Family physicians overestimate diagnosis probabilities regardless of the test results.

Introduction: As useful tools for clinical decision-making, diagnostic tests require careful interpretation in order to prevent underdiagnosis, overdiagnosis or misdiagnosis. The aim of this study was to explore primary care practitioners' understanding and interpretation of the probability of disease before and after test results for six common clinical scenarios. Methods: This cross-sectional study was conducted with 414 family physicians who were working at primary care in Istanbul via face-to-face interviews held between November 2021 and March 2022. The participants were asked to estimate the probability of diagnosis in six clinical scenarios provided to them. Clinical scenarios were about three cancer screening cases (breast, cervical and colorectal), and three infectious disease cases (pneumonia, urinary tract infection, and COVID-19). For each scenario participants estimated the probability of the diagnosis before application of a diagnostic test, after a positive test result, and after a negative test result. Their estimates were compared with the true answers derived from relevant guidelines. Results: For all scenarios, physicians' estimates were significantly higher than the scientific evidence range. The minimum overestimation was positive test result for COVID-19 and maximum was pre-test case for cervical cancer. In the hypothetical control question for prevalence and test accuracy, physicians estimated disease probability as 95.0% for a positive test result and 5.0% for a negative test result while the correct answers were 2.0 and 0%, respectively (p < 0.001). Discussion: Comparing the scientific evidence, overestimation in all diagnostic scenarios, regardless of if the disease is an acute infection or a cancer, may indicate that the probabilistic approach is not conducted by the family physicians. To prevent inaccurate interpretation of the tests that may lead to incorrect or unnecessary treatments with adverse consequences, evidence-based decision-making capacity must be strengthened.

Monocyte to high-density lipoprotein ratio at hospital admission predicts intrahospital mortality in patients with Stanford type-A dissection.

BACKGROUND: Immune inflammatory mechanisms have crucial roles not only in the presence but also in the progression of aortic dissection (AD). Monocyte count to high-density lipoprotein ratio (MHR) has recently emerged as an indicator of inflammation and oxidative stress. Thus, we aimed to examine the prognostic value of MHR in patients with AD. METHODS: A total of 204 consecutive patients with Stanford type-A dissection who managed surgically were retrospectively enrolled in the present study. Recruited patients were divided into two groups according to the occurrence of intrahospital death; Group 1 consisted of 165 patients who were discharged alive, and Group 2 consisted of 39 patients who died during index hospitalization. Two groups were compared with respect to baseline clinical data and admission laboratory parameters including MHR. RESULTS: The mean age of the Group 1 was 55.2 ± 12.3 years, while the mean age of the Group 2 was 60.6 ± 10.8 years (p = .012). The patients who were discharged alive (Group 1) had significantly lower MHR than the deceased patients (Group 2) (0.02099 ± 0.00140 vs. 0.02848 ± 0.01513, p = .004). At receiver operating characteristics curve analysis, MHR = 0.020699 had 67% sensitivity and 59% specificity in predicting intrahospital mortality among patients with AD. In multivariate analysis, MHR was found to be an independent risk factor of intrahospital mortality among those (ß = 1.094, p = .011). CONCLUSION: MHR is an inexpensive and easily calculated biomarker, which is useful to predict intrahospital mortality in patients with Stanford type-A dissection who managed surgically.

A new scoring system for early diagnosis of ventilator-associated pneumonia: LUPPIS.

INTRODUCTION: The Clinical Pulmonary Infection Score (CPIS) based on chest X-ray has been developed to facilitate clinical diagnosis of ventilator-associated pneumonia (VAP); however, this scoring system has a low diagnostic performance. We developed the Lung Ultrasound and Pentraxin-3 Pulmonary Infection Score (LUPPIS) for early diagnosis of VAP and evaluated the performance of this new scoring system. MATERIAL AND METHODS: In a prospective study of 78 patients with suspected VAP, we assessed the detection accuracy of LUPPIS for pneumonia in adult patients. We also evaluated the diagnostic performance of pentraxin-3 (PTX-3) findings of infection. On the day of the study, lung ultrasound was performed, PTX-3 levels were determined, and an endotracheal aspirate was obtained for Gram staining and culture. RESULTS: No significant differences were found between groups with respect to age, mechanical ventilation time, APACHE II score, or SOFA score (p > 0.05). Procalcitonin and PTX-3 levels were significantly higher in the VAP (+) group (p < 0.001 and p < 0.001, respectively). The threshold for LUPPIS in differentiating VAP (+) patients from VAP (-) patients was > 7. In predicting VAP, LUPPIS > 7 (sensitivity of 84%, specificity of 87.7%) was superior to CPIS > 6 (sensitivity of 40.1%, specificity of 84.5%). CONCLUSIONS: LUPPIS appears to provide better results in the prediction of VAP compared to CPIS, and the importance of lung ultrasound and PTX-3 is emphasized, which is a distinctive property of LUPPIS.

Comparison of neutrophil to lymphocyte ratio with other prognostic markers affecting 30 day mortality in acute pulmonary embolism.

Introduction: Identifying the prognostic factors for patients with acute pulmonary embolism (APE) play a critical role in determining of the treatment strategy and to reduce mortality. The aim of this study is to evaluate the prognostic value of Neutrophil to Lymphocyte Ratio (NLR) and compare NLR with other prognostic factors in APE. Materials and Methods: We retrospectively examined 550 cases of acute pulmonary embolism diagnosed by spiral computed tomographic angiography. A receiver operating characteristics (ROC) curve was used to determine the sensitivity and specificity of parameters and the optimal cut-off value for predicting mortality. Significance of each prognostic factors selected by univariate analysis confirmed using Cox regression model. Result: Baseline NLR, Platelet to Lymphocyte Ratio (PLR), N-terminal pro-Brain Natriuretic Peptide (NT-proBNP), and D-dimer values respectively were found significantly high in patients who died within 30 days (p< 0.05). Patients with high-risk status and sPESI > 2 points had a significantly higher short-term mortality rate (p< 0.05). Short-time mortality was found significantly higher in patients with NLR > 7.3 (p< 0.05). Cox regression analysis indicated that patient risk status and sPESI score were independent prognostic factors (p< 0.05). However, NLR was not found as a predictor of mortality in APE (p> 0.05). After the subgroup analysis of the study, in patients without comorbid diseases NLR, patient's risk status, sPESI score were found the predictor of mortality in APE (p< 0.05). Conclusions: NLR maybe a useful prognostic factor for patients without comorbid diseases in short time of mortality in APE.

Pleural effusion as an indicator of short term mortality in acute pulmonary embolism.

INTRODUCTION: Pulmonary embolism (PE) is known as one of the major causes of cardiovascular morbidity and mortality. Identification of high risk patients for short term and long-term mortality is crucial. The purpose of this study is to demonstrate the prognostic importance of simplified pulmonary embolism severity index (sPESI), radiological investigations and comorbidities in terms of short-term mortality by simultaneous assessment of sPESI score, pulmonary computed tomography (CT) angiography findings and underlying comorbidities in patients diagnosed with acute pulmonary embolism. MATERIALS AND METHODS: We retrospectively evaluated 570 patients diagnosed with acute PE confirmed by computer tomography pulmonary angiography (CTPA). Comorbidities were recorded, pulmonary embolism severity index scores were calculated and CTPA data were evaluated as predictors for short-term mortality. RESULT: The study population consisted of 570 patients, 292 (51.2%) patients were female and 74 patients (12.9%) died within 30 days due to PE diagnosis. In univariate analysis male gender (p= 0.031), congestive heart failure (CHF)(p< 0.029), main pulmonary artery involvement (p= 0.045), presence of pleural effusion (p= 0.001) and pericardial effusion (p= 0.004) at time of diagnosis and high risk sPESI group (p< 0.001) had a significant influence on mortality. In the multivariate analysis, pleural effusions (HR, 1.67; CI, 1.05-2.66; p< 0.030) and sPESI high risk group (HR, 9.56; CI, 4.71-19.43; p< 0.001) were remained significant and independent prognostic factors for survival. CONCLUSIONS: The present study underlined that presence of pleural effusion at the time of diagnosis in patients with massive pulmonary embolism and a high sPESI score in other patients were significant predictors of short-term mortality.

Diagnostic Accuracy of Procalcitonin for Differentiating Bacteraemic Gram-Negative Sepsis from Gram-Positive Sepsis.

OBJECTIVE: The identification of bacteraemia in patients with suspected sepsis is crucial for survival. A cheap, fast and reliable biomarker, which can predict the causative pathogen group, may be useful to confirm or exclude the presence of bacteraemia. This study aimed to evaluate the relationship between procalcitonin (PCT) and the causative pathogen in intensive care patients with sepsis and bacteraemia. METHODS: Patients with diagnosed sepsis, a positive blood culture and measured serum procalcitonin levels during their intensive care unit stay were included in the study. Demographic data, PCT level, leukocyte count, C-reactive protein level, creatinine level, lymphocyte count, leukocyte/lymphocyte ratio and the group of the pathogen that detected in the blood culture were retrospectively recorded. RESULTS: Overall, 136 sepsis patients who were diagnosed with bacteraemia were included in the study. The PCT level was 7.31 ng mL-1 in the gram-negative group and 0.46 ng mL-1 in the gram-positive group. For PCT, the sensitivity was 70.83% and the specificity was 84.21%, with the cut-off value being ≤1.3. The area under the receiver operating characteristics curve for PCT was 0.80. CONCLUSION: Patients with gram-negative sepsis had higher PCT values than those with gram-positive sepsis. Our results suggest that PCT value may be a useful tool for distinguishing between gram-negative and gram-positive bacteraemia.

Helicobacter pylori eradication increases telomere length in gastric mucosa.

BACKGROUND/AIMS: Our purpose in this study was to analyze telomere length and telomerase activity before and after eradication treatment in gastric mucosa in patients positive for H. pylori. METHODOLOGY: There were two groups: a control group (n=17) and a study group (n=21). For H. pylori eradication, the patients were administrated proton pump inhibitor (PPI) + clarithromycin + amoxicillin or PPI + metronidazole + tetracycline + bismuth for 14 days. Telomere length was analyzed with RT-PCR and telomerase activity with PCR-ELISA on biopsy specimens from the antrum. The result p<0.05 was considered significant. RESULTS: Prior to eradication, there was no significant difference between telomere lengths of the patient and control groups (2481.2±1823 and 2958.9±1345.7 bp, p=0.11, respectively). The telomere length of the study group became longer after eradication (before 2481.2±1823bp, after 3766.3±1608.8bp, p=0.01). Telomerase activity was not detected in either the patient or the control group. CONCLUSIONS: An increase in telomere length was observed with H. pylori eradication. This finding may indicate the importance of H. pylori eradication to avoid the development of gastric cancer.