Combination Of Clinical Suspicion Research Articles

A sperm viability test using SYBR-14/propidium iodide flow cytometry as a tool for rapid screening of primary ciliary dyskinesia patients and for choosing sperm sources for intracytoplasmic sperm injection

Spermatozoa viability tests based on dual-color flow cytometry after staining with Sybr-14/propidium iodide were performed on 44 men with complete asthenospermia for primary ciliary dyskinesia (PCD) screening, and seven were identified with PCD by electron microscopy of ultrastructural ciliary defects. Six PCD patients underwent eight intracytoplasmic sperm injection therapy cycles using ejaculated sperm or testicular sperm, obtaining a mean fertilization rate of 46.6%, with three healthy babies born and one in utero at the time of writing.

Audit on the use of empirical antibiotics in pregnant women with presumed UTI and their correlation to MSU results

BackgroundUrinary tract infection (UTI) is one of the most frequently seen ‘medical’ complications in pregnancy. It is common to treat pregnant patients with empirical antibiotics before awaiting the results of...

Pitfalls of Clinical Diagnosis Strategies for Heparin-Induced Thrombocytopenia (HIT) After Cardiac Surgery (CS).

Abstract 3516Poster Board III-453 BackgroundHIT is an infrequent but potentially serious complication of heparin therapy. Its diagnosis is complex and depends on a combination of clinical suspicion and laboratory confirmation through ELISA and functional tests such as the serotonin release assay (SRA). The 4Ts score comprises 4 clinical parameters (severity and timing of onset of thrombocytopenia, development of thrombosis, and clinician's appraisal of the likelihood of alternate causes for thrombocytopenia) and has been proposed to predict the probability of HIT in patients deemed to be at risk. However, the validity of the 4Ts score in patients undergoing cardiac surgery (CS) is questionable considering the numerous other factors that predispose such patients to thrombocytopenia and thrombosis. In addition, in CS patients the HIT ELISA assay has been reported to have 25 - 50% false positive results making it less useful. ObjectivesTo determine the usefulness of the 4T score in the post cardiac surgical population and the value of the HIT ELISA optical density for predicting HIT. MethodsRetrospective case-control study of patients admitted for cardiac surgery to the London Health Sciences Centre between January 2006 and December 2008 and for whom a HIT ELISA assay was requested. Patients with an equivocal or positive ELISA test were tested by SRA which considered the gold standard. Information collected included clinical variables related to the surgery and post-operative period, calculated 4T scores, ELISA optical density (OD) and SRA results. Categorical variables were compared using chi2 or Fisher's exact tests as appropriate. Continuous variables were compared using a Mann-Whitney U test. Covariates achieving a p value ≤0.1 in univariate analysis and the components of the 4Ts score were incorporated in logistic regression models using stepwise forward selection. Finally, we constructed a Receiver Operating Characteristic (ROC) curve for the ELISA OD. Results73 patients were included in the analysis. Results of the univariate analysis are shown in the table. On regression analysis only the ELISA optical density (per each OD arbitrary unit increase) was correlated with a diagnosis of HIT (OR 37.266; 95% CI 2.342-593.013; p=0.010). For the ELISA OD the area under the ROC curve was 0.990 (SE 0.013) (Figure). A cutoff value for the OD of 0.475 had a Sensitivity of 1, a specificity of 0.9, a positive likelihood ratio (LR) of 10 and a negative LR of 0.00. Assuming a prevalence proportion of 0.082 the posterior probability of HIT if the ELISA has an OD <0.475 is 0 (95% CI 0 – 9). On the other hand, an OD >0.92 resulted in a LR+ of 20 with a posterior probability of 64% (95% CI 35 – 80). ConclusionsIn this study, we found that the 4T score does not accurately predict HIT in post CS patients. Limitations of this study include a reduced sample size and its retrospective nature. Our findings suggest that in post CS patients developing thrombocytopenia between 10 and 100 × 109 or a platelet drop of 50% or more (100% of our population) a HIT ELISA with an OD < 0.475 could be used to rule out HIT. Our findings need to be confirmed in prospective studies.ControlsCasesPAge (years) [Median]74.00066.0000.175Gender1.000Male [%]58.20066.700Cardiac surgery type [%]0.556CABG22.433.3Valve replacement28.40CABG + Valve replacement43.366.7Other30Transplant30Use of intra-aortic balloon pump [%]26.933.30.663Clamp time (minutes) [Median]121.000112.0000.651Pump time (minutes) [Median]174.000167.0000.507Heparin used in surgery (units) [Median]55000.00085500.0000.007Baseline platelet count (x 10∧9) [Median]211.000250.0000.315Nadir platelet count [Median]39.00038.5000.912Percent platelet fall [Median]81.41080.7970.659Time from cardiac Sx to HIT ELISA request OR Plt Nadir (days) [Median]4.0007.0000.032Time to HIT ELISA /Plt nadir >=5 days [%]29.983.30.016Heparin exposure within 100 days [%]49.333.30.676Confirmed new thrombosis [%]033.30.006Suspected new thrombosis [%]1.501Skin necrosis [%]016.70.082Alternate cause for thrombocytopenia[%]0.221No34.30Possible20.933.3Definite44.866.74T Score Calculated [Median]4.0005.0000.0594Ts Score pretest probability category [%]0.125Low37.30Intermediate43.383.3High19.416.7HIT ELISA Assay<0.001Negative80.60Equivocal11.90Positive7.5100ELISA optical density (arbitrary units) [Median]0.1702.306<0.001 Disclosures:No relevant conflicts of interest to declare.

Inter-Observer Variability in the Assessment of the 4Ts Score for the Diagnosis of Heparin Induced Thrombocytopenia (HIT) in Patients Undergoing Cardiac Surgery (CS).

Abstract 4467 BackgroundHIT is a potentially serious complication of heparin therapy. Because of the multiple conditions potentially causing thrombocytopenia, particularly in clinical scenarios such as patients undergoing CS or admitted to intensive care units, its diagnosis is frequently not straightforward and depends on a combination of clinical suspicion and laboratory tests. The 4Ts score has been proposed as a tool to assess the pretest probability of a HIT diagnosis (as low, intermediate or high) and it comprises 4 clinical parameters: severity and timing of onset of thrombocytopenia, development of thrombosis, and the presence of alternate causes for thrombocytopenia. This score has several handicaps including the fact that the temporal profile of thrombocytopenia onset is frequently unclear, the history of previous heparin exposure is not always available, the diagnosis of new thrombosis (including extensions of previous ones) is often difficult, and the judgment about the likelihood of an alternate cause for the thrombocytopenia is entirely subjective. The clinical usefulness of a scoring system depends mainly on its robustness and reproducibility and therefore inclusion of difficult to evaluate or subjective components might compromise its clinical performance. ObjectivesWe evaluated the inter-observer agreement for classifying the probability of HIT in a population of patients undergoing CS. MethodsWe conducted a retrospective study of patients admitted for cardiac surgery to our institution between January 2006 and December 2008 and in whom HIT was suspected. Clinical information including all necessary data for calculating the 4 components of the 4Ts score was collected in a standardized database which was used by 2 independent observers (blinded to serological tests results) to calculate the score and the pretest probability for HIT as low (≤3 points), intermediate (4-5 points), or high (≥6 points). Scores assigned by both observers were compared using a Wilcoxon signed ranks test and the inter-observer agreement for scores and pretest probabilities was evaluated using a Kappa statistic. 95% confidence intervals for proportions were estimated using the Wilson score method. Results73 patients were included in the analysis. The score assigned by both observers differed in 40 cases (54.8%; 95% CI 43.4, 65.7; p=0.001). The value of the Kappa statistic for the inter-observer agreement for scores was 0.266 (95% CI 0.111, 0.421) and for pretest probabilities was 0.400 (95% CI 0.218, 0.582). ConclusionsIn this study, we found that the 4Ts score has an inter-observer agreement ranging between slight and moderate when applied to patients undergoing CS. The variability observed in the assessment of the score raises doubts about its usefulness when evaluating the possibility of HIT in this patient population. Limitations of this study include a relatively small sample size, inclusion of a single clinical setting, and its retrospective nature. Further studies in this and other populations are needed to assess the reproducibility of the 4Ts score. Disclosures:No relevant conflicts of interest to declare.

Extracranial infected carotid artery aneurysm

Infected aneurysms of the extracranial carotid arteries are rare. This is a case report of a 63-year-old female who developed an infected internal carotid artery aneurysm due to group B Streptococcus ten days after a dental procedure. She was successfully treated with excision of the aneurysm and common to internal carotid artery bypass with greater saphenous vein.

Diagnosis of Lemierre Syndrome by Bedside Emergency Department Ultrasound

Oropharyngeal infections such as pharyngitis and odontogenic abscess are routinely encountered in emergency and primary care medical practice. Lemierre syndrome is a rare but serious complication of such infections. This syndrome is characterized by penetration of the primary infection into the lateral pharyngeal space, suppurative thrombophlebitis of the internal jugular vein, and metastatic infections resulting from septic emboli. A combination of clinical suspicion, microbiologic identification of the causative organism, and diagnostic imaging may be required to make the diagnosis. We present a case of Lemierre syndrome that was rapidly diagnosed in the Emergency Department with bedside ultrasound of the internal jugular vein. This case suggests that bedside ultrasound, performed before other radiologic imaging, may lead to earlier diagnosis and treatment of this syndrome, which historically has been associated with significant morbidity and mortality.

The treatment of deep shoulder infection and glenohumeral instability with debridement, reverse shoulder arthroplasty and postoperative antibiotics

We retrospectively reviewed 21 patients (22 shoulders) who presented with deep infection after surgery to the shoulder, 17 having previously undergone hemiarthroplasty and five open repair of the rotator cuff. Nine shoulders had undergone previous surgical attempts to eradicate their infection. The diagnosis of infection was based on a combination of clinical suspicion (16 shoulders), positive frozen sections (> 5 polymorphonuclear leukocytes per high-power field) at the time of revision (15 shoulders), positive intra-operative cultures (18 shoulders) or the pre-operative radiological appearances. The patients were treated by an extensive debridement, intravenous antibiotics, and conversion to a reverse shoulder prosthesis in either a single- (10 shoulders) or a two-stage (12 shoulders) procedure. At a mean follow-up of 43 months (25 to 66) there was no evidence of recurrent infection. All outcome measures showed statistically significant improvements. Mean abduction improved from 36.1 degrees (sd 27.8) pre-operatively to 75.7 degrees (sd 36.0) (p < 0.0001), the mean forward flexion from 43.1 degrees (sd 33.5) to 79.5 degrees (sd 43.2) (p = 0.0003), and mean external rotation from 10.2 degrees (sd 18.7) to 25.4 degrees (sd 23.5) (p = 0.0037). There was no statistically significant difference in any outcome between the single-stage and the two-stage group.

Ischemic colitis: Clinical practice in diagnosis and treatment

Ischemic colitis is the most common form of ischemic injury of the gastrointestinal tract and can present either as an occlusive or a non-occlusive form. It accounts for 1 in 1000 hospitalizations but its incidence is underestimated because it often has a mild and transient nature. The etiology of ischemic colitis is multifactorial and the clinical presentation variable. The diagnosis is based on a combination of clinical suspicion, radiographic, endoscopic and histological findings. Therapy and outcome depends on the severity of the disease. Most cases of the non-gangrenous form are transient and resolve spontaneously without complications. On the other hand, high morbidity and mortality and urgent operative intervention are the hallmarks of gangrenous ischemic colitis.

Preterm premature rupture of membranes: diagnosis, evaluation and management strategies

Preterm premature rupture of the membranes (PPROM) is responsible for one-third of all preterm births and affects 120,000 pregnancies in the United States each year. Effective treatment relies on accurate diagnosis and is gestational age dependent. The diagnosis of PPROM is made by a combination of clinical suspicion, patient history and some simple tests. PPROM is associated with significant maternal and neonatal morbidity and mortality from infection, umbilical cord compression, placental abruption and preterm birth. Subclinical intrauterine infection has been implicated as a major aetiological factor in the pathogenesis and subsequent maternal and neonatal morbidity associated with PPROM. The frequency of positive cultures obtained by transabdominal amniocentesis at the time of presentation with PPROM in the absence of labour is 25-40%. The majority of amniotic fluid infection in the setting of PPROM does not produce the signs and symptoms traditionally used as diagnostic criteria for clinical chorioamnionitis. Any evidence of infection by amniocentesis should be considered carefully as an indication for delivery. Documentation of amniotic fluid infection in women who present with PPROM enables us to triage our therapeutic decision making rationally. In PPROM, the optimal interval for delivery occurs when the risks of immaturity are outweighed by the risks of pregnancy prolongation (infection, abruption and cord accident). Lung maturity assessment may be a useful guide when planning delivery in the 32- to 34-week interval. A gestational age approach to therapy is important and should be adjusted for each hospital's neonatal intensive care unit. Antenatal antibiotics and corticosteroid therapies have clear benefits and should be offered to all women without contraindications. During conservative management, women should be monitored closely for placental abruption, infection, labour and a non-reassuring fetal status. Women with PPROM after 32 weeks of gestation should be considered for delivery, and after 34 weeks the benefits of delivery clearly outweigh the risks.

INVASIVE ASPERGILLOSIS IN CRITICALLY ILL PATIENTS: ANALYSIS OF RISK FACTORS FOR ACQUISITION AND MORTALITY

Objective: To investigate outcome in patients who develop invasive aspergillosis in the ICU, and to evaluate whether specific risk factors for the acquisition of invasive aspergillosis are associated with mortality.Design: Retrospective cohort study (07/1997–12/1999) with screening of 8988 admissions.Setting: 54-bed ICU of the 1060-bed Ghent University Hospital.Patients: 38 ICU patients with invasive aspergillosis. Invasive aspergillosis was defined as proven by positive histology and tissue culture and as probable by a combination of clinical suspicion as well as microbiological and radiological data. Seventeen patients had risk factors (neutropenia, haematological malignancy, immunosuppressive therapy). In the other 21 apparently immunocompetent patients, invasive aspergillosis was a complication following ARDS, COPD, pneumonia, acute liver failure, burns, severe bacterial infection and malnutrition.Measurements: Population characteristics and outcome were compared for patients with and without risk factors for the acquisition of invasive aspergillosis.Results: Patients with risk factors had higher APACHE II scores. No difference was found between patients with and without risk factors in in-hospital mortality (82% vs. 71%; p=0.431). In patients with specific risk factors, the observed mortality was not different from the mortality as expected on basis of the APACHE II (p=0.940). In patients without risk factors the observed mortality exceeded the expected mortality (p<0.001).Conclusion:The incidence of invasive aspergillosis in this series is 4/1000 admissions. No difference in mortality was found between patients with and without risk factors for the acquisition of invasive aspergillosis. Yet, the prognosis of the patients without risk factors seems to alter more seriously by the development of this infection.

Painless acute aortic dissection and rupture presenting as syncope

Acute aortic dissection is an emergency that may not only cause significant morbidity but often results in death. A timely diagnosis can prove difficult in the event of an atypical presentation. Classically, aortic dissection presents as sudden, severe chest, back, or abdominal pain that is characterized as ripping or tearing in nature. This article reports on a case of a completely painless acute dissection and rupture in a middle-aged man who presented with syncope. The diagnosis was made by a combination of clinical suspicion, emergent bedside echocardiography, and computed tomography scan. This patient underwent immediate surgery, and ultimately had a successful outcome.

Bone Marrow Failure Syndromes

Diagnosis of the inherited bone marrow failure syndromes depends on a combination of clinical suspicion and laboratory specificity. The major pancytopenias include Fanconi’s anemia, dyskeratosis congenita, Schwachman-Diamond syndrome, cartilage-hair hypoplasia, Pearson’s syndrome, reticular dysgenesis, amegakaryocytic thrombocytopenia, and familial aplastic anemias. The single cytopenias include Diamond-Blackfan anemia, Kostmann’s syndrome, and thrombocytopenia with absent radii. This chapter discusses the laboratory analyses which may be useful for these diagnoses.

6 Investigation of the patient with abnormal liver function tests

About one-half of patients with ulcerative colitis develop abnormal liver function tests at some time during the course of the illness. This should prompt an investigation for primary sclerosing cholangitis and other common hepatobiliary diseases. Primary sclerosing cholangitis occurs in 2–10% of patients with ulcerative colitis. The diagnosis of primary sclerosing cholangitis is most often made by endoscopic retrograde cholangiography. Liver histopathology is often inconclusive but magnetic resonance cholangiography shows promise as a useful non-invasive diagnostic tool. Cholangiocarcinoma complicates 20–40% of patients with end-stage primary sclerosing cholangitis and is now one of the most common causes of death in patients with ulcerative colitis. Distinction between benign and malignant strictures can be difficult and is best done with a combination of clinical suspicion, repeated imaging for mass lesions, cholangiography, and endoscopic brushings and/or biopsies. Dominant lesions of the common bile duct or common hepatic duct produce progressive jaundice and liver damage. Early treatment may improve prognosis. Single strictures can be dilated endoscopically. If the stricture is more complicated and extends into the intrahepatic ducts or there is suspicion of cholangiocarcinoma, surgical resection may be more appropriate. Liver transplantation should be considered in end-stage disease.

Inborn errors of urea synthesis.

Inborn errors of urea synthesis can present in the newborn period as a catastrophic illness or later in childhood or adulthood with an indolent course punctuated by hyperammonemic episodes. Because symptoms mimic other neuropsychiatric disorders, it is common for there to be a delay in diagnosis, often with dire consequences. Diagnosis relies on the combination of clinical suspicion and the measurement of ammonium, lactate, and amino acids in plasma and organic acids and orotic acid in urine. Treatment involves nitrogen restriction combined with the stimulation of alternate pathways of waste nitrogen excretion. More recently liver transplantation has been performed as enzyme replacement therapy. The outcome is poor in children who survive prolonged neonatal hyperammonemic coma, with most manifesting developmental disabilities. The etiology of neuronal injury in this disorder is unclear but may involve some combination of ammonia/amino acid accumulation, neurotransmitter alterations, and excitotoxic injury. Gene therapy holds the promise of improved treatment in the future.

Diagnosing Pulmonary Embolism: New Facts and Strategies

To provide a clinical approach to the diagnosis of pulmonary embolism. An English-language literature search using MEDLINE (1982 to 1990) and bibliographic reviews of textbooks and review articles. In addition to several reviews, studies that evaluated the diagnostic technology of pulmonary embolism were selected. Preference was given to studies with a prospective design, particularly those done within the past decade. Studies were assessed independently by three unblinded observers. Data were chosen to describe the efficacy of diagnostic technology on the basis of disease prevalence, sensitivity and specificity, and predictive value. A normal lung scan or pulmonary angiogram rules out the diagnosis of clinically important pulmonary embolism with at least 95% certainty. Lung scan interpretations indicating high or low probability have approximately a 15% error in diagnosing or ruling out pulmonary embolism. The accuracy of either scan result improves when the clinical suspicion of pulmonary embolism matches the lung scan result. Serial impedance plethysmography of the lower extremities may exclude thromboembolism with 95% certainty in patients without high-probability lung scan results or cardiopulmonary disease. The combination of clinical suspicion and the results of the lung scan and impedance plethysmography appear to offer acceptable diagnostic accuracy in evaluating many patients suspected of having pulmonary embolism. The usefulness of this approach for patients with cardiopulmonary disease is still unknown.