Full blood count values as a predictor of poor outcome of pneumonia among HIV-infected patients

EMR Combined with CRB-65 Superior to CURB-65 in Predicting Mortality in Patients with Community-Acquired Pneumonia

Background

Data about eosinophil-to-lymphocyte ratio (ELR) and eosinophil-to-monocyte ratio (EMR) in patients with community-acquired pneumonia (CAP) are rare. We aimed to evaluate the role of EMR and ELR in predicting disease severity and mortality in patients with CAP.

Methods

A total of 454 patients (76 with severe CAP (SCAP), 378 with non-SCAP) were enrolled from November 18, 2020, and November 21, 2021. Laboratory examination on day 1 after admission was measured. The ELR and EMR values were calculated for patients. Propensity score matching (PSM) was performed to balance potential confounding factors. Binary logistic regression model was fitted to identify the potential risk factors for disease severity and Cox proportional hazards regression model analysis for mortality in CAP. Receiver operating characteristic (ROC) analysis was performed to distinguish disease severity and mortality.

Results

EMR and ELR at admission were significantly lower in SCAP patients than in non-SCAP patients (P<0.001). EMR < 0.018 ([OR] = 12.104, 95% CI: 4.970-29.479), neutrophil (NEU) ([OR]=1.098, 95% CI:1.005-1.199), and age ([OR]=1.091, 95% CI:1.054-1.130) were independent risk factors for disease severity of CAP. EMR < 0.032 ([HR] = 5.816, 95% CI: 1.704-9.848) was an independent predictor of in-hospital mortality. Combining EMR or ELR with CRB-65 improved the overall accuracy of disease severity prediction (AUC from 0.894 to 0.937), the same as CURB-65. The area under the curve of EMR (AUC=0.704; 95% CI: 0.582-0.827) to predict in-hospital mortality was higher than that of CURB-65 (AUC=0.619; 95% CI: 0.484-0.754). Otherwise, EMR combined with CRB-65 (AUC=0.721; 95% CI: 0.592-0.851) had significantly higher diagnostic accuracy for in-hospital mortality than that of CURB-65 alone.

Conclusion

EMR combined with CRB-65 was superior to CURB-65 in predicting mortality in patients with CAP. This new combination was simpler and easier to obtain for physicians in clinics or admission, and it was more convenient for early recognition of patients with poor prognoses.

Relationship between preoperative red blood cell distribution width and postoperative pneumonia in elderly patients with hip fracture: a retrospective cohort study

OBJECTIVE

The relationship between the preoperative red blood cell distribution width and postoperative pneumonia in elderly patients with hip fractures remains unclear. This study investigated whether the preoperative red blood cell distribution width was associated with postoperative pneumonia in elderly patients with hip fractures.

METHODS

Clinical data of patients with hip fractures in the Department of orthopedics of a hospital from January 2012 to December 2021 were retrospectively analyzed. A generalized additive model was used to identify both linear and nonlinear relationships between red blood cell distribution width and postoperative pneumonia. A two-piecewise linear regression model was used to calculate the saturation effect. Subgroup analyses were performed using stratified logistic regression.

RESULTS

This study included a total of 1444 patients. The incidence of postoperative pneumonia was 6.30% (91/1444), the mean age of the patients was 77.55 ± 8.75 years, and 73.06% of them (1055/1444) were female. After full adjustment for covariates, the preoperative red blood cell distribution width showed a nonlinear relationship with postoperative pneumonia. The two-piecewise regression model showed an inflection point at 14.3%. On the left side of the inflection point, the incidence of postoperative pneumonia increased by 61% for every 1% increase in red blood cell distribution width (OR: 1.61, 95% CI 1.13-2.31, P = 0.0089). The effect size was not statistically significant on the right side of the inflection point (OR: 0.83, 95% CI 0.61-1.12, P = 0.2171).

CONCLUSION

The relationship between preoperative red blood cell distribution width and incidence or postoperative pneumonia was nonlinear in elderly patients with hip fractures. The incidence of postoperative pneumonia was positively correlated with red blood cell distribution width when it was < 14.3%. A saturation effect was observed when the red blood cell distribution width reached 14.3%.

White blood cell classification via a discriminative region detection assisted feature aggregation network

White blood cell (WBC) classification plays an important role in human pathological diagnosis since WBCs will show different appearance when they fight with various disease pathogens. Although many previous white blood cell classification have been proposed and earned great success, their classification accuracy is still significantly affected by some practical issues such as uneven staining, boundary blur and nuclear intra-class variability. In this paper, we propose a deep neural network for WBC classification via discriminative region detection assisted feature aggregation (DRFA-Net), which can accurately locate the WBC area to boost final classification performance. Specifically, DRFA-Net uses an adaptive feature enhancement module to refine multi-level deep features in a bilateral manner for efficiently capturing both high-level semantic information and low-level details of WBC images. Considering the fact that background areas could inevitably produce interference, we design a network branch to detect the WBC area with the supervision of segmented ground truth. The bilaterally refined features obtained from two directions are finally aggregated for final classification, and the detected WBC area is utilized to highlight the features of discriminative regions by an attention mechanism. Extensive experiments on several public datasets are conducted to validate that our proposed DRFA-Net can obtain higher accuracies when compared with other state-of-the-art WBC classification methods.

Construction and validation of a prognostic nomogram for predicting the survival of HIV/AIDS adults who received antiretroviral therapy: a cohort between 2003 and 2019 in Nanjing

BACKGROUND

Great achievements have been achieved by free antiretroviral therapy (ART). A rapid and accurate prediction of survival in people living with HIV/AIDS (PLHIV) is needed for effective management. We aimed to establish an effective prognostic model to forecast the survival of PLHIV after ART.

METHODS

The participants were enrolled from a follow-up cohort over 2003-2019 in Nanjing AIDS Prevention and Control Information System. A nested case-control study was employed with HIV-related death, and a propensity-score matching (PSM) approach was applied in a ratio of 1:4 to allocate the patients. Univariable and multivariable Cox proportional hazards analyses were performed based on the training set to determine the risk factors. The discrimination was qualified using the area under the curve (AUC) and concordance index (C-Index). The nomogram was calibrated using the calibration curve. The clinical benefit of prognostic nomogram was assessed by decision curve analysis (DCA).

RESULTS

Predictive factors including CD4 cell count (CD4), body mass index (BMI) and hemoglobin (HB) were determined and incorporated into the nomogram. In the training set, AUC and C-index (95% CI) were 0.831 and 0.798 (0.758, 0.839), respectively. The validation set revealed a good discrimination with an AUC of 0.802 and a C-index (95% CI) of 0.786 (0.681, 0.892). The calibration curve also exhibited a high consistency in the predictive power (especially in the first 3 years after ART initiation) of the nomogram. Moreover, DCA demonstrated that the nomogram was clinically beneficial.

CONCLUSION

The nomogram is effective and accurate in forecasting the survival of PLHIV, and beneficial for medical workers in health administration.

Can thrombocytosis or thrombocytopenia predict complicated clinical course and 30-days mortality in patients with pneumonia?

Background/aim

While several different scoring systems aim to determine the clinical outcomes for patients with pneumonia, there is limited emphasis on the platelet count. This study investigated the relationships between thrombocyte count and 30-day mortality and complicated clinical course of patients with pneumonia.

Materials and methods

This prospective cross-sectional study enrolled patients over 18 years old with a diagnosis of pneumonia in the emergency department for six months. The primary outcome was to establish the relationship between platelet count, mortality, complicated clinical course, and initial vital parameters on admission. The secondary outcome was comparing the platelet count with mortality and complicated clinical course during the hospital stay.

Results

Four hundred-five patients were included (58.8% male, mean age 75.1 ± 12.7 years). On admission, thrombocytosis was observed in 14.1% and thrombocytopenia in 4.2%. There was no difference between the 30-day mortality according to the platelet count at admission and follow-up. Patients who developed thrombocytopenia during follow-up needed more intensive care admissions, invasive mechanical ventilation, noninvasive mechanical ventilation, and vasopressor treatment, while patients with thrombocytosis needed invasive mechanical ventilation more frequently.

Conclusion

Neither thrombocytopenia nor thrombocytosis is not associated with 30-day mortality in ED patients with pneumonia. Thrombocytopenia during follow-up was associated with a higher incidence for a complicated clinical course.

Burden of pneumococcal disease among adults in Southern Europe (Spain, Portugal, Italy, and Greece): a systematic review and meta-analysis

The aim was to summarize pneumococcal disease burden data among adults in Southern Europe and the potential impact of vaccines on epidemiology. Of 4779 identified studies, 272 were selected. Invasive pneumococcal disease (IPD) incidence was 15.08 (95% CI 11.01-20.65) in Spain versus 2.56 (95% CI 1.54-4.24) per 100,000 population in Italy. Pneumococcal pneumonia incidence was 19.59 (95% CI 10.74-35.74) in Spain versus 2.19 (95% CI 1.36-3.54) per 100,000 population in Italy. Analysis of IPD incidence in Spain comparing pre-and post- PCV7 and PCV13 periods unveiled a declining trend in vaccine-type IPD incidence (larger and statistically significant for the elderly), suggesting indirect effects of childhood vaccination programme. Data from Portugal, Greece and, to a lesser extent, Italy were sparse, thus improved surveillance is needed. Pneumococcal vaccination uptake, particularly among the elderly and adults with chronic and immunosuppressing conditions, should be improved, including shift to a higher-valency pneumococcal conjugate vaccine when available.

New segmentation and feature extraction algorithm for classification of white blood cells in peripheral smear images

This article addresses a new method for the classification of white blood cells (WBCs) using image processing techniques and machine learning methods. The proposed method consists of three steps: detecting the nucleus and cytoplasm, extracting features, and classification. At first, a new algorithm is designed to segment the nucleus. For the cytoplasm to be detected, only a part of it located inside the convex hull of the nucleus is involved in the process. This attitude helps us overcome the difficulties of segmenting the cytoplasm. In the second phase, three shapes and four novel color features are devised and extracted. Finally, by using an SVM model, the WBCs are classified. The segmentation algorithm can detect the nucleus with a dice similarity coefficient of 0.9675. The proposed method can categorize WBCs in Raabin-WBC, LISC, and BCCD datasets with accuracies of 94.65%, 92.21%, and 94.20%, respectively. Besides, we show that the proposed method possesses more generalization power than pre-trained CNN models. It is worth mentioning that the hyperparameters of the classifier are fixed only with the Raabin-WBC dataset, and these parameters are not readjusted for LISC and BCCD datasets.

Immunologic biomarkers, morbidity and mortality among HIV patients hospitalised in a Tertiary Care Hospital in the Brazilian Amazon

Background

The irregular use of antiretroviral therapy (ART) and late diagnosis still account for a large part of HIV-associated mortality in people living with HIV (PLHIV). Herein, we describe HIV-associated morbidity among hospitalised HIV/AIDS patients with advanced immunosuppression and assess the comorbidities, laboratory parameters, and immunological markers associated with mortality.

Methods

The cross-sectional study was conducted at the Fundação de Medicina Tropical Doutor Heitor Vieira Dourado (FMT-HVD) in Manaus, Brazil. In all, 83 participants aged between 12 and 70 years were enrolled by convenience within 72 h of their hospitalisation. Clinical and laboratory data were obtained from electronic medical records. We prospectively measured the cytokines Th1/Th2/Th17 and inflammatory cytokines IL-8, IL-1β, and IL-12 using cytometric bead array, and the soluble CD14 using in-house enzyme-linked immunosorbent assay.

Results

The HIV/AIDS inpatients presented a scenario of respiratory syndromes as the most prevalent comorbidity. Almost all patients had CD4 T counts below 350 cells/mL and the mortality rate was 20.5%. Pulmonary tuberculosis, neurotoxoplasmosis and oropharyngeal–esophageal candidiasis were the most prevalent opportunistic infections. TB and weight loss were more prevalent in HIV/AIDS inpatients who died. The Mann Whitney analysis showed that those who died had higher platelet distribution width (PDW) on admission, which is suggestive for platelet activation. The Poisson multivariate analysis showed the prevalence of TB, digestive syndrome and increases in IL-8 and lactate dehydrogenase (LDH) associated to death.

Conclusions

The advanced immunosuppression characterized by the opportunistic infections presented in these HIV/AIDS inpatients was the major factor of mortality. The role of platelet activation in worse outcomes of hospitalisation and the IL-8 associated with the context of advanced immunosuppression may be promising markers in the prediction of mortality in HIV/AIDS patients.

A Prognostic Model to Assess Long-Term Survival of Patients on Antiretroviral Therapy: A 15-Year Retrospective Cohort Study in Southwestern China

BACKGROUND

Because there is no assessment tool for survival of people with human immunodeficiency virus (PWH) who received antiretroviral therapy (ART) in rural southwestern China, we aimed to formulate and validate a simple-to-use model to predict long-term overall survival at the initiation of ART.

METHODS

In total, 36 268 eligible participants registered in the Guangxi autonomous region between December 2003 and December 2018 were enrolled and randomized into development and validation cohorts. Predictive variables were determined based on Cox hazard models and specialists' advice. Discrimination, calibration, and clinical utility were measured, respectively.

RESULTS

The prognostic combined 14 variables: sex, age, marital status, infectious route, opportunistic infection, acquired immunodeficiency syndrome (AIDS)-related symptoms, body mass index, CD4+ T lymphocyte count, white blood cell, platelet, hemoglobin, serum creatinine, aspartate transaminase, and total bilirubin. Age, aspartate transaminase, and serum creatinine were assigned higher risk scores than that of CD4+ T lymphocytopenia count and having opportunistic infections or AIDS-related symptoms. At 3 time points (1, 3, and 5 years), the area under the curve ranged from 0.75 to 0.81 and the Brier scores ranged from 0.03 to 0.07. The decision curve analysis showed an acceptable clinical net benefit.

CONCLUSIONS

The prognostic model incorporating routine baseline data can provide a useful tool for early risk appraisal and treatment management in ART in rural southwestern China. Moreover, our study underscores the role of non-AIDS-defining events in long-term survival in ART.

Plasma hemoglobin and the risk of death in HIV/AIDS patients treated with antiretroviral therapy

Background: Previous studies concerning the effect of plasma hemoglobin (HB) and other factors that may modify the risk of death in people living with HIV/AIDS (PLHIV) treated with antiretroviral therapy (ART) are limited.

Results: Higher HB was independently linked to a lower death risk in PLHIV, with a decrease of 29% (13%, 43%) per standard deviation (SD) increment after adjusting for CD4, VL and other potential factors [hazard ratio (HR): 0.71, 95% confidence interval (CI): 0.57-0.87, P<0.001]. In addition, the addition of HB to the predictive model containing VL and CD4 significantly improved the C-index, by 0.69% (95% CI: 0.68%-0.71%), and net discrimination, by 0.5% (95% CI: 0.0%-1.6%, P=0.040), when predicting the death risk of PLHIV.

Conclusions: A lower level of HB was an independent risk factor for HIV/AIDS-associated death in PLHIV. HB combined with VL and CD4 may be an appropriate predictive model of the death risk of PLHIV.

Materials and methods: A propensity-score matching (PSM) approach was applied to select a total of 750 PLHIV (150 deceased and 600 living) from the AIDS prevention and control information system in the Wenzhou area from 2006 to 2018. Multivariable Cox proportional hazards regression models were formulated to estimate the effect of HB. The predictive performance improvement contributed by HB was evaluated using the C-index and net reclassification improvement.

Development and validation of a prognostic nomogram for HIV/AIDS patients who underwent antiretroviral therapy: Data from a China population-based cohort

BACKGROUND

Accurate forecast of the death risk is crucial to the administration of people living with HIV/AIDS (PLHIV). We aimed to establish and validate an effective prognosis nomogram in PLHIV receiving antiretroviral therapy (ART).

METHODS

All the data were obtained from 2006 to 2018 in the Wenzhou area from China AIDS prevention and control information system. Factors included in the nomogram were determined by univariate and multiple Cox proportional hazard analysis based on the training set. The receiver operating characteristic (ROC) and calibration curves were used to assess its predictive accuracy and discriminative ability. Its clinical utility was also evaluated using decision curve analysis (DCA), X-tile analysis and Kaplan-Meier curve, respectively in an independent validation set.

FINDINGS

Independent prognostic factors including haemoglobin, viral load and CD4+ T-cell count were determined and contained in the nomogram. Good agreement between the prediction by nomogram and actual observation could be detected in the calibration curve for mortality, especially in the first year. In the training cohort, AUC (95% CI) and C-index (95% CI) were 0.93 (0.90, 0.96) and 0.90 (0.85, 0.96), respectively. In the validation set, the nomogram still revealed excellent discriminations [AUC (95% CI): 0.95 (0.91, 1.00)] and good calibration [C-index (95% CI): 0.92 (0.82-1.00)]. Moreover, DCA also demonstrated that the nomogram was clinical beneficial. Additionally, participants could be classified into three distinct (low, middle and high) risk groups by the nomogram.

INTERPRETATION

The nomogram presents accurate and favourable prognostic prediction for PLHIV who underwent ART.

FUNDING

This work was supported by Zhejiang Basic Public Welfare Research Project (LGF19H260011), Wenzhou Basic Public Welfare Research Project (Y20180201), the Initial Scientific Research Fund (KYQD170301), the Major Project of the Eye Hospital Wenzhou the Major Project of the Eye Hospital Wenzhou Medical University (YNZD201602). Part of this work was also funded by National Natural Science Foundation of China (81670777) and Science and Technology Innovation Activity Plan and New Talents Plan for College Students in Zhejiang Province (2019R413073). The funders had no roles in study design, data collection, data analysis, interpretation and writing of the report.

Community-acquired pneumonia as an emergency condition

PURPOSE OF REVIEW

Despite the improvements in its management, community-acquired pneumonia (CAP) still exhibits high global morbidity and mortality rates, especially in elderly patients. This review focuses on the most recent findings on the epidemiology, cause, diagnosis and management of CAP.

RECENT FINDINGS

There is consistent evidence that the trend in CAP mortality has declined over time. However, the mortality of pneumococcal CAP has not changed in the last two decades, with an increase in the rate of hospitalization and more severe forms of CAP. Streptococcus pneumoniae remains the most frequent cause of CAP in all settings, age groups and regardless of comorbidities. However, the implementation of molecular diagnostic tests in the last years has identified respiratory viruses as a common cause of CAP too. The emergency of multidrug-resistance pathogens is a worldwide concern. An improvement in our ability to promptly identify the causative cause of CAP is required in order to provide pathogen-directed antibiotic therapy, improve antibiotic stewardship programs and implement appropriate vaccine strategies.

SUMMARY

It is time to apply all the knowledge generated in the last decade in order to optimize the management of CAP.

Incidence and significance of an elevated red blood cell distribution width among hospitalised HIV-infected adult patients

We audited the records of unselected hospitalised HIV-positive adults admitted to a University-affiliated inner London hospital to identify the frequency of elevated red blood cell distribution width (RDW), and potential associations with specific diagnoses, and with outcome. Of 259 patients audited, 188 (73%) were men. Patients’ median age was 47 years (interquartile range = 41–54). An elevated RDW was seen in 50 patients (19%); 200 (77%) had an elevated C-reactive protein (CRP), and 77 (30%) had a low haemoglobin. Only five patients had an elevated RDW without an elevated CRP and/or low haemoglobin. An elevated RDW was associated with a wide range of infectious, inflammatory, and malignant conditions similar to observed associations reported in the general non-HIV infected adult population. Additionally an elevated RDW occurred both in patients with well-controlled HIV infection and in receipt of antiretroviral therapy, as well as in those with newly diagnosed and poorly-controlled infection. Five (10%) of 50 patients with an elevated RDW needed intensive care unit (ICU) admission and two (4%) died. Two (0.95%) of 209 patients with a normal RDW needed ICU admission and four (1.9%) died. The findings of this audit are limited by the relatively small number of patients and the single site nature of the audit.

Correlation of malaria parasitaemia with peripheral blood monocyte to lymphocyte ratio as indicator of susceptibility to severe malaria in Ghanaian children

Background

Even though malaria is generally on the decline due extensive control and elimination efforts, it still remains a public health problem for over 40% of the world’s population. During the course of malaria infection, parasites and red blood cells come under oxidative stress and there is host immune response in an attempt to protect the red blood cells. The frequency of monocytes and lymphocytes in peripheral blood might, therefore, be expected to reflect the state of an individual’s immune response to the infection. Circulating monocytes and lymphocytes could therefore serve as an index in relation to malaria parasitaemia. The purpose of this study was to determine whether the relative count of monocytes to lymphocytes in peripheral blood (M:L ratio) can predict parasitaemia and, therefore, the severity of malaria infection.

Methods

Two millilitre of venous blood sample were taken from participants by venisection into anticoagulant tubes. Thick and thin blood films were made and stained with Giemsa and examined for malaria parasites. Whole blood specimen were analysed for full blood count using ABX Pentra 60 C+ automated haematological analyzer. Data was entered into Microsoft Word and analysed using Statistical Package for Social Sciences (SPSS, Version 20.0) and Graphpad prism. Spearman’s correlation was used to determine correlation between occurrences of clinical malaria and the monocytes and lymphocytes ratio. Statistical significance was taken as p ≤ 0.05 with 95% confidence interval.

Results

The study comprised of 1629 (m = 896; f = 733) children up to 5 years presenting with clinical malaria as cases and 445 (m = 257; f = 188) apparently healthy children as controls. The results indicated that there was a significant positive correlation between the monocytes to lymphocytes ratio and the presence of parasites (p = 0.04) and the level of parasitaemia within the age group of 0–3 years (p = 0.02) and 4–5 years (p = 0.03).

Conclusions

The monocyte to lymphocyte ratio obtained correlated positively with the presence of malaria as well as the level of parasitaemia. The outcome of this work implies that monocyte to lymphocyte ratio can be used to predict the level of parasitaemia and together with other factors, the development of severe malaria.

Treating HIV-Positive/Non-AIDS Patients for Community-Acquired Pneumonia with ART

PURPOSE OF REVIEW

This article reviews the most recent publications on community-acquired pneumonia (CAP) in the HIV-infected population on antiretroviral therapy (ART), focusing on epidemiology, prognostic factors, etiology, and antimicrobial therapy. The data discussed here were mainly obtained from a non-systematic review using Medline and references from relevant articles.

RECENT FINDINGS

CAP remains a major cause of morbidity and mortality among HIV-infected patients and incurs high health costs despite the introduction of ART. HIV-infected patients are generally known to be more susceptible to bacterial pneumonia. Streptococcus pneumoniae is the most frequently reported pathogen in HIV-infected patients on ART, who present a higher rate of bacteremia than non-HIV-infected patients. Several studies have also examined microbial etiology and prognostic factors of CAP in HIV-infected patients on ART. Despite the high rate of bacterial pneumonia in these patients, mortality rates are not higher than in patients without HIV infection.