Assessment of the charlson comorbidity index score, CHADS2 and CHA2DS2-VASc scores in predicting death in patients with thoracic empyema

Expert Review on Nonsurgical Management of Parapneumonic Effusion: Advances, Controversies, and New Directions

Parapneumonic effusion and empyema are rising in incidence worldwide, particularly in association with comorbidities in an aging population. Also driving this change is the widespread uptake of pneumococcal vaccines, leading to the emergence of nonvaccine-type pneumococci and other bacteria. Early treatment with systemic antibiotics is essential but should be guided by local microbial guidelines and antimicrobial resistance patterns due to significant geographical variation. Thoracic ultrasound has emerged as a leading imaging technique in parapneumonic effusion, enabling physicians to characterize effusions, assess the underlying parenchyma, and safely guide pleural procedures. Drainage decisions remain based on longstanding criteria including the size of the effusion and fluid gram stain and biochemistry results. Small-bore chest drains appear to be as effective as large bore and are adequate for the delivery of intrapleural enzyme therapy (IET), which is now supported by a large body of evidence. The IET dosing regimen used in the UK Multicenter Sepsis Trial -2 has the most evidence available but data surrounding alternative dosing, concurrent and once-daily instillations, and novel fibrinolytic agents are promising. Prognostic scores used in pneumonia (e.g., CURB-65) tend to underestimate mortality in parapneumonic effusion/empyema. Scores specifically based on pleural infection have been developed but require validation in prospective cohorts.

ERS/ESTS statement on the management of pleural infection in adults

Pleural infection is a common condition encountered by respiratory physicians and thoracic surgeons alike. The European Respiratory Society (ERS) and European Society of Thoracic Surgeons (ESTS) established a multidisciplinary collaboration of clinicians with expertise in managing pleural infection with the aim of producing a comprehensive review of the scientific literature. Six areas of interest were identified: 1) epidemiology of pleural infection, 2) optimal antibiotic strategy, 3) diagnostic parameters for chest tube drainage, 4) status of intrapleural therapies, 5) role of surgery and 6) current place of outcome prediction in management. The literature revealed that recently updated epidemiological data continue to show an overall upwards trend in incidence, but there is an urgent need for a more comprehensive characterisation of the burden of pleural infection in specific populations such as immunocompromised hosts. There is a sparsity of regular analyses and documentation of microbiological patterns at a local level to inform geographical variation, and ongoing research efforts are needed to improve antibiotic stewardship. The evidence remains in favour of a small-bore chest tube optimally placed under image guidance as an appropriate initial intervention for most cases of pleural infection. With a growing body of data suggesting delays to treatment are key contributors to poor outcomes, this suggests that earlier consideration of combination intrapleural enzyme therapy (IET) with concurrent surgical consultation should remain a priority. Since publication of the MIST-2 study, there has been considerable data supporting safety and efficacy of IET, but further studies are needed to optimise dosing using individualised biomarkers of treatment failure. Pending further prospective evaluation, the MIST-2 regimen remains the most evidence based. Several studies have externally validated the RAPID score, but it requires incorporating into prospective intervention studies prior to adopting into clinical practice.

Effects of age and gender on body composition indices as predictors of mortality in middle-aged and old people

To determine whether body composition indices interact with age and gender as a predictor of all-cause mortality, 1200 participants at least 40 years of age were recruited in 2009 and 2010. A multi-frequency bioelectrical impedance analysis device was used to measure each participant's body composition indices, including the fat mass index (FMI), fat free mass index (FFMI), skeletal muscle mass index (SMMI), and visceral fat area index (VFAI). A baseline questionnaire was used to collect demographic information about lifestyle habits, socioeconomic status, and medical conditions. All claimed records of death from 2009 to 2018 in the National Health Insurance Research Databank were identified. The all-cause mortality rate was 8.67% after a mean follow-up period of 5.86 ± 2.39 person-years. The Cox proportional hazard model analysis showed significantly negative associations between FFMI or SMMI with all-cause mortality in the total group and those aged ≥ 65 y/o. The FFMI and SMMI were negative predictors of mortality in both genders. The FMI and VFAI were positive predictors of mortality exclusively in females. In conclusion, the SMMI is a better predictor of mortality than the BMI, FMI, and FFMI, especially in older adults. A higher fat mass or visceral fat distribution may predict higher mortality in females.

Association of Mortality and Charlson Comorbidity Index in Surgical Spinal Trauma Patients at a Level I Academic Center

OBJECTIVES

The Charlson Comorbidity Index score (CCI) records the presence of comorbidities with various weights for a total score to estimate mortality within 1 year of hospital admission. Our study sought to assess the association of CCI with mortality rates of patients undergoing surgical intervention.

STUDY DESIGN

Retrospective study.

METHODS

Retrospective study of patients with surgical spinal trauma at a large academic level I trauma tertiary center from 2015 to 2018. Information collected included age, sex, American Society of Anesthesiologists physical status, body mass index, Charlson comorbidities, injury severity score, the presence of spinal cord injury, and mortality. Mortality was measured at 30 days, 90 days, and 1 year. Descriptive and bivariate analyses were completed. The results were significant at P < 0.05.

RESULTS

The highest proportion of 1-year mortality was in the patients with cervical (11.3%) and thoracolumbar injuries (7.4%) (P = 0.002). Patients with low CCI had low 1-year mortality (1.7%). Patients with high CCI had high 1-year mortality (13.8%) (P < 0.001). A significant association existed between CCI and mortality at 30 days, 90 days, and 1 year (P < 0.001). Mortality was higher in patients with spinal cord injury (14/108; 13%) than in those without (11/232; 5%) (P = 0.021). No association existed between ISS and mortality (P = 0.26).

DISCUSSION

The CCI was associated with a higher proportion of deaths at 30 days, 90 days, and 1 year. This association may help predict this unfortunate complication and guide the surgical team in formulating treatment plans and counseling patients and families regarding mortality associated with these injuries and the risks of surgical intervention.

Recent Insights into the Management of Pleural Infection

Pleural infection in adults has considerable morbidity and continues to be a life-threatening condition. The term “pleural infection” encompasses complicated parapneumonic effusions and primary pleural infections, and includes but is not limited to empyema, which refers to collection of pus in the pleural cavity. The incidence of pleural infection in adults has been continuously increasing over the past two decades, particularly in older adults, and most of such patients have comorbidities. Management of pleural infection requires prolonged duration of hospitalization (average 14 days). There are recognized differences in microbial etiology of pleural infection depending on whether the infection was acquired in the community or in a health-care setting. Anaerobic bacteria are acknowledged as a major cause of pleural infection, and thus anaerobic coverage in antibiotic regimens for pleural infection is mandatory. The key components of managing pleural infection are appropriate antimicrobial therapy and chest-tube drainage. In patients who fail medical therapy by manifesting persistent sepsis despite standard measures, surgical intervention to clear the infected space or intrapleural fibrinolytic therapy (in poor surgical candidates) are recommended. Recent studies have explored the role of early intrapleural fibrinolytics or first-line surgery, but due to considerable costs of such interventions and the lack of convincing evidence of improved outcomes with early use, early intervention cannot be recommended, and further evidence is awaited from ongoing studies. Other areas of research include the role of routine molecular testing of infected pleural fluid in improving the rate of identification of causative organisms. Other research topics include the benefit of such interventions as medical thoracoscopy, high-volume pleural irrigation with saline/antiseptic solution, and repeated thoracentesis (as opposed to chest-tube drainage) in reducing morbidity and improving outcomes of pleural infection. This review summarizes current knowledge and practice in managing pleural infection and future research directions.

Comparison of Measures to Predict Mortality and Length of Stay in Hospitalized Patients

BACKGROUND

Patient risk adjustment is critical for hospital benchmarking and allocation of healthcare resources. However, considerable heterogeneity exists among measures.

OBJECTIVES

The performance of five measures was compared to predict mortality and length of stay (LOS) in hospitalized adults using claims data; these include three comorbidity composite scores (Charlson/Deyo age-comorbidity score, V W Elixhauser comorbidity score, and V W Elixhauser age-comorbidity score), 3 M risk of mortality (3 M ROM), and 3 M severity of illness (3 M SOI) subclasses.

METHODS

Binary logistic and zero-truncated negative binomial regression models were applied to a 2-year retrospective dataset (2013-2014) with 123,641 adult inpatient admissions from a large hospital system in New York City.

RESULTS

All five measures demonstrated good to strong model fit for predicting in-hospital mortality, with C-statistics of 0.74 (95% confidence interval [CI] [0.74, 0.75]), 0.80 (95% CI [0.80, 0.81]), 0.81(95% CI [0.81, 0.82]), 0.94 (95% CI [0.93, 0.94]), and 0.90 (95% CI [0.90, 0.91]) for Charlson/Deyo age-comorbidity score, V W Elixhauser comorbidity score, V W Elixhauser age-comorbidity score, 3 M ROM, and 3 M SOI, respectively. The model fit statistics to predict hospital LOS measured by the likelihood ratio index were 0.3%, 1.2%, 1.1%, 6.2%, and 4.3%, respectively.

DISCUSSION

The measures tested in this study can guide nurse managers in the assignment of nursing care and coordination of needed patient services and administrators to effectively and efficiently support optimal nursing care.