The elusive SIRS diagnosis

Infective endocarditis by Nocardia species: a systematic review

Nocardiosis, is a potentially life-threatening disease, especially in immunocompromised individuals where it manifests as a disseminated disease. Infective Endocarditis (IE) is a rare disease with significant morbidity and mortality. Importantly, even though there are scarce data of IE by Nocardia spp. in the literature, a review adequately summarizing systematically all available evidence on the topic is lacking. The aim of this study was to systematically review all cases of IE by Nocardia spp. and describe the epidemiology, microbiology, clinical characteristics, treatment and outcomes of this infection. A systematic review of PubMed, Scopus and Cochrane library (through 7 December 2021) for studies providing epidemiological, clinical, microbiological as well as treatment data and outcomes of patients with IE by Nocardia spp. was performed. A total of 25 studies providing data for 26 patients were included. A prosthetic valve was present in 30.8%, while the most common microorganism was N. asteroides. Aortic valve was the most commonly infected intracardiac site, followed by the mitral valve. Diagnosis was most commonly performed with transthoracic echocardiography, while the diagnosis was made at autopsy in 11.5%. Co-trimoxazole, aminoglycosides and carbapenems were the most commonly used antimicrobials. Clinical cure was noted in 73.1%, while mortality was 26.9%. This systematic review thoroughly describes IE by Nocardia and provides information on epidemiology, clinical presentation, treatment and outcomes.

Diagnostic Errors in Tuberculous Patients: A Multicenter Study from a Developing Country

Although there is still much to learn about the types of errors committed in health care and why they occur, enough is known today to recognize that a serious concern exists for patients. Tuberculosis (TB) is an infectious disease that is frequently subject to diagnostic errors. Missed or delayed diagnosis of TB can affect patients and community adversely. Our aim in the present study was at evaluating the type of diagnostic errors in TB patients from symptom onset to diagnosis. This was a multicenter cross-sectional study conducted in three university hospitals in Mashhad, Iran. We showed a long delay in diagnosing TB that is mostly related to the time from first medical visit to diagnosis. Errors in the diagnostic process were identified in 97.5% of patients. The most common type of error in diagnosing TB was failure in hypothesis generation (72%), followed by history taking and physical examination. In conclusion, it seems likely that efforts to improve public awareness of and health literacy for TB, to coordinate the referral and follow-up systems of patients, and to improve physicians' skills in history taking and physical examination and clinical reasoning will result in reduced delay in diagnosis of TB and, perhaps, improved patient safety and community health.

[Value of indoleamine 2,3-dioxygenase in diagnosis of systemic inflammatory response syndrome after cardiopulmonary bypass in children with congenital heart disease]

OBJECTIVE

To study the value of indoleamine 2,3-dioxygenase (IDO) in the early diagnosis of systemic inflammatory response syndrome (SIRS) after cardiopulmonary bypass in children with congenital heart disease.

METHODS

A total of 90 children with congenital heart disease who underwent cardiopumonary bypass surgery between May 2012 and January 2016 were enrolled. According to the prsence or absence of SIRS after surgery, they were divided into SIRS group (n=43) and control group (n=47). Peripheral blood samples were collected before surgery, during surgery, and after surgery. Serum levels of IDO, C-reactive protein (CRP), and interleukin-6 (IL-6) were measured and compared between the two groups. The receiver operating characteristic (ROC) curve was used to evaluate their diagnostic efficiency.

RESULTS

Compared with the control group, the SIRS group had higher serum CRP levels at 72 hours after surgery, higher IL-6 levels during surgery and at 72 hours after surgery, and higher IDO levels at 24 and 72 hours after surgery. IDO had a certain value in the diagnosis of SIRS at 24 hours after surgery with an area under the ROC curve (AUC) of 0.793, a specificity of 100%, and a sensitivity of 58.14%. CRP, IL-6, and IDO had a certain value in the diagnosis of SIRS at 72 hours after surgery. IDO had the highest diagnostic efficiency with an AUC of 0.927, a specificity of 95.74%, and a sensitivity of 76.74% at 72 hours after surgery.

CONCLUSIONS

IL-6, CRP, and IDO have a certain value in the diagnosis of SIRS after surgery for congenital heart disease, and IDO has a higher diagnostic efficiency. IDO can predict the development of SIRS in children after surgery for congenital heart disease earlier.

Development and Validation of a Disease Severity Scoring Model for Pediatric Sepsis

BACKGROUND

Multiple severity scoring systems have been devised and evaluated in adult sepsis, but a simplified scoring model for pediatric sepsis has not yet been developed. This study aimed to develop and validate a new scoring model to stratify the severity of pediatric sepsis, thus assisting the treatment of sepsis in children.

METHODS

Data from 634 consecutive patients who presented with sepsis at Children's hospital of Hunan province in China in 2011-2013 were analyzed, with 476 patients placed in training group and 158 patients in validation group. Stepwise discriminant analysis was used to develop the accurate discriminate model. A simplified scoring model was generated using weightings defined by the discriminate coefficients. The discriminant ability of the model was tested by receiver operating characteristic curves (ROC).

RESULTS

The discriminant analysis showed that prothrombin time, D-dimer, total bilirubin, serum total protein, uric acid, PaO2/FiO2 ratio, myoglobin were associated with severity of sepsis. These seven variables were assigned with values of 4, 3, 3, 4, 3, 3, 3 respectively based on the standardized discriminant coefficients. Patients with higher scores had higher risk of severe sepsis. The areas under ROC (AROC) were 0.836 for accurate discriminate model, and 0.825 for simplified scoring model in validation group.

CONCLUSIONS

The proposed disease severity scoring model for pediatric sepsis showed adequate discriminatory capacity and sufficient accuracy, which has important clinical significance in evaluating the severity of pediatric sepsis and predicting its progress.