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Keller K, Schmitt VH, Sagoschen I, Münzel T, Espinola-Klein C, Hobohm L. CRB-65 for Risk Stratification and Prediction of Prognosis in Pulmonary Embolism. J Clin Med 2023; 12:jcm12041264. [PMID: 36835800 PMCID: PMC9961795 DOI: 10.3390/jcm12041264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/29/2023] [Accepted: 02/01/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Pulmonary embolism (PE) is accompanied by high morbidity and mortality. The search for simple and easily assessable risk stratification scores with favourable effectiveness is still ongoing, and prognostic performance of the CRB-65 score in PE might promising. METHODS The German nationwide inpatient sample was used for this study. All patient cases of patients with PE in Germany 2005-2020 were included and stratified for CRB-65 risk class: low-risk group (CRB-65-score 0 points) vs. high-risk group (CRB-65-score ≥1 points). RESULTS Overall, 1,373,145 patient cases of patients with PE (76.6% aged ≥65 years, 47.0% females) were included. Among these, 1,051,244 patient cases (76.6%) were classified as high-risk according to CRB-65 score (≥1 points). The majority of high-risk patients according to CRB-65 score were females (55.8%). Additionally, high-risk patients according to CRB-65 score showed an aggravated comorbidity profile with increased Charlson comorbidity index (5.0 [IQR 4.0-7.0] vs. 2.0 [0.0-3.0], p < 0.001). In-hospital case fatality (19.0% vs. 3.4%, p < 0.001) and MACCE (22.4% vs. 5.1%, p < 0.001) occurred distinctly more often in PE patients of the high-risk group according to CRB-65 score (≥1 points) compared to the low-risk group (= 0 points). The CRB-65 high-risk class was independently associated with in-hospital death (OR 5.53 [95%CI 5.40-5.65], p < 0.001) as well as MACCE (OR 4.31 [95%CI 4.23-4.40], p < 0.001). CONCLUSIONS Risk stratification with CRB-65 score was helpful for identifying PE patients being at higher risk of adverse in-hospital events. The high-risk class according to CRB-65 score (≥1 points) was independently associated with a 5.5-fold increased occurrence of in-hospital death.
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Affiliation(s)
- Karsten Keller
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany
- Correspondence:
| | - Volker H. Schmitt
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Ingo Sagoschen
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Christine Espinola-Klein
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Lukas Hobohm
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
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Development and validation of a new scoring system for prognostic prediction of community-acquired pneumonia in older adults. Sci Rep 2021; 11:23878. [PMID: 34903833 PMCID: PMC8668907 DOI: 10.1038/s41598-021-03440-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/30/2021] [Indexed: 01/22/2023] Open
Abstract
The discriminative power of CURB-65 for mortality in community-acquired pneumonia (CAP) is suspected to decrease with age. However, a useful prognostic prediction model for older patients with CAP has not been established. This study aimed to develop and validate a new scoring system for predicting mortality in older patients with CAP. We recruited two prospective cohorts including patients aged ≥ 65 years and hospitalized with CAP. In the derivation (n = 872) and validation cohorts (n = 1,158), the average age was 82.0 and 80.6 years and the 30-day mortality rate was 7.6% (n = 66) and 7.4% (n = 86), respectively. A new scoring system was developed based on factors associated with 30-day mortality, identified by multivariate analysis in the derivation cohort. This scoring system named CHUBA comprised five variables: confusion, hypoxemia (SpO2 ≤ 90% or PaO2 ≤ 60 mmHg), blood urea nitrogen ≥ 30 mg/dL, bedridden state, and serum albumin level ≤ 3.0 g/dL. With regard to 30-day mortality, the area under the receiver operating characteristic curve for CURB-65 and CHUBA was 0.672 (95% confidence interval, 0.607–0.732) and 0.809 (95% confidence interval, 0.751–0.856; P < 0.001), respectively. The effectiveness of CHUBA was statistically confirmed in the external validation cohort. In conclusion, a simpler novel scoring system, CHUBA, was established for predicting mortality in older patients with CAP.
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González FJ, Miranda FA, Chávez SM, Gajardo AI, Hernández AR, Guiñez DV, Díaz GA, Sarmiento NV, Ihl FE, Cerda MA, Valencia CS, Cornejo RA. Clinical characteristics and in-hospital mortality of patients with COVID-19 in Chile: A prospective cohort study. Int J Clin Pract 2021; 75:e14919. [PMID: 34564929 PMCID: PMC8646285 DOI: 10.1111/ijcp.14919] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 09/08/2021] [Accepted: 09/23/2021] [Indexed: 01/08/2023] Open
Abstract
AIMS OF THIS STUDY To describe the Latin American population affected by COVID-19, and to determine relevant risk factors for in-hospital mortality. METHODS We prospectively registered relevant clinical, laboratory, and radiological data of adult patients with COVID-19, admitted within the first 100 days of the pandemic from a single teaching hospital in Santiago, Chile. The primary outcome was in-hospital mortality. Secondary outcomes included the need for respiratory support and pharmacological treatment, among others. We combined the chronic disease burden and the severity of illness at admission with predefined clinically relevant risk factors. Cox regression models were used to identify risk factors for in-hospital mortality. RESULTS We enrolled 395 adult patients, their median age was 61 years; 62.8% of patients were male and 40.1% had a Modified Charlson Comorbidity Index (MCCI) ≥5. Their median Sequential Organ Failure Assessment (SOFA) score was 3; 34.9% used a high-flow nasal cannula and 17.5% required invasive mechanical ventilation. The in-hospital mortality rate was 14.7%. In the multivariate analysis, were significant risk factors for in-hospital mortality: MCCI ≥5 (HR 4.39, P < .001), PaO2 /FiO2 ratio ≤200 (HR 1.92, P = .037), and advanced chronic respiratory disease (HR 3.24, P = .001); pre-specified combinations of these risk factors in four categories was associated with the outcome in a graded manner. CONCLUSIONS AND CLINICAL IMPLICATIONS The relationship between multiple prognostic factors has been scarcely reported in Latin American patients with COVID-19. By combining different clinically relevant risk factors, we can identify COVID-19 patients with high-, medium- and low-risk of in-hospital mortality.
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Affiliation(s)
- Francisco J. González
- Department of Internal MedicineUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
- Internal Medicine SectionUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
| | - Fabián A. Miranda
- Department of Internal MedicineUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
- Internal Medicine SectionUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
- Critical Care UnitUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
| | - Sebastián M. Chávez
- Department of Internal MedicineUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
- Internal Medicine SectionUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
- Critical Care UnitUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
| | - Abraham I. Gajardo
- Department of Internal MedicineUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
- Critical Care UnitUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
| | - Ariane R. Hernández
- Department of Internal MedicineUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
- Internal Medicine SectionUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
- Critical Care UnitUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
| | - Dannette V. Guiñez
- Department of Internal MedicineUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
- Internal Medicine SectionUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
- Critical Care UnitUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
| | - Gonzalo A. Díaz
- Department of Internal MedicineUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
- Internal Medicine SectionUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
- Critical Care UnitUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
| | - Natalia V. Sarmiento
- Department of Internal MedicineUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
- Internal Medicine SectionUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
| | - Fernando E. Ihl
- Department of Internal MedicineUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
- Internal Medicine SectionUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
| | - María A. Cerda
- Department of Internal MedicineUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
- Internal Medicine SectionUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
- Critical Care UnitUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
| | - Camila S. Valencia
- Department of Internal MedicineUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
- Internal Medicine SectionUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
| | - Rodrigo A. Cornejo
- Department of Internal MedicineUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
- Critical Care UnitUniversity of Chile Clinical HospitalUniversity of ChileSantiagoChile
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Li L, Wang C, Sun L, Zhang X, Yang G. Clinical characteristics and prognostic risk factors of mortality in patients with interstitial lung diseases and viral infection: a retrospective cohort study. J Med Microbiol 2021; 70. [PMID: 34738890 PMCID: PMC8742552 DOI: 10.1099/jmm.0.001449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction. Patients with interstitial lung disease (ILD) who subsequently develop a viral infection have high rates of morbidity and mortality.Hypothesis/Gap Statement. Few large-scale epidemiological studies have investigated potential prognostic factors for morbidity and mortality in this patient group.Aim. To evaluate the risk factors for morbidity and mortality in hospitalized patients with ILD and viral infection, as well as the clinical characteristics.Methodology. This retrospective cohort study included patients with ILD who were hospitalized for a viral infection in two tertiary academic hospitals in China, between 1 January 2013 and 31 December 2019. We analysed the prevalence of comorbidities, clinical characteristics, 30 day mortality rates, and prognostic risk factors.Results. A total of 282 patients were included; 195 and 87 were immunocompromised and immunocompetent, respectively. The most common underlying interstitial diseases were idiopathic pulmonary fibrosis (42.9 %) and connective tissue disease (36.9 %). The 30 day mortality rate was 20.6 %. During the influenza season, an increase in influenza virus (IFV) (25.7 %), respiratory syncytial virus (14.9 %) and cytomegalovirus (CMV) (11.3 %) cases was observed in the immunocompromised group. The most frequently detected virus in the immunocompetent group was IFV (44.8 %), followed by respiratory syncytial virus (11.5 %), and human rhinovirus (9.2 %). During the non-influenza season, CMV (34.4 %) was the main virus detected in the immunocompromised group. The 30 day mortality rates of non-IFV patients were higher than those of IFV patients. Older age (>60 years), respiratory failure, persistent lymphocytopenia, invasive mechanical ventilation and non-IFV virus infection were significantly associated with increased 30 day mortality.Conclusion. Patients with ILD who develop viral infection have high rates of morbidity and mortality, which are associated with increased age (>60 years), respiratory failure, mechanical ventilation, persistent lymphocytopenia and non-IFV virus infection. These risk factors should be carefully considered when determining treatment strategies for this patient population.
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Affiliation(s)
- Lijuan Li
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, PR China
| | - Chulei Wang
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, PR China
| | - Lingxiao Sun
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, PR China
| | - Xiaoqi Zhang
- Department of Pulmonary and Critical Care Medicine, Second People's Hospital of Weifang, Weifang 261041, PR China
| | - Guoru Yang
- Department of Pulmonary and Critical Care Medicine, Second People's Hospital of Weifang, Weifang 261041, PR China
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Computerized Mortality Prediction for Community-acquired Pneumonia at 117 Veterans Affairs Medical Centers. Ann Am Thorac Soc 2021; 18:1175-1184. [PMID: 33635750 DOI: 10.1513/annalsats.202011-1372oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Computerized severity assessment for community-acquired pneumonia could improve consistency and reduce clinician burden. Objectives: To develop and compare 30-day mortality-prediction models using electronic health record data, including a computerized score with all variables from the original Pneumonia Severity Index (PSI) except confusion and pleural effusion ("ePSI score") versus models with additional variables. Methods: Among adults with community-acquired pneumonia presenting to emergency departments at 117 Veterans Affairs Medical Centers between January 1, 2006, and December 31, 2016, we compared an ePSI score with 10 novel models employing logistic regression, spline, and machine learning methods using PSI variables, age, sex and 26 physiologic variables as well as all 69 PSI variables. Models were trained using encounters before January 1, 2015; tested on encounters during and after January 1, 2015; and compared using the areas under the receiver operating characteristic curve, confidence intervals, and patient event rates at a threshold PSI score of 970. Results: Among 297,498 encounters, 7% resulted in death within 30 days. When compared using the ePSI score (confidence interval [CI] for the area under the receiver operating characteristic curve, 0.77-0.78), performance increased with model complexity (CI for the logistic regression PSI model, 0.79-0.80; CI for the boosted decision-tree algorithm machine learning PSI model using the Extreme Gradient Boosting algorithm [mlPSI] with the 19 original PSI factors, 0.83-0.85) and the number of variables (CI for the logistic regression PSI model using all 69 variables, 0.84-085; CI for the mlPSI with all 69 variables, 0.86-0.87). Models limited to age, sex, and physiologic variables also demonstrated high performance (CI for the mlPSI with age, sex, and 26 physiologic factors, 0.84-0.85). At an ePSI score of 970 and a mortality-risk cutoff of <2.7%, the ePSI score identified 31% of all patients as being at "low risk"; the mlPSI with age, sex, and 26 physiologic factors identified 53% of all patients as being at low risk; and the mlPSI with all 69 variables identified 56% of all patients as being at low risk, with similar rates of mortality, hospitalization, and 7-day secondary hospitalization being determined. Conclusions: Computerized versions of the PSI accurately identified patients with pneumonia who were at low risk of death. More complex models classified more patients as being at low risk of death and as having similar adverse outcomes.
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Saha R, Aich S, Tripathy S, Kim HC. Artificial Intelligence Is Reshaping Healthcare amid COVID-19: A Review in the Context of Diagnosis & Prognosis. Diagnostics (Basel) 2021; 11:1604. [PMID: 34573946 PMCID: PMC8471992 DOI: 10.3390/diagnostics11091604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/28/2021] [Accepted: 09/01/2021] [Indexed: 12/24/2022] Open
Abstract
Preventing respiratory failure is crucial in a large proportion of COVID-19 patients infected with SARS-CoV-2 virus pneumonia termed as Novel Coronavirus Pneumonia (NCP). Rapid diagnosis and detection of high-risk patients for effective interventions have been shown to be troublesome. Using a large, computed tomography (CT) database, we developed an artificial intelligence (AI) parameter to diagnose NCP and distinguish it from other kinds of pneumonia and traditional controls. The literature was studied and analyzed from diverse assets which include Scopus, Nature medicine, IEEE, Google scholar, Wiley Library, and PubMed. The search terms used were 'COVID-19', 'AI', 'diagnosis', and 'prognosis'. To strengthen the overall performance of AI in COVID-19 diagnosis and prognosis, we segregated several components to perceive threats and opportunities, as well as their inter-dependencies that affect the healthcare sector. This paper seeks to pick out the crucial fulfillment of factors for AI with inside the healthcare sector in the Indian context. Using critical literature review and experts' opinion, a total of 11 factors affecting COVID-19 diagnosis and prognosis were detected, and we eventually used an interpretive structural model (ISM) to build a framework of interrelationships among the identified factors. Finally, the matrice d'impacts croisés multiplication appliquée á un classment (MICMAC) analysis resulted the driving and dependence powers of these identified factors. Our analysis will help healthcare stakeholders to realize the requirements for successful implementation of AI.
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Affiliation(s)
- Rajnandini Saha
- School of Biotechnology, KIIT Deemed to be University, Bhubaneswar 751024, Odisha, India;
| | | | - Sushanta Tripathy
- School of Mechanical Engineering, KIIT Deemed to be University, Bhubaneswar 751024, Odisha, India
| | - Hee-Cheol Kim
- Institute of Digital Anti-Aging Healthcare, College of AI Convergence, u-AHRC, Inje University, Gimhae 50834, Korea
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Bahlis LF, Diogo LP, Fuchs SC. Charlson Comorbidity Index and other predictors of in-hospital mortality among adults with community-acquired pneumonia. ACTA ACUST UNITED AC 2021; 47:e20200257. [PMID: 33656092 PMCID: PMC8332672 DOI: 10.36416/1806-3756/e20200257] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/17/2020] [Indexed: 12/14/2022]
Abstract
Objective: To compare the performance of Charlson Comorbidity Index (CCI) with those of the mental Confusion, Urea, Respiratory rate, Blood pressure, and age = 65 years (CURB-65) score and the Pneumonia Severity Index (PSI) as predictors of all-cause in-hospital mortality in patients with community-acquired pneumonia (CAP). Methods: This was a cohort study involving hospitalized patients with CAP between April of 2014 and March of 2015. Clinical, laboratory, and radiological data were obtained in the ER, and the scores of CCI, CURB-65, and PSI were calculated. The performance of the models was compared using ROC curves and AUCs (95% CI). Results: Of the 459 patients evaluated, 304 met the eligibility criteria. The all-cause in-hospital mortality rate was 15.5%, and 89 (29.3%) of the patients were admitted to the ICU. The AUC for the CCI was significantly greater than those for CURB-65 and PSI (0.83 vs. 0.73 and 0.75, respectively). Conclusions: In this sample of hospitalized patients with CAP, CCI was a better predictor of all-cause in-hospital mortality than were the PSI and CURB-65.
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Affiliation(s)
- Laura Fuchs Bahlis
- . Faculdade de Medicina, Universidade do Vale do Rio dos Sinos - UNISINOS - São Leopoldo (RS) Brasil.,. Programa de Pós-Graduação em Epidemiologia, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil.,. Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
| | - Luciano Passamani Diogo
- . Faculdade de Medicina, Universidade do Vale do Rio dos Sinos - UNISINOS - São Leopoldo (RS) Brasil.,. Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
| | - Sandra Costa Fuchs
- . Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
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Kaya AE, Ozkan S, Usul E, Arslan ED. Comparison of pneumonia severity scores for patients diagnosed with pneumonia in emergency department. Indian J Med Res 2021; 152:368-377. [PMID: 33380701 PMCID: PMC8061599 DOI: 10.4103/ijmr.ijmr_595_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background & objectives: Sepsis due to pneumonia or pneumonia itself is one of the main causes of deaths in patients despite the advanced treatment methods. The optimal prognostic tool in pneumonia is still not clear. This study was aimed to compare the pneumonia severity scores and the possibility of using the new scores in patients who were diagnosed with pneumonia in the emergency department. Methods: Demographic data, laboratory and imaging results, confusion, elevated blood urea nitrogen, respiratory rate and blood pressure plus age ≥65 yr (CURB-65), pneumonia severity index (PSI), national early warning score (NEWS), NEWS-lactate (NEWS-L) scores, hospitalization, referral, discharge and 30-day mortality of patients who were diagnosed with pneumonia in emergency department were recorded. Results: A total of 250 patients were included in the study. The most successful score in predicted mortality was found to be NEWS-L. This was followed by NEWS, CURB-65 and PSI, respectively. Most successful scores in anticipation of admission to the intensive care unit were NEWS-L followed by NEWS. This was followed by CURB-65 and PSI scores, respectively. The most successful score in anticipation of hospital admission was NEWS-L, followed by NEWS, CURB-65 and PSI, respectively. There was a significant difference between all pneumonia severity scores of the patients who died and survived within 30 days. There was a significant difference between the scores of patients in intensive care unit (ICU) and service, compared to non-ICU patients. Interpretation & conclusions: NEWS-L score was found to be the most successful score in predicting mortality, ICU admission and hospitalization requirement. Both NEWS-L and NEWS scores can be used in determining the mortality, need for hospitalization and intensive care of the patients with pneumonia in the emergency department.
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Affiliation(s)
- Aynur Ecevit Kaya
- Department of Emergency Medicine, Bursa City Hospital, Bursa, Turkey
| | - Seda Ozkan
- Department of Emergency Medicine, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Eren Usul
- Department of Emergency Medicine, Sincan State Hospital, Ankara, Turkey
| | - Engin Deniz Arslan
- Department of Emergency Medicine, Antalya Training & Research Hospital, Antalya, Turkey
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Li L, Hsu SH, Gu X, Jiang S, Shang L, Sun G, Sun L, Zhang L, Wang C, Ren Y, Wang J, Pan J, Liu J, Bin C. Aetiology and prognostic risk factors of mortality in patients with pneumonia receiving glucocorticoids alone or glucocorticoids and other immunosuppressants: a retrospective cohort study. BMJ Open 2020; 10:e037419. [PMID: 33109645 PMCID: PMC7592294 DOI: 10.1136/bmjopen-2020-037419] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES Long-term use of high-dose glucocorticoids can lead to severe immunosuppression and increased risk of treatment-resistant pneumonia and mortality. We investigated the aetiology and prognostic risk factors of mortality in hospitalised patients who developed pneumonia while receiving glucocorticoid therapy alone or glucocorticoid and other immunosuppressant therapies. DESIGN Retrospective cohort study. SETTING Six secondary and tertiary academic hospitals in China. PARTICIPANTS Patients receiving glucocorticoids who were hospitalised with pneumonia between 1 January 2013 and 31 December 2019. MAIN OUTCOMES We analysed the prevalence of comorbidities, microbiology, antibiotic susceptibility patterns, 30-day and 90-day mortality and prognostic risk factors. RESULTS CONCLUSIONS: A total of 716 patients were included, with pneumonia pathogens identified in 69.8% of patients. Significant morbidities occurred, including respiratory failure (50.8%), intensive care unit transfer (40.8%) and mechanical ventilation (36%), with a 90-day mortality of 26.0%. Diagnosis of pneumonia occurred within 6 months of glucocorticoid initiation for 69.7% of patients with Cytomegalovirus (CMV) pneumonia and 79.0% of patients with Pneumocystis jirovecii pneumonia (PCP). Pathogens, including Pneumocystis, CMV and multidrug-resistant bacteria, were identified more frequently in patients with persistent lymphocytopenia and high-dose glucocorticoid treatment (≥30 mg/day of prednisolone or equivalent within 30 days before admission). The 90-day mortality was significantly lower for non-CMV viral pneumonias than for PCP (p<0.05), with a similar mortality as CMV pneumonias (24.2% vs 38.1% vs 27.4%, respectively). Cox regression analysis indicated several independent negative predictors for mortality in this patient population, including septic shock, respiratory failure, persistent lymphocytopenia, interstitial lung disease and high-dose glucocorticoid use.Patients who developed pneumonia while receiving glucocorticoid therapy experienced high rates of opportunistic infections, with significant morbidity and mortality. These findings should be carefully considered when determining treatment strategies for this patient population.
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Affiliation(s)
- Lijuan Li
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Steven H Hsu
- Department of Medical Intensive Care Unit, Houston Methodist Hospital, Houston, Texas, USA
| | - Xiaoying Gu
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Shan Jiang
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Lianhan Shang
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Guolei Sun
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Lingxiao Sun
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Li Zhang
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Chuan Wang
- Department of Pulmonary and Critical Care Medicine, First Hospital of Shijiazhuang, Shijiazhuang, China
| | - Yali Ren
- Department of Pulmonary and Critical Care Medicine, Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jinxiang Wang
- Department of Respiratory and Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Jianliang Pan
- Department of Pulmonary and Critical Care Medicine, Second People's Hospital of Weifang, Weifang, China
| | - Jiangbo Liu
- Department of Pulmonary and Critical Care Medicine, Tianjin First Central Hospital, Tianjin, China
| | - Cao Bin
- Department of Pulmonary and Critical Care Medicine, Laboratory of Clinical Microbiology and Infectious Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Science; Tsinghua University-Peking University Joint Center for Life Sciences, China-Japan Friendship Hospital, Beijing, China
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Artificial Intelligence for clinical decision support in Critical Care, required and accelerated by COVID-19. Anaesth Crit Care Pain Med 2020; 39:691-693. [PMID: 33099016 PMCID: PMC7577289 DOI: 10.1016/j.accpm.2020.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 09/13/2020] [Accepted: 09/15/2020] [Indexed: 01/10/2023]
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Community-Acquired Pneumonia. Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) Guidelines. 2020 Update. Arch Bronconeumol 2020. [PMID: 32139236 DOI: 10.1016/j.arbres.2020.01.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The guidelines for community-acquired pneumonia, last published in 2010, have been updated to provide recommendations based on a critical summary of the latest literature to help health professionals make the best decisions in the care of immunocompetent adult patients. The methodology was based on 6 PICO questions (on etiological studies, assessment of severity and decision to hospitalize, antibiotic treatment and duration, and pneumococcal conjugate vaccination), agreed by consensus among a working group of pulmonologists and an expert in documentation science and methodology. A comprehensive review of the literature was performed for each PICO question, and these were evaluated in in-person meetings. The American Thoracic Society guidelines were published during the preparation of this paper, so the recommendations of this association were also evaluated. We concluded that the etiological source of the infection should be investigated in hospitalized patients who have suspected resistance or who fail to respond to treatment. Prognostic scales, such as PSI, CURB 65, and CRB65, are useful for assessing severity and the decision to hospitalize. Different antibiotic regimens are indicated, depending on the treatment setting - outpatient, hospital, or intensive care unit - and the resistance of PES microorganisms should be calculated. The minimum duration of antibiotic treatment should be 5 days, based on criteria of clinical stability. Finally, we reviewed the indication of the 13-valent conjugate vaccine in immunocompetent patients with risk factors and comorbidity.
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Mizera L, Boehm K, Duckheim M, Groga-Bada P, Gawaz M, Zuern CS, Eick C. Autonomic Nervous System Activity for Risk Stratification of Emergency Patients With Pneumonia. J Emerg Med 2018; 55:472-480. [PMID: 30057006 DOI: 10.1016/j.jemermed.2018.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 06/01/2018] [Accepted: 06/12/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Community-acquired pneumonia (CAP) causes appreciable morbidity and mortality in adults, especially in those ≥65 years of age. At hospital admission, an immediate and reliable risk assessment is necessary to detect patients with possible fatal outcome. OBJECTIVE We aimed to evaluate markers of the autonomic nervous system based on an electrocardiogram to predict mortality in patients with CAP. METHODS For this purpose, the deceleration capacity (DC) of heart rate was calculated in 253 patients who presented to the emergency department with CAP. The 30-day mortality rate was defined as the primary endpoint (PEP). The secondary endpoint was the total mortality within 180 days. RESULTS PEP was reached in 33 patients (13%). The DC, measured in milliseconds, was significantly lower in patients who reached the PEP than in those who did not (2.3 ± 1.5 ms vs. 3.6 ± 2.3 ms, p = 0.004). The DC was also significantly lower in nonsurvivors than in survivors at the time of the secondary endpoint (2.3 ± 1.5 ms vs. 3.7 ± 2.4 ms, p < 0.001). Our results indicate that DC is an independent predictor of 30- and 180-day mortality. CONCLUSION DC was independently associated with death from CAP in our study. As a practical consequence, DC could be useful in triage decisions. Patients with certain high risks could benefit from adjuvant treatment and special medical attention.
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Affiliation(s)
- Lars Mizera
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Katharina Boehm
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Martin Duckheim
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Patrick Groga-Bada
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Meinrad Gawaz
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Christine S Zuern
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany; Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Christian Eick
- Department of Cardiology, University Hospital Tuebingen, Tuebingen, Germany
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Hamaguchi S, Suzuki M, Sasaki K, Abe M, Wakabayashi T, Sando E, Yaegashi M, Morimoto S, Asoh N, Hamashige N, Aoshima M, Ariyoshi K, Morimoto K. Six underlying health conditions strongly influence mortality based on pneumonia severity in an ageing population of Japan: a prospective cohort study. BMC Pulm Med 2018; 18:88. [PMID: 29792181 PMCID: PMC5967104 DOI: 10.1186/s12890-018-0648-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 05/10/2018] [Indexed: 11/16/2022] Open
Abstract
Background Mortality prediction of pneumonia by severity scores in patients with multiple underlying health conditions has not fully been investigated. This prospective cohort study is to identify mortality-associated underlying health conditions and to analyse their influence on severity-based pneumonia mortality prediction. Methods Adult patients with community-acquired pneumonia or healthcare-associated pneumonia (HCAP) who visited four community hospitals between September 2011 and January 2013 were enrolled. Candidate underlying health conditions, including demographic and clinical characteristics, were incorporated into the logistic regression models, along with CURB (confusion, elevated urea nitrogen, tachypnoea, and hypotension) score as a measure of disease severity. The areas under the receiver operating characteristic curves (AUROC) of the predictive index based on significant underlying health conditions was compared to that of CURB65 (CURB and age ≥ 65) score or Pneumonia severity index (PSI). Mortality association between disease severity and the number of underlying health conditions was analysed. Results In total 1772 patients were eligible for analysis, of which 140 (7.9%) died within 30 days. Six underlying health conditions were independently associated: home care (adjusted odds ratio, 5.84; 95% confidence interval, CI, 2.28–14.99), recent hospitalization (2.21; 1.36–3.60), age ≥ 85 years (2.15; 1.08–4.28), low body mass index (1.99, 1.25–3.16), neoplastic disease (1.82; 1.17–2.85), and male gender (1.78; 1.16–2.75). The predictive index based on these conditions alone had a significantly or marginally higher AUROC than that based on CURB65 score (0.78 vs 0.66, p = 0.02) or PSI (0.78 vs 0.71, p = 0.05), respectively. Compared to this index, the AUROC of the total score consisting of six underlying health conditions and CURB score (range 0–10) did not improve mortality predictions (p = 0.3). In patients with one or less underlying health conditions, the mortality was discretely associated with severe pneumonia (CURB65 ≥ 3) (risk ratio: 7.24, 95%CI: 3.08–25.13), whereas in patients with 2 or more underlying health conditions, the mortality association with severe pneumonia was not detected (risk ratio: 1.53, 95% CI: 0.94–2.50). Conclusions Mortality prediction based on pneumonia severity scores is highly influenced by the accumulating number of underlying health conditions in an ageing society. The validation using a different cohort is necessary to generalise the conclusion. Electronic supplementary material The online version of this article (10.1186/s12890-018-0648-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sugihiro Hamaguchi
- Department of General Internal Medicine, Fukushima Medical University, Fukushima, Japan.,Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan
| | - Motoi Suzuki
- Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan
| | - Kota Sasaki
- Department of Laboratory Medicine, Ebetsu City Hospital, Ebetsu, Japan
| | - Masahiko Abe
- Department of General Internal Medicine, Ebetsu City Hospital, Ebetsu, Japan
| | - Takao Wakabayashi
- Department of General Medicine, Sapporo Hokushin Hospital, Sapporo, Japan
| | - Eiichiro Sando
- Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan.,Department of General Internal Medicine, Kameda Medical Centre, Kamogawa, Japan
| | - Makito Yaegashi
- Department of General Internal Medicine, Kameda Medical Centre, Kamogawa, Japan
| | - Shimpei Morimoto
- Innovation platform & office for precision medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Norichika Asoh
- Department of Internal Medicine, Juzenkai Hospital, Nagasaki, Japan
| | | | - Masahiro Aoshima
- Department of Pulmonology, Kameda Medical Centre, Kamogawa, Japan
| | - Koya Ariyoshi
- Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan
| | - Konosuke Morimoto
- Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan.
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Predicting the Risk of Readmission in Pneumonia. A Systematic Review of Model Performance. Ann Am Thorac Soc 2018; 13:1607-14. [PMID: 27299853 DOI: 10.1513/annalsats.201602-135sr] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
RATIONALE Predicting which patients are at highest risk for readmission after hospitalization for pneumonia could enable hospitals to proactively reallocate scarce resources to reduce 30-day readmissions. OBJECTIVES To synthesize the available literature on readmission risk prediction models for adults who are hospitalized because of pneumonia and describe their performance. METHODS We systematically searched Ovid MEDLINE, Embase, The Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature databases from inception through July 2015. We included studies of adults discharged with pneumonia that developed or validated a model that predicted hospital readmission. Two independent reviewers abstracted data and assessed the risk of bias. MEASUREMENTS AND MAIN RESULTS Of 992 citations reviewed, 7 studies met inclusion criteria, which included 11 unique risk prediction models. All-cause 30-day readmission rates ranged from 11.8 to 20.8% (median, 17.3%). Model discrimination (C statistic) ranged from 0.59 to 0.77 (median, 0.63) with the highest-quality, best-validated model, the Centers for Medicare and Medicaid Services Pneumonia Administrative Model performing modestly (C Statistic of 0.63 in 4 separate multicenter cohorts). The best performing model (C statistic of 0.77) was a single-site study that lacked internal validation. The models had adequate calibration, with patients predicted as high risk for readmission having a higher average observed readmission rate than those predicted to be low risk. None of the studies included pneumonia illness severity scores, and only one included measures of in-hospital clinical trajectory and stability on discharge, robust predictors of readmission. CONCLUSIONS We found a limited number of validated pneumonia-specific readmission models, and their predictive ability was modest. To improve predictive accuracy, future models should include measures of pneumonia illness severity, hospital complications, and stability on discharge.
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Makam AN, Nguyen OK, Clark C, Zhang S, Xie B, Weinreich M, Mortensen EM, Halm EA. Predicting 30-Day Pneumonia Readmissions Using Electronic Health Record Data. J Hosp Med 2017; 12:209-216. [PMID: 28411288 PMCID: PMC6296251 DOI: 10.12788/jhm.2711] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Readmissions after hospitalization for pneumonia are common, but the few risk-prediction models have poor to modest predictive ability. Data routinely collected in the electronic health record (EHR) may improve prediction. OBJECTIVE To develop pneumonia-specific readmission risk-prediction models using EHR data from the first day and from the entire hospital stay ("full stay"). DESIGN Observational cohort study using stepwise-backward selection and cross-validation. SUBJECTS Consecutive pneumonia hospitalizations from 6 diverse hospitals in north Texas from 2009-2010. MEASURES All-cause nonelective 30-day readmissions, ascertained from 75 regional hospitals. RESULTS Of 1463 patients, 13.6% were readmitted. The first-day pneumonia-specific model included sociodemographic factors, prior hospitalizations, thrombocytosis, and a modified pneumonia severity index; the full-stay model included disposition status, vital sign instabilities on discharge, and an updated pneumonia severity index calculated using values from the day of discharge as additional predictors. The full-stay pneumonia-specific model outperformed the first-day model (C statistic 0.731 vs 0.695; P = 0.02; net reclassification index = 0.08). Compared to a validated multi-condition readmission model, the Centers for Medicare and Medicaid Services pneumonia model, and 2 commonly used pneumonia severity of illness scores, the full-stay pneumonia-specific model had better discrimination (C statistic range 0.604-0.681; P < 0.01 for all comparisons), predicted a broader range of risk, and better reclassified individuals by their true risk (net reclassification index range, 0.09-0.18). CONCLUSIONS EHR data collected from the entire hospitalization can accurately predict readmission risk among patients hospitalized for pneumonia. This approach outperforms a first-day pneumonia-specific model, the Centers for Medicare and Medicaid Services pneumonia model, and 2 commonly used pneumonia severity of illness scores. Journal of Hospital Medicine 2017;12:209-216.
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Affiliation(s)
- Anil N. Makam
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
- Address for correspondence and reprint requests: Anil N. Makam, MD, MAS; 5323 Harry Hines Blvd., Dallas, TX, 75390-9169; Telephone: 214-648-3272; Fax: 214-648-3232;
| | - Oanh Kieu Nguyen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christopher Clark
- Office of Research Administration, Parkland Health and Hospital System, Dallas, Texas
| | - Song Zhang
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bin Xie
- Parkland Center for Clinical Innovation, Dallas, Texas
| | - Mark Weinreich
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Eric M. Mortensen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
- VA North Texas Health Care System, Dallas, Texas
| | - Ethan A. Halm
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
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Khan F, Owens MB, Restrepo M, Povoa P, Martin-Loeches I. Tools for outcome prediction in patients with community acquired pneumonia. Expert Rev Clin Pharmacol 2016; 10:201-211. [PMID: 27911103 DOI: 10.1080/17512433.2017.1268051] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Community-acquired pneumonia (CAP) is one of the most common causes of mortality world-wide. The mortality rate of patients with CAP is influenced by the severity of the disease, treatment failure and the requirement for hospitalization and/or intensive care unit (ICU) management, all of which may be predicted by biomarkers and clinical scoring systems. Areas covered: We review the recent literature examining the efficacy of established and newly-developed clinical scores, biological and inflammatory markers such as C-Reactive protein (CRP), procalcitonin (PCT) and Interleukin-6 (IL-6), whether used alone or in conjunction with clinical severity scores to assess the severity of CAP, predict treatment failure, guide acute in-hospital or ICU admission and predict mortality. Expert commentary: The early prediction of treatment failure using clinical scores and biomarkers plays a developing role in improving survival of patients with CAP by identifying high-risk patients requiring hospitalization or ICU admission; and may enable more efficient allocation of resources. However, it is likely that combinations of scoring systems and biomarkers will be of greater use than individual markers. Further larger studies are needed to corroborate the additive value of these markers to clinical prediction scores to provide a safer and more effective assessment tool for clinicians.
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Affiliation(s)
- Faheem Khan
- a Intensive Care Medicine , St James's University Hospital , Dublin , Ireland
| | - Mark B Owens
- a Intensive Care Medicine , St James's University Hospital , Dublin , Ireland
| | - Marcos Restrepo
- b Department of Respiratory Medicine , South Texas Veterans Health Care System and the University of Texas Health Science Center at San Antonio , San Antonio , TX , USA
| | - Pedro Povoa
- c Department of Intensive Care Medicine , Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental , Lisbon , Portugal.,d Nova Medical School, CEDOC, New University of Lisbon , Lisbon , Portugal
| | - Ignacio Martin-Loeches
- a Intensive Care Medicine , St James's University Hospital , Dublin , Ireland.,e Department of Clinical Medicine , Trinity College, Welcome Trust-HRB Clinical Research Facility, St James Hospital , Dublin , Ireland
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Andersen SB, Baunbæk Egelund G, Jensen AV, Petersen PT, Rohde G, Ravn P. Failure of CRP decline within three days of hospitalization is associated with poor prognosis of Community-acquired Pneumonia. Infect Dis (Lond) 2016; 49:251-260. [DOI: 10.1080/23744235.2016.1253860] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Stine Bang Andersen
- Department of Pulmonary and Infectious Diseases, Nordsjællands Hospital – Hillerød, Hillerød, Denmark
- Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Gertrud Baunbæk Egelund
- Department of Pulmonary and Infectious Diseases, Nordsjællands Hospital – Hillerød, Hillerød, Denmark
- Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Vestergaard Jensen
- Department of Pulmonary and Infectious Diseases, Nordsjællands Hospital – Hillerød, Hillerød, Denmark
- Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Pelle Trier Petersen
- Department of Pulmonary and Infectious Diseases, Nordsjællands Hospital – Hillerød, Hillerød, Denmark
- Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Gernot Rohde
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, Netherlands
- CAPNETZ-Stiftung, Hannover Medical School, Hannover, Germany
| | - Pernille Ravn
- Department of Pulmonary and Infectious Diseases, Nordsjællands Hospital – Hillerød, Hillerød, Denmark
- Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
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Relster MM, Holm A, Pedersen C. Plasma cytokines eotaxin, MIP-1α, MCP-4, and vascular endothelial growth factor in acute lower respiratory tract infection. APMIS 2016; 125:148-156. [PMID: 27859623 DOI: 10.1111/apm.12636] [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: 04/26/2016] [Accepted: 09/22/2016] [Indexed: 01/11/2023]
Abstract
Major overlaps of clinical characteristics and the limitations of conventional diagnostic tests render the initial diagnosis and clinical management of pulmonary disorders difficult. In this pilot study, we analyzed the predictive value of eotaxin, macrophage inflammatory protein 1 alpha (MIP-1α), monocyte chemoattractant protein 4 (MCP-4), and vascular endothelial growth factor (VEGF) in 40 patients hospitalized with acute lower respiratory tract infections (LRTI). The cytokines contribute to the pathogenesis of several inflammatory respiratory diseases, indicating a potential as markers for LRTI. Patients were stratified according to etiology and severity of LRTI, based on baseline C-reactive protein and CURB-65 scores. Using a multiplex immunoassay of plasma, levels of eotaxin and MCP-4 were shown to increase from baseline until day 6 after admission to hospital. The four cytokines were unable to predict the etiology and severity. Eotaxin and MCP-4 were significantly lower in patients with C-reactive protein ≥100, and MIP-1α was significantly higher in the patients with CURB-65 > 3, but the predictive power was low. In conclusion, further evaluation, including more patients, is required to assess the full potential of eotaxin, MCP-4, MIP-1α, and VEGF as biomarkers for LRTI because of their low predictive power and a high interindividual variation of cytokine levels.
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Affiliation(s)
- Mette Marie Relster
- Department of Internal Medicine, Division of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | - Anette Holm
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | - Court Pedersen
- Department of Internal Medicine, Division of Infectious Diseases, Odense University Hospital, Odense, Denmark
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Mbwele B, Slot A, De Mast Q, Kweka P, Msuya M, Hulscher M. The Use of Guidelines for Lower Respiratory Tract Infections in Tanzania: A Lesson from Kilimanjaro Clinicians. Ann Med Health Sci Res 2016; 6:100-8. [PMID: 27213093 PMCID: PMC4866362 DOI: 10.4103/2141-9248.181845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Evaluations of the guidelines for the management of Lower Respiratory Tract Infections (LRTI) Sub-Saharan Africa, particularly in Tanzania is scant. Aim: The aim of the study was to assess the usefulness of the current Tanzanian treatment guideline for the management lower respiratory tract infection. Subjects and Methods: A descriptive cross sectional study in 11 hospitals of different levels in the Kilimanjaro region Data were collected from May 2012 to July 2012 by semi-structured interview for clinicians using 2 dummy cases for practical assessment. Data were analyzed by STATA v11 (StataCorp, TX, USA). Qualitative narratives from the interviews were translated, transcribed then coded by colors into meaningful themes. Results: A variety of principles for diagnosing and managing LRTI were demonstrated by 53 clinicians of Kilimanjaro. For the awareness, 67.9% (36/53) clinicians knew their responsibility to use Standard Treatment Guideline for managing LRTI. The content derived from Standard Treatment Guideline could be cited by 11.3% of clinicians (6/53) however they all showed concern of gaps in the guideline. Previous training in the management of patients with LRTI was reported by 25.9% (14/53), majority were pulmonary TB related. Correct microorganisms causing different forms of LRTI were mentioned by 11.3% (6/53). Exact cause of Atypical pneumonia and Q fever as an example was stated by 13.0% (7/53) from whom the need of developing the guideline for LRTI was explicitly elaborated. Conclusion: The current guidelines have not been used effectively for the management of LRTI in Tanzania. There is a need to review its content for the current practical use.
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Affiliation(s)
- B Mbwele
- Kilimanjaro Christian Medical Center, Kilimanjaro Clinical Research Institute, Zanzibar, Tanzania; Programme Manager - Reproductive Maternal Newborn Child Health, Nutrition and WASH, Save the Children, Zanzibar, Tanzania
| | - A Slot
- Nijmegen Institute for International Health (NIIH, UMC Nijmegen), Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Q De Mast
- Nijmegen Institute for International Health (NIIH, UMC Nijmegen), Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - P Kweka
- Vijiji International, Kilimani Tower, Mawenzi Road, Moshi, Tanzania
| | - M Msuya
- Faculty of Nursing, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - M Hulscher
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Exploratory mixed methods study of respiratory physiotherapy for patients with lower respiratory tract infections. Physiotherapy 2016; 102:111-8. [DOI: 10.1016/j.physio.2015.03.3723] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 03/04/2015] [Indexed: 11/21/2022]
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Jo S, Jeong T, Lee JB, Jin Y, Yoon J, Park B. Validation of modified early warning score using serum lactate level in community-acquired pneumonia patients. The National Early Warning Score-Lactate score. Am J Emerg Med 2015; 34:536-41. [PMID: 26803715 DOI: 10.1016/j.ajem.2015.12.067] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 12/22/2015] [Indexed: 11/17/2022] Open
Abstract
STUDY OBJECTIVE The aim of this study was to investigate the prognostic prediction power of a newly introduced early warning score modified by serum lactate level, the National Early Warning Score-Lactate (NEWS-L) score, among community-acquired pneumonia (CAP) patients. We also compared the NEWS-L score with the pneumonia severity index (PSI) and CURB-65. METHODS We designed a retrospective observational study and collected data on confirmed adult CAP patients who visited the study hospital between October 2013 and September 2014. Variables relevant to, the NEWS-L score, PSI, and CURB-65 were extracted from electronic medical records. Survival status at hospital discharge was determined in the same manner. The NEWS-L score was calculated as NEWS-L=NEWS+serum lactate level (mmol/L). The NEWS-L was divided into quartiles. The ability to predict mortality was assessed through area under the receiver operating characteristic curve analysis and calibration analysis. RESULTS A total of 553 patients were enrolled, and the inpatient mortality rate was 10.8% (n=60). Mortality rates increased incrementally in conjunction with the NEWS-L quartiles: first quartile, 2.2%; second quartile, 7.9%; third quartile, 9.6%; and fourth quartile, 23.9%. The area under the receiver operating characteristic curve of the NEWS-L score was 0.73 (95% confidence interval [CI], 0.66-0.80), which showed no significant difference from that of the PSI (0.68; 95% CI, 0.61-0.76; P=.28) and CURB-65 (0.66; 95% CI, 0.59-0.73; P=.06). CONCLUSIONS The newly introduced early warning score modified by serum lactate level, NEWS-L score, was comparable to PSI and CURB-65, for predicting inpatient mortality among adult CAP patients.
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Affiliation(s)
- Sion Jo
- Department of Emergency Medicine, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
| | - Taeoh Jeong
- Department of Emergency Medicine, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea.
| | - Jae Baek Lee
- Department of Emergency Medicine, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
| | - Youngho Jin
- Department of Emergency Medicine, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
| | - Jaechol Yoon
- Department of Emergency Medicine, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
| | - Boyoung Park
- National Cancer Control Institute, National Cancer Center, Goyang-si, Kyunggi-do, Republic of Korea
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Aelvoet W, Terryn N, Blommaert A, Molenberghs G, Hens N, De Smet F, Callens M, Beutels P. Community-acquired pneumonia (CAP) hospitalizations and deaths: is there a role for quality improvement through inter-hospital comparisons? Int J Qual Health Care 2015; 28:22-32. [PMID: 26590376 DOI: 10.1093/intqhc/mzv092] [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] [Accepted: 10/12/2015] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE To assess between-hospital variations in standardized in-hospital mortality ratios of community-acquired pneumonia (CAP), and identify possible leads for quality improvement. DESIGN We used an administrative database to estimate standardized in-hospital mortality ratios for 111 Belgian hospitals, by carrying out a set of hierarchical logistic regression models, intended to disentangle therapeutic attitudes and biases. To facilitate the detection of false-negative/positive results, we added an inconclusive zone to the funnel plots, derived from the results of the study. Data quality was validated by comparison with (i) alternative data from the largest Belgian Sickness Fund, (ii) published German hospital data and (iii) the results of an on-site audit. SETTING All Belgian hospital discharge records from 2004 to 2007. STUDY PARTICIPANTS A total of 111 776 adult patients were admitted for CAP. MAIN OUTCOME MEASURE Risk-adjusted standardized in-hospital mortality ratios. RESULTS Out of the 111 hospitals, we identified five and six outlying hospitals, with standardized mortality ratios of CAP consistently on the extremes of the distribution, as providing possibly better or worse care, respectively, and 18 other hospitals as having possible quality weaknesses/strengths. At the individuals' level of the analysis, adjusted odds ratios showed the paramount importance of old age, comorbidity and mechanical ventilation. The data compared well with the different validation sources. CONCLUSIONS Despite the limitations inherent to administrative data, it seemed possible to establish inter-hospital differences in standardized in-hospital mortality ratios of CAP and to identify leads for quality improvement. Monitoring is needed to assess progress in quality.
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Affiliation(s)
- W Aelvoet
- Federal Public Service (FPS) Health, Food Chain Safety and Environment, Eurostation Bloc II-First Floor-01D327, Place Victor Horta 40 bte 10, B-1060 Brussels, Belgium Vrije Universiteit Brussel, Faculteit Geneeskunde en Farmacie, Brussels, Belgium
| | - N Terryn
- Federal Public Service (FPS) Health, Food Chain Safety and Environment, Eurostation Bloc II-First Floor-01D327, Place Victor Horta 40 bte 10, B-1060 Brussels, Belgium
| | - A Blommaert
- Centre for Health Economics Research and Modeling Infectious Diseases (CHERMID), Vaccine and Infectious Disease Institute (WHO Collaborating Centre), University of Antwerp, Antwerp, Belgium
| | - G Molenberghs
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BioStat), Universiteit Hasselt and KU Leuven, Belgium
| | - N Hens
- Centre for Health Economics Research and Modeling Infectious Diseases (CHERMID), Vaccine and Infectious Disease Institute (WHO Collaborating Centre), University of Antwerp, Antwerp, Belgium Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BIOSTAT), Hasselt University
| | - F De Smet
- National Alliance of Christian Mutualities, Brussels, Belgium Department of Public Health and Primary Care, Occupational, Environmental and Insurance Medicine, KU Leuven, Louvain, Belgium
| | - M Callens
- National Alliance of Christian Mutualities, Brussels, Belgium
| | - P Beutels
- Centre for Health Economics Research and Modeling Infectious Diseases (CHERMID), Vaccine and Infectious Disease Institute (WHO Collaborating Centre), University of Antwerp, Antwerp, Belgium School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia
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Risk Prediction of One-Year Mortality in Patients with Cardiac Arrhythmias Using Random Survival Forest. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2015; 2015:303250. [PMID: 26379761 PMCID: PMC4562335 DOI: 10.1155/2015/303250] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 06/26/2015] [Accepted: 07/28/2015] [Indexed: 11/17/2022]
Abstract
Existing models for predicting mortality based on traditional Cox proportional hazard approach (CPH) often have low prediction accuracy. This paper aims to develop a clinical risk model with good accuracy for predicting 1-year mortality in cardiac arrhythmias patients using random survival forest (RSF), a robust approach for survival analysis. 10,488 cardiac arrhythmias patients available in the public MIMIC II clinical database were investigated, with 3,452 deaths occurring within 1-year followups. Forty risk factors including demographics and clinical and laboratory information and antiarrhythmic agents were analyzed as potential predictors of all-cause mortality. RSF was adopted to build a comprehensive survival model and a simplified risk model composed of 14 top risk factors. The built comprehensive model achieved a prediction accuracy of 0.81 measured by c-statistic with 10-fold cross validation. The simplified risk model also achieved a good accuracy of 0.799. Both results outperformed traditional CPH (which achieved a c-statistic of 0.733 for the comprehensive model and 0.718 for the simplified model). Moreover, various factors are observed to have nonlinear impact on cardiac arrhythmias prognosis. As a result, RSF based model which took nonlinearity into account significantly outperformed traditional Cox proportional hazard model and has great potential to be a more effective approach for survival analysis.
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Meta-review: adverse effects of inhaled corticosteroids relevant to older patients. Drugs 2015; 74:539-47. [PMID: 24659375 DOI: 10.1007/s40265-014-0202-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND In recent years, clinical trials and observational studies have raised concerns about the potential adverse effects of inhaled corticosteroids (ICS) such as pneumonia, cataract, fractures and hyperglycaemia, which are of particular concern for older patients. METHODS We conducted a meta-review by searching electronic databases (MEDLINE, EMBASE, PubMed) for systematic reviews and meta-analyses of ICS use and the adverse effects of interest. We also evaluated new primary studies that reported information beyond that available from previously published meta-analyses. Two reviewers independently extracted data on measures of associated harm with ICS use. RESULTS We identified five relevant meta-analyses for inclusion in this meta-review, and also three new studies of ICS and pneumonia. We found consistent evidence of a dose-response relationship between ICS use and serious adverse effects such as fractures and pneumonia. The estimated number needed to treat for harm due to fracture with ICS was 83 with 3-years use, and 60 per year for pneumonia. Both asthma and chronic obstructive pulmonary disease (COPD) users of ICS were at risk of pneumonia, with fluticasone appearing to confer higher risk than budesonide. There is also some suggestion that ICS use is associated with cataracts in a dose-response manner but the evidence is less robust here. Equally, the influence of ICS on diabetes mellitus remains uncertain. CONCLUSIONS In view of the dose-response relationship seen between ICS use and important adverse effects such as fractures and pneumonia, clinicians needs to carefully balance the benefits of ICS versus the harms in older patients receiving long-term high-dose ICS.
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Gwak MH, Jo S, Jeong T, Lee JB, Jin YH, Yoon J, Park B. Initial serum lactate level is associated with inpatient mortality in patients with community-acquired pneumonia. Am J Emerg Med 2015; 33:685-90. [DOI: 10.1016/j.ajem.2015.03.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 03/02/2015] [Accepted: 03/03/2015] [Indexed: 02/04/2023] Open
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Simplified CRB-65 for risk stratification and predicting prognosis in acute pulmonary embolism. PHLEBOLOGIE 2015. [DOI: 10.12687/phleb2251-4-2015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
SummaryBackground: Pulmonary embolism (PE) and community acquired pneumonia (CAP) are potentially life-threatening diseases. In CAP CRB-65 is used for risk stratification and prognosis prediction. The aim of this study was to examine a simplified CRB-65 (sCRB-65) for predicting prognosis in PE.Methods: We retrospectively analyzed the data of 182 PE patients. Patients were, according to the score of sCRB-65 (respectively 1 point for dyspnoea, systolic blood pressure < 90 mmHg or diastolic blood pressure60 mmHg, age65years), subdivided in risk-classes 1–4.Risk classes were compared with Kruskal-Wallis test. Logistic multivariable regression and Pearson correlation matrix were calculated for coherence of sCRB-65 and in-hospital death, right ventricular load and PE severity stadium as well as sCRB-65 > 2points and in-hospital death an PE stadium. ROC analysis was performed to evaluate efficiency of sCRB-65 score to predict in-hospital death and PE severity stadium.Results: PE severity stadium, systolic pulmonary artery pressure (sPAP) and frequency of in-hospital death increased with growing risk class.Risk class 1 showed lower PE sever-ity stadium than 2 (P=0.0253), 3 (P=0.0132) and 4 (P=0.00162), lower percentage of patients with sPAP > 30mmHg than 2 (0 % vs. 48.9 %, P=0.0419), 3 (0 % vs. 70.8 %, P=0.00112) and 4 (0 % vs. 75.0 %, P=0.0113). Frequency of in-hospital deaths was higher in risk class 4 than in 1 (P=0.0024), 2 (P=0.00014) and 3 (P=0.000058). Multi-variable logistic regression showed an association between sCRB-65 scored>0 and PE severity stadium (OR 11.42, 95 %CI: 1.35–96.66, P=0.0254), RVD (OR 10.09, 1.16–87.78, P=0.0363) and sPAP (OR 1.08, 1.02–1.15, P=0.0092) as well as a trend towards significance (OR 12.39, 0.90–171.34, P=0.060) between in-hospital death and sCRB-65. sCRB-65 correlated with PE severity stadium (r=0.258, P<0.001) and sPAP (r=0.280, P=0.001). sCRB-65 >2 points was strongly associated with both inhospital death (OR 36.22, 95%CI: 1.59–827.71, P=0.0245) and high-risk PE stadium (OR 57.94, 95%CI: 7.17–468.33, P=0.000141). ROC analysis for CRB-65 predicting in-hospital death and high-risk PE stadium showed AUC values of respectively 0.764 and 0.892 with sCRB-65 cut-off value of 2.5 points, respectively.Conclusions: sCRB-65 is closely correlated with PE severity stadium and load of the right heart as well as prognosis. PE patients with sCRB-65 score >2 points revealed a 36.2-fold risk to die during in-hospital course after acute PE event. Efficiency of sCRB-65 to predict in-hospital death was good.
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Uematsu H, Kunisawa S, Sasaki N, Ikai H, Imanaka Y. Development of a risk-adjusted in-hospital mortality prediction model for community-acquired pneumonia: a retrospective analysis using a Japanese administrative database. BMC Pulm Med 2014; 14:203. [PMID: 25514976 PMCID: PMC4279890 DOI: 10.1186/1471-2466-14-203] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 12/01/2014] [Indexed: 11/22/2022] Open
Abstract
Background Community-acquired pneumonia (CAP) is a common cause of patient hospitalization and death, and its burden on the healthcare system is increasing in aging societies. Here, we develop and internally validate risk-adjustment models and scoring systems for predicting mortality in CAP patients to enable more precise measurements of hospital performance. Methods Using a multicenter administrative claims database, we analyzed 35,297 patients hospitalized for CAP who had been discharged between April 1, 2012 and September 30, 2013 from 303 acute care hospitals in Japan. We developed hierarchical logistic regression models to analyze predictors of in-hospital mortality, and validated the models using the bootstrap method. Discrimination of the models was assessed using c-statistics. Additionally, we developed scoring systems based on predictors identified in the regression models. Results The 30-day in-hospital mortality rate was 5.8%. Predictors of in-hospital mortality included advanced age, high blood urea nitrogen level or dehydration, orientation disturbance, respiratory failure, low blood pressure, high C-reactive protein levels or high degree of pneumonic infiltration, cancer, and use of mechanical ventilation or vasopressors. Our models showed high levels of discrimination for mortality prediction, with a c-statistic of 0.89 (95% confidence interval: 0.89-0.90) in the bootstrap-corrected model. The scoring system based on 8 selected variables also showed good discrimination, with a c-statistic of 0.87 (95% confidence interval: 0.86-0.88). Conclusions Our mortality prediction models using administrative data showed good discriminatory power in CAP patients. These risk-adjustment models may support improvements in quality of care through accurate hospital evaluations and inter-hospital comparisons.
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Affiliation(s)
| | | | | | | | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto City, Kyoto 606-8501, Japan.
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