Prediction model for pneumonia in primary care patients with an acute respiratory tract infection: role of symptoms, signs, and biomarkers.

BACKGROUND: Diagnosing pneumonia can be challenging in general practice but is essential to distinguish from other respiratory tract infections because of treatment choice and outcome prediction. We determined predictive signs, symptoms and biomarkers for the presence of pneumonia in patients with acute respiratory tract infection in primary care. METHODS: From March 2012 until May 2016 we did a prospective observational cohort study in three radiology departments in the Leiden-The Hague area, The Netherlands. From adult patients we collected clinical characteristics and biomarkers, chest X ray results and outcome. To assess the predictive value of C-reactive protein (CRP), procalcitonin and midregional pro-adrenomedullin for pneumonia, univariate and multivariate binary logistic regression were used to determine risk factors and to develop a prediction model. RESULTS: Two hundred forty-nine patients were included of whom 30 (12%) displayed a consolidation on chest X ray. Absence of runny nose and whether or not a patient felt ill were independent predictors for pneumonia. CRP predicts pneumonia better than the other biomarkers but adding CRP to the clinical model did not improve classification (- 4%); however, CRP helped guidance of the decision which patients should be given antibiotics. CONCLUSIONS: Adding CRP measurements to a clinical model in selected patients with an acute respiratory infection does not improve prediction of pneumonia, but does help in giving guidance on which patients to treat with antibiotics. Our findings put the use of biomarkers and chest X ray in diagnosing pneumonia and for treatment decisions into some perspective for general practitioners.

[A patient with hypoaesthesia of the mandible]. / Een patiënt met hypesthesie in de mandibula.

In a patient with hypoaesthesia of the central region of the mandible, no oral cause could be found which could explain his complaint. Further examination by a neurologist and a specialist in internal medicine revealed the numb chin syndrome. The syndrome was caused by meningeal localisation of a high-grade B-cell lymphoma stade IV. After intensive chemotherapy and radiotherapy of the skull, the complaints disappeared.

Predicting the need for radiologic imaging in adults with febrile urinary tract infection.

BACKGROUND: Radiologic evaluation of adults with febrile urinary tract infection (UTI) is frequently performed to exclude urological disorders. This study aims to develop a clinical rule predicting need for radiologic imaging. METHODS: We conducted a prospective, observational study including consecutive adults with febrile UTI at 8 emergency departments (EDs) in the Netherlands. Outcomes of ultrasounds and computed tomographs of the urinary tract were classified as "urgent urological disorder" (pyonephrosis or abscess), "nonurgent urologic disorder," "normal," and "incidental nonurological findings." Urgent and nonurgent urologic disorders were classified as "clinically relevant radiologic findings." The data of 5 EDs were used as the derivation cohort, and 3 EDs served as the validation cohort. RESULTS: Three hundred forty-six patients were included in the derivation cohort. Radiologic imaging was performed for 245 patients (71%). A prediction rule was derived, being the presence of a history of urolithiasis, a urine pH ≥7.0, and/or renal insufficiency (estimated glomerular filtration rate, ≤40 mL/min/1.73 m(3)). This rule predicts clinically relevant radiologic findings with a negative predictive value (NPV) of 93% and positive predictive value (PPV) of 24% and urgent urological disorders with an NPV of 99% and a PPV of 10%. In the validation cohort (n = 131), the NPV and PPV for clinically relevant radiologic findings were 89% and 20%, respectively; for urgent urological disorders, the values were 100% and 11%, respectively. Potential reduction of radiologic imaging by implementing the prediction rule was 40%. CONCLUSIONS: Radiologic imaging can selectively be applied in adults with febrile UTI without loss of clinically relevant information by using a simple clinical prediction rule.

[Guideline 'Precautionary measures for contrast media containing iodine']. / Richtlijn 'Voorzorgsmaatregelen bij jodiumhoudende contrastmiddelen'.

Annually, 0.5-1 million injections of contrast media containing iodine are administered in the Netherlands. Almost all contrast media nowadays are low-osmolar and nonionic. Nevertheless, the development ofcontrast-induced nephropathy is still a relevant clinical problem. Through an initiative by the Radiological Society of the Netherlands and with aid of the Dutch Institute for Healthcare Improvement (CBO), a guideline was conceived for the intravascular use of iodine-containing contrast media, based on recent scientific literature. The guideline defines the risk factors for contrast-induced nephropathy. One of the major risk factors is an impaired renal function. It is important to measure the glomerular filtration rate (GFR) in patients with a possible impaired kidney function, preferably by using the 'Modification of diet in renal disease' (MDRD)-study formula. The key measures for avoidance of contrast nephropathy are: limiting the amount of contrast agent used and to assure good hydration, by infusion of sodium chloride 0.9% 12-16 ml/kg body weight, both prior to and after contrast infusion. If time is limited, intravenous administration of sodium bicarbonate is an option. The guideline recommends discontinuation of metformin use from the day of contrast injection, if the GFR < 60 ml/min/1.73 m2, and to restart metformin 2 days following contrast infusion providing the GFR has not significantly deteriorated. Only in the case of previous moderate or severe adverse reactions to contrast media, prophylaxis with corticosteroids and antihistamines is recommended. Iodine allergy or an atopic condition is not a contraindication for the use of iodine-containing contrast media, and no prophylaxis is required. No specific measures are indicated in case of hyperthyroidism, acute pancreatitis, or phaeochromocytoma. Injection of contrast media is not contraindicated in case of pregnancy or lactation.

An uncommon cause of stroke in young adults.

We describe a previously healthy 48-year-old man who presented with clinical characteristics suggestive of internal carotid artery dissection, confirmed by magnetic resonance imaging. He developed a massive infarction of the left cerebral hemisphere and died after 3 days of transtentorial herniation. Post-mortem examination identified a dissection of the thoracic aorta caused by Erdheim-Gsell cystic medionecrosis, with the characteristic degeneration of the elastic fibers of the lamina media. The dissection showed an unusually large extension not only distally into both iliac arteries, but also proximally into both carotid arteries. To our knowledge, such an extensive dissection has not been described previously. Underlying vessel wall disorders of the aorta, such as Erdheim Gsell cystic medionecrosis, should be considered in young patients with spontaneous arterial dissection.

Assessment of the progression of emphysema by quantitative analysis of spirometrically gated computed tomography images.

RATIONALE AND OBJECTIVES: The authors assessed the progression of pulmonary emphysema by means of quantitative analysis of computed tomography images. METHODS: Twenty-three patients suffering from emphysema due to an alpha 1-antitrypsin deficiency, aged 45 +/- 7 years and exsmokers, were scanned twice with a 1-year time interval. At 90% of the vital lung capacity, slices with a thickness of 1.5 mm were acquired at the level of the carina and 5 cm above the carina; slices with a thickness of 1 cm were acquired 5 cm below the carina. The entire lung was scanned spirally at a respiratory status, corresponding with 75% of the total lung capacity at baseline. The mean lung densities (MLD) were calculated in an objective manner with new analytic software featuring automated detection of the lung contours. RESULTS: Mean lung densities decreased by 14.2 +/- 12.0 Hounsfield units (HU; P < 0.001) above the carina, by 18.1 +/- 14.4 HU (P < 0.001) at the carina level, by 23.6 +/- 15.0 HU (P < 0.001) below the carina, and by 12.8 +/- 22.2 HU (P < 0.01) for the entire lung. The decrease in MLD was most obvious in the lower lung lobes. For the same patient group, the annual decrease in the forced expiratory volume (FEV1) and the carbon monoxide-diffusion were 120 +/- 190 mL (P < 0.01) and 10 +/- 70 mmol/kg/minute ( P < 0.2), respectively. No significant correlation was found between the decrease in MLD and the decrease in FEV1. CONCLUSIONS: Progression of emphysema can be assessed in an objective manner based on the mean lung density (MLD), measured from computed tomography volume scans as well as from single-slice scans. Mean lung density has proved to be more sensitive than FEV1 and carbon monoxide-diffusion.

Quantitative analysis of computed tomography scans of the lungs for the diagnosis of pulmonary emphysema. A validation study of a semiautomated contour detection technique.

RATIONALE AND OBJECTIVES: To develop an analytic software package based on automated contour detection for the objective and reproducible assessment of emphysema from computed tomography (CT) scans. METHODS: A semiautomated technique was developed for the definition of lung contours in CT cross-sections followed by the assessment of pulmonary CT parameters describing the disease state. For 78 images, the semiautomated contour detection was performed and compared with contours drawn by an experienced radiologist by calculating the systematic area difference (bias) and differences in pulmonary CT parameters such as the mean lung density (MLD). In addition, intraobserver and interobserver variabilities were determined in a subset of 15 images. RESULTS: The areas enclosed by the semiautomatically detected contours were slightly larger than the manual ones (bias < 2.1%). The biases in the observer studies were smaller in the semiautomated versus the manual case (0.3% vs. 1.3%). The standard deviation of the MLD differences with a manual analysis was larger by a factor of five than in the semiautomated case. On average, manual analysis required 2 minutes, 18 seconds per lung; this time was reduced to 11.5 to 29 seconds with the semiautomated approach, depending on the respiration state. CONCLUSIONS: The semiautomated approach is preferred over the manual approach because of its higher consistency and its shorter analysis time.

Optimization of chest films of equalization radiography (advanced multiple beam equalization radiography). Comparison by means of a receiver operating characteristic study of simulated nodular interstitial disease.

RATIONALE AND OBJECTIVE: To optimize screen-film combinations for equalization radiography (advanced multiple beam equalization radiography [AMBER]), five different film-screen-technique combinations were compared by receiver operating characteristics study of simulated interstitial disease. MATERIALS AND METHODS: The Ortho C-Lanex Regular and the Insight Thoracic Imaging HC system were compared in conventional nonequalized technique; T-Mat G-Lanex Regular and T-Max L-Lanex Regular were compared in conventional, nonequalized, and AMBER technique; and an experimental high-contrast, low-noise, near-zero crossover film-screen combination was compared in AMBER technique. Interstitial disease was simulated by superimposing birdseed on the back of a humanoid phantom. Twenty-five posterior-anterior radiographs were made with each technique. Seven observers scored the presence of interstitial disease in each of the quadrants on a 5-point scale following receiver operating characteristic methodology. RESULTS: The highest performance was found with the experimental film-screen-AMBER combination (Az = 0.92) and the lowest with the T-Mat L-Lanex Regular-AMBER combination (Az = 0.83) and the Insight Thoracic Imaging HC system-conventional combination (Az = 0.85). T-Mat L-Lanex Regular-conventional ranked second (Az = 0.90) while T-Mat G-Lanex Regular-conventional (Az = 0.89), T-Mat L-Lanex Regular-AMBER (Az = 0.88) and Ortho-C-Lanex Regular-conventional (Az = 0.87) scored lower. CONCLUSION: Higher contrast films in AMBER improve diagnostic performance, whereas a loss of information is found if the AMBER system is combined with lower contrast films.

Plasma secretory leukocyte protease inhibitor in febrile patients.

OBJECTIVES: Secretory leukocyte protease inhibitor (SLPI) forms an integral part of the lung's defence, by its antimicrobial activity and by its ability to neutralize serine proteases that are released by granulocytes into the inflammatory exudate. Here, we investigate in febrile patients admitted to hospital whether plasma SLPI can serve as a marker of lung infection. METHODS: We prospectively determined the SLPI concentration in 152 febrile patients (median 73 [inter-quantile range (IQR): 58-82] year; 50% male) admitted to hospital because of infection of the airways (n = 44) or pneumonia (n = 108; i.e. consolidation on chest X-ray), and in 48 febrile patients (78 [IQR: 71-85] year; 52% male) admitted because of pyelonephritis, as well as afebrile age-matched controls (n = 38). In addition, erythrocyte sedimentation rate (ESR), peripheral blood leukocytes, plasma TNFalpha and IL-10, and parameters of the APACHE-II score were determined on admission. RESULTS: In febrile patients, SLPI was significantly increased (P < 0.001) compared with afebrile controls (63 [IQR: 50-76] ng/mL): plasma SLPI (113 [IQR: 83-176] ng/mL) was highest (P < 0.005) in patients with pneumonia compared with other groups (88 [IQR: 70-118] ng/mL). Only in patients with pneumonia, bacteremia significantly increased (P < 0.01) SLPI concentrations. Using a radiological classification of pulmonary infiltrates based on their size, it was found that plasma SLPI was proportional to the extent of lung tissue involved: the median concentration increased from 95 [IQR: 74-139] ng/mL in unilateral segmental consolidation up to 271 [IQR: 180-460] ng/mL in bilateral lobar consolidations. In a multivariate analysis, the association between SLPI and extent of consolidation was about two-fold stronger than, and independent of, the association between SLPI and erythrocyte sedimentation rate, TNFalpha, and parameters of the composite APACHE-II score, such as heart rate and blood pressure, that reflect severity of illness. CONCLUSION: SLPI is an indicator of the presence and extent of pneumonia in febrile patients admitted to hospital. In patients with an infection with its primary source located outside the lung, plasma SLPI likely reflects the mucosal response to circulating inflammatory mediators reflecting severity of illness.

Patient and staff radiation dose in fluoroscopy-guided TIPS procedures and dose reduction, using dedicated fluoroscopy exposure settings.

Fluoroscopy guided interventions, such as transjugular intrahepatic portosystemic shunt (TIPS) procedures, can results in relatively high radiation doses to patients and staff. The purpose of this study was to evaluate the possible benefit of dedicated fluoroscopy exposure factors in the reduction of doses. Doses to patients and staff were measured during fluoroscopy-guided TIPS procedures in two Dutch university hospitals. Patient doses were calculated from dose-area product (DAP) measurements, entrance beam dimensions and DAP conversion factors. Staff doses were measured outside lead aprons using electronic personal dosemeters. Average patient entrance skin dose (ESD) rate during fluoroscopy was 49 mGy min-1 (13 cases, average fluoroscopy duration 32 min) in one hospital, and 6 mGy min-1 (10 cases, average fluoroscopy duration 50 min) in the other. Estimated staff effective dose per procedure was 28 microSv average in the first hospital compared with 4 microSv average in the other. The use of dedicated fluoroscopy exposure factors, with a relatively high tube voltage and lower tube current resulted in a significant dose reduction for patient and staff in this type of radiological intervention.

Visualization of basal pleural space and lung with advanced multiple beam equalization radiography (AMBER).

During clinical use of AMBER (Advanced Multiple Beam Equalization Radiography) it was frequently felt that the basal lung and pleural space were better appreciated than with standard chest radiography. We aimed to quantify the amount of additional relevant anatomy seen in this part region and to review the normal radiographic anatomy. Four hundred patients without known chest disease were evaluated. Two groups of 200 patients (50% female) were studied with either AMBER or standard chest radiography (140 kVp, 180 cm FFD, Kodak Tmat G film, Lanex regular screen; for both techniques). Visualization of the pleural sinuses (in percent of the transverse thoracic diameter) and the basal pulmonary vessels (4-point scale) was evaluated by a panel of 3 radiologists. The shape of the sinus was traced if sufficiently visible and subjectively evaluated. A significantly (P < 0.05) larger segment of the dorsal (41 +/- 34%) and ventral (14 +/- 15%) sinuses was seen with the AMBER technique than with the standard technique (16 +/- 21% and 9 +/- 11%, respectively). Vessel visibility was also significantly (P < 0.001) better with AMBER (3.2 +/- 0.6) than with the standard technique (1.9 +/- 0.6). The dorsal sinus showed alternatively a curved or pointed configuration.

Facial thermography in the diagnosis of cerebrovascular disease and in evaluation of carotid endarterectomy.

Some 60% of strokes are due to extracranial occlusive arterial lesions, most frequently at the bifurcation of the common carotid artery. Since these lesions are accessible to endarterectomy, their prestroke diagnosis is very important. Facial thermography quickly supplies reliqble information on the circulatory area in which these lesions occur, and this information can be atraumatically obtained in an out-patient setting. The success rate of facial thermography versus aortic arch angiography was 83% and 80%, respectively, in our case material, and this rate corresponds with data in the literature. In a series of 23 patients with facial thermograms and angiograms obtained before and after endarterectomy, facial thermography proved to be a useful diagnostic and prognostic aid in neurological out-patient guidance after carotid endarterectomy. By virtue of its rapidity and atraumatic character, because it can be carried out by technicians and because the findings are suitable for computer data processing, facial thermography would seem to be suitable for potential stroke screening of a high-risk asymptomatic population.

[Examination of the mediastinum in staging of primary bronchial carcinoma]. / Onderzoek van het mediastinum bij de stadiëring van het primaire bronchuscarcinoom.

Mediastinoscopy and CT are used to evaluate the mediastinum in patients with non small cell lung cancer to determine operability. Generally, the sensitivity and negative predictive value of CT are high, in a personal study in 150 patients 86% and 92%, respectively. When CT does not reveal enlarged lymph nodes, we recommend thoracotomy without mediastinoscopy. However, micrometastases in non-enlarged lymph nodes will be missed. All positive CT scans necessitate mediastinoscopy, because enlarged lymph nodes frequently are not invaded with tumour (in our study in 33%). CT used in this way will increase the percentage of positive results of mediastinoscopy. In patients with a peripheral tumour lymphogenic spread to the mediastinum is not uncommon (in our study in 22%) and mediastinal evaluation should not be omitted. In these patients mediastinoscopy is also of diagnostic value.

[Two patients with fever, chills and pain in the right upper abdominal quadrant accompanied by hyperbilirubinaemia: pylephlebitis]. / Twee patiënten met koorts, koude rillingen en pijn rechts in de bovenbuik en hyperbilirubinemie: pyleflebitis.

Two male patients aged 55 and 77 years, respectively, presented to the casualty department with fever, chills and right abdominal upper quadrant tenderness. They also had hyperbilirubinaemia. Based on CT scan findings and blood cultures yielding Bacteroides fragilis, a diagnosis of pylephlebitis (septic thrombophlebitis of the mesenteric veins and/or the portal vein) was made. This is a condition with a mortality rate of 10-70%. Primary sources such as diverticulitis are often seen in patients with pylephlebitis, in which bacteria are drained by the mesenteric veins and cause a thrombus in the portal system. In the two patients no primary focus was detected. They were treated with intravenous antibiotic therapy followed by oral antibiotics, and were discharged in good health. Pylephlebitis can be complicated by liver abscesses. Treatment consists of broad-spectrum antibiotics which are adjusted based on the blood cultures results. The duration of treatment is between two and six weeks, depending on the presence of liver abscesses. In patients with abscesses that cannot be drained, longer treatment may be indicated.

Randomised trial of no hydration vs. sodium bicarbonate hydration in patients with chronic kidney disease undergoing acute computed tomography-pulmonary angiography.

BACKGROUND: Hydration to prevent contrast-induced acute kidney injury (CI-AKI) induces a diagnostic delay when performing computed tomography-pulmonary angiography (CTPA) in patients suspected of having acute pulmonary embolism. AIM: To analyze whether withholding hydration is non-inferior to sodium bicarbonate hydration before CTPA in patients with chronic kidney disease (CKD). METHODS: We performed an open-label multicenter randomized trial between 2009 and 2013. One hundred thirty-nine CKD patients were randomized, of whom 138 were included in the intention-to-treat population: 67 were randomized to withholding hydration and 71 were randomized to 1-h 250 mL 1.4% sodium bicarbonate hydration before CTPA. Primary outcome was the increase in serum creatinine 48-96 h after CTPA. Secondary outcomes were the incidence of CI-AKI (creatinine increase > 25%/> 0.5 mg dL(-1) ), recovery of renal function, and the need for dialysis within 2 months after CTPA. Withholding hydration was considered non-inferior if the mean relative creatinine increase was ≤ 15% compared with sodium bicarbonate. RESULTS: Mean relative creatinine increase was -0.14% (interquartile range -15.1% to 12.0%) for withholding hydration and -0.32% (interquartile range -9.7% to 10.1%) for sodium bicarbonate (mean difference 0.19%, 95% confidence interval -5.88% to 6.25%, P-value non-inferiority < 0.001). CI-AKI occurred in 11 patients (8.1%): 6 (9.2%) were randomized to withholding hydration and 5 (7.1%) to sodium bicarbonate (relative risk 1.29, 95% confidence interval 0.41-4.03). Renal function recovered in 80.0% of CI-AKI patients within each group (relative risk 1.00, 95% confidence interval 0.54-1.86). None of the CI-AKI patients developed a need for dialysis. CONCLUSION: Our results suggest that preventive hydration could be safely withheld in CKD patients undergoing CTPA for suspected acute pulmonary embolism. This will facilitate management of these patients and prevents delay in diagnosis as well as unnecessary start of anticoagulant treatment while receiving volume expansion.

Bifrontal epidural haematoma after shunt operation and posterior fossa exploration: report of a case with survival.

A case of bifrontal epidural haematoma secondary to ventriculocardiac (Spitz-Holter) shunt operation and posterior fossa exploration is reported. The relevant literature has been reviewed. The diagnosis of this complication was made by CT scan.