An ongoing trend in medicine toward evidence-based practice emphasizes efficiency and algorithmic approaches toward diagnosis and treatment. This approach has a number of potential benefits including cost-savings, standardization of practice, and improvement in quality of care. 1 A proliferation of clinical scoring systems has in part been a consequence of this movement. These scoring systems are designed to inform clinical decision-making and may involve tools for diagnosis (eg, Wells Criteria), prognosis of disease (eg, the Model for End-Stage Liver Disease score), and future risk of developing a disease (eg, Atherosclerotic Cardiovascular Disease risk score).Clinical scoring systems vary from those that are widely recognized and used (eg, National Institutes of Health Stroke Scale, APGAR [Appearance, Pulse, Grimace, Activity, Respiration]) to those that are highly specialized and used less commonly (eg, A 2 DS 2 [age, atrial fibrillation, dysphagia, sex, and severity]). However, there has been a large recent increase in scoring systems without evidence of any clear clinical benefit for most. Each week, new scoring systems are published in the medical literature. In this Viewpoint, we assess this phenomenon and explore the clinical usefulness of these scores.A search of the MEDLINE/PubMed database using various search terms (eAppendix in the Supplement) to identify peer-reviewed articles related to clinical scoring systems resulted in approximately 250 000 publications since 1965, with an almost exponential increase in yearly publications of scoring systems over time (Figure). Until the mid-1990s, fewer than 5 publications per 1000 total publications were identified, whereas in 2018, more than 20 publications per 1000 publications were identified.
A 61-year-old man with relapsing chronic lymphocytic leukaemia, status post allogeneic stem cell transplant and multiple chemotherapy regimens presented to the emergency room after suffering a grand mal seizure. His evaluation revealed a 1.5-2 cm ring-enhancing left temporal lobe brain lesion on the CT scan. This brain lesion was resected and the histopathology revealed an invasive fungal organism resembling mucormycosis. Amplification and sequencing of the 28S ribosomal RNA gene identified the organism as The patient was treated with liposomal amphotericin B 5 mg/kg every 24 hours for 4 weeks, and then was transitioned to oral posaconazole. Serial brain imaging at 1 and 3 months, while on therapy, showed significant improvement.
Histoplasma capsulatum is an endemic fungus that most oftenly causes a self‐limiting illness but can result in severe infections in immunocompromised patients including pulmonary or extra‐pulmonary disease. Rarely it can also cause a chronic progressive infection of the larynx. Herein, we report a case of laryngeal histoplasmosis in a kidney transplant patient who presented with progressive symptoms of several weeks of hoarseness, dysphagia and odynophagia. Laryngoscopic examination revealed thick plaques in the oropharynx with surrounding hyper‐erythema and histopathology showed numerous intracellular yeasts forms consistent with H capsulatum. Patient was initiated on treatment with itraconazole. Infection of the larynx due to H capsulatum is highly uncommon and therefore can result in an inappropriate or delayed diagnosis. A review of literature showed four previously reported cases of laryngeal histoplasmosis in patients with solid organ transplant. This is the first case series of laryngeal histoplasmosis in transplant recipients.
A 70-year-old man with non-ischaemic dilated cardiomyopathy presented with symptoms of fatigue, chills and unintentional weight loss over the past 2 months. Initial evaluation revealed anaemia, peripheral leucocytosis and elevated inflammatory markers. Results of an oesophagogastroduodenoscopy, colonoscopy, blood bacterial and fungal cultures and bone marrow biopsy were negative. An F-FDG positron-emission tomography-CT demonstrated an indeterminate, intensely FDG-avid 5 cm × 2 cm × 5.6 cm × 6.7 cm mass centred within the junction of the superior vena cava and right atrium, suggestive of probable malignancy versus an inflammatory thrombus. After multidisciplinary consideration, patient underwent a diagnostic minithoracotomy and a thick fibrotic mediastinal mass was visualised and evacuated. The encapsulated mass contained thick, white creamy liquid that appeared to be purulent/necrotic material. The biopsies of the capsule wall on frozen section demonstrated fungal elements consistent with Aspergillosis species. Fungal culture confirmed diagnosis of.
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