Severity prediction rules in community acquired pneumonia: a validation study

Comparing large scale and selected feature learning for community acquired pneumonia prognosis prediction using clinical data: a stacked ensemble approach

This study investigated and validated all-cause in-hospital death prediction models for hospitalized pneumonia patients based on large-scale clinical data, including diagnoses, medication prescriptions, and laboratory test codes. Feature selection was performed using both large-scale feature learning with a Common Data Model (CDM) and specific pneumonia-related risk factors. A stacked ensemble mixed machine-learning model was compared with traditional machine-learning models. Accuracy, F1-score, the Area Under Precision Recall Curve (AUPRC) and the Area Under the Receiver Operating Characteristic (AUROC) were used for performance evaluation. For large-scale feature learning using a CDM, the ensemble model (LASSO LR + GBM + RF) achieved the highest performance. For the 365-day lookback, the ensemble model's AUROC was 0.867 (95% CI: 0.823-0.910), and for the 7-day lookback (AUROC 0.867, 95% CI: 0.822-0.912). In contrast, for feature learning based on selected pneumonia risk factors, among the traditional models, the RF model performed best with AUROCs of 0.774 (95% CI: 0.717-0.830) for the 365-day lookback and 0.773 (95% CI: 0.717-0.828) for the 7-days lookback. Leveraging large-scale feature learning within the CDM and using a stacked ensemble model predicts more accurately and robustly, highlighting the potential to capture complex relationships among clinical features and improve prognostic assessments.

The role of CTGF and MFG-E8 in the prognosis assessment of SCAP: a study combining machine learning and nomogram analysis

Background

Severe Community-Acquired Pneumonia (SCAP) is a serious global health issue with high incidence and mortality rates. In recent years, the role of biomarkers such as Connective Tissue Growth Factor (CTGF) and Milk Fat Globule-Epidermal Growth Factor 8 (MFG-E8) in disease diagnosis and prognosis has increasingly gained attention. However, their specific functions in SCAP have still remained unclear. By conducting a prospective analysis, this study has explored the relationship between these two proteins and the diagnosis and mortality of SCAP patients. Additionally, founded on comparing the applications of machine learning and nomograms as predictive models in forecasting the 28-day mortality risk of SCAP patients, this paper has discussed their performance in different medical scenarios to provide more accurate treatment options and improve prognosis.

Methods

198 patients diagnosed with SCAP, 80 patients with CAP and 80 healthy individuals were encompassed in the study. Demographic characteristics, clinical features and biomarkers were extracted. The ELISA method was employed to measure the levels of MFG-E8 and CTGF in the three groups. The 28-day mortality of SCAP patients was tracked. Eleven models, including XGBoost and CatBoost, were used as prediction models and compared with a nomogram. And 14 scoring methods, like F1 Score and AUC Score, were used to evaluate the prediction models.

Results

Compared to healthy controls, SCAP patients had higher serum levels of CTGF and MFG-E8, suggesting that these biomarkers are associated with poor prognosis. Compared to CAP patients, SCAP patients had lower levels of MFG-E8 and higher levels of CTGF. In the deceased group of SCAP patients, their CTGF levels were higher and MFG-E8 levels were lower. Using the CatBoost model for prediction, it performed the best, with key predictive features including Oxygenation Index, cTnT, MFG-E8, Dyspnea, CTGF and PaCO2.

Conclusion

This study has highlighted the critical role of clinical and biochemical markers such as CTGF and MFG-E8 in assessing the severity and prognosis of SCAP. The CatBoost model has shown the significant potential in predicting mortality risk by virtue of its unique algorithmic advantages and efficiency.

Prognostic clinical decision support for pneumonia in the emergency department: A randomized trial

BACKGROUND

Hospitalization rates for childhood pneumonia vary widely. Risk-based clinical decision support (CDS) interventions may reduce unwarranted variation.

METHODS

We conducted a pragmatic randomized trial in two US pediatric emergency departments (EDs) comparing electronic health record (EHR)-integrated prognostic CDS versus usual care for promoting appropriate ED disposition in children (<18 years) with pneumonia. Encounters were randomized 1:1 to usual care versus custom CDS featuring a validated pneumonia severity score predicting risk for severe in-hospital outcomes. Clinicians retained full decision-making authority. The primary outcome was inappropriate ED disposition, defined as early transition to lower- or higher-level care. Safety and implementation outcomes were also evaluated.

RESULTS

The study enrolled 536 encounters (269 usual care and 267 CDS). Baseline characteristics were similar across arms. Inappropriate disposition occurred in 3% of usual care encounters and 2% of CDS encounters (adjusted odds ratio: 0.99, 95% confidence interval: [0.32, 2.95]). Length of stay was also similar and adverse safety outcomes were uncommon in both arms. The tool's custom user interface and content were viewed as strengths by surveyed clinicians (>70% satisfied). Implementation barriers include intrinsic (e.g., reaching the right person at the right time) and extrinsic factors (i.e., global pandemic).

CONCLUSIONS

EHR-based prognostic CDS did not improve ED disposition decisions for children with pneumonia. Although the intervention's content was favorably received, low subject accrual and workflow integration problems likely limited effectiveness. Clinical Trials Registration: NCT06033079.

A Deep Learning Model Using Chest Radiographs for Prediction of 30-Day Mortality in Patients With Community-Acquired Pneumonia: Development and External Validation

BACKGROUND. Chest radiography is an essential tool for diagnosing community-acquired pneumonia (CAP), but it has an uncertain prognostic role in the care of patients with CAP. OBJECTIVE. The purpose of this study was to develop a deep learning (DL) model to predict 30-day mortality from diagnosis among patients with CAP by use of chest radiographs to validate the performance model in patients from different time periods and institutions. METHODS. In this retrospective study, a DL model was developed from data on 7105 patients from one institution from March 2013 to December 2019 (3:1:1 allocation to training, validation, and internal test sets) to predict the risk of all-cause mortality within 30 days after CAP diagnosis by use of patients' initial chest radiographs. The DL model was evaluated in a cohort of patients diagnosed with CAP during emergency department visits at the same institution from January 2020 to March 2020 (temporal test cohort [n = 947]) and in two additional cohorts from different institutions (external test cohort A [n = 467], January 2020 to December 2020; external test cohort B [n = 381], March 2019 to October 2021). AUCs were compared between the DL model and an established risk prediction tool based on the presence of confusion, blood urea nitrogen level, respiratory rate, blood pressure, and age 65 years or older (CURB-65 score). The combination of CURB-65 score and DL model was evaluated with a logistic regression model. RESULTS. The AUC for predicting 30-day mortality was significantly larger (p < .001) for the DL model than for CURB-65 score in the temporal test set (0.77 vs 0.67). The larger AUC for the DL model than for CURB-65 score was not significant (p > .05) in external test cohort A (0.80 vs 0.73) or external test cohort B (0.80 vs 0.72). In the three cohorts, the DL model, in comparison with CURB-65 score, had higher (p < .001) specificity (range, 61-69% vs 44-58%) at the sensitivity of CURB-65 score. The combination of DL model and CURB-65 score, in comparison with CURB-65 score, yielded a significant increase in AUC in the temporal test cohort (0.77, p < .001) and external test cohort B (0.80, p = .04) and a nonsignificant increase in AUC in external test cohort A (0.80, p = .16). CONCLUSION. A DL-based model consisting of initial chest radiographs was predictive of 30-day mortality among patients with CAP with improved performance over CURB-65 score. CLINICAL IMPACT. The DL-based model may guide clinical decision-making in the care of patients with CAP.

Adjunctive intravenous then oral vitamin C for moderate and severe community-acquired pneumonia in hospitalized adults: feasibility of randomized controlled trial

Patients hospitalised with community acquired pneumonia (CAP) have low peripheral blood vitamin C concentrations and limited antioxidant capacity. The feasibility of a trial of vitamin C supplementation to improve patient outcomes was assessed. Participants with moderate and severe CAP (CURB-65 ≥ 2) on intravenous antimicrobial treatment were randomised to either intravenous vitamin C (2.5 g 8 hourly) or placebo before switching to oral intervention (1 g tds) for 7 days when they were prescribed oral antimicrobial therapy. Of 344 patients screened 75 (22%) were randomised and analysed. The median age was 76 years, and 43 (57%) were male. In each group, one serious adverse event that was potentially intervention related occurred, and one subject discontinued treatment. Vitamin C concentrations were 226 µmol/L in the vitamin C group and 19 µmol/L in the placebo group (p < 0.001) after 3 intravneous doses. There were no signficant differences between the vitamin C and placebo groups for death within 28 days (0 vs. 2; p = 0.49), median length of stay (69 vs. 121 h; p = 0.07), time to clinical stability (22 vs. 49 h; p = 0.08), or readmission within 30 days (1 vs. 4; p = 0.22). The vitamin C doses given were safe, well tolerated and saturating. A randomised controlled trial to assess the efficacy of vitamin C in patients with CAP would require 932 participants (CURB-65 ≥ 2) to observe a difference in mortality and 200 participants to observe a difference with a composite endpoint such as mortality plus discharge after 7 days in hospital. These studies are feasible in a multicentre setting.

Clinical Features of COVID-19 and Differentiation from Other Causes of CAP

Community-acquired pneumonia (CAP) is a significant cause of morbidity and mortality, one of the most common reasons for infection-related death worldwide. Causes of CAP include numerous viral, bacterial, and fungal pathogens, though frequently no specific organism is found. Beginning in 2019, the COVID-19 pandemic has caused incredible morbidity and mortality. COVID-19 has many features typical of CAP such as fever, respiratory distress, and cough, and can be difficult to distinguish from other types of CAP. Here, we highlight unique clinical features of COVID-19 pneumonia such as olfactory and gustatory dysfunction, lymphopenia, and distinct imaging appearance.

Machine-Learning Model for Mortality Prediction in Patients With Community-Acquired Pneumonia: Development and Validation Study

BACKGROUND

Artificial intelligence tools and techniques such as machine learning (ML) are increasingly seen as a suitable manner in which to increase the prediction capacity of currently available clinical tools, including prognostic scores. However, studies evaluating the efficacy of ML methods in enhancing the predictive capacity of existing scores for community-acquired pneumonia (CAP) are limited. We aimed to apply and validate a causal probabilistic network (CPN) model to predict mortality in patients with CAP.

RESEARCH QUESTION

Is a CPN model able to predict mortality in patients with CAP better than the commonly used severity scores?

STUDY DESIGN AND METHODS

This was a derivation-validation retrospective study conducted in two Spanish university hospitals. The ability of a CPN designed to predict mortality in sepsis (SepsisFinder [SeF]), and adapted for CAP (SeF-ML), to predict 30-day mortality was assessed and compared with other scoring systems (Pneumonia Severity Index [PSI], Sequential Organ Failure Assessment [SOFA], quick Sequential Organ Failure Assessment [qSOFA], and CURB-65 criteria [confusion, urea, respiratory rate, BP, age ≥ 65 years]). The SeF models are proprietary software. Differences between receiver operating characteristic curves were assessed by the DeLong method for correlated receiver operating characteristic curves.

RESULTS

The derivation cohort comprised 4,531 patients, and the validation cohort consisted of 1,034 patients. In the derivation cohort, the areas under the curve (AUCs) of SeF-ML, CURB-65, SOFA, PSI, and qSOFA were 0.801, 0.759, 0.671, 0.799, and 0.642, respectively, for 30-day mortality prediction. In the validation study, the AUC of SeF-ML was 0.826, concordant with the AUC (0.801) in the derivation data (P = .51). The AUC of SeF-ML was significantly higher than those of CURB-65 (0.764; P = .03) and qSOFA (0.729, P = .005). However, it did not differ significantly from those of PSI (0.830; P = .92) and SOFA (0.771; P = .14).

INTERPRETATION

SeF-ML shows potential for improving mortality prediction among patients with CAP, using structured health data. Additional external validation studies should be conducted to support generalizability.

A Novel Index in the Prediction of Pneumonia Following Acute Ischemic Stroke

BACKGROUND

The aim of our study was to search for predictive factors and to develop a model (index) for the risk of pneumonia following acute ischemic stroke.

MATERIAL AND METHODS

This study is an analysis of prospectively collected data from the neurology department of a district general hospital in Poland, comprising 1001 patients suffering from an acute ischemic stroke. Based on the medical data, the formula for the prediction of pneumonia was calculated.

RESULTS

Multivariate assessment for pneumonia occurrence was performed using the new PNEUMOINDEX. The study showed a significant increase in pneumonia risk with an increasing PNEUMOINDEX (OR non-adjusted = 2.738, p < 0.001). After accounting for age and comorbidities as confounders, the effect of the Index on pneumonia changed marginally (OR = 2.636, p < 0.001).

CONCLUSIONS

This study presents factors that show a significant association with the occurrence of pneumonia in patients with acute ischemic stroke. The calculated PNEUMOINDEX consists of data obtained at admission, namely NYHA III and IV heart failure, COPD, generalized atherosclerosis, NIHHS score on admission, and CRP/Hgb ratio, and shows high prediction accuracy in predicting hospital-acquired pneumonia in ischemic stroke patients.

Acute Lower Respiratory Tract Infection Increased the Risk of Cardiovascular Events and All-Cause Mortality in Elderly Patients With Stable Coronary Artery Disease

Objective: To investigate the predictors of acute cardiovascular events within 90 days after an acute lower respiratory tract infection (ALRTI) in elderly patients with stable coronary artery disease (sCAD). Methods: Observational analyses were conducted in a prospective cohort of the elderly with sCAD, during 90 days after they were hospitalized for ALRTI. Multiple logistic regression analysis was performed to identify predictors for acute cardiovascular events and all-cause mortality. Results: The present study comprised 426 patients with sCAD (median age: 88 years; IQR: 84-91; range: 72-102). Among these patients, 257 suffering from ALRTI were enrolled in the infection group. Meanwhile, 169 patients who did not suffer from ALRTI were regarded as the non-infection group. Compared with the non-infection group, patients in the infection group had a higher incidence of acute cardiovascular events (31.9 vs. 13.6%, p < 0.001) and all-cause mortality (13.2 vs. 1.8%, p < 0.001) during the 90-day follow-up. In addition, in the infection group, the incidence of cardiovascular events was also higher than those in the non-infection group during the 7-day and 30-day follow-up (10.9 vs. 2.4%, p = 0.001; 20.6 vs. 6.5%, p < 0.001). The same difference in the incidence of all-cause mortality during 7 and 30 days (1.2 vs. 0%, p = 0.028; 3.9 vs. 0.6%, p = 0.021) was observed between the two groups. Furthermore, multiple regression analysis found that ALRTI was independently associated with increased risk of cardiovascular events and all-cause mortality in elderly patients with sCAD. Conclusion: In elderly patients with sCAD, ALRTI was an independent predictor for both cardiovascular events and all-cause mortality.

Study of immune-mediated mechanisms in patients tested positive for SARS-CoV-2: phenotypic and functional analysis of monocytes, NK and T cells in the blood of subjects affected by COVID 19

Background

The novel coronavirus has a high mortality rate (over 1% for patients older than 50 years). This can only be partially ascribed to other comorbidities. A possible explanation is a factor that assures a prompt response to SARS-CoV-2 in younger people, independent from the novelty of the virus itself. A factor is believed to stimulate the immune system and provide immunity against more antigens. The only external stimulation received by healthy people is vaccination (eg, the diphtheria, tetanus, and pertussis [DTP] vaccine). One hypothesis is that vaccination helps develop specific immunity but generates sprouting immunity against antigens in transit. The underlying immunological phenomena are the “bystander effect” and “trained immunity.” The developed immunity gives protection for years until it naturally fades out. After the fifth decade of life, the immune system is almost incompetent when a viral infection occurs, and thus, at this stage, the novel coronavirus can enter the body and cause acute respiratory distress syndrome.

Objective

The initial aim is to demonstrate that blood monocytes and natural killer cells show overpowering hyperactivity, while CD4+ and CD8+ T cells experience impediments to their defensive functions in patients with severe SARS-CoV-2 infection. The secondary objectives are to correlate clinical data and vaccination history with laboratory immune patterns in order to identify protective factors. Subsequently, we are also interested in characterizing the phenotypes and state of the degree of activation of peripheral blood mononuclear cells, including monocytes, natural killer cells, and CD4+ and CD8+ T cells, in healthy subjects vaccinated with the Pfizer vaccine.

Methods

Data will be collected using the following 3 approaches: (1) an experimental analysis to study the innate immune response and to identify genetic profiles; (2) an epidemiological analysis to identify the patients’ vaccination history; and (3) a clinical analysis to detect the immunological profile.

Results

The protocol was approved by the Ethics Committee on April 16, 2020, and the study started on April 27, 2020. As of February 2021, enrollment has been completed. Immunological analysis is ongoing, and we expect to complete this analysis by December 2022.

Conclusions

We will recognize different populations of patients, each one with a specific immunological pattern in terms of cytokines, soluble factor serum levels, and immune cell activity. Anamnestic data, such as preceding vaccinations and comorbidities, biochemical findings like lymphocyte immunophenotyping, and pre-existing persistent cytomegalovirus infection, allow depicting the risk profile of severe COVID-19. Proof of the roles of these immunological phenomena in the development of COVID-19 can be the basis for the implementation of therapeutic immunomodulatory treatments.

Trial Registration

ClinicalTrials.gov NCT04375176; https://clinicaltrials.gov/ct2/show/NCT04375176

International Registered Report Identifier (IRRID)

DERR1-10.2196/29892

The Importance of Respiratory Rate Monitoring: From Healthcare to Sport and Exercise

Respiratory rate is a fundamental vital sign that is sensitive to different pathological conditions (e.g., adverse cardiac events, pneumonia, and clinical deterioration) and stressors, including emotional stress, cognitive load, heat, cold, physical effort, and exercise-induced fatigue. The sensitivity of respiratory rate to these conditions is superior compared to that of most of the other vital signs, and the abundance of suitable technological solutions measuring respiratory rate has important implications for healthcare, occupational settings, and sport. However, respiratory rate is still too often not routinely monitored in these fields of use. This review presents a multidisciplinary approach to respiratory monitoring, with the aim to improve the development and efficacy of respiratory monitoring services. We have identified thirteen monitoring goals where the use of the respiratory rate is invaluable, and for each of them we have described suitable sensors and techniques to monitor respiratory rate in specific measurement scenarios. We have also provided a physiological rationale corroborating the importance of respiratory rate monitoring and an original multidisciplinary framework for the development of respiratory monitoring services. This review is expected to advance the field of respiratory monitoring and favor synergies between different disciplines to accomplish this goal.

Usefulness of circulating microRNAs miR-146a and miR-16-5p as prognostic biomarkers in community-acquired pneumonia

Introduction

Patients with community-acquired pneumonia (CAP) undergo a dysregulated host response that is related to mortality. MicroRNAs (miRNAs) participate in this response, but their expression pattern and their role as biomarkers in CAP have not been fully characterized.

Methods

A prospective observational study was performed in a cohort of 153 consecutive patients admitted to hospital with CAP. Clinical and analytical variables were collected, and the main outcome variable was 30-day mortality. Small RNA was purified from plasma of these patients obtained on the first day of admission, and miRNA expression was analyzed by RT-PCR. Univariate and multivariate analyses were carried out through the construction of a logistic regression model. The proposed model was compared with established prognostic clinical scales using ROC curve analysis.

Results

The mean age of the patients included was 74.7 years [SD 15.9]. Their mean PSI was 100.9 [SD 34.6] and the mean modified Charlson index was 2.9 [SD 3.0]. Both miR-146a and miR-16-5p showed statistically significant association with 30-day mortality after admission due to CAP (1.10 vs. 0.23 and 51.74 vs. 35.23, respectively), and this association remained for miR-16-5p in the multivariate analysis adjusted for age, gender and history of bronchoaspiration (OR 0.95, p = 0.021). The area-under-the-curve (AUC) of our adjusted multivariate model (AUC = 0.954 95%CI [0.91–0.99]), was better than those of prognostic scales such as PSI (AUC = 0.799 [0.69–0.91]) and CURB-65 (AUC = 0.722 [0.58–0.86]).

Conclusions

High levels of miR-146a-5p and miR-16-5p upon admission due to CAP are associated with lower mortality at 30 days of follow-up. Both miRNAs could be used as biomarkers of good prognosis in subjects hospitalized with CAP.

Respiratory tract infections (RTIs) in primary care: narrative review of C reactive protein (CRP) point-of-care testing (POCT) and antibacterial use in patients who present with symptoms of RTI

Antimicrobial resistance (AMR) continues to be a global problem and continues to be addressed through national strategies to improve diagnostics, develop new antimicrobials and promote antimicrobial stewardship. Patients who attend general (ambulatory) practice with symptoms of respiratory tract infections (RTIs) are invariably assessed by some sort of clinical decision rule (CDR). However, CDRs rely on a cluster of non-specific clinical observations. A narrative review of the literature was undertaken to ascertain the value of C reactive protein (CRP) point-of-care testing (POCT) to guide antibacterial prescribing in adult patients presenting to general practitioner (GP) practices with symptoms of RTI. Studies that were included were Cochrane reviews, systematic reviews, randomised controlled trials, cluster randomised trials, controlled before and after studies, cohort studies and economic evaluations. An overwhelming number of studies demonstrated that the use of CRP tests in patients presenting with RTI symptoms reduces index antibacterial prescribing. GPs and patients report a good acceptability for a CRP POCT and economic evaluations show cost-effectiveness of CRP POCT over existing RTI management in primary care. POCTs increase diagnostic precision for GPs in the better management of patients with RTI. With the rapid development of artificial intelligence, patients will expect greater precision in diagnosing and managing their illnesses. Adopting systems that markedly reduce antibiotic consumption is a no-brainer for governments that are struggling to address the rise in AMR.

Community-acquired pneumonia in critically ill very old patients: a growing problem

Very old (aged ≥80 years) adults constitute an increasing proportion of the global population. Currently, this subgroup of patients represents an important percentage of patients admitted to the intensive care unit. Community-acquired pneumonia (CAP) frequently affects very old adults. However, there are no specific recommendations for the management of critically ill very old CAP patients. Multiple morbidities, polypharmacy, immunosenescence and frailty contribute to an increased risk of pneumonia in this population. CAP in critically ill very old patients is associated with higher short- and long-term mortality; however, because of its uncommon presentation, diagnosis can be very difficult. Management of critically ill very old CAP patients should be guided by their baseline characteristics, clinical presentation and risk factors for multidrug-resistant pathogens. Hospitalisation in intermediate care may be a good option for critical ill very old CAP patients who do not require invasive procedures and for whom intensive care is questionable in terms of benefit.

There is currently no international recommendation for the management of critically ill older patients over 80 years of age with CAP. We report and discuss recent literature in order to help physicians in the decision-making process of these patients.http://bit.ly/2ql0mIz

Hot topics and current controversies in community-acquired pneumonia

Community-acquired pneumonia (CAP) is one of the most common infectious diseases, as well as a major cause of death both in developed and developing countries, and it remains a challenge for physicians around the world. Several guidelines have been published to guide clinicians in how to diagnose and take care of patients with CAP. However, there are still many areas of debate and uncertainty where research is needed to advance patient care and improve clinical outcomes. In this review we highlight current hot topics in CAP and present updated evidence around these areas of controversy.

Community-acquired pneumonia is the most frequent cause of infectious death worldwide; however, there are several areas of controversy that should be addressed to improve patient care. This review presents the available data on these topics.http://bit.ly/2ShnH7A

Mean nocturnal respiratory rate predicts cardiovascular and all-cause mortality in community-dwelling older men and women

Respiratory frequency (f _R) predicts in-hospital and short-term mortality in patients with a variety of pathophysiological conditions, but its predictive value for long-term cardiovascular and all-cause mortality in the general population is unknown. Here, we investigated the relationship between mean nocturnal f _R and mortality in community-dwelling older men and women.We measured mean nocturnal f _R during sleep from overnight polysomnography in 2686 men participating in the Osteoporotic Fractures in Men Study (MrOS) Sleep study and 406 women participating in the Study of Osteoporotic Fractures (SOF) to investigate the relationship between mean nocturnal f _R and long-term cardiovascular and all-cause mortality.166 (6.1%) men in the MrOS cohort (8.9±2.6 years' follow-up) and 46 (11.2%) women in the SOF cohort (6.4±1.6 years' follow-up) died from cardiovascular disease. All-cause mortality was 51.2% and 26.1% during 13.7±3.7 and 6.4±1.6 years' follow-up in the MrOS Sleep study and the SOF cohorts, respectively. Multivariable Cox regression analysis adjusted for significant covariates demonstrated that f _R dichotomised at 16 breaths·min^-1 was independently associated with cardiovascular mortality (MrOS: hazard ratio (HR) 1.57, 95% CI 1.14-2.15; p=0.005; SOF: HR 2.58, 95% CI 1.41-4.76; p=0.002) and all-cause mortality (MrOS: HR 1.18, 95% CI 1.04-1.32; p=0.007; SOF: HR 1.50, 95% CI 1.02-2.20; p=0.04).In community-dwelling older men and women, polysomnography-derived mean nocturnal f _R ≥16 breaths·min^-1 is an independent predictor of long-term cardiovascular and all-cause mortality. Whether nocturnal mean f _R can be used as a risk marker warrants further prospective studies.

Is chronic obstructive pulmonary disease a risk factor for death in patients with community acquired pneumonia?

BACKGROUND

It is still a matter of debate whether the outcome of community acquired pneumonia is more severe in patients with chronic obstructive pulmonary disease. We aimed to determine whether chronic obstructive pulmonary disease was associated with increased mortality and to identify risk-factors for mortality in patients with community acquired pneumonia and chronic obstructive pulmonary disease.

METHODS

Retrospective cohort study comparing patients with community acquired pneumonia and chronic obstructive pulmonary disease to patients without chronic obstructive pulmonary disease. We included 1309 patients with community acquired pneumonia admitted from 2011 until 2012 (243 patients with chronic obstructive pulmonary disease and 1066 without chronic obstructive pulmonary disease).

RESULTS

At admission patients with community acquired pneumonia and chronic obstructive pulmonary disease presented with more severe pneumonia as measured by CURB-65 score compared to patients without chronic obstructive pulmonary disease. Mortality on day 30 was generally high, and higher among patients with community acquired pneumonia and chronic obstructive pulmonary disease compared to those without chronic obstructive pulmonary disease (16.0% versus 11.3%, p = .04). In an adjusted analysis, however, chronic obstructive pulmonary disease was not independently associated with 30-d mortality (odds ratio 0.94, confidence interval 95% 0.59-1.50). Factors related to mortality in patients with community acquired pneumonia and chronic obstructive pulmonary disease were age, premorbid condition, severity of pneumonia as determined by CURB-65 score, and pleural effusion and multi-lobular infiltrate on chest X-ray.

CONCLUSIONS

Chronic obstructive pulmonary disease was not independently associated with 30-d mortality in patients with community acquired pneumonia.

Pleural infection: a closer look at the etiopathogenesis, microbiology and role of antibiotics

INTRODUCTION

Pleural infection is a condition that continues to pose a significant challenge to respiratory physicians. We hypothesize that the main barriers to progress include limited understanding of the etiopathogenesis, microbiology,and role of antibiotics in the pleural space. Areas covered: PubMed was searched for articles related to adult pleural infection using the terms 'pleural infection', 'empyema' and 'parapneumonic'. The search focused on relevant literature within the last 10 years, with any older citations used only to display context or lack of progress. Tuberculous pleural infection was excluded. We chose to give specific attention to the etiopathogenesis of pleural infection, including recent advances in diagnostics and biomarkers. We discuss our understanding of the pleural microbiome and rationalize the current use of antibiotics in treating this condition. Expert commentary: Understanding of key events in the development of this condition remains limited. The microbiology is unique compared to the lung, and highly variable. Higher culture yields from pleural biopsy may add new insights into the etiopathogenesis. There is little evidence into achievable effective antibiotic concentration within the pleura. Research into issues including the relevance of biofilm formation and significance of pleural thickening is necessary for treatment progress.

Predictors of Physician Confidence to Diagnose Pneumonia and Determine Illness Severity in Ventilated Patients. Australian and New Zealand Practice in Intensive Care (ANZPIC II)

The manner in which elements of clinical history, physical examination and investigations influence subjectively assessed illness severity and outcome prediction is poorly understood. This study investigates the relationship between clinician and objectively assessed illness severity and the factors influencing clinician's diagnostic confidence and illness severity rating for ventilated patients with suspected pneumonia in the intensive care unit (ICU).

A prospective study of fourteen ICUs included all ventilated admissions with a clinical diagnosis of pneumonia. Data collection included pneumonia type – community-acquired (CAP), hospital-acquired (HAP) and ventilator-associated (VAP), clinician determined illness severity (CDIS), diagnostic methods, clinical diagnostic confidence (CDC), microbiological isolates and antibiotic use.

For 476 episodes of pneumonia (48% CAP, 24% HAP, 28% VAP), CDC was greatest for CAP (64% CAP, 50% HAP and 49% VAP, P<0.01) or when pneumonia was considered “life-threatening” (84% high CDC, 13% medium CDC and 3% low CDC, P<0.001). “Life-threatening” pneumonia was predicted by worsening gas exchange (OR 4.8, CI 95% 2.3–10.2, P<0.001), clinical signs of consolidation (OR 2.0, CI 95% 1.2–3.2, P<0.01) and the Sepsis-Related Organ Failure Assessment (SOFA) Score (OR 1.1, CI 95% 1.1–1.2, P<0.001). Diagnostic confidence increased with CDIS (OR 16.3, CI 95% 8.4–31.4, P<0.001), definite pathogen isolation (OR 3.3, CI 95% 2.0–5.6) and clinical signs of consolidation (OR 2.1, CI 95% 1.3–3.3, P=0.001). Although the CDIS, SOFA Score and the Simplified Acute Physiologic Score (SAPS II) were all associated with mortality, the SAPS II Score was the best predictor of mortality (P=0.02).

Diagnostic confidence for pneumonia is moderate but increases with more classical presentations. A small set of clinical parameters influence subjective assessment. Objective assessment using SAPS II Scoring is a better predictor of mortality.

Hyponatremia, falls and bone fractures: A systematic review and meta-analysis

OBJECTIVE

To perform a meta-analysis based on published studies that compared falls and bone fractures between patients with and without hyponatremia.

CONTEXT

There is evidence suggesting that hyponatremia is associated with an increased risk of falls and bone fractures.

DESIGN

An extensive Medline, Embase and Cochrane search was performed to retrieve all studies published up to, 30 April 2017, using the following words: "hyponatremia" or "hyponatraemia" AND "falls" and "bone fractures." A meta-analysis was performed including all studies comparing falls and bone fractures in subjects with or without hyponatremia.

PATIENTS AND RESULTS

Of 216 retrieved articles, 15 studies satisfied inclusion criteria encompassing a total of 51 879 patients, of whom 2329 were hyponatremic. Across all studies, hyponatremia was associated with a significantly increased risk of falls (MH-OR = 2.14[1.71; 2.67]. This result was confirmed when only hospitalized patients were considered (MH-OR = 2.44 [1.97; 3.02]). A meta-regression analysis showed that the hyponatremia-related risk of falls was higher in those studies considering a lower serum [Na+ ] cut-off to define hyponatremia. Interestingly, the estimated risk of falls related to hyponatremia was already significantly higher when a serum [Na+ ] cut-off of 135 mmol/L was considered (MH-OR = 1.26[1.23;1.29]). The presence of hyponatremia was also associated with a higher risk of fractures, particularly hip fractures (MH-OR = 2.00[1.43;2.81]).

CONCLUSIONS

This study confirms that hyponatremia is associated with an increased risk of falls and bone fractures. The clinical, social and economic relevance of such association is strengthened by the increased incidence of hyponatremia in older people.

2018 recommendations for the management of community acquired pneumonia

Community-acquired pneumonia (CAP) is the leading cause of death worldwide. Despite the vast diversity of respiratory microbiota, Streptococcus pneumoniae remains the most prevalent pathogen among etiologic agents. Despite the significant decrease in the mortality rates for lower respiratory tract infections in recent decades, CAP ranks third as a cause of death in Brazil. Since the latest Guidelines on CAP from the Sociedade Brasileira de Pneumologia e Tisiologia (SBPT, Brazilian Thoracic Association) were published (2009), there have been major advances in the application of imaging tests, in etiologic investigation, in risk stratification at admission and prognostic score stratification, in the use of biomarkers, and in the recommendations for antibiotic therapy (and its duration) and prevention through vaccination. To review these topics, the SBPT Committee on Respiratory Infections summoned 13 members with recognized experience in CAP in Brazil who identified issues relevant to clinical practice that require updates given the publication of new epidemiological and scientific evidence. Twelve topics concerning diagnostic, prognostic, therapeutic, and preventive issues were developed. The topics were divided among the authors, who conducted a nonsystematic review of the literature, but giving priority to major publications in the specific areas, including original articles, review articles, and systematic reviews. All authors had the opportunity to review and comment on all questions, producing a single final document that was approved by consensus.

Pneumonia in Patients with Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a frequent comorbid condition associated with increased morbidity and mortality. Pneumonia is the most common infectious disease condition. The purpose of this review is to evaluate the impact of pneumonia in patients with COPD. We will evaluate the epidemiology and factors associated with pneumonia. We are discussing the clinical characteristics of COPD that may favor the development of infections conditions such as pneumonia. Over the last 10 years, there is an increased evidence that COPD patients treated with inhaled corticosteroids are at increased risk to develp pneumonia. We will review the avaialbe information as well as the possible mechanism for this events. We also discuss the impact of influenza and pneumococcal vaccination in the prevention of pneumonia in COPD patients.

Sodium levels on admission are associated with mortality risk in hospitalized patients

AIMS

Abnormal sodium values are common among hospitalized patients. We aimed to investigate the association of admission sodium values and mortality.

METHODS

Historical prospectively data of adult patients hospitalized to medical wards between January 2011 and December 2013. Admission sodium values were classified to five categories: severe hyponatremia (<125mEq/L), mild hyponatremia (125-135mEq/L), normal sodium values (135-145mEq/L), mild hypernatremia (145-150mEq/L) and severe hypernatremia (>150mEq/L). Main outcomes were length of hospitalization, in-hospital mortality and mortality at the end-of-follow-up.

RESULTS

The cohort included 27,889 patients (mean age 67±18years, 52% males). The total follow-up was 1065days. Most patients had normal sodium values (76%), 22% had hyponatremia, 3% had hypernatremia. Mean age increased with increase in severity of hyponatremia or hypernatremia. Median length of hospitalization was longer with mild and severe hypernatremia (7 and 5days, respectively) or with mild and severe hyponatremia (4 and 4days, respectively), compared to normal sodium levels (3days). Compared to in-hospital mortality with normal sodium levels (5%), mortality was higher with mild and severe hyponatremia (9% and 14%, respectively) and was highest with mild (28%), and severe hypernatremia (52%). Mortality rate at the end of follow-up was 28% with normal sodium levels, 44% and 48% with mild and severe hyponatremia, 66% and 90% with mild and severe hypernatremia, respectively.

CONCLUSIONS

Abnormal sodium values on admission were associated with longer hospitalization and increased short- and long-term mortality. Mortality risk was higher with hypernatremia, compared to hyponatremia.

Emergency Medicine Evaluation of Community-Acquired Pneumonia: History, Examination, Imaging and Laboratory Assessment, and Risk Scores

BACKGROUND

Pneumonia is a common infection, accounting for approximately one million hospitalizations in the United States annually. This potentially life-threatening disease is commonly diagnosed based on history, physical examination, and chest radiograph.

OBJECTIVE

To investigate emergency medicine evaluation of community-acquired pneumonia including history, physical examination, imaging, and the use of risk scores in patient assessment.

DISCUSSION

Pneumonia is the number one cause of death from infectious disease. The condition is broken into several categories, the most common being community-acquired pneumonia. Diagnosis centers on history, physical examination, and chest radiograph. However, all are unreliable when used alone, and misdiagnosis occurs in up to one-third of patients. Chest radiograph has a sensitivity of 46-77%, and biomarkers including white blood cell count, procalcitonin, and C-reactive protein provide little benefit in diagnosis. Biomarkers may assist admitting teams, but require further study for use in the emergency department. Ultrasound has shown utility in correctly identifying pneumonia. Clinical gestalt demonstrates greater ability to diagnose pneumonia. Clinical scores including Pneumonia Severity Index (PSI); Confusion, blood Urea nitrogen, Respiratory rate, Blood pressure, age 65 score (CURB-65); and several others may be helpful for disposition, but should supplement, not replace, clinical judgment. Patient socioeconomic status must be considered in disposition decisions.

CONCLUSION

The diagnosis of pneumonia requires clinical gestalt using a combination of history and physical examination. Chest radiograph may be negative, particularly in patients presenting early in disease course and elderly patients. Clinical scores can supplement clinical gestalt and assist in disposition when used appropriately.

Healthcare-associated Pneumonia: Clinical Features and Retrospective Analysis Over 10 Years

Background:

Healthcare-associated pneumonia (HCAP) is associated with drug-resistant pathogens and high mortality, and there is no clear evidence that this is due to inappropriate antibiotic therapy. This study was to elucidate the clinical features, pathogens, therapy, and outcomes of HCAP, and to clarify the risk factors for drug-resistant pathogens and prognosis.

Methods:

Retrospective observational study among hospitalized patients with HCAP over 10 years. The primary outcome was 30-day all-cause hospital mortality after admission. Demographics (age, gender, clinical features, and comorbidities), dates of admission, discharge and/or death, hospitalization costs, microbiological results, chest imaging studies, and CURB-65 were analyzed. Antibiotics, admission to Intensive Care Unit (ICU), mechanical ventilation, and pneumonia prognosis were recorded. Patients were dichotomized based on CURB-65 (low- vs. high-risk).

Results:

Among 612 patients (mean age of 70.7 years), 88.4% had at least one comorbidity. Commonly detected pathogens were Acinetobacter baumannii, Pseudomonas aeruginosa, and coagulase-negative staphylococci. Initial monotherapy with β-lactam antibiotics was the most common initial therapy (50%). Mean age, length of stay, hospitalization expenses, ICU admission, mechanical ventilation use, malignancies, and detection rate for P. aeruginosa, and Staphylococcus aureus were higher in the high-risk group compared with the low-risk group. CURB-65 ≥3, malignancies, and mechanical ventilation were associated with an increased mortality. Logistic regression analysis showed that cerebrovascular diseases and being bedridden were independent risk factors for HCAP.

Conclusion:

Initial treatment of HCAP with broad-spectrum antibiotics could be an appropriate approach. CURB-65 ≥3, malignancies, and mechanical ventilation may result in an increased mortality.

Tools for outcome prediction in patients with community acquired pneumonia

INTRODUCTION

Community-acquired pneumonia (CAP) is one of the most common causes of mortality world-wide. The mortality rate of patients with CAP is influenced by the severity of the disease, treatment failure and the requirement for hospitalization and/or intensive care unit (ICU) management, all of which may be predicted by biomarkers and clinical scoring systems. Areas covered: We review the recent literature examining the efficacy of established and newly-developed clinical scores, biological and inflammatory markers such as C-Reactive protein (CRP), procalcitonin (PCT) and Interleukin-6 (IL-6), whether used alone or in conjunction with clinical severity scores to assess the severity of CAP, predict treatment failure, guide acute in-hospital or ICU admission and predict mortality. Expert commentary: The early prediction of treatment failure using clinical scores and biomarkers plays a developing role in improving survival of patients with CAP by identifying high-risk patients requiring hospitalization or ICU admission; and may enable more efficient allocation of resources. However, it is likely that combinations of scoring systems and biomarkers will be of greater use than individual markers. Further larger studies are needed to corroborate the additive value of these markers to clinical prediction scores to provide a safer and more effective assessment tool for clinicians.

Plasma cytokines eotaxin, MIP-1α, MCP-4, and vascular endothelial growth factor in acute lower respiratory tract infection

Major overlaps of clinical characteristics and the limitations of conventional diagnostic tests render the initial diagnosis and clinical management of pulmonary disorders difficult. In this pilot study, we analyzed the predictive value of eotaxin, macrophage inflammatory protein 1 alpha (MIP-1α), monocyte chemoattractant protein 4 (MCP-4), and vascular endothelial growth factor (VEGF) in 40 patients hospitalized with acute lower respiratory tract infections (LRTI). The cytokines contribute to the pathogenesis of several inflammatory respiratory diseases, indicating a potential as markers for LRTI. Patients were stratified according to etiology and severity of LRTI, based on baseline C-reactive protein and CURB-65 scores. Using a multiplex immunoassay of plasma, levels of eotaxin and MCP-4 were shown to increase from baseline until day 6 after admission to hospital. The four cytokines were unable to predict the etiology and severity. Eotaxin and MCP-4 were significantly lower in patients with C-reactive protein ≥100, and MIP-1α was significantly higher in the patients with CURB-65 > 3, but the predictive power was low. In conclusion, further evaluation, including more patients, is required to assess the full potential of eotaxin, MCP-4, MIP-1α, and VEGF as biomarkers for LRTI because of their low predictive power and a high interindividual variation of cytokine levels.

Improving outcomes in community-acquired pneumonia

PURPOSE OF REVIEW

Community-acquired pneumonia (CAP) is a pervasive disease that is encountered in outpatient and inpatient settings. CAP is the leading cause of death from an infectious disease and accounts for significant worldwide morbidity and mortality. This update reviews current advances that can be used to promote improved outcomes in CAP.

RECENT FINDINGS

Early recognition of CAP and its severe presentations, with appropriate site of care decisions, leads to reduced patient mortality. In addition to traditional prognostic tools, certain serum biomarkers can assist in defining disease severity and guide treatment and management strategies. The use of macrolides as part of combination antibiotic therapy has shown beneficial mortality effects across the CAP disease spectrum, especially for those with severe illness. When treating community-associated, methicillin-resistant Staphylococcus aureus pneumonia, use of an antitoxin antibiotic is likely to be valuable. Adjunctive therapy with corticosteroids may prevent delayed clinical resolution in selected patients with severe CAP. Recent data expand on the interaction of CAP with comorbid disease, particularly cardiovascular disease, and its impact on mortality in CAP patients.

SUMMARY

Improved diagnostic tools, optimized treatment regimens, and enhanced understanding of CAP-induced perturbations in comorbid disease states hold promise to improve patient outcomes.

Mortality in Patients Admitted for Concurrent COPD Exacerbation and Pneumonia

It is unclear whether concurrent pneumonia and chronic obstructive pulmonary disease (COPD) have a higher mortality than either condition alone. Further, it is unknown how this interaction changes over time. We explored the effect of pneumonia and COPD on inpatient, 30-day and overall mortality. We used a Veterans Health Affairs database to compare patients who were hospitalized for a COPD exacerbation without pneumonia (AECOPD), patients hospitalized for pneumonia without COPD (PNA) and patients hospitalized for pneumonia who had a concurrent diagnosis of COPD (PCOPD). We studied records of 15,065 patients with the following primary discharge diagnoses: (a) AECOPD cohort (7,154 individuals); (b) PNA cohort (4,433 individuals); and (c) PCOPD (3,478 individuals), comparing inpatient, 30-day and overall mortality in the three study cohorts. We observed a stepwise increase in inpatient mortality for AECOPD, PNA and PCOPD (4.8%, 9.5% and 13.2%, respectively). These differences persisted at 30 days post-discharge (AECOPD = 6.7%, PNA = 12.4% and PCOPD = 14.6%; p < 0.0001), but not throughout the study period (median follow-up: 37 months). With time, the death rate rose disproportionally in patients who had been admitted for AECOPD (AECOPD = 64.5%; PNA = 57.4% and PCOPD 66.2%; p < 0.001). In multivariate analysis, PCOPD predicted the greatest inpatient mortality (p < 0.001). The data showed a progression in inpatient and 30-day mortality from AECOPD to PNA to PCOPD. Pneumonia and COPD differentially affected inpatient, 30-day and overall mortality with pneumonia affecting predominantly inpatient and 30-day mortality while COPD affecting the overall mortality.

Prevalence and Prognostic Significance of Hyponatremia in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease: Data from the Akershus Cardiac Examination (ACE) 2 Study

BACKGROUND

Hyponatremia is prevalent and associated with mortality in patients with heart failure (HF). The prevalence and prognostic implications of hyponatremia in acute exacerbation of chronic obstructive pulmonary (AECOPD) have not been established.

METHOD

We included 313 unselected patients with acute dyspnea who were categorized by etiology of dyspnea according to established guidelines (derivation cohort). Serum Na+ was determined on hospital admission and corrected for hyperglycemia, and hyponatremia was defined as [Na+]<137 mmol/L. Survival was ascertained after a median follow-up of 816 days and outcome was analyzed in acute HF (n = 143) and AECOPD (n = 83) separately. Results were confirmed in an independent AECOPD validation cohort (n = 99).

RESULTS

In the derivation cohort, median serum Na+ was lower in AECOPD vs. acute HF (138.5 [135.9-140.5] vs. 139.2 [136.7-141.3] mmol/L, p = 0.02), while prevalence of hyponatremia (27% [22/83] vs. 20% [29/143], p = 0.28) and mortality rate (42% [35/83] vs. 46% [66/143], p = 0.56) were similar. By univariate Cox regression analysis, hyponatremia was associated with increased mortality in acute HF (HR 1.85 [95% CI 1.08, 3.16], p = 0.02), but not in AECOPD (HR 1.00 [0.47, 2.15], p = 1.00). Analogous to the results of the derivation cohort, hyponatremia was prevalent also in the AECOPD validation cohort (25% [25/99]), but not associated with mortality. The diverging effect of hyponatremia on outcome between AECOPD and acute HF was statistically significant (p = 0.04).

CONCLUSION

Hyponatremia is prevalent in patients with acute HF and AECOPD, but is associated with mortality in patients with acute HF only.

Hyponatremia: incidence, risk factors, and consequences in the elderly in a home-based primary care program

Aims: To determine the incidence, risk factors, etiology, and associations of hyponatremia in community-dwelling elderly with geriatric morbidity and mortality. Materials: Elderly participants of a single center home-based primary care program were included. Method: Retrospective chart review was conducted on demographic and clinical variables, comorbid diseases, frailty by Fried criteria and biochemical tests over a 1-year period. Primary outcome measure was a composite of falls, fractures due to falls, and hospitalization witnessed within the first year of enrollment into the program. Secondary outcome was all-cause mortality. Results: The study population (n = 608) had a mean age of 84.3 ± 9.3 years and was largely female (77.1%) and African-American (89.5%). Mean follow-up was 41.5 months. Frailty was seen in 44.4%. Incidence of all-cause mortality was 26.9%. Initial hyponatremia occurred in 8.71% (n = 53), and persistent hyponatremia (> 6 months of low serum sodium) in 4.1% (n = 25) of the study population. The major causes of hyponatremia included multiple potential causes, idiopathic syndrome of inappropriate anti-diuretic hormone (SIADH) and medications (thiazides and selective serotonin reuptake inhibitor (SSRI)). Primary outcome was independently associated with frailty (Odds ratio (OR) of 2.33) and persistent but not initial hyponatremia (OR 3.52). Secondary outcome was independently associated with age > 75 years (OR 2.88) and Afro-American race (OR 2.09) only but not to frailty or hyponatremia. Conclusions: Hyponatremia is common in home-bound elderly patients and its persistence independently contributes to falls, fractures, and hospitalization but not mortality. Our study highlights a new association of hyponatremia with frailty and underscores the need to study time-dependent association of hyponatremia with epidemiological outcomes.

Clinical Usefulness of Urinary Fatty Acid Binding Proteins in Assessing the Severity and Predicting Treatment Response of Pneumonia in Critically Ill Patients: A Cross-Sectional Study

To investigate the clinical relevance of urinary fatty acid binding proteins (FABPs), including intestinal-FABP, adipocyte-FABP, liver-FABP, and heart-FABP in pneumonia patients required admission to respiratory intensive care unit (RICU).Consecutive pneumonia patients who admitted to RICU from September 2013 to October 2014 were enrolled except for those with pneumonia for more than 24 h before admission to RICU. Pneumonia patients were further divided into with and without septic shock subgroups. Twelve patients without infection were enrolled to serve as control group. Urine samples were collected on days 1 and 7 after admission to RICU for measuring FABPs and inflammatory cytokines. Clinical and laboratory data were collected and compared between pneumonia and control groups, and between the pneumonia patients with and without septic shock.There were no significant differences in urinary levels of various FABPs and inflammatory cytokines measured on day 1 between control and pneumonia groups. Urinary values of intestine-FABP (P = 0.020), adipocyte-FABP (P = 0.005), heart-FABP (P = 0.025), and interleukin-6 (P = 0.019) were significantly higher and arterial oxygen tension/fraction of inspired oxygen (PaO2/FiO2, P/F) ratio (P = 0.024) was significantly lower in pneumonia patients with septic shock on day 1 than in those without septic shock. After multivariate analysis, adipocyte-FABP was the independent factor (P = 0.026). Urinary levels of FABPs measured on day 7 of pneumonia patients were significantly lower in the improved than in nonimproved groups (P = 0.030 for intestine-FABP, P = 0.003 for adipocyte-FABP, P = 0.010 for heart-FABP, and P = 0.008 for liver-FABP, respectively). After multivariate analysis, adipocyte-FABP was the independent factor (P = 0.023).For pneumonia patients required admission to RICU, urinary levels of adipocyte-FABP on days 1 and 7 after admission to RICU may be valuable in assessing the pneumonia severity and in predicting treatment response, respectively. Further studies with larger populations are needed to verify these issues.

Pneumococcal lower respiratory tract infections in adults: an observational case-control study in primary care in Belgium

Background

Serious lower respiratory tract infections (SLRTIs), especially Streptococcus pneumoniae (SP)-related pneumonia cause considerable morbidity and mortality. Chest imaging, sputum and blood culture are not routinely obtained by general practitioners (GPs). Antibiotic therapy is usually started empirically. The BinaxNOW® and Urine Antigen Detection (UAD) assays have been developed respectively to detect a common antigen from all pneumococcal strains and the 13 pneumococcal serotypes present in the vaccine Prevenar 13® (PCV13).

Methods

OPUS-B was a multicentre, prospective, case-control, observational study of patients with SLRTI in primary care in Belgium, conducted during two winter seasons (2011–2013). A urine sample was collected at baseline for the urine assays. GPs were blinded to the results. All patients with a positive BinaxNOW® test and twice as much randomly selected BinaxNOW® negative patients were followed up. Recorded data included: socio-demographics, medical history, vaccination history, clinical symptoms, CRB-65 score, treatments, hospitalization, blood cultures, healthcare use, EQ-5D score. The objectives were to evaluate the percentage of SP SLRTI within the total number of SLRTIs, to assess the percentage of SP serotypes and to compare the burden of disease between pneumococcal and non-pneumococcal SLRTIs.

Results

There were 26 patients with a BinaxNOW® positive test and 518 patients with a BinaxNOW® negative test. The proportion of pneumococcal SLRTI was 4.8 % (95 % CI: 3.1 %–7.2 %). Sixty-eight percent of positive cases showed serotypes represented in PCV13. In the BinaxNOW-positive patients, women were more numerous, there was less exposure to young children, seasonal influenza vaccination was less frequent, COPD was more frequent, the body temperature and the number of breaths per minute were higher, the systolic blood pressure was lower, the frequency of sputum, infiltrate, chest pain, muscle ache, confusion/disorientation, diarrhoea, pneumonia and exacerbations of COPD was more frequent, EQ-5D index and VAS scale were lower, the number of visits to the GP, of working days lost and of days patients needed assistance were higher.

Conclusions

SP was responsible for approximately 5 % of SLRTIs observed in primary care in Belgium. Pneumococcal infection was associated with a significant increase in morbidity. Sixty-eight percent of serotypes causing SLRTI were potentially preventable by PCV13.

Quantitative analysis of lung ultrasonography for the detection of community-acquired pneumonia: a pilot study

Background and Objective. Chest X-ray is recommended for routine use in patients with suspected pneumonia, but its use in emergency settings is limited. In this study, the diagnostic performance of a new method for quantitative analysis of lung ultrasonography was compared with bedside chest X-ray and visual lung ultrasonography for detection of community-acquired pneumonia, using thoracic computed tomography as a gold standard. Methods. Thirty-two spontaneously breathing patients with suspected community-acquired pneumonia, undergoing computed tomography examination, were consecutively enrolled. Each hemithorax was evaluated for the presence or absence of abnormalities by chest X-ray and quantitative or visual ultrasonography. Results. Quantitative ultrasonography showed higher sensitivity (93%), specificity (95%), and diagnostic accuracy (94%) than chest X-ray (64%, 80%, and 69%, resp.), visual ultrasonography (68%, 95%, and 77%, resp.), or their combination (77%, 75%, and 77%, resp.). Conclusions. Quantitative lung ultrasonography was considerably more accurate than either chest X-ray or visual ultrasonography in the diagnosis of community-acquired pneumonia and it may represent a useful first-line approach for confirmation of clinical diagnosis in emergency settings.

Studying the burden of community-acquired pneumonia in adults aged ≥50 years in primary health care: an observational study in rural Crete, Greece

Background:

Community-acquired pneumonia (CAP) is a potentially life-threatening condition that often requires hospitalisation particularly in the elderly population or in patients with comorbidities.

Aims:

The aims of this study were to estimate the CAP frequency and severity in a well-defined primary healthcare setting in rural Crete, to record patient characteristics, their immunisation status and to estimate hospitalisation frequency and determinants.

Methods:

An observational study was designed and implemented in a rural setting within the prefecture of Heraklion in the island of Crete, Greece. Eligible patients were those aged 50 years or above, presenting with CAP based on signs and symptoms and positive X-ray findings.

Results:

A total of 124 CAP cases were recorded, 40 of which (32.3%) were hospitalised. Τhe age-standardised CAP incidence was estimated to be 236.7 cases per 100,000 persons aged ⩾50 years. Forty-three patients (35.2%) were vaccinated against pneumococcus. The most frequent chronic illnesses were heart disease (64.5%), chronic obstructive pulmonary disease (32.5%), and type 2 diabetes (21%). Hospitalisation determinants included advanced age (⩾74 years, Odds ratio (OR) 7.13; P value=0.001; 95% confidence interval (CI), 2.23–22.79), obesity (OR 3.36, P=0.037; 95% CI, 1.08–10.52), ⩾40 pack-years of smoking (OR 3.82, P value=0.040; 95% CI, 1.07–18.42), presence of multimorbidity (OR 5.77, P value=0.003; 95% CI, 1.81–18.42) and pneumococcal vaccination (OR 0.29, P value=0.041; 95% CI, 0.09–0.95).

Conclusions:

This study highlighted patient characteristics and aspects of CAP epidemiology in the context of a rural primary care setting in southern Europe where limited data have been published until now.

A simple 5-point scoring system, NaURSE (Na+, urea, respiratory rate and shock index in the elderly), predicts in-hospital mortality in oldest old

BACKGROUND

the mortality is high in acutely ill oldest old patients. Understanding the prognostic factors which influence mortality will help clinicians make appropriate management decisions.

METHODS

we analysed prospective mortality audit data (November 2008 to January 2009) to identify variables associated with in-patient mortality in oldest old. We selected those with P < 0.10 from univariate analysis and determined at which cut-point they served as the strongest predictor of mortality. Using these cut-off points, we constructed multivariate logistic regression models. A 5-point score was derived from cut-off points which were significantly associated with mortality tested in a smaller independent re-audit sample conducted in October 2011.

RESULTS

a total of 405 patients (mean 93.5 ± 2.7 years) were included in the study. The mean length of stay was 18.5 ± 42.4 days and 13.8% died as in-patients. Variables (cut-off values) found to be significantly associated with in-patient mortality were admission sodium (>145 mmol/l), urea (≥14 mmol/l), respiratory rate (>20/min) and shock index (>1.0): creating a 5-point score (NaURSE: NaURS in the Elderly). The crude mortality rates were 9.5, 19.9, 34.4, 66.7, and 100% for scores 0, 1, 2, 3 and 4, respectively. Using the cut-off point of ≥2, the NaURSE score has a specificity of 87% (83.1-90.3) and sensitivity of 39% (28.5-50.0), with an AUC value of 0.69 (0.63-0.76). An external independent validation study (n = 121) showed similar results.

CONCLUSIONS

the NaURSE score may be particularly useful in identifying oldest old who are likely to die in that admission to guide appropriate care.

An evaluation of the discriminant and predictive validity of relative social disadvantage as screening criteria for priority access to public general dental care, in Australia

Background

Most public dental care services provide preventive, general dental care on a chronological, first come – first served basis. There is concern about lack of transparency, equity and timeliness in access to public dental services across Australia. Using social determinants as screening criteria is a novel approach to triage in dental care and is relatively untested in the literature. The research evaluated the discriminant and predictive validity of relative social disadvantage in prioritising access to public general dental care.

Methods

A consecutive sample of 615 adults seeking general dental care was selected. The validation measure used was clinical assessment of priority. Nine indicators of relative social disadvantage (RSD) were collected: Indigenous status; intellectual disability; physical disability; wheelchair usage; dwelling conditions; serious medical condition; serious medical condition and taking regular medication; hospitalised within 12 months; and, regular medical visits. At the first dental visit, dentists rated care as a priority if treatment was required ≤6 months (PriorityTx) and otherwise non-priority (non-PriorityTx). A standardised dental examination was conducted. Sensitivity, specificity, positive and negative predictive value and area under the ROC curve analyses of 1+ of RSD in predicting clinical priority were calculated.

Results

In bivariate analyses, one or more indicators of relative social disadvantage status were significantly associated with PriorityTx (P < 0.001; χ²). In multivariate analyses, one or more indicators of relative social disadvantage persisted as an independent predictor of PriorityTx (OR 3.8, 95% CI = 2.6-5.6). Compared with clinicians’ classification of PriorityTx, one or more indicators of relative social disadvantage had a sensitivity of 77.1%, and specificity of 53.3%, together with a positive predictive value of 81.9% and negative predictive value of 46.0%. ROC curve analysis supported one or more indicators of relative social disadvantage as a predictor of greater priority for access to general dental care (0.66).

Conclusions

Considerable heterogeneity exists among persons seeking public general dental care in New South Wales. RSD performs as a valid predictor of priority for access to treatment and acts as valid screening criteria for triaging priority access to treatment. Such indicators may address issues of inequality in access to general public oral health services.

External validation of the CURSI criteria (confusion, urea, respiratory rate and shock index) in adults hospitalised for community-acquired pneumonia

Background

For patients hospitalised due to community-acquired pneumonia (CAP), mortality risk is usually estimated with prognostic scores such as CRB-65 or CURB-65. For elderly patients, a new score referred to as CURSI has been proposed which uses shock index (SI) instead of the blood pressure (B) and age (65) criteria. The new score has not been externally validated to date.

Methods

We used data from a hospital-based CAP registry to compare the ability of CURSI, CURB-65 and CRB-65 to predict mortality at day 30 after hospital admission. Patients were stratified by score points as well as score-point-based risk categories, and mortality for each group was assessed. To compare test performance, receiver-operating characteristic (ROC) curves were constructed, and the areas under the curve (AUROC) were calculated with 95% confidence intervals (CI).

Results

We analysed 553 inpatients (45% females, median age 78 years) hospitalised between 2005 and 2009 for CAP. Overall, mortality at day 30 was 11% (59/553). The study sample was characterised by advanced comorbidity (chronic heart failure: 22%, chronic kidney failure: 27%) and functional impairment (nursing home residency: 26%, dementia: 31%). All risk scores were significantly associated with 30-day mortality. The AUROC values with 95% CI using score points for risk prediction were as follows: 0.63 [0.56-0.71] for CRB-65, 0.68 [0.61-0.75] for CURB-65 and 0.68 [0.61-0.75] for CURSI. The CURSI-defined low-risk group (0 or 1 score point) had a higher mortality (8%) than the low-risk groups defined by CURB-65 and CRB-65 (4% and 3%, respectively). Lowering the cut-off for the CURSI-defined low-risk group (0 point only) would lower the mortality to 4%, making it comparable to the CURB-65-defined low-risk group.

Conclusions

In our study, the CURSI-defined low-risk group had a higher 30-day mortality than the low-risk groups defined by CURB-65 and CRB-65. Lowering the cut-off value for the CURSI low-risk group would result in a mortality comparable to the CURB-65-defined low risk group. Even then, however, CURSI does not perform better than the established risk scores.

Risk prediction models for mortality in community-acquired pneumonia: a systematic review

BACKGROUND

Several models have been developed to predict the risk of mortality in community-acquired pneumonia (CAP). This study aims to systematically identify and evaluate the performance of published risk prediction models for CAP.

METHODS

We searched MEDLINE, EMBASE, and Cochrane library in November 2011 for initial derivation and validation studies for models which predict pneumonia mortality. We aimed to present the comparative usefulness of their mortality prediction.

RESULTS

We identified 20 different published risk prediction models for mortality in CAP. Four models relied on clinical variables that could be assessed in community settings, with the two validated models BTS1 and CRB-65 showing fairly similar balanced accuracy levels (0.77 and 0.72, resp.), while CRB-65 had AUROC of 0.78. Nine models required laboratory tests in addition to clinical variables, and the best performance levels amongst the validated models were those of CURB and CURB-65 (balanced accuracy 0.73 and 0.71, resp.), with CURB-65 having an AUROC of 0.79. The PSI (AUROC 0.82) was the only validated model with good discriminative ability among the four that relied on clinical, laboratorial, and radiological variables.

CONCLUSIONS

There is no convincing evidence that other risk prediction models improve upon the well-established CURB-65 and PSI models.

The usefulness of confusion, urea, respiratory rate, and shock index or adjusted shock index criteria in predicting combined mortality and/or ICU admission compared to CURB-65 in community-acquired pneumonia

Background and Objectives. The study aims to assess the usefulness of age-independent criteria CURSI and temperature adjusted CURSI (CURASI) compared to CURB-65 in predicting community-acquired pneumonia (CAP) mortality. The criteria, CRSI and CRASI, were adapted for use in primary care and compared to CRB-65. Methods. A retrospective analysis of a prospectively identified cohort of community-acquired pneumonia inpatients was conducted. Outcomes were (1) mortality and (2) mortality and/or ICU admission within six weeks. Results. 95 patients (median age = 61 years) were included. All three criteria had similar sensitivity in predicting mortality alone, with CURB-65 having slightly higher specificity. When predicting mortality and/or intensive care admission, CURSI/CURASI showed higher sensitivity and slightly lower specificity. CRSI and CRASI had higher sensitivity and lower specificity when compared with CRB-65 for predicting both primary and secondary outcomes. Results for both analyses had P values >0.05. Conclusions. In a cohort of younger patients CURSI and adjusted CURSI perform at least as well as CURB-65, with a similar trend for CRSI and adjusted CRSI compared to CRB-65. Further studies are needed in different age groups and in primary and secondary care settings.

Long-term prognosis in community-acquired pneumonia

PURPOSE OF REVIEW

Pneumonia is considered the leading infectious diseases cause of death and the seventh leading cause of death overall in the US. There is significant interest in understanding the relationship between community-acquired pneumonia (CAP) and mortality.

RECENT FINDINGS

Most clinical studies examining patients with CAP have used an arbitrary in-hospital or 30-day mortality as a short-term mortality clinical end point. However, long-term mortality (arbitrary >3 months) factors, incidence, prediction, and implications on patient care are important issues that require further evaluation in patients with CAP. This review focuses on the most recent literature assessing the importance and the frequency of long-term associated outcomes in patients with CAP, the risk factors, and possible implications for future strategies. Multiple risk factors that include age, sex, comorbid conditions, type of pneumonia, and severity of illness are associated with higher long-term mortality. In addition, several biomarkers were demonstrated to be independently associated with long-term mortality.

SUMMARY

Despite advances in the understanding of long-term mortality among CAP patients, there is still a high unacceptable long-term mortality. Public health programs should address this important gap, considering the high level of complexity factors in patients with CAP.

Chronic obstructive pulmonary disease and mortality from pneumonia: meta-analysis

BACKGROUND

We aimed to determine whether patients with concomitant community-acquired pneumonia (CAP) and chronic obstructive pulmonary disease (COPD) are at greater risk of death when compared with those with CAP or acute COPD exacerbation alone. We also assessed the effect of inhaled corticosteroids (ICS) on pneumonia mortality in COPD.

METHODS

We searched MEDLINE and EMBASE from inception to March 2012 for studies reporting on mortality in patients with COPD and CAP. We assessed ascertainment of disease, mortality, drug exposure and adjustment for confounders. Data were pooled using random effects meta-analysis, and heterogeneity was estimated using I².

RESULTS

We identified 24 eligible articles overall. Evaluation of 13 studies revealed considerable heterogeneity and a non-significant mortality risk associated with concomitant COPD and CAP as compared with CAP in five studies that reported adjusted or severity-matched data, pooled RR 1.44 (95% CI 0.97-2.16, I² = 50%). There was also considerable inconsistency amongst the effect estimates from five studies that reported on the associated mortality with concomitant CAP and COPD as compared with acute COPD exacerbations alone. Evaluation of six datasets found that ICS use in COPD was not consistently associated with lower mortality in CAP. Reports of reduced mortality with prior ICS use stemmed from three studies that enrolled participants from the same healthcare database.

CONCLUSIONS

Evidence on associated mortality risk with concomitant CAP and COPD (as opposed to CAP alone, or COPD exacerbation alone) is weak and heterogeneous. ICS use was not consistently associated with reduced mortality from pneumonia.

Hypocapnia and hypercapnia are predictors for ICU admission and mortality in hospitalized patients with community-acquired pneumonia

OBJECTIVE

The purpose of our study was to examine in patients hospitalized with community acquired pneumonia (CAP) the association between abnormal Pa CO 2 and ICU admission and 30-day mortality.

METHODS

A retrospective cohort study was conducted at two tertiary teaching hospitals. Eligible subjects were admitted with a diagnosis of CAP. Arterial blood gas analyses were obtained with measurement of PaCO2 on admission. Multivariate analyses were performed using 30-day mortality and ICU admission as the dependent measures.

RESULTS

Data were abstracted on 453 subjects with a documented arterial blood gas analysis. One hundred eighty-nine patients (41%) had normal PaCO2 (35-45 mm Hg), 194 patients (42%) had aPa CO 2 , 35 mm Hg (hypocapnic), and 70 patients (15%) had a Pa CO 2 . 45 mm Hg (hypercapnic).In the multivariate analysis, after adjusting for severity of illness, hypocapnic patients had greater 30-day mortality (OR= 2.84; 95% CI, 1.28-6.30) and a higher need for ICU admission (OR= 2.88;95% CI, 1.68-4.95) compared with patients with normal PaCO2. In addition, hypercapnic patients had a greater 30-day mortality (OR= 3.38; 95% CI, 1.38-8.30) and a higher need for ICU admission(OR =5.35; 95% CI, 2.80-10.23). When patients with COPD were excluded from the analysis,the differences persisted between groups.

CONCLUSION

In hospitalized patients with CAP, both hypocapnia and hypercapnia were associated with an increased need for ICU admission and higher 30-day mortality. These findings persisted after excluding patients with CAP and with COPD. Therefore, PaCO2 should be considered for inclusion in future severity stratification criteria to appropriate identified patients who will require a higher level of care and are at risk for increased mortality.

Effects of inhaled corticosteroids on pneumonia severity and antimicrobial resistance

BACKGROUND

Limited information is available regarding the impact of prior use of inhaled corticosteroids (ICS) in patients subsequently developing community-acquired pneumonia (CAP). We assessed the effects of prior ICS use on severity of illness and microbiology in CAP hospitalized patients.

METHODS

A retrospective cohort study of subjects with CAP (by the International Classification of Diseases, 9th Revision, Clinical Modification) was conducted over a 4-year period at 2 tertiary teaching hospitals. Subjects were considered to be ICS users if they received ICS prior to admission. Primary outcomes were severity of illness and microbiology at admission.

RESULTS

Data were abstracted on 664 subjects: 89 prior ICS users (13.4%) and 575 non-users (86.6%). Prior ICS users had higher severity of illness at admission: mean ± SD Pneumonia Severity Index 100.8 ± 31.4 vs 68.8 ± 33.4, P = .001, and CURB-65 (confusion, urea nitrogen, respiratory rate, blood pressure, ≥ 65 years of age) score 1.56 ± 1.02 vs 1.19 ± 1.02, P = .002. Prior ICS use was independently associated with antimicrobial-resistant pathogens: 11.2% vs 5.9%, odds ratio 2.6, 95% CI 1.1-6.1, P = .04.

CONCLUSIONS

Prior ICS use was associated with higher severity of illness at admission and higher incidence of antimicrobial-resistant pathogens in CAP hospitalized patients.

Predicting mortality among older adults hospitalized for community-acquired pneumonia: an enhanced confusion, urea, respiratory rate and blood pressure score compared with pneumonia severity index

BACKGROUND AND OBJECTIVE

Pneumonia Severity Index (PSI) predicts mortality better than Confusion, Urea >7 mmol/L, Respiratory rate >30/min, low Blood pressure: diastolic blood pressure <60 mm Hg or systolic blood pressure <90 mm Hg, and age >65 years (CURB-65) for community-acquired pneumonia (CAP) but is more cumbersome. The objective was to determine whether CURB enhanced with a small number of additional variables can predict mortality with at least the same accuracy as PSI.

METHODS

Retrospective review of medical records and administrative data of adults aged 55 years or older hospitalized for CAP over 1 year from three hospitals.

RESULTS

For 1052 hospital admissions of unique patients, 30-day mortality was 17.2%. PSI class and CURB-65 predicted 30-day mortality with area under curve (AUC) of 0.77 (95% confidence interval (CI): 0.73-0.80) and 0.70 (95% CI: 0.66-0.74) respectively. When age and three co-morbid conditions (metastatic cancer, solid tumours without metastases and stroke) were added to CURB, the AUC improved to 0.80 (95% CI: 0.77-0.83). Bootstrap validation obtained an AUC estimate of 0.78, indicating negligible overfitting of the model. Based on this model, a clinical score (enhanced CURB score) was developed that had possible values from 5 to 25. Its AUC was 0.79 (95% CI: 0.76-0.83) and remained similar to that of PSI class.

CONCLUSIONS

An enhanced CURB score predicted 30-day mortality with at least the same accuracy as PSI class did among older adults hospitalized for CAP. External validation of this score in other populations is the next step to determine whether it can be used more widely.