Diagnostic Performance of Physician Gestalt for Bacteremia in Patients in the Process of Being Admitted With Suspected Infection.

BACKGROUND: Due to potentially fatal consequences of missed bacteremia, blood cultures are often overused. While there are several prediction models that can be used to identify patients who truly need blood cultures, physicians often rely on their gestalt. We evaluated the diagnostic performance of physician gestalt for bacteremia in comparison with 2 existing prediction models: Takeshima and Shapiro. METHODS: The study enrolled consecutive adult patients with suspected infection who were in the process of being admitted to the general medicine department at 2 hospitals between April 2017 and January 2019. Attending physicians provided gestalt regarding risk of bacteremia (0%-100%). Patients with a <10% risk estimated via each strategy (ie, physician gestalt or 2 existing models) were categorized as bacteremia excluded (ie, blood cultures were considered unnecessary). Strategies were compared in terms of safety (proportion of patients with bacteremia among those classified as bacteremia excluded) and efficiency (proportion of patients classified as bacteremia excluded among the total cohort). RESULTS: Among 2014 patients, 292 (14.5%) were diagnosed with bacteremia. The safety of physician gestalt and the Takeshima and Shapiro models was 3.7% (95% confidence interval [CI], 2.2% to 5.7%), 6.5% (95% CI, 5.0% to 7.9%), and 10.8% (95% CI, 9.4% to 12.3%), whereas the efficiency of each strategy was 22.4% (95% CI, 22.5% to 26.3%), 52.7% (95% CI, 50.5% to 54.9%), and 87.8% (95% CI, 86.3% to 89.2%), respectively. CONCLUSIONS: Physician gestalt was safer but less efficient than existing models. Clinical prediction models could help reduce the overuse of blood cultures.

Usefulness of computed tomography in the diagnosis of acute pyelonephritis in older patients suspected of infection with unknown focus.

BACKGROUND: In older adults, the diagnosis of acute pyelonephritis is challenging because of non-specific symptoms and false-positive urine test results. Few studies have investigated the diagnostic performance of computed tomography (CT) signs. PURPOSE: To evaluate the diagnostic performance of CT signs for acute pyelonephritis in older patients suspected of infection with unknown focus. MATERIAL AND METHODS: This cross-sectional study was conducted between 2015 and 2018. Patients aged ≥65 years who underwent blood cultures, urine culture, and non-contrast or contrast-enhanced CT on admission were included. Cases with clinically presumable infection focus before CT were excluded. Two radiologists blinded to clinical information independently reviewed five CT signs: perirenal fat stranding; pelvicalyceal wall thickening and enhancement; renal enlargement; thickening of Gerota's fascia; and area(s) of decreased attenuation. The final diagnoses were made by a clinical expert panel. RESULTS: Among 473 eligible patients, 61 were diagnosed with acute pyelonephritis. When the laterality of findings between the left and right kidneys were considered, the positive and negative likelihood ratios of perirenal fat stranding were 4.0 (95% confidence interval [CI] = 2.3-7.0) and 0.8 (95% CI = 0.7-0.9) in non-contrast CT, respectively. The other signs in non-contrast CT showed similar diagnostic performance with positive and negative likelihood ratios of 3.5-11.3 and 0.8-0.9, respectively. CONCLUSION: CT signs can help physicians diagnose acute pyelonephritis in older patients suspected of infection with unknown focus.

Impact of clinical information on CT diagnosis by radiologist and subsequent clinical management by physician in acute abdominal pain.

OBJECTIVE: The impact of clinical information on radiological diagnoses and subsequent clinical management has not been sufficiently investigated. This study aimed to compare diagnostic performance between radiological reports made with and without clinical information and to evaluate differences in the clinical management decisions based on each of these reports. METHODS: We retrospectively reviewed 410 patients who presented with acute abdominal pain and underwent unenhanced (n = 248) or enhanced CT (n = 162). Clinical information including age, sex, current and past history, physical findings, and laboratory tests were collected. Six radiologists independently interpreted CTs that were randomly assigned with or without clinical information, made radiological diagnoses, and scored the diagnostic confidence level. Four general and emergency physicians simulated clinical management (i.e., followed up in the outpatient clinic, hospitalized for conservative therapy, or referred to other departments for invasive therapy) based on reports made with or without the clinical information. Reference standards for the radiological diagnoses and clinical management were defined by an independent expert panel. RESULTS: The radiological diagnoses made with clinical information were more accurate than those made without clinical information (93.7% vs. 87.8%, p = 0.008). Median interpretation time for radiological reporting with clinical information was significantly shorter than that without clinical information (median 122.0 vs. 139.0 s, p < 0.001). Clinical simulation better matched the reference standard for clinical management when radiological diagnoses were made with reference to clinical information (97.3% vs. 87.8%, p < 0.001). CONCLUSION: Access to adequate clinical information enables accurate radiological diagnoses and appropriate subsequent clinical management of patients with acute abdominal pain. KEY POINTS: • Radiological interpretation improved diagnostic accuracy and confidence level when clinical information was provided. • Providing clinical information did not extend the interpretation time required by radiologists. • Radiological interpretation with clinical information led to correct clinical management by physicians.

Added value of inflammatory markers to vital signs to predict mortality in patients suspected of severe infection.

OBJECTIVE: To evaluate the added value of inflammatory markers to vital signs to predict mortality in patients suspected of severe infection. METHODS: This study was conducted at an acute care hospital (471-bed capacity). Consecutive adult patients suspected of severe infection who presented to either ambulatory care or the emergency department from April 2015 to March 2017 were retrospectively evaluated. A prognostic model for predicting 30-day in-hospital mortality based on previously established vital signs (systolic blood pressure, respiratory rate, and mental status) was compared with an extended model that also included four inflammatory markers (C-reactive protein, neutrophil-lymphocyte ratio, mean platelet volume, and red cell distribution width). Measures of interest were model fit, discrimination, and the net percentage of correctly reclassified individuals at the pre-specified threshold of 10% risk. RESULTS: Of the 1015 patients included, 66 (6.5%) died. The extended model including inflammatory markers performed significantly better than the vital sign model (likelihood ratio test: p < 0.001), and the c-index increased from 0.69 (range 0.67-0.70) to 0.76 (range 0.75-0.77) (p = 0.01). All included markers except C-reactive protein showed significant contribution to the model improvement. Among those who died, 9.1% (95% CI -2.8-21.8) were correctly reclassified by the extended model at the 10% threshold. CONCLUSIONS: The inflammatory markers except C-reactive protein showed added predictive value to vital signs. Future studies should focus on developing and validating prediction models for use in individualized predictions including both vital signs and the significant markers.

[A Case of Desmoid Tumor Initially Diagnosed as a Metastasis from Renal Cell Carcinoma --A CASE REPORT-].

We report a case of desmoid tumor that was initially diagnosed as metastasis from renal cell carcinoma. A follow-up computed tomographic (CT) scan after nephrectomy for renal cell carcinoma in a 64-year-old man revealed a right retroperitoneal tumor 3.5 cm in diameter. Though the CT density of the tumor was similar to that of muscles, we first suspected metastasis from renal cell carcinoma or other cancer because the tumor growth was relatively fast. We resected the tumor. The pathological diagnosis was desmoid type fibromatosis. We also review six cases of desmoid tumors after nephrectomy for renal cell carcinoma reported in Japan. Careful followup is required for the patients with desmoid tumors because of frequent recurrence.

[A Case of Pelvic Organ Prolapse and Bladder Diverticulum Surgically Treated at the Same Time].

We report a case of bladder diverticulum presumably caused by lower urinary tract dysfunction due to pelvic organ prolapse (POP) simultaneously treated with transurethral coagulation (TUC) of the bladder diverticulum and laparoscopic sacrocolpopexy (LSC). A literature search showed this is the first report of bladder diverticulum and POP surgically treated at the same time. A 71-year-old woman was referred to our hospital for the treatment of cystocele. She had both storage and voiding symptoms. She had a POPQ stage III cystocele and stage I uterine prolapse. Ultrasonography and computed tomographic scan showed a large volume of residual urine along with a bladder diverticulum. Since urodynamic studies revealed a low compliance bladder and obstruction, we opined that the lower urinary tract symptoms were induced by the cystocele. TUC of the bladder diverticulum and LSC were performed at the same time. After the operation, clean intermittent catheterization (CIC) was needed once a day for one month. Gradually, residual urine decreased and CIC became unnecessary. The bladder diverticulum disappeared, and there has been no recurrence of POP.

Are prehospital airway management resources compatible with difficult airway algorithms? A nationwide cross-sectional study of helicopter emergency medical services in Japan.

PURPOSE: Immediate access to the equipment required for difficult airway management (DAM) is vital. However, in Japan, data are scarce regarding the availability of DAM resources in prehospital settings. The purpose of this study was to determine whether Japanese helicopter emergency medical services (HEMS) are adequately equipped to comply with the DAM algorithms of Japanese and American professional anesthesiology societies. METHODS: This nationwide cross-sectional study was conducted in May 2015. Base hospitals of HEMS were mailed a questionnaire about their airway management equipment and back-up personnel. Outcome measures were (1) call for help, (2) supraglottic airway device (SGA) insertion, (3) verification of tube placement using capnometry, and (4) the establishment of surgical airways, all of which have been endorsed in various airway management guidelines. The criteria defining feasibility were the availability of (1) more than one physician, (2) SGA, (3) capnometry, and (4) a surgical airway device in the prehospital setting. RESULTS: Of the 45 HEMS base hospitals questioned, 42 (93.3 %) returned completed questionnaires. A surgical airway was practicable by all HEMS. However, in the prehospital setting, back-up assistance was available in 14.3 %, SGA in 16.7 %, and capnometry in 66.7 %. No HEMS was capable of all four steps. CONCLUSION: In Japan, compliance with standard airway management algorithms in prehospital settings remains difficult because of the limited availability of alternative ventilation equipment and back-up personnel. Prehospital health care providers need to consider the risks and benefits of performing endotracheal intubation in environments not conducive to the success of this procedure.

Difficult airway management resources and capnography use in Japanese intensive care units: a nationwide cross-sectional study.

PURPOSE: The availability of difficult airway management (DAM) resources and the extent of capnometry use in Japanese intensive care units (ICUs) remained unclear. The purpose of this study was to clarify whether: (1) DAM resources were adequate, and (2) capnometry was routinely applied in Japanese ICUs. METHODS: This nationwide cross-sectional study was conducted from September 2015 to February 2016. All ICUs received a mailed questionnaire about their DAM resources and use of capnometry. Outcome measures were availability of: (1) 24-h in-house backup coverage; (2) a supraglottic airway device (SGA); (3) a dedicated DAM cart; and (4) surgical airway devices, and (5) routine use of capnometry to verify tube placement and for continuous monitoring of ventilator-dependent patients. The association between these outcomes and ICU type (academic, high-volume, closed, surgical) was also analyzed. RESULTS: Of the 289 ICUs, 196 (67.8 %) returned completed questionnaires. In-house backup coverage and surgical airway devices were highly available (89.3 and 95.9 %), but SGAs and dedicated DAM carts were not (60.2 and 60.7 %). The routine use of capnometry to confirm tube placement was reported by 55.6 % of the ICUs and was highest in closed ICUs (67.2 %, p = 0.03). The rate of continuous capnography monitoring was also 55.6 % and was highest in academic ICUs (64.5 %, p = 0.04). CONCLUSION: In Japanese ICUs, SGAs and dedicated DAM carts were less available, and capnometry was not universally applied either to confirm tube placement, or for continuous monitoring of ventilated patients. Our study revealed areas in need of improvement.

Sublingual administration of atropine eye drops for treating organophosphorus poisoning.

An 89-year-old patient with fenitrothion toxicity received sublingual atropine eye drops, reducing the intravenous atropine requirement. This alternative method enabled rapid rehabilitation, and he walked unaided, leading to discharge.

Added value of non-contrast CT for the diagnosis of acute pyelonephritis in older patients with suspected infection with an unknown focus: a retrospective diagnostic study.

OBJECTIVES: In older patients, the diagnosis of acute pyelonephritis (APN) is challenging. The aim was to evaluate the added value of CT to history, physical examination and urinalysis for the diagnosis of APN in older patients with suspected infection with an unknown focus. DESIGN: Retrospective diagnostic study. SETTING: Department of General Medicine in an acute care hospital in Japan. PARTICIPANTS: Patients aged ≥65 years who underwent blood cultures, a urine culture, and chest and abdominal CT to detect the focus of infection were included. PRIMARY OUTCOME MEASURES: Two radiologists independently reviewed four non-contrast CT signs: perirenal fat stranding, pelvicalyceal wall thickening, enlargement of the kidney and thickening of Gerota's fascia. Findings on contrast-enhanced CT could not be evaluated due to an insufficient number of patients in whom contrast-enhanced CT was performed. An expert panel was used as the reference standard for APN. The added value of CT findings was quantified by comparing the diagnostic performance between a model based on 10 predictors available before CT and an extended model including the CT findings. RESULTS: Of 473 patients, 61 (14.8%) were diagnosed with APN. When the laterality of the CT findings was taken into account, the model fit was not improved by adding them. In the laterality-insensitive analysis, the model performance was significantly improved by adding the CT signs (likelihood-ratio test p=0.03; c-index 0.89 vs 0.91, p=0.03). However, their clinical utility was only to improve the classification of 11.5% of patients with APN. CONCLUSIONS: The added value of non-contrast CT findings to history, physical examination and urinalysis was limited for the diagnosis of APN in older patients with a suspected infection with an unknown focus.

Guanfacine poisoning resulting in transient ST-segment elevation: a case report.

BACKGROUND: Guanfacine is an alpha-2 adrenergic agonist that decreases norepinephrine release and sympathetic outflow. With the increased use of guanfacine for attention-deficit hyperactivity disorder (ADHD), reports of guanfacine poisoning have also risen. CASE PRESENTATION: A 15-year-old male (height: 170 cm, weight: 48 kg), who was taking 2 mg/day of guanfacine for ADHD, was brought to our emergency department after ingesting 40 tablets of guanfacine due to poor exam results. He presented with impaired consciousness and sinus bradycardia on an electrocardiogram (ECG), leading to diagnosis of guanfacine poisoning. Gastric lavage (5 L) was performed, and activated charcoal was administered. Although his consciousness gradually recovered, he developed ST-segment elevation on the ECG. Despite the absence of chest pain and elevated myocardial enzymes, coronary artery stenosis was not observed on coronary artery computed tomography. As his blood guanfacine level decreased, his ECG returned to normal. CONCLUSIONS: This case highlights the need for careful monitoring of guanfacine poisoning patients due to the potential for various cardiovascular events.

Localized skin mottling associated with acute gastric dilatation.

We present a case of a 55-year-old woman complaining of abdominal distension owing to acute gastric dilatation. Her localized skin mottling had spread from the lower abdomen to both knees. The skin mottling in the area affected by gastric dilatation improved immediately after stomach emptying using a gastric tube and upper endoscopy.

Coronavirus disease 2019 with Chilaiditi sign.

In patients with the Chilaiditi sign, pulmonary lower lobes collapse occurs because of interposition of the bowel between diaphragm and liver. When such patients suffer from COVID-19 pneumonia, clinicians should carefully monitor respiratory status.

Intestinal obstruction caused by consuming diet food containing psyllium.

A 26-year-old man presented to our institution with abdominal pain and nausea after eating food containing Psyllium to lose weight. Since patients undergoing extreme slimming regimens may cause intestinal obstruction if psyllium is taken without adequate fluid intake caution should be taken when eating psyllium.

Commercial massage tool-induced spinal epidural hematoma.

Background: Spinal epidural hematoma (SEH), which may develop into an emergency condition, is a rare disease. Here, we present the case of a patient with SEH caused by cervical massage using a commercial massage tool. Case Presentation: A 75-year-old man was brought to our hospital with a chief complaint of posterior neck pain during sleep. He had used a commercial massage tool before going to bed. Upon arrival, hypotension and respiratory failure were observed. His muscle strength in both the upper and lower extremities rated 0 on the manual muscle test, and sensory loss below the papillae was observed. His symptoms resolved spontaneously after 2 h. Magnetic resonance imaging suggested a spinal cord epidural hematoma at the C2/C3 to C3/C4 level. On day 6, the patient was discharged without any impairment. Conclusion: Fatal complications could occur by cervical massage using a commercial massage tool.

The impact of autopsy participation on clinical residency.

BACKGROUND: Autopsy has had an essential role in ensuring the quality of education and medical care. However, its role in clinical residency has not been clarified. This study assessed actual autopsy circumstances during clinical residency and evaluated the association between autopsy and clinical knowledge. METHODS: We conducted a cross-sectional study involving postgraduate second year residents in Japan who took the General Medicine In-Training Examination in 2019. We modeled the General Medicine In-Training Examination scores of the residents to examine their association with autopsy experiences and the number of autopsy experiences to assess its predictors. RESULTS: Of 2715 postgraduate second year residents, 353 (13.8%) had no autopsy participation, and 1015 (39.7%) had only one experience. Although autopsy participation was not related to the mean General Medicine In-Training Examination score, the residents' clinicopathological conference participation, self-study for more than 60 min per day, and wish to be pathologists were significantly associated with autopsy experiences. They experienced more autopsies when they belonged to small-sized hospitals in rural areas performing many autopsies. CONCLUSION: We reported the current status of autopsy in clinical residency and showed that more than half of the residents experienced no or only one autopsy. General Medicine In-Training Examination scores were not correlated with the number of autopsy experiences.

Diagnostic performance of food consumption for bacteraemia in patients admitted with suspected infection: a prospective cohort study.

OBJECTIVES: A previous study reported that food consumption is useful to rule out bacteraemia in hospitalised patients. We aimed to validate the diagnostic performance of (1) food consumption and (2) a previously reported algorithm using food consumption and shaking chills for bacteraemia in patients admitted to hospital with suspected infection. DESIGN: Prospective cohort study. SETTING: Department of General Medicine in two acute care hospitals in Japan. PARTICIPANTS: A total of 2009 adult patients who underwent at least two blood cultures on admission. PRIMARY OUTCOME MEASURES: The reference standard for bacteraemia was judgement by two independent specialists of infectious diseases. Food consumption was evaluated by the physician in charge asking the patient or their caregivers the following question on admission: 'What percentage of usual food intake were you able to eat during the past 24 hours?' RESULTS: Among 2009 patients, 326 patients were diagnosed with bacteraemia (16.2%). Diagnostic performance of food consumption was sensitivity of 84.4% (95% CI 80.1 to 88), specificity of 19.8% (95% CI 18 to 21.8), positive predictive value (PPV) of 16.9% (95% CI 15.2 to 18.9) and negative predictive value (NPV) of 86.8% (95% CI 83.1 to 89.8). The discriminative performance was an area under the curve of 0.53 (95% CI 0.50 to 0.56). The performance of the algorithm using food consumption and shaking chills was sensitivity of 89% (95% CI 85.1 to 91.9), specificity of 18.8% (95% CI 17 to 20.7), PPV of 17.5% (95% CI 15.7 to 19.4) and NPV of 89.8% (95% CI 86.2 to 92.5). CONCLUSION: Our results did not show the usefulness of food consumption and the algorithm using food consumption and shaking chills for the diagnosis of bacteraemia in patients admitted to hospital with suspected infection.

Human and equipment resources for difficult airway management, airway education programs, and capnometry use in Japanese emergency departments: a nationwide cross-sectional study.

BACKGROUND: Although human and equipment resources, proper training, and the verification of endotracheal intubation are vital elements of difficult airway management (DAM), their availability in Japanese emergency departments (EDs) has not been determined. How ED type and patient volume affect DAM preparation is also unclear. We conducted the present survey to address this knowledge gaps. METHODS: This nationwide cross-sectional study was conducted from April to September 2016. All EDs received a mailed questionnaire regarding their DAM resources, airway training methods, and capnometry use for tube placement. Outcome measures were the availability of: (1) 24-h in-house back-up; (2) key DAM resources, including a supraglottic airway device (SGA), a dedicated DAM cart, surgical airway devices, and neuromuscular blocking agents; (3) anesthesiology rotation as part of an airway training program; and (4) the routine use of capnometry to verify tube placement. EDs were classified as academic, tertiary, high-volume (upper quartile of annual ambulance visits), and urban. RESULTS: Of the 530 EDs, 324 (61.1%) returned completed questionnaires. The availability of in-house back-up coverage, surgical airway devices, and neuromuscular blocking agents was 69.4, 95.7, and 68.5%, respectively. SGAs and dedicated DAM carts were present in 51.5 and 49.7% of the EDs. The rates of routine capnometry use (47.8%) and the availability of an anesthesiology rotation (38.6%) were low. The availability of 24-h back-up coverage was significantly higher in academic EDs and tertiary EDs in both the crude and adjusted analysis. Similarly, neuromuscular blocking agents were more likely to be present in academic EDs, high-volume EDs, and tertiary EDs; and the rate of routine use of capnometry was significantly higher in tertiary EDs in both the crude and adjusted analysis. CONCLUSIONS: In Japanese EDs, the rates of both the availability of SGAs and DAM carts and the use of routine capnometry to confirm tube placement were approximately 50%. These data demonstrate the lack of standard operating procedures for rescue ventilation and post-intubation care. Academic, tertiary, and high-volume EDs were likely to be well prepared for DAM.