Modifiable risk factors for pneumonia requiring hospitalization of community-dwelling older adults: the Health, Aging, and Body Composition Study

Role of lifestyle factors on the development and long-term prognosis of pneumonia and cardiovascular disease in the Chinese population

BACKGROUND

Whether adherence to a healthy lifestyle is associated with a lower risk of developing pneumonia and a better long-term prognosis remains unclear. This study aimed to investigate associations of individual and combined lifestyle factors (LFs) with the incidence risk and long-term prognosis of pneumonia hospitalization.

METHODS

Using data from the China Kadoorie Biobank study, we used the multistate models to investigate the role of five high-risk LFs, including smoking, excessive alcohol drinking, unhealthy dietary habits, physical inactivity, and unhealthy body shape, alone or in combination in the transitions from a generally healthy state at baseline to pneumonia hospitalization or cardiovascular disease (CVD, regarded as a reference outcome), and subsequently to mortality.

RESULTS

Most of the five high-risk LFs were associated with increased risks of transitions from baseline to pneumonia and from pneumonia to death, but with different risk estimates. The greater the number of high-risk LFs, the higher the risk of developing pneumonia and long-term mortality risk after pneumonia, with the strength of associations comparable to that of LFs and CVD. Compared to participants with 0-1 high-risk LF, the adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for transitions from baseline to pneumonia and from pneumonia to death in those with five high-risk LFs were 1.43 (1.28-1.60) and 1.98 (1.61-2.42), respectively. Correspondingly, the respective HRs (95% CIs) for transitions from baseline to CVD and from CVD to death were 2.00 (1.89-2.11) and 1.44 (1.30-1.59), respectively. The risk estimates changed slightly when further adjusting for the presence of major chronic diseases.

CONCLUSION

In this Chinese population, unhealthy LFs were associated with an increased incidence and long-term mortality risk of pneumonia.

Association between timed up-and-go test and subsequent pneumonia: A cohort study

BACKGROUND

Sarcopenia is a risk factor for pneumonia in the elderly, and the timed up-and-go test (TUG) can be used as a screening tool for sarcopenia in this population. This study aimed to evaluate the association between TUG test results and future pneumonia or ventilator care.

MATERIALS AND METHODS

From the National Health Insurance Service-Senior Cohort database, we identified 19,804 people without neurological diseases who underwent the TUG test in the National Screening Program for Transitional Ages at the age of 66 years during 2007-2008. Gait abnormality was defined as taking 10 s or longer to perform the TUG test. Pneumonia occurrence was defined using the International Classification of Diseases 10th Revision (ICD-10) code for pneumonia (J12-J18, J69), and ventilator care was defined by procedure codes (M5830, M5850, M5867, M5858, M5860, M5859) according to the Healthcare Common Procedure Coding system codes from 2007 to 2015.

RESULTS

The mean follow-up period was 7.4 years (standard error, SE 0.02). The incidence rates of pneumonia in the normal and slow TUG groups were 38 and 39.5/1000 person-years, respectively. The slow TUG group did not show a higher risk of pneumonia (adjusted hazard ratio [aHR], 1.042; 95% confidence interval [95% CI], 0.988-1.107]). Regarding ventilator care, the incidence was 4.7 and 5.2 cases per 1,000 person-years in the normal and slow TUG groups, respectively. Slow TUG groups also did not show an increased risk of ventilator occurrence (aHR, 1.136, [95% CI = 0.947-1.363]).

CONCLUSION

The TUG test result was not associated with future pneumonia or ventilator care and may not be useful for predicting pneumonia in community-dwelling elderly individuals. Further studies are needed to identify additional functional tools for sarcopenia associated with future pneumonia occurrences.

Assessing the contributions of modifiable risk factors to serious falls and fragility fractures among older persons living with HIV

BACKGROUND

Although 50 years represents middle age among uninfected individuals, studies have shown that persons living with HIV (PWH) begin to demonstrate elevated risk for serious falls and fragility fractures in the sixth decade; the proportions of these outcomes attributable to modifiable factors are unknown.

METHODS

We analyzed 21,041 older PWH on antiretroviral therapy (ART) from the Veterans Aging Cohort Study from 01/01/2010 through 09/30/2015. Serious falls were identified by Ecodes and a machine-learning algorithm applied to radiology reports. Fragility fractures (hip, vertebral, and upper arm) were identified using ICD9 codes. Predictors for both models included a serious fall within the past 12 months, body mass index, physiologic frailty (VACS Index 2.0), illicit substance and alcohol use disorders, and measures of multimorbidity and polypharmacy. We separately fit multivariable logistic models to each outcome using generalized estimating equations. From these models, the longitudinal extensions of average attributable fraction (LE-AAF) for modifiable risk factors were estimated.

RESULTS

Key risk factors for both outcomes included physiologic frailty (VACS Index 2.0) (serious falls [15%; 95% CI 14%-15%]; fractures [13%; 95% CI 12%-14%]), a serious fall in the past year (serious falls [7%; 95% CI 7%-7%]; fractures [5%; 95% CI 4%-5%]), polypharmacy (serious falls [5%; 95% CI 4%-5%]; fractures [5%; 95% CI 4%-5%]), an opioid prescription in the past month (serious falls [7%; 95% CI 6%-7%]; fractures [9%; 95% CI 8%-9%]), and diagnosis of alcohol use disorder (serious falls [4%; 95% CI 4%-5%]; fractures [8%; 95% CI 7%-8%]).

CONCLUSIONS

This study confirms the contributions of risk factors important in the general population to both serious falls and fragility fractures among older PWH. Successful prevention programs for these outcomes should build on existing prevention efforts while including risk factors specific to PWH.

Associated Factors of Pneumonia in Individuals with Chronic Obstructive Pulmonary Disease (COPD) Apart from the Use of Inhaled Corticosteroids

Inhaled corticosteroids (ICSs) are widely used in chronic obstructive pulmonary disease (COPD) and in combination with long-acting β2 agonists (LABAs) to reduce exacerbations and improve patient lung function and quality of life. However, ICSs have been associated with an increased risk of pneumonia in individuals with COPD, although the magnitude of this risk remains unclear. Therefore, it is difficult to make informed clinical decisions that balance the benefits and adverse effects of ICSs in people with COPD. There may be other causes of pneumonia in patients with COPD, and these causes are not always considered in studies on the risks of using ICSs in COPD. We consider it very useful to clarify these aspects in assessing the influence of ICSs on the incidence of pneumonia and their role in the treatment of COPD. This issue has important implications for current practice and the evaluation and management of COPD, since COPD patients may benefit from specific ICS-based treatment strategies. Many of the potential causes of pneumonia in patients with COPD can act synergistically, so they can be included in more than one section.

Health promotion through structured oral hygiene and good tooth alignment

Aim

Periodontal diseases and caries are two of the most common forms of chronic degenerative diseases, with consequences not only for the oral cavity manifesting as tooth loss, orofacial pain and xerostomia, but also with effects on the cardiovascular system and, in the elderly, on the pneumonia rate. This can be prevented or controlled by structured oral hygiene.

Method

Based on a systematic literature search in PubMed, the possibilities for ensuring structured oral hygiene are analyzed.

Results and conclusion

Limiting the consumption of sugary meals and beverages, regular removal of food debris - supplemented by sugar-free chewing gum if desired - and preventing plaque formation by brushing with fluoridated toothpastes, using dental floss and interdental brushes after meals, serve to prevent or control gingivitis, periodontitis and caries. In the long term, the development of periodontitis-associated cardiovascular diseases and, in the elderly, the risk of pneumonia can probably be reduced. Antiseptic rinsing of the oral cavity is an important supplement to prevent periodontitis, especially in cases of limited ability to perform mechanical biofilm removal, but also for the prevention of respiratory infections. Proper functional tooth alignment is important for optimal mechanical cleaning to prevent plaque accumulation. If correction of misaligned teeth is possible with the use of removable aligners instead of fixed orthodontic appliances, these are to be preferred because of the better accessibility for mechanical hygiene measures.

Association between the mid-upper arm circumference (MUAC) and calf circumference (CC) screening indicators of sarcopenia with the risk of pneumonia in stable patients diagnosed with schizophrenia

AIM

Here, we investigate the relationship between mid-upper arm circumference (MUAC) and calf circumference (CC) screening indicators of sarcopenia and the risk of pneumonia in stable patients diagnosed with schizophrenia.

METHOD

The study is prospective and includes inpatients with schizophrenia from two mental health centers in Western China. The studied screening indicators, MUAC and CC were assessed in standing patients. The relationship between MUAC and CC as sarcopenia screening indicators with the risk of pneumonia in patients with schizophrenia was analyzed by performing a statistical logistic regression analysis.

RESULT

For this study, 339 patients with schizophrenia, aged 50 years and over were recruited. Moreover, four patients with pneumonia that occurred within 1 week of the relapse of schizophrenia were excluded. As a result, only 335 patients were included in the analysis. Pneumonia has been reported in 82 (24.5%) of all included patients with schizophrenia. Our data analysis confirmed that in the male patients, the higher CC was associated with a lower risk of pneumonia (odds ratio [OR] = 0.751, 95% CI: 0.635-0.889). We have divided men into two cohorts following the values of CC. Our analysis further showed that the patients with CC ≥ 34 cm had a lower risk of pneumonia in men (OR = 0.36, 95% CI: 0.163-0.795).

CONCLUSION

We demonstrate that CC is associated with pneumonia risk in stable men with schizophrenia.

Sex-Related Disparities in the Incidence and Outcomes of Community-Acquired Pneumonia among Type 2 Diabetes Patients: A Propensity Score-Matching Analysis Using the Spanish National Hospital Discharge Database for the Period 2016-2019

(1) Background: To analyze incidence, clinical characteristics, procedures, and in-hospital outcomes among patients hospitalized with community-acquired pneumonia (CAP) according to the presence of T2DM in Spain (2016-2019) and to assess the role of gender among those with T2DM. (2) Methods: Using the Spanish National Hospital Discharge Database, we estimated hospitalized CAP incidence. Propensity score matching was used to compare population subgroups. (3) Results: CAP was coded in 520,723 patients, of whom 140,410 (26.96%) had T2DM. The hospitalized CAP incidence was higher in patients with T2DM (both sexes) (IRR 4.25; 95% CI 4.23-4.28). The hospitalized CAP incidence was higher in men with T2DM than in women with T2DM (IRR 1.46; 95% CI 1.45-1.47). The hospitalized CAP incidence among T2DM patients increased over time; however, the in-hospital mortality (IHM) decreased between 2016 and 2019. IHM was higher among non-T2DM men and women than matched T2DM men and women (14.23% and 14.22% vs. 12.13% and 12.91%; all p < 0.001, respectively), After adjusting for confounders, men with T2DM had a 6% higher mortality risk than women (OR 1.06; 95% CI 1.02-1.1). (4) Conclusions: T2DM is associated with a higher hospitalized CAP incidence and is increasing overtime. Patients hospitalized with CAP and T2DM have lower IHM. Male sex is a significant risk factor for mortality after CAP among T2DM patients.

The effectiveness of the information-motivation-behavioral skills model-based intervention on preventive behaviors against respiratory infection among community-dwelling older adults

OBJECTIVE

To evaluate the effectiveness of an information-motivation-behavioral skills (IMB) model-based multi-component intervention on engagement and the quality of preventive behaviors against respiratory infections among community-dwelling older adults.

METHODS

This study was a controlled pretest-posttest study in which 91 community-dwelling older adults aged above 65 years were included. The intervention group (n = 42) received the six-week intervention theoretically based on the IMB model that comprised weekly group education and 5-10 min of tele-counseling per week.

RESULTS

The results showed that, after the intervention, the improvement in the level of knowledge, self-efficacy, self-reported engagement, and the quality of respiratory infection preventive behaviors was significantly greater in the intervention group compared to the control group. There was no significant difference between the two groups for the perceived threat of respiratory infection.

CONCLUSION

The IMB model-based intervention improved the engagement and quality of preventive behaviors by increasing the level of knowledge and self-efficacy in community-dwelling older adults.

PRACTICE IMPLICATIONS

The IMB model-based multi-component intervention can be an effective approach to improve preventive behaviors and will contribute to the preparation of communities for outbreaks of respiratory infections.

Effect of Community-Acquired Pneumonia on Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Community-acquired pneumonia (CAP) is a major contributor to hospitalization for acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The clinical manifestations of AECOPD with and without CAP are confusing. The difference in the survival or readmission rate of AECOPD with or without CAP remains controversial. A prospective cohort study was conducted to evaluate the clinical and laboratory characteristics and in-hospital outcomes of patients who were consecutively hospitalized due to AECOPD from May 2015 to December 2019. Grouping was based on chest computed tomography findings. Multivariable logistic regression was used to explore the predictors for early identification between CAP exacerbations and non-CAP exacerbations. Kaplan-Meier analysis was used to compare the cumulative survival rate and readmission rate for a 12-month follow-up between the two groups. A total of 378 patients with AECOPD were enrolled, including 200 patients with CAP and 178 patients without CAP. The presence of pleuritic pain, usage of ICS, and elevated levels of C-reactive protein and procalcitonin on admission were the predictors for the early discrimination between AECOPD with and without CAP. During a 1-year follow-up, the cumulative survival rate was lower in patients with AECOPD with CAP than in those with AECOPD without CAP (13.0% vs. 3.37%; HR: 4.099; 95% CI, 2.049-8.199; p < 0.001), but the readmission rate was similar in both groups. Patients with first-time exacerbation due to CAP were more likely to experience subsequent pneumonic exacerbation. CAP is frequent among patients hospitalized for AECOPD and associated with increased mortality and successive pneumonic exacerbation.

How Do Changes in Oral Health and Chewing Efficiency Affect the Changes of Oral-Health-Related Quality of Life of Nursing-Home Residents in the Short Term?

Objective

To evaluate how changes in oral health and chewing efficiency affect the changes in oral-health-related quality of life (OHRQoL) of nursing-home residents over six months.

Methods

The study was conducted in nine nursing homes. Sociodemographic and general data were collected for all eligible individuals (n = 150). Of these, 114 participants (mean age 82.0 [± 9.5] years, 77.2% women) were available for the following tests at baseline and six months later: a comprehensive examination of dental and general health, a two-colour mixing-ability test (to assess chewing efficiency), the Geriatric Oral Health Assessment Index (GOHAI; to evaluate the OHRQoL), and the Mini Mental State Examination (MMSE; to diagnose the presence and severity of dementia). Univariate and multivariate linear regression models were compiled to analyse possible factors affecting OHRQoL.

Results

For the final analysis, 108 participants were available. For the study cohort as a whole, a decrease in the number of functional occluding pairs (C: 0.195; p = 0.034) and an increase in dental-treatment needs (C: −1.968; p = 0.056) had the greatest negative effects on OHRQoL as expressed by the GOHAI score. For denture wearers, a deterioration of denture condition (C: −2.946; p = 0.003) was the most important predictor for a decline in OHRQoL.

Conclusion

A short-term decline in oral health and function affects the OHRQoL of nursing-home residents. The most important dental variables in this regard are the number of functional occluding pairs and dental and denture-related treatment needs.

Pneumonia prevention in the elderly patients: the other sides

Pneumonia is one of the leading causes of morbidity and mortality from infection in elderly patients. The increased frequency of pneumonia among elderly subjects can be explained by the physiological changes linked to the progressive aging of the respiratory tree and the diminished immunological response. A spiral of event leads to frailty, infection and possible death; preventing pneumonia consists of controlling the risk factors. Dysphagia, which is associated with malnutrition and dehydration, is recognized as one of the major pathophysiological mechanism leading to pneumonia and its screening is crucial for the pneumonia risk assessment. The impairment in the oropharyngeal reflexes results in stagnation of foreign material in the lateral cavities of the pharynx which may then get aspirated repeatedly in the lungs and cause pneumonia. Pneumonia prevention starts with lifestyle modifications such as alcohol and tobacco cessation. A careful review of the risk-benefit of the prescribed medication is critical and adaptation may be required in elders with multiple morbidities. Respiratory physiotherapy and mobilization improve the functional status and hence may help reduce the risk of pneumonia. Maintaining teeth and masticatory efficiency is important if malnutrition and its consequences are to be avoided. Daily oral hygiene and regular professional removal of oral biofilm can prevent the onset of periodontitis and can avoid an oral environment favoring the colonization of respiratory pathogens than can then be aspirated into the lungs.

Activity of daily living upon admission is an independent predictor of in-hospital mortality in older patients with community-acquired pneumonia

BACKGROUND

Older patients hospitalized with community-acquired pneumonia (CAP) are at high risk for short-term mortality. Activity of daily living (ADL) is associated with clinical outcomes in older patients. We aimed to investigate the prognostic value of ADL upon admission on the in-hospital mortality in older patients with CAP.

METHODS

We conducted a retrospective cohort study involving patients aged ≥65 years admitted to Beijing Chao-Yang hospital due to CAP between June 2012 and June 2020. ADL evaluation upon admission was performed by Barthel Index (BI). Data from all patients were extracted from the electronic medical records.

RESULTS

Four thousand eight hundred eighty patients were included, 131 patients (2.7%) died during their hospitalization. Median BI in the Deceased group was 45 (20-65), Deceased group had lower BI scores than Survivors group (p < 0.001). Low BI (< 60) was more frequent in patients who died in the hospital than in patients discharged alive (69.5% vs. 13%, p < 0.001). In-hospital mortality was higher among patients with worse ADL upon admission (BI< 60) compared to those BI≥60 (12.6% vs. 0.9%). The worse ADL upon admission (BI< 60) was associated with an increase in the risk of death during CAP hospitalization, worse ADL upon admission (BI< 60) showed an odds ratio (OR) for in-hospital mortality of 7.53 (95%CI: 2.77-20.48; P < 0.01). This association remained significant after adjustment for age, comorbid conditions, respiratory failure, pathogens and laboratory findings (OR, 3.74; 95%CI, 2.37-5.91; P < 0.01). Receiver operating characteristic (ROC) curve revealed that BI upon admission is a predictor related to in-hospital mortality in elderly patients, the area under the ROC curve of BI in predicting in-hospital mortality was 0.81 (with 95% confidence interval: 0.78-0.85). The predictive value of ADL upon admission was better than age in our study population.

CONCLUSION

Activity of daily living upon admission is an independent predictor of in-hospital mortality in older patients with community-acquired pneumonia.

Gender differences in incidence and in-hospital outcomes of community-acquired, ventilator-associated and nonventilator hospital-acquired pneumonia in Spain

AIMS

We aim to compare the incidence and in-hospital outcomes of community-acquired pneumonia (CAP), ventilator-associated pneumonia (VAP) and nonventilator hospital-acquired pneumonia (NV-HAP) according to gender.

METHODS

This was a retrospective observational epidemiological study using the Spanish National Hospital Discharge Database for the years 2016 and 2017.

RESULTS

Of 277 785 hospital admissions, CAP was identified in 257 455 (41.04% females), VAP was identified in 3261 (30.42% females) and NV-HAP was identified in 17 069 (36.58% females). The incidence of all types of pneumonia was higher amongst males (CAP: incidence rate ratio [IRR] 1.05, 95% CI 1.03-1.06; VAP: IRR 1.36, 95% CI 1.26-1.46; and NV-HAP: IRR 1.16, 95% CI 1.14-1.18). The crude in-hospital mortality (IHM) rate for CAP was 11.44% in females and 11.80% in males (P = .005); for VAP IHM, the rate was approximately 35% in patients of both genders and for NV-HAP IHM, the rate was 23.97% for females and 26.40% for males (P < .001). After multivariable adjustment, in patients of both genders, older age and comorbidities were factors associated with IHM in the three types of pneumonia analysed. Female gender was a risk factor for IHM after VAP (OR 1.24; 95% CI 1.06-1.44), and no gender differences were found for CAP or NV-HAP.

CONCLUSIONS

Our findings show a difference between females and males, with females presenting a lower incidence of all types of pneumonia. However, female gender was a risk factor for IHM after VAP.

Introducing Standardized Assessment and Management of Oral Cares in a Rehabilitation Unit: Patient Outcomes and Experiences

PURPOSE

The aim of this study was to improve patient oral hygiene outcomes in a rehabilitation unit by implementing a nursing education package and oral hygiene assessment tool.

DESIGN

A case-control design with 50 rehabilitation patients was performed.

METHODS

Nursing staff received education and training in applying the Modified Oral Health Assessment Tool. Clinician assessment of patient oral hygiene occurred on admission and at days 5-7. Each patient reported their perceptions of oral hygiene and comfort prior to hospitalization, while in the hospital, and after transfer to the rehabilitation unit.

FINDINGS

Oral hygiene rating scores improved significantly from admission to the rehabilitation unit to days 5-7 (p = .00). The mean score of patient perceived cleanliness improved from hospital admission to admission to the rehabilitation unit.

CONCLUSION

Oral hygiene was improved following admission to a rehabilitation unit with a consistent and individualized approach to oral hygiene.

CLINICAL RELEVANCE

The introduction of a consistent and individualized approach to oral hygiene demonstrates positive patient outcomes and high patient acceptance.

The Effects of Dental Status and Chewing Efficiency on the Oral-Health-Related Quality of Life of Nursing-Home Residents

Objective

The aim of this study was to evaluate the effects of dental status and chewing efficiency on the oral-health-related quality of life (OHRQoL) of nursing-home residents.

Materials and Methods

The study was conducted in nine nursing homes. All eligible participants were included, and general and medical data, information about nutritional status and their dental and prosthetic status were collected. Chewing efficiency was assessed by means of a two-colour mixing-ability test. The simple count version of the Geriatric Oral Health Assessment Index (SC-GOHAI) was used to evaluate participants’ OHRQoL, and the Mini-Mental State Examination to classify the presence of cognitive impairment. Univariate and multivariate regression models were used to analyse data.

Results

The mean age of the participants was 82.1 (± 9.8) years and most participants suffered from at least very mild cognitive impairment. OHRQoL for all participants (n = 143) and denture wearers only (n = 105) was substantially associated with the type of prosthesis, the presence of natural teeth, the number of functional occluding pairs and dental and denture-related (if applicable) treatment needs. Furthermore, in both model’s univariate analysis showed that chewing efficiency also affected OHRQoL. In contrast, multivariate analysis of all participants revealed that only a higher number of functional occluding pairs (C: 0.250; p < 0.001), fewer dental treatment needs (C: −1.733; p = 0.019) and a better nutritional status (C: −1.298; p = 0.048) were relevant for better OHRQoL. For denture wearers, a higher number of functional occluding pairs (C: 0.192; p = 0.011), a better denture condition (C: −2.194; p= 0.003) and a higher body mass index (BMI) (C: 0.145; p = 0.006) were the main variables associated with better OHRQoL among participants.

Conclusion

Good oral health and oral function, including chewing efficiency, are associated with a high OHRQoL of nursing-home residents. However, few dental treatment needs, well-fitting dentures without treatment needs and a high number of functional occluding pairs seem to be the principal variables for an acceptable OHRQoL of nursing-home residents.

Pneumonic versus Nonpneumonic Exacerbations of Chronic Obstructive Pulmonary Disease

Patients with chronic obstructive pulmonary disease (COPD) often suffer acute exacerbations (AECOPD) and community-acquired pneumonia (CAP), named nonpneumonic and pneumonic exacerbations of COPD, respectively. Abnormal host defense mechanisms may play a role in the specificity of the systemic inflammatory response. Given the association of this aspect to some biomarkers at admission (e.g., C-reactive protein), it can be used to help to discriminate AECOPD and CAP, especially in cases with doubtful infiltrates and advanced lung impairment. Fever, sputum purulence, chills, and pleuritic pain are typical clinical features of CAP in a patient with COPD, whereas isolated dyspnea at admission has been reported to predict AECOPD. Although CAP may have a worse outcome in terms of mortality (in hospital and short term), length of hospitalization, and early readmission rates, this has only been confirmed in a few prospective studies. There is a lack of methodologically sound research confirming the impact of severe AECOPD and COPD + CAP. Here, we review studies reporting head-to-head comparisons between AECOPD and CAP + COPD in hospitalized patients. We focus on the epidemiology, risk factors, systemic inflammatory response, clinical and microbiological characteristics, outcomes, and treatment approaches. Finally, we briefly discuss some proposals on how we should orient research in the future.

Pneumonia prevention effects of perioperative oral management in approximately 25,000 patients following cancer surgery

AIM

We conducted a multicenter study to explore the risk factors of developing pneumonia and the effectiveness of perioperative oral management (POM) for the prevention of pneumonia in postsurgical patients.

METHODS AND RESULTS

A survey covering eight regional hospitals was conducted over 4 years, from April 2010 to March 2014. Using the Diagnosis Procedure Combination database, a target group of 25,554 patients with cancer who underwent surgery was selected and assessed from a population of 346,563 patients without pneumonia on admission (sample population). The study compared the incidence of pneumonia and attempted to identify the significant predictive factors for its occurrence in these patients using multiple logistic regression analysis. Comparative assessment for the occurrence of pneumonia before and after POM implementation showed a significant incidence decrease after POM introduction in the target group, with no such change observed in the sample population. Multiple logistic regression analysis showed that the odds ratio for pneumonia occurrence after POM introduction was 0.44, indicating a reduced risk of pneumonia.

CONCLUSION

POM in cancer patients was indeed effective in reducing the incidence of pneumonia in hospitals and thereby helped in preventing pneumonia during hospitalization.

Gender differences in community-acquired pneumonia

INTRODUCTION

Community-acquired pneumonia (CAP) is the most common type of lower respiratory tract infection and a major cause of morbidity and mortality in adults worldwide. Sex and gender play an active role in the incidence and outcomes of major infectious diseases, including CAP.

EVIDENCE ACQUISITION

We searched the following electronic databases from January 2001 to December 2018: MEDLINE, EMBASE, CINHAIL, CENTRAL (Cochrane Central register of Controlled Trials), DARE (Database of Abstracts of Reviews of Effectiveness), Cochrane Database of Systematic Reviews and ACP Journal Club database.

EVIDENCE SYNTHESIS

Several studies have reported higher male susceptibility to pulmonary infections and higher risk of death due to sepsis. Biological differences (e.g. hormonal cycles and cellular immune-mediated responses) together with cultural, behavioral and socio-economic differences are important determinants of the course and outcome of CAP. However, gender-related bias in the provision of care and use of hospital resources has been reported among women, resulting in delayed hospital admission and consequently necessary care.

CONCLUSIONS

CAP is more severe in males than in females, leading to higher mortality in males, especially in older age. To identify gender differences in CAP can guide patient's prognostication and management.

Short-Term Effects of a Deterioration of General Health on the Oral Health of Nursing-Home Residents

Purpose

The purpose of this study was to identify how changes to general health might affect the oral health of nursing-home residents over a six-month period.

Materials and Methods

The study was conducted in nine nursing homes in Germany. Sociodemographic and general data were collected at baseline and after six months. Complete baseline and follow-up data were available for 114 participants. The Clinical Dementia Rating (CDR) and the Global Deterioration Scale (GDS) were used to identify the presence and, if applicable, severity of dementia among participants. The Apraxia Screen of TULIA (AST) was used to identify motor impairment. A comprehensive dental examination of each participant was also performed. The examination included the documentation of dental and denture status and the number of decayed, missing and filled teeth (DMF-T). In addition, dental and denture hygiene were quantitatively assessed using the Plaque Index (PI) and the Denture Hygiene Index (DHI), respectively. Global dental treatment needs were evaluated by use of the Oral Health Assessment Tool (OHAT). Univariate and multivariate linear regression models were compiled to analyse possible factors affecting the dependent target variables.

Results

During the study period, denture hygiene among the study population worsened by an average of 15%. The regression models detected that a more advanced age (in years) was associated with a less pronounced deterioration of denture hygiene as measured by use of the DHI (−0.806 per additional year of age; p = 0.030). Furthermore, an increase in the level of care needed (coefficient (C): −1.948; p = 0.002) and a more poorly graded assessment of general health compared with the value at baseline (C: 1.054; p = 0.026) were both associated with a deterioration of oral health as evaluated by use of the OHAT. In addition to these results, an increase in care needs was also associated with a deterioration of dental health as evaluated by use of the DMF-T (C: 0.966; p = 0.013).

Conclusion

In the short term, a deterioration of general health, including an increase in care needs, seems to be the predominant factor associated with a more pronounced deterioration of oral health among nursing-home residents.

Gaps between current clinical practice and evidence-based guidelines for treatment and care of older patients with Community Acquired Pneumonia: a descriptive cross-sectional study

Background

Community acquired pneumonia (CAP) remains a significant cause of morbidity and in-hospital mortality, and readmission rates are rising for older persons (> 65 years). Optimized treatment and nursing care will benefit patients and the health economy. Hence, there is a need to describe gaps between current clinical practice and recommendations in evidence-based guidelines for diagnostic procedures, medical treatment and nursing interventions for older patients with CAP.

Methods

Structured observations, individual ad hoc interviews and audits of patient records were carried out in an emergency department and three medical units. Data were analysed by manifest content analysis and descriptive statistics.

Results

Thirty patients (median age 74 years) admitted with CAP and 86 physicians, nurses, physiotherapists were included. The median length of stay (LOS) was 6.5 days, in-hospital mortality was10 and 40.7% were readmitted within one month. The severity assessment tool (CURB-65) was used in 16.7% of the patients, correct antibiotic treatment prescribed for 13.3% and chest radiography (≤6 weeks post-discharge) prescribed for 22.2%. Fluid therapy, nutrition support and mobilisation plans were found to be developed sporadically, and interventions to be performed unsystematically and sparingly. Positive Expiratory Pressure therapy and oral care were the nursing interventions with lowest adherence, ranging from 18.2 to 55.6%.

Conclusions

Adherence to recommendations was low for several central treatment and nursing care interventions for patients with CAP with possible consequences for patients and the use of resources. Thus, there is an urgent need to identify and remove barriers to adherence to recommendations in the neglected areas in view of the potential to improve patient outcomes.

Factors associated with hospitalization for community-acquired pneumonia in home health care patients in Taiwan

BACKGROUND

Pneumonia is a leading cause of hospitalization and death worldwide. However, studies focusing on risk factors of community-acquired pneumonia (CAP) in the home health care (HHC) population remain scarce.

AIMS

This study aimed to evaluate risk factors associated with hospitalization for CAP among HHC patients in Taiwan.

METHODS

This retrospective cross-sectional study extracted data from patients' electronic medical records between 1 January 2017 and 31 December 2017. Multiple logistic regression analyses were performed to explore factors associated with hospitalization for CAP.

RESULTS

In total, 598 patients (men/women: 236/362) were included. One hundred ninety-nine patients (33.28%) were hospitalized for pneumonia. Inpatients showed a higher proportion of the following: male sex, functional impairment, hypoalbuminemia, anemia, nasogastric tube use, excessive polypharmacy, stroke, dementia, heart failure, chronic respiratory disease, and chronic liver disease. Furthermore, nasogastric tube use (odds ratio [OR] 3.01, 95% confidence interval [CI] 1.88-4.82), anemia (OR 2.37, 95% CI 1.48-3.80), male sex (OR 2.14, 95% CI 1.43-3.20), chronic respiratory disease (OR 2.09, 95% CI 1.33-3.30), dementia (OR 1.94, 95% CI 1.27-2.97), heart failure (OR 1.69, 95% CI 1.11-2.56), and hypoalbuminemia (OR 1.57, 95% CI 1.03-2.40) significantly increased the risk of hospitalization for CAP.

CONCLUSIONS

Our results revealed risk factors associated with hospitalization for CAP in HHC patients. In addition to chronic diseases, malnutrition is an important risk factor. Caregivers should make prompt assessments and take preventive measures for such patients.

Rates of hospitalization for community-acquired pneumonia among US adults: A systematic review

BACKGROUND

Community-acquired pneumonia (CAP) is associated with significant disease burden in adults but has not been measured uniformly. Reconciling differences across studies is critical for understanding the true burden of CAP.

METHODS

We performed a systematic literature review of the incidence of hospitalized CAP among US adults and described the impact of key study characteristics on these estimates.

RESULTS

After review of 8361 articles as of January 31, 2019, we identified 28 studies with 41 unique estimates of hospitalized CAP incidence. Among adults ≥65 years of age, annual rates of hospitalized CAP ranged from 847 to 3500 per 100,000 persons with median = 1830. Rates were lower in studies that excluded patients with healthcare-associated (but community-onset) pneumonia (HCAP; median = 2003 vs 1286; P = 0.02) or immunocompromising conditions (median = 1895 vs 1409; P = 0.27) compared to those that did not. Rates of CAP were also lower in studies that used more restrictive criteria for diagnosing pneumonia (eg, pneumonia coded in any diagnosis position [median = 2270] vs pneumonia coded in the first position only [median = 1375] in studies of administrative claims; P = 0.02). For adults <65 years of age, rates of CAP were lower (range: 89 to 1138 per 100,000; median = 199).

CONCLUSIONS

CAP causes a significant disease burden among adults, particularly among those ≥65 years of age. Commonly-applied exclusion criteria (eg, persons with HCAP or immunocompromising conditions) or restrictive case definitions (eg, only including pneumonias coded in the primary diagnosis position) have led to systematic underestimation of CAP incidence in many previous studies. In studies that did not apply these restrictive criteria, the rate of hospitalization was approximately 2000 per 100,000 annually. Understanding the true burden of adult CAP is critical for highlighting the ongoing need for expanded prevention programs, including vaccination.

The oral health-related section of the interRAI: Evaluation of test content validity by expert rating and assessment of potential reasons for inaccurate assessments based on focus group discussions with caregivers

OBJECTIVES

To explore the failure of the oral health-related section of the interRAI (ohr-interRAI), this study investigated test content validity (A.) and reasons for inaccurate assessments (B.).

BACKGROUND

Poor oral health negatively affects quality of life and is associated with a number of systemic diseases. The interRAI instruments, internationally used for geriatric assessment, should accurately detect oral conditions that require care. Previous research showed that the ohr-interRAI and related precursor versions do not achieve this goal.

MATERIALS AND METHODS

(A.) A group of 12 experts rated completeness, relevance, clarity of wording and feasibility of the ohr-interRAI. Content validity indices were calculated per item (threshold 0.78). (B.) Focus group discussions with 23 caregivers were organized. A semi-structured question guide made sure that all topics of interest were covered. Qualitative content structuring analysis was applied after transcription.

RESULTS

(A.) Experts agreed on the relevance of the items on chewing, pain, gingival inflammation and damaged teeth. They regarded none of the items as worded clearly and only prosthesis use and pain were considered to be assessable by untrained caregivers. All experts agreed that the ohr-interRAI was incomplete. (B.) Focus group discussions revealed that in the care environment oral health had low priority. Aspects related to the ohr-interRAI itself and aspects related to the assessment situation impeded the oral health assessment. The approach of the caregivers to complete the ohr-interRAI was inappropriate to accurately detect oral care needs.

CONCLUSIONS

Findings challenge test content validity of the ohr-interRAI and reveal reasons for inaccurate assessments.

Antiepileptic Drug Use Is Associated with an Increased Risk of Pneumonia Among Community-Dwelling Persons with Alzheimer's Disease-Matched Cohort Study

BACKGROUND

Antiepileptic drugs (AEDs) have sedative properties which may lead to an increased risk of pneumonia.

OBJECTIVES

To investigate whether incident AED use is associated with an increased risk of pneumonia among community-dwelling persons with Alzheimer's disease (AD). In addition, we determined the risk according to duration of AED use and specific AEDs.

METHODS

Persons with AD were identified from the MEDALZ dataset which includes all community-dwelling persons who received a clinically verified diagnosis of AD during 2005-2011 in Finland (N=70,718). New AED users were identified with one-year washout period. A matched cohort (1 : 1, N=5,769, matching criteria age, gender, and time since AD diagnoses) of nonusers was formed. Data from nationwide registers included dispensed medications which were modelled with PRE2DUP method, hospitalizations, and causes of death. The association between AED use and hospital admission or death due to pneumonia was analyzed with Cox proportional hazard models.

RESULTS

AED use was associated with an increased risk of pneumonia (adjusted HR 1.92, 95% CI 1.63-2.26; incidence rate per 100 person-years 12.58, 95% CI 12.49-12.66 during AED use and 6.41, 95% CI 6.37-6.45 during nonuse). The highest risk was observed during the first month of use (aHR 3.59, 95% CI 2.29-5.61) and the risk remained elevated until two years of use. Of specific drug substances, phenytoin, carbamazepine, valproic acid, and pregabalin were associated with an increased risk.

CONCLUSION

Antiepileptic drug use may increase the risk of pneumonia which is concerning as persons with AD have elevated risk of pneumonia.

Biological Age, Not Chronological Age, Is Associated with Late-Life Depression

Background

The pathophysiology of late-life depression (LLD) is complex and heterogeneous, with age-related processes implicated in its pathogenesis. This study examined the cross-sectional and longitudinal association between depressive symptoms and a baseline multibiomarker algorithm of biological age (BA) that aggregates indicators of inflammatory, metabolic, cardiovascular, lung, liver, and kidney functioning.

Method

Data were analyzed from 2,776 men and women from the prospective observational Health Aging and Body Composition Study, who had both evaluable chronological age (CA) and BA. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression (CES-D) scale.

Results

A covariate-adjusted regression model showed that BA (B = 0.03, p = .0471) but not CA (B = -0.01, p = .7185) is associated with baseline CES-D scores. The mean baseline BA for individuals with a CES-D ≥ 10 was 1.28 years greater than in those with a CES-D < 10. Comparatively, there is only a 0.05-year difference in mean CA between the two depression groups. A covariate-adjusted longitudinal model found that baseline BA predicts CES-D score at follow-up (B = 0.04, p = .0058), whereas CA does not (B = 0.03, p = .4125). Additionally, an older BA significantly predicted a CES-D ≥ 10 (B = 0.02, p = .032) over a 10-year period.

Conclusions

A multibiomarker index of an older adult's BA outperformed their CA in predicting subsequent increased and clinically significant depressive symptoms. This result supports the evolving view of LLD as a brain disorder resulting from deleterious age-associated changes across numerous physiological systems.

Contributions of COPD, asthma, and ten comorbid conditions to health care utilization and patient-centered outcomes among US adults with obstructive airway disease

Background

Among persons with obstructive airway disease, the relative contributions of chronic obstructive pulmonary disease (COPD), asthma, and common comorbid conditions to health care utilization and patient-centered outcomes (PCOs) have not been previously reported.

Methods

We followed a total of 3,486 persons aged ≥40 years with COPD, asthma, or both at baseline, from the Medical Expenditure Panel Survey (MEPS) cohorts enrolled annually from 2008 through 2012 for 1 year. MEPS is a prospective observational study of US households recording self-reported COPD, asthma, and ten medical conditions: angina, arthritis, cancer, coronary heart disease, cognitive impairment, diabetes, hypertension, lung cancer, myocardial infarction, and stroke/transient ischemic attack. We studied the separate contributions of these conditions to health care utilization (all-cause and respiratory disease hospitalization, any emergency department [ED] visit, and six or more outpatient visits) and PCOs (seven or more days spent in bed due to illness, incident loss of mobility, and incident decline in self-perceived health).

Results

COPD made the largest contributions to all-cause and respiratory disease hospitalization and ED visits, while arthritis made the largest contribution to outpatient health care. Arthritis and COPD, respectively, made the greatest contributions to the PCOs.

Conclusion

COPD made the largest and second largest contributions to health care utilization and PCOs among US adults with obstructive airway disease. The twelve medical conditions collectively accounted for between 52% and 61% of the health care utilization outcomes and between 53% and 68% of the PCOs. Cognitive impairment, diabetes, hypertension, and stroke also made significant contributions.

Predicting 2-Year Risk of Developing Pneumonia in Older Adults without Dementia

OBJECTIVES

To develop three prognostic indices of varying degree of required detail for 2-year pneumonia risk in older adults.

DESIGN

Retrospective cohort study.

SETTING

Group Health (GH), an integrated healthcare delivery system.

PARTICIPANTS

Community-dwelling dementia-free individuals aged 65 and older who had been GH members for at least 2 years before start of follow-up and were enrolled in the Adult Changes in Thought study (N = 3,375; development cohort, n = 2,250; validation cohort, n = 1,125.

MEASUREMENTS

Potential pneumonia risk factors were identified from questionnaire data and interviewer assessments of functional status, medical history, smoking and alcohol use, cognitive function, personal care, and problem solving. Risk factors were also identified based on physical measures such as grip strength and gait speed and administrative database information on comorbid illnesses, laboratory tests, and prescriptions dispensed. Incident community-acquired pneumonia was defined presumptively from administrative data and validated using medical record review.

RESULTS

Participants (59% female) contributed 12,998 visits at which risk factors were assessed; 642 pneumonia events were observed during follow-up. Age, sex, chronic obstructive pulmonary disease, congestive heart failure, body mass index, and use of inhaled or oral corticosteroids were critical predictors in all prognostic indices. A risk score based on these seven variables, information on which is commonly available in electronic medical records (EMRs), had equal or better performance (c-index = 0.69 in the validation cohort) than scores including more-detailed data such as functional status.

CONCLUSION

Data commonly available in EMRs can stratify older adults into groups with varying subsequent 2-year pneumonia risk.

Oral Care and Prevention of Pneumonia in Hospitalized Patients With Psychiatric Disorders in Japan

Purpose:

Oral care in hospitalized patients with psychiatric disorders is important. However, some patients with psychiatric disorders cannot undergo oral care because of psychiatric symptoms and cognitive decline. The effect of a standardized oral hygiene intervention on the prevention of pneumonia in hospitalized patients with psychiatric disorders was investigated.

Method:

Patients were divided into 2 groups: control group (N = 259), patients without standardized intervention who were enrolled on April 2014 as the time point of baseline, and intervention group (N = 263), patients with standardized intervention who were enrolled on April 2015 as the time point of baseline. Two end points were evaluated: (1) pneumonia onset within 1 year after the enrollment and (2) no pneumonia for 1 year after the enrollment. The following parameters were compared between the groups: sex, age, psychiatric disorders, past history of diseases of the respiratory system, hypertension, diabetes, hyperlipidemia, heart impairment, and pneumonia.

Results:

No statistically significant differences were found between the 2 groups in the distributions of characteristics except pneumonia by univariate analysis. The presence of pneumonia was significantly associated with age and the absence of the standardized oral hygiene intervention by multivariate logistic regression analysis.

Conclusions:

The standardized oral hygiene intervention appears to be effective for preventing pneumonia in patients with psychiatric disorders.

Age-related differences in management and outcomes in hospitalized healthy and well-functioning bacteremic pneumococcal pneumonia patients: a cohort study

Background

Limited data are available regarding fit and healthy patients with pneumonia at different ages. We evaluated the association of age with clinical presentation, serotype and outcomes among healthy and well-functioning patients hospitalized for bacteremic pneumococcal community–acquired pneumonia.

Methods

We performed a prospective cohort study of consecutive healthy and well-functioning patients hospitalized for this type of pneumonia. Patients were stratified into younger (18 to 64 years) and older (≥65 years) groups.

Results

During the study period, 399 consecutive patients were hospitalized with bacteremic pneumococcal pneumonia. We included 203 (50.8%) patients who were healthy and well-functioning patients, of whom 71 (35%) were classified as older. No differences were found in antibiotic treatment, treatment failure rate, antibiotic resistance, or serotype, except for serotype 7F that was less common in older patients. In the adjusted multivariate analysis, the older patients had higher 30-day mortality (OR 6.83; 95% CI 1.22–38.22; P = 0.028), but were less likely to be admitted to the ICU (OR 0.14; 95% CI 0.05–0.39; P < 0.001) and had shorter hospital stays (OR 0.71; 95% CI 0.54–0.94; P = 0.017).

Conclusions

Healthy and well-functioning older patients have higher mortality than younger patients, but nevertheless, ICU admission was less likely and hospital stays were shorter. These results suggest that the aging process is a determinant of mortality, beyond the functional status of patients with bacteremic pneumococcal pneumonia.

Oral health-related quality of life and prosthetic status of nursing home residents with or without dementia

Purpose

The objective of this cross-sectional study was to evaluate the effect of prosthetic status on the oral health-related quality of life (OHRQoL) of nursing home residents with or without dementia.

Methods

The study was performed in 14 nursing homes across the federal state of Baden-Württemberg, Germany. All eligible participants were included, and general and medical information and information about their dental and prosthetic statuses were collected. The Geriatric Oral Health Assessment Index (GOHAI) was administered to evaluate OHRQoL. The Mini-Mental State Examination (MMSE) served to classify participants into living or not living with dementia according to the established cutoff value for dementia (MMSE <24). Parametric bivariate statistics and logistic regression models were used to analyze data at P<0.05.

Results

A total of 169 participants were included in this study. The mean age of the participants was 82.9 years. A total of some 70% of the sample was living with dementia. The mean GOHAI score along the sample was 49.1 (8.3), and 41% of the sample reported substantially compromised OHRQoL (GOHAI <50). OHRQoL was statistically similar for people with or without dementia (P=0.234); objective oral health was also similar in both groups (P>0.05). The number of teeth (odds ratio [OR]: 2.0), the type of prosthetic status (OR: 6.5), and denture-related treatment needs (OR: 2.4) were the major factors significantly affecting OHRQoL (P<0.05).

Conclusion

The OHRQoL of elderly nursing home residents is substantially compromised. Several prosthetic treatment needs for residents living with or without dementia were identified. Edentulism without tooth replacement and having <5 teeth resulted in an increased risk of substantially compromised OHRQoL. Further studies should be conducted to determine whether improvements in prosthetic status can increase OHRQoL.

Enhanced Oral Care and Health Outcomes Among Nursing Facility Residents: Analysis Using the National Long-Term Care Database in Japan

BACKGROUND AND OBJECTIVE

Although oral care may have salutary effects among frail elderly people, access to dental care is often limited in long-term care facilities. In 2009, the Japanese long-term care insurance system introduced an additional reimbursement scheme for enhanced oral care supervised by dentists in nursing facilities. The aim of this study was to examine whether enhanced oral care provided by trained nursing facility staff members is sufficient to improve health outcomes among nursing facility residents.

DESIGN, SETTING, AND PARTICIPANTS

This was a quasi-experimental study using a nationwide long-term care database. Using facility-level propensity score matching, we identified 170,874 residents in 742 facilities that provided enhanced oral care and 167,546 residents in 742 control facilities that provided only standard care from 2009 to 2012. We used a resident-level difference-in-differences approach to analyze the impact of enhanced oral care on health outcomes among nursing facility residents.

RESULTS

After controlling for resident characteristics and background time trends, no significant differences were found between residents admitted to the facilities with and without enhanced oral care in the incidence of critical illness, transfer to a hospital, mortality, or costs. Yearly change in the odds of discharge to home was significantly increased for residents with enhanced oral care (odds ratio = 1.07; 95% confidence interval: 1.02-1.12; P = .008).

CONCLUSION

The results suggest that enhanced oral care provided by trained nursing facility staff members may improve the general condition of elderly residents in nursing facilities and promote their discharge to home.

Oral hygiene of hospitalised older patients with lower limb fracture

INTRODUCTION

good oral hygiene is important for eating, talking and improved quality of life, and is part of basic patient care, but there are few observational studies in hospitalised older patients. The aim of this study is to investigate dental plaque load in older patients over time in hospital.

METHODS

we examined the mouths of 93 patients with lower limb fracture prospectively at day 1, 7 and 14 after admission in a Newcastle upon Tyne Hospital. We assessed dental and denture plaque load, dry mouth symptoms and tooth number, along with demographic and frailty variables. We used univariate generalised linear modelling and mixed effects models to investigate associations between increased plaque and patient characteristics.

RESULTS

in dentate patients, plaque score increased with time in hospital (P = 0.007, odds ratio (OR): 1.02; 95% confidence of interval (CI): 1.01-1.04). Frailty (P = 0.015, OR: 1.19; 95% CI: 1.04-1.37), dementia (P < 0.001, OR: 4.30; 95% CI: 2.03-9.12), residence in an institution (P < 0.001, OR: 4.61; 95% CI: 2.18-9.74), decreased mobility (P = 0.013, OR: 0.97; 95% CI: 0.96-0.99), but not Charlson comorbidity index (P = 0.102, OR: 1.08; 95% CI: 0.99-1.19), were associated with increased plaque scores at every time point.

CONCLUSIONS

oral hygiene deteriorated in dentate patients in hospital. Plaque scores were significantly higher in patients who were more likely to be dependent on others for their oral hygiene.

Post-stroke pneumonia at the stroke unit - a registry based analysis of contributing and protective factors

BACKGROUND

To investigate prevalence and risk factors for post stroke pneumonia (PSP) in patients with acute ischemic stroke treated at stroke units (SU).

METHOD

We analysed data from the Austrian Stroke Unit registry concerning admissions from January 2003 to December 2013 and assessed the prevalence of PSP at the stroke unit. Patients with and without PSP were compared in univariate and multivariate models searching for factors associated with the occurrence of PSP at the SU.

RESULTS

Three thousand one hundred eleven patients (5.2%) of 59,558 analysed patients were diagnosed with PSP. While age and stroke severity were non-modifiable factors associated with PSP, modifiable risk factors included chronic alcohol consumption and atrial fibrillation. Patients who developed neurological, cardiac, and other infective complications showed a higher prevalence of PSP, an increased prevalence was also found in connection with the placement of nasogastric tubes or urinary catheters. Female sex, left hemispheric stroke, cryptogenic stroke pathogenesis and additionally, treatment with lipid lowering drugs were factors associated with a lower PSP prevalence.

CONCLUSION

Pneumonia in acute ischemic stroke is associated with a variety of modifiable and unmodifiable factors that allow to identify patients at high risk of developing PSP and to focus on early preventive measures at the SU. Further studies could use the results of this study to explore potential benefits of specific interventions targeted at these factors.

Anthropometric measurements may be informative for nursing home-acquired pneumonia

Objective:

To evaluate the relationship between anthropometric measurements and Nursing Home-Acquired Pneumonia (NHAP) risk.

Methods:

Consecutive patients of 65 years or elderly who were living in the Balikli Rum Hospital Nursing Homes were included in this prospective study. At the beginning of this study, the patients’ anthropometrics values were measured. The patients were followed for one year, and any incidences of pneumonia attacks were recorded. The relationship between the anthropometric measurements and pneumonia occurrences was analyzed.

Results:

There were 133 inmates at the initial assessments. Of 108 patients who were eligible for the study, 77 (72.2%) were female and 37 (27.8%) were male. The mean age of the group was 79.8±10.5. Patients were assigned to a group according to the presence of pneumonia during the one -year follow-up. There were 74 (55.6%) patients who had suffered from at least one attack of pneumonia during the follow-up period. The mean triceps skinfold was significantly thinner in the pneumonia group, and the mean handgrip measurements in both the dominant and non-dominant hands were significantly weaker in the pneumonia group. Furthermore, the frequency of Chronic Obstructive Pulmonary Diseases (COPD) was significantly higher in this group (p < 0.001).

Conclusions:

The risk of pneumonia was high in the elderly population who live in nursing homes. Simple anthropometric values may be predictive of the potential for Nursing Home-Acquired Pneumonia.

Ceftaroline fosamil as first-line versus second-line treatment for acute bacterial skin and skin structure infections (ABSSSI) or community-acquired bacterial pneumonia (CABP)

The Clinical Assessment Program and Teflaro(®) Utilization Registry (CAPTURE) is a multicenter registry study of acute bacterial skin and skin structure infection (ABSSSI) and community-acquired bacterial pneumonia (CABP) patients treated with ceftaroline fosamil in the US. Data for this analysis were collected between August 2011 and February 2013 at US study centres by randomly ordered chart review. Clinical success rates among ABSSSI patients were >81% when ceftaroline fosamil was used as first- or second-line therapy, including monotherapy and concurrent therapy. Among CABP patients, clinical success rates were >77% among first-line and second-line patients and patients who received first-line concurrent therapy or second line monotherapy or concurrent therapy. For CABP patients treated with ceftaroline fosamil as first-line monotherapy, the clinical success rate was 70%. Ceftaroline fosamil is an effective treatment option for patients with ABSSSI or CABP with similar clinical success rates when used as first-line or second-line treatment.

Severe sepsis in older adults

Severe sepsis may be underrecognized in older adults. Therefore, the purpose of this article is to review special considerations related to early detection of severe sepsis in older adults. Normal organ changes attributed to aging may delay early detection of sepsis at the time when interventions have the greatest potential to improve patient outcomes. Systems are reviewed for changes. For example, the cardiovascular system may have a limited or absent compensatory response to inflammation after an infectious insult, and the febrile response and recruitment of white blood cells may be blunted because of immunosenescence in aging. Three of the 4 hallmark responses (temperature, heart rate, and white blood cell count) to systemic inflammation may be diminished in older adults as compared with younger adults. It is important to consider that older adults may not always manifest the typical systemic inflammatory response syndrome. Atypical signs such as confusion, decreased appetite, and unsteady gait may occur before sepsis related organ failure. Systemic inflammatory response syndrome criteria and a comparison of organ failure criteria were reviewed. Mortality rates in sepsis and severe sepsis remain high and are often complicated by multiple organ failures. As the numbers of older adults increase, early identification and prompt treatment is crucial in improving patient outcomes.

An investigation of multimorbidity measures as risk factors for pneumonia in elderly frail patients admitted to hospital

OBJECTIVES

To investigate the association of different chronic comorbidities, considered singularly and together in Cumulative Illness Rating Scale (CIRS) indexes, with pneumonia diagnosis in a group of elderly frail hospitalized patients.

DESIGN AND METHODS

With a retrospective cohort design, all clinical records of frail (Rockwood ≥ 5) nonterminal patients ≥ 65 years old acutely admitted over a 8-month span in an internal medicine ward were evaluated. Pneumonia status and its categorization (community-acquired, CAP, vs healthcare-associated, HCAP) were defined according to chest radiology findings and validated criteria. Chronic comorbidities, CIRS Comorbidity Score and CIRS Severity Index were collected for each participant through a standardized methodology. Multivariate logistic regression models were applied to assess the association of each comorbid condition or scores with pneumonia.

RESULTS

1199 patients (546 M, median age 81.9, IQR 72.8-87.9 years), of whom 239 with pneumonia (180 CAP, 59 HCAP) were evaluated. CIRS Comorbidity Score was significantly associated with pneumonia, both at an age- and sex-adjusted model and at a multivariate model (OR for each unitary increase 1.03, 95% CI 1.001-1.062, p=0.04), together with provenience from nursing home (OR 1.96, 95% CI 1.41-2.73, p<0.001). Among single comorbidities, only COPD (OR 2.7, 95% CI 1.9-3.6, p<0.001) and dementia (OR 2.3, 95% CI 1.7-3.3, p<0.001) were associated with pneumonia, while stroke, cancer, cardiovascular, chronic liver and kidney disease were not.

CONCLUSIONS

In a small cohort of elderly frail hospitalized patients, measures of multimorbidity, like CIRS, are significantly associated with the risk of pneumonia. COPD and dementia are the main conditions concurring to define this risk.

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

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.

Risk of community-acquired pneumonia with outpatient proton-pump inhibitor therapy: a systematic review and meta-analysis

BACKGROUND

Proton-pump inhibitors (PPIs) are among the most frequently prescribed medications. Community-acquired pneumonia (CAP) is a common cause of morbidity, mortality and healthcare spending. Some studies suggest an increased risk of CAP among PPI users. We conducted a systematic review and meta-analysis to determine the association between outpatient PPI therapy and risk of CAP in adults.

METHODS

We conducted systematic searches of MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Scopus and Web of Science on February 3, 2014. Case-control studies, case-crossover, cohort studies and randomized controlled trials reporting outpatient PPI exposure and CAP diagnosis for patients ≥18 years old were eligible. Our primary outcome was the association between CAP and PPI therapy. A secondary outcome examined the risk of hospitalization for CAP and subgroup analyses evaluated the association between PPI use and CAP among patients of different age groups, by different PPI doses, and by different durations of PPI therapy.

RESULTS

Systematic review of 33 studies was performed, of which 26 studies were included in the meta-analysis. These 26 studies included 226,769 cases of CAP among 6,351,656 participants. We observed a pooled risk of CAP with ambulatory PPI therapy of 1.49 (95% CI 1.16, 1.92; I2 99.2%). This risk was increased during the first month of therapy (OR 2.10; 95% CI 1.39, 3.16), regardless of PPI dose or patient age. PPI therapy also increased risk for hospitalization for CAP (OR 1.61; 95% CI: 1.12, 2.31).

DISCUSSION

Outpatient PPI use is associated with a 1.5-fold increased risk of CAP, with the highest risk within the first 30 days after initiation of therapy. Providers should be aware of this risk when considering PPI use, especially in cases where alternative regimens may be available or the benefits of PPI use are uncertain.

Radical serotype rearrangement of carried pneumococci in the first 3 years after intensive vaccination started in Hungary

Streptococcus pneumoniae is responsible for a significant amount of morbidity and mortality worldwide. Healthy carriers, mainly young children, are the most important sources of infections. In the current study, we aimed to determine the changes that have occurred since the introduction of PCV-7 in Hungary. Nasal specimens were collected from 1,022 healthy children aged 3-6 years attending day-care centres. After thorough identification, pneumococcal isolates were serotyped, and their antibiotic sensitivity was determined. The carriage rate was found to be 34.9%. A huge serotype rearrangement was detected compared to earlier results, with the previously leading serotype 14 having completely disappeared. Serotypes 11A, 35F, 19A, 6B, 15B, 3 and 38 were most prevalent, and 29 different types were identified in total. The PCV-7 types were responsible for 16.5% of all serotypes, and 36.0% are not covered by any pneumococcal vaccines. The isolates were sensitive to most tested antibiotics, except erythromycin (resistance was 21.6%). Only one penicillin-resistant strain was found. The newly and rapidly emerging non-vaccine serotypes are much more sensitive, except serotype 19A.

CONCLUSION

Due to PCV vaccination, a complete serotype arrangement occurred also in Hungary. The old "paediatric" serotypes were replaced by serotypes 11A, 35F, 19A, 6B, 15B, 3 and 38.

Denture wearing during sleep doubles the risk of pneumonia in the very elderly

Poor oral health and hygiene are increasingly recognized as major risk factors for pneumonia among the elderly. To identify modifiable oral health-related risk factors, we prospectively investigated associations between a constellation of oral health behaviors and incident pneumonia in the community-living very elderly (i.e., 85 years of age or older). At baseline, 524 randomly selected seniors (228 men and 296 women; mean age, 87.8 years) were examined for oral health status and oral hygiene behaviors as well as medical assessment, including blood chemistry analysis, and followed up annually until first hospitalization for or death from pneumonia. During a 3-year follow-up period, 48 events associated with pneumonia (20 deaths and 28 acute hospitalizations) were identified. Among 453 denture wearers, 186 (40.8%) who wore their dentures during sleep were at higher risk for pneumonia than those who removed their dentures at night (log rank P = 0.021). In a multivariate Cox model, both perceived swallowing difficulties and overnight denture wearing were independently associated with an approximately 2.3-fold higher risk of the incidence of pneumonia (for perceived swallowing difficulties, hazard ratio [HR], 2.31; and 95% confidence interval [CI], 1.11-4.82; and for denture wearing during sleep, HR, 2.38; and 95% CI, 1.25-4.56), which was comparable with the HR attributable to cognitive impairment (HR, 2.15; 95% CI, 1.06-4.34), history of stroke (HR, 2.46; 95% CI, 1.13-5.35), and respiratory disease (HR, 2.25; 95% CI, 1.20-4.23). In addition, those who wore dentures during sleep were more likely to have tongue and denture plaque, gum inflammation, positive culture for Candida albicans, and higher levels of circulating interleukin-6 as compared with their counterparts. This study provided empirical evidence that denture wearing during sleep is associated not only with oral inflammatory and microbial burden but also with incident pneumonia, suggesting potential implications of oral hygiene programs for pneumonia prevention in the community.

Management of community-acquired pneumonia in older adults

Community-acquired pneumonia (CAP) is an increasing problem among the elderly. Multiple factors related to ageing, such as comorbidities, nutritional status and swallowing dysfunction have been implicated in the increased incidence of CAP in the older population. Moreover, mortality in patients with CAP rises dramatically with increasing age. Streptococcus pneumoniae is still the most common pathogen among the elderly, although CAP may also be caused by drug-resistant microorganisms and aspiration pneumonia. Furthermore, in the elderly CAP has a different clinical presentation, often lacking the typical acute symptoms observed in younger adults, due to the lower local and systemic inflammatory response. Several independent prognostic factors for mortality in the elderly have been identified, including factors related to pneumonia severity, inadequate response to infection, and low functional status. CAP scores and biomarkers have lower prognostic value in the elderly, and so there is a need to find new scales or to set new cut-off points for current scores in this population. Adherence to the current guidelines for CAP has a significant beneficial impact on clinical outcomes in elderly patients. Particular attention should also be paid to nutritional status, fluid administration, functional status, and comorbidity stabilizing therapy in this group of frail patients. This article presents an up-to-date review of the main aspects of CAP in elderly patients, including epidemiology, causative organisms, clinical features, and prognosis, and assesses key points for best practices for the management of the disease.