A diagnostic algorithm for detection of urinary tract infections in hospitalized patients with bacteriuria: The "Triple F" approach supported by Procalcitonin and paired blood and urine cultures

For acute medicine physicians, distinguishing between asymptomatic bacteriuria (ABU) and clinically relevant urinary tract infections (UTI) is challenging, resulting in overtreatment of ABU and under-recognition of urinary-source bacteraemia without genitourinary symptoms (USB). We conducted a retrospective analysis of ED encounters in a university hospital between October 2013 and September 2018 who met the following inclusion criteria: Suspected UTI with simultaneous collection of paired urinary cultures and blood cultures (PUB) and determination of Procalcitonin (PCT). We sought to develop a simple algorithm based on clinical signs and PCT for the management of suspected UTI. Individual patient presentations were retrospectively evaluated by a clinical "triple F" algorithm (F1 ="fever", F2 ="failure", F3 ="focus") supported by PCT and PUB. We identified 183 ED patients meeting the inclusion criteria. We introduced the term UTI with systemic involvement (SUTI) with three degrees of diagnostic certainty: bacteremic UTI (24.0%;44/183), probable SUTI (14.2%;26/183) and possible SUTI (27.9%;51/183). In bacteremic UTI, half of patients (54.5%;24/44) presented without genitourinary symptoms. Discordant bacteraemia was diagnosed in 16 patients (24.6% of all bacteremic patients). An alternative focus was identified in 67 patients, five patients presented withS.aureusbacteremia. 62 patients were diagnosed with possible UTI (n = 20) or ABU (n = 42). Using the proposed "triple F" algorithm, dichotomised PCT of < 0.25 pg/ml had a negative predictive value of 88.7% and 96.2% for bacteraemia und accordant bacteraemia respectively. The application of the algorithm to our cohort could have resulted in 33.3% reduction of BCs. Using the diagnostic categories "possible" or "probable" SUTI as a trigger for initiation of antimicrobial treatment would have reduced or streamlined antimicrobial use in 30.6% and 58.5% of cases, respectively. In conclusion, the "3F" algorithm supported by PCT and PUB is a promising diagnostic and antimicrobial stewardship tool

Impact of baseline adipose tissue characteristics on change in adipose tissue volume during a low calorie diet in people with obesity-results from the LION study

BACKGROUND/OBJECTIVES Weight loss outcomes vary individually. Magnetic resonance imaging (MRI)-based evaluation of adipose tissue (AT) might help to identify AT characteristics that predict AT loss. This study aimed to assess the impact of an 8-week low-calorie diet (LCD) on different AT depots and to identify predictors of short-term AT loss using MRI in adults with obesity. METHODS Eighty-one adults with obesity (mean BMI 34.08 ± 2.75 kg/m², mean age 46.3 ± 10.97 years, 49 females) prospectively underwent baseline MRI (liver dome to femoral head) and anthropometric measurements (BMI, waist-to-hip-ratio, body fat), followed by a post-LCD-examination. Visceral and subcutaneous AT (VAT and SAT) volumes and AT fat fraction were extracted from the MRI data. Apparent lipid volumes based on MRI were calculated as approximation for the lipid contained in the AT. SAT and VAT volumes were subdivided into equidistant thirds along the craniocaudal axis and normalized by length of the segmentation. T-tests compared baseline and follow-up measurements and sex differences. Effect sizes on subdivided AT volumes were compared. Spearman Rank correlation explored associations between baseline parameters and AT loss. Multiple regression analysis identified baseline predictors for AT loss. RESULTS Following the LCD, participants exhibited significant weight loss (11.61 ± 3.07 kg, p < 0.01) and reductions in all MRI-based AT parameters (p < 0.01). Absolute SAT loss exceeded VAT loss, while relative apparent lipid loss was higher in VAT (both p < 0.01). The lower abdominopelvic third showed the most significant SAT and VAT reduction. The predictor of most AT and apparent lipid losses was the normalized baseline SAT volume in the lower abdominopelvic third, with smaller volumes favoring greater AT loss (p < 0.01 for SAT and VAT loss and SAT apparent lipid volume loss). CONCLUSIONS The LCD primarily reduces lower abdominopelvic SAT and VAT. Furthermore, lower abdominopelvic SAT volume was detected as a potential predictor for short-term AT loss in persons with obesity

Temporal Tendinitis in Craniomandibular Dysfunction (CMD) – Does it Really Exist? A Temporomandibular MRI Investigation

Objectives The aim of the study was to analyze the role of temporal muscle and particularly tendon pathology in patients suffering from craniomandibular dysfunction (CMD) using magnetic resonance imaging. Materials and Methods Retrospective analysis of MRI examinations was carried out with regard to temporal muscle fibrosis and fatty degeneration and particularly temporal tendon rupture, thickening, and degenerative signal alterations. Descriptive statistics and the Mann-Whitney U-test were used for statistical evaluation. Results Structural lesions of temporal muscle parenchyma were the absolute exception. PD hyperintensity, pronounced contrast enhancement, or peritendinous fluid collections along the temporal tendon were found only to a small extent, and a (partial) rupture occurred in only one case. The tendon diameter showed only slight variability. The Mann-Whitney U-test provided no results indicating a causal connection between degenerative joint or disc disease and temporal tendon pathology. Conclusion A large sample of 128 magnetic resonance imaging examinations provided no evidence of a major role of temporal tendinitis in clinical CMD syndrome. Key Points:  Citation Format </jats:p

Preoperative Hyperlactatemia Predicts Mortality in Acute Stanford Type A Dissection: A 16-Year-Period, Single-Center, Retrospective Study

Background: Acute Stanford Type A aortic dissection (ATAAD) is a devastating disease requiring immediate surgery. A life-threatening complication hereby represents organ malperfusion. Lactate is a product of anaerobic glycolysis indicating organ malperfusion. The current study analyzes preoperative lactate acidosis as a surrogate marker for patients&rsquo; outcome after surgery for ATAAD over a 15-year period. Methods: In a single-center setting, 306 consecutive patients, who underwent surgery for ATAAD between 2000 and 2016, were analyzed retrospectively. Serum lactate measurements were taken before surgery. To define a simple cut-point of the predictor lactate, the maximally selected rank statistics method was used. Results: Median survival was 9.3 &plusmn; 0.5 and CI 95% [8.3&ndash;10.2] years. Mean lactate levels were 1.95 mmol/L &plusmn; 2.19 mmol/L (range: 0.15&ndash;19.27 mmol/L). Patients with a lactate level &gt; 3.71 mmol/L had a higher 30-day mortality compared to patients with lactate levels &le; 3.71 mmol/L (51.5% versus 18.7%). In a logistic regression model adjusted for clinical baseline characteristics at index procedure, lactate levels &gt; 3.71 mmol/L reached the highest Odd for 30-day mortality of all tested risk factors (OR = 7.292; CI95% [3.029&ndash;17.555]; p &lt; 0.0001). Analyzing the overall mortality, the early effect of lactate level &gt; 3.71 mmol/L persists. The HRs for overall mortality, however, revealed substantially lower effects (HR = 2.772; (CI95% [1.689&ndash;4.550]; p &lt; 0.0001). In patients who survived the first 30 days postoperatively, no clinical parameter other than age had a significant impact on survival, including lactate &gt; 3.71 mmol/L (p = 0.494). Conclusions: In patients with ATAAD, preoperative lactate represents an easily obtainable surrogate marker for organ malperfusion. A preoperative lactate level &gt; 3.71 mmol/L depicts the strongest marker for early mortality after surgery

MRI- and CT-determined changes of dysphagia / aspiration-related structures (DARS) during and after radiotherapy.

PurposeThe concept of dysphagia/aspiration-related structures (DARS) was developed against the background of severe late side effects of radiotherapy (RT) for head and neck cancer (HNC). DARS can be delineated on CT scans, but with a better morphological discrimination on magnetic resonance imaging (MRI). Swallowing function was analyzed by use of patient charts and prospective investigations and questionnaires.MethodSeventeen HNC patients treated with intensity-modulated radiotherapy (IMRT) ± chemotherapy between 5/2012 - 8/2015 were included. Planning CT (computed tomography) scans and MRIs (magnetic resonance imaging) prior, during 40 Gray (Gy) radiotherapy and posttreatment were available and co-registered to delineate DARS. The RT dose of each DARS was calculated. Five patients were investigated posttreatment for swallowing function and assessed by means of various questionnaires for quality of life (QoL), swallowing, and voice function.ResultsBy retrospective comparison of DARS volume, a significant change in four of eight DARS was detected over time. Three increased and one diminished. The risk of posttreatment dysphagia rose by every 1Gy above the mean dose (D mean) of RT to DARS. 7.5 was the risk factor for dysphagia in the first 6 months, reducing to 4.7 for months 6-12 posttreatment. For all five patients of the prospective part of swallowing investigations, a function disturbance was detected. These results were in contrast to the self-assessment of patients by questionnaires. There was neither a dose dependency of D mean DARS volume changes over time nor of dysphonia and no correlation between volume changes, dysphagia or dysphonia.ConclusionDelineation of DARS on MRI co-registered to planning CT gave the opportunity to differentiate morphology better than by CT alone. Due to the small number of patients with complete MRI scans over time, we failed to detect a dose dependency of DARS and swallowing and voice disorder posttreatment

Outcomes of immediate oncoplastic surgery and adjuvant radiotherapy in breast cancer patients

Abstract Background Oncoplastic surgery techniques lead to a rearrangement of the breast tissue and impede target definition during adjuvant radiotherapy (RT). The aim of this study was to assess local control rates after immediate oncoplastic surgery and adjuvant RT. Methods This study comprises 965 patients who underwent breast-conserving therapy and adjuvant RT between 01/2000 and 12/2005. 288 patients received immediate oncoplastic surgery (ONC) and 677 patients breast-conserving surgery only (NONC). All patients were treated with adjuvant external tangential-beam RT (total dose: 50/50.4 Gy; fraction dose 1.8/2.0 Gy). An additional boost dose of 10–16 Gy to the primary tumor bed was given in 900 cases (93.3%). Local control rates (LCR), Progression free survival (PFS) and overall survival (OS) were assessed retrospectively after a median follow-up period of 67 (Q25-Q75: 51–84) months. Results No significant difference was found between ONC and NONC in regard to LCR (5-yr: ONC 96.8% vs. NONC 95.3%; p = 0.25). This held also true for PFS (5-yr: ONC 92.1% vs. NONC 89.3%; p = 0.09) and OS (5-yr: ONC 96.0% vs. NONC 94.8%; p = 0.53). On univariate analyses G2–3 (p = 0.04), a younger age (p = 0.01), T-stage (p &lt; 0.01) lymph node involvement (p &lt; 0.01) as well as triple negative tumors (p &lt; 0.01) were identified as risk factors for local recurrence. In a propensity score stratified Cox-regression model no significant impact of oncoplastic surgery on local control rate was found (HR: 2.05, 95% CI [0.93; 4.51], p = 0.08). Conclusion Immediate oncoplastic surgery seems not to affect the effectiveness of adjuvant whole breast RT on local control rates in breast cancer patients. </jats:sec

Exercise-dependent changes in ventricular–arterial coupling and aortopulmonary collateral flow in Fontan patients: a real-time CMR study

Abstract Aims Inefficient ventricular–arterial (V–A) coupling has been described in Fontan patients and may result in adverse haemodynamics. A varying amount of aortopulmonary collateral (APC) flow is also frequently present that increases volume load of the single ventricle. The aim of the study was to assess changes in V–A coupling and APC flow during exercise CMR. Methods and results Eighteen Fontan patients (age 24 ± 3 years) and 14 controls (age 23 ± 4 years) underwent exercise CMR using a cycle ergometer. Ventricular volumetry and flow measurements in the ascending aorta (AAO), inferior (IVC), and superior (SVC) vena cava were assessed using real-time sequences during stepwise increases in work load. Measures of systemic arterial elastance Ea, ventricular elastance Ees, and V–A coupling (Ea/Ees) were assessed. APC flow was quantified as AAO − (SVC + IVC). Ea remained unchanged during all levels of exercise in both groups (P = 0.39 and P = 0.11). Ees increased in both groups (P = 0.001 and P &amp;lt; 0.001) with exercise but was lower in the Fontan group (P = 0.04). V–A coupling was impaired in Fontan patients at baseline (P = 0.04). Despite improvement during exercise (P = 0.002) V–A coupling remained impaired compared with controls (P = 0.001). Absolute APC flow in Fontan patients did not change during exercise even at maximum work load (P = 0.98). Conclusions Inefficient V–A coupling was already present at rest in Fontan patients and aggravated during exercise due to a limited increase in ventricular contractility which demonstrates the importance of a limited functional reserve of the single ventricle. APC flow remained unchanged suggesting no further increase in volume load during exercise. </jats:sec

Investigation of the Relationship between MR-Based Supraclavicular Fat Fraction and Thyroid Hormones

&lt;b&gt;&lt;i&gt;Purpose:&lt;/i&gt;&lt;/b&gt; Brown adipose tissue (BAT) plays a potential role in energy and glucose metabolism in humans. Thyroid hormones (TH) are main regulators of BAT development and function. However, it remains unknown how the magnetic resonance (MR)-based proton density fat fraction (PDFF) of supraclavicular adipose tissue used as a surrogate marker for BAT presence relates to TH. Therefore, the purpose of this analysis was to investigate the relationship between supraclavicular PDFF and serum levels of TH. &lt;b&gt;&lt;i&gt;Methods:&lt;/i&gt;&lt;/b&gt; In total, 96 adult volunteers from a large cross-sectional study who underwent additional MR examination of the neck and pelvis were included in this analysis. Segmented PDFF maps of the supraclavicular and gluteal subcutaneous adipose tissue were generated. Delta PDFF was calculated as the difference between gluteal and supraclavicular PDFF and grouped as high (≥12%) or low (&amp;#x3c;12%) based on the median and the clinical rationale of a high versus low probability of BAT being present. Thyroid-stimulating hormone (mIU/L), free triiodothyronine (FT3, pg/mL) and free thyroxine (FT4, ng/dL) levels were determined in blood samples. Body mass index (BMI) was calculated as weight (kg)/height (m)&lt;sup&gt;2&lt;/sup&gt;. Statistical analyses included the use of paired samples &lt;i&gt;t&lt;/i&gt;test, simple linear regression analysis and a multivariable linear regression analysis. &lt;b&gt;&lt;i&gt;Results:&lt;/i&gt;&lt;/b&gt; The median age of the subjects (77% female) was 33 years, BMI ranged from 17.2 to 43.1 kg/m&lt;sup&gt;2&lt;/sup&gt;. Supraclavicular and gluteal PDFF differed significantly (76.5 ± 4.8 vs. 89.4 ± 3.5 %, &lt;i&gt;p&lt;/i&gt; &amp;#x3c; 0.01). Supraclavicular PDFF was associated with FT3 in subjects with high delta PDFF (&lt;i&gt;R&lt;/i&gt;&lt;sup&gt;2&lt;/sup&gt; = 0.17, &lt;i&gt;p&lt;/i&gt; &amp;#x3c; 0.01), with higher FT3 being associated with lower supraclavicular PDFF (&lt;i&gt;y&lt;/i&gt; = 85.2 + –3.6 &lt;i&gt;x&lt;/i&gt;). In a multivariable linear regression analysis considering further potential prognostic factors, the interaction between the delta PDFF group and FT3 remained a predictor for supraclavicular PDFF (B = –4.65, &lt;i&gt;p&lt;/i&gt; &amp;#x3c; 0.01). &lt;b&gt;&lt;i&gt;Discussion/Conclusions:&lt;/i&gt;&lt;/b&gt; Supraclavicular PDFF corresponds to the presence of BAT. In the present analysis, supraclavicular PDFF is correlated with FT3 in subjects with high delta PDFF. Therefore, the present findings suggest that biologically active T3 may be involved in the development of supraclavicular BAT. </jats:p

Investigation of the Relationship between MR-Based Supraclavicular Fat Fraction and Thyroid Hormones

&lt;jats:p&gt;&amp;lt;b&amp;gt;&amp;lt;i&amp;gt;Purpose:&amp;lt;/i&amp;gt;&amp;lt;/b&amp;gt; Brown adipose tissue (BAT) plays a potential role in energy and glucose metabolism in humans. Thyroid hormones (TH) are main regulators of BAT development and function. However, it remains unknown how the magnetic resonance (MR)-based proton density fat fraction (PDFF) of supraclavicular adipose tissue used as a surrogate marker for BAT presence relates to TH. Therefore, the purpose of this analysis was to investigate the relationship between supraclavicular PDFF and serum levels of TH. &amp;lt;b&amp;gt;&amp;lt;i&amp;gt;Methods:&amp;lt;/i&amp;gt;&amp;lt;/b&amp;gt; In total, 96 adult volunteers from a large cross-sectional study who underwent additional MR examination of the neck and pelvis were included in this analysis. Segmented PDFF maps of the supraclavicular and gluteal subcutaneous adipose tissue were generated. Delta PDFF was calculated as the difference between gluteal and supraclavicular PDFF and grouped as high (≥12%) or low (&amp;amp;#x3c;12%) based on the median and the clinical rationale of a high versus low probability of BAT being present. Thyroid-stimulating hormone (mIU/L), free triiodothyronine (FT3, pg/mL) and free thyroxine (FT4, ng/dL) levels were determined in blood samples. Body mass index (BMI) was calculated as weight (kg)/height (m)&amp;lt;sup&amp;gt;2&amp;lt;/sup&amp;gt;. Statistical analyses included the use of paired samples &amp;lt;i&amp;gt;t&amp;lt;/i&amp;gt;test, simple linear regression analysis and a multivariable linear regression analysis. &amp;lt;b&amp;gt;&amp;lt;i&amp;gt;Results:&amp;lt;/i&amp;gt;&amp;lt;/b&amp;gt; The median age of the subjects (77% female) was 33 years, BMI ranged from 17.2 to 43.1 kg/m&amp;lt;sup&amp;gt;2&amp;lt;/sup&amp;gt;. Supraclavicular and gluteal PDFF differed significantly (76.5 ± 4.8 vs. 89.4 ± 3.5 %, &amp;lt;i&amp;gt;p&amp;lt;/i&amp;gt; &amp;amp;#x3c; 0.01). Supraclavicular PDFF was associated with FT3 in subjects with high delta PDFF (&amp;lt;i&amp;gt;R&amp;lt;/i&amp;gt;&amp;lt;sup&amp;gt;2&amp;lt;/sup&amp;gt; = 0.17, &amp;lt;i&amp;gt;p&amp;lt;/i&amp;gt; &amp;amp;#x3c; 0.01), with higher FT3 being associated with lower supraclavicular PDFF (&amp;lt;i&amp;gt;y&amp;lt;/i&amp;gt; = 85.2 + –3.6 &amp;lt;i&amp;gt;x&amp;lt;/i&amp;gt;). In a multivariable linear regression analysis considering further potential prognostic factors, the interaction between the delta PDFF group and FT3 remained a predictor for supraclavicular PDFF (B = –4.65, &amp;lt;i&amp;gt;p&amp;lt;/i&amp;gt; &amp;amp;#x3c; 0.01). &amp;lt;b&amp;gt;&amp;lt;i&amp;gt;Discussion/Conclusions:&amp;lt;/i&amp;gt;&amp;lt;/b&amp;gt; Supraclavicular PDFF corresponds to the presence of BAT. In the present analysis, supraclavicular PDFF is correlated with FT3 in subjects with high delta PDFF. Therefore, the present findings suggest that biologically active T3 may be involved in the development of supraclavicular BAT. &lt;/jats:p&gt