Epidemiology and long-term clinical and biologic risk factors for pneumonia in community-dwelling older Americans: analysis of three cohorts

The Global Burden of Sepsis and Septic Shock

A dysregulated host response to infection causes organ dysfunction in sepsis and septic shock, two potentially fatal diseases. They continue to be major worldwide health burdens with high rates of morbidity and mortality despite advancements in medical care. The goal of this thorough review was to present a thorough summary of the current body of knowledge about the prevalence of sepsis and septic shock worldwide. Using widely used computerized databases, a comprehensive search of the literature was carried out, and relevant studies were chosen in accordance with predetermined inclusion and exclusion criteria. A narrative technique was used to synthesize the data that were retrieved. The review's conclusions show how widely different locations and nations differ in terms of sepsis and septic shock's incidence, prevalence, and fatality rates. Compared to high-income countries (HICs), low- and middle-income countries (LMICs) are disproportionately burdened more heavily. We talk about risk factors, comorbidities, and difficulties in clinical management and diagnosis in a range of healthcare settings. The review highlights the need for more research, enhanced awareness, and context-specific interventions in order to successfully address the global burden of sepsis and septic shock.

Cigarette smoking and risk of severe infectious respiratory diseases in UK adults: 12-year follow-up of UK biobank

BACKGROUND

The relevance of tobacco smoking for infectious respiratory diseases (IRD) is uncertain. We investigated the associations of cigarette smoking with severe IRD resulting in hospitalization or death in UK adults.

METHODS

We conducted a prospective study of cigarette smoking and risk of severe IRD in UK Biobank. The outcomes included pneumonia, other acute lower respiratory tract infections (OA-LRTI) and influenza. Multivariable Cox regression analyses were used to estimate hazard ratios (HRs) of severe IRD associated with smoking habits after adjusting for confounding factors.

RESULTS

Among 341 352 participants with no prior history of major chronic diseases, there were 12 384 incident cases with pneumonia, 7054 with OA-LRTI and 795 with influenza during a 12-year follow-up. Compared with non-smokers, current smoking was associated with ⁓2-fold higher rates of severe IRD (HR 2.40 [2.27-2.53] for pneumonia, 1.99 [1.84-2.14] for OA-LRTI and 1.82 [95% confidence interval: 1.47-2.24] for influenza). Incidence of all severe IRDs were positively associated with amount of cigarettes smoked. The HRs for each IRD (except influenza) also declined with increasing duration since quitting.

CONCLUSIONS

Current cigarette smoking was positively associated with higher rates of IRD and the findings extend indications for tobacco control measures and vaccination of current smokers for prevention of severe IRD.

Predicting Mycoplasma pneumoniae and Chlamydophila pneumoniae in community-acquired pneumonia (CAP) pneumonia: epidemiological study of respiratory tract infection using multiplex PCR assays

Community-acquired pneumonia (CAP) is a common illness that can lead to mortality. β-lactams are ineffective against atypical pathogen including Mycoplasma pneumoniae. We used molecular examinations to develop a decision tree to predict atypical pathogens with CAP and to examine the prevalence of macrolide resistance in Mycoplasma pneumoniae. We conducted a prospective observational study of patients aged ≥ 18 years who had fever and respiratory symptoms and were diagnosed with CAP in one of two community hospitals between December 2016 and October 2018. We assessed combinations of clinical variables that best predicted atypical pathogens with CAP by classification and regression tree (CART) analysis. Pneumonia was defined as respiratory symptoms and new infiltration recognized on chest X-ray or chest computed tomography. We analyzed 47 patients (21 females, 44.7%, mean age: 47.6 years). Atypical pathogens were detected in 15 patients (31.9%; 12 Mycoplasma pneumoniae, 3 Chlamydophila pneumoniae). Ten patients carried macrolide resistant Mycoplasma pneumoniae (macrolide resistant rate 83.3%). CART analysis suggested that factors associated with presence of atypical pathogens were absence of crackles, age < 45 years, and LD ≥ 183 U/L (sensitivity 86.7% [59.5, 98.3], specificity 96.9% [83.8, 99.9]). ur simple clinical decision rules can be used to identify primary care patients with CAP that are at risk for atypical pathogens. Further research is needed to validate its usefulness in various populations.Trial registration Clinical Trial (UMIN trial ID: UMIN000035346).

The Dynamics of B Cell Aging in Health and Disease

Aging is considered to be an important risk factor for several inflammatory diseases. B cells play a major role in chronic inflammatory diseases by antibody secretion, antigen presentation and T cell regulation. Different B cell subsets have been implicated in infections and multiple autoimmune diseases. Since aging decreases B cell numbers, affects B cell subsets and impairs antibody responses, the aged B cell is expected to have major impacts on the development and progression of these diseases. In this review, we summarize the role of B cells in health and disease settings, such as atherosclerotic disease. Furthermore, we provide an overview of age-related changes in B cell development and function with respect to their impact in chronic inflammatory diseases.

Aging associated altered response to intracellular bacterial infections and its implication on the host

The effects of senescence on geriatric disorders are well explored, but how it influences infections in the elderly is poorly addressed. Here, we show that several anti-microbial responses are elevated in senescent epithelial cells and old mice, which results in decreased bacterial survival in the host after infection. We identify higher levels of iNOS as a crucial host response and show that p38 MAPK in senescent epithelial cells acts as a negative regulator of iNOS transcription. However, in older mice, the ability to impede bacterial infection does not result in enhanced survival, possibly because elevated pro-inflammatory responses are not countered by a robust host protective anti-inflammatory response. Overall, while addressing an alternate advantage of senescent cells, our study demonstrates that infection-associated morbidity in the elderly may not be the sole outcome of pathogen loads but may also be influenced by the host's ability to resolve inflammation-induced damage.

A risk score for predicting hospitalization for community-acquired pneumonia in ITP using nationally representative data

Infection is one of the primary causes of death from immune thrombocytopenia (ITP), and the lungs are the most common site of infection. We identified the factors associated with hospitalization for community-acquired pneumonia (CAP) in nonsplenectomized adults with ITP and established the [corrected] (ACPA) prediction model to predict the incidence of hospitalization for CAP. This was a retrospective study of nonsplenectomized adult patients with ITP from 10 large medical centers in China. The derivation cohort included 145 ITP inpatients with CAP and 1360 inpatients without CAP from 5 medical centers, and the validation cohort included the remaining 63 ITP inpatients with CAP and 526 inpatients without CAP from the other 5 centers. The 4-item ACPA model, which included age, Charlson Comorbidity Index score, initial platelet count, and initial absolute lymphocyte count, was established by multivariable analysis of the derivation cohort. Internal and external validation were conducted to assess the performance of the model. The ACPA model had an area under the curve of 0.853 (95% confidence interval [CI], 0.818-0.889) in the derivation cohort and 0.862 (95% CI, 0.807-0.916) in the validation cohort, which indicated the good discrimination power of the model. Calibration plots showed high agreement between the estimated and observed probabilities. Decision curve analysis indicated that ITP patients could benefit from the clinical application of the ACPA model. To summarize, the ACPA model was developed and validated to predict the occurrence of hospitalization for CAP, which might help identify ITP patients with a high risk of hospitalization for CAP.

Risk of community-acquired pneumonia requiring hospitalization in patients with spondyloarthritis

AIMS

To compare the risk of community-acquired pneumonia (CAP) requiring hospitalization in spondyloarthritis (SpA) and non-specific back pain (NSBP), and to identify the risk factors for CAP in SpA.

METHODS

A total of 2984 patients with SpA from 11 rheumatology centers and 2526 patients with NSBP from orthopedic units were reviewed from the centralized electronic database in Hong Kong. Incidence of CAP requiring hospitalization and demographic data including age, gender, smoking and drinking status, use of sulfasalazine, individual biological-disease modifying anti-rheumatic drugs (DMARDs) used, micro-organisms, other immunosuppressants or immunosuppressive states, use of steroid for more than ½ year, and co-morbidities were identified. Risks of CAP in SpA were compared with those in NSBP using propensity score regression method. Multivariate Cox regression model was used to identify the risk factors in SpA.

RESULTS

CAP requiring hospitalization was found in 183 patients with SpA and 138 patients with NSBP. Increased risk for CAP was found in the following groups with SpA: all subgroups (hazard ratio (HR) 2.14, p < 0.001), without use of DMARDs (HR 2.64, p < 0.001), without psoriasis and not taking DMARDs (HR 2.38, p < 0.001). Infliximab (HR2.55, p = 0.04), smoking (HR 1.68, p = 0.003), comorbid psoriasis (HR 1.67, p = 0.003), and use of steroid for more than ½ year (HR 1.94, p = 0.003) were found to associate with CAP after adjustments for traditional risk factors.

CONCLUSION

Risk of CAP is increased in patients with SpA. Our data favor universal influenza and pneumococcal vaccination programs in the population. Rheumatologists should also advise smoking cessation and avoid long term steroid therapy.

Predictive Accuracy of Quick Sequential Organ Failure Assessment for Hospital Mortality Decreases With Increasing Comorbidity Burden Among Patients Admitted for Suspected Infection

OBJECTIVES

Evaluate the accuracy of the quick Sequential Organ Failure Assessment tool to predict mortality across increasing levels of comorbidity burden.

DESIGN

Retrospective observational cohort study.

SETTING

Twelve acute care hospitals in the Southeastern United States.

PATIENTS

A total of 52,187 patients with suspected infection presenting to the Emergency Department between January 2014 and September 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was hospital mortality. We used electronic health record data to calculate quick Sequential Organ Failure Assessment risk scores from vital signs and laboratory values documented during the first 24 hours. We calculated Charlson Comorbidity Index scores to quantify comorbidity burden. We constructed logistic regression models to evaluate differences in the performance of quick Sequential Organ Failure Assessment greater than or equal to 2 to predict hospital mortality in patients with no documented (Charlson Comorbidity Index = 0), low (Charlson Comorbidity Index = 1-2), moderate (Charlson Comorbidity Index = 3-4), or high (Charlson Comorbidity Index ≥ 5) comorbidity burden. Among the cohort, 2,030 patients died in the hospital (4%). No comorbidities were documented for 5,038 patients (10%), 9,235 patients (18%) had low comorbidity burden, 12,649 patients (24%) had moderate comorbidity burden, and 25,265 patients (48%) had high comorbidity burden. Overall model discrimination for quick Sequential Organ Failure Assessment greater than or equal to 2 was the area under the receiver operating characteristic curve of 0.71 (95% CI, 0.69-0.72). A model including both quick Sequential Organ Failure Assessment and Charlson Comorbidity Index had improved discrimination compared with Charlson Comorbidity Index alone (area under the receiver operating characteristic curve, 0.77; 95% CI, 0.76-0.78 vs area under the curve, 0.61; 95% CI, 0.59-0.62). Discrimination was highest among patients with no documented comorbidities (quick Sequential Organ Failure Assessment area under the receiver operating characteristic curve, 0.84; 95% CI; 0.79-0.89) and lowest among high comorbidity patients (quick Sequential Organ Failure Assessment area under the receiver operating characteristic curve, 0.67; 95% CI, 0.65-0.68). The strength of association between quick Sequential Organ Failure Assessment and mortality ranged from 30.5-fold increased likelihood in patients with no comorbidities to 4.7-fold increased likelihood in patients with high comorbidity.

CONCLUSIONS

The accuracy of quick Sequential Organ Failure Assessment to predict hospital mortality diminishes with increasing comorbidity burden. Patients with comorbidities may have baseline abnormalities in quick Sequential Organ Failure Assessment variables that reduce predictive accuracy. Additional research is needed to better understand quick Sequential Organ Failure Assessment performance across different comorbid conditions with modification that incorporates the context of changes to baseline variables.

Analyses of Mitochondrial DNA and Immune Phenotyping Suggest Accelerated T-Cell Turnover in Treated HIV

BACKGROUND

HIV infection is associated with premature aging, and mitochondrial integrity is compromised during the aging process. Because mitochondrial toxicity is a consequence of antiretroviral therapies (ARTs), we hypothesized HIV and long-term ART would correlate with immunosenescence and mitochondrial DNA (mtDNA) pathology.

SETTING

Thirteen older HIV-infected individuals (aged >40 years) with virologic suppression (stratified by duration of ART) were compared with 10 uninfected controls well-matched for age.

METHODS

Peripheral blood T-cells were immunophenotyped to measure immune activation, proliferation, and immunosenescence in subsets. mtDNA copies per cell and the relative abundance of mtDNA carrying the "common deletion" (RACD) were quantified by droplet digital polymerase chain reaction.

RESULTS

Immune activation was higher in HIV-infected individuals than HIV-uninfected individuals in mature CD4 T-cell subsets (CD4TTM P = 0.025, CD4TEM P = 0.0020) regardless of ART duration. Cell populations from uninfected individuals were more likely to be more senescent populations in mature CD4 T-cell subsets (TTM P = 0.017), and CD8 (CD8TEMRA+ P = 0.0026). No differences were observed in mtDNA or RACD levels in any CD4 T-cell subsets, while CD8TSCM of infected individuals trended to have more mtDNA (P = 0.057) and reduced RACD (P = 0.0025).

CONCLUSIONS

HIV-infected individuals demonstrated increased immune activation, but reduced senescence in more mature T-cell subsets. Increased mtDNA content and lower RACD in CD8TSCM suggest immune activation driven turnover of these cells in HIV-infected persons.

HIV infection is associated with elevated biomarkers of immune activation in Ugandan adults with pneumonia

INTRODUCTION

Pneumonia is an important cause of morbidity and mortality in persons living with human immunodeficiency virus (HIV) infection. How immune activation differs among HIV-infected and HIV-uninfected adults with pneumonia is unknown.

METHODS

The Inflammation, Aging, Microbes, and Obstructive Lung Disease (I AM OLD) Cohort is a prospective cohort of adults with pneumonia in Uganda. In this cross-sectional analysis, plasma was collected at pneumonia presentation to measure the following 12 biomarkers: interleukin 6 (IL-6), soluble tumor necrosis factor receptors 1 and 2 (sTNFR-1 and sTNFR-2), high sensitivity C-reactive protein (hsCRP), fibrinogen, D-dimer, soluble CD27 (sCD27), interferon gamma-inducible protein 10 (IP-10), soluble CD14 (sCD14), soluble CD163 (sCD163), hyaluronan, and intestinal fatty acid binding protein. We asked whether biomarker levels differed between HIV-infected and HIV-uninfected participants, and whether higher levels of these biomarkers were associated with mortality.

RESULTS

One hundred seventy-three participants were enrolled. Fifty-three percent were HIV-infected. Eight plasma biomarkers-sTNFR-1, sTNFR-2, hsCRP, D-dimer, sCD27, IP-10, sCD14, and hyaluronan-were higher among participants with HIV infection, after adjustment for pneumonia severity. Higher levels of 8 biomarkers-IL-6, sTNFR-1, sTNFR-2, hsCRP, IP-10, sCD14, sCD163, and hyaluronan-were associated with increased 2-month mortality.

CONCLUSIONS

As in other clinical contexts, HIV infection is associated with a greater degree of immune activation among Ugandan adults with pneumonia. Some of these are also associated with short-term mortality. Further study is needed to explore whether these biomarkers might predict poor long-term outcomes-such as the development of obstructive lung disease-in patients with HIV who have recovered from pneumonia.

Effects of microbiota-driven therapy on inflammatory responses in elderly individuals: A systematic review and meta-analysis

Current evidence suggests that age-associated inflammation, a strong risk factor for the health status of elderly individuals, is closely associated with gut microbiota. Previous animal studies have demonstrated a benefit of microbiota-driven therapy in decreasing low-grade chronic inflammation in elderly individuals; however, it remains controversial in clinical studies. Therefore, the present systematic review and meta-analysis were designed to assess the effects of microbiota-driven therapy on inflammatory markers in elderly individuals. PubMed, EMBASE, and the Cochrane Library were searched with no language restrictions from the inception of the database to November 11th, 2018 to identify all existing literature. We calculated pooled standard mean difference (SMD) using fixed effect model or random effect model to assess the effects of microbiota-driven therapy on elderly individuals. The methodological quality of the studies was determined according to the Cochrane Handbook. The publication bias was evaluated by funnel plot and Egger regression test. Ten randomized controlled studies, with 689 elderly individuals (347 individuals in the microbiota-driven therapy group and 342 individuals in the placebo group), were included in the analysis. Compared with placebo, microbiota-driven therapy did not decrease the levels of tumor necrosis factor-α (SMD, -0.24; 95% CI, -0.69 to 0.21; p = 0.30; I² = 82.7%), interleukin-6 (SMD, -0.13; 95% CI, -0.74 to 0.49; p = 0.69; I² = 90.7%) and interleukin-10 (SMD, 1.00; 95% CI, -0.15 to 2.15; p = 0.09; I² = 96.3%). In addition, the microbiota-driven therapy also did not decrease the levels of C reactive protein (SMD, -1.28; 95% CI, -2.62 to 0.06; p = 0.06; I² = 96.2%), interleukin-1β (SMD, -0.22; 95% CI, -0.81 to 0.37; p = 0.46; I² = 73.8%), interleukin-8 (SMD, -0.03; 95% CI, -0.67 to 0.61; p = 0.93; I² = 88.0%) and monocyte chemoattractant protein-1 (SMD, -0.11; 95% CI, -0.41 to 0.20; p = 0.49; I² = 0%) when compared with placebo. No obvious publication bias was observed (p>0.05). In conclusion, the present meta-analysis of available randomized controlled studies did not suggest any significant benefit of microbiota-driven therapy in decreasing the inflammatory responses of elderly individuals.

Non-alcoholic fatty liver disease and 30-day all-cause mortality in adult patients with community-acquired pneumonia

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is a common and serious form of chronic liver disease. Risk factors of NAFLD include obesity and type 2 diabetes which are associated with infections.

AIM

We aimed to determine the association of NAFLD with 30-day all-cause mortality in adult patients with community-acquired pneumonia (CAP).

METHODS

A retrospective cohort study on hospitalized patients with CAP that was conducted during a period of 4 years. We included patients aged ≥18 years with CAP who underwent abdominal ultrasonography. We compared between patients with and without NAFLD in term of age, gender, body mass index (BMI), comorbidities, CURB-65, pneumonia severity index (PSI), liver enzymes, C-reactive protein (CRP) and 30-day all-cause mortality. We used fibrosis score to distinguish between patients with NAFLD who have advanced fibrosis (F3-F4) and do not have (F0-F2).

RESULTS

A total of 561 patients were included in this study. The overall prevalence of NAFLD was 200/561 (35.6%). Significant differences were found between the groups with and without NAFLD in term of BMI, CURB-65, ALT, GGT and CRP. The 30-day all-cause mortality rate was 9.8% (55/561). Among the NAFLD group 34/200 (17%) subjects died vs. 21/361 (5.82%) among patients without NAFLD, P < 0.001. Multi-variate logistic regression analysis after adjusting for other multiple covariates showed that NAFLD with fibrosis score 0-2 [odds ratio (OR) 1.38, 95% confidence interval (CI) 1.12-1.51, P = 0.04], NAFLD with fibrosis score> 2 (1.52; 1.25-1.70, P = 0.03) were associated with 30-day all-cause mortality among patients with CAP.

CONCLUSIONS

NAFLD was associated with 30-day all-cause mortality in patients with CAP. This association was more significant in patients with advanced hepatic fibrosis.

Risk prediction and segmentation models used in the United States for assessing risk in whole populations: a critical literature review with implications for nurses' role in population health management

Objective

We sought to assess the current state of risk prediction and segmentation models (RPSM) that focus on whole populations.

Materials

Academic literature databases (ie MEDLINE, Embase, Cochrane Library, PROSPERO, and CINAHL), environmental scan, and Google search engine.

Methods

We conducted a critical review of the literature focused on RPSMs predicting hospitalizations, emergency department visits, or health care costs.

Results

We identified 35 distinct RPSMs among 37 different journal articles (n = 31), websites (n = 4), and abstracts (n = 2). Most RPSMs (57%) defined their population as health plan enrollees while fewer RPSMs (26%) included an age-defined population (26%) and/or geographic boundary (26%). Most RPSMs (51%) focused on predicting hospital admissions, followed by costs (43%) and emergency department visits (31%), with some models predicting more than one outcome. The most common predictors were age, gender, and diagnostic codes included in 82%, 77%, and 69% of models, respectively.

Discussion

Our critical review of existing RPSMs has identified a lack of comprehensive models that integrate data from multiple sources for application to whole populations. Highly depending on diagnostic codes to define high-risk populations overlooks the functional, social, and behavioral factors that are of great significance to health.

Conclusion

More emphasis on including nonbilling data and providing holistic perspectives of individuals is needed in RPSMs. Nursing-generated data could be beneficial in addressing this gap, as they are structured, frequently generated, and tend to focus on key health status elements like functional status and social/behavioral determinants of health.

Alcohol and the risk of pneumonia: a systematic review and meta-analysis

OBJECTIVE

A systematic review and meta-analysis to estimate the magnitude of the association between alcohol consumption and the risk of community-acquired pneumonia (CAP) in adults was undertaken.

DESIGN

Systematic review and meta-analysis.

METHODS

Comprehensive searches of Medline, Embase and Web of Science were carried out to identify comparative studies of the association between alcohol intake and CAP between 1985 and 2017. Reference lists were also screened. A random-effects meta-analysis was used to estimate pooled effect sizes. A dose-response meta-analysis was also performed.

RESULTS

We found 17 papers eligible for inclusion in the review, of which 14 provided results which could be pooled. Meta-analysis of these 14 studies identified an 83% increased risk of CAP among people who consumed alcohol or in higher amounts, relative to those who consumed no or lower amounts of alcohol, respectively (relative risk=1.83, 95% CI 1.30 to 2.57). There was substantial between-study heterogeneity, which was attributable in part to differences in study continent, adjustment for confounders and pneumonia diagnosis (clinical vs death). Dose-response analysis found that for every 10-20 g higher alcohol intake per day, there was an 8% increase in the risk of CAP.

CONCLUSIONS

The findings suggest that alcohol consumption increases the risk of CAP. Therefore, strengthening policies to reduce alcohol intake would be likely to reduce the incidence of CAP.

Hospital Volume of Immunosuppressed Patients with Sepsis and Sepsis Mortality

RATIONALE

Immunosuppressive medical conditions are risk factors for mortality from severe infections. It is unknown whether hospital characteristics affect this risk.

OBJECTIVES

To determine whether the odds of death for an immunosuppressed patient with sepsis relative to a nonimmunosuppressed patient with sepsis varies according to the hospital's yearly case volume of immunosuppressed patients with sepsis.

METHODS

Patients with sepsis at hospitals in the Vizient database were characterized as immunosuppressed or not immunosuppressed on the basis of diagnosis codes and medication use. Hospitals were grouped into quartiles based on their average volumes of immunosuppressed patients with sepsis per year. Multilevel logistic regression with clustering of patients by hospital was used to determine whether the odds of in-hospital death from sepsis owing to a suppressed immune state varied by hospital quartile.

RESULTS

There were 350,183 patients with sepsis at 60 hospitals in the Vizient database from 2010 to 2012. Immunosuppressed patients with sepsis at the 15 hospitals in the lowest quartile (64 to 224 immunosuppressed patients with sepsis per year) had an increased odds of in-hospital death relative to nonimmunosuppressed patients with sepsis at these hospitals (adjusted odds ratio, 1.38; 95% confidence interval, 1.27-1.50; P < 0.001). The odds of in-hospital death for immunosuppressed patients with sepsis relative to nonimmunosuppressed patients with sepsis was similar for patients at hospitals in the second, third, and fourth quartiles (225 to 1,056 immunosuppressed patients with sepsis per year). The adjusted odds of death from sepsis owing to a suppressed immune state of 1.21 (95% confidence interval, 1.18-1.25; P < 0.001) for patients at these 45 hospitals was significantly less than for patients at the 15 hospitals in the lowest quartile (P = 0.004 for difference).

CONCLUSIONS

The risk of death from sepsis owing to a suppressed immune state was greatest at hospitals with the lowest volume of immunosuppressed patients with sepsis. Further study is needed to determine whether this finding is related to differences in patient characteristics or in care delivery at hospitals with different amounts of exposure to immunosuppressed patients.

Protracted immune disorders at one year after ICU discharge in patients with septic shock

Background

Sepsis is a leading cause of mortality and critical illness worldwide and is associated with an increased mortality rate in the months following hospital discharge. The occurrence of persistent or new organ dysfunction(s) after septic shock raises questions about the mechanisms involved in the post-sepsis status. The present study aimed to explore the immune profiles of patients one year after being discharged from the intensive care unit (ICU) following treatment for abdominal septic shock.

Methods

We conducted a prospective, single-center, observational study in the surgical ICU of a university hospital. Eighty-six consecutive patients admitted for septic shock of abdominal origin were included in this study. Fifteen different plasma biomarkers were measured at ICU admission, at ICU discharge and at one year after ICU discharge. Three different clusters of biomarkers were distinguished according to their functions, namely: (1) inflammatory response, (2) cell damage and apoptosis, (3) immunosuppression and resolution of inflammation. The primary objective was to characterize variations in the immune status of septic shock patients admitted to ICU up to one year after ICU discharge. The secondary objective was to evaluate the relationship between these biomarker variations and patient outcomes.

Results

At the onset of septic shock, we observed a cohesive pro-inflammatory profile and low levels of inflammation resolution markers. At ICU discharge, the immune status demonstrated decreased but persistent inflammation and increased immunosuppression, with elevated programmed cell death protein-1 (PD-1) levels, and a counterbalanced resolution process, with elevated levels of interleukin-10 (IL-10), resolvin D5 (RvD5), and IL-7. One year after hospital discharge, homeostasis was not completely restored with several markers of inflammation remaining elevated. Remarkably, IL-7 was persistently elevated, with levels comparable to those observed after ICU discharge, and PD-1, while lower, remained in the elevated abnormal range.

Conclusions

In this study, protracted immune disturbances were observed one year after ICU discharge. The study results suggested the presence of long-lasting immune illness disorders following a long-term septic insult, indicating the need for long-term patient follow up after ICU discharge and questioning the use of immune intervention to restore immune homeostasis after abdominal septic shock.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1934-4) contains supplementary material, which is available to authorized users.

Pneumonia in the Noninstitutionalized Older Population

BACKGROUND

Pneumonia is a common and potentially serious disease, with an incidence of ca. 300 per 100 000 persons per year. Until now, there have been only a few population-based studies of risk factors for pneumonia.

METHODS

From 2000 to 2002, nearly 10 000 persons aged 50 to 75 were recruited into the prospective ESTHER cohort study while visiting their family physician for a check-up. The mean duration of follow-up was 10.6 years. Data on newly diagnosed pneumonia were acquired from the participants and their physicians by means of standardized questionnaires. Potential associations with various predictors were studied in survival-time regression models.

RESULTS

435 participants had pneumonia at least once during follow-up. The cumulative 10-year-incidence was 4.5% (95% confidence interval [4.0; 4.9]). Multiple regression revealed that age (relative risk [RR]: 1.43 [1.22; 1.67] per 10 years), current cigarette smoking (RR: 1.56 [1.19; 2.05], compared with never having smoked), and known congestive heart failure (RR: 1.65 [1.24; 2.20]) were independently associated with an elevated risk of pneumonia. The risk was insignificantly elevated in persons with diabetes mellitus (RR: 1.29 [0.98; 1.68]). Alcohol consumption, obesity, stroke, and cancer were not associated with an elevated risk of pneumonia in age- and sex-adjusted analyses.

CONCLUSION

Pneumonia plays an important role in the medical care of non-institutionalized older people. With the aid of the predictors identified in this study, primary care physicians can identify patients at risk, smokers can gain additional motivation to quit, treatment compliance can be increased, and patients may become more willing to be vaccinated as recommended in the current guidelines.

Exploring the microbiome in health and disease

The analysis of human microbiome is an exciting and rapidly expanding field of research. In the past decade, the biological relevance of the microbiome for human health has become evident. Microbiome comprises a complex collection of microorganisms, with their genes and metabolites, colonizing different body niches. It is now well known that the microbiome interacts with its host, assisting in the bioconversion of nutrients and detoxification, supporting immunity, protecting against pathogenic microbes, and maintaining health. Remarkable new findings showed that our microbiome not only primarily affects the health and function of the gastrointestinal tract but also has a strong influence on general body health through its close interaction with the nervous system and the lung. Therefore, a perfect and sensitive balanced interaction of microbes with the host is required for a healthy body. In fact, growing evidence suggests that the dynamics and function of the indigenous microbiota can be influenced by many factors, including genetics, diet, age, and toxicological agents like cigarette smoke, environmental contaminants, and drugs. The disruption of this balance, that is called dysbiosis, is associated with a plethora of diseases, including metabolic diseases, inflammatory bowel disease, chronic obstructive pulmonary disease, periodontitis, skin diseases, and neurological disorders. The importance of the host microbiome for the human health has also led to the emergence of novel therapeutic approaches focused on the intentional manipulation of the microbiota, either by restoring missing functions or eliminating harmful roles. In the present review, we outline recent studies devoted to elucidate not only the role of microbiome in health conditions and the possible link with various types of diseases but also the influence of various toxicological factors on the microbial composition and function.

Life expectancy after cervical laminoplasty-Causes of the fatal prognosis at the early stage (within 5 years)

INTRODUCTION

In more than 20 years' follow-up after cervical laminoplasty, some patients died at an early stage, within 5 years postoperatively. The details remain unclear. This study was conducted to elucidate the clinical features in patients who died at an early stage after cervical laminoplasty to determine possible preventive measures against early death after surgery.

METHODS

A total of 74 patients who died with the follow-up period were included. The patients were divided into two groups: patients with a short survival period (S group, died ≤5 years after surgery) and patients with a long survival period (L group, died >5 years after surgery). Diseases, gender, age, causes of the death, general complications before surgery, and the pre- and postoperative JOA scores were compared between the two groups.

RESULTS

Eleven patients (15%) died within 5 years after laminoplasty. The average age at death in the S group was 68.7 years which was considerably younger than that in the L group (80.2 years). The ratio of pneumonia was higher in the S group, compared to that in the L group. Postoperative JOA score in the S group was lower than that in the L group.

CONCLUSIONS

11 patients out of 74 patients (15%) died within 5 years after laminoplasty. The average age at the death in the S group was much younger than that in the L group. The postoperative JOA score in the S group was lower than that in the L group. As pneumonia was more prevalent in the S group, it might be reasonable to give the information for the protection of pneumonia after cervical laminoplasty.

Interleukin-36γ and IL-36 receptor signaling mediate impaired host immunity and lung injury in cytotoxic Pseudomonas aeruginosa pulmonary infection: Role of prostaglandin E2

Pseudomonas aeruginosa is a Gram-negative pathogen that can lead to severe infection associated with lung injury and high mortality. The interleukin (IL)-36 cytokines (IL-36α, IL-36β and IL-36γ) are newly described IL-1 like family cytokines that promote inflammatory response via binding to the IL-36 receptor (IL-36R). Here we investigated the functional role of IL-36 cytokines in the modulating of innate immune response against P. aeruginosa pulmonary infection. The intratracheal administration of flagellated cytotoxic P. aeruginosa (ATCC 19660) upregulated IL-36α and IL-36γ, but not IL-36β, in the lungs. IL-36α and IL-36γ were expressed in pulmonary macrophages (PMs) and alveolar epithelial cells in response to P. aeruginosa in vitro. Mortality after bacterial challenge in IL-36 receptor deficient (IL-36R-/-) mice and IL-36γ deficient (IL-36γ-/-) mice, but not IL-36α deficient mice, was significantly lower than that of wild type mice. Decreased mortality in IL-36R-/- mice and IL-36γ-/- mice was associated with reduction in bacterial burden in the alveolar space, bacterial dissemination, production of inflammatory cytokines and lung injury, without changes in lung leukocyte influx. Interestingly, IL-36γ enhanced the production of prostaglandin E2 (PGE2) during P. aeruginosa infection in vivo and in vitro. Treatment of PMs with recombinant IL-36γ resulted in impaired bacterial killing via PGE2 and its receptor; EP2. P. aeruginosa infected EP2 deficient mice or WT mice treated with a COX-2-specific inhibitor showed decreased bacterial burden and dissemination, but no change in lung injury. Finally, we observed an increase in IL-36γ, but not IL-36α, in the airspace and plasma of patients with P. aeruginosa-induced acute respiratory distress syndrome. Thus, IL-36γ and its receptor signal not only impaired bacterial clearance in a possible PGE2 dependent fashion but also mediated lung injury during P. aeruginosa infection.

Hospitalized Patients with Acute Pneumonia

Pneumonia is one of the leading causes of mortality and hospitalization among US adults. The decision to admit patients from the emergency department is a major one because of its impact on patients and the hospital. The diagnosis of pneumonia is often clinical and based on symptoms and signs combined with radiographic findings. There are multiple severity assessments available that can guide treatment, prognosis, and disposition. Viruses are an important cause of pneumonia and require early recognition and treatment. The recommended treatment for community-acquired pneumonia includes a beta lactam plus a macrolide or a respiratory fluoroquinolone.

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.

Breaking Down Walls: Microbiota and the Aging Gut

A range of animal species show increased inflammation with age. In this issue of Cell Host & Microbe, Thevaranjan et al. (2017) reveal that heightened inflammation is associated with deregulation of homeostatic interactions between intestinal microbes and the aging host.

A new method to predict hospital mortality in severe community acquired pneumonia

BACKGROUND & AIMS

The aim of this study is to develop a new method that is able to accurately predict the 28day hospital mortality in patients with severe community acquired pneumonia (SCAP) at an early stage.

METHODS

We selected 37,348 SCAP patients in ICU from 173 hospitals during 2011.1-2013.12. The predictive factors for 28day hospital mortality were evaluated retrospectively. All cases underwent intensive care, blood routine, blood biochemical tests and arterial blood gas analysis. Under the Classification and Regression Tree (CART) analysis, a new clinical scoring system was developed for early prediction in SCAP patients. The receiver-operating characteristic (ROC) curve was plotted to calculate the area under the receiver operating characteristic curve (AUC).

RESULTS

A novel clinical model named CLCGH scoring system, including Serum creatinine (Cr) >259.5μmol/L, leukocyte (WBC)>17.35×10⁹/L, C-reactive protein (CRP)>189.4μg/mL, GCS≤9 and serum HCO₃^-≤17.65mmol/L, was carried out and each index was an independent factor for hospital mortality in SCAP. In validation cohort, the AUC of the new scoring system was 0.889 for prediction of hospital mortality, which was similar to SOFA score 0.877, APACHEII score 0.864, and was better than the PSI score 0.761 and CURB-65 score 0.767.

CONCLUSIONS

The new scoring system CLCGH is an efficient, accurate and objective method to predicate the early hospital mortality among SCAP patients.

Age-Associated Microbial Dysbiosis Promotes Intestinal Permeability, Systemic Inflammation, and Macrophage Dysfunction

Levels of inflammatory mediators in circulation are known to increase with age, but the underlying cause of this age-associated inflammation is debated. We find that, when maintained under germ-free conditions, mice do not display an age-related increase in circulating pro-inflammatory cytokine levels. A higher proportion of germ-free mice live to 600 days than their conventional counterparts, and macrophages derived from aged germ-free mice maintain anti-microbial activity. Co-housing germ-free mice with old, but not young, conventionally raised mice increases pro-inflammatory cytokines in the blood. In tumor necrosis factor (TNF)-deficient mice, which are protected from age-associated inflammation, age-related microbiota changes are not observed. Furthermore, age-associated microbiota changes can be reversed by reducing TNF using anti-TNF therapy. These data suggest that aging-associated microbiota promote inflammation and that reversing these age-related microbiota changes represents a potential strategy for reducing age-associated inflammation and the accompanying morbidity.

•

Age-associated inflammation drives macrophage dysfunction and tissue damage

•

Mice under germ-free conditions are protected from age-associated inflammation

•

Co-housing germ-free mice with old, but not young, mice increases age-related inflammation

•

Age-related microbiota changes can be reversed by reducing TNF levels

Mortality Among Black Men in the USA

IMPORTANCE

Black men have the lowest life expectancy of all major ethnic-sex populations in the USA, yet no recent studies have comprehensively examined black male mortality.

OBJECTIVE

The purpose of this study was to analyze recent mortality trends for black men, including black to white (B to W) disparities.

DESIGN

The study design was national mortality surveillance for 2000 to 2014.

SETTING

The setting was the USA.

POPULATION

All black non-Hispanic males aged ≥15 years old in the USA, including institutionalized persons, were included.

EXPOSURE

The 15 leading causes of death were analyzed.

MAIN OUTCOMES AND MEASURES

Linear regression of log-transformed annual age-adjusted death rates was used to calculate average annual percent change (AAPC) in mortality. Black to white (B to W) disparity rate ratios (RR) and 95% confidence intervals (CI) were compared for 2000 and 2014. The most recent available social and economic profile data were obtained from the U.S. Census of Population.

RESULTS

The top five causes of death for black men in 2014, with percentage of total deaths, were (1) heart disease (24.8%), (2) cancer (23.0%), (3) unintentional injuries (5.8%), (4) stroke (5.1%), and (5) homicide (4.3%). Significant mortality declines for 12 of the 15 leading causes occurred through 2014, with the strongest decline for HIV/AIDS (AAPC -8.0, 95% CI -8.8 to -7.1). Only Alzheimer's disease, ranked #15, significantly increased (AAPC +2.5, 95% CI +1.4 to +3.7). Significant black disadvantage persisted for 10 of the 15 leading causes in 2014, including homicide (RR = 10.43, 95% CI 9.98 to 10.89), HIV/AIDS (RR = 8.01, 95% CI 7.50 to 8.54), diabetes (RR = 1.88, 95% CI 1.82 to 1.93), and stroke (RR = 1.61, 95% CI 1.57 to 1.65). The B to W disparity did not improve for heart disease (RR 1.24 in 2000 vs. RR 1.23 in 2014), but did improve for cancer (RR 1.39 in 2000 vs. 1.20 in 2014). Death rates were significantly lower in black men for five causes, including unintentional injuries (RR = 0.83, 95% CI 0.80 to 0.84), chronic lower respiratory diseases (RR = 0.75, 95% CI 0.73 to 0.78), and suicide (RR = 0.37, 95% CI 0.35 to 0.39).

CONCLUSIONS AND RELEVANCE

Total mortality significantly declined for black men from 2000 to 2014, and the overall B to W disparity narrowed to RR = 1.21 (95% CI 1.20 to 1.23) in 2014. However, significant black disadvantages relative to white men persisted for 10 leading causes of death.

Pneumococcal Conjugated Vaccine Reduces the High Mortality for Community-Acquired Pneumonia in the Elderly: an Italian Regional Experience

BACKGROUND

Community-acquired pneumonia (CAP) is an important cause of illness and death worldwide, particularly among the elderly. Previous studies on the factors associated with mortality in patients hospitalized for CAP revealed a direct association between the type of microorganism involved, the characteristics of the patient and mortality. Vaccination status against pneumococcal disease was not considered. We conducted a retrospective analysis on the mortality rates after a first hospitalization for CAP in north-east Italy with a view to examining especially the role of anti-pneumococcal vaccination as a factor associated with pneumonia-related mortality at one year.

METHOD

Between 2012-2013, patients aged 65+ hospitalized with a primary diagnosis of CAP, identified based on International Classification of Diseases, Ninth Revision, Clinical Modification codes 481-486, were enrolled in the study only once. Patients were divided into three groups by pneumococcal vaccination status: 1) 13-valent pneumococcal conjugate vaccine (PCV13) prior to their hospitalization; 2) 23-valent pneumococcal polysaccharide vaccine (PPV23) within 5 years before hospitalization and 3) unvaccinated or PPV23 more than 5 years prior to admission. Gender, age, length of hospital stay and influenza vaccination were considered. Comorbidities were ascertained by means of a properly coded diagnosis. Every patient was followed up for 1 year and the outcome investigated was mortality for any cause and for pneumonia.

RESULTS

A total of 4,030 patient were included in the study; mean age at the time of admission to hospital was 84.3±7.7; 50.9% were female. 74.2% of subjects had at least one comorbidity; 73.7% has been vaccinated against influenza. Regard to pneumococcal vaccine, 80.4% of patients were not vaccinated, 14.5% vaccinated with PPV23 and 5.1% with PCV13. The 1-year survival rates after hospitalization for pneumonia were 83.6%, 85.9% and 89.3% in the unvaccinated, PPV23 and PCV13 groups, respectively. Regression analysis indicated that the risk of death due to pneumonia increased significantly with age (adjusted OR: 1.073; 1.061-1.085), shorter hospital stay (adjusted OR: 0.981; 0.971-0.990), and male gender (adjusted OR: 1.372; 1.165-1.616). The model also confirmed the pneumococcal 13-valent conjugated vaccine as an independent protective factor for mortality-related pneumonia (adjusted OR: 0.599; 0.390-0.921).

CONCLUSION

The main finding of our observational cohort study is a high mortality rate among elderly patients admitted to hospital for pneumonia. The present study suggests a protective role for PCV13 vaccination.

Burden and risk factors of ambulatory or hospitalized CAP: A population based cohort study

BACKGROUND

Data on incidence, risk factors and outcome of community-acquired pneumonia (CAP) including outpatients is sparse.

METHODS

We conducted a cohort study on 1.837.080 adults insured by a German statutory health insurance in 2010-2011. CAP was identified via ICD-10-GM codes, ambulatory cases were validated by antibiotic prescription within 7 days. Primary outcomes were incidence, hospitalisation and 30-day all-cause mortality. Evaluated risk factors included age, sex and comorbidities. Evaluation was done by multivariate regression analysis adjusting for these factors and health care utilization.

RESULTS

CAP incidence was 9.7 per 1000 person years, hospitalisation rate 46.5%, and 30-day mortality 12.9%. 30-day mortality of ambulatory cases was 5% (with 27% subsequently hospitalized for another diagnosis before death). 30-day mortality of hospitalized patients was 21.9%, but in-hospital mortality 17.2%. Risk factors for CAP included age, male sex and all evaluated comorbidities with highest risk for neurologic (OR 2.4), lung (OR 2.3) or immunosuppressive (OR 2.1) disease. Mortality risk was highest for neurologic (OR 2.3) and malignant (OR 2.0) disease.

CONCLUSIONS

CAP constitutes a major burden in terms of incidence, morbidity and all-cause mortality in hospitalized and ambulatory patients. Interventions to raise awareness for disease impact also in ambulatory patients with risk factors are warranted.

Risk Factors for Long-Term Mortality after Hospitalization for Community-Acquired Pneumonia: A 5-Year Prospective Follow-Up Study

BACKGROUND

Contributors to long-term mortality in patients with community-acquired pneumonia (CAP) remain unclear, with little attention paid to pneumonia etiology. We examined long-term survival, causes of death, and risk factors for long-term mortality in adult patients who had been hospitalized for CAP, with emphasis on demographic, clinical, laboratory, and microbiological characteristics.

METHODS

Two hundred and sixty-seven consecutive patients admitted in 2008-2011 to a general hospital with CAP were prospectively recruited and followed up. Patients who died during hospital stay were excluded. Demographic, clinical, and laboratory data were collected within 48 hours of admission. Extensive microbiological work-up was performed to establish the etiology of CAP in 63% of patients. Mortality data were obtained from the Norwegian Cause of Death Registry. Cox regression models were used to identify independent risk factors for all-cause mortality.

RESULTS

Of 259 hospital survivors of CAP (median age 66 years), 79 (30.5%) died over a median of 1,804 days (range 1-2,520 days). Cumulative 5-year survival rate was 72.9% (95% CI 67.4-78.4%). Standardized mortality ratio was 2.90 for men and 2.05 for women. The main causes of death were chronic obstructive pulmonary disease (COPD), vascular diseases, and malignancy. Independent risk factors for death were the following (hazard ratio, 95% CI): age (1.83 per decade, 1.47-2.28), cardiovascular disease (2.63, 1.61-4.32), COPD (2.09, 1.27-3.45), immunocompromization (1.98, 1.17-3.37), and low serum albumin level at admission (0.75 per 5 g/L higher, 0.58-0.96), whereas active smoking was protective (0.32, 0.14-0.74); active smokers were younger than non-smokers (P < 0.001). Microbial etiology did not predict mortality.

CONCLUSIONS

Results largely confirm substantial comorbidity-related 5-year mortality after hospitalization for CAP and the impact of several well-known risk factors for death, and extend previous findings on the prognostic value of serum albumin level at hospital admission. Pneumonia etiology had no prognostic value, but this remains to be substantiated by further studies using extensive diagnostic microbiological methods in the identification of causative agents of CAP.

Intermediate and long-term risk of new-onset heart failure after hospitalization for pneumonia in elderly adults

BACKGROUND

Pneumonia is associated with high risk of heart failure (HF) in the short term (30 days) postinfection. Whether this association persists beyond this period is unknown.

METHODS

We studied 5,613 elderly (≥65 years) adults enrolled in the Cardiovascular Health Study between 1989 and 1994 at 4 US communities. Participants had no clinical diagnosis of HF at enrollment, and they were followed up through December 2010. Hospitalizations for pneumonia were identified using validated International Classification of Disease Ninth Revision codes. A centralized committee adjudicated new-onset HF events. Using Cox regression, we estimated adjusted hazard ratios (HRs) of new-onset HF at different time intervals after hospitalization for pneumonia.

RESULTS

A total of 652 participants hospitalized for pneumonia during follow-up were still alive and free of clinical diagnosis of HF by day 30 posthospitalization. Relative to the time of their hospitalization, new-onset HF occurred in 22 cases between 31 and 90 days (HR 6.9, 95% CI 4.46-10.63, P < .001), 14 cases between 91 days and 6 months (HR 3.2, 95% CI 1.88-5.50, P < .001), 20 cases between 6 months and 1 year (HR 2.6, 95% CI 1.64-4.04, P < .001), 76 cases between 1 and 5 years (HR 1.7, 95% CI 1.30-2.12, P < .001), and 71 cases after 5 years (HR 2.0, 95% CI 1.56-2.58, P < .001). Results were robust to sensitivity analyses using stringent definitions of pneumonia and extreme assumptions for potential informative censoring.

CONCLUSION

Hospitalization for pneumonia is associated with increased risk of new-onset HF in the intermediate and long term. Studies should characterize the mechanisms of this association in order to prevent HF in elderly pneumonia survivors.

Association between hospitalization for pneumonia and subsequent risk of cardiovascular disease

IMPORTANCE

The risk of cardiovascular disease (CVD) after infection is poorly understood.

OBJECTIVE

To determine whether hospitalization for pneumonia is associated with an increased short-term and long-term risk of CVD.

DESIGN, SETTINGS, AND PARTICIPANTS

We examined 2 community-based cohorts: the Cardiovascular Health Study (CHS, n = 5888; enrollment age, ≥65 years; enrollment period, 1989-1994) and the Atherosclerosis Risk in Communities study (ARIC, n = 15,792; enrollment age, 45-64 years; enrollment period, 1987-1989). Participants were followed up through December 31, 2010. We matched each participant hospitalized with pneumonia to 2 controls. Pneumonia cases and controls were followed for occurrence of CVD over 10 years after matching. We estimated hazard ratios (HRs) for CVD at different time intervals, adjusting for demographics, CVD risk factors, subclinical CVD, comorbidities, and functional status.

EXPOSURES

Hospitalization for pneumonia.

MAIN OUTCOMES AND MEASURES

Incident CVD (myocardial infarction, stroke, and fatal coronary heart disease).

RESULTS

Of 591 pneumonia cases in CHS, 206 had CVD events over 10 years after pneumonia hospitalization. CVD risk after pneumonia was highest in the first year. CVD occurred in 54 cases and 6 controls in the first 30 days (HR, 4.07; 95% CI, 2.86-5.27); 11 cases and 9 controls between 31 and 90 days (HR, 2.94; 95% CI, 2.18-3.70); and 22 cases and 55 controls between 91 days and 1 year (HR, 2.10; 95% CI, 1.59-2.60). Additional CVD risk remained elevated into the tenth year, when 4 cases and 12 controls developed CVD (HR, 1.86; 95% CI, 1.18-2.55). In ARIC, of 680 pneumonia cases, 112 had CVD over 10 years after hospitalization. CVD occurred in 4 cases and 3 controls in the first 30 days (HR, 2.38; 95% CI, 1.12-3.63); 4 cases and 0 controls between 31 and 90 days (HR, 2.40; 95% CI, 1.23-3.47); 11 cases and 8 controls between 91 days and 1 year (HR, 2.19; 95% CI, 1.20-3.19); and 8 cases and 7 controls during the second year (HR, 1.88; 95% CI, 1.10-2.66). After the second year, the HRs were no longer statistically significant.

CONCLUSIONS AND RELEVANCE

Hospitalization for pneumonia was associated with increased short-term and long-term risk of CVD, suggesting that pneumonia may be a risk factor for CVD.

Oral health disparities in older adults: oral bacteria, inflammation, and aspiration pneumonia

Poor oral hygiene has been suggested to be a risk factor for aspiration pneumonia in the institutionalized and disabled elderly. Control of oral biofilm formation in these populations reduces the numbers of potential respiratory pathogens in the oral secretions, which in turn reduces the risk for pneumonia. Together with other preventive measures, improved oral hygiene helps to control lower respiratory infections in frail elderly hospital and nursing home patients.

Risk of cardiovascular events in survivors of severe sepsis

RATIONALE

The risk of cardiovascular events after severe sepsis is not known, and these events may explain increased long-term mortality in survivors of severe sepsis.

OBJECTIVES

To determine whether survivors of severe sepsis hospitalization have high long-term risk of cardiovascular events. We examined whether higher risk is due to severe sepsis hospitalization or poor prehospitalization health status, and if the higher risk is also observed in patients hospitalized for infectious and noninfectious reasons, and in other critically ill patients.

METHODS

Unmatched and matched-cohort analyses of Medicare beneficiaries. For unmatched analysis, we compared patients with severe sepsis admitted to the intensive care unit (ICU) and survived hospitalization (n = 4,179) to unmatched population control subjects (n = 819,283). For matched analysis, we propensity-score-matched each patient with severe sepsis to four control subjects (population, hospitalized, non-severe sepsis ICU control subjects, and infection hospitalization). Primary outcome was 1-year incidence rate of hospitalization for cardiovascular events.

MEASUREMENTS AND MAIN RESULTS

Cardiovascular events were common among patients discharged alive after severe sepsis hospitalization (29.5%; 498.2 events/1,000 person-years). Survivors of severe sepsis had a 13-fold higher risk of cardiovascular events compared with unmatched control subjects (498.2 vs. 36 events/1,000 person-years; P < 0.0001), and a 1.9-fold higher risk compared with matched-population control subjects (P < 0.0001). Survivors of severe sepsis had 1.1-fold higher risk compared with matched hospitalized patients and infection hospitalizations (P = 0.002 and 0.001) and similar risk compared with matched-ICU control subjects.

CONCLUSIONS

Survivors of severe sepsis have high risk of cardiovascular events. The higher risk is mainly due to poor prehospitalization health status, and is also seen in a broader population of acutely ill patients.

Interplay between sepsis and chronic health

Severe sepsis is associated with high short-term mortality. Several studies suggest that severe sepsis also worsens health status and increases disability among survivors. As the incidence of severe sepsis increases, and advances in critical care reduce the short-term mortality, the number of individuals who are at risk for poor long-term outcomes will increase. Recent studies suggest that the relationship between sepsis and chronic health may be bidirectional; however, the mechanisms underlying this relationship remain poorly understood. Here we review the epidemiologic studies examining the interplay between sepsis and chronic health and propose a conceptual model, which has implications for preclinical and human study design.