Clinical diagnosis of pneumonia, typical of experts

Background Clinical diagnosis of pneumonia is a concern when a patient presents with recent cough – new or worsened – together with fever as the chief complaint. Given this presentation, the doctor would benefit from having access to software that specifies, first, what diagnostic indicators experts typically use in that diagnosis; then, upon entry of those facts, what experts’ typical probability of pneumonia is in such a case; and finally, how much this probability might change upon adding the facts from chest radiography. Methods We specified a set of 36 hypothetical presentations of this type by patients 20–70 years of age, involving a comprehensive set of clinical‐diagnostic indicators. Members of three separate expert panels independently set the probability of pneumonia in each of these cases, and also the range of possible post‐radiography probabilities. A logistic function of the diagnostic indicators was fitted to the medians of the probabilities. Results The median probability of pneumonia was a joint function of the patient’s age and current rate of cigarette smoking; history as to the cough’s duration, the fever’s maximum, dyspnea (including whether on effort only) and rigors; and physical examination as to temperature, signs of upper respiratory infection, prolongation of expiration, dullness on percussion and some auscultation findings. Non‐contributory were history of wheezing, pain on inspiration, type of sputum and signs of cold or influenza. This probability function, and the post‐radiography functions based on the same indicators, are accessible at http://www.evimed.ch/pneumonia . Interpretation The expert inputs to clinical diagnosis that were derived and made readily accessible provide for expertly clinical diagnosis of pneumonia, relevant for decisions about radiography and treatment without it.     

Self-reported Pain Scores in the Emergency Department: Lack of Association with Vital Signs

Background: Some practitioners and investigators have presumed relationships between pain scores and heart rate, blood pressure, or respiratory rate. Previous literature has not adequately addressed the association of pain and vital signs.
Objectives: To identify any association between self-reported pain and heart rate, blood pressure, or respiratory rate.
Methods: In this retrospective, observational study, emergency department patients older than 17 years of age presenting between May 2004 and April 2005 with verifiable painful diagnoses (including nephrolithiasis, myocardial infarction, small bowel obstruction, fracture, burn, crush injury, stab wound, amputation, corneal abrasion, and dislocation) were identified. Data were extracted from the hospital's database, including patients' age, gender, emergency department diagnosis, self-reported pain score, heart rate, blood pressure, and respiratory rate.
Results: Among 1,063 subjects, the most common diagnoses were nephrolithiasis (25%; n = 267) and fracture (23%; n = 249). The mean (± SD) triage pain score was 7 (± 3). The mean (± SD) heart rate was 85 (± 16) beats/min, mean (± SD) systolic blood pressure was 141 (± 23) mm Hg, and mean (± SD) respiratory rate was 19 (± 3) breaths/min. There were no clinically significant differences in mean vital signs across the individual pain scores, as demonstrated by overlapping confidence intervals across pain scores.
Conclusions: No clinically significant associations were identified between self-reported triage pain scores and heart rate, blood pressure, or respiratory rate.     

Acute bacterial maxillary sinusitis: time to symptom resolution and return to normal activities with moxifloxacin

Objectives: This prospective, single‐arm, open‐label, multicentre phase IV (postmarketing surveillance) study determined time to resolution of key symptoms and return to normal activities in adults with acute bacterial maxillary sinusitis treated with moxifloxacin 400 mg qd for 10 days. The study also assessed whether responses to the Sino‐Nasal Outcome Test‐16 (SNOT‐16) questionnaire [not yet validated for acute bacterial sinusitis (ABS)] accurately reflect clinical findings in these patients. Methods: Adults with a clinical diagnosis of acute bacterial maxillary sinusitis with signs/symptoms present for ≥ 7 but < 28 days took part. Patients were evaluated bacteriologically and clinically on day 1 (pretherapy), days 2–4 and 10–13 (test of cure), for bacterial presence and improvement/resolution of the signs/symptoms of acute bacterial maxillary sinusitis. They completed SNOT‐16 and Activity Impairment Assessment questionnaires daily, before receiving moxifloxacin, until day 10. Results: In both the bacteriologically and clinically evaluable populations, over 85% of patients showed clinical improvement by day 2, rising to over 96% by day 4. Pretherapy, according to the SNOT‐16 questionnaire, almost all of the bacteriologically evaluable patients reported facial pain/pressure but this proportion had fallen to below 50% by day 4. In the bacteriologically evaluable population, 32/42 (76%) patients reported an improvement in facial pain/pressure from the pretherapy visit to day 4. Of patients showing improvement, 50% improved from ‘moderate‐to‐severe facial pain’ at pretherapy to ‘no problem’ at day 4. At day 4, 45–50% of patients reported impairment of normal activities, compared with 79–88% pretherapy. Conclusions: Moxifloxacin rapidly improves the signs and symptoms of acute bacterial maxillary sinusitis and results in clinical cure in most patients. Responses to the SNOT‐16 questionnaire accurately reflected clinical assessments, indicating that when fully validated the SNOT‐16 questionnaire may be a valuable tool for the assessment of patient outcomes in ABS.     

Atypical orofacial pain disorders: A study of diagnostic subtypes

Atypical facial pain is a persistent pain in the face or intraoral region that does not fit into the diagnostic criteria associated with specific orofacial pain disorders. This article presents the results of a study, which showed that in most cases of presumed atypical facial pain, there is a specific physical diagnosis or multiple diagnoses that causes the persistent pain. These difficult to diagnose disorders are reviewed with discussion of future research that is needed in this area.     

ICU无创正压通气患者发生鼻面部压力性损伤危险因素分析

目的探讨重症监护室(ICU)无创正压通气(NPPV)患者发生鼻面部压力性损伤的危险因素,为制定预防鼻面部压力性损伤措施提供参考。方法选取2015年1月—2017年12月ICU收治的行NPPV患者189例为研究对象,对其中10例发生压力性损伤患者(压力性损伤组)与179例未发生压力性损伤患者(未发生压力性损伤组)的病历资料进行回顾性分析,使用Cox回归模型分析ICU行NPPV患者发生鼻面部压力性损伤独立危险因素。结果经调查发现,189例NPPV患者发生鼻面部压力性损伤10(5.29%)例,其中1期8(4.23%)例,2期2(1.06%)例。Cox回归模型分析发现高龄、上机形式、面部皮肤潮湿高热、强迫体位及患者合并有糖尿病等慢性疾病是NPPV发生患者鼻面部压力性损伤的独立危险因素(P<0.01)。结论高龄、上机形式、面部皮肤潮湿高热、强迫体位及患者合并糖尿病等慢性疾病是ICU的NPPV患者鼻面部压力性损伤的独立危险因素。护理人员应高度重视,采取积极应对保护措施,预防和降低NPPV患者鼻面部压力性损伤发生风险,保障患者的护理安全。     

Comparison of clinical characteristics in myogenic, TMJ internal derangement and atypical facial pain patients

Temporomandibular joint (TMJ) disorders have been collectively grouped as myofascial pain-dysfunction syndrome (MPDS) or temporomandibular joint dysfunction syndrome (TMJDS). In the past, these terms have been used synonomously to describe a set of clinical signs and symptoms that include pain in the TMJ and muscles of mastication, limited or deviant opening of the mandible, and/or joint sounds. The present study segregated two major subgroups subsumed within this diagnostic classification and assigned them to a myogenic facial pain (MFP) group and a TMJ internal derangement (TMJID) group. Previous studies may have included both of these disorders as MPDS/TMJDS. While some signs and symptoms are similar, the primary differentiation is based on meniscus displacement present with TMJID patients and pain distribution patterns between the two groups. While MFP/TMJID patients comprise the majority of the facial pain population, a third major group of patients is encountered, being classified under the diagnostic appellation of atypical facial pain (AFP). Patients with AFP usually complain of vague and wandering pain in the maxilla or mandible; however, no identifiable source of infection or organic disease can be uncovered. One hundred fifty patients seeking consultation and care for facial pain met the criteria for inclusion into one of three clinical groups. The groups were compared for age, sex, duration of symptoms, bruxism and/or clenching habits, and disturbed sleep patterns. Differences in surface electromyographic levels from the facial and cervical muscles were also examined. Minnesota Multiphasic Personality Inventory (MMPI) scores from 95 subjects were compared with self-report measures of depression and anxiety. It was concluded that subcategorization of myofascial pain dysfunction patients into a MFP and TMJID group is justified on the basis of psychometric differences, clenching habits, masseter EMG levels, and male:female ratio. Furthermore, psychopathological factors are more significant among MFP and AFP subjects than TMJID patients.     

The International Classification of Headache Disorders: accurate diagnosis of orofacial pain?

The aim was to apply diagnostic criteria, as published by the International Headache Society (IHS), to the diagnosis of orofacial pain. A total of 328 consecutive patients with orofacial pain were collected over a period of 2 years. The orofacial pain clinic routinely employs criteria published by the IHS, the American Academy of Orofacial Pain (AAOP) and the Research Diagnostic Criteria for Temporomandibular Disorders (RDCTMD). Employing IHS criteria, 184 patients were successfully diagnosed (56%), including 34 with persistent idiopathic facial pain. In the remaining 144 we applied AAOP/RDCTMD criteria and diagnosed 120 as masticatory myofascial pain (MMP) resulting in a diagnostic efficiency of 92.7% (304/328) when applying the three classifications (IHS, AAOP, RDCTMD). Employing further published criteria, 23 patients were diagnosed as neurovascular orofacial pain (NVOP, facial migraine) and one as a neuropathy secondary to connective tissue disease. All the patients were therefore allocated to predefined diagnoses. MMP is clearly defined by AAOP and the RDCTMD. However, NVOP is not defined by any of the above classification systems. The features of MMP and NVOP are presented and analysed with calculations for positive (PPV) and negative predictive values (NPV). In MMP the combination of facial pain aggravated by jaw movement, and the presence of three or more tender muscles resulted in a PPV = 0.82 and a NPV = 0.86. For NVOP the combination of facial pain, throbbing quality, autonomic and/or systemic features and attack duration of > 60 min gave a PPV = 0.71 and a NPV = 0.95. Expansion of the IHS system is needed so as to integrate more orofacial pain syndromes.     

Three‐ and 4‐Dimensional Ultrasound in Obstetric Practice

OBJECTIVE: The purpose of this article was to review the published literature on 3-dimensional ultrasound (3DUS) and 4-dimensional ultrasound (4DUS) in obstetrics and determine whether 3DUS adds diagnostic information to what is currently provided by 2-dimensional ultrasound (2DUS) and, if so, in what areas. METHODS: A PubMed search was conducted for articles reporting on the use of 3DUS or 4DUS in obstetrics. Seven-hundred six articles were identified, and among those, 525 were actually related to the subject of this review. Articles describing technical developments, clinical studies, reviews, editorials, and studies on fetal behavior or maternal-fetal bonding were reviewed. RESULTS: Three-dimensional ultrasound provides additional diagnostic information for the diagnosis of facial anomalies, especially facial clefts. There is also evidence that 3DUS provides additional diagnostic information in neural tube defects and skeletal malformations. Large studies comparing 2DUS and 3DUS for the diagnosis of congenital anomalies have not provided conclusive results. Preliminary evidence suggests that sonographic tomography may decrease the examination time of the obstetric ultrasound examination, with minimal impact on the visualization rates of anatomic structures. CONCLUSIONS: Three-dimensional ultrasound provides additional diagnostic information for the diagnosis of facial anomalies, evaluation of neural tube defects, and skeletal malformations. Additional research is needed to determine the clinical role of 3DUS and 4DUS for the diagnosis of congenital heart disease and central nervous system anomalies. Future studies should determine whether the information contained in the volume data set, by itself, is sufficient to evaluate fetal biometric measurements and diagnose congenital anomalies.     

Chronic sinusitis: an update.

An accurate history is essential to the diagnosis of chronic sinusitis. Patients classically present with several weeks of daily facial pain or pressure between the eyes, headache, nasal congestion, postnasal drip, ear pain or blockage, and fatigue. The headache in chronic sinusitis is usually worse in the morning and following head movement. Purulent nasal discharge, spiking fever, an elevated white blood cell count, and intense, brief headache associated with nausea and vomiting are uncommon. Palpation, transillumination of the sinuses and anterior rhinoscopy are of minimal value in making the diagnosis. Fiberoptic nasopharyngoscopy can be used to identify the source of sinus discharge and the cause of obstruction. Although plain sinus radiographs are useful in diagnosing and monitoring acute sinusitis, they are of limited value in confirming chronic sinusitis. The sinuses are better imaged with computed tomographic scanning. Prolonged antibiotic therapy, in combination with decongestants and steroids, is usually effective for chronic sinusitis. In recalcitrant cases, sinus surgery may be necessary.     

Facial pain in a neurological tertiary care centre--evaluation of the International Classification of Headache Disorders

The aim of this study was to examine the diagnostic spectrum of facial pain and to evaluate the clinical features relevant to the differential diagnosis in a neurological tertiary care centre. This is the first investigation comparing the first with the second edition of the International Classification of Headache Disorders (ICHD-I, ICHD-II) in consecutively referred patients comprising a broad spectrum of disorders without restricting the inclusion to certain diagnoses. Studying 97 consecutive patients referred for facial pain, we found trigeminal neuralgia or other types of cranial neuralgia in 38% and 39% according to ICHD-I and ICHD-II, respectively; persistent idiopathic facial pain was diagnosed in 27% and 21%, respectively. The proportion of patients who could not be classified was 24% in ICHD-I and 29% in ICHD-II. Six per cent of the patients had cluster headache or chronic paroxysmal hemicrania, the remaining 5% had various other disorders. The agreement between ICHD-I and ICHD-II was very good to perfect. In ICHD-II, sensitivity and specificity were similar to ICHD-I, the specificity and negative predictive value were imrpoved in single features of trigeminal neuralgia, but were widely unchanged in persistent idiopathic facial pain. The number of patients who could not be classified was larger in ICHD-II than in ICHD-I. Modifying the diagnostic criteria for different types of facial pain, in particular changes in the criteria of persistent idiopathic facial pain, might be helpful in reducing the number of patients with unclassifiable facial pain.     

基于无创指标的IgA肾病诊断预测模型的建立与验证

目的 建立便于临床操作且诊断效能较高的无创预测模型以辅助诊断IgA肾病。方法 收集2015年10月至2021年6月在复旦大学附属金山医院肾内科经肾活检确诊的276例原发性肾小球疾病患者的临床资料,按65∶35随机分为训练集（n=181,IgA肾病85例、非IgA肾病96例）和验证集（n=95,IgA肾病46例、非IgA肾病49例）。在训练集中通过单因素及多因素logistic回归分析方法,筛选IgA肾病诊断的无创临床指标,建立IgA肾病的无创诊断模型,通过R语言将该模型转化为可视化的Nomogram图。在验证集中,采用训练集中所建立的诊断预测模型进行外部验证。绘制ROC曲线并计算曲线下面积（AUC）,评价与验证模型的区分度;绘制校准曲线评价模型校准度。结果 根据多因素logistic回归分析结果,最终纳入5个预测因子：血IgA/C3、血纤维蛋白原、血尿情况（镜下血尿或肉眼血尿）、血白蛋白、血高密度脂蛋白。根据上述预测因子建立诊断模型,训练集中,模型AUC为0.934(P<0.001,95%CI 0.899～0.970),具有较好的区分度,根据约登指数确定最佳诊断界值为0.437,...     

Bread mold infection in diabetes. The life-threatening condition of rhinocerebral zygomycosis

Rhinocerebral zygomycosis is a rare but dangerous fungal infection that affects primarily diabetic patients in ketoacidosis but other debilitated patients as well. A high index of suspicion among primary care physicians will lead to earlier diagnosis and help reduce the severe morbidity and mortality associated with the condition. Zygomycosis should be strongly suspected in diabetic patients presenting with unilateral headache, nasal congestion, or facial pain and swelling. If hyphae are not seen in nasal secretions on microscopy, biopsy of infected tissue must be done immediately to establish a diagnosis. Prompt treatment, including appropriate surgical intervention, amphotericin B therapy, and correction of metabolic derangements, is essential.     

Facial pain and the second edition of the International Classification of Headache Disorders

BACKGROUND: Recurrent or chronic facial pain may be a diagnostic challenge. Applying the diagnostic criteria of the second edition of the International Classification of Headache Disorders (ICHD-II) leaves a considerable number of patients unclassifiable. OBJECTIVE: The aim of this study was to establish and evaluate revised criteria of trigeminal neuralgia and persistent idiopathic facial pain. METHODS: Based on the diagnostic value of 12 clinical features of trigeminal neuralgia and 15 features of persistent idiopathic facial in 97 patients referred for facial pain to a neurological tertiary care centre we established revised criteria for persistent idiopathic facial pain and additional criteria for probable trigeminal neuralgia and probable idiopathic facial pain. RESULTS: Applying the newly proposed criteria reduced the number of patients with facial pain not classifiable by more than 50%. The new criteria improved the sensitivity, particularly in idiopathic facial pain and did not cause a relevant decrease in specificity compared to ICHD-II. CONCLUSION: This study suggests that amendments to the ICHD-II criteria improve the diagnostic classification of facial pain.     

Pharmacotherapy of orofacial pain

OBJECTIVES. Pharmacotherapy of chronic orofacial pain is unsatisfactory. Here we set out to prepare a systematic review of randomized controlled clinical trials (RCTs) on pharmacotherapy of facial pain. METHODS. The diagnostic groups "temporomandibular disorders" (TMDs), "atypical facial pain", and "trigeminal neuralgia" were included. RCTs published between 1966 and August 2001 were identified by Medline search, from review articles, and from the Cochrane and Bandolier databases. The quality of the trials was judged according to established criteria. Good or excellent pain reduction or >50% pain reduction were used as endpoints for successful treatment. Numbers needed to treat (NNTs) and their 95% confidence intervals were calculated where dichotomous data were available. RESULTS. Twelve studies were identified for the TMDs, 11 for trigeminal neuralgia, four for atypical facial pain. Many studies had methodological problems and small numbers of patients. There was sufficient evidence of efficacy of carbamazepin in trigeminal neuralgia, also for baclofen and lamotrigine. In the TMD studies, there was evidence of a moderate effect of muscle relaxants/tranquilizers. Two studies of atypical facial pain showed a moderate effect of antidepressants. CONCLUSIONS. Apart from studies in trigeminal neuralgia, there is little evidence of efficacy of pharmacotherapy in orofacial pain. High quality studies with sufficient numbers of patients using operational definitions of disease entities are warranted.     

Cluster headaches

Cluster headaches are episodes of excruciating unilateral facial pain, typically occurring in young men. Ipsilateral autonomic symptoms of nasal congestion, rhinorrhea, conjunctival injection and lacrimation are commonly present. Characteristic facial features may be found. Migraine and trigeminal neuralgia are two important considerations in the differential diagnosis. Prednisone and lithium are effective prophylactic medications for episodic and chronic forms of cluster headaches. Treatment with oxygen or ergotamines may be useful in aborting attacks.     

Pain assessment tools for unconscious or sedated intensive care patients: a systematic review

Title.  Pain assessment tools for unconscious or sedated intensive care patients: a systematic review.
Aim.  This paper is a report of a systematic review describing instruments developed for pain assessment in unconscious or sedated intensive care patients.
Background.  Intensive care patients who are unconscious or sedated are unable to communicate and therefore recognition and assessment of the pain is difficult. To assess these patients' pain, it is important to use a valid and reliable pain assessment tool.
Data sources.  A systematic bibliographical review was conducted, based on seven databases, covering the period from January 1987 to February 2007. A total of 1,586 abstracts was identified and reviewed, 58 papers were selected for full-text review and nine papers were included in the review.
Methods.  Two researchers independently reviewed the abstracts and three reviewers extracted the papers. The included papers were evaluated using a quality assessment instrument previously developed to evaluate pain assessment tools.
Results.  Five different pain assessment tools were identified that had been used with unconscious or sedated intensive care patients. All five instruments included behavioural indicators and three included physiological indicators. Their psychometric properties varied and it was not possible to deduce their clinical utility.
Conclusion.  All instruments were reasonably new. In most of them psychometric testing was in an early stage or even absent. Before any of the reported instruments can be chosen in preference to others, it is essential to test their validity, reliability and feasibility further.     

Headache With Autonomic Features in a Child: Cluster Headache or Contact‐Point Headache?

Headache and facial pain due to diseases of the nose and sinuses are not uncommon in children. However, nasal contact-point associated with headache is relatively uncommon and has unclear etiological significance. We herein report a child having headache with autonomic features and contact-point in the nose, and discuss the difficulties in diagnostic categorization.     

Intravenous Morphine for Early Pain Relief in Patients with Acute Abdominal Pain

Objective: To determine whether morphine affects evaluation or outcome for patients with acute abdominal pain.
Methods: Prospective, double-blind, placebo-controlled administration of morphine sulfate (MS) or normal saline (NS) in the setting of acute abdominal pain. The study was performed at a military ED with an annual census of 60, 000 visits. Patients ±18 years old who had abdominal pain for ± 48 hours were included. Patients who were allergic to MS or who had systolic blood pressures < 90 mm Hg were excluded. The physicians indicated a provisional diagnosis, a differential diagnosis, and a provisional disposition. Study solution was titrated to the patient's assessment of adequate analgesia (up to a volume equivalent of 20 mg of MS); pain response was monitored using a visual analog scale (VAS). The patients were followed until diagnosis occurred or symptoms resolved.
Results: Of 75 patients enrolled, 71 completed the study; 35 patients received MS and 36 received NS. More than half (44; 62%) of the patients were admitted from the ED: 28 patients underwent surgery. The VAS pain level improved more for the MS group, 3.9 2 2.8 cm, than it did for the NS group, 0.8 ± 1.5 cm (p < 0.01). Study solution dose was less in the MS group than it was in the NS group, 1.5 ± 0.5 mL vs 1.8 ± 0.4 mL (p <0.01). There was no difference between the groups when comparing accuracy of provisional or differential diagnosis with that of final diagnosis. Differences between provisional and actual dispositions were the same in all groups. There were 3 diagnostic or management errors in each group.
Conclusions: When compared with saline placebo, the administration of MS to patients with acute abdominal pain effectively relieved pain and did not alter the ability of physicians to accurately evaluate and treat patients. Key words: abdominal pain; analgesia; analgesics; emergency department; morphine; opiates; pain.     

Chronic daily headache: When to suspect sinus disease

Migraine may be responsible for many headaches thought to be caused by the sinuses. Patients complaining of “sinus headache” must have a complete ear, nose, and throat examination. Occasionally, chronic headaches may arise from the sinuses; a thorough history is important to search for symptoms of facial pain and pressure along with other nasal sinus symptoms.