Assessment of oxygenation and comorbidities improves outcome prediction in patients with community-acquired pneumonia with a low CRB-65 score.

BACKGROUND: Addition of assessment of comorbid diseases ('D') and oxygen saturation ('S') to the CRB-65 score has been recommended to improve its accuracy for risk stratification in community-acquired pneumonia (CAP). The aim of this study was to validate the resulting DS-CRB-65 score in a large cohort of patients with CAP. METHODS: A total of 4432 patients prospectively enrolled in the CAPNETZ cohort were included in this study. Predefined end points were 28-day mortality, requirement for mechanical ventilation or vasopressors (MV/VS) and requirement for MV/VS or intensive care unit admission (MV/VS/ICU). Receiver operating characteristic curve analysis was used to determine the accuracy of the CRB-65 score and the addition of D (extra-pulmonary comorbidities) and S (oxygen saturation <90% or partial pressure of oxygen <8 kPa). Binary logistic regression and the method of Hanley and McNeil were used to compare the criteria. RESULTS: The mortality rate was 4.0%, and 4.2% of patients required MV/VS and 6.6% required MV/VS/ICU. After multivariate analysis, D and S independently were added to the CRB-65 criteria for mortality prediction, but only S improved prediction of MV/VS and MV/VS/ICU (P < 0.001 for all). The area under the curve of the CRB-65 score was significantly improved by adding D and S for all end points (P < 0.02). Amongst patients who died or required MV/VS despite a CRB-65 score of 0, 64-80% would have been identified by the DS-CRB-65 score. CONCLUSIONS: The addition of assessment of oxygenation and comorbidities significantly improved the prognostic accuracy of the CRB-65 score. Consequently, the DS-CRB-65 score may have a useful role in risk stratification algorithms for CAP.

Growth modulation index as metric of clinical benefit assessment among advanced soft tissue sarcoma patients receiving trabectedin as a salvage therapy.

BACKGROUND: The growth modulation index (GMI) is the ratio of time to progression with the nth line (TTP(n)) of therapy to the TTP(n)(-1) with the n-1th line. GMI >1.33 is considered as a sign of activity in phase II trials. PATIENTS AND METHODS: This retrospective analysis evaluated the concordance between the GMI and the efficacy outcomes in 279 patients with advanced soft tissue sarcoma (ASTS) treated with trabectedin 1.5 mg/m² (24-h infusion every 3 weeks) in four phase II trials. RESULTS: One hundred and forty-two (51%) patients received one prior line and 137 ≥ 2 lines. The median TTP(n) was 2.8 months (range 0.2-26.8), whereas the median TTP(n)(-1) was 4.0 months (0.3-79.5). The median GMI was 0.6 (0.0-14.4). Overall, 177 patients (63%) had a GMI <1; 21 (8%) a GMI equal to 1-1.33 and 81 (29%) a GMI >1.33, which correlated with the median overall survival in those patients (9.1, 13.9 and 23.8 months, respectively, P = 0.0005). A high concordance rate between the GMI and response rate (P < 0.0001) and progression-free survival (PFS, P < 0.0001) was observed. Good performance status (PS) was the only factor associated with GMI >1.33 (PS = 0; P < 0.04). CONCLUSIONS: A high GMI was associated with favorable efficacy outcomes in patients treated with trabectedin. Further research is needed to assess GMI as an indicator in this setting.

The burden of pneumococcal pneumonia - experience of the German competence network CAPNETZ.

BACKGROUND: Pneumococcal pneumonia is still an important cause of mortality. The objective of this study was to compare frequency, clinical presentation, outcome and vaccination status of patients with pneumococcal community-acquired pneumonia (CAP) to CAP due to other or no detected pathogen based on data of the German Network for community-acquired pneumonia (CAPNETZ). METHODS: Demographic, clinical and diagnostic data were recorded using standardized web-based data acquisition. Standardized microbiological sampling and work-up were conducted in each patient. RESULTS: 7400 patients with CAP from twelve clinical centers throughout Germany were included. In 2259 patients (32 %) a pathogen was identified, Streptococcus pneumonia being the most frequent (n = 676, 30 % of all patients with identified pathogens). Compared to those with non-pneumococcal pneumonia, patients with pneumococcal pneumonia were more frequently admitted to hospital (80 % vs. 66 %, p < 0.001), had higher CURB score values on admission, had more frequently pleural effusion (19 % vs. 14 %, p = 0.001) and needed more frequently oxygen insufflation (58 % vs. 44 %, p < 0.001). There was no relevant difference in overall mortality. CONCLUSIONS: Pneumococcal pneumonia was associated with a more severe clinical course demanding more medical resources as compared to non-pneumococcal pneumonia.

Is duplex venous surveillance worthwhile after arthroplasty?

Deep venous thrombosis (DVT) complicates 60% of knee and 80% of hip arthroplasties performed without prophylactic therapy. Routine postoperative duplex ultrasound surveillance has been proposed for the detection of venous thrombosis following arthroplasty. In order to determine whether surveillance represents an effective strategy to detect postoperative DVT when prophylaxis is used, surveillance duplex exams obtained after primary or revision hip or knee arthroplasty were analyzed using decision analysis techniques. DVT was suspected clinically after 95 of 738 (13%) arthroplasties, with no symptoms suggestive of DVT after the remaining 643 procedures. Surveillance duplex scans were performed within 2 weeks of 371 procedures, while no surveillance studies were performed after the remaining 272 procedures. In these asymptomatic patients only 2 (0.5%) surveillance duplex studies were positive for DVT. In contrast, 4 of 37 (11%) duplex exams and 5 of 62 (8%) contrast phlebograms performed among symptomatic patients were positive for DVT. The overall incidence of DVT after arthroplasty in the entire population was 1.4% (10/738) with no pulmonary emboli. Patient follow-up averaged 162 +/- 285 days. Using the 1995 Medicare reimbursement of $163 for venous duplex, the incremental cost was $35,000 to detect 1 additional unsuspected DVT and $110,000 per additional quality-adjusted life-year gained. The low incidence of clinically significant DVT and pulmonary emboli with current prophylaxis does not justify an aggressive screening program. Decision analysis suggests that a greater incidence of DVT is required for screening to be worthwhile.

[Practical significance of measuring high formant spectra in phoniatric voice assessment]. / Zur praktischen Bedeutung der Messung hoher Formantpegel bei der phoniatrischen Stimmbeurteilung.

The measurement of sound energy in the spectral region between 2 and 5 kHz provides additional information to the auditive assessment of voice quality. It can be applied to healthy an sick voices, e. g. in tracing the therapeutic course. Devices for measuring voice range profiles with the possibility of evaluating the high formant region are especially useful and valuable. But, nonetheless, simultaneous auditive assessment is crucial to avoid misinterpretation. Calculation of the quotient of the sound pressure level in the region between 2 and 5 kHz by the total sound pressure level allows to determine vocal sound characteristics and changes of the sound. Pre- and postoperative sound spectra obtained from the voices of patients with diseases of the vocal folds illustrate the improvement of the harmonic structure and the decrease of noise components. The measurement of the high formant intensity has proven to be appropriate for the registration of the voice quality before and after therapy in 130 cases. Although the value of these measurements is highly validated in the phoniatric practice, extensive studies and, especially, expert discussions are still needed. The authors come to terms with opinions that question the validity of the described methods.

CT assessment of resectability prior to transhiatal esophagectomy for esophageal/gastroesophageal junction carcinoma.

The ability of preoperative CT to assess resectability and to stage carcinoma of the esophagus and gastroesophageal junction was studied in 71 patients who underwent transhiatal esophagectomy. Patients with preoperatively proven distant metastases who did not have surgery were not included in the present study. At surgery the tumor invaded adjacent mediastinal or abdominal structures in 18 patients (prevalence 25%), but was nonresectable in only 7 of these 18 patients (39%). Invasions of the tracheobronchial tree, the aorta, and the diaphragm were correctly detected on CT in 5 of 6, 1 of 2, and 2 of 10 patients. There were four false-positive results on CT; tracheobronchial invasion and pericardial invasion were incorrectly predicted in one and three patients, respectively. Invasion of adjacent structures was correctly assessed on CT in 58 (82%) patients and the depth of tumor invasion was correctly determined in 49 (69%) patients. Computed tomography correctly staged 57% of patients according to the classification of the American Joint Committee on Cancer. Understaging (31%) occurred more often than overstaging (11%). In the present study, computed tomography was not effective in assessing non-resectability by diagnosing invasion because of the relatively low prevalence of invasion of adjacent structures and the fact that invasion was often not associated with nonresectability. In assessing invasion itself, CT was accurate in diagnosing tracheobronchial involvement, but was limited in diagnosing invasion of other adjacent structures. In assessing stage grouping, CT was limited in detecting either diaphragmatic invasion or lymph node involvement.

Improved assessment of supraclavicular and abdominal metastases in oesophageal and gastro-oesophageal junction carcinoma with the combination of ultrasound and computed tomography.

The purpose of the study was to evaluate ultrasound and computed tomography in the assessment of distant metastases, supraclavicular and abdominal, in 113 patients with carcinoma of the oesophagus and gastrooesophageal junction. Ultrasound and computed tomographic findings were compared with the cytological data in 29 patients and with the surgical data in 84 patients. In assessing distant metastases, ultrasound and computed tomography had a sensitivity of 61% and 70%, and a specificity of 93% and 85%, respectively (p = 1.0). When ultrasound and computed tomography were combined the sensitivity increased to 83% and the specificity decreased to 81%. There was no significant difference in the assessment of supraclavicular metastases (p = 0.8), coeliac metastases (p = 1.0) or liver and other non-lymphatic abdominal metastases (p = 1.0) on ultrasound or computed tomography. The results show that both ultrasound and computed tomography should be used for assessment of distant metastases and abnormalities confirmed by image-guided biopsy.

Assessment of distant metastases with ultrasound-guided fine-needle aspiration biopsy and cytologic study in carcinoma of the esophagus and gastroesophageal junction.

The use of ultrasound (US)-guided fine-needle aspiration biopsy (FNAB) for the assessment of distant metastases was prospectively studied in 135 consecutive patients with carcinoma of the esophagus and gastroesophageal junction. Patients with accessible lesions on US and computed tomographic (CT) studies of the supraclavicular regions and the abdomen underwent US-guided FNAB. In patients with multiple lesions biopsies were preferentially performed on enlarged supraclavicular nodes. Forty-nine patients underwent US-guided FNABs of 53 lesions. A cytologic diagnosis was established in 46 of 53 (87%) biopsies. Seven of 53 (13%) biopsies were nondiagnostic. Distant metastases were diagnosed by means of cytologic study in 33 of 135 (24%) patients. Supraclavicular metastases were diagnosed in 22 patients and abdominal metastases were diagnosed in 12 patients, including one patient who also had supraclavicular metastases. US-guided FNAB can improve the selection of patients for surgical and nonsurgical treatment by diagnosing distant metastases in an important number of patients.

Benign lesions of the vocal folds: uniformity in assessment of clinical diagnosis.

The names given to a number of benign lesions of the vocal folds are not well standardized and lead to difficulties in comparing treatment. In the present study photographs of benign lesions of the larynx were presented to groups of clinicians together with a questionnaire, and the answers analysed. The results show great variation between clinicians in interpretation and naming of these lesions. Definitions are suggested for different benign conditions in order to standardize the nomenclature.

Bone scintigraphy in oncology: an update with emphasis on efficacy and cost-effectiveness.

Bone scintigraphy has been helpful to oncologists in the initial evaluation and diagnostic follow-up of patients with primary and secondary neoplasms. This review discusses this way of bone imaging with respect to the choice of the bone seeking radiopharmaceutical and puts emphasis on its diagnostic yield and cost-effectiveness in various malignant diseases.