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Zhao M, Feng L, Zhao K, Cui Y, Li Z, Ke C, Yang X, Qiu Q, Lu W, Liang Y, Xie C, Wan X, Liu Z. An MRI-based scoring system for pretreatment risk stratification in locally advanced rectal cancer. Br J Cancer 2023; 129:1095-1104. [PMID: 37558922 PMCID: PMC10539304 DOI: 10.1038/s41416-023-02384-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Accurately assessing the risk of recurrence in patients with locally advanced rectal cancer (LARC) before treatment is important for the development of treatment strategies. The purpose of this study is to develop an MRI-based scoring system to predict the risk of recurrence in patients with LARC. METHODS This was a multicenter observational study that enrolled participants who underwent neoadjuvant chemoradiotherapy. To evaluate the risk of recurrence in these patients, we developed the mrDEC scoring system and assessed inter-reader agreement. Additionally, we plotted Kaplan-Meier curves to compare the 3-year disease-free survival (DFS) and 5-year overall survival (OS) rates among patients with different mrDEC scores. RESULTS A total of 1287 patients with LARC were included in this study. We observed substantial inter-reader agreement for mrDEC. Based on the mrDEC scores ranging from 0 to 3, the patients were categorized into four groups. The 3-year DFS rates for the groups were 91.0%, 79.5%, 65.5%, and 44.0% (P < 0.0001), respectively, and the 5-year OS rates were 92.9%, 87.1%, 74.8%, and 44.5%, respectively (P < 0.0001). CONCLUSIONS The mrDEC scoring system proved to be an effective tool for predicting the prognosis of patients with LARC and can assist clinicians in clinical decision-making.
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Affiliation(s)
- Minning Zhao
- Department of Radiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Radiology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Lili Feng
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Radiology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Ke Zhao
- Department of Radiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China.
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangzhou, China.
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
| | - Yanfen Cui
- Department of Radiology, Shanxi Cancer Hospital, Shanxi Medical University, Taiyuan, China
| | - Zhenhui Li
- Department of Radiology, the Third Affiliated Hospital of Kunming Medical University, Yunnan Cancer Hospital, Yunnan Cancer Center, Kunming, China
| | - Chenglu Ke
- Department of Radiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Xinyue Yang
- Department of Radiology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Qing Qiu
- Department of Radiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Weirong Lu
- Department of Medical Imaging Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yanting Liang
- Department of Radiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - ChuanMiao Xie
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China.
- Department of Radiology, Sun Yat-Sen University Cancer Center, Guangzhou, China.
| | - Xiangbo Wan
- Provincial Key Laboratory of Radiation Medicine in Henan (Under construction), The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
- Department of Radiation Oncology, the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
| | - Zaiyi Liu
- Department of Radiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China.
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangzhou, China.
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Levinson T, Feigin E, Berliner S, Shenhar-Tsarfaty S, Shapira I, Rogowski O, Zeltzer D, Goldiner I, Shtark M, Katz Shalhav M, Wasserman A. Normoferremia in Patients with Acute Bacterial Infections-A Hitherto Unexplored Field of the Dichotomy between CRP and Ferritin Expression in Patients with Hyper Inflammation and Failure to Increase Ferritin. Int J Mol Sci 2023; 24:11350. [PMID: 37511109 PMCID: PMC10379163 DOI: 10.3390/ijms241411350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
Ferritin is an acute phase response protein, which may not rise as expected in acute bacterial infections. This could be due to the time required for its production or to a lack of response of ferritin to the bacterial inflammatory process. Medical records of hospitalized patients with acute hyper inflammation were retrieved and studied, looking closely at two acute phase proteins: C-reactive protein (CRP) and ferritin. The estimated time between symptom onset and the procurement of blood tests was also measured. 225 patients had a median ferritin level of 109.9 ng/mL [IQR 85.1, 131.7] and a median CRP level of 248.4 mg/L [IQR 221, 277.5]. An infectious inflammatory process was identified in 195 patients. Ferritin levels were relatively low in comparison with the CRP in each group, divided according to time from symptom onset until the procurement of blood tests. The discrepancy between high CRP and low ferritin suggests that these two acute phase response proteins utilize different pathways, resulting in a failure to increase ferritin concentrations in a documented state of hyperinflammation. A new entity of normoferremic inflammation accounts for a significant percentage of patients with acute bacterial infections, which enables bacteria to better survive the inflammation and serves as a new "inflammatory stamp".
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Affiliation(s)
- Tal Levinson
- Infectious Diseases Unit, Tel-Aviv Sourasky Medical Center Affiliated to the Faculty of Medicine, Tel-Aviv University, Tel Aviv 6423906, Israel
- Departments of Internal Medicine C, D and E, Tel Aviv Sourasky Medical Center Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Eugene Feigin
- Departments of Internal Medicine C, D and E, Tel Aviv Sourasky Medical Center Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
- Department of Endocrinology, Tel Aviv Sourasky Medical Center Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Shlomo Berliner
- Departments of Internal Medicine C, D and E, Tel Aviv Sourasky Medical Center Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Shani Shenhar-Tsarfaty
- Departments of Internal Medicine C, D and E, Tel Aviv Sourasky Medical Center Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Itzhak Shapira
- Departments of Internal Medicine C, D and E, Tel Aviv Sourasky Medical Center Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Ori Rogowski
- Departments of Internal Medicine C, D and E, Tel Aviv Sourasky Medical Center Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - David Zeltzer
- Department of Emergency Medicine, Tel-Aviv Sourasky Medical Center, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Ilana Goldiner
- Clinical Laboratory Services, Tel Aviv Sourasky Medical Center, Tel Aviv, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Moshe Shtark
- Clinical Laboratory Services, Tel Aviv Sourasky Medical Center, Tel Aviv, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Malka Katz Shalhav
- Department of Emergency Medicine, Tel-Aviv Sourasky Medical Center, Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Asaf Wasserman
- Departments of Internal Medicine C, D and E, Tel Aviv Sourasky Medical Center Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
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Xu T, Wu S, Li J, Wang L, Huang H. Development of a risk prediction model for bloodstream infection in patients with fever of unknown origin. J Transl Med 2022; 20:575. [PMID: 36482449 PMCID: PMC9733314 DOI: 10.1186/s12967-022-03796-8] [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: 04/10/2022] [Accepted: 11/27/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Bloodstream infection (BSI) is a significant cause of mortality among patients with fever of unknown origin (FUO). Inappropriate empiric antimicrobial therapy increases difficulty in BSI diagnosis and treatment. Knowing the risk of BSI at early stage may help improve clinical outcomes and reduce antibiotic overuse. METHODS We constructed a multivariate prediction model based on clinical features and serum inflammatory markers using a cohort of FUO patients over a 5-year period by Least Absolute Shrinkage and Selection Operator (LASSO) and logistic regression. RESULTS Among 712 FUO patients, BSI was confirmed in 55 patients. Five independent predictors available within 24 h after admission for BSI were identified: presence of diabetes mellitus, chills, C-reactive protein level of 50-100 mg/L, procalcitonin > 0.3 ng/mL, neutrophil percentage > 75%. A predictive score incorporating these 5 variables has adequate concordance with an area under the curve of 0.85. The model showed low positive predictive value (22.6%), but excellent negative predictive value (97.4%) for predicting the risk of BSI. The risk of BSI reduced to 2.0% in FUO patients if score < 1.5. CONCLUSIONS A simple tool based on 5 variables is useful for timely ruling out the individuals at low risk of BSI in FUO population.
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Affiliation(s)
- Teng Xu
- grid.8547.e0000 0001 0125 2443Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, 200040 China ,grid.453135.50000 0004 1769 3691Key Laboratory of Clinical Pharmacology of Antibiotics, National Health and Family Planning Commission, Shanghai, 200040 China
| | - Shi Wu
- grid.8547.e0000 0001 0125 2443Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, 200040 China ,grid.453135.50000 0004 1769 3691Key Laboratory of Clinical Pharmacology of Antibiotics, National Health and Family Planning Commission, Shanghai, 200040 China
| | - Jingwen Li
- grid.8547.e0000 0001 0125 2443Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, 200040 China ,grid.453135.50000 0004 1769 3691Key Laboratory of Clinical Pharmacology of Antibiotics, National Health and Family Planning Commission, Shanghai, 200040 China
| | - Li Wang
- grid.8547.e0000 0001 0125 2443Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, 200040 China ,grid.453135.50000 0004 1769 3691Key Laboratory of Clinical Pharmacology of Antibiotics, National Health and Family Planning Commission, Shanghai, 200040 China
| | - Haihui Huang
- grid.8547.e0000 0001 0125 2443Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, 200040 China ,grid.453135.50000 0004 1769 3691Key Laboratory of Clinical Pharmacology of Antibiotics, National Health and Family Planning Commission, Shanghai, 200040 China
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Chen J, Xing M, Xu D, Xie N, Zhang W, Ruan Q, Song J. Diagnostic models for fever of unknown origin based on 18F-FDG PET/CT: a prospective study in China. EJNMMI Res 2022; 12:69. [DOI: 10.1186/s13550-022-00937-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/24/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
This study aims to analyze the 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) characteristics of different causes of fever of unknown origin (FUO) and identify independent predictors to develop a suitable diagnostic model for distinguishing between these causes. A total of 524 patients with classical FUO who underwent standard diagnostic procedures and PET/CT were prospectively studied. The diagnostic performance of PET/CT imaging was analyzed, and relevant clinical parameters that could improve diagnostic efficacy were identified. The model was established using the data of 369 patients and the other 155 patients comprised the validation cohort for verifying the diagnostic performance of the model.
Results
The metabolic characteristics of the “hottest” lesion, the spleen, bone marrow, and lymph nodes varied for various causes. PET/CT combined with clinical parameters achieved better discrimination in the differential diagnosis of FUO. The etiological diagnostic models included the following factors: multisite metabolic characteristics, blood cell counts, inflammatory indicators (erythrocyte sedimentation rate, C-reactive protein, serum ferritin, and lactate dehydrogenase), immunological indicators (interferon gamma release assay, antinuclear antibody, and anti-neutrophil cytoplasm antibody), specific signs (weight loss, rash, and splenomegaly), and age. In the testing cohort, the AUCs of the infection prediction model, the malignancy diagnostic model, and the noninfectious inflammatory disease prediction model were 0.89 (95% CI 0.86–0.92), 0.94 (95% CI 0.92–0.97), and 0.95 (95% CI 0.93–0.97), respectively. The corresponding AUCs for the validation cohort were 0.88 (95% CI 0.82–0.93), 0.93 (95% CI 0.89–0.98), and 0.95 (95% CI 0.92–0.99), respectively.
Conclusions
18F-FDG PET/CT has a certain level of sensitivity and accuracy in diagnosing FUO, which can be further improved by combining it with clinical parameters. Diagnostic models based on PET/CT show excellent performance and can be used as reliable tools to discriminate the cause of FUO.
Trial registration This study (a two-step method apparently improved the physicians’ level of diagnosis decision-making for adult patients with FUO) was registered on the website http://www.clinical-trials.gov on January 14, 2014, with registration number NCT02035670.
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Wright WF, Yenokyan G, Auwaerter PG. Geographic Upon Noninfectious Diseases Accounting for Fever of Unknown Origin (FUO): A Systematic Review and Meta-analysis. Open Forum Infect Dis 2022; 9:ofac396. [PMID: 36004312 PMCID: PMC9394765 DOI: 10.1093/ofid/ofac396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/29/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Diagnostic outcomes for fever of unknown origin (FUO) remain with notable numbers of undiagnosed cases. A recent systemic review and meta-analysis of studies reported geographic variation in FUO-related infectious diseases. Whether geography influences types of FUO noninfectious diagnoses deserves examination.
Methods
Medline (PubMed), Embase, Scopus, and Web of Science databases were searched systematically using medical subject headings published from January 1, 1997, to March 31, 2021. Prospective clinical studies investigating participants meeting adult FUO defining criteria were selected if they assessed final diagnoses. Meta-analyses were based on the random-effects model according to World Health Organization (WHO) geographical regions.
Results
Nineteen studies with significant heterogeneity were analyzed, totaling 2,667 participants. Noninfectious inflammatory disorders had a pooled estimate at 20.0% (95%CI: 17.0-23.0%). Undiagnosed illness had a pooled estimate of 20.0% (95%CI: 14.0-26.0%). The pooled estimate for cancer was 15.0% (95%CI: 12.0-18.0%). Miscellaneous conditions had a pooled estimate of 6.0% (95%CI: 4.0-8.0%). Noninfectious inflammatory disorders and miscellaneous conditions were most prevalent in the Western Pacific region with a 27.0% pooled estimate (95%CI: 20.0-34.0%) and 9.0% (95%CI: 7.0-11.0%), respectively. The highest pooled estimated for cancer was in the Eastern Mediterranean region at 25.0% (95%CI: 18.0-32.0%). Adult-onset Still’s disease (114 [58.5%]), systemic lupus (52 [26.7%]), and giant-cell arteritis (40 [68.9%]) predominated among the noninfectious inflammatory group. Lymphoma (164 [70.1%]) was the most common diagnosis in the cancer group.
Conclusions
In this systematic review and meta-analysis, noninfectious disease diagnostic outcomes varied among WHO-defined geographies. Evaluation of FUO should consider local variations in disease prevalence.
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Affiliation(s)
- William F Wright
- Correspondence: William F. Wright, DO, MPH, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, 733 North Broadway, Baltimore, MD 21205 ()
| | - Gayane Yenokyan
- Johns Hopkins Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Betrains A, Moreel L, De Langhe E, Blockmans D, Vanderschueren S. Rheumatic disorders among patients with fever of unknown origin: A systematic review and meta-analysis. Semin Arthritis Rheum 2022; 56:152066. [PMID: 35868032 DOI: 10.1016/j.semarthrit.2022.152066] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/23/2022] [Accepted: 07/05/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To conduct a systematic literature review and meta-analysis to estimate the proportion of fever of unknown origin (FUO) and inflammation of unknown origin (IUO) cases that are due to rheumatic disorders and the relative frequency of specific entities associated with FUO/IUO. METHODS We searched PubMed and EMBASE between January 1, 2002, and December 31, 2021, for studies with ≥50 patients reporting on causes of FUO/IUO. The primary outcome was the proportion of FUO/IUO patients with rheumatic disease. Secondary outcomes include the association between study and patient characteristics and the proportion of rheumatic disease in addition to the relative frequency of rheumatic disorders within this group. Proportion estimates were calculated using random-effects models. RESULTS The included studies represented 16884 patients with FUO/IUO. Rheumatic disease explained 22.2% (95%CI 19.6 - 25.0%) of cases. Adult-onset Still's disease (22.8% [95%CI 18.4-27.9%]), giant cell arteritis (11.4% [95%CI 8.0-16.3%]), and systemic lupus erythematosus (11.1% [95%CI 9.0-13.8%]) were the most frequent disorders. The proportion of rheumatic disorders was significantly higher in high-income countries (25.9% [95%CI 21.5 - 30.8%]) versus middle-income countries (19.5% [95%CI 16.7 - 22.7%]) and in prospective studies (27.0% [95%CI 21.9-32.8%]) versus retrospective studies (20.6% [95%CI 18.1-24.0%]). Multivariable meta-regression analysis demonstrated that rheumatic disease was associated with the fever duration (0.011 [95%CI 0.003-0.021]; P=0.01) and with the fraction of patients with IUO (1.05 [95%CI 0.41-1.68]; P=0.002). CONCLUSION Rheumatic disorders are a common cause of FUO/IUO. The care of patients with FUO/IUO should involve physicians who are familiar with the diagnostic workup of rheumatic disease.
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Affiliation(s)
- A Betrains
- Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.
| | - L Moreel
- Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - E De Langhe
- Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - D Blockmans
- Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - S Vanderschueren
- Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
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Wright WF, Betz JF, Auwaerter PG. Prospective Studies Comparing Structured vs Nonstructured Diagnostic Protocol Evaluations Among Patients With Fever of Unknown Origin: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2215000. [PMID: 35653154 PMCID: PMC9164007 DOI: 10.1001/jamanetworkopen.2022.15000] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 04/14/2022] [Indexed: 11/14/2022] Open
Abstract
Importance Patients meeting the criteria for fever of unknown origin (FUO) can be evaluated with structured or nonstructured approaches, but the optimal diagnostic method is unresolved. Objective To analyze differences in diagnostic outcomes among patients undergoing structured or nonstructured diagnostic methods applied to prospective clinical studies. Data Sources PubMed, Embase, Scopus, and Web of Science databases with librarian-generated query strings for FUO, PUO, fever or pyrexia of unknown origin, clinical trial, and prospective studies identified from January 1, 1997, to March 31, 2021. Study Selection Prospective studies meeting any adult FUO definition were included. Articles were excluded if patients did not precisely fit any existing adult FUO definition or studies were not classified as prospective. Data Extraction and Synthesis Abstracted data included years of publication and study period, country, setting (eg, university vs community hospital), defining criteria and category outcome, structured or nonstructured diagnostic protocol evaluation, sex, temperature threshold and measurement, duration of fever and hospitalization before final diagnoses, and contribution of potential diagnostic clues, biochemical and immunological serologic studies, microbiology cultures, histologic analysis, and imaging studies. Structured protocols compared with nonstructured diagnostic methods were analyzed using regression models. Main Outcomes and Measures Overall diagnostic yield was the primary outcome. Results Among the 19 prospective trials with 2627 unique patients included in the analysis (range of patient ages, 10-94 years; 21.0%-55.3% female), diagnoses among FUO series varied across and within World Health Organization (WHO) geographic regions. Use of a structured diagnostic protocol was not significantly associated with higher odds of yielding a diagnosis compared with nonstructured protocols in aggregate (odds ratio [OR], 0.98; 95% CI, 0.65-1.49) or between Western Europe (Belgium, France, the Netherlands, and Spain) (OR, 0.95; 95% CI, 0.49-1.86) and Eastern Europe (Turkey and Romania) (OR, 0.83; 95% CI, 0.41-1.69). Despite the limited number of studies in some regions, analyses based on the 6 WHO geographic areas found differences in the diagnostic yield. Western European studies had the lowest percentage of achieving a diagnosis. Southeast Asia led with infections at 49.0%. Noninfectious inflammatory conditions were most prevalent in the Western Pacific region (34.0%), whereas the Eastern Mediterranean region had the highest proportion of oncologic explanations (24.0%). Conclusions and Relevance In this systematic review and meta-analysis, diagnostic yield varied among WHO regions. Available evidence from prospective studies did not support that structured diagnostic protocols had a significantly better rate of achieving a diagnosis than nonstructured protocols. Clinicians worldwide should incorporate geographical disease prevalence in their evaluation of patients with FUO.
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Affiliation(s)
- William F. Wright
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joshua F. Betz
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Paul G. Auwaerter
- The Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Wright WF, Yenokyan G, Simner PJ, Carroll KC, Auwaerter PG. Geographic Variation of Infectious Disease Diagnoses Among Patients with Fever of Unknown Origin (FUO) – A Systematic Review and Meta-analysis. Open Forum Infect Dis 2022; 9:ofac151. [PMID: 35450085 PMCID: PMC9017373 DOI: 10.1093/ofid/ofac151] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/18/2022] [Indexed: 11/12/2022] Open
Abstract
Background Fever of unknown origin (FUO) investigations yield a substantial number of patients with infectious diseases. This systematic review and meta-analysis aimed to quantify more common FUO infectious diseases etiologies and to underscore geographic variation. Methods Four databases (PubMed, Embase, Scopus, and Web of Science) were searched for prospective studies reporting FUO rates among adult patients from 1 January 1997 to 31 March 2021. The pooled proportion for infectious diseases etiology was estimated using the random-effects meta-analysis model. Results Nineteen prospective studies were included with 2667 total cases. No studies were available for Africa or the Americas. Overall, 37.0% (95.0% confidence interval [CI], 30.0%–44.0%) of FUO patients had an infectious disease etiology. Infections were more likely from Southeastern Asia (pooled proportion, 0.49 [95% CI, .43–.55]) than from Europe (pooled proportion, 0.31 [95% CI, .22–.41]). Among specifically reported infectious diseases (n = 832), Mycobacterium tuberculosis complex predominated across all geographic regions (n = 285 [34.3%]), followed by brucellosis (n = 81 [9.7%]), endocarditis (n = 62 [7.5%]), abscesses (n = 61 [7.3%]), herpesvirus (eg, cytomegalovirus and Epstein-Barr virus) infections (n = 60 [7.2%]), pneumonia (n = 54 [6.5%]), urinary tract infections (n = 54 [6.5%]), and enteric fever (n = 40 [4.8%]). Conclusions FUO patients from Southeastern Asia were more likely to have an infectious diseases etiology when compared to other regions. The predominant factor for this finding appears to be differences in disease prevalence among various geographical locations or other factors such as access to timely care and diagnosis. Noting epidemiological disease factors in FUO investigations could improve diagnostic yields and clinical outcomes.
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Affiliation(s)
- William F Wright
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gayane Yenokyan
- Johns Hopkins Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Patricia J Simner
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Karen C Carroll
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Paul G Auwaerter
- The Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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