ED with abdominal pain, more senior physicians utilize fewer imaging resources, have fewer 72-h revisits, while maintaining equivalent hospital admissions and ED LOS as the youngest cohort of physicians. Further research is needed to discern what specific features of senior physicians contribute to the associations highlighted in this study.

Assessing artificial intelligence-generated patient discharge information for the emergency department: a pilot study

BACKGROUND

Effective patient discharge information (PDI) in emergency departments (EDs) is vital and often more crucial than the diagnosis itself. Patients who are well informed at discharge tend to be more satisfied and experience better health outcomes. The combination of written and verbal instructions tends to improve patient recall. However, creating written discharge materials is both time-consuming and costly. With the emergence of generative artificial intelligence (AI) and large language models (LMMs), there is potential for the efficient production of patient discharge documents. This study aimed to investigate several predefined key performance indicators (KPIs) of AI-generated patient discharge information.

METHODS

This study focused on three significant patients' complaints in the ED: nonspecific abdominal pain, nonspecific low back pain, and fever in children. To generate the brochures, we used an English query for ChatGPT using the GPT-4 LLM and DeepL software to translate the brochures to Dutch. Five KPIs were defined to assess these PDI brochures: quality, accessibility, clarity, correctness and usability. The brochures were evaluated for each KPI by 8 experienced emergency physicians using a rating scale from 1 (very poor) to 10 (excellent). To quantify the readability of the brochures, frequently used indices were employed: the Flesch Reading Ease, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook, and Coleman-Liau Index on the translated text.

RESULTS

The brochures generated by ChatGPT/GPT-4 were well received, scoring an average of 7 to 8 out of 10 across all evaluated aspects. However, the results also indicated a need for some revisions to perfect these documents. Readability analysis indicated that brochures require high school- to college-level comprehension, but this is likely an overestimation due to context-specific reasons as well as features inherent to the Dutch language.

CONCLUSION

Our findings indicate that AI tools such as LLM could represent a new opportunity to quickly produce patient discharge information brochures. However, human review and editing are essential to ensure accurate and reliable information. A follow-up study with more topics and validation in the intended population is necessary to assess their performance.

Investigation and Comparison of Preoperative Symptoms in Patients With Appendicitis and Cholecystitis Before Appendectomy and Cholecystectomy Surgeries

INTRODUCTION

Appendectomy and cholecystectomy are the surgical procedures to treat appendicitis and cholecystitis, respectively. However, there is a lack of investigation regarding these two similar types of abdominal complication-based disease which may primarily create confusion within patients.

METHODS

To understand the variation and similarities within the preoperative symptoms of these two diseases, we included 224 participants including both appendicitis (n = 175) and cholecystitis (n = 49) patients. We obtained the preoperative symptoms through physical check-ups, thorough observation, and questionnaires.

RESULT

We found several symptoms in both patients where abdominal pain was present in all patients in both groups. However, followed by abdominal pain, vomiting (118 (67.42%)), pain RIF (right iliac fossa) (101 (57.71%)), nausea (71 (40.57%)), and sharp pain (22 (12.57%)) were prevalent in the appendicitis group whereas tenderness (49 (100%)), epigastric pain (13 (26.53%)), and hypertension (10 (20.41%)) were prevalent in the cholecystitis group. However, fever was commonly present in several patients in both groups.  Conclusion: Abdominal pain can be a major indicator of surgery in both appendicitis and cholecystitis patients. However, observation of other symptoms is crucial for initial symptomatic diagnosis and differentiating between these diseases.

The role of protein post-translational modifications in prostate cancer

Involving addition of chemical groups or protein units to specific residues of the target protein, post-translational modifications (PTMs) alter the charge, hydrophobicity, and conformation of a protein, which in turn influences protein function, protein-protein interaction, and protein aggregation. These alterations, which include phosphorylation, glycosylation, ubiquitination, methylation, acetylation, lipidation, and lactylation, are significant biological events in the development of cancer, and play vital roles in numerous biological processes. The processes behind essential functions, the screening of clinical illness signs, and the identification of therapeutic targets all depend heavily on further research into the PTMs. This review outlines the influence of several PTM types on prostate cancer (PCa) diagnosis, therapy, and prognosis in an effort to shed fresh light on the molecular causes and progression of the disease.

PLA inhibits TNF-α-induced PANoptosis of prostate cancer cells through metabolic reprogramming

Previous studies have shown that phenyllactic acid (alpha-Hydroxyhydrocinnamic acid, 2-Hydroxy-3-phenylpropionic acid, PLA), a type of organic acid metabolite, has excellent diagnostic efficacy when used to differentiate between prostate cancer, benign prostatic hyperplasia, and prostatitis. This research aims to explore the molecular mechanism by which PLA influences the PANoptosis of prostate cancer (PCa) cell lines. First, we found that PLA was detected in all prostate cancer cell lines (PC-3, PC-3 M, DU145, LNCAP). Further experiments showed that the addition of PLA to prostate cancer cells could promote ATP generation, enhance cysteine desulfurase (NFS1) expression, and reduce tumor necrosis factor alpha (TNF-α) levels, thereby inhibiting apoptosis in prostate cancer cells. Notably, overexpression of NFS1 can inhibit the binding of TNF-α to serpin mRNA binding protein 1 (SERBP1), suggesting that NFS1 competes with TNF-α for binding to SERBP1. Knockdown of SERBP1 significantly reduced the level of small ubiquity-related modifier (SUMO) modification of TNF-α. This suggests that NFS1 reduces the SUMO modification of TNF-α by competing with SERBP1, thereby reducing the expression and stability of TNF-α and ultimately inhibiting apoptosis in prostate cancer cell lines. In conclusion, PLA inhibits TNF-α induced panapoptosis of prostate cancer cells through metabolic reprogramming, providing a new idea for targeted treatment of prostate cancer.

Does Patient Weight, Age, or Gender Correlate With the Ability to Visualize the Distal Aorta on Bedside Aortic Ultrasounds in the Emergency Department?

INTRODUCTION

Abdominal aortic aneurysms (AAA) have a varied presentation, which often makes the diagnosis difficult. The most common location for an AAA is in the infra-renal or distal aorta, which can be difficult to visualize using bedside ultrasound.  Objective: This study was designed to identify if a patient's weight, gender, or age influenced our ability to visualize the distal aorta on bedside abdominal aortic ultrasound scans.  Methods: All aortic scans completed in the Emergency Department (ED) from September 2010 to September 2013 were retrospectively evaluated. Patients 21 years and older were included. Scans missing age, gender, or self-reported weight were excluded.  Results: 500 aortic scans were included. The distal aorta was visualized in 393 scans (78.6%). The mid aorta was visualized in 417 scans (83.4%). The proximal aorta was visualized in 454 scans (90.8%). For the distal aorta, the average weight for visualized versus not visualized was 75.7 kg versus 79.7 kg. For the proximal aorta, the average weight for visualized versus not visualized was 75.8 kg versus 84.0 kg. Weight significantly predicted the ability to visualize the proximal aorta (unadjusted p=0.0098, adjusted p=0.0095) and marginally predicted the ability to visualize the distal aorta (unadjusted p=0.071, adjusted p=0.019). Neither age (unadjusted p=0.13, adjusted p=0.052) nor gender (unadjusted p=0.74, adjusted p=0.40) was significantly associated with visualization.

CONCLUSION

There is no clinically significant difference in the ability to visualize a patient's distal aorta with bedside ultrasound based on a patient's body weight, gender, or age.

Not Like the Textbook: An Atypical Case of Ectopic Pregnancy

Ectopic pregnancy is a potentially life-threatening outcome of pregnancy that occurs with the implantation of an embryo outside of the endometrial cavity. Classically considered a “must not miss” diagnosis, ectopic pregnancy is a common emergency department presentation, associated with a symptom triad of amenorrhea, vaginal bleeding, and abdominal pain. However, varied presentations of ectopic pregnancy or lack of typical risk factors can complicate the evaluation and diagnosis of this condition. This case report describes an atypical presentation of ectopic pregnancy after a reported spontaneous abortion, in which the patient was initially discharged with a diagnosis of pelvic inflammatory disease. This case provides an illustration of ectopic pregnancy that presented without classically associated symptoms, and also highlights how anchoring bias and pre-emptive closure, among other cognitive biases, contributed to a missed diagnosis.

Gastro-intestinal emergency surgery: Evaluation of morbidity and mortality. Protocol of a prospective, multicenter study in Italy for evaluating the burden of abdominal emergency surgery in different age groups. (The GESEMM study)

Gastrointestinal emergencies (GE) are frequently encountered in emergency department (ED), and patients can present with wide-ranging symptoms. more than 3 million patients admitted to US hospitals each year for EGS diagnoses, more than the sum of all new cancer diagnoses. In addition to the complexity of the urgent surgical patient (often suffering from multiple co-morbidities), there is the unpredictability and the severity of the event. In the light of this, these patients need a rapid decision-making process that allows a correct diagnosis and an adequate and timely treatment. The primary endpoint of this Italian nationwide study is to analyze the clinicopathological findings, management strategies and short-term outcomes of gastrointestinal emergency procedures performed in patients over 18. Secondary endpoints will be to evaluate to analyze the prognostic role of existing risk-scores to define the most suitable scoring system for gastro-intestinal surgical emergency. The primary outcomes are 30-day overall postoperative morbidity and mortality rates. Secondary outcomes are 30-day postoperative morbidity and mortality rates, stratified for each procedure or cause of intervention, length of hospital stay, admission and length of stay in ICU, and place of discharge (home or rehabilitation or care facility). In conclusion, to improve the level of care that should be reserved for these patients, we aim to analyze the clinicopathological findings, management strategies and short-term outcomes of gastrointestinal emergency procedures performed in patients over 18, to analyze the prognostic role of existing risk-scores and to define new tools suitable for EGS. This process could ameliorate outcomes and avoid futile treatments. These results may potentially influence the survival of many high-risk EGS procedure.

Point-of-Care Ultrasonography as an Extension of the Physical Examination for Abdominal Pain in the Emergency Department: The Diagnosis of Small-Bowel Volvulus as a Rare Complication after Changing the Feeding Jejunostomy Tube

Point-of-care ultrasonography (POCUS) has become the most popular modality of testing for physicians in recent years and is used for improving the quality of care and increasing patient safety. However, POCUS is not always acceptable to all physicians. To address the benefits and importance of POCUS, numerous studies have examined the use of POCUS in clinical practice and even medical education. This article aims to highlight the effects of POCUS as an extension of the physical examination, and we present a case to address the reasons it should be performed. For a man experiencing abdominal pain immediately after his feeding jejunostomy tube was changed, there was high suspicion of small-bowel volvulus after a “whirlpool sign” was observed during the POCUS, whereby mesenteric vessels presented in a whirling or spiral shape. This impression was subsequently confirmed by computed tomography. Small-bowel volvulus is a rare complication of changing a feeding jejunostomy tube. The images submitted here add to the sparse evidence from the literature on the use of POCUS as an extension of the physical examination for evaluating abdominal pain. POCUS can be used after taking the patient’s history and conducting a physical examination. The observation of a whirlpool sign may indicate the presence of a volvulus that is life-threatening.