Utility of the New Early Warning Score (NEWS) in combination with the neutrophil-lymphocyte ratio for the prediction of prognosis in older patients with pneumonia

OBJECTIVE

Predictors of prognosis are necessary for use in routine clinical practice for older patients with pneumonia, given the ageing of the population. Recently, the National Early Warning Score (NEWS), a comprehensive predictor of severity that consists solely of physiological indicators, has been proposed to predict the prognosis of pneumonia. The neutrophil/lymphocyte ratio (NLR) is a simple index of inflammation that may also be predictive of pneumonia. In the present study, we aimed to determine whether NEWS or a combination of NEWS and NLR predicts mortality in older patients with pneumonia.

DESIGN

A retrospective cohort study.

SETTING

A general hospital in Japan.

PARTICIPANTS

We collected data from patients aged ≥65 years with pneumonia who were admitted between 2018 and 2020 (n=282; age=85.3 (7.9)). Data regarding vital signs, demographics and the length of hospital stay, in addition to the NEWS and NLR, were extracted from the participants' electronic medical records.

INTERVENTION

The utility of the combination of NEWS and NLR was assessed using NEWS×NLR and NEWS+NLR.

MAIN OUTCOME MEASURES

Their predictive ability for 30-day mortality as the primary outcome was assessed using receiver operating characteristic (ROC) curve analysis.

RESULTS

According to the NEWS classification, 80 (28.3%), 64 (22.7%) and 138 (48.9%) of the participants were at low, medium and high risk of mortality, respectively. The 30-day mortality for the entire cohort was 9.2% (n=26), and the mortality rate increased with the NEWS classification: low, 1.3%; medium, 7.8%; and high, 14.5%. The NLRs were 6.0 (4.2-9.8), 6.8 (4.8-10.4) and 14.6 (9.4-22.2), respectively (p<0.001). The areas under the ROC curves for 30-day mortality were 0.73 for the NEWS score, 0.84 for NEWS×NLR and 0.83 for NEWS+NLR, indicating that the combinations represent superior predictors of mortality to the NEWS alone. NEWS×NLR and NEWS+NLR tended to have better sensitivity, accuracy, positive predictive value and negative predictive value than NEWS alone (p=0.06).

CONCLUSIONS

A combination of the NEWS and NLR (NEWS×NLR or NEWS+NLR) may be superior to the NEWS alone for the prediction of 30-day mortality in older patients with pneumonia. However, further validation of these combinations for use in the prediction of prognosis is required.

Kikuchi-Fujimoto disease following SARS-CoV-2 vaccination

A previously healthy Japanese woman in her 20s was admitted to our hospital with a 2-week history of fever (39.0°C) and a 1-week history of painful cervical lymphadenopathy. The day before fever onset, she had received her first Pfizer-BioNTech SARS-CoV-2 vaccine in her left arm. She had previously been treated with empirical antibiotics with no improvement. Physical examination revealed painful lymphadenopathy in both posterior cervical regions. CT showed symmetrical lymphadenopathies in the neck, supraclavicular, axillary and inguinal regions as well as hepatosplenomegaly. We suspected lymphoma and performed a lymph node biopsy in the right inguinal region, which revealed necrotising histiocytic lymphadenitis. The patient was, therefore, diagnosed with Kikuchi-Fujimoto disease (KFD). She improved after the corticosteroid therapy. This report highlights the importance of including KFD as a differential diagnosis of lymphadenopathy after SARS-CoV-2 vaccination. Additionally, lymph node biopsy is helpful for diagnosing KFD because it rules out other entities.

Electromagnetic-guided versus endoscopic-guided postpyloric placement of nasoenteral feeding tubes

BACKGROUND

For people who are malnourished and unable to consume food by mouth, nasoenteral feeding tubes are commonly used for the administration of liquid food and drugs. Postpyloric placement is when the tip of the feeding tube is placed beyond the pylorus, in the small intestine.  Endoscopic-guided placement of postpyloric feeding tubes is the most common approach. Usually, an endoscopist and two or more medical professionals perform this procedure using a guidewire technique. The position of the tube is then confirmed with fluoroscopy or radiography, which requires moving people undergoing the procedure to the radiology department. Alternatively, electromagnetic-guided placement of postpyloric nasoenteral feeding tubes can be performed by a single trained nurse, at the bedside and with less equipment than endoscopic-guided placement. Hence, electromagnetic-guided placement may represent a promising alternative to endoscopic-guided placement, especially in settings where endoscopy and radiographic facilities are unavailable or difficult to access.

OBJECTIVES

To assess the efficacy and safety of electromagnetic-guided placement of postpyloric nasoenteral feeding tubes compared to endoscopic-guided placement.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and OpenGrey until February 2021. We screened the reference lists of relevant review articles and current treatment guidelines for further literature. We contacted the study authors for missing data.

SELECTION CRITERIA

We included randomised trials comparing electromagnetic-guided placement with endoscopic-guided placement of nasoenteral feeding tubes. We excluded prospective cohort studies, retrospective cohort studies, (nested) case-control studies, cross-sectional studies, and case series or case reports.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the methodological quality of potentially eligible trials and extracted data from the included trials. The primary outcomes were technical success in insertion and aspiration pneumonitis. The secondary outcomes were the time for postpyloric placement of nasoenteral feeding tubes, direct healthcare costs, and adverse events. We performed a random-effects meta-analysis. We calculated risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous outcomes and mean differences (MDs) with 95% CIs for continuous outcomes. We evaluated the certainty of evidence based on the GRADE approach.

MAIN RESULTS

We identified four randomised controlled trials with 541 participants which met our inclusion criteria. All trials had methodological limitations, and lack of blinding of participants and investigators was a major source of bias. We had 'some concerns' for the overall risk of bias in all trials.  Electromagnetic-guided postpyloric placement of nasoenteral feeding tubes may result in little to no difference in technical success in insertion compared to endoscopic-guided placement (RR 1.09, 95% CI 0.88 to 1.35; I2 = 81%; low-certainty evidence). Electromagnetic-guided placement may result in a difference in the proportion of participants with aspiration pneumonitis compared to endoscopic-guided placement, but these results are unclear (RR 0.24, 95% CI 0.03 to 2.18; I2 = 0%; low-certainty evidence).  Electromagnetic-guided placement may result in little to no difference in the time for postpyloric placement of nasoenteral feeding tubes compared to endoscopic-guided placement (MD 4.06 minutes, 95% CI -0.47 to 8.59; I2 = 97%; low-certainty evidence). Electromagnetic-guided placement likely reduces direct healthcare costs compared to endoscopic-guided placement (MD -127.69 US dollars, 95% CI -135.71 to -119.67; moderate-certainty evidence). Electromagnetic-guided placement likely results in little to no difference in adverse events compared with endoscopic-guided placement (RR 0.78, 95% CI 0.41 to 1.49; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

We found low-certainty evidence that electromagnetic-guided placement at the bedside results in little to no difference in technical success in insertion and aspiration pneumonitis, compared to endoscopic-guided placement. The heterogeneity of the healthcare professionals who performed the procedures and the small sample sizes limited our confidence in the evidence. Future research should be based on large studies with well-defined endpoints to potentially elucidate the differences between these two procedures.

Reversible cerebral vasoconstriction syndrome associated with tetrodotoxin poisoning: A case report

An 81-year-old woman with a history of hypertension and Alzheimer's disease presented to the emergency department because of impaired consciousness. Physical examination revealed acute progressive generalized flaccid paralysis, hypertension, respiratory failure, and pupillary dilation. Although the patient did not complain of headache, head magnetic resonance angiography and magnetic resonance imaging showed multifocal segmental cerebral vasospasm and cerebral infarction in the left occipital lobe. Her family reported that although she did not have a license to cook pufferfish, she was in the habit of eating pufferfish. We subsequently detected tetrodotoxin in the patient's urine, and she was diagnosed with tetrodotoxin poisoning. As the symptoms of tetrodotoxin intoxication improved, head magnetic resonance angiography showed the disappearance of the multifocal segmental cerebral vasospasm. The patient's clinical course and imaging findings were consistent with reversible cerebral vasoconstriction syndrome (RCVS). Sympathetic overactivity after tetrodotoxin intoxication possibly caused the development of RCVS, and RCVS could not be ruled out even in the absence of the typical thunderclap headache. Magnetic resonance angiography is a useful modality when performing repeated examinations.

The influences of the environment and information on the complications of diabetes on patient outcomes

This letter was written to address two concerns about the results of the paper published by Zeynep et al. (BMC Health Qual Life Outcomes 18:265, 2020). First, the differences between the two groups in the environment with or without occupation may strengthen the primary outcome results. Second, lack of information on the complications and treatments of diabetes makes interpretation of the results difficult.

Lidocaine spray versus viscous lidocaine solution for pharyngeal local anesthesia in upper gastrointestinal endoscopy: Systematic review and meta-analysis

OBJECTIVES

There are two major methods for local anesthesia by lidocaine before upper gastrointestinal endoscopy: simple spray and viscous solution. We aimed to assess the efficacy and safety by meta-analysis between these two methods.

METHODS

We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov databases through October 2019 to perform meta-analyses using random-effects models. The primary outcomes were participants' pain/discomfort, satisfaction, and anaphylactic shock. Three reviewers independently searched for articles, extracted data, and assessed the risk of bias. We evaluated the certainty of evidence based on the Grading of Recommendations, Assessment, Development, and Evaluation approach. This study was registered in PROSPERO (CRD42020155611).

RESULTS

We included seven randomized controlled trials (2667 participants). The participants' pain/discomfort may be similar between the lidocaine spray and viscous solution [standardized mean difference 0.03, 95% confidence intervals (CI) -0.37 to 0.42; I²  = 93%; low certainty of evidence]. The lidocaine spray probably increased participants' satisfaction compared with the viscous solution (relative risk 1.22; 95% CI, 1.02 to 1.47; I²  = 47%; moderate certainty of evidence). No anaphylactic shock occurred in four studies (low certainty of evidence). Four studies had high risks of selection bias.

CONCLUSION

The use of lidocaine spray for local anesthesia provided better satisfaction scores than the viscous solution, and both methods have the same effect with regards to the control of discomfort and pain. Further studies in large multicenter randomized controlled trials with a pre-registration protocol are needed.

Older-age onset of Kimura's disease

A 60-year-old man was admitted to our hospital with bilateral post auricular masses, first noticed 1 year earlier. Blood tests showed eosinophilia and high immunoglobulin E (IgE) levels, and cervical computed tomography showed 10-mm soft tissue masses with scattered lymphadenopathy. The tumors showed intermediate and high signal intensity on T1- and T2-weighted cervical magnetic resonance imaging, respectively. After mass resection, the tumors were diagnosed as Kimura’s disease (KD). Generally, KD affects young men; however, even in older patients, KD should be included as a differential diagnosis for head and neck tumors in patients with eosinophilia and high IgE.

Efficacy and safety of the starting position during colonoscopy: a systematic review and meta-analysis

Background and study aims  We aimed to assess the efficacy and safety of the starting position during colonoscopy. Patients and methods  We searched CENTRAL, MEDLINE, EMBASE, and the WHO International Clinical Trials Registry Platform through February 2019 to identify studies reporting the comparison between the right/supine/prone/tilt-down and left lateral starting position during colonoscopy. The primary outcomes were mean cecal insertion time and adverse events requiring medication. Two reviewers performed study selection and risk of bias assessment. We determined the quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation method. This study was registered in PROSPERO (CRD42019124360). Results  We identified 10 randomized controlled trials (RCTs) (2083 participants), including three trials on right/tilt-down versus left, two trials on supine/prone versus left, respectively. Mean difference in mean cecal insertion time in supine versus left was -41.0 s (95 % confidence interval [CI] -57.3 to -24.7) in one study and in tilt-down versus left was - 37.3 s (95 % CI -72.1 to -2.4; I ²  = 58 %) in three studies; however, there were no statistically significant differences in prone/right versus left position (very low certainty of evidence). Four of eight studies noted adverse effects requiring medication (moderate certainty of evidence). One RCT applying the tilt-down position was terminated because of increased occurrence of oxygen desaturation. Conclusion  We could not conclusively determine the efficacy and safety of the starting position during colonoscopy because of low certainty of evidence. Further studies are needed to confirm the efficacy and safety of the starting potion during colonoscopy.

Kimura's disease: effects of age on clinical presentation

BACKGROUND

Kimura's disease (KD) is known to be dominant among young Asian men, but it can also occur in middle- and advanced-aged people. The clinical characteristics of KD, especially by age, are not well known.

AIM

This study was performed to investigate the effects of age on the clinical characteristics of KD.

DESIGN

We conducted a case series study.

METHODS

All case studies of patients diagnosed with KD were collected via a PubMed search of studies published until August 2018. The data were analyzed by age group.

RESULTS

In total, 215 studies were reviewed (238 patients; mean age of 36 years). The male:female ratio was 4:1 overall, 17:1 in patients aged <20 years, 4:1 in patients aged 20-39 years and 2:1 in patients aged ≥40 years (P = 0.01). The percentage of patients with pruritus was 15.4% overall, 3.8% in patients aged <20 years, 15.5% in patients aged 20-39 years and 21.7% in patients aged ≥40 years (P = 0.02). The time to diagnosis was 5.3 years overall, 3.2 years in patients aged <20 years, 4.7 years in patients aged 20-39 years and 7.1 years in patients aged ≥40 years (P < 0.01).

CONCLUSIONS

The proportion of female patients affected the incidence of pruritus, and the time to diagnosis increased as the patients' age increased. There were no significant age-related differences in region/race, complications, multiplicity, laterality, anatomical distribution, maximum size, eosinophil count, immunoglobulin E level, initial treatment, recurrence or outcomes. This may be useful information for the diagnosis of KD.

High-Density Lipoprotein Cholesterol and Risk of Stroke Subtypes: Jichi Medical School Cohort Study

We aimed to investigate the relationship between high-density lipoprotein cholesterol (HDL-C) concentration and the incident stroke subtypes. We enrolled 11 027 participants between the ages of 18 and 90 years without a history of stroke in 12 Japanese communities. Cox's regression models were used for stroke subtypes, adjusted for traditional risk factors, according to the categories based on HDL-C concentrations: 1.04 to 1.55 mmol/L, ≥1.56 mmol/L, and <1.03 mmol/L (as the reference). During a mean follow-up of 10.7 years, 412 stroke events had occurred. However, HDL-C was not significantly associated with the incidence of cerebral infarction and subarachnoid hemorrhage. High HDL-C concentration was associated with a decreased incidence of intracerebral hemorrhage in women (hazard ratio = 0.23; 95% confidence interval = 0.06-0.89), but not in men (hazard ratio = 0.73; 95% confidence interval = 0.27-1.97). Therefore, high HDL-C concentration might have a protective effect on the incidence of intracerebral hemorrhage, particularly in women.

Isolated low levels of high-density lipoprotein cholesterol and stroke incidence: JMS Cohort Study

Background

The cardiovascular relevance of isolated low levels of high‐density lipoprotein cholesterol (HDL‐C) is yet to be determined. Stroke often leads to long‐term disability, and thus, not only stroke mortality but also stroke incidence is a topic of research. Although isolated low HDL‐C level has been found to be a predictor for stroke mortality previously, whether it can predict stroke incidence is unknown.

Methods

In the Jichi Medical School cohort study, 11 025 community‐living residents without a history of stroke were examined. Hazard ratios (HRs) for isolated and non‐isolated low HDL‐C levels were calculated relative to those for normal HDL‐C levels in stroke patients using Cox's regression models.

Results

During the mean follow‐up period of 10.7 years, 412 residents had their first‐ever stroke. The multivariable‐adjusted HRs for the levels of isolated and non‐isolated low HDL‐C were 1.11 (95% confidence interval, 0.85‐1.44) and 1.35 (1.01‐1.81), respectively, when compared to that for normal HDL‐C.

Conclusion

Low HDL‐C levels with other dyslipidemias may contribute to the incidence of stroke, not isolated low HDL‐C.

Magnetic resonance imaging and symptoms in patients with neurosarcoidosis and central diabetes insipidus

INTRODUCTION

In the clinical setting, the diagnosis of neurosarcoidosis in patients with central diabetes insipidus (CDI) is typically based both on symptoms (i.e. polydipsia or polyuria) and brain magnetic resonance imaging (MRI) findings (e.g. pituitary abnormality). However, inconsistent changes in the patient's symptoms and brain MRI findings may occur during the clinical course of the disease. This review was performed to summarise the relationship between symptoms and brain MRI findings in previously reported cases of neurosarcoidosis with CDI.

MATERIAL AND METHODS

Case studies of patients diagnosed with neurosarcoidosis with CDI were collected via a PubMed search of studies published through 30 June 2018.

RESULTS

Thirteen eligible studies were reviewed (20 patients; 12 men, 8 women; mean age 33 years). Polydipsia or polyuria was the first symptom in 13 patients. The mean duration from disease onset to diagnosis was 3.4 months. Brain MRIs showed abnormal findings in the hypothalamus and pituitary for 17 patients. Immunosuppressive drugs were used in 17 patients. For 14 patients, MRI findings improved, while symptoms did not.

CONCLUSION

Patients with both neurosarcoidosis and CDI symptoms often do not improve, despite the fact that brain MRI findings often improve following treatment. More studies involving detailed pathological analyses and longer follow-up periods are necessary.

The ratio of fasting plasma glucose to hemoglobin A1c as a predictor of all-cause mortality in individuals with normal glucose levels: The Jichi Medical School cohort study

Objectives:

The fasting plasma glucose/hemoglobin A1c ratio is considered a marker associated with glucose metabolism disorders, including fasting hyperglycemia. However, it remains unclear whether this ratio can be used for the prevention of deaths in individuals with normal fasting plasma glucose levels. This study aimed to see the predictive value of the fasting plasma glucose/hemoglobin A1c ratio for all-cause mortality in a general population with normal fasting plasma glucose levels.

Methods:

The study investigated prospectively a cohort of 1087 multi-regional, community-dwelling Japanese participants (women, 69.2%) for a follow-up period of 11.3 years. We included individuals with fasting plasma glucose levels <6.11 mmol/L and excluded those meeting the diabetes criteria. All-cause mortality was the primary outcome and hazard ratios were calculated using the Cox proportional hazard model after dividing the fasting plasma glucose/hemoglobin A1c ratios into tertiles.

Results:

There were 54 deaths (25 women) during the follow-up period. The high tertile group had a significantly higher hazard ratio for all-cause mortality than the low tertile group in women (multivariate-adjusted hazard ratio = 4.45; 95% confidence interval = 1.26–15.72), but not clearly in men.

Conclusion:

The data of the population-based cohort study suggest that a high fasting plasma glucose/hemoglobin A1c ratio can predict all-cause mortality in women with normal fasting plasma glucose levels.

Metabolic syndrome is a risk factor for cancer mortality in the general Japanese population: the Jichi Medical School Cohort Study

BACKGROUND

Metabolic syndrome (MetS) and cancer are major public health problems worldwide. The relationship between MetS and cancer death is of great interest. We examined the predictive value of MetS for cancer mortality in Japan.

METHODS

Study participants included 4495 men and 7028 women aged 18-90 years who were registered between 1992 and 1995 as part of the Jichi Medical School Cohort Study. We used a definition of MetS modified for the Japanese population. The primary outcome was cancer mortality. Additionally, the relationship between MetS and cancer-type specific mortality was examined. Analyses were conducted with Cox's regression models adjusted for age, smoking status, alcohol drinking status, marital status, educational attainment, physical activity, occupational category, and menopausal status (only in women).

RESULTS

During a mean follow-up of 18.5 years, 473 men and 297 women died from cancer. MetS was positively associated with cancer mortality in women (hazard ratio [HR], 1.69; 95% confidence interval [CI] 1.21-2.36), but not in men (HR, 1.21; 95% CI 0.90-1.62). Additionally, MetS was associated with a high risk of colorectal (HR, 3.48; 95% CI 1.68-7.22) and breast (HR, 11.90; 95% CI 2.25-62.84) cancer deaths in women.

CONCLUSION

MetS was a significant predictor of cancer mortality in women.

Superior Mesenteric Artery Vasculitis in Behçet's Disease: A Case Report and Literature Review

A 55-year-old male presented with abdominal pain that had begun about 5 days ago. Physical examination revealed oral aphtha, genital aphthosis, and pseudofolliculitis, and the patient was diagnosed with incomplete Behçet's disease (BD). Contrast-enhanced computed tomography (CECT) showed dilation of the superior mesenteric artery and mesenteric infiltration of inflammation, indicating vasculo-BD. The symptoms were improved by 3-day of intravenous methylprednisolone pulse therapy followed by oral prednisolone. A literature review suggested that vasculo-BD should be included as a differential diagnosis in cases with unexplained abdominal pain, arterial dilation, and mesenteric invasion, and CECT examination and steroid therapy should be considered.

Non-diabetic Glucose levels and Cancer Mortality: A Literature Review

BACKGROUND

Although diabetes mellitus is a risk factor for cancer, the relationship of an increased glucose concentration at a non-diabetic glucose level with cancer mortality is yet to be determined.

OBJECTIVE

The aim was to observe whether an increased glucose concentration and/or glucose intolerance at the non-diabetic glucose level can predict cancer mortality.

METHODS

Population-based prospective cohort studies evaluating cancer mortality at the non-diabetic level (defined as fasting plasma glucose <7.0 mmol/L and two-hour plasma glucose <11.1mmol/L following an oral glucose tolerance test) were collected via a PubMed search with an additional Google scholar search between 1 January 1966 and 31 July 2016.

RESULTS

We identified seven studies, which met the defined criteria. Studies examining fasting/casual states indicated an increase in cancer mortality with a slight increase in fasting/casual glucose levels in men in particular. Not all, but some studies using a glucose tolerance test indicated an increase in cancer mortality with impaired glucose tolerance/prediabetes. Concerning cause-cancer mortality, glucose intolerance states appeared to have an increase in mortality, particularly due to the stomach, liver and pancreatic cancers.

CONCLUSION

In these studies reviewed, cancer mortality increased in individuals with an increased glucose concentration and an increased potential was seen in those patients with glucose intolerance even at non-diabetic glucose levels. The outcome of these findings is promising and forms the basis for further studies to directly address the relevance of increased (non-diabetic) glucose and glucose intolerance as a prognostic indicator of cancer mortality.

[A case of ruptured duodenal varices successfully treated by combination therapy with endoscopic clipping and balloon-occluded retrograde transvenous obliteration]

An 80-year-old woman with a history of chronic hepatitis B was referred to our hospital because of upper gastrointestinal bleeding of unknown origin. Dynamic computed tomography revealed liver cirrhosis and hepatofugal collateral vessels around the duodenum. Emergency esophagogastroduodenoscopy showed duodenal varices with an erosive spot, highly suggestive of a variceal rupture site. We immediately performed endoscopic clipping of the ruptured site to achieve temporary hemostasis. Ten days later, elective balloon-occluded retrograde transvenous obliteration (B-RTO) was performed to prevent recurrence. We describe a successfully treated case of duodenal variceal rupture managed by combination therapy with endoscopic clipping and B-RTO.

Serum non-high-density lipoprotein cholesterol levels and the incidence of ischemic stroke in a Japanese population: the Jichi Medical School cohort study

The predictive value of serum non-high-density lipoprotein cholesterol (non-HDL-C) levels for the incidence of ischemic stroke and its subtypes has not yet been established. The present cohort study investigated their relationships in a Japanese population. The first incidence of ischemic stroke and its subtypes was documented as the primary outcome. A total of 249 ischemic stroke patients (men/women = 145/104) were identified during a follow-up period of 10.7 years among 10 760 community-dwelling subjects (men/women = 4212/6548). Cox proportional hazard model analyses revealed that when compared with the lowest tertile of non-HDL-C, multivariate-adjusted hazard ratios for the highest tertile were 0.55 (95% confidence interval = 0.32-0.95, P = .03) on ischemic stroke and 0.29 (95% confidence interval = 0.08-1.05, P = .06) on cardioembolic infarction in women. Men did not show such significant relationships. Low serum non-HDL-C levels may be a predictive marker associated with an increase in the incidence of ischemic stroke and possibly of cardioembolic infarction in Japanese women.