[Lymphogranuloma venereum, an STI that is sometimes recognized late in secondary care]. / Lymphogranuloma venereum.

Lymphogranuloma venereum (LGV) is an invasive sexually transmitted infection caused by Chlamydia trachomatis genotypes L1, L2 and L3. Until recently, LGV was rarely seen in developed countries. However, an outbreak of LGV infections in Europe amongst men who have sex with men (MSM) has been reported in the past decades. Diagnosing LGV can be challenging since there is no pathognomic clinical presentation. Most patients are diagnosed with LGV by Community Healthcare Services and general practitioners. Recent data show that a significant diagnostic delay can occur when patients present in a hospital with symptoms due to LGV infection. This can result in unnecessary additional diagnostic procedures and a subsequent diagnostic delay. In order to create more awareness, we describe 3 cases in our hospital with an initially unrecognized LGV infection. We also discuss the epidemiology, clinical manifestations, diagnostic process and treatment of LGV infection.

The utility of peripheral venous lactate in emergency department patients with normal and higher lactate levels: A prospective observational study.

OBJECTIVE: to assess the utility of peripheral venous lactate (PVL) in Emergency Department patients. METHODS: arteriovenous agreement was assessed in three subgroups: PVL <2 mmol/l, PVL ≥ 2 mmol/l to < 4 mmol/l and PVL ≥ 4 mmol/l. The predictive value of PVL to predict arterial lactate (AL) ≥2 mmol/l was assessed at different cut-off values. RESULTS: 74 samples were analysed. The venous-arterial mean difference and 95% limits of agreement for the subgroups were 0.25 mmol/l (-0.18 to 0.68), 0.37 mmol/l (-0.57 to 1.32) and -0.89 mmol/l (-3.75 to 1.97). PVL ≥2 mmol/l predicts AL ≥2 mmol/l with 100% sensitivity. CONCLUSION: PVL <2 mmol/l rules out arterial hyperlactatemia. As agreement declines in higher levels, arterial sampling should be considered.

Agreement between arterial and peripheral venous lactate levels in the ED: A systematic review.

BACKGROUND: In the Emergency Department, lactate measurement is a useful tool to risk-stratify critically ill patients. However, it is unclear whether arterial or peripheral venous lactate levels can be used interchangeably for this purpose. In this systematic review, we provide an overview of studies investigating the agreement between arterial and peripheral venous lactate levels in the Emergency Department. METHODS: PubMed, Embase, the Cochrane Central Register of Controlled Trials/Wiley, Web of Science/Clarivate Analytics, and references of selected articles were assessed for all studies comparing arterial and peripheral venous lactate levels in adult patients in the emergency department. Two reviewers independently screened all potentially relevant titles and abstracts for eligibility using a standardized data-worksheet. RESULTS: Nine studies were included. Peripheral venous lactate levels tend to be higher than arterial lactate levels with mean differences ranging from 0.18 mmol/l to 1.06 mmol/l. Importantly, poorer agreement occurs in hyperlactatemia. At a cut-of level of 1.6 mmol/l, peripheral venous lactate can rule out arterial hyperlactatemia with a sensitivity between 94% and 100%. At a cut off value of 2 mmol/l, sensitivities of 97% and 100% were found. CONCLUSION: Agreement between arterial and peripheral venous lactate is poor in hyperlactatemia, making peripheral venous lactate an unreliable parameter to use interchangeably in the ED. In clinical practice, peripheral venous lactate can be used as a screening tool to rule out arterial hyperlactatemia at a cut-off value of 2 mmol/l. However, hyperlactatemia should be confirmed using arterial sampling in case of a peripheral venous lactate level > 2 mmol/l.

Pitfalls in SIADH-diagnosed hyponatraemia: Report of two cases.

In the majority of hospitalised patients with hyponatraemia, syndrome of inappropriate antidiuretic hormone secretion (SIADH) is the primary cause. Before considering SIADH, adrenal, thyroid and pituitary insufficiency should be ruled out. However, the evaluation of these contains potential pitfalls which could lead to incorrect diagnosing of SIADH. Here we present two cases in which a suspected SIADH turned out to be caused by hypopituitarism, emphasising the importance of correctly excluding adrenal, thyroid and pituitary insufficiency.

[Splenic abscess]. / Het miltabces.

Splenic abscess is a rare and potentially lethal clinical condition. The most common symptoms of a splenic abscess - abdominal pain, nausea and fever - are non-specific. As a result, a splenic abscess is often not considered in the initial work-up. This might lead to a delay in diagnosis and treatment. In this case series we successively describe a 41-year-old female with a splenic abscess after Streptococcus milleri bacteraemia, a 78-year-old male with a splenic abscess caused by a colon carcinoma and a 52-year-old male with a splenic abscess resulting from a colosplenic fistula after bariatric surgery. By emphasizing the different aetiologies, the different clinical presentations and the different therapeutic options of a splenic abscess, we aim to create greater awareness of this rare clinical phenomenon.

The impact of the use of the Early Warning Score (EWS) on patient outcomes: a systematic review.

BACKGROUND: Acute deterioration in critical ill patients is often preceded by changes in physiological parameters, such as pulse, blood pressure, temperature and respiratory rate. If these changes in the patient's vital parameters are recognized early, excess mortality and serious adverse events (SAEs) such as cardiac arrest may be prevented. The Early Warning Score (EWS) is a scoring system which assists with the detection of physiological changes and may help identify patients at risk of further deterioration. OBJECTIVES: The aim of this systematic review is to evaluate the impact of the use of the Early Warning Score (EWS) on particular patient outcomes, such as in-hospital mortality, patterns of intensive care unit admission and usage, length of hospital stay, cardiac arrests and other serious adverse events of adult patients on general wards and in medical admission units. DESIGN AND SETTING: Systematic review of studies identified from the bibliographic databases of PubMed, EMBASE.com and The Cochrane Library. SELECTION CRITERIA: All controlled studies which measured in-hospital mortality, ICU mortality, serious adverse events (SAEs), cardiopulmonary arrest, length of stay and documentation of physiological parameters which used a EWS on the ward or the emergency department to identify patients at risk were included in the review. DATA COLLECTION AND ANALYSIS: Three reviewers (NA, AT and EH) independently screened all potentially relevant titles and abstracts for eligibility, by using a standardized data-worksheet. Meta-analysis was not possible due to heterogeneity. MAIN RESULTS: Seven studies met the inclusion criteria. The results of our included studies were mixed, with a positive trend towards better clinical outcomes following the introduction of the EWS chart, sometimes coupled with an outreach service. Six of the seven included studies used mortality as an endpoint: two of these studies reported no significant difference in in-hospital mortality rate; two found a significant reduction of in-hospital mortality; two other studies described a trend towards improved survival. Although, both ICU mortality and serious adverse events were not significantly improved, there was a trend towards reduction of these endpoints after introduction of the EWS. However only two studies looked respectively at each endpoint. There were conflicting results concerning cardiopulmonary arrests. One study found a reduction in the incidence of cardiac arrest calls as well as in the mortality of patients who underwent CPR, while another one found an increased incidence of cardio-pulmonary arrests. Neither study met all methodological quality criteria. CONCLUSION: The EWS itself is a simple and easy to use tool at the bedside, which may be of help in recognizing patients with potential for acute deterioration. Coupled with an outreach service, it may be used to timely initiate adequate treatment upon recognition, which may influence the clinical outcomes positively. However, the use of adapted forms of the EWS together with different thresholds, poor or inadequate methodology makes it difficult in drawing comparisons. A general conclusion can thus not be generated from the lack of use of a single standardized score and the use of different populations. In future large multi-centre trials using one standardized score are needed also in order to facilitate comparison.