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Lin SH, Perng DW, Chen CP, Chai WH, Yeh CS, Kor CT, Cheng SL, Chen JJ, Lin CH. Increased risk of community-acquired pneumonia in COPD patients with comorbid cardiovascular disease. Int J Chron Obstruct Pulmon Dis 2016; 11:3051-3058. [PMID: 27980402 PMCID: PMC5147399 DOI: 10.2147/copd.s115137] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background and objective COPD patients with community-acquired pneumonia (CAP) have worse clinical outcomes, as compared to those without COPD. Cardiovascular disease (CVD) is a common comorbidity for COPD patients. Whether COPD with comorbid CVD will increase the risk of CAP is not well investigated. The incidence and factors associated with CAP in COPD patients with and without CVD were analyzed. Methods The medical records of patients with newly diagnosed COPD between 2007 and 2010 were reviewed. The patients’ characteristics, medical history of CVD, occurrence of CAP, and type of medication were recorded. Kaplan–Meier curves were used to assess the differences in cumulative incidence of CAP. Cox’s proportional hazards regression model was used to determine the adjusted hazard ratios with 95% confidence intervals in relation to factors associated with CAP in COPD patients with and without CVD. Results Among 2,440 patients, 475 patients (19.5%) developed CAP during the follow-up period. COPD patients who developed CAP were significantly older, had lower forced expiratory volume in 1 second, frequent severe exacerbation and comorbid CVD, as well as received inhaled corticosteroid (ICS)-containing therapy than those without CAP. The cumulative incidence of CAP was higher in COPD patients with CVD compared to those without CVD. Patients who received ICS-containing therapy had significantly increased risk of developing CAP compared to those who did not. Conclusion For patients with COPD, comorbid CVD is an independent risk factor for developing CAP. ICS-containing therapy may increase the risk of CAP among COPD patients.
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Affiliation(s)
- Sheng-Hao Lin
- Department of Internal Medicine, Division of Chest Medicine, Changhua Christian Hospital, Changhua; Institute of Biomedical Sciences, National Chung Hsing University, Taichung
| | - Diahn-Warng Perng
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei; School of Medicine, National Yang-Ming University, Taipei
| | - Ching-Pei Chen
- Department of Internal Medicine, Division of Cardiology, Changhua Christian Hospital; Department of Beauty Science and Graduate Institute of Beauty Science Technology, Chien-Kuo Technology University
| | - Woei-Horng Chai
- Department of Internal Medicine, Division of Chest Medicine, Changhua Christian Hospital, Changhua
| | - Chin-Shui Yeh
- Department of Internal Medicine, Division of Chest Medicine, Changhua Christian Hospital, Changhua
| | - Chew-Teng Kor
- Department of Internal Medicine, Internal Medicine Research Center, Changhua Christian Hospital, Changhua
| | - Shih-Lung Cheng
- Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei; Department of Chemical Engineering and Materials Science, Yuan Ze University, Zhongli City, Taoyuan
| | - Jeremy Jw Chen
- Institute of Biomedical Sciences, National Chung Hsing University, Taichung
| | - Ching-Hsiung Lin
- Department of Internal Medicine, Division of Chest Medicine, Changhua Christian Hospital, Changhua; Department of Respiratory Care, College of Health Sciences, Chang Jung Christian University, Tainan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan
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Loffredo L, Cangemi R, Perri L, Catasca E, Calvieri C, Carnevale R, Nocella C, Equitani F, Ferro D, Violi F, Battaglia S, Bertazzoni G, Biliotti E, Bucci T, Calabrese CM, Casciaro M, Celestini A, De Angelis M, De Marzio P, Esvan R, Falcone M, Fazi L, Sulekova LF, Franchi C, Giordo L, Grieco S, Manzini E, Marinelli P, Mordenti M, Morelli S, Palange P, Pastori D, Pignatelli P, Capparuccia MR, Romiti GF, Rossi E, Ruscio E, Russo A, Scarpellini MG, Solimando L, Taliani G, Trapè S, Toriello F. Impaired flow-mediated dilation in hospitalized patients with community-acquired pneumonia. Eur J Intern Med 2016; 36:74-80. [PMID: 27727076 DOI: 10.1016/j.ejim.2016.09.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 06/21/2016] [Accepted: 09/09/2016] [Indexed: 01/27/2023]
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is complicated by cardiovascular events as myocardial infarction and stroke but the underlying mechanism is still unclear. We hypothesized that endothelial dysfunction may be implicated and that endotoxemia may have a role. METHODS Fifty patients with CAP and 50 controls were enrolled. At admission and at discharge, flow-mediated dilation (FMD), serum levels of endotoxins and oxidative stress, as assessed by serum levels of nitrite/nitrate (NOx) and isoprostanes, were studied. RESULTS At admission, a significant difference between patients with CAP and controls was observed for FMD (2.1±0.3 vs 4.0±0.3%, p<0.001), serum endotoxins (157.8±7.6 vs 33.1±4.8pg/ml), serum isoprostanes (341±14 vs 286±10 pM, p=0.009) and NOx (24.3±1.1 vs 29.7±2.2μM). Simple linear correlation analysis showed that serum endotoxins significantly correlated with Pneumonia Severity Index score (Rs=0.386, p=0.006). Compared to baseline, at discharge CAP patients showed a significant increase of FMD and NOx (from 2.1±0.3 to 4.6±0.4%, p<0.001 and from 24.3±1.1 to 31.1±1.5μM, p<0.001, respectively) and a significant decrease of serum endotoxins and isoprostanes (from 157.8±7.6 to 55.5±2.3pg/ml, p<0.001, and from 341±14 to 312±14 pM, p<0.001, respectively). Conversely, no changes for FMD, NOx, serum endotoxins and isoprostanes were observed in controls between baseline and discharge. Changes of FMD significantly correlated with changes of serum endotoxins (Rs=-0.315; p=0.001). CONCLUSIONS The study provides the first evidence that CAP is characterized by impaired FMD with a mechanism potentially involving endotoxin production and oxidative stress.
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Affiliation(s)
- Lorenzo Loffredo
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Roberto Cangemi
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Ludovica Perri
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Elisa Catasca
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Camilla Calvieri
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Roberto Carnevale
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Cristina Nocella
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Francesco Equitani
- Transfusion Medicine and Immuno-Hematology Unit, Santa Maria Goretti Hospital, Latina, Italy
| | - Domenico Ferro
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Francesco Violi
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy.
| | - Simona Battaglia
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Giuliano Bertazzoni
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Elisa Biliotti
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Tommaso Bucci
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Cinzia Myriam Calabrese
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Marco Casciaro
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Andrea Celestini
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Maurizio De Angelis
- Infectious and Tropical Diseases Unit, Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Paolo De Marzio
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Rozenn Esvan
- Infectious and Tropical Diseases Unit, Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Marco Falcone
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Lucia Fazi
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Lucia Fontanelli Sulekova
- Infectious and Tropical Diseases Unit, Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Cristiana Franchi
- Infectious and Tropical Diseases Unit, Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Laura Giordo
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Stefania Grieco
- Infectious and Tropical Diseases Unit, Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Elisa Manzini
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Paolo Marinelli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Michela Mordenti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Sergio Morelli
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Paolo Palange
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Daniele Pastori
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Pasquale Pignatelli
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Marco Rivano Capparuccia
- Infectious and Tropical Diseases Unit, Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Giulio Francesco Romiti
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Elisabetta Rossi
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Eleonora Ruscio
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Alessandro Russo
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Maria Gabriella Scarpellini
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Luisa Solimando
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Gloria Taliani
- Infectious and Tropical Diseases Unit, Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Stefano Trapè
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Filippo Toriello
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
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Ottiger M, Nickler M, Steuer C, Odermatt J, Huber A, Christ-Crain M, Henzen C, Hoess C, Thomann R, Zimmerli W, Mueller B, Schuetz P. Trimethylamine-N-oxide (TMAO) predicts fatal outcomes in community-acquired pneumonia patients without evident coronary artery disease. Eur J Intern Med 2016; 36:67-73. [PMID: 27567042 DOI: 10.1016/j.ejim.2016.08.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 08/09/2016] [Accepted: 08/09/2016] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The pro-atherosclerotic metabolite trimethylamine-N-oxide (TMAO) is a risk factor for incident cardiovascular events and a potentially modifiable mediator of chronic inflammation through broad-spectrum antibiotic treatment by changing the microbiome. Whether TMAO is associated with adverse clinical outcomes in acute inflammatory community-acquired pneumonia (CAP) patients is unknown. METHODS A total of 317 CAP patients from a previous Swiss multicenter trial were prospectively followed for a median of 6.1years. TMAO plasma levels were measured by liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS). We used Cox regression models to investigate associations between baseline TMAO levels and all-cause mortality. RESULTS Six-year mortality was 45.1%, and 18.9% of the patients had coronary artery disease (CAD). Median admission TMAO (μmolL-1) levels were significantly higher in non-survivors compared to survivors (4.1 [interquartile range (IQR), 2.2-7.2] vs. 2.5 [IQR, 1.5-4.1]; p<0.001). A strong association between TMAO and 6-year all-cause mortality was found for patients without CAD (adjusted hazard ratio (HR) 1.9 ([95% CI 1.2-3.1]; p<0.05). In patients with known CAD, no such association was found (adjusted HR 0.6 (0.2-1.6); p=0.309, interaction p=0.009). In patients without antibiotic pretreatment receiving antibiotic treatment, TMAO significantly decreased from admission to day seven (median, 3.9 [IQR, 2.1-7.5] vs. 3.1 [IQR, 1.4-6.6]; p<0.01). CONCLUSIONS TMAO is associated with long-term fatal outcomes in CAP patients without evident CAD and modifiable through antibiotic treatment. Whether chronic modulation of TMAO by targeting the microbiome reduces mortality risk needs to be evaluated in future interventional trials.
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Affiliation(s)
- Manuel Ottiger
- University Department of Internal Medicine, Kantonsspital Aarau, Switzerland.
| | - Manuela Nickler
- University Department of Internal Medicine, Kantonsspital Aarau, Switzerland.
| | - Christian Steuer
- Department of Laboratory Medicine, Kantonsspital Aarau, Switzerland.
| | - Jonas Odermatt
- University Department of Internal Medicine, Kantonsspital Aarau, Switzerland.
| | - Andreas Huber
- Department of Laboratory Medicine, Kantonsspital Aarau, Switzerland.
| | - Mirjam Christ-Crain
- Endocrinology, Diabetology and Metabolism, University Hospital Basel, Switzerland.
| | - Christoph Henzen
- Department of Internal Medicine, Kantonsspital Luzern, Switzerland.
| | - Claus Hoess
- Department of Internal Medicine, Kantonsspital Münsterlingen, Switzerland.
| | - Robert Thomann
- Department of Internal Medicine, Bürgerspital Solothurn, Switzerland.
| | - Werner Zimmerli
- Department of Internal Medicine, Kantonsspital Liestal, Switzerland.
| | - Beat Mueller
- University Department of Internal Medicine, Kantonsspital Aarau, Switzerland.
| | - Philipp Schuetz
- University Department of Internal Medicine, Kantonsspital Aarau, Switzerland.
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204
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Fuijkschot WW, Morrison MC, van der Linden R, Krijnen PAJ, Zethof IPA, Theyse LFH, Kleemann R, Niessen HWM, Smulders YM. Orthopedic surgery increases atherosclerotic lesions and necrotic core area in ApoE-/- mice. Atherosclerosis 2016; 255:164-170. [PMID: 27825629 DOI: 10.1016/j.atherosclerosis.2016.07.909] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 07/19/2016] [Accepted: 07/20/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Observational studies show a peak incidence of cardiovascular events after major surgery. For example, the risk of myocardial infarction increases 25-fold early after hip replacement. The acuteness of this increased risk suggests abrupt enhancement in plaque vulnerability, which may be related to intra-plaque inflammation, thinner fibrous cap and/or necrotic core expansion. We hypothesized that acute systemic inflammation following major orthopedic surgery induces such changes. METHODS ApoE-/- mice were fed a western diet for 10 weeks. Thereafter, half the mice underwent mid-shaft femur osteotomy followed by realignment with an intramedullary K-wire, to mimic major orthopedic surgery. Mice were sacrificed 5 or 15 days post-surgery (n = 22) or post-saline injection (n = 13). Serum amyloid A (SAA) was measured as a marker of systemic inflammation. Paraffin embedded slides of the aortic root were stained to measure total plaque area and to quantify fibrosis, calcification, necrotic core, and inflammatory cells. RESULTS Surgery mice showed a pronounced elevation of serum amyloid A (SAA) and developed increased plaque and necrotic core area already at 5 days, which reached significance at 15 days (p = 0.019; p = 0.004 for plaque and necrotic core, respectively). Macrophage and lymphocyte density significantly decreased in the surgery group compared to the control group at 15 days (p = 0.037; p = 0.024, respectively). The density of neutrophils and mast cells remained unchanged. CONCLUSIONS Major orthopedic surgery in ApoE-/- mice triggers a systemic inflammatory response. Atherosclerotic plaque area is enlarged after surgery mainly due to an increase of the necrotic core. The role of intra-plaque inflammation in this response to surgical injury remains to be fully elucidated.
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Affiliation(s)
- Wessel W Fuijkschot
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands; Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands; Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands.
| | - Martine C Morrison
- Department of Metabolic Health Research, The Netherlands Organization for Applied Scientific Research (TNO), Leiden, The Netherlands
| | | | - Paul A J Krijnen
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands; Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands
| | - Ilse P A Zethof
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands
| | - Lars F H Theyse
- Department Clinical Sciences and Services, Royal Veterinary College London, University of London, United Kingdom
| | - Robert Kleemann
- Department of Metabolic Health Research, The Netherlands Organization for Applied Scientific Research (TNO), Leiden, The Netherlands; Department of Vascular Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Hans W M Niessen
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands; Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands; Department of Cardiac Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Yvo M Smulders
- Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, Amsterdam, The Netherlands; Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
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Kolditz M, Tesch F, Mocke L, Höffken G, Ewig S, Schmitt J. Burden and risk factors of ambulatory or hospitalized CAP: A population based cohort study. Respir Med 2016; 121:32-38. [PMID: 27888989 DOI: 10.1016/j.rmed.2016.10.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 10/20/2016] [Accepted: 10/23/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Data on incidence, risk factors and outcome of community-acquired pneumonia (CAP) including outpatients is sparse. METHODS We conducted a cohort study on 1.837.080 adults insured by a German statutory health insurance in 2010-2011. CAP was identified via ICD-10-GM codes, ambulatory cases were validated by antibiotic prescription within 7 days. Primary outcomes were incidence, hospitalisation and 30-day all-cause mortality. Evaluated risk factors included age, sex and comorbidities. Evaluation was done by multivariate regression analysis adjusting for these factors and health care utilization. RESULTS CAP incidence was 9.7 per 1000 person years, hospitalisation rate 46.5%, and 30-day mortality 12.9%. 30-day mortality of ambulatory cases was 5% (with 27% subsequently hospitalized for another diagnosis before death). 30-day mortality of hospitalized patients was 21.9%, but in-hospital mortality 17.2%. Risk factors for CAP included age, male sex and all evaluated comorbidities with highest risk for neurologic (OR 2.4), lung (OR 2.3) or immunosuppressive (OR 2.1) disease. Mortality risk was highest for neurologic (OR 2.3) and malignant (OR 2.0) disease. CONCLUSIONS CAP constitutes a major burden in terms of incidence, morbidity and all-cause mortality in hospitalized and ambulatory patients. Interventions to raise awareness for disease impact also in ambulatory patients with risk factors are warranted.
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Affiliation(s)
- Martin Kolditz
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany.
| | - Falko Tesch
- Dresden University Centre for Evidence-Based Healthcare, Medical Faculty, Technische Universität Dresden, Germany
| | - Luise Mocke
- Dresden University Centre for Evidence-Based Healthcare, Medical Faculty, Technische Universität Dresden, Germany
| | - Gert Höffken
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Santiago Ewig
- Thoraxzentrum Ruhrgebiet, Department of Respiratory and Infectious Diseases, EVK Herne and Augusta-Kranken-Anstalt Bochum, Germany
| | - Jochen Schmitt
- Dresden University Centre for Evidence-Based Healthcare, Medical Faculty, Technische Universität Dresden, Germany
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Polyakov DS, Fomin IV, Valikulova FY, Vaisberg AR, Kraiem N. [Evaluation of the impact of community-acquired pneumonia on short-term and long-term prognosis in a patient with chronic decompensated heart failure]. TERAPEVT ARKH 2016; 88:17-22. [PMID: 27735909 DOI: 10.17116/terarkh201688917-22] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
AIM To evaluate the impact of community-acquired pneumonia (CAP) on short-term and long-term prognosis in patients hospitalized with signs of chronic decompensated heart failure (CDHF). SUBJECTS AND METHODS A total of 852 cases were admitted to therapy/cardiology hospital with signs of CDHF during a year. RESULTS Among the patients hospitalized with signs of CDHF, the prevalence of CAP was 16.5%. This indicator did not depend on the age of hospitalized patients. Among the multisystem disorders, hypertension, different forms of coronary heart disease, diabetes mellitus, and chronic obstructive pulmonary disease were more common in the patients with CAP. The presence of the latter in a patient with CDHF statistically significantly increased the length of hospital stay (13.1 versus 11.9 days; p = 0.009) and also the probability of rehospitalization during a year (odds ratio (OR) 1.9; p = 0.02). The presence of CAP in a patient with CDHF resulted in an increase in mortality rates (OR 13.5; p < 0.001); moreover, the highest risk of a fatal outcome was noted on day 1 of hospitalization (12.7%). During one-year follow-up, the risk of death in patients hospitalized with CDHF and concomitant pneumonia proved to be higher (OR 4.8; p < 0.001) than in those without pneumonia.
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Affiliation(s)
- D S Polyakov
- Nizhny Novgorod State Medical Academy, Ministry of Health of Russia, Nizhny Novgorod, Russia
| | - I V Fomin
- Nizhny Novgorod State Medical Academy, Ministry of Health of Russia, Nizhny Novgorod, Russia
| | - F Yu Valikulova
- Nizhny Novgorod State Medical Academy, Ministry of Health of Russia, Nizhny Novgorod, Russia
| | - A R Vaisberg
- Nizhny Novgorod State Medical Academy, Ministry of Health of Russia, Nizhny Novgorod, Russia
| | - N Kraiem
- Nizhny Novgorod State Medical Academy, Ministry of Health of Russia, Nizhny Novgorod, Russia
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207
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Siniorakis EE, Arapi SM, Panta SG, Pyrgakis VN, Ntanos IT, Limberi SJ. Emergency department triage of acute heart failure triggered by pneumonia; when an intensive care unit is needed? Int J Cardiol 2016; 220:479-82. [PMID: 27390973 DOI: 10.1016/j.ijcard.2016.06.228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 06/25/2016] [Indexed: 11/30/2022]
Abstract
Community acquired pneumonia (CAP) is a frequent triggering factor for decompensation of a chronic cardiac dysfunction, leading to acute heart failure (AHF). Patients with AHF exacerbated by CAP, are often admitted through the emergency department for ICU hospitalization, even though more than half the cases do not warrant any intensive care treatment. Emergency department physicians are forced to make disposition decisions based on subjective criteria, due to lack of evidence-based risk scores for AHF combined with CAP. Currently, the available risk models refer distinctly to either AHF or CAP patients. Extrapolation of data by arbitrarily combining these models, is not validated and can be treacherous. Examples of attempts to apply acuity scales provenient from different disciplines and the resulting discrepancies, are given in this review. There is a need for severity classification tools especially elaborated for use in the emergency department, applicable to patients with mixed AHF and CAP, in order to rationalize the ICU dispositions. This is bound to facilitate the efforts to save both lives and resources.
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Affiliation(s)
| | - Sophia M Arapi
- Department of Cardiology, G. Gennimatas General Hospital, Athens, Greece.
| | - Stamatia G Panta
- Department of Cardiology, Sotiria Chest Diseases Hospital, Athens, Greece
| | | | - Ioannis Th Ntanos
- 9th Department of Pneumonology, Sotiria Chest Diseases Hospital, Athens, Greece
| | - Sotiria J Limberi
- Department of Cardiology, Sotiria Chest Diseases Hospital, Athens, Greece
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Abstract
PURPOSE OF REVIEW Here, we review the incidence, prognosis, potential mechanisms and therapeutic implications of cardiovascular disease in community-acquired pneumonia (CAP). RECENT FINDINGS Recent evidence suggests that a large proportion of deaths from CAP are attributable to cardiovascular disease, including sudden cardiac death, acute myocardial infarction (MI), arrhythmias and cardiac failure. Up to one-third of patients with CAP may experience cardiovascular complications within 30 days of hospital admission, while data also suggest that CAP managed in the community is associated with increased risk of acute MI. The risk is maximal within a few days of hospitalization with CAP and reduces over time. Most studies suggest that risk is still increased at 1 year, and some suggest risk continues to be increased at 10 years post-CAP. This clearly contributes to the well-recognized increased long-term mortality associated with CAP. The mechanism is not entirely clear, but recent published data have better defined the impact of the host response, including systemic inflammation and platelet activation. The contribution of Streptococcus pneumoniae has also been recently investigated, with animal studies suggesting a direct effect of S. pneumoniae on the myocardium, forming microlesions that heal with resulting myocardial fibrosis. Several studies suggest a key role for the pore-forming toxin pneumolysin in S. pneumoniae-induced cardiac toxicity. SUMMARY Several therapies have been shown to improve the outcomes in cardiovascular disease, but whether these would be effective in improving outcomes in CAP is unknown. In this review, we argue that cardioprotective treatments may hold the greatest promise in terms of reducing long-term mortality in patients with CAP.
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209
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Sharafkhaneh A, Spiegelman AM, Main K, Tavakoli-Tabasi S, Lan C, Musher D. Mortality in Patients Admitted for Concurrent COPD Exacerbation and Pneumonia. COPD 2016; 14:23-29. [PMID: 27661473 DOI: 10.1080/15412555.2016.1220513] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Amir Sharafkhaneh
- a Medical Care Line, Michael E. DeBakey VA Medical Center , Houston , TX , USA.,b Department of Medicine , Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine , Houston , TX , USA
| | | | - Kevin Main
- d Allied Health Sciences, Baylor College of Medicine , Houston , TX , USA
| | - Shahriar Tavakoli-Tabasi
- a Medical Care Line, Michael E. DeBakey VA Medical Center , Houston , TX , USA.,c Department of Medicine , Section of Infectious Diseases, Baylor College of Medicine , Houston , TX , USA
| | - Charlie Lan
- a Medical Care Line, Michael E. DeBakey VA Medical Center , Houston , TX , USA.,b Department of Medicine , Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine , Houston , TX , USA
| | - Daniel Musher
- a Medical Care Line, Michael E. DeBakey VA Medical Center , Houston , TX , USA.,c Department of Medicine , Section of Infectious Diseases, Baylor College of Medicine , Houston , TX , USA
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210
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Makara MA, Hoang KV, Ganesan LP, Crouser ED, Gunn JS, Turner J, Schlesinger LS, Mohler PJ, Rajaram MVS. Cardiac Electrical and Structural Changes During Bacterial Infection: An Instructive Model to Study Cardiac Dysfunction in Sepsis. J Am Heart Assoc 2016; 5:e003820. [PMID: 27620887 PMCID: PMC5079037 DOI: 10.1161/jaha.116.003820] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 08/18/2016] [Indexed: 01/14/2023]
Abstract
BACKGROUND Sepsis patients with cardiac dysfunction have significantly higher mortality. Although several pathways are associated with myocardial damage in sepsis, the precise cause(s) remains unclear and treatment options are limited. This study was designed to develop a new model to investigate the early events of cardiac damage during sepsis progression. METHODS AND RESULTS Francisella tularensis subspecies novicida (Ft.n) is a Gram-negative intracellular pathogen causing severe sepsis syndrome in mice. BALB/c mice (N=12) were sham treated or infected with Ft.n through the intranasal route. Serial electrocardiograms were recorded at multiple time points until 96 hours. Hearts were then harvested for histology and gene expression studies. Similar to septic patients, we illustrate both cardiac electrical and structural phenotypes in our murine Ft.n infection model, including prominent R' wave formation, prolonged QRS intervals, and significant left ventricular dysfunction. Notably, in infected animals, we detected numerous microlesions in the myocardium, previously observed following nosocomial Streptococcus infection and in sepsis patients. We show that Ft.n-mediated microlesions are attributed to cardiomyocyte apoptosis, increased immune cell infiltration, and expression of inflammatory mediators (tumor necrosis factor, interleukin [IL]-1β, IL-8, and superoxide dismutase 2). Finally, we identify increased expression of microRNA-155 and rapid degradation of heat shock factor 1 following cardiac Ft.n infection as a primary cause of myocardial inflammation and apoptosis. CONCLUSIONS We have developed and characterized an Ft.n infection model to understand the pathogenesis of cardiac dysregulation in sepsis. Our findings illustrate novel in vivo phenotypes underlying cardiac dysfunction during Ft.n infection with significant translational impact on our understanding of sepsis pathophysiology.
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Affiliation(s)
- Michael A Makara
- Department of Physiology and Cell Biology, Dorothy M. Davis Heart and Lung Institute, Wexner Medical Center, College of Medicine, The Ohio State University, Columbus, OH
| | - Ky V Hoang
- Department of Microbial Infection and Immunity, Center for Microbial Interface Biology, Wexner Medical Center, College of Medicine, The Ohio State University, Columbus, OH
| | - Latha P Ganesan
- Department of Physiology and Cell Biology, Dorothy M. Davis Heart and Lung Institute, Wexner Medical Center, College of Medicine, The Ohio State University, Columbus, OH
| | - Elliot D Crouser
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Internal Medicine, Wexner Medical Center, College of Medicine, The Ohio State University, Columbus, OH
| | - John S Gunn
- Department of Microbial Infection and Immunity, Center for Microbial Interface Biology, Wexner Medical Center, College of Medicine, The Ohio State University, Columbus, OH
| | - Joanne Turner
- Department of Microbial Infection and Immunity, Center for Microbial Interface Biology, Wexner Medical Center, College of Medicine, The Ohio State University, Columbus, OH
| | - Larry S Schlesinger
- Department of Microbial Infection and Immunity, Center for Microbial Interface Biology, Wexner Medical Center, College of Medicine, The Ohio State University, Columbus, OH
| | - Peter J Mohler
- Department of Physiology and Cell Biology, Dorothy M. Davis Heart and Lung Institute, Wexner Medical Center, College of Medicine, The Ohio State University, Columbus, OH
| | - Murugesan V S Rajaram
- Department of Microbial Infection and Immunity, Center for Microbial Interface Biology, Wexner Medical Center, College of Medicine, The Ohio State University, Columbus, OH
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211
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Myocardial infarction caused by surgery: Blame inflammation not the surgeon. Atherosclerosis 2016; 255:113-116. [PMID: 27616135 DOI: 10.1016/j.atherosclerosis.2016.08.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 08/31/2016] [Indexed: 01/19/2023]
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212
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Aliberti S, Tobaldini E, Giuliani F, Nunziata V, Casazza G, Suigo G, D'Adda A, Bonaiti G, Roveda A, Queiroz A, Monzani V, Pesci A, Blasi F, Montano N. Cardiovascular autonomic alterations in hospitalized patients with community-acquired pneumonia. Respir Res 2016; 17:98. [PMID: 27491412 PMCID: PMC4973093 DOI: 10.1186/s12931-016-0414-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 07/21/2016] [Indexed: 01/08/2023] Open
Abstract
Background Alterations of cardiac autonomic control (CAC) are associated with poor outcomes in patients with infectious and non-infectious diseases. No evaluation of CAC in patients with community-acquired pneumonia (CAP) has been performed so far. The aim of the study was to assess CAC in patients with CAP and evaluate the impact of its alterations on disease severity and clinical outcomes in a multicenter, prospective, observational study. Methods Consecutive patients hospitalized for CAP were enrolled between 2011 and 2013 two university hospitals in Italy. CAC was assessed by linear spectral and non-linear symbolic analysis of heart rate variability. The presence of severe CAP was evaluated on hospital admission. The primary study outcome was time to clinical stability (TCS) during hospitalization. Results Among the 75 patients enrolled (median age: 75 years; 57 % males), a significantly lower total variability and reduction of sympathetic rhythmical component with predominant respiratory modulation was detected in comparison to controls. Among CAP patients affected by a severe CAP on admission, CAC showed a lower sympathetic modulation and predominant parasympathetic oscillatory rhythm. At the multivariate analysis, variables independently correlated with a TCS >7 days were total power, as marker of total variability, [OR (95 % CI): 0.997 (0.994–1.000), p = 0.0454] and sympathetic modulation [OR (95 % CI): 0.964 (0.932–0.998), p = 0.0367]. Conclusions Loss of sympathetic rhythmical oscillation is associated with a more severe disease and worse early clinical outcome in hospitalized patients with CAP. Electronic supplementary material The online version of this article (doi:10.1186/s12931-016-0414-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stefano Aliberti
- Department of Pathophysiology and Transplantation, University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan, Italy.
| | - Eleonora Tobaldini
- Departments of Internal Medicine, and Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan, Italy
| | - Fabio Giuliani
- Department of Pathophysiology and Transplantation, University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan, Italy
| | - Vanessa Nunziata
- Departments of Internal Medicine, and Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan, Italy
| | - Giovanni Casazza
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Via Giovanni Battista Grassi 74, Milan, Italy
| | - Giulia Suigo
- Health Science Department, University of Milan Bicocca, Clinica Pneumologica, AO San Gerardo, Via Pergolesi 33, Monza, Italy
| | - Alice D'Adda
- Department of Pathophysiology and Transplantation, University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan, Italy
| | - Giulia Bonaiti
- Health Science Department, University of Milan Bicocca, Clinica Pneumologica, AO San Gerardo, Via Pergolesi 33, Monza, Italy
| | - Andrea Roveda
- Departments of Internal Medicine, and Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan, Italy
| | - Andreia Queiroz
- Departments of Internal Medicine, and Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan, Italy.,Department of Physical Education, Federal University of Juiz de Fora, Minas Gerais, Brazil
| | - Valter Monzani
- Department of Emergency Medicine, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan, Italy
| | - Alberto Pesci
- Health Science Department, University of Milan Bicocca, Clinica Pneumologica, AO San Gerardo, Via Pergolesi 33, Monza, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan, Italy
| | - Nicola Montano
- Departments of Internal Medicine, and Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan, Italy
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213
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Dharmarajan K, Strait KM, Tinetti ME, Lagu T, Lindenauer PK, Lynn J, Krukas MR, Ernst FR, Li SX, Krumholz HM. Treatment for Multiple Acute Cardiopulmonary Conditions in Older Adults Hospitalized with Pneumonia, Chronic Obstructive Pulmonary Disease, or Heart Failure. J Am Geriatr Soc 2016; 64:1574-82. [PMID: 27448329 DOI: 10.1111/jgs.14303] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To determine how often hospitalized older adults principally diagnosed with pneumonia, chronic obstructive pulmonary disease (COPD), or heart failure (HF) are concurrently treated for two or more of these acute cardiopulmonary conditions. DESIGN Retrospective cohort study. SETTING 368 U.S. hospitals in the Premier research database. PARTICIPANTS Individuals aged 65 and older principally hospitalized with pneumonia, COPD, or HF in 2009 or 2010. MEASUREMENTS Proportion of diagnosed episodes of pneumonia, COPD, or HF concurrently treated for two or more of these acute cardiopulmonary conditions during the first 2 hospital days. RESULTS Of 91,709 diagnosed pneumonia hospitalizations, 32% received treatment for two or more acute cardiopulmonary conditions (18% for HF, 18% for COPD, 4% for both). Of 41,052 diagnosed COPD hospitalizations, 19% received treatment for two or more acute cardiopulmonary conditions (all of which involved additional HF treatment). Of 118,061 diagnosed HF hospitalizations, 38% received treatment for two or more acute cardiopulmonary conditions (34% for pneumonia, 9% for COPD, 5% for both). CONCLUSION Hospitalized older adults diagnosed with pneumonia, COPD, or HF are frequently treated for two or more acute cardiopulmonary conditions, suggesting that clinical syndromes often fall between traditional diagnostic categories. Research is needed to evaluate the risks and benefits of real-world treatment for the many older adults whose presentations elicit diagnostic uncertainty or concern about coexisting acute conditions.
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Affiliation(s)
- Kumar Dharmarajan
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Kelly M Strait
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Mary E Tinetti
- Section of Geriatrics, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.,Section of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, Connecticut
| | - Tara Lagu
- Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts.,Division of General Internal Medicine, Baystate Medical Center, Springfield, Massachusetts.,Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Peter K Lindenauer
- Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts.,Division of General Internal Medicine, Baystate Medical Center, Springfield, Massachusetts.,Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Joanne Lynn
- Altarum Institute, Washington, District of Columbia
| | | | - Frank R Ernst
- Premier Research Services, Premier, Inc., Charlotte, North Carolina
| | - Shu-Xia Li
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.,Section of Health Policy and Administration, Yale University School of Public Health, New Haven, Connecticut.,Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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214
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Feldman C, Anderson R. Prevalence, pathogenesis, therapy, and prevention of cardiovascular events in patients with community-acquired pneumonia. Pneumonia (Nathan) 2016; 8:11. [PMID: 28702290 PMCID: PMC5471702 DOI: 10.1186/s41479-016-0011-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 07/04/2016] [Indexed: 12/11/2022] Open
Abstract
It is now well recognised that cardiac events occur relatively commonly in patients with acute community-acquired pneumonia. While these events are more frequent in patients with underlying risk factors—such as those with underlying chronic cardiovascular and respiratory comorbidities, the elderly, and in nursing home residents—they also occur in patients with no underlying risks other than severe pneumonia. Recent research elucidating the underlying pathogenic mechanisms related to these cardiac events has indicated a probable role for platelet activation, which is possibly exacerbated by pneumolysin in the case of pneumococcal infections. This, in turn, has resulted in the identification of possible therapeutic strategies targeting platelet activation, as well as the cardio-toxic activity of pneumolysin. These issues represent the primary focus of the current review.
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Affiliation(s)
- Charles Feldman
- Division of Pulmonology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, University of the Witwatersrand Medical School, 7 York Road, Parktown, 2193 Johannesburg, South Africa
| | - Ronald Anderson
- Institute for Cellular and Molecular Medicine, Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
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215
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Cangemi R, Pignatelli P, Carnevale R, Bartimoccia S, Nocella C, Falcone M, Taliani G, Violi F. Low-grade endotoxemia, gut permeability and platelet activation in community-acquired pneumonia. J Infect 2016; 73:107-14. [PMID: 27288596 DOI: 10.1016/j.jinf.2016.05.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 05/22/2016] [Accepted: 05/28/2016] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Platelet activation seems to be implicated in the cardiovascular events occurring in patients with community-acquired pneumonia (CAP) but the underlying mechanism is still unclear. Aim of the study was to assess the mechanism involved in platelet activation in CAP patients. METHODS Two-hundred-seventy-eight consecutive patients hospitalized for CAP were recruited and followed-up until discharge. Hospitalized patients matched for sex, age and comorbidities but without acute infectious diseases were used as controls. RESULTS At hospital admission patients disclosed enhanced plasma levels of sP-selectin, a maker of in-vivo platelet activation, serum sNOX2-dp, a marker of NADPH-oxidase activation, serum Lipopolysaccharide (LPS) and serum zonulin, a marker of gut permeability, compared to controls (p < 0.001). Baseline sP-selectin was independently associated to serum LPS, sNOX2-sp and Pneumonia Severity Index score (p < 0.001). Plasma sP-selectin, serum sNOX2-dp, LPS and zonulin coincidentally decreased at hospital discharge (p < 0.001). An in vitro study showed that LPS, at concentration similar to that found in CAP patients, induced sP-selectin release by agonist-activated platelets, a phenomenon that was counteract by treating cells with gp91ds-tat, a specific inhibitor of NOX2. CONCLUSIONS CAP patients display enhanced platelet activation, which is related to LPS-mediated NOX2 activation. Enhanced gut permeability seems be implicated in enhancing circulating levels of LPS.
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Affiliation(s)
- Roberto Cangemi
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Pasquale Pignatelli
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Roberto Carnevale
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Simona Bartimoccia
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Cristina Nocella
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Marco Falcone
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Italy
| | - Gloria Taliani
- Infectious and Tropical Diseases Unit, Department of Clinical Medicine, Sapienza University of Rome, Italy
| | - Francesco Violi
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy.
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216
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Abstract
Streptococcus pneumoniae is an opportunistic pathogen globally associated with significant morbidity and mortality. It is capable of causing a wide range of diseases including sinusitis, conjunctivitis, otitis media, pneumonia, bacteraemia, sepsis, and meningitis. While its capsular polysaccharide is indispensible for invasive disease, and opsonising antibodies against the capsule are the basis for the current vaccines, a long history of biomedical research indicates that other components of this Gram-positive bacterium are also critical for virulence. Herein we review the contribution of pneumococcal virulence determinants to survival and persistence in the context of distinct anatomical sites. We discuss how these determinants allow the pneumococcus to evade mucociliary clearance during colonisation, establish lower respiratory tract infection, resist complement deposition and opsonophagocytosis in the bloodstream, and invade secondary tissues such as the central nervous system leading to meningitis. We do so in a manner that highlights both the critical role of the capsular polysaccharide and the accompanying and necessary protein determinants. Understanding the complex interplay between host and pathogen is necessary to find new ways to prevent pneumococcal infection. This review is an attempt to do so with consideration for the latest research findings.
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217
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Jafarzadeh SR, Thomas BS, Warren DK, Gill J, Fraser VJ. Longitudinal Study of the Effects of Bacteremia and Sepsis on 5-year Risk of Cardiovascular Events. Clin Infect Dis 2016; 63:495-500. [PMID: 27193746 DOI: 10.1093/cid/ciw320] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 05/07/2016] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The long-term and cumulative effect of multiple episodes of bacteremia and sepsis across multiple hospitalizations on the development of cardiovascular (CV) events is uncertain. METHODS We conducted a longitudinal study of 156 380 hospitalizations in 47 009 patients (≥18 years old) who had at least 2 inpatient admissions at an academic tertiary care center in St Louis, Missouri, from 1 January 2008 through 31 December 2012. We used marginal structural models, estimated by inverse probability weighting (IPW) of bacteremia or sepsis and IPW of censoring, to estimate the marginal causal effects of bacteremia and sepsis on developing the first observed incident CV event, including stroke, transient ischemic attack, and myocardial infarction (MI), during the study period. RESULTS Bacteremia and sepsis occurred during 4923 (3.1%) and 5544 (3.5%) hospitalizations among 3932 (8.4%) and 4474 (9.5%) patients, respectively. CV events occurred in 414 (10.5%) and 538 (12.0%) patients with prior episodes of bacteremia or sepsis, respectively, vs 3087 (7.2%) and 2963 (7.0%) patients without prior episodes of bacteremia or sepsis. The causal odds of experiencing a CV event was 1.52-fold (95% confidence interval [CI], 1.21- to 1.90-fold) and 2.39-fold (95% CI, 1.88- to 3.03-fold) higher in patients with prior instances of bacteremia or sepsis, respectively, compared to those without. Prior instances of septic shock resulted in a 6.91-fold (95% CI, 5.34- to 8.93-fold) increase in the odds of MI. CONCLUSIONS Prior instances of bacteremia and sepsis substantially increase the 5-year risk of CV events.
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Affiliation(s)
- S Reza Jafarzadeh
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Benjamin S Thomas
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu
| | - David K Warren
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Jeff Gill
- Division of Biostatistics, Division of Public Health Sciences, Washington University School of Medicine, St Louis, Missouri
| | - Victoria J Fraser
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri
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218
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Pneumolysin Mediates Platelet Activation In Vitro. Lung 2016; 194:589-93. [PMID: 27192991 DOI: 10.1007/s00408-016-9900-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 05/09/2016] [Indexed: 12/11/2022]
Abstract
This study has explored the role of the pneumococcal toxin, pneumolysin (Ply), in activating human platelets. Following exposure to Ply (10-80 ng/ml), platelet activation and cytosolic Ca(2+) concentrations were measured flow cytometrically according to the level of expression of CD62P (P-selectin) and spectrofluorimetrically, respectively. Exposure to Ply resulted in marked upregulation of expression of platelet CD62P, achieving statistical significance at concentrations of 40 ng/ml and higher (P < 0.05), in the setting of increased influx of Ca(2+). These potentially pro-thrombotic actions of Ply were attenuated by depletion of Ca(2+) from the extracellular medium or by exposure of the cells to a pneumolysoid devoid of pore-forming activity. These findings are consistent with a mechanism of Ply-mediated platelet activation involving sub-lytic pore formation, Ca(2+) influx, and mobilization of CD62P-expressing α-granules, which, if operative in vivo, may contribute to the pathogenesis of associated acute lung and myocardial injury during invasive pneumococcal disease.
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219
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Infiltrated Macrophages Die of Pneumolysin-Mediated Necroptosis following Pneumococcal Myocardial Invasion. Infect Immun 2016; 84:1457-69. [PMID: 26930705 DOI: 10.1128/iai.00007-16] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 02/20/2016] [Indexed: 11/20/2022] Open
Abstract
Streptococcus pneumoniae (the pneumococcus) is capable of invading the heart. Herein we observed that pneumococcal invasion of the myocardium occurred soon after development of bacteremia and was continuous thereafter. Using immunofluorescence microscopy (IFM), we observed that S. pneumoniae replication within the heart preceded visual signs of tissue damage in cardiac tissue sections stained with hematoxylin and eosin. Different S. pneumoniae strains caused distinct cardiac pathologies: strain TIGR4, a serotype 4 isolate, caused discrete pneumococcus-filled microscopic lesions (microlesions), whereas strain D39, a serotype 2 isolate, was, in most instances, detectable only using IFM and was associated with foci of cardiomyocyte hydropic degeneration and immune cell infiltration. Both strains efficiently invaded the myocardium, but cardiac damage was entirely dependent on the pore-forming toxin pneumolysin only for D39. Early microlesions caused by TIGR4 and microlesions formed by a TIGR4 pneumolysin-deficient mutant were infiltrated with CD11b(+) and Ly6G-positive neutrophils and CD11b(+) and F4/80-positive (F4/80(+)) macrophages. We subsequently demonstrated that macrophages in TIGR4-infected hearts died as a result of pneumolysin-induced necroptosis. The effector of necroptosis, phosphorylated mixed-lineage kinase domain-like protein (MLKL), was detected in CD11b(+) and F4/80(+) cells associated with microlesions. Likewise, treatment of infected mice and THP-1 macrophages in vitro with the receptor-interacting protein 1 kinase (RIP1) inhibitor necrostatin-5 promoted the formation of purulent microlesions and blocked cell death, respectively. We conclude that pneumococci that have invaded the myocardium are an important cause of cardiac damage, pneumolysin contributes to cardiac damage in a bacterial strain-specific manner, and pneumolysin kills infiltrated macrophages via necroptosis, which alters the immune response.
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220
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Pletz MW, Rohde GG, Welte T, Kolditz M, Ott S. Advances in the prevention, management, and treatment of community-acquired pneumonia. F1000Res 2016; 5. [PMID: 26998243 PMCID: PMC4786904 DOI: 10.12688/f1000research.7657.1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2016] [Indexed: 01/06/2023] Open
Abstract
Community-acquired pneumonia (CAP) is the infectious disease with the highest number of deaths worldwide. Nevertheless, its importance is often underestimated. Large cohorts of patients with CAP have been established worldwide and improved our knowledge about CAP by far. Therefore, current guidelines are much more evidence-based than ever before. This article discusses recent major studies and concepts on CAP such as the role of biomarkers, appropriate risk stratification to identify patients in need of hospitalisation or intensive care, appropriate empiric antibiotic therapy (including the impact of macrolide combination therapy and antibiotic stewardship), and CAP prevention with novel influenza and pneumococcal vaccines.
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Affiliation(s)
- Mathias W Pletz
- Center for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Gernot G Rohde
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Martin Kolditz
- Division of Pulmonology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Sebastian Ott
- Department of Pulmonary Medicine, Inselspital, University Hospital, Bern, Switzerland
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Nel JG, Theron AJ, Durandt C, Tintinger GR, Pool R, Mitchell TJ, Feldman C, Anderson R. Pneumolysin activates neutrophil extracellular trap formation. Clin Exp Immunol 2016; 184:358-67. [PMID: 26749379 DOI: 10.1111/cei.12766] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 12/14/2015] [Accepted: 12/23/2015] [Indexed: 02/06/2023] Open
Abstract
The primary objective of the current study was to investigate the potential of the pneumococcal toxin, pneumolysin (Ply), to activate neutrophil extracellular trap (NET) formation in vitro. Isolated human blood neutrophils were exposed to recombinant Ply (5-20 ng ml(-1) ) for 30-90 min at 37°C and NET formation measured using the following procedures to detect extracellular DNA: (i) flow cytometry using Vybrant® DyeCycle™ Ruby; (ii) spectrofluorimetry using the fluorophore, Sytox(®) Orange (5 μM); and (iii) NanoDrop(®) technology. These procedures were complemented by fluorescence microscopy using 4', 6-diamino-2-phenylindole (DAPI) (nuclear stain) in combination with anti-citrullinated histone monoclonal antibodies to visualize nets. Exposure of neutrophils to Ply resulted in relatively rapid (detected within 30-60 min), statistically significant (P < 0·05) dose- and time-related increases in the release of cellular DNA impregnated with both citrullinated histone and myeloperoxidase. Microscopy revealed that NETosis appeared to be restricted to a subpopulation of neutrophils, the numbers of NET-forming cells in the control and Ply-treated systems (10 and 20 ng ml(-1) ) were 4·3 (4·2), 14.3 (9·9) and 16·5 (7·5), respectively (n = 4, P < 0·0001 for comparison of the control with both Ply-treated systems). Ply-induced NETosis occurred in the setting of retention of cell viability, and apparent lack of involvement of reactive oxygen species and Toll-like receptor 4. In conclusion, Ply induces vital NETosis in human neutrophils, a process which may either contribute to host defence or worsen disease severity, depending on the intensity of the inflammatory response during pneumococcal infection.
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Affiliation(s)
| | - A J Theron
- Department of Immunology, Faculty of Health Sciences, University of Pretoria and Tshwane Academic Division of the National Health Laboratory Service.,South African Medical Research Council Unit for Stem Cell Research, Institute for Cellular and Molecular Medicine, Department of Immunology, Faculty of Health Sciences, University of Pretoria
| | - C Durandt
- South African Medical Research Council Unit for Stem Cell Research, Institute for Cellular and Molecular Medicine, Department of Immunology, Faculty of Health Sciences, University of Pretoria
| | - G R Tintinger
- Department of Internal Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - R Pool
- Department of Haematology
| | - T J Mitchell
- Institute of Microbiology and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - C Feldman
- Division of Pulmonology, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg and Charlotte Maxeke Academic Hospital, Johannesburg, South Africa
| | - R Anderson
- South African Medical Research Council Unit for Stem Cell Research, Institute for Cellular and Molecular Medicine, Department of Immunology, Faculty of Health Sciences, University of Pretoria
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Bader MS, Yi Y, Abouchehade K, Haroon B, Bishop LD, Hawboldt J. Community-Acquired Pneumonia in Patients With Diabetes Mellitus: Predictors of Complications and Length of Hospital Stay. Am J Med Sci 2016; 352:30-5. [PMID: 27432032 DOI: 10.1016/j.amjms.2016.02.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/19/2016] [Accepted: 02/23/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND The primary objective of the study was to determine factors associated with complications and length of hospital stay (LOS) in hospitalized adult patients with diabetes along with community-acquired pneumonia (CAP). CAP is a common infection in patients with diabetes mellitus and is associated with a significant mortality and morbidity. MATERIALS AND METHODS This is a retrospective cohort study of 215 adult patients with diabetes who were admitted with CAP. A multivariate logistic and Cox regression analysis were used to assess factors associated with complications and LOS of CAP, respectively. RESULTS During the follow-up period from admission until discharge, 94 patients (43.7%) developed complications. Respiratory failure was the most common complication (43.6%). The average LOS of study cohort was 9.47 days. In the multivariate analysis, complications of CAP were associated with time to first dose of appropriate antibiotic therapy >8 hours since triage at emergency department (ED) (odds ratio = 3.16; 95% CI: 1.58-6.32; P = 0.001) and pneumonia severity index score >90 (odds ratio = 3.52; 95% CI: 1.45-8.53; P = 0.005). In the multivariate Cox regression analysis, time to first dose of appropriate antibiotic therapy >8 hours since triage at ED (hazard ratio [HR] = 0.56, P = 0.01), pneumonia severity index score >90 (HR = 0.62, P = 0.01), presence of complications (HR = 0.53, P = 0.002), duration of antibiotics (HR = 0.90, P ≤ 0.0001) and duration of symptoms prior presentation to ED (HR = 0.96, P = 0.04) were independently determinants of LOS. CONCLUSIONS Delayed administration of appropriate antibiotic therapy at ED and moderate-to-severe pneumonia were associated with both increased risk of complications and prolonged LOS in hospitalized adult patients with diabetes along with CAP.
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Affiliation(s)
- Mazen S Bader
- Faculty of Health Sciences, Division of Infectious Diseases, Department of Medicine, Memorial University, Newfoundland and Labrador, Canada.
| | - Yanqing Yi
- Faculty of Medicine, Division of Community Health, Memorial University, Newfoundland and Labrador, Canada
| | - Kassem Abouchehade
- School of Pharmacy, Memorial University, Newfoundland and Labrador, Canada
| | - Babar Haroon
- Department of Medicine, Memorial University, Newfoundland and Labrador, Canada
| | - Lisa D Bishop
- School of Pharmacy, Memorial University, Newfoundland and Labrador, Canada
| | - John Hawboldt
- School of Pharmacy, Memorial University, Newfoundland and Labrador, Canada
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Abstract
PURPOSE OF REVIEW Treatment of parapneumonic effusions (PPEs) is challenged by the decision of whether or not to insert chest tubes. This review focuses on the factors that may aid in determining which patients require an immediate drainage of the pleural space, that is, have a complicated PPE. RECENT FINDINGS Clinical guidelines advocate the evaluation of radiological (large effusion or loculation), bacteriological (Gram-positive stain or culture), biochemical (pH < 7.20 or glucose <60 mg/dl), and macroscopic (pus) characteristics of the pleural fluid to assist in the identification of complicated PPEs. In the past few years, a number of new pleural fluid biomarkers have been tested for the same purpose, but with the exception of C-reactive protein (CRP), they should be considered investigative. A pleural fluid CRP higher than 100 mg/l or a serum CRP higher than 200 mg/l, when combined with pleural fluid pH or glucose, may greatly increase our capability to predict the need for instituting tube thoracostomy. Although some ultrasonographic and computed tomography features favor the diagnosis of pleural infection, their role in uncomplicated-complicated PPE discrimination has not been systematically evaluated. SUMMARY No pleural fluid tests, other than pH or glucose, have gained wide acceptance for the assessment of patients with PPE. However, if corroborated with further studies, the measurement of pleural fluid or serum CRP, in combination with the classical fluid parameters, may have the potential to be incorporated into medical decision making.
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Polverino E, Torres A, Terraneo S. Community acquired pneumonia in asthma: Not a threatening combination. Respir Med 2015; 112:136. [PMID: 26708771 DOI: 10.1016/j.rmed.2015.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Eva Polverino
- Department of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona - SGR 911 - Ciber de Enfermedades Respiratorias (CIBERES), Spain
| | - Antoni Torres
- Department of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona - SGR 911 - Ciber de Enfermedades Respiratorias (CIBERES), Spain.
| | - Silvia Terraneo
- Respiratory Unit, San Paolo Hospital, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
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Claessens YE, Debray MP, Tubach F, Brun AL, Rammaert B, Hausfater P, Naccache JM, Ray P, Choquet C, Carette MF, Mayaud C, Leport C, Duval X. Early Chest Computed Tomography Scan to Assist Diagnosis and Guide Treatment Decision for Suspected Community-acquired Pneumonia. Am J Respir Crit Care Med 2015; 192:974-82. [DOI: 10.1164/rccm.201501-0017oc] [Citation(s) in RCA: 162] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Aliberti S, Ramirez J, Cosentini R, Valenti V, Voza A, Rossi P, Stolz D, Legnani D, Pesci A, Richeldi L, Peyrani P, Massari FM, Blasi F. Acute myocardial infarction versus other cardiovascular events in community-acquired pneumonia. ERJ Open Res 2015; 1:00020-2015. [PMID: 27730139 PMCID: PMC5005139 DOI: 10.1183/23120541.00020-2015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 07/21/2015] [Indexed: 11/29/2022] Open
Abstract
The aim of the present study was to define the prevalence, characteristics, risk factors and impact on clinical outcomes of acute myocardial infarction (AMI) versus other cardiovascular events (CVEs) in patients with community-acquired pneumonia (CAP). This was an international, multicentre, observational, prospective study of CAP patients hospitalised in eight hospitals in Italy and Switzerland. Three groups were identified: those without CVEs, those with AMI and those with other CVEs. Among 905 patients, 21 (2.3%) patients experienced at least one AMI, while 107 (11.7%) patients experienced at least one other CVE. Patients with CAP and either AMI or other CVEs showed a higher severity of the disease than patients with CAP alone. Female sex, liver disease and the presence of severe sepsis were independent predictors for the occurrence of AMI, while female sex, age >65 years, neurological disease and the presence of pleural effusion predicted other CVEs. In-hospital mortality was significantly higher among those who experienced AMI in comparison to those experiencing other CVEs (43% versus 21%, p=0.039). The presence of AMI showed an adjusted odds ratio for in-hospital mortality of 3.57 (p=0.012) and for other CVEs of 2.63 (p=0.002). These findings on AMI versus other CVEs as complications of CAP may be important when planning interventional studies on cardioprotective medications. Acute myocardial infarction is associated with specific risk factors and accounts for worse outcomes in CAP patientshttp://ow.ly/QhT2t
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Affiliation(s)
- Stefano Aliberti
- Health Science Department, University of Milan Bicocca, Respiratory Unit, AO San Gerardo, Monza, Italy
| | - Julio Ramirez
- Division of Infectious Diseases, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Roberto Cosentini
- Emergency Medicine Unit, IRCCS Fondazione Ospedale Maggiore Policlinico Cà Granda, Milan, Italy
| | - Vincenzo Valenti
- Pulmonary Unit, University of Milan, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Antonio Voza
- Emergency Department, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Paolo Rossi
- Internal Medicine Department, Azienda Ospedaliero-Universitaria "S. Maria della Misericordia", Udine, Italy
| | - Daiana Stolz
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland
| | - Delfino Legnani
- Department of Biomedical and Clinical Sciences, University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Alberto Pesci
- Health Science Department, University of Milan Bicocca, Respiratory Unit, AO San Gerardo, Monza, Italy
| | - Luca Richeldi
- National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK; Centre for Rare Lung Disease, University of Modena and Reggio Emilia, AO Policlinico, Modena, Italy
| | - Paula Peyrani
- Division of Infectious Diseases, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Fernando Maria Massari
- UOC Malattie Cardiovascolari, Università degli Studi di Milano, IRCCS Fondazione Ospedale Maggiore Policlinico Cà Granda, Milan, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, IRCCS Fondazione Ospedale Maggiore Policlinico Cà Granda, Milan, Italy
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Bello S, Fandos S, Lasierra A, Mincholé E, Panadero C, Simon A, Gavin O, De Pablo F, Menendez R, Torres A. Red blood cell distribution width [RDW] and long-term mortality after community-acquired pneumonia. A comparison with proadrenomedullin. Respir Med 2015. [DOI: 10.1016/j.rmed.2015.07.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Cangemi R, Calvieri C, Falcone M, Bucci T, Bertazzoni G, Scarpellini MG, Barillà F, Taliani G, Violi F, Battaglia S, Biliotti E, Calabrese CM, Casciaro M, De Angelis M, De Marzio P, Esvan R, Fazi L, Sulekova LF, Franchi C, Giordo L, Grieco S, Manzini E, Marinelli P, Mordenti M, Morelli S, Palange P, Pastori D, Pignatelli P, Capparuccia MR, Romiti GF, Rossi E, Ruscio E, Russo A, Solimando L, Trapè S, Toriello F. Relation of Cardiac Complications in the Early Phase of Community-Acquired Pneumonia to Long-Term Mortality and Cardiovascular Events. Am J Cardiol 2015; 116:647-51. [PMID: 26089009 DOI: 10.1016/j.amjcard.2015.05.028] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 05/14/2015] [Accepted: 05/14/2015] [Indexed: 01/05/2023]
Abstract
Community-acquired pneumonia (CAP) is complicated by cardiac events in the early phase of the disease. Aim of this study was to assess if these intrahospital cardiac complications may account for overall mortality and cardiovascular events occurring during a long-term follow-up. Three hundred one consecutive patients admitted to the University-Hospital, Policlinico Umberto I, with community-acquired pneumonia were prospectively recruited and followed up for a median of 17.4 months. Primary end point was the occurrence of death for any cause, and secondary end point was the occurrence of cardiovascular events (cardiovascular death, nonfatal myocardial infarction [MI], and stroke). During the intrahospital stay, 55 patients (18%) experienced a cardiac complication. Of these, 32 had an MI (29 non-ST-elevation MI and 3 ST-elevation MI) and 30 had a new episode of atrial fibrillation (7 nonmutually exclusive events). During the follow-up, 89 patients died (51% of patients with an intrahospital cardiac complication and 26% of patients without, p <0.001) and 73 experienced a cardiovascular event (47% of patients with and 19% of patients without an intrahospital cardiac complication, p <0.001). A Cox regression analysis showed that intrahospital cardiac complications, age, and Pneumonia Severity Index were significantly associated with overall mortality, whereas intrahospital cardiac complications, age, hypertension, and diabetes were significantly associated with cardiovascular events during the follow-up. In conclusion, this prospective study shows that intrahospital cardiac complications in the early phase of pneumonia are associated with an enhanced risk of death and cardiovascular events during long-term follow-up.
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230
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Goldstein LH, Gabin A, Fawaz A, Freedberg NA, Schwartz N, Elias M, Saliba W. Azithromycin is not associated with QT prolongation in hospitalized patients with community-acquired pneumonia. Pharmacoepidemiol Drug Saf 2015; 24:1042-8. [DOI: 10.1002/pds.3842] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 05/14/2015] [Accepted: 06/30/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Lee Hilary Goldstein
- Department of Internal Medicine C; Ha'emek Medical Center; Afula Israel
- Bruce Rappaport Faculty of Medicine; Technion-Israel Institute of Technology; Haifa Israel
- Clinical Pharmacology Unit; Ha'emek Medical Center; Haifa Israel
| | - Ahmad Gabin
- Department of Internal Medicine C; Ha'emek Medical Center; Afula Israel
| | - Abdallah Fawaz
- Department of Internal Medicine C; Ha'emek Medical Center; Afula Israel
| | - Nahum Adam Freedberg
- Bruce Rappaport Faculty of Medicine; Technion-Israel Institute of Technology; Haifa Israel
- Department of Cardiology and Electrophysiology Unit; Ha'emek Medical Center; Afula Israel
| | - Naama Schwartz
- Clinical Research Unit; Ha'emek Medical Center; Afula Israel
- School of public health; University of Haifa; Haifa Israel
| | - Mazen Elias
- Department of Internal Medicine C; Ha'emek Medical Center; Afula Israel
- Bruce Rappaport Faculty of Medicine; Technion-Israel Institute of Technology; Haifa Israel
| | - Walid Saliba
- Department of Internal Medicine C; Ha'emek Medical Center; Afula Israel
- Bruce Rappaport Faculty of Medicine; Technion-Israel Institute of Technology; Haifa Israel
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Corrales-Medina VF, Taljaard M, Yende S, Kronmal R, Dwivedi G, Newman AB, Elkind MSV, Lyles MF, Chirinos JA. Intermediate and long-term risk of new-onset heart failure after hospitalization for pneumonia in elderly adults. Am Heart J 2015; 170:306-12. [PMID: 26299228 PMCID: PMC4548825 DOI: 10.1016/j.ahj.2015.04.028] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 04/25/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pneumonia is associated with high risk of heart failure (HF) in the short term (30 days) postinfection. Whether this association persists beyond this period is unknown. METHODS We studied 5,613 elderly (≥65 years) adults enrolled in the Cardiovascular Health Study between 1989 and 1994 at 4 US communities. Participants had no clinical diagnosis of HF at enrollment, and they were followed up through December 2010. Hospitalizations for pneumonia were identified using validated International Classification of Disease Ninth Revision codes. A centralized committee adjudicated new-onset HF events. Using Cox regression, we estimated adjusted hazard ratios (HRs) of new-onset HF at different time intervals after hospitalization for pneumonia. RESULTS A total of 652 participants hospitalized for pneumonia during follow-up were still alive and free of clinical diagnosis of HF by day 30 posthospitalization. Relative to the time of their hospitalization, new-onset HF occurred in 22 cases between 31 and 90 days (HR 6.9, 95% CI 4.46-10.63, P < .001), 14 cases between 91 days and 6 months (HR 3.2, 95% CI 1.88-5.50, P < .001), 20 cases between 6 months and 1 year (HR 2.6, 95% CI 1.64-4.04, P < .001), 76 cases between 1 and 5 years (HR 1.7, 95% CI 1.30-2.12, P < .001), and 71 cases after 5 years (HR 2.0, 95% CI 1.56-2.58, P < .001). Results were robust to sensitivity analyses using stringent definitions of pneumonia and extreme assumptions for potential informative censoring. CONCLUSION Hospitalization for pneumonia is associated with increased risk of new-onset HF in the intermediate and long term. Studies should characterize the mechanisms of this association in order to prevent HF in elderly pneumonia survivors.
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Affiliation(s)
- Vicente F Corrales-Medina
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Monica Taljaard
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sachin Yende
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Richard Kronmal
- Department of Statistics. University of Washington, Seattle, WA
| | - Girish Dwivedi
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Anne B Newman
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA
| | - Mitchell S V Elkind
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Mary F Lyles
- Department of Medicine, Wake Forest University, Winston-Salem, NC
| | - Julio A Chirinos
- University of Pennsylvania, Philadelphia, PA; Philadelphia VA Medical Center, Philadelphia, PA
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233
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Kolditz M, Ewig S, Schütte H, Suttorp N, Welte T, Rohde G. Assessment of oxygenation and comorbidities improves outcome prediction in patients with community-acquired pneumonia with a low CRB-65 score. J Intern Med 2015; 278:193-202. [PMID: 25597400 DOI: 10.1111/joim.12349] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Addition of assessment of comorbid diseases ('D') and oxygen saturation ('S') to the CRB-65 score has been recommended to improve its accuracy for risk stratification in community-acquired pneumonia (CAP). The aim of this study was to validate the resulting DS-CRB-65 score in a large cohort of patients with CAP. METHODS A total of 4432 patients prospectively enrolled in the CAPNETZ cohort were included in this study. Predefined end points were 28-day mortality, requirement for mechanical ventilation or vasopressors (MV/VS) and requirement for MV/VS or intensive care unit admission (MV/VS/ICU). Receiver operating characteristic curve analysis was used to determine the accuracy of the CRB-65 score and the addition of D (extra-pulmonary comorbidities) and S (oxygen saturation <90% or partial pressure of oxygen <8 kPa). Binary logistic regression and the method of Hanley and McNeil were used to compare the criteria. RESULTS The mortality rate was 4.0%, and 4.2% of patients required MV/VS and 6.6% required MV/VS/ICU. After multivariate analysis, D and S independently were added to the CRB-65 criteria for mortality prediction, but only S improved prediction of MV/VS and MV/VS/ICU (P < 0.001 for all). The area under the curve of the CRB-65 score was significantly improved by adding D and S for all end points (P < 0.02). Amongst patients who died or required MV/VS despite a CRB-65 score of 0, 64-80% would have been identified by the DS-CRB-65 score. CONCLUSIONS The addition of assessment of oxygenation and comorbidities significantly improved the prognostic accuracy of the CRB-65 score. Consequently, the DS-CRB-65 score may have a useful role in risk stratification algorithms for CAP.
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Affiliation(s)
- M Kolditz
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technical University, Dresden, Germany
| | - S Ewig
- Thoraxzentrum Ruhrgebiet, Department of Respiratory and Infectious Diseases, EVK Herne and Augusta-Kranken-Anstalt, Bochum, Germany
| | - H Schütte
- Department of Pulmonology, Klinikum Ernst von Bergmann, Potsdam, Germany.,Department of Internal Medicine, Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany.,CAPNETZ STIFTUNG, Hannover, Germany
| | - N Suttorp
- Department of Internal Medicine, Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany.,CAPNETZ STIFTUNG, Hannover, Germany
| | - T Welte
- CAPNETZ STIFTUNG, Hannover, Germany.,Department of Respiratory Medicine, Medizinische Hochschule, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), The German Center for Lung Research (DZL), Hannover, Germany
| | - G Rohde
- CAPNETZ STIFTUNG, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), The German Center for Lung Research (DZL), Hannover, Germany.,Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
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Anxiety disorders and physical comorbidity: increased prevalence but reduced relevance of specific risk factors for hospital-based mortality during a 12.5-year observation period in general hospital admissions. Eur Arch Psychiatry Clin Neurosci 2015; 265:387-98. [PMID: 25472881 DOI: 10.1007/s00406-014-0566-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 11/24/2014] [Indexed: 12/18/2022]
Abstract
Anxiety disorders (AD) are associated with an increase in physical comorbidities, but the effects of these diseases on hospital-based mortality are unclear. Consequently, we investigated whether the burden of physical comorbidity and its relevance on hospital-based mortality differed between individuals with and without AD during a 12.5-year observation period in general hospital admissions. During 1 January 2000 and 30 June 2012, 11,481 AD individuals were admitted to seven General Manchester Hospitals. All comorbidities with a prevalence ≥ 1 % were compared with those of 114,810 randomly selected and group-matched hospital controls of the same age and gender, regardless of priority of diagnoses or specialized treatments. Comorbidities that increased the risk of hospital-based mortality (but not mortality outside of the hospital) were identified using multivariate logistic regression analyses. AD individuals compared to controls had a substantial excess comorbidity, but a reduced hospital-based mortality rate. Twenty-two physical comorbidities were increased in AD individuals compared with controls, which included cardiovascular diseases and their risk factors. The most frequent physical comorbidities in AD individuals were hypertension, asthma, cataract, and ischaemic heart disease. Risk factors for hospital-based mortality in AD individuals were lung cancer, alcoholic liver disease, respiratory failure, heart failure, pneumonia, bronchitis, non-specific dementia, breast cancer, COPD, gallbladder calculus, atrial fibrillation, and angina. The impact of atrial fibrillation, angina, and gallbladder calculus on hospital-based mortality was higher in AD individuals than in controls. In contrast, other mortality risk factors had an equal or lower impact on hospital-based mortality in sample comparisons. Therefore AD individuals have a higher burden of physical comorbidity that is associated with a reduced risk of general hospital-based mortality. Atrial fibrillation, angina, and gallbladder calculus are major risk factors for general hospital-based mortality in AD individuals.
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Torres A, Blasi F, Dartois N, Akova M. Which individuals are at increased risk of pneumococcal disease and why? Impact of COPD, asthma, smoking, diabetes, and/or chronic heart disease on community-acquired pneumonia and invasive pneumococcal disease. Thorax 2015. [PMID: 26219979 PMCID: PMC4602259 DOI: 10.1136/thoraxjnl-2015-206780] [Citation(s) in RCA: 204] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Pneumococcal disease (including community-acquired pneumonia and invasive pneumococcal disease) poses a burden to the community all year round, especially in those with chronic underlying conditions. Individuals with COPD, asthma or who smoke, and those with chronic heart disease or diabetes mellitus have been shown to be at increased risk of pneumococcal disease compared with those without these risk factors. These conditions, and smoking, can also adversely affect patient outcomes, including short-term and long-term mortality rates, following pneumonia. Community-acquired pneumonia, and in particular pneumococcal pneumonia, is associated with a significant economic burden, especially in those who are hospitalised, and also has an impact on a patient's quality of life. Therefore, physicians should target individuals with COPD, asthma, heart disease or diabetes mellitus, and those who smoke, for pneumococcal vaccination at the earliest opportunity at any time of the year.
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Affiliation(s)
- Antoni Torres
- Servei de Pneumologia, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBER de Enfermedades Respiratorias (CIBERes), University of Barcelona, Barcelona, Spain
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, IRCCS Fondazione Cà Granda Ospedale Maggiore, Milan, Italy
| | | | - Murat Akova
- Department of Infectious Diseases, Hacettepe University School of Medicine, Ankara, Turkey
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Outcome of community-acquired pneumonia with cardiac complications. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2015. [DOI: 10.1016/j.ejcdt.2015.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Violi F, Carnevale R, Calvieri C, Nocella C, Falcone M, Farcomeni A, Taliani G, Cangemi R. Nox2 up-regulation is associated with an enhanced risk of atrial fibrillation in patients with pneumonia. Thorax 2015; 70:961-6. [DOI: 10.1136/thoraxjnl-2015-207178] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 06/12/2015] [Indexed: 01/27/2023]
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Alhamdi Y, Neill DR, Abrams ST, Malak HA, Yahya R, Barrett-Jolley R, Wang G, Kadioglu A, Toh CH. Circulating Pneumolysin Is a Potent Inducer of Cardiac Injury during Pneumococcal Infection. PLoS Pathog 2015; 11:e1004836. [PMID: 25973949 PMCID: PMC4431880 DOI: 10.1371/journal.ppat.1004836] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 03/26/2015] [Indexed: 11/19/2022] Open
Abstract
Streptococcus pneumoniae accounts for more deaths worldwide than any other single pathogen through diverse disease manifestations including pneumonia, sepsis and meningitis. Life-threatening acute cardiac complications are more common in pneumococcal infection compared to other bacterial infections. Distinctively, these arise despite effective antibiotic therapy. Here, we describe a novel mechanism of myocardial injury, which is triggered and sustained by circulating pneumolysin (PLY). Using a mouse model of invasive pneumococcal disease (IPD), we demonstrate that wild type PLY-expressing pneumococci but not PLY-deficient mutants induced elevation of circulating cardiac troponins (cTns), well-recognized biomarkers of cardiac injury. Furthermore, elevated cTn levels linearly correlated with pneumococcal blood counts (r=0.688, p=0.001) and levels were significantly higher in non-surviving than in surviving mice. These cTn levels were significantly reduced by administration of PLY-sequestering liposomes. Intravenous injection of purified PLY, but not a non-pore forming mutant (PdB), induced substantial increase in cardiac troponins to suggest that the pore-forming activity of circulating PLY is essential for myocardial injury in vivo. Purified PLY and PLY-expressing pneumococci also caused myocardial inflammatory changes but apoptosis was not detected. Exposure of cultured cardiomyocytes to PLY-expressing pneumococci caused dose-dependent cardiomyocyte contractile dysfunction and death, which was exacerbated by further PLY release following antibiotic treatment. We found that high PLY doses induced extensive cardiomyocyte lysis, but more interestingly, sub-lytic PLY concentrations triggered profound calcium influx and overload with subsequent membrane depolarization and progressive reduction in intracellular calcium transient amplitude, a key determinant of contractile force. This was coupled to activation of signalling pathways commonly associated with cardiac dysfunction in clinical and experimental sepsis and ultimately resulted in depressed cardiomyocyte contractile performance along with rhythm disturbance. Our study proposes a detailed molecular mechanism of pneumococcal toxin-induced cardiac injury and highlights the major translational potential of targeting circulating PLY to protect against cardiac complications during pneumococcal infections.
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Affiliation(s)
- Yasir Alhamdi
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Daniel R. Neill
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Simon T. Abrams
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Hesham A. Malak
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Reham Yahya
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Richard Barrett-Jolley
- Department of Musculoskeletal Biology, Institute of Aging and Chronic Diseases, University of Liverpool, Liverpool, United Kingdom
| | - Guozheng Wang
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Aras Kadioglu
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Cheng-Hock Toh
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Roald Dahl Haemostasis & Thrombosis Centre, Royal Liverpool University Hospital, Liverpool, United Kingdom
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Mejer N, Gotland N, Uhre ML, Westh H, Schønheyder HC, Petersen A, Jensen AG, Larsen AR, Skov R, Benfield T. Increased risk of arterial thromboembolic events after Staphylococcus aureus bacteremia: A matched cohort study. J Infect 2015; 71:167-78. [PMID: 25936743 DOI: 10.1016/j.jinf.2015.03.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 03/04/2015] [Accepted: 03/18/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVES An association between infection and arterial thromboembolic events (ATE) has been suggested. Here we examined the risk of myocardial infarction (MI), stroke and other ATE after Staphylococcus aureus bacteremia (SAB). METHODS Danish register-based nation-wide observational cohort study between 1995 and 2008 with matched control subjects from the general population. RESULTS Within a year, 278 of 15,669 SAB patients and 2570 of 156,690 controls developed MI, stroke or another ATE. The incidence rates among SAB patients were highest within the first 30 days and decreased over a year. The adjusted relative risk of MI, stroke and other ATE during the first 30 days after SAB in patients compared to controls were 2.2 (95% CI: 1.6-3.1), 5.5 (95% CI: 3.8-8.3) and 15.5 (95% CI: 6.9-35), respectively. Compared to controls, the increased adjusted relative risk persisted for 30 days for MI, 180 days for stroke and one year for other ATE. Increasing age, hypertension, atrial flutter/fibrillation, prior ATE and endocarditis in SAB patients were associated with an increased risk of ATE. CONCLUSIONS SAB was associated with a short-term increased risk of ATE that persisted longer dependent on type of event. Studies are warranted to investigate treatment strategies to diminish ATE after SAB.
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Affiliation(s)
- N Mejer
- Department of Infectious Diseases, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark.
| | - N Gotland
- Department of Infectious Diseases, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - M L Uhre
- Department of Infectious Diseases, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - H Westh
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Microbiology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - H C Schønheyder
- Department of Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - A Petersen
- Staphylococcus Laboratory, Statens Serum Institut, Copenhagen, Denmark
| | - A G Jensen
- Staphylococcus Laboratory, Statens Serum Institut, Copenhagen, Denmark; Bristol-Myers Squibb, Virum, Denmark
| | - A R Larsen
- Staphylococcus Laboratory, Statens Serum Institut, Copenhagen, Denmark
| | - R Skov
- Staphylococcus Laboratory, Statens Serum Institut, Copenhagen, Denmark
| | - T Benfield
- Department of Infectious Diseases, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Clinical Research Centre, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
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Brown AO, Orihuela CJ. Visualization of Streptococcus pneumoniae within Cardiac Microlesions and Subsequent Cardiac Remodeling. J Vis Exp 2015:52590. [PMID: 25939051 PMCID: PMC4541479 DOI: 10.3791/52590] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
During bacteremia Streptococcus pneumoniae can translocate across the vascular endothelium into the myocardium and form discrete bacteria-filled microscopic lesions (microlesions) that are remarkable due to the absence of infiltrating immune cells. Due to their release of cardiotoxic products, S. pneumoniae within microlesions are thought to contribute to the heart failure that is frequently observed during fulminate invasive pneumococcal disease in adults. Herein is demonstrated a protocol for experimental mouse infection that leads to reproducible cardiac microlesion formation within 30 hr. Instruction is provided on microlesion identification in hematoxylin & eosin stained heart sections and the morphological distinctions between early and late microlesions are highlighted. Instruction is provided on a protocol for verification of S. pneumoniae within microlesions using antibodies against pneumococcal capsular polysaccharide and immunofluorescent microscopy. Last, a protocol for antibiotic intervention that rescues infected mice and for the detection and assessment of scar formation in the hearts of convalescent mice is provided. Together, these protocols will facilitate the investigation of the molecular mechanisms underlying pneumococcal cardiac invasion, cardiomyocyte death, cardiac remodeling as a result of exposure to S. pneumoniae, and the immune response to the pneumococci in the heart.
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Affiliation(s)
- Armand O Brown
- Department of Microbiology and Immunology, The University of Texas Health Science Center at San Antonio
| | - Carlos J Orihuela
- Department of Microbiology and Immunology, The University of Texas Health Science Center at San Antonio;
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241
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Lee YJ, Lee H, Park JS, Kim SJ, Cho YJ, Yoon HI, Lee JH, Lee CT, Park JS. Cardiac troponin I as a prognostic factor in critically ill pneumonia patients in the absence of acute coronary syndrome. J Crit Care 2015; 30:390-4. [DOI: 10.1016/j.jcrc.2014.12.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 11/30/2014] [Accepted: 12/01/2014] [Indexed: 11/27/2022]
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Abstract
PURPOSE OF REVIEW The aim is to evaluate basic mechanisms, prevalence, risk factors, outcomes, and potential treatments of cardiovascular events (CVEs) in patients with community-acquired pneumonia (CAP). RECENT FINDINGS In this review, we present a new model to evaluate the pathophysiology of cardiac disease in patients with pneumonia based on plaque-related events, such as acute myocardial infarction, versus plaque-unrelated events, such as arrhythmias and heart failure. CAP increases the risk for both plaque-related and plaque-unrelated events with an absolute rate of CVE across different cohorts that varies broadly from 10 to 30%. These complications may happen among both ambulatory patients and inpatients, either on admission or during hospitalization, and/or after discharge. CVEs represent a major cause for increased mortality in CAP patients, contributing to more than 30% of deaths at long-term follow-up. SUMMARY From a clinical perspective, especially during the first 24 h after hospitalization, CAP patients should be tested for the probability to have or develop during hospitalization a cardiac event. From a research point of view, there is an urgent need to prospectively evaluate cardioprotective interventions.
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244
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Liapikou A, Rosales-Mayor E, Torres A. The management of severe community acquired pneumonia in the intensive care unit. Expert Rev Respir Med 2015; 8:293-303. [PMID: 24838089 DOI: 10.1586/17476348.2014.896202] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Severe CAP (SCAP), accounting for 6% of admissions to intensive care units (ICUs) needs early diagnosis and aggressive interventions at the most proximal point of disease presentation. The prognostic scores as the ATS/IDSA rule, the systolic blood pressure, multilobar infiltrates, albumin, respiratory rate, tachycardia, confusion, oxygen and pH or SCAP system are appropriate in early identification of eligible patients requiring admission to ICU. Then the recommended initial resuscitation in SCAP in the ICU consists of fluid volume intake titrated to specific goals after a fluid challenge and hemodynamic optimization. The first selection of antimicrobial therapy should be started in the first hour and would be broad enough to cover all likely pathogens. Combination therapy may be useful in patients with non refractory septic shock and severe sepsis pneumococcal bacteremia as well. After 6 hours the patient would be reevaluated in terms of hemodynamic stability and antibiotic and therapy. Future developments will focus on sepsis biomarkers, molecular diagnostic techniques and the development of novel therapeutic immunomodulaty agents.
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Affiliation(s)
- Adamantia Liapikou
- 6th Respiratory Department, Sotiria Hospital, Mesogion 152, 11527, Athens, Greece
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245
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Welte T. Managing CAP patients at risk of clinical failure. Respir Med 2015; 109:157-69. [DOI: 10.1016/j.rmed.2014.10.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 10/07/2014] [Accepted: 10/27/2014] [Indexed: 12/11/2022]
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Falcone M, Russo A, Cangemi R, Farcomeni A, Calvieri C, Barillà F, Scarpellini MG, Bertazzoni G, Palange P, Taliani G, Venditti M, Violi F. Lower mortality rate in elderly patients with community-onset pneumonia on treatment with aspirin. J Am Heart Assoc 2015; 4:e001595. [PMID: 25564372 PMCID: PMC4330080 DOI: 10.1161/jaha.114.001595] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Pneumonia is complicated by high rate of mortality and cardiovascular events (CVEs). The potential benefit of aspirin, which lowers platelet aggregation by inhibition of thromboxane A2 production, is still unclear. The aim of the study was to assess the impact of aspirin on mortality in patients with pneumonia. METHODS AND RESULTS Consecutive patients admitted to the University-Hospital Policlinico Umberto I (Rome, Italy) with community-onset pneumonia were recruited and prospectively followed up until discharge or death. The primary end point was the occurrence of death up to 30 days after admission; the secondary end point was the intrahospital incidence of nonfatal myocardial infarction and ischemic stroke. One thousand and five patients (age, 74.7±15.1 years) were included in the study: 390 were receiving aspirin (100 mg/day) at the time of hospitalization, whereas 615 patients were aspirin free. During the follow-up, 16.2% of patients died; among these, 19 (4.9%) were aspirin users and 144 (23.4%; P<0.001) were aspirin nonusers. Overall, nonfatal CVEs occurred in 7% of patients, 8.3% in nonaspirin users, and 4.9% in aspirin users (odds ratio, 1.77; 95% confidence interval, 1.03 to 3.04; P=0.040). The Cox regression analysis showed that pneumonia severity index (PSI), severe sepsis, pleural effusion, and PaO(2)/FiO(2) ratio <300 negatively influenced survival, whereas aspirin therapy was associated with improved survival. Compared to patients receiving aspirin, the propensity score adjusted analysis confirmed that patients not taking aspirin had a hazard ratio of 2.07 (1.08 to 3.98; P=0.029) for total mortality. CONCLUSIONS This study shows that chronic aspirin use is associated with lower mortality rate within 30 days after hospital admission in a large cohort of patients with pneumonia.
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Affiliation(s)
- Marco Falcone
- Department of Public Health and Infectious Diseases, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy (M.F., A.R., A.F., P.P., M.V.)
| | - Alessandro Russo
- Department of Public Health and Infectious Diseases, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy (M.F., A.R., A.F., P.P., M.V.)
| | - Roberto Cangemi
- Department of Internal Medicine and Medical Specialties, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy (R.C., C.C., F.B., F.V.)
| | - Alessio Farcomeni
- Department of Public Health and Infectious Diseases, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy (M.F., A.R., A.F., P.P., M.V.)
| | - Camilla Calvieri
- Department of Internal Medicine and Medical Specialties, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy (R.C., C.C., F.B., F.V.)
| | - Francesco Barillà
- Department of Internal Medicine and Medical Specialties, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy (R.C., C.C., F.B., F.V.)
| | - Maria Gabriella Scarpellini
- Department of Emergency Medicine, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy (M.G.S., G.B.)
| | - Giuliano Bertazzoni
- Department of Emergency Medicine, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy (M.G.S., G.B.)
| | - Paolo Palange
- Department of Public Health and Infectious Diseases, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy (M.F., A.R., A.F., P.P., M.V.)
| | - Gloria Taliani
- Department of Clinical Medicine, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy (G.T.)
| | - Mario Venditti
- Department of Public Health and Infectious Diseases, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy (M.F., A.R., A.F., P.P., M.V.)
| | - Francesco Violi
- Department of Internal Medicine and Medical Specialties, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy (R.C., C.C., F.B., F.V.)
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Rajas O, Ortega-Gómez M, Galván Román JM, Curbelo J, Fernández Jiménez G, Vega Piris L, Rodríguez Salvanes F, Arnalich B, Luquero Bueno S, Díaz López A, de la Fuente H, Suárez C, Ancochea J, Aspa J. The incidence of cardiovascular events after hospitalization due to CAP and their association with different inflammatory markers. BMC Pulm Med 2014; 14:197. [PMID: 25495677 PMCID: PMC4320510 DOI: 10.1186/1471-2466-14-197] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 12/04/2014] [Indexed: 01/13/2023] Open
Abstract
Background Late prognosis of Community-Acquired Pneumonia (CAP) patients is related to cardiovascular events. Persistence of inflammation-related markers, defined by high circulatory levels of interleukin 6 and 10 (IL-6/IL-10), is associated with a higher post-event mortality rate for CAP patients. However, association between these markers and other components of the immune response, and the risk of cardiovascular events, has not been adequately explored. The main objectives of this study are: 1) to quantify the incidence of cardiovascular disease, in the year post-dating their hospital admittance due to CAP and, 2) to describe the distribution patterns of a wide spectrum of inflammatory markers upon admittance to and release from hospital, and to determine their relationship with the incidence of cardiovascular disease. Methods/design A cohort prospective study. All patients diagnosed and hospitalized with CAP will be candidates for inclusion. The study will take place in the Universitary Hospital La Princesa, Spain, during two years. Two samples of blood will be taken from each patient: the first upon admittance and the second one prior to release, in order to analyse various immune agents. The main determinants are: pro-adrenomedullin, copeptin, IL-1, IL-6, TNF-α, IL-17, IFN-γ, IL-10 and TGF-β, E-Selectin, ICAM-1, VCAM-1 and subpopulations of peripheral T lymphocytes (T regulator, Th1 and Th17), together with other clinical and analytical variables. Follow up will start at admittance and finish a year after discharge, registering incidence of death and cardiovascular events. The main objective is to establish the predictive power of different inflammatory markers in the prognosis of CAP, in the short and long term, and their relationship with cardiovascular disease. Discussion The level of some inflammatory markers (IL-6/IL-10) has been proposed as a means to differentiate the degree of severity of CAP, but their association with cardiovascular risk is not well established. In this study we aim to define new inflammatory markers associated with cardiovascular disease that could be helpful for the prognosis of CAP patients, by describing the distribution of a wide spectrum of inflammatory mediators and analyzing their association with the incidence of cardiovascular disease and mortality one year after release from hospital.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Javier Aspa
- Servicio de Neumología, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Hospital Universitario de la Princesa, IP, Madrid, España.
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Schoepf D, Heun R. Bipolar disorder and comorbidity: increased prevalence and increased relevance of comorbidity for hospital-based mortality during a 12.5-year observation period in general hospital admissions. J Affect Disord 2014; 169:170-8. [PMID: 25194786 DOI: 10.1016/j.jad.2014.08.025] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 07/26/2014] [Accepted: 08/06/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Bipolar disorder (BD) is associated with an increase of psychiatric and physical comorbidities, but the effects of these disorders on general hospital-based mortality are unclear. Consequently, we investigated whether the burden of comorbidity and its relevance on hospital-based mortality differed between individuals with and without BD during a 12.5-year observation period in general hospital admissions. METHODS During 1 January 2000 and 30 June 2012, 621 individuals with BD were admitted to three General Manchester Hospitals. All comorbidities with a prevalence ≥1% were compared with those of 6210 randomly selected and group-matched hospital controls of the same age and gender, regardless of priority of diagnoses. Comorbidities that increased the risk for hospital-based mortality (but not mortality outside of the hospitals) were identified using multivariate logistic regression analyses. RESULTS Individuals with BD had a more severe course of disease than controls that was associated with a higher total number of in-hospital deaths. Individuals with BD compared to controls had a substantial higher burden of comorbidities, the most frequent comorbidities included asthma, type-2 diabetes mellitus (T2DM), and alcohol dependence. 18 other diseases with a surplus of diabetes related complications were also increased. Fourteen comorbidities contributed to the prediction of hospital-based mortality in univariate analyses. Risk factors for hospital-based mortality in multivariate analyses were ischemic stroke, pneumonia, bronchitis, chronic obstructive pulmonary disease, T2DM, and hypertension. The impact of T2DM on hospital-based mortality was higher in individuals with BD than in controls. LIMITATIONS The study design was not assigned to assess the type of BD, the current bipolar status, and if individuals with BD were treated with medication. It was neither possible to compare drug effects, nor to compare the adherence to treatment between samples. CONCLUSION In one of the largest samples of individuals with BD in general hospitals, the excess comorbity in individuals with BD compared to controls is in particular caused by asthma and T2DM. T2DM and its complications cause significant excess hospital-based mortality in individuals with BD.
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Affiliation(s)
- Dieter Schoepf
- Department of Psychiatry, University of Bonn, D-53105 Bonn, Germany.
| | - Reinhard Heun
- Department of Psychiatry, University of Bonn, D-53105 Bonn, Germany; Department of Psychiatry, Radbourne Unit Royal Derby Hospital, Uttoxeter Road, Derby, United Kingdom
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Gamst J, Christiansen CF, Rasmussen BS, Rasmussen LH, Thomsen RW. Pre-existing atrial fibrillation and risk of arterial thromboembolism and death following pneumonia: a population-based cohort study. BMJ Open 2014; 4:e006486. [PMID: 25398678 PMCID: PMC4244399 DOI: 10.1136/bmjopen-2014-006486] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES To examine the effect of pre-existing atrial fibrillation (AF) and associated therapy on the risk of arterial thromboembolism (ATE) and death following pneumonia. DESIGN, SETTING AND PARTICIPANTS Population-based cohort study (1997-2012) of 88,315 patients with first-time hospitalisation with pneumonia in Northern Denmark. RESULTS Of the included patients (median age 73.4 years), 8880 (10.1%) had pre-existing AF. The risk of ATE within 30 days of admission was 5.2% in patients with AF and 3.6% in patients without AF. After adjustment for higher age and comorbidity, the adjusted HR (aHR) with AF was 1.06 (95% CI 0.96 to 1.18). Among patients with AF, reduced risk of ATE was observed in vitamin-K antagonist users compared with non-users (aHR 0.74 (95% CI 0.61 to 0.91)). Thirty-day mortality was 20.1% in patients with AF and 13.9% in patients without AF. Corresponding 1-year mortalities were 43.7% and 30.3%. The aHRs for 30-day and 1-year mortality with AF were 1.00 (95% CI 0.94 to 1.05) and 1.01 (95% CI 0.98 to 1.05). In patients with AF, reduced mortality risk was observed in users of vitamin-K antagonists (aHR 0.70 (95% CI 0.63 to 0.77)) and β-blockers (aHR 0.77 (95% CI 0.70 to 0.85). Increased mortality was found in digoxin users (aHR 1.16 (95% CI 1.06 to 1.28)). CONCLUSIONS Pre-existing AF is frequent in patients hospitalised with pneumonia and a marker of increased risk of ATE and death, explained by higher patient age and comorbidity. Prognosis is closely related to preadmission medical treatment for AF.
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Affiliation(s)
- Jacob Gamst
- Department of Clinical Epidemiology, Institute of Clinical Medicine, Aarhus University Hospital, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Anaesthesia and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Atrial Fibrillation Study Group, Aalborg, Denmark
| | - Christian Fynbo Christiansen
- Department of Clinical Epidemiology, Institute of Clinical Medicine, Aarhus University Hospital, Aalborg, Denmark
| | - Bodil Steen Rasmussen
- Department of Anaesthesia and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Lars Hvilsted Rasmussen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Atrial Fibrillation Study Group, Aalborg, Denmark
| | - Reimar Wernich Thomsen
- Department of Clinical Epidemiology, Institute of Clinical Medicine, Aarhus University Hospital, Aalborg, Denmark
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Cangemi R, Casciaro M, Rossi E, Calvieri C, Bucci T, Calabrese CM, Taliani G, Falcone M, Palange P, Bertazzoni G, Farcomeni A, Grieco S, Pignatelli P, Violi F. Platelet activation is associated with myocardial infarction in patients with pneumonia. J Am Coll Cardiol 2014; 64:1917-25. [PMID: 25444147 DOI: 10.1016/j.jacc.2014.07.985] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 06/17/2014] [Accepted: 07/08/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Troponins may be elevated in patients with pneumonia, but associations with myocardial infarction (MI) and with platelet activation are still undefined. OBJECTIVES The aim of this study was to investigate the relationship between troponin elevation and in vivo markers of platelet activation in the early phase of hospitalization of patients affected by community-acquired pneumonia. METHODS A total of 278 consecutive patients hospitalized for community-acquired pneumonia, who were followed up until discharge, were included. At admission, platelet activation markers such as plasma soluble P-selectin, soluble CD40 ligand, and serum thromboxane B2 (TxB2) were measured. Serum high-sensitivity cardiac troponin T levels and electrocardiograms were obtained every 12 and 24 h, respectively. RESULTS Among 144 patients with elevated high-sensitivity cardiac troponin T, 31 had signs of MI and 113 did not. Baseline plasma levels of soluble P-selectin and soluble CD40 ligand and serum TxB2 were significantly higher in patients who developed signs of MI. Logistic regression analysis showed plasma soluble CD40 ligand (p < 0.001) and soluble P-selectin (p < 0.001), serum TxB2 (p = 0.030), mean platelet volume (p = 0.037), Pneumonia Severity Index score (p = 0.030), and ejection fraction (p = 0.001) to be independent predictors of MI. There were no significant differences in MI rate between the 123 patients (45%) taking aspirin (100 mg/day) and those who were not aspirin treated (12% vs. 10%; p = 0.649). Aspirin-treated patients with MIs had higher serum TxB2 compared with those without MIs (p = 0.005). CONCLUSIONS MI is an early complication of pneumonia and is associated with in vivo platelet activation and serum TxB2 overproduction; aspirin 100 mg/day seems insufficient to inhibit thromboxane biosynthesis. (MACCE in Hospitalized Patients With Community-acquired Pneumonia; NCT01773863).
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Affiliation(s)
| | - Marco Casciaro
- I Clinica Medica, Sapienza University of Rome, Rome, Italy
| | | | - Camilla Calvieri
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Tommaso Bucci
- I Clinica Medica, Sapienza University of Rome, Rome, Italy
| | | | - Gloria Taliani
- Infectious and Tropical Diseases Unit, Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Marco Falcone
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Paolo Palange
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Giuliano Bertazzoni
- UOC Emergency Medicine, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Alessio Farcomeni
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Stefania Grieco
- Infectious and Tropical Diseases Unit, Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
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