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Bouam M, Binquet C, Moretto F, Sixt T, Vourc’h M, Piroth L, Ray P, Blot M. Delayed diagnosis of pneumonia in the emergency department: factors associated and prognosis. Front Med (Lausanne) 2023; 10:1042704. [PMID: 37250656 PMCID: PMC10213245 DOI: 10.3389/fmed.2023.1042704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 04/25/2023] [Indexed: 05/31/2023] Open
Abstract
Introduction Whether a delayed diagnosis of community-acquired pneumonia (CAP) in the emergency department (ED) is associated with worse outcome is uncertain. We sought factors associated with a delayed diagnosis of CAP in the ED and those associated with in-hospital mortality. Methods Retrospective study including all inpatients admitted to an ED (Dijon University Hospital, France) from 1 January to 31 December 2019, and hospitalized with a diagnosis of CAP. Patients diagnosed with CAP in the ED (n = 361, early diagnosis) were compared with those diagnosed later, in the hospital ward, after the ED visit (n = 74, delayed diagnosis). Demographic, clinical, biological and radiological data were collected upon admission to the ED, as well as administered therapies and outcomes including in-hospital mortality. Results 435 inpatients were included: 361 (83%) with an early and 74 (17%) with a delayed diagnosis. The latter less frequently required oxygen (54 vs. 77%; p < 0.001) and were less likely to have a quick-SOFA score ≥ 2 (20 vs. 32%; p = 0.056). Absence of chronic neurocognitive disorders, of dyspnea, and of radiological signs of pneumonia were independently associated with a delayed diagnosis. Patients with a delayed diagnosis less frequently received antibiotics in the ED (34 vs. 75%; p < 0.001). However, a delayed diagnosis was not associated with in-hospital mortality after adjusting on initial severity. Conclusion Delayed diagnosis of pneumonia was associated with a less severe clinical presentation, lack of obvious signs of pneumonia on chest X-ray, and delayed antibiotics initiation, but was not associated with worse outcome.
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Affiliation(s)
- Maria Bouam
- Emergency Department, Dijon-Bourgogne University Hospital, Dijon, France
| | - Christine Binquet
- CHU Dijon-Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- LabEx LipSTIC, University of Burgundy, Dijon, France
| | - Florian Moretto
- Department of Infectious Diseases, Dijon-Bourgogne University Hospital, Dijon, France
| | - Thibault Sixt
- Department of Infectious Diseases, Dijon-Bourgogne University Hospital, Dijon, France
| | - Michèle Vourc’h
- Biostatistics and Bioinformatics Department (DIM), Dijon-Bourgogne University Hospital, Dijon, France
| | - Lionel Piroth
- CHU Dijon-Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- LabEx LipSTIC, University of Burgundy, Dijon, France
- Department of Infectious Diseases, Dijon-Bourgogne University Hospital, Dijon, France
| | - Patrick Ray
- Emergency Department, Dijon-Bourgogne University Hospital, Dijon, France
| | - Mathieu Blot
- CHU Dijon-Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- LabEx LipSTIC, University of Burgundy, Dijon, France
- Department of Infectious Diseases, Dijon-Bourgogne University Hospital, Dijon, France
- Lipness Team, INSERM Research Centre LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, Dijon, France
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Wang Y, Qu Z, Liang W, Chen X, Chen C, Cheng H, Hu H, Wei Z, Su K, Yang L, Wang H. Clinical features and markers to identify pulmonary lesions caused by infection or vasculitis in AAV patients. BMC Pulm Med 2023; 23:27. [PMID: 36653805 PMCID: PMC9850570 DOI: 10.1186/s12890-023-02317-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 01/10/2023] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES Pulmonary lesion is frequently seen in ANCA-associated vasculitis (AAV) patients primarily due to AAV lung involvement or infection, which are hard to differentiate due to their high similarity in clinical manifestations. We aimed to analyze the clinical features of pulmonary lesions consequent to AAV involvement or infection in AAV patients and further identify the markers for differential diagnosis. METHODS 140 AAV patients who admitted to the Renmin Hospital of Wuhan University from January 2016 to July 2021 were included in this study. According to the nature of lung conditions, these patients were divided into the non-pulmonary lesion group, the lung infection group and the non-pulmonary infection group, and their demographics, clinical symptoms, imaging features, as well as laboratory findings were compared. A receiver operating characteristic (ROC) curve was drawn, and the diagnostic efficacy of single biomarker and composite biomarkers on pulmonary infection was then evaluated. RESULTS The patients in the lung infection group were significantly older than those in the no lesion group (63.19 ± 14.55 vs 54.82 ± 15.08, p = 0.022). Patients in the lung infection group presented more frequent symptoms and more obvious pulmonary image findings. Compared with patients in the non-pulmonary infection group, patients in the lung infection group showed a higher symptom incidence of fever, chest tightness, cough and expectoration, and hemoptysis (52.94% vs 16.00%, 61.76% vs 40.00%, 72.06% vs 46.00%, 27.94% vs 8.00%, p < 0.05, respectively), and more changes in pulmonary CT scanning images in terms of patched/striped compact opacity, alveolar hemorrhage, bronchiectasis, pleural effusion, as well as mediastinal lymphadenopathy (89.71% vs 52.00%, 11.76% vs 2.00%, 22.06% vs 8.00%, 50.00% vs 20.00%, 48.53% vs 24.00%, p < 0.05, respectively). In addition, patients in the lung infection group had significantly higher levels of serum pro-calcitonin (PCT), C-reactive protein (CRP), amyloid A (SAA), blood neutrophil-to-lymphocyte ratio (NLCR), erythrocyte sedimentation rate (ESR), as well as Birmingham vasculitis activity score (BVAS) than patients in the other two groups (p < 0.05). Among all biomarkers, PCT exhibited the highest diagnostic efficacy (0.928; 95%CI 0.89-0.97) for pulmonary infected AAV patients at a cut-off score of 0.235 ng/ml with 85.3% sensitivity and 84% specificity. Moreover, the composite biomarker of PCT-CRP-NLCR showed more diagnostic efficacy (0.979; 95% CI 0.95-1.00) in distinguishing the infectious and non-infectious lung injuries in AAV patients. CONCLUSIONS AAV patients with lung infection manifested more clinical symptoms and prominent lung image changes. The PCT and composite biomarker PCT-CRP-NLCR showed high diagnostic efficacy for a lung infection in AAV patients. Pulmonary lesion caused by either infection or AAV involvement is commonly seen and difficult to distinguish. We aim to identify the biomarkers that can be applied in the differentiation diagnosis of pulmonary lesions in AAV patients.
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Affiliation(s)
- Yujuan Wang
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
| | - Zhuan Qu
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
| | - Wei Liang
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
| | - Xinghua Chen
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
| | - Cheng Chen
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
| | - Hui Cheng
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
| | - Haiyun Hu
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
| | - Zhongpin Wei
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
| | - Ke Su
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
| | - Lianhua Yang
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
| | - Huiming Wang
- grid.412632.00000 0004 1758 2270Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, 430060 Hubei Province People’s Republic of China
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Abstract
Pneumonia is very common and continues to exact a high burden on health. The Global Burden of Disease Study 2015 found lower respiratory infections (LRIs) were the leading infectious cause of death and the fifth leading cause of death overall. Pneumococcal pneumonia caused 55% of LRI deaths in all ages (1.5 million deaths). Novel pathogens, particularly viruses, continue to emerge as causes of pneumonia. The rise of drug-resistance among common respiratory pathogens is a further challenge. Pneumonia is commonly classified according to patient location at the time of infection, leading to the categories of community-acquired, hospital-acquired and ventilator-acquired pneumonia.
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Diagnosing community-acquired pneumonia via a smartphone-based algorithm: a prospective cohort study in primary and acute-care consultations. Br J Gen Pract 2021; 71:e258-e265. [PMID: 33558330 DOI: 10.3399/bjgp.2020.0750] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 11/09/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is an essential consideration in patients presenting to primary care with respiratory symptoms; however, accurate diagnosis is difficult when clinical and radiological examinations are not possible, such as during telehealth consultations. AIM To develop and test a smartphone-based algorithm for diagnosing CAP without need for clinical examination or radiological inputs. DESIGN AND SETTING A prospective cohort study using data from participants aged >12 years presenting with acute respiratory symptoms to a hospital in Western Australia. METHOD Five cough audio-segments were recorded and four patient-reported symptoms (fever, acute cough, productive cough, and age) were analysed by the smartphone-based algorithm to generate an immediate diagnostic output for CAP. Independent cohorts were recruited to train and test the accuracy of the algorithm. Diagnostic agreement was calculated against the confirmed discharge diagnosis of CAP by specialist physicians. Specialist radiologists reported medical imaging. RESULTS The smartphone-based algorithm had high percentage agreement (PA) with the clinical diagnosis of CAP in the total cohort (n = 322, positive PA [PPA] = 86.2%, negative PA [NPA] = 86.5%, area under the receiver operating characteristic curve [AUC] = 0.95); in participants 22-<65 years (n = 192, PPA = 85.7%, NPA = 87.0%, AUC = 0.94), and in participants aged ≥65 years (n = 86, PPA = 85.7%, NPA = 87.5%, AUC = 0.94). Agreement was preserved across CAP severity: 85.1% (n = 80/94) of participants with CRB-65 scores 1 or 2, and 87.7% (n = 57/65) with a score of 0, were correctly diagnosed by the algorithm. CONCLUSION The algorithm provides rapid and accurate diagnosis of CAP. It offers improved accuracy over current protocols when clinical evaluation is difficult. It provides increased capabilities for primary and acute care, including telehealth services, required during the COVID-19 pandemic.
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Hunold KM, Caterino JM, Bischof JJ. Diagnostic Uncertainty in Dyspneic Patients with Cancer in the Emergency Department. West J Emerg Med 2021; 22:170-176. [PMID: 33856297 PMCID: PMC7972394 DOI: 10.5811/westjem.2020.10.48091] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 10/26/2020] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Dyspnea is the second most common symptom experienced by the approximately 4.5 million patients with cancer presenting to emergency departments (ED) each year. Distinguishing pneumonia, the most common reason for presentation, from other causes of dyspnea is challenging. This report characterizes the diagnostic uncertainty in patients with dyspnea and pneumonia presenting to an ED by establishing the rates of co-diagnosis, co-treatment, and misdiagnosis. METHODS Visits by individuals ≥18 years old with cancer who presented with a complaint of dyspnea were identified using the National Hospital Ambulatory Medical Care Survey between 2012-2014 and analyzed for rates of co-diagnosis, co-treatment (treatment or diagnosis for >1 of pneumonia, chronic obstructive pulmonary disease [COPD], and heart failure), and misdiagnosis of pneumonia. Additionally, we assessed rates of diagnostic uncertainty (co-diagnosis, co-treatment, or a lone diagnosis of dyspnea not otherwise specified [NOS]). RESULTS Among dyspneic cancer visits (1,593,930), 15.2% (95% confidence interval [CI], 11.1-20.5%) were diagnosed with pneumonia, 22.5% (95% CI, 16.7-29.7%) with COPD, and 7.4% (95% CI 4.7-11.4%) with heart failure. Dyspnea NOS was diagnosed in 32.3% (95% CI, 25.7-39.7%) of visits and as the only diagnosis in 23.1% (95% CI, 16.3-31.6%) of all visits. Co-diagnosis occurred in 4.0% (95% CI, 2.0-7.6%) of dyspneic adults with cancer and co-treatment in 12.1% (95% CI, 7.5-18.9%). Agreement between emergency physician and inpatient documentation for presence of pneumonia was 57.7% (95% CI, 37.0-76.1%). CONCLUSION Diagnostic uncertainty remains a significant concern in patients with cancer presenting to the ED with dyspnea. Clinical uncertainty among dyspneic patients results in both misdiagnosis and under-treatment of patients with pneumonia and cancer.
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Affiliation(s)
- Katherine M Hunold
- The Ohio State University Wexner Medical Center, Department of Emergency Medicine, Columbus, Ohio
| | - Jeffrey M Caterino
- The Ohio State University Wexner Medical Center, Department of Emergency Medicine, Columbus, Ohio
| | - Jason J Bischof
- The Ohio State University Wexner Medical Center, Department of Emergency Medicine, Columbus, Ohio
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Affiliation(s)
| | | | - Barry C Fox
- University of Wisconsin–Madison, Madison, WI
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White PT, Harries TH. Have rates of readmission for COPD been overestimated? NPJ Prim Care Respir Med 2016; 26:16066. [PMID: 27734967 PMCID: PMC5062563 DOI: 10.1038/npjpcrm.2016.66] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Patrick T White
- Department of Primary Care and Public Health Sciences, Division of Health and Social Care Research, King's College London, London, UK
| | - Timothy H Harries
- Department of Primary Care and Public Health Sciences, Division of Health and Social Care Research, King's College London, London, UK
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Magnetic bead fluorescent immunoassay for the rapid detection of the novel inflammation marker YKL40 at the point-of-care. J Immunol Methods 2015; 427:36-41. [DOI: 10.1016/j.jim.2015.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 08/21/2015] [Accepted: 09/23/2015] [Indexed: 11/19/2022]
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Coon ER, Maloney CG, Shen MW. Antibiotic and Diagnostic Discordance Between ED Physicians and Hospitalists for Pediatric Respiratory Illness. Hosp Pediatr 2015; 5:111-118. [PMID: 25732983 DOI: 10.1542/hpeds.2014-0110] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Imperfect diagnostic tools make it difficult to know the extent to which a bacterial process is contributing to respiratory illness, complicating the decision to prescribe antibiotics. We sought to quantify diagnostic and antibiotic prescribing disagreements between emergency department (ED) and pediatric hospitalist physicians for children admitted with respiratory illness. METHODS Manual chart review was used to identify testing, diagnostic, and antibiotic prescribing decisions for consecutive children admitted for respiratory illness in a winter (starting February 20, 2012) and a summer (starting August 20, 2012) season to a tertiary, freestanding children's hospital. Respiratory illness diagnoses were grouped into 3 categories: bacterial, viral, and asthma. RESULTS A total of 181 children admitted for respiratory illness were studied. Diagnostic discordance was significant for all 3 types of respiratory illness but greatest for bacterial (P<.001). Antibiotic prescribing discordance was significant (P<.001), with pediatric hospitalists changing therapy for 93% of patients prescribed antibiotics in the ED, including stopping antibiotics altogether for 62% of patients. CONCLUSIONS Significant diagnostic and antibiotic discordance between ED and pediatric hospitalist physicians exists for children admitted to the hospital for respiratory illness.
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Affiliation(s)
- Eric R Coon
- Division of Inpatient Medicine, Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah; and
| | - Christopher G Maloney
- Division of Inpatient Medicine, Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah; and
| | - Mark W Shen
- University of Texas Southwestern, Dell Children's Hospital, Austin, Texas
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Huttner B, Jones M, Huttner A, Rubin M, Samore MH. Antibiotic prescription practices for pneumonia, skin and soft tissue infections and urinary tract infections throughout the US Veterans Affairs system. J Antimicrob Chemother 2013; 68:2393-9. [DOI: 10.1093/jac/dkt171] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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