Objectives To quantify the diagnostic accuracy of selected inflammatory markers in addition to symptoms and signs for predicting pneumonia and to derive a diagnostic tool.Design Diagnostic study performed between 2007 and 2010. Participants had their history taken, underwent physical examination and measurement of C reactive protein (CRP) and procalcitonin in venous blood on the day they first consulted, and underwent chest radiography within seven days. Setting Primary care centres in 12 European countries.Participants Adults presenting with acute cough.Main outcome measures Pneumonia as determined by radiologists, who were blind to all other information when they judged chest radiographs. ResultsOf 3106 eligible patients, 286 were excluded because of missing or inadequate chest radiographs, leaving 2820 patients (mean age 50, 40% men) of whom 140 (5%) had pneumonia. Re-assessment of a subset of 1675 chest radiographs showed agreement in 94% (κ 0.45, 95% confidence interval 0.36 to 0.54). Six published "symptoms and signs models" varied in their discrimination (area under receiver operating characteristics curve (ROC) ranged from 0.55 (95% confidence interval 0.50 to 0.61) to 0.71 (0.66 to 0.76)). The optimal combination of clinical prediction items derived from our patients included absence of runny nose and presence of breathlessness, crackles and diminished breath sounds on auscultation, tachycardia, and fever, with an ROC area of 0.70 (0.65 to 0.75). Addition of CRP at the optimal cut off of >30 mg/L increased the ROC area to 0.77 (0.73 to 0.81) and improved the diagnostic classification (net reclassification improvement 28%). In the 1556 patients classified according to symptoms, signs, and CRP >30 mg/L as "low risk" (<2.5%) for pneumonia, the prevalence of pneumonia was 2%. In the 132 patients classified as "high risk" (>20%), the prevalence of pneumonia was 31%. The positive likelihood ratio of low, intermediate, and high risk for pneumonia was 0.4, 1.2, and 8.6 respectively. Measurement of procalcitonin added no relevant additional diagnostic information. A simplified diagnostic score based on symptoms, signs, and CRP >30 mg/L resulted in proportions of pneumonia of 0.7%, 3.8%, and 18.2% in the low, intermediate, and high risk group respectively.Conclusions A clinical rule based on symptoms and signs to predict pneumonia in patients presenting to primary care with acute cough performed best in patients with mild or severe clinical presentation. RESEARCHAddition of CRP concentration at the optimal cut off of >30 mg/L improved diagnostic information, but measurement of procalcitonin concentration did not add clinically relevant information in this group. IntroductionDiagnosis of pneumonia in adults presenting with signs of lower respiratory tract infection in primary care is important because pneumonia requires specific treatment and follow-up, whereas for acute bronchitis expectant management is usually appropriate.1 Nonetheless, accurate diagnosis of pneumonia in primary care is difficult as it...

Loes C. M. Bertens and colleagues survey the published diagnostic research literature for use of expert panels to define the reference standard, characterize components and missing information, and recommend elements that should be reported in diagnostic studies. Please see later in the article for the Editors' Summary

Background Efficient incorporation of e‐health in patients with heart failure (HF) may enhance health care efficiency and patient empowerment. We aimed to assess the effect on self‐care of (i) the European Society of Cardiology/Heart Failure Association website ‘ heartfailurematters.org ’ on top of usual care, and (ii) an e‐health adjusted care pathway leaving out ‘in person’ routine HF nurse consultations in stable HF patients. Methods and results In a three‐group parallel‐randomized trial in stable HF patients from nine Dutch outpatient clinics, we compared two interventions ( heartfailurematters.org website and an e‐health adjusted care pathway) to usual care. The primary outcome was self‐care measured with the European Heart Failure Self‐care Behaviour Scale. Secondary outcomes were health status, mortality, and hospitalizations. In total, 450 patients were included. The mean age was 66.8 ± 11.0 years, 74.2% were male, and 78.8% classified themselves as New York Heart Association I or II at baseline. After 3 months of follow‐up, the mean score on the self‐care scale was significantly higher in the groups using the website and the adjusted care pathway compared to usual care (73.5 vs. 70.8, 95% confidence interval 0.6–6.2; and 78.2 vs. 70.8, 95% confidence interval 3.8– 9.4, respectively). The effect attenuated, until no differences after 1 year between the groups. Quality of life showed a similar pattern. Other secondary outcomes did not clearly differ between the groups. Conclusions Both the heartfailurematters.org website and an e‐health adjusted care pathway improved self‐care in HF patients on the short term, but not on the long term. Continuous updating of e‐health facilities could be helpful to sustain effects. Clinical Trial registration: ClinicalTrials.gov ID NCT01755988.

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