EUH Morning Report: What is the reliability of the physical examination of the chest and accuracy of findings for diagnosing pleural effusion?

The Bottom Line: The interobserver reliability of the physical examination of the chest in patients with respiratory conditions has been found to be relatively low (Metlay). But the physical examination can be used to gain diagnostic certainty with pulmonary effusion, specifically the findings of dullness to percussion and asymmetric chest expansion, and confirmed with a chest radiograph (Wong).

“The calculated interobserver reliability among the physicians for several chest signs…  presented in the form of both mean pair observer agreement rates and κ values, which account for rates of chance agreement ranging from 0, when agreement is no better than chance, to 1, when there is perfect agreement. In fact, 2 of the most reliable findings, dullness to percussion and wheezes on auscultation, had only fair to good κ values of 0.52 and 0.51, corresponding to agreement rates of 77% and 79%, respectively. Crackles had a κ value of 0.41 (agreement rate of 72%), and several findings such as whispered pectoriloquy and increased tactile fremitus had κ values indicating poor agreement (range, 0.01-0.11), in part explained by the rarity of these findings overall.” (Matley)

(Matley)

“Of the 8 physical examination maneuvers, the presence of dullness to conventional percussion (summary positive LR, 8.7; 95% CI, 2.2-34) and asymmetric chest expansion (positive LR, 8.1; 95% CI, 5.2-13) were most accurate in diagnosing pleural effusion. The diagnostic OR of the 2 studies that compared conventional percussion (summary diagnostic OR, 34; 95% CI, 16-72) with auscultatory percussion (summary diagnostic OR, 8.1; 95% CI, 4.7-14.0) favored conventional percussion. The extremely low negative LR for auscultatory percussion popularized by Guarino (negative LR, 0.05; 95% CI, 0.02-0.11) has not been replicated in other studies (negative LR range, 0.50-1.0).” (Wong)

Midtown Morning Report: What is the differential for foot drop?

The Bottom Line:     Differential Diagnosis of foot drop

• Upper motor neuron involvement – CVA can cause weakness of the whole extremity. Due to spasticity, the limb is artificially long. To ambulate, the person rotates the leg in a semicircular fashion, also referred to as circumduction. Dysphagia, aphasia, or upper limb weakness are also evident.
• Cerebellar gait – The cerebellum is responsible for the smoothness and balance of gait. Cerebellar gait deficits are seen as ataxia and failure to walk in tandem.
• Ataxic gait – Presentation is bilateral. Due to the involvement of long tracks of the spinal cord, position and vibration senses are lost. This leads to high steppage and side to side sway, as can be seen in alcohol use disorder.
• Severe L5 lumbar radiculopathy
• Parkinsonian gait – Involvement of substantia nigra causes failure of the smooth transition of the gait cycle leading to initiation problems coupled with short and fast steps called festinate gait.
• Lumbar plexus involvement such as autoimmune, compressive-tumor,
• Diabetic amyotrophy
• Conversion reaction, somatization disorder, and malingering should be considered if the workup is unremarkable, and there is potential for substantial secondary gain, depression, anxiety, or other suspected psychological issues. (Nori)

Carolus

EUH Morning Report: Review of Mitochondrial Diseases

The Bottom Line: “Most diagnostic algorithms [for mitochondrial diseases] recommend evaluation of selected mitochondrial biomarkers in blood, urine, and spinal fluid. These typically include measurements of lactate and pyruvate in plasma and cerebrospinal fluid (CSF), plasma, urine, and CSF amino acids, plasma acylcarnitines, and urine organic acids.” (Parikh)

“The key to any successful diagnostic algorithm for mitochondrial diseases is astute clinical observation and awareness. The recognition of mitochondrial disease syndromes or specific clinical features can permit targeted genetic analysis, which enables the rapid diagnosis of patients and family members. For example, cardiomyopathy and cataracts are frequently associated with AGK mutations (Sengers syndrome). Equally, detailed clinical and laboratory tests are vital for the accurate interpretation of new genetic mutations that are identified through next generation sequencing technologies. The diagnostic algorithm is heavily influenced by the age of the patient, and the presence of consanguinity and common genetic founder mutations in certain parts of the world.” (Gorman)

(Gorman)

EUH Morning Report: What are the diagnostic accuracy of the Kernig and Brudzinski sings for diagnosing adult meningitis? Part 2

The Bottom Line: “In the broad spectrum of adults with suspected meningitis, 3 classic meningeal signs did not have diagnostic value; better bedside diagnostic signs are needed.” (Thomas)

See Part 1 on the Kernig and Brudzinski signs: https://emorymedicine.wordpress.com/2024/03/14/euh-morning-report-what-are-the-sensitivity-and-specificity-of-the-kernig-and-brudzinski-sings-for-diagnosing-adult-meningitis/

Thomas et. al’s prospective study found that “the 3 classic meningeal signs—Kernig’s sign, Brudzinski’s sign, and nuchal rigidity—were of limited clinical diagnostic value for adults with suspected meningitis. None of these meningeal signs were able to accurately discriminate patients with meningitis (⩾6 WBCs/mL of CSF) from those without it. Furthermore, no significant correlation existed between these meningeal signs and moderate meningeal inflammation (⩾100 WBCs/mL of CSF) or between these meningeal signs and microbiological evidence of CSF infection. Only for the 4 patients with severe meningeal inflammation (⩾1000 WBCs/mL of CSF) did nuchal rigidity have 100% sensitivity, 100% negative predictive value, and LR+ : LR- that approached infinity.” (Thomas)

“The sensitivity of both Kernig’s sign and Brudzinski’s sign was 5%, which suggests that these bedside diagnostic tools did not reliably identify the need for lumbar puncture among patients with meningitis. Although the specificity of both signs was 95%, the high specificity values were a result of the overall paucity of positive results of examination for Kernig’s sign and Brudzinski’s sign, rather than a reflection of the discriminating ability of these indicators. The positive and negative predictive values for Kernig’s sign (27% and 72%, respectively), Brudzinski’s sign (27% and 72%, respectively), and nuchal rigidity (26% and 73%, respectively) also indicate that none of the classic meningeal signs were clinically discriminating indicators of the presence or absence of meningitis” (Thomas)

(Thomas)

EUH Morning Report: What are the important clinical features for diagnosing the different types of inflammatory myopathies?

The Bottom Line: “Idiopathic inflammatory myopathy (IIM) includes dermatomyositis (DM), polymyositis (PM), overlap myositis (OM), sporadic inclusion body myositis (IBM) and necrotising autoimmune myopathy (NAM), also known as immune-mediated necrotising myopathy. DM, OM and NAM all present similarly, with proximal weakness and elevated creatine kinase (CK) level. By contrast, IBM preferentially involves the long finger flexors and quadriceps, and presents with a normal or only mildly elevated CK. Developments in serological testing and imaging are shifting the diagnostic paradigm away from a reliance on histopathology.” (Ashton)

“There is some debate as to whether PM exists as a discrete entity, or is an ill-defined condition encompassing connective tissue disease (CTD) associated myositis, or OM, and the previously poorly recognised NAM” (Ashton)

(Greenberg & Amato)

“Epidemiologic studies suggest that the incidence of IM grouped together is >4 cases per 100,000 with prevalence in the range of 14–32 per 100,000. Defining the actual incidence and prevalence of the individual myositides is limited, however, by the different diagnostic criteria employed in various epidemiologic studies, increasing recognition of AS, and frequent misdiagnosis of IBM and IMNM. Idiopathic PM without signs of an overlap syndrome is quite rare, while DM, IBM, and IMNM occur in roughly similar frequencies. DM can occur in children (juvenile DM), while IBM always occurs in adults and is the most common cause of myopathy in those aged >50. DM, PM, and AS are more common in women, while IBM is more common in men.” (Greenberg & Amato)

EUH Morning Report: What are the ECG changes in hypokalemia?

The Bottom Line: “Although the ECG findings are more subtle in the case of hypokalemia compared to hyperkalemia, it is important that clinicians are alert to these. ECG changes in hypokalemia include increased amplitude of P-waves, prolonged PR interval, prolonged QT-interval, ST-segment depression and appearance of pathologic U-waves or bifid T-waves. The understanding of ECG changes in electrolyte disturbances is important both in the diagnosis and implementation of timely and appropriate treatment to these patients.” (Khan)

Khan

EUH Morning Report: What are the diagnostic criteria and treatment for thyroid storm?

The Bottom Line: “Thyroid storm is diagnosed as a combination of thyroid function studies showing low to undetectable thyroid stimulating hormone (TSH) (<0.01mU/L) with elevated free thyroxine (T4) and/or triiodothyronine (T3), positive thyroid receptor antibody (TRab) (if Graves’ disease is the underlying etiology), and with clinical signs and symptoms of end organ damage. Treatment involves bridging to a euthyroid state prior to total thyroidectomy or radioactive iodine ablation to limit surgical complications such as excessive bleeding from highly vascular hyperthyroid tissue or exacerbation of thyrotoxicosis.” (De Almeida)

“The diagnosis of thyroid storm should be made clinically in a severely thyrotoxic patient with evidence of systemic decompensation. Adjunctive use of a sensitive diagnostic system should be considered. Patients with a Burch– Wartofsky Point Scale (BWPS) of ‡45 or Japanese Thyroid Association ( JTA) categories of thyroid storm 1 (TS1) or thyroid storm 2 (TS2) with evidence of systemic decompensation require aggressive therapy. The decision to use aggressive therapy in patients with a BWPS of 25–44 should be based on clinical judgment.” (Ross)

(Ross)

EUH Morning Report: Should physicians consider patients in or formerly in the military with occupational exposure to radar higher risk for hemolymphatic cancers?

The Bottom Line: Though there is a possible connection supported by some case reports and a few retrospective cohort studies, a definitive causation of military occupational exposure to radar with hemolymphatic and other cancers has not been established. However, physicians can still consider hemolymphatic cancer in their differential diagnosis if they know their patient has had occupational exposure to radar.

In their retrospective cohort study of a previously published case series of 47 patients diagnosed with cancer following years of occupational exposure to radiofrequency radiation (RFR), Peleg (2018) found “the consistent association of RFR and highly elevated HL cancer risk in the four groups spread over three countries, operating different RFR equipment types and analyzed by different research protocols, suggests a cause-effect relationship between RFR and HL cancers in military/occupational settings.”

In 2023, Peleg et. al published a second study analyzing data from a new case series of 46 patients diagnosed with cancer that had exposure to radar in a military setting and comparing them with similar groups from other studies, finding “a consistent, statistically significant, and well-documented atypically high HL PF, distinctly higher than expected in the community (Cancer Registry) or computed from unexposed comparison groups.”

(Peleg)

EUH Morning Report: What are the Helpful Clinical Findings from the Physical Examination for Detecting Heart Failure?

The Bottom Line: “Patients with symptoms of heart failure and those with risk factors should be examined for pulmonary rales, jugular venous distention, a third heart sound, and peripheral edema and should have an ECG and chest radiograph” (Badgett)

“Very helpful findings [for detection of heart failure] are radiographic redistribution and jugular venous distention. These findings, when used alone, only help when they are abnormal and so can confirm the presence of increased filling pressure in patients with known severe systolic dysfunction. Among patients referred for consideration of cardiac transplant with a high (73%) prevalence of increased filling pressure, radiographic redistribution indicates an 80% to 90% probability and jugular venous distention, an85% to 100% probability of increased filling pressure. The absence of either finding cannot rule out increased filling pressure. In patients with lesser probabilities of increased filling pressure, such as those without known severe systolic dysfunction, isolated findings may not be useful. Somewhat helpful findings include dyspnea and abnormal vital signs. Radiographic cardiomegaly is somewhat helpful but loses its specificity after the initial detection of increased filling pressure because it can be a permanent finding and not fluctuate with changes in filling pressure. Dependent edema is helpful only when present. Edema is highly specific for increased filling pressure, although it has poor sensitivity.” (Badgett)

(Badgett)

“Patients with heart failure can have decreased exercise tolerance with dyspnea, fatigue, generalized weakness, and fluid retention, with peripheral or abdominal swelling and possibly orthopnea. Patient history and physical examination are useful to evaluate for alternative or reversible causes. Nearly all patients with heart failure have dyspnea on exertion. However, heart failure accounts for only 30 percent of the causes of dyspnea in the primary care setting. The absence of dyspnea on exertion only slightly decreases the probability of systolic heart failure, and the presence of orthopnea or paroxysmal nocturnal dyspnea has a small effect in increasing the probability of heart failure (positive likelihood ratio [LR+] = 2.2 and 2.6).” (King)

Midtown Morning Report: What are the indications for lung cancer biopsy?

The Bottom Line:

“The National Comprehensive Cancer Network (NCCN), the American College of Chest Physicians (ACCP, and the American Society of Clinical Oncology (ASCO)) have created guidelines for the diagnosis and treatment of lung cancer. They advise the following recommendations:

• Patients with a strong clinical suspicion of stage 1 or 2 lung cancer (based on risk factors and radiologic appearance) do not require a biopsy before surgery. A biopsy adds time, costs, and procedural risk and may not be needed for treatment decisions. 
• A preoperative biopsy may be appropriate if a non-lung cancer diagnosis is strongly suspected that can be diagnosed by core biopsy or fine needle aspiration.
• A preoperative biopsy may be appropriate if an intraoperative diagnosis appears difficult or very risky. If a preoperative tissue diagnosis has not been obtained, then an intraoperative diagnosis (ie, wedge resection, needle biopsy) is necessary before lobectomy or pneumonectomy.
• Invasive mediastinal imaging is recommended before surgical resection for most patients with clinical stage 1 or 2 lung cancer.
• The preferred diagnostic strategy for an individual patient depends on the size and location of the tumor, the presence of mediastinal or distant disease, patient characteristics (such as pulmonary pathology and/or other significant comorbidities), and local experience and expertise.
• The least invasive biopsy with the highest yield is preferred as the first diagnostic study.
• Anatomic pulmonary resection is preferred for the majority of patients with NSCLC.
• Patients suspected of having the metastatic disease should have confirmation from one of the metastatic sites if feasible but should have a biopsy of the primary lung lesion or mediastinal lymph nodes if it is technically difficult or very risky to biopsy a metastatic site.
• Patients with metastatic disease should have the histologic subtype established with adequate tissue for molecular testing (including consideration for re-biopsy or plasma biopsy) to enable the best guidance for chemotherapy options.
• Decisions about the optimal diagnostic steps for suspected stage 1 to 3 lung cancer should be made by thoracic radiologists, interventional radiologists, interventional pulmonologists, and thoracic surgeons who devote a significant portion of their practice to thoracic oncology.
• A joint decision among a radiologist, a pulmonologist, and a medical or radiation oncologist is the desirable approach.
• In patients suspected of having small cell lung cancer (SCLC) based on radiographic and clinical findings, it is recommended that a pathologic diagnosis be confirmed by the least invasive method (sputum cytology, thoracentesis, fine needle aspiration (FNA), or transbronchial aspiration, as dictated by the patient’s presentation (Grade 1C).
• In patients suspected of having lung cancer who have a solitary extrathoracic site suspicious of metastasis, it is recommended that tissue confirmation of the metastatic site be obtained if an FNA or biopsy of the site is feasible (Grade 1C).
• In patients suspected of having lung cancer who have lesions in multiple distant sites suspected of metastases but in whom biopsy of a metastatic site would be technically difficult, it is recommended that diagnosis of the primary lung lesion be obtained by the least invasive method (Grade 1C).
• In patients suspected of having lung cancer with a peripheral lung nodule, when tissue diagnosis is required due to the uncertainty of diagnosis or poor surgical candidacy, radial EBUS is recommended as an adjunct imaging modality (Grade 1C). If radial EBUS is thought to be unlikely to achieve a diagnosis, then electromagnetic navigation guidance is recommended if the equipment and the expertise are available (Grade 1C). Remark: If electromagnetic navigation is not available, then percutaneous lung lesion biopsy is recommended.
• If specimens obtained initially are not adequate for histologic and molecular characterization, then pursuing a second biopsy is acceptable, given the importance of accurate tumor characterization.
• In the case of a small (less than 3 cm), solitary, peripheral lung lesion that is suspicious for lung cancer in a patient who appears to have early-stage disease and is a surgical candidate, the diagnostic dilemma generally centers around whether it is necessary to obtain a biopsy specimen to confirm the diagnosis of cancer before surgical resection is carried out. When the lesion is moderate to highly suspicious for lung cancer, surgical excision performed via thoracoscopy is the most definitive method of establishing a diagnosis and determining treatment. In nodules with an indeterminate likelihood of malignancy, sampling via percutaneous lung lesion biopsy or bronchoscopy with or without guidance technology (radial EBUS or electromagnetic navigation) may be considered.” (Young)

Young